October 13, 2022


In "A New Phase," Dr. Osterholm and Chris Dall discuss the many new subvariants that are competing with BA.5, the Ebola outbreak in Uganda, and the challenges that will come with the next phase of the pandemic.

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Chris Dall: [00:00:06] Hello and welcome to the Osterholm Update COVID-19, a podcast on the COVID-19 pandemic 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 will draw on more than 45 years of experience investigating infectious disease outbreaks to provide straight talk on the COVID-19 pandemic. 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. In this third autumn of the COVID-19 pandemic, with cases continuing to decline in the United States but now rising again in Europe and other parts of the world, the operative word of the day is uncertainty. Will one of the many new SARS-CoV-2 variants circulating around the world challenge the dominance of BA.5 and usher in a new wave of infections? Will the updated booster shots provide enough protection to keep COVID manageable? Will enough people be convinced to get the booster shot? Is our health care system prepared for what could be another tough winter? But with all the uncertainty, one thing that remains certain is the profound social disruption that this pandemic continues to cause. As much as COVID-19 has challenged our public health and health care systems, it has also strained and in some cases broken the bonds that hold communities, friends, and families together. And repairing those bonds may be the biggest challenge we face in coming years. These are some of the issues we'll discuss on this October 13th episode of the podcast as we assess the state of the pandemic here in the US and around the world and discuss what the next phase of this pandemic looks like. We'll also provide an overview of the variant situation, discuss the latest news on monkeypox and Ebola, and share a beautiful place submission from one of our listeners. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Michael Osterholm: [00:02:04] Thank you, Chris. And welcome back to all of you who are part of the podcast family for another update. And to all of you who may be new to this podcast, I hope that we're able to provide you with the information that you're seeking. Surely we are listening to our listeners and appreciate the input that you all have provided on how we can be most helpful. Let me begin this week's podcast emphasizing something Chris just said in the introduction, uncertainty. We are absolutely living in one of the most uncertain times in the entire pandemic. That's not something I know you want to hear. It's not something I want to talk about, but it's something that we must acknowledge because it will tell us where we're going in the days and the weeks and even the months ahead. Now, given the sense that there is uncertainty, there is one thing, however, that is absolutely certain. This pandemic continues to cause us all great pain, not only physical pain, but emotional pain. Today, we're going to talk about that. There are a lot of people who are hurting today, not because of what the virus did to them, but what the pandemic did to their relationships and their lives. And I can be the first in line to comment on that in the sense that I, too, have felt that very, very much. And so stay tuned for that part of it. I can't promise we're going to have answers that will solve all the problems, but we are going to acknowledge the challenge and provide some hopeful information about what it might look like in the future in terms of our relationships. Just in the last week, a study was released that was actually conducted by the Child Mind Institute. It was a survey sponsored by the Blue Shield of California with data collection by Ipsos, and they surveyed 3,200 parents of children aged 24 and younger. And they found a number of very disturbing findings with regard to what children have experienced with this pandemic and how it's affected their mood, their education, their entire psyche. But one of the really remarkable figures that cannot be overstated. They found that 20% of the kids, 24 years of age and younger, and that number held through all age groups down to literally infants. 20% of kids in this country have lost a family member due to COVID. That's substantial. That's incredible. And yet it's real. It's real. So today we're going to talk about that. We're going to talk about the pain of our hearts as well as the pain of our bodies. And I think that's that is something that as we talk about uncertainty and where we're going, we have to have that type of discussion to understand how we're going to move through these next months. Now, given that, of course, I have to add my balance of which is very important to me is my sunlight. And today I'm very happy to report in Auckland, New Zealand, one of my most favorite places in the world, they will have 12 hours and 54 minutes and 43 seconds of sunlight. They're gaining on average 2 minutes and 18 seconds a day. And just in the last week they've gained 16 minutes of sunlight. Now they are, I know, kindly sharing that sunlight with those of us in the northern hemisphere who are watching the days get darker and darker and darker and oh, how we love our light. So hold on. They are our beacon for the future. And I also want to do a shout out to my dear friends at the Occidental Belgium Beer Huis on the historic Vulcan Lane in Auckland, and say that you've got to help us with this light situation. And so, Chris, I think it's fair to say that today is going to be a challenging podcast for us, you and me, but for our audience. But I hope we come away from it at the end with a better understanding not only of what we know but what we feel and what we can do to improve both of those categories.


Chris Dall: [00:06:13] Mike, as I mentioned in the intro, cases do appear to be on the rise across Europe with notable increases in Germany and France and European health officials warning that another wave of infections has begun. Is this being driven by the new variants?


Michael Osterholm: [00:06:28] First of all, let me just say that none of us want to be at this place to have a question asked like that. Okay? You could actually feel like I'm going to stop this podcast right now just based on that question. But it is so important and let us try to peel back the onion on this to try to understand what it means. Just know I'm coming into this question and in fact, this entire podcast with the sense that the world has done with the pandemic. But I'm also again, stating, as I have so many times, reminding all of you, that this virus is not done with us yet. So, Chris, at this point, most of the activity we're seeing in Europe really can't be attributed to the new variants you just spoke of. At least as of right now. That being said, when you start looking at the different sequencing data in Europe, you'll notice that some of the newer Omicron sub-variants keep gaining ground on BA.5. So continuing to monitor these variants, which we will cover in more detail later in this episode, surely is and will be critical if we're going to try and maintain at least some sense of what's coming down the pike. But regardless, even with the apparent growth advantage they hold over BA.5, the overall frequencies of these variants remain fairly low in most European countries at this time. In other words, although BA.5's position at the top of the variant food chain seems to be slipping away, it still accounts for majority of the region's current caseload. Take, for instance, Germany and France, the two countries you mentioned in the lead up to your question. If you look of the total number of samples that were sequenced in these countries during the past two weeks from September 27th to October 10th, 84% in France and 94% in Germany were BA.5. And although both those numbers have been declining, you can see that what's been happening in France, Germany and Europe as a whole can't be simply explained away by these new variants. So what is happening? Well, before I get to that, let me just take a quick step back and share some of the latest numbers being reported out of Europe to provide a little more context on the current situation. Throughout the past month, cases in the region, which is comprised of 53 countries that are members of the W.H.O.'s European branch, have been climbing. In fact, if you look at the number of weekly cases being reported, you can see that they've now gone from just over 1.1 million a week and that was in early September to now around 1.8 million a week. So an increase of almost 700,000 cases a week reported. According to the latest weekly update published by Europe's CDC last Friday, there were 26 countries in the European Union that reported case numbers for the week of September 26th to October 2nd. In 17 of those countries, the latest weekly case totals have increased. On Tuesday of this week, I actually went into this COVID dashboard hosted by W.H.O. Europe, and counted a total of 14 countries that have documented increases of 20% or more in just the past two weeks. Of course, by now most of us know how I feel about using case numbers as a metric to understand what's happening. In fact, in the same ECDC report I just mentioned, they themselves specifically acknowledge the volatility that can accompany case totals. Thanks to a number of factors such as altered criteria for testing, more emphasis on rapid tests that do not get reported, and changes in overall reporting even by public health agencies. And I'd agree. I have no doubt that the reported case numbers are a mere fraction of the true total, and if anything, that becomes more of a problem. At the same time, when you see overlapping or even simultaneous increases in more than a dozen countries, all of which are located in the same region, it's a pretty good indication that a real uptick is actually happening. On top of that, when you start factoring in the actual size of these increases, which have more or less played out in just a few weeks time, it's clear that something important is going on. Take Austria, for example. At this time last month, they reported an average of just over 4,000 cases a day. Two weeks later, cases there climbed to above 7,000 and now they're at 14,000. Germany went from less than 30,000 cases per day a month ago to more than 105,000 a day now. France is reporting 56,000 cases a day. That compares to just over 17,000 a month ago. And similar situations are playing out in other countries there as well. Italy has watched as cases doubled from 20,000 a day to more than 40,000 a day in just the past two weeks. Now, it's important to understand that with this underreporting problem, you would expect to see not as many cases reported. Instead, we're seeing many more reported, which suggests that the tip of the iceberg is what we're seeing. But in fact, underneath the iceberg, there are probably many, many more cases not getting reported because of rapid tests or change in surveillance. And now, unfortunately, we're also seeing signs of growing hospitalizations in these places. In the ECDC report, it noted that 15 of the 26 countries reporting data experienced a weekly increase in COVID hospitalizations. Included in this are the same countries I just mentioned. As of this Tuesday, Austria had a total of just over 2,400 COVID patients admitted to a hospital. Two weeks earlier, that number was just over 1,100. During this same time, ICU admissions climb from 66 to 118. In Germany, the number of COVID patients in an ICU has gone from less than 802 weeks ago to more than 1,600 now. And again, there are some similar stories out there of other places like Italy and the U.K.. So from the standpoint of health care systems, the capacity to function as intended, this wave can pose a real challenge for some places. It is real and it is causing serious disease. In fact, just this past Monday, there was news of a clinic in Munich, Germany, that's dealing with a sudden wave of COVID patients, while 30 to 50% of its staff are out sick. Does that not sound like Omicron? The clinic's work council reportedly issued a statement that they could not guarantee optimal care of their patients. Of course, this is happening in the same city that just got done hosting Octoberfest celebrations after a two year hiatus with an estimated 5.7 million people in attendance for the festivities. So is Octoberfest, the catalyst of all this? Well, it could certainly be a type of setting that the respiratory pathogens might well enjoy and do very well in, and it might have contributed the steep ascent of cases in Germany. In fact, last week, the country's health minister specifically mentioned that the festival likely had an impact on activity. But when it comes to explain the latest surge we're seeing it across a large swath of Europe, there's got to be more to it. If you're looking for evidence in support of this belief, consider the cases were growing in a number of countries before the festival even begin. So once again, we are left without a simple explanation. At the same time, there's still talk of other things like changing behaviors and or waning immunity being the trigger for Europe's situation. For example, in the same ECDC report published last week, which I mentioned earlier, the author stated that changes in population mixing following summer break are likely to be the main driver of these increases. Again, maybe. In fact, I'm sure it is playing a role. But how much? I don't know. But these changes in population mixing are not exclusive to Europe. I can tell you that plenty of mixing has been happening right here in the US. Yet Europe remains the primary region in the world experiencing increases at this time. Taking a look at the overall global numbers, there's been more or less a high plains plateau for this past month, even as things have been heating up in Europe. As of Tuesday, daily cases stood at 463,000 and deaths were at 1,500. So for now, Europe is the anomaly, at least in a large regional basis. We are hearing about increased cases in Bangladesh and Singapore. Having said all this, what I've just described to you in Europe could easily become a glimpse of what's ahead. It's an uncomfortable truth, but this virus isn't going away. And in a moment, we'll comment more on the fact that combined with waning immunity in humans and the potential for these variants that are highly immune evasive to take over will add even more dimensions to what is likely to happen. I want to just conclude this international section with a note about China. Even in China, it keeps cropping up over and over again. In fact, they just reported 2,100 locally transmitted cases in 28 of 31 provinces just this past Monday. This is the highest it's been since August. And this happened in spite of the extra vigilance observed in different parts of China ahead of next week's congressional meeting in Beijing. Notably, the capital city is one of the locations currently reporting cases. And overall, at least 36 cities there are under some form of lockdown, which is affecting nearly 2 million residents. The Chinese story continues, and it reaffirms the challenges of trying to control this virus in China from a zero-COVID policy perspective. And also to those listeners who have had to deal with supply chain shortages associated with this lockdowns in China, you understand what this is also done to the global economy.


Chris Dall: [00:16:30] Here in the US while deaths remains stubbornly high, cases and hospitalizations continue to decline. But given what we're seeing in Europe, which throughout the pandemic has been a bellwether for what happens here, is this just the calm before another storm?


Michael Osterholm: [00:16:44] As we've seen several times during this pandemic, what we are seeing happening in Europe can often be a glimpse into the US's future. And I don't think the coming months are going to be any exception to this trend, but I do think it's going to catch this country off guard. So to answer your question, Chris, yes, this very well could be the calm before the storm. And I worry our severe weather sirens are not working, nor do people hear them when they do. Like you mentioned, COVID-19 activity continues to decline. Hospitalizations are the lowest they've been since May, and deaths are 10% lower than they were just two weeks ago. However, that reminds us all, that that still means a number of well over 400 deaths a day. And while these numbers are moving in the right direction, I worry that this declining activity will further drive the false hope messaging that the pandemic is over. I hate saying that. I really do not want to say that. But it is absolutely the scientific and public health truth. We're nowhere close to a place where we should be declaring victory. It's actually quite the opposite. I will go more in depth about why I'm especially concerned about the coming months a little later in this episode. But the declining COVID-19 activity that you mentioned is actually one of my causes for concern. We're in a strange phase of this pandemic where I think we're creating the perfect storm, yet we're constantly celebrating a false victory. I still cannot understand a context in which we should be celebrating losing an average of nearly 400 Americans every single day. This week, I want to provide some more context to these 400 lives lost daily, because this is not just a number. These are people's loved ones. This goes to the very heart of my dedication at the beginning to this podcast. These are our grandpas and grandmas, our moms and our dads, our brothers and our sisters, and sometimes even our children. These are individuals with faces and names and hearts and souls who have been lost to COVID. We must never forget that because this is also what we will be experiencing going forward. So who are these people who are dying? In short, they are older, unvaccinated individuals. Last month alone, 88% of lives lost to COVID were people aged 65 and older. That is more than 7,000 deaths during September alone. As of July, when the last CDC health data by vaccination status was released, unvaccinated Americans were seven times more likely to die of COVID-19 compared to someone who had received their primary series and their first booster dose. Now, looking at the deaths that have occurred this year alone, indigenous Americans are dying at a much higher rate, 58 per 100,000 population than any other racial or ethnic group, followed by Pacific Islanders and black Americans at 47 per 100,000, Latino at 43 per 100,000, whites at 36 per 100,000, and Asian Americans at 22 per 100,000. For each racial ethnic group, those who are 75 years of age and older are dying at a much higher rate than any other age group. A paper published by the National Bureau of Economic Research from last month found that the rate of excess deaths was 76% higher in Republican voters than Democratic voters. Now, this virus does not know whether you are a Democrat or Republican, Independent or whatever, but it does know if you have been vaccinated. And in fact, that's what this is really marking, who are more likely to be vaccinated among those who may be of a particular political persuasion. This is all to say that 400 is not just a number. The next time you hear about the death rate in the US, remember, we cannot be celebrating losing nearly 400 lives every day. Now is the time to double down and be diligent because we could be sailing straight towards some rough waters ahead and there is not a single siren to be heard. And again, as I noted later in the podcast, I will cover why I think this new phase of the pandemic could be amongst the most challenging phases we've seen to date.


Chris Dall: [00:20:52] So now let's get a little bit deeper into the variant picture. We appear to have an alphabet soup of competitors right now, BA.2.75.2, BQ.1.1, BF.7, XBB. But do any of these variants appear primed to challenge BA.5, Mike?


Michael Osterholm: [00:21:09] The short answer here, Chris, is yes, I think these sub-variants are poised to outperform BA.5, but it's a bit more of a complex picture on who is winning the variant race right now. As always, we have to start this discussion with the fact that our knowledge of which variants are circulating relies on the testing and surveillance we have available. But funding and support for these programs, including how often data can be collected and analyzed, wanes along with the COVID-19 funding. So the caveat is that the data I described tells us only part of the ever changing picture of what this virus is doing. Similar to the past few months, BA.5 is still very much in charge of the US making up nearly 80% of infections, according to the CDC variant monitoring. This reinforces the decisions that Moderna and Pfizer have made to release Bivalent boosters focused on BA.4 and BA.5. However, as we've discussed in this podcast series, we're still waiting on more conclusive data as to how well these vaccines perform in the real world. This includes, over time, as well as confronting immune evasive sub-variants, unlike we've seen at any time in the pandemic. So as to which variants are emerging now. We are still in an Omicron era. And as a reminder, BA.4 and BA.5 are both sub-variants of Omicron. Coming to the next phase of the pandemic, there doesn't seem to be a sub-variant yet that is singularly driving the next wave across the world. The W.H.O. noted they are closely tracking more than 300 sub-lineages of Omicron at this time. For the most part, the sub-variants gaining traction appear to be Omicron sub-lineages from BA.2 and BA.5. We are now seeing recombinant variants emerge as well. Essentially two variants coming together to create its own unique variant. Four names that are appearing most in conversation right now are the ones you mentioned in your question, Chris, XBB, BQ.1.1, B.F.7 and BA.2.75.2. Each of these strains are highly immune evasive, and not only make reinfection much more likely, but unfortunately make therapies like monoclonal antibodies ineffective and protection from recent vaccines less effective and maybe even in some cases not effective. As listeners know, my crystal ball can't tell us exactly what's on the horizon. I think there is some likelihood that the splintered Omicron variants that are picking up similar mutations on the spike protein to evade immunity will become much, much more prevalent. There may not be a single variant or sub-variant that takes on the vast majority of cases across the world, but instead variants with convergent mutations that result in this highly immune evasive status take off in locations with opportunity, namely waning immunity, people gathering indoors, and low vaccine protection. And right now, the world is giving this virus plenty of opportunity to do that. Now, it doesn't rule out the possibility that a PI or Sigma variant can come along and take out Omicron. Once again, we're in a wait and see moment. But right now my big concern remains these highly immune evasive sub-variants that we're suddenly seen appearing around the world.


Chris Dall: [00:24:36] So, Mike, given all the uncertainty you've laid out, do you have a sense of what this next phase of the pandemic look like? You said it could be among the most challenging phases. So what are your big concerns?


Michael Osterholm: [00:24:47] Chris, it's really difficult to describe where we are in this pandemic. I know in the past I've used baseball innings or acts in a play. I do think we're in a fourth phase of this pandemic right now. I really can't say how many total phases there will be, but I can give some context as to where we are and what we would be walking into. Let me share with you how I see these four phases. This is, in a sense, my own invention, so I will take full blame for those that listen to this and think I'm ridiculous. Phase one was, for many, the most chaotic. It was at the onset of the pandemic back in January of 2020. We were still very naive as to what this virus was and what it could do. We had limited guidance and resources for diagnosis and treatments. There were major policy decisions that resulted in limited indoor gatherings, moving schools and workplaces to virtual environments, and a push for universal masking. It was during this time that we saw heavy hits in certain geographic areas around the world, but often limited to cities or regions of a country not widespread across the country. At that time we all talked about variants as more like ways to measure like the rings on a tree as to how old the virus was. Really not attributing any functionality to that variant. Well, that changed towards the end of 2020 as vaccines begin to roll out and we started to have a sense of optimism. Some of us also saw what was happening with the variants, and I realized at the end of 2020, early 2021, when we saw Alpha emerge, that this virus was not going to follow a classic kind of influenza model necessarily, and that the changes that would occur with these mutations were very significant in terms of what that means for what this virus could do to us as humans. They surely made us understand that infectivity could go up substantially from one variant to another, that we could see immune evasion occur, which we had not previously witnessed, and that it might even result in more severe illness. To me, it was in that time period that we went from phase one to phase two. And as you may recall, I got nailed pretty heavily by a lot of people out there when I said in January of 2021 on Meet the Press that I thought the darkest days of the pandemic were still ahead of us. I saw what these variants were doing, and this was going to be game changers. Well, that happened. We saw Alpha, we saw Delta, we saw Omicron during 2021 even with vaccines, we had these devastating mountain peaks of cases associated with these variants, not sub-variants, but the variants. And then the case numbers would drop precipitously to that mountain valley. And then we all had a sense of, oh, it's over with now. And then the next variant came and lo and behold, we had another mountain peak. Then it dropped again. Well, that changed when we got to Omicron. So phase two was where we surely started out more hopeful that we had developed the vaccines. We now had more diagnostics and treatments available, and we actually had in place certain regulations and recommendations for mitigating the spread. But with phase three was what we saw post Omicron. This is where the pandemic became disheartening, frustrating and confusing. The age of the variants begin to complicate some of our previous wins. We saw that now, instead of the virus going down to that mountain valley level, BA.5 gave us the high plains plateau, where for much of the spring, until just recently, we saw case numbers dropping, which I attributed at least in part to surveillance artifacts. We saw hospitalizations just drift down slowly and we saw deaths almost remain stable. That was so different than the first two phases of the pandemic. Well, that's phase three. I think right now we are about to enter phase four. What is phase four? This is the period where, one, the public has no interest in mitigation and in fact, there's hostility against it. This means that in workplace settings, everyone's back to work. Any kind of respiratory protection is minimized. We already see that in our health care systems where recommendations no longer exist for using respiratory protection as we had. We also see the fact that people are back into public places just like they want to be in. Oh boy, do I want to be. I want to be there. But it's without regard to any concerns about the virus, much as I described about Octoberfest. And with that, we have a setup now for seeing case increases like they're seeing in Europe. But add to that what is coming. These sub-variants of BA.5 that now have this very high level of immune evasion. What does that mean for protection against serious illness, hospitalizations, and deaths? I've already shared that the vast majority of deaths we're seeing are unvaccinated individuals in older populations. Well, will that change with these highly immune evasive strains? What does that mean? We don't know. Second of all, I am frustrated by this continued reference of how our vaccines are doing by putting data out to say that there are 78 or 82% effective in preventing hospitalizations or whatever, without any indication of how long these individuals have been studied, followed their vaccination. I am convinced, as we're seeing more data come forward, whether it's 30 days out, 60 days out, 180 days out, 360 days out since your last dose it's very critical in how much protection you have, i.e. waning immunity. And one of the issues about getting people vaccinated today and I strongly urge people to get their boosters today, get everything you can get on board now, because it may not give you high level protection against serious illness or hospitalizations six months from now. It very likely will give it to you now, if the immune evasive strains, in fact, don't cancel that out. So get your vaccinations. So here we are in this fourth phase. We surely have behaviors that are doing everything to increase transmission. Number two, we have these immune evasive variants, which are going to be descending upon us soon. Number three, we have human waning immunity, something we hadn't really talked about much in that first year of the vaccine programs. On top of that, then we also have a health care system that is stretched beyond imagination. I don't think people have any idea how challenged our health care system is. COVID has brought out all of the major challenges in modern health care in the United States. One, even though we've seen workers come back after the pandemic, our health care systems are absolutely strapped for professionals. Hospital beds across the country have been reduced because they don't have enough staff to actually care for those patients. In addition, because long term care and stepdown care has the same challenges with the number of employees, there are many people today who are residing in hospital beds around the country that don't need to be there or shouldn't be there, but there's no place to send them. There's no stepdown or long term care beds available. Well, that all goes to, again, how capable is a hospital to respond to a surge in cases? And I don't think that we have a sense yet just how tight this is. I've heard it from any number of health care providers, including intensivists. That said, if we even see a minor bump from COVID or influenza this fall, it will take us over the top. Now, that may sound like extreme language, but it's not. People are talking about challenges that even exceed those seen during Omicron earlier this year. So if you add this all up, this isn't a pretty picture. And I really, really don't like talking about it, but it's the reality that we have to face. So what are we going to do about it? First of all, we have to be clear. I don't know this is going to happen. Up front. You know, what's the chance of this happening? It's somewhere between one and ten. When people say, well, what's your number? I say it's somewhere between one and ten, although I would argue it's probably above five for sure. And at this point, what we need to do is be able to pivot our recommendations to the public without knowledge that that will really make any difference if we start to see this big increase in cases like they're seeing in Europe right now or in Singapore. Then we have to understand what we can do to limit transmission that people will actually abide by. Right now, only about 5.5% of the adult population in this country that are eligible for a BA.4/BA.5 bivalent vaccine have received it. That's it. And that vaccine, while I've already shared, might only provide limited protection over time. Right now it is the best tool we have to make certain that you don't end up in a hospital or be seriously ill. If you look at the data today, it's clear if you've been vaccinated and you have Paxlovid on board, even for those over age 70, the incidence of death has dropped dramatically. On top of it, for those of us that continue to wear our N95s in public and still do everything we're doing, and I'm out there publicly right now, I'm speaking, I'm traveling, but I have my N95 on and I'm not embarrassed by it. Last week I gave a talk to a group of older physicians for which very few of them in the room had any kind of respiratory protection on board. And I, very proudly and without any question, gave the presentation in my N95. And I was actually asked by a physician in the group, should they all be wearing N95s. And my response was, well, I wear mine. So, again, if you're believe that you're at increased risk for severe illness, hospitalizations and deaths or older, underlying health conditions, you can also help protect yourself by using your N95 and live life. But I'm very concerned that so many of the people, as we now enter into what I call phase four, are not at all ready for that eventuality.


Chris Dall: [00:35:35] Now for our COVID query segment. And this week, once again, we're highlighting more of a comment than a question and one that gets to the heart of the emotional pain that you discussed in your opening, Mike. So here's an email we received from Rebecca, who wrote, "I would love for you to address the emotional and psychological aspects of how COVID has changed our lives, how the disease has transformed our lives, destroyed friendships and families because of vaccines and masking. Our only daughter got married two years ago at the height of COVID when there were no vaccines or medicines. We urged her to put the wedding on hold, but she refused. When we told her that we would not be removing our masks at the wedding, it caused a family implosion. Our daughter disowned us and we have not seen her for almost two years. We went to the wedding and left after the vows because not one guest had a mask on and there was no social distancing. I am prone to say that COVID killed our family, even though, thank God none of us have gotten sick. My husband is a doctor at a prestigious medical institution, and there was no way that we were going to risk getting sick or cause others to get sick. We thought it was totally irresponsible to not wear masks. I personally thought that it was more important to stay alive and healthy so I could be there for my daughter rather than risk my life for photos. Now we have paid a heavy price. Our family is broken and in tatters, and we suffer psychologically. I don't think we talk enough about how this disease has affected us mentally and how it has destroyed families and friendships. Thanks again for all your hard work and dedication in helping us to learn and understand this horrible disease. We are with you. We don't want to get this disease. We continue to do what's right and protect ourselves the best we can. But it certainly has a cost." And Mike, I'm sure this similar situation has probably happened to many families throughout this pandemic. So your thoughts on this?


Michael Osterholm: [00:37:17] Chris, even though I have read this comment multiple times and I actually had an opportunity to talk to Rebecca on the phone, every time I hear these words, it becomes very emotional and the tears flow. There have been so many people, so many people who the pain of the pandemic was not in of itself the pain of illness. It was the pain of loneliness, the pain of rejection, the pain of misunderstanding. The pain that until you experience it, you'll never know what it means. And there have been many families and I'm aware of them. And I can say it starts in my own family and friends. I lost a friend who, despite my best attempt to get him vaccinated, refused to, and he subsequently died of COVID. I've seen it. I've been there. All I can say to Rebecca, I'm so sorry. I am so sorry, but thank you. Thank you for what it is that you shared with this audience, because sometimes it just takes hearing these words to actually understand you're not alone. You're not alone. That doesn't make it better, but it makes you understand that what you're doing and how you're doing it is you are not alone. And I would say at this point that we have to take a step back and understand the damage that's been done. And I can only hope that there's a whole series of four letter words that will direct where the future is for all of us. And it starts out, first of all, understanding the pain. The pain is real. It's very hard when you think you've been rejected by a daughter for which you are doing exactly the right thing to try to minimize disease transmission to others that could be fatal. The other four letter word that comes to mind is time. Some of you who are routine listeners to this podcast know I've come from a pretty tough upbringing where physical violence and the loneliness from a lack of love was a real challenge. But I've also come to recognize the power of time and how with time you can move on, even finding forgiveness, finding understanding, finding acceptance. So in this case, Rebecca, I just wish you the best with time and the other two four letter words, I think that make that happen is one kind and two is love. Is you just have to understand that hopefully with time, those too will be the emotions that help us get over this pandemic. So for every one of you out here today feeling this loss, feeling this pain, please know you're not alone. I know that doesn't make it go away, but hopefully it gives you a sense that it is the right thing to do to try to prevent transmission to others when they themselves don't realize that that's what it's all about. I would also urge you to realize that over the days ahead, if in fact this phase four unfolds as I think it could, things are going to get tough again. They're going to even get tougher. And that's the time to keep this in perspective and hope we'll get over it. Just as families surely have histories where after 30 years they haven't gotten over things and after 30 years they've grown close again. I have to tell you, I had a a colleague who is a very well noted Civil War historian once say to me with regard to the COVID pandemic that for the first time in his life, he understood what it must have felt like for fathers and mothers to watch half their sons go fight for the north and half for the south. And how painful that was. Well, we have that pain today with this pandemic. So, Rebecca, you're right. Everything you said was absolutely right. My heart goes out to you as it does to all of us who have had this pain and suffering. And all we can do is just keep perspective, have faith in time, have faith in love, have faith in kindness, and know that we may not be done and we're still going to have to find ways to get through this part that we're not done with yet. So I just thank you for sharing this. This was an amazing sense of honesty that I think is a gift to every one of the listeners on this podcast. Thank you so much for your bravery, for your sense of purpose and for your kindness.


Chris Dall: [00:41:53] And now onto the non-COVID portion of the podcast. Mike, what's going on with the monkeypox outbreak and the growing Ebola outbreak in Uganda?


Michael Osterholm: [00:42:03] Well, Chris, I'll start by addressing where we're at right now with the current monkeypox outbreak. Globally, there have been over 71,000 cases, over 26,000 of which have been in the United States. Daily cases are slowly continuing to decline, down slightly from last week. As cases decline, we're continuing to see a lot of the same challenges with this virus that we've seen over the last several weeks with COVID. This includes racial disparities and low vaccine uptake. A Kaiser Family Foundation report published last week provides us with even more data on the racial disparities we're seeing with this outbreak. According to this report, monkey pox case rates in black Americans are over 5.5 times higher than case rates in white Americans. Case rates in Native Hawaiian Pacific Islanders are nearly four times higher, and case rates in Hispanic Americans are nearly three times higher than in white Americans. Despite this, black and Hispanic Americans continue to receive a disproportionately low percentage of monkeypox vaccines. This brings me to the other challenge I want to briefly highlight with regards to this outbreak, low vaccine uptake. Despite an increase in vaccine availability, we are not seeing major increases in monkeypox vaccinations. According to a technical report recently published by the CDC,, only 32% of individuals with the highest risk for monkeypox, namely men who have sex with men taking pre-exposure prophylaxis for HIV or living currently with HIV have received at least one dose of the vaccine. Again, only 32%. Many people who have received one dose have not yet received a second dose. We need to continue emphasizing the importance of getting both doses of vaccine to all those at risk to prevent more transmission from occurring in this group. Let me remind you that once you have been infected with monkeypox, you likely do have a relatively long period of immunity with regard to this virus, maybe even a lifetime. That is the good news and surely can be part of why we're seeing case numbers drop. Also, it's clear that behavior change has played some role where people are putting themselves at less high risk situations to acquire monkeypox virus. That will hopefully continue for some time, at least until people get vaccinated. But we know that behavior change like that will likely not last a lifetime. Let me move on to Ebola. I want to address both what is happening in Uganda and what this means for the United States. In Uganda, there have been at least 63 confirmed or probable cases of Ebola and 29 confirmed or probable deaths. This is a case fatality rate of over 46%. On this past Tuesday, the first death occurred in Kampala, the country's capital of 1.6 million people. This is a significant development as one of the areas that we really have concerns about is the potential for enhanced transmission in crowded cities such as Kampala. I want to remind everyone that we currently do not have any approved vaccine or treatments for Sudan Ebola, the strain of the virus that is causing the outbreak. This makes the spread of the disease far more difficult to control than had been in other recent outbreaks that have been caused by Zaire Ebola, a strain with approved vaccines and treatments. This disease is brutal even for young, healthy individuals with no underlying risk factors, and it spreads easily to caregivers due to the amount of contact they have with blood and other body fluids, especially when access to personal protective equipment is limited. I certainly don't want to downplay the seriousness of this outbreak and the fear and pain that people in the impacted regions of Uganda are experiencing. But I also want to be very clear that we should not expect this crisis to spread widely in high income countries anywhere in the world. Last week, CDC issued a health advisory reminding physicians to be diligent when taking patient travel histories and to consider the potential for an Ebola virus infection of patients had recently arrived from Uganda and are showing symptoms consistent with Ebola. That caused some to panic, assuming that this meant that the virus poses a serious threat to the United States, But again, this is not the case. There are a number of reasons for this recommendation. The first is that Ebola is not as easily transmitted as other viruses like SARS-CoV-2. It's spread through contact with blood or body fluids and through contacts with things like contaminated needles, not through respiratory droplets. Patients are also typically not infectious during the incubation period. So while a patient infected with SARS-CoV-2 could infect a room full of people without even coming within two feet of them a day before the onset of their symptoms, an Ebola patient would be unlikely to affect anyone at this point. This means that if someone infected with the Ebola virus were to get on a plane and fly to the United States, it is very unlikely they would infect anyone during the travel as long as they were asymptomatic and people do not have contact with one of their body fluids. In addition, the US is taking precautions to prevent Ebola patients from entering the country in the first place. Travelers coming to the United States from Uganda are being rerouted to five airports in the United States where they will be screened for potential symptoms of and exposures to Ebola. However, even with these precautions in place, we need to recognize it's very possible that an Ebola patient could enter the country if they are asymptomatic and not believe that they were exposed. We saw this happen during the major Ebola outbreak in West Africa in 2014 and 15, when a man caring for a sick family friend in Liberia did not disclose this exposure during the airport screening process. And when a doctor who believed that his PPE had fully protected him entered the country and then later developed symptoms, the doctor was immediately admitted to the hospital after developing a fever and all the necessary precautions were taken to protect the health care workers treating him as it was assumed he could have Ebola. He did not transmit the virus to anyone else. The man from Liberia went to an emergency room at a Dallas hospital after developing flu-like symptoms. Though he disclosed his recent travel to Liberia, he was discharged from the hospital and not tested for Ebola. He returned a few days later with more severe symptoms and then was admitted and tested for Ebola. Days later, he died from his infection. Two nurses that were caring for him were infected and both recovered. I want to emphasize a few things here. The first is that when a travel history was appropriately considered an Ebola virus on the radar, such as in the physician who returned from treating patients in West Africa, the patient survived and no one else was infected. In addition to these four patients who developed Ebola symptoms while here in the United States, seven other Ebola patients have been treated in the country after being evacuated from West Africa due to their illness, meaning we knew they had Ebola when they arrived. And as a result, all the appropriate precautions were taken. None of these seven patients transmitted the virus to any of their health care workers or other contacts, and six of them survived. Again, when Ebola virus infection is suspected and early appropriate precautions taken, no transmission should occur. That is why health advisories like the one released last week from the CDC are so important, not because Ebola presents a serious threat to the United States, but because if physicians catch it early enough, we can prevent transmission and often see much better patient outcomes. The second thing I want to emphasize here is that even when things went wrong and Ebola was not considered as early in the diagnostic process as it should have been, we did not see long chains of transmission occur. The fact that any health care workers were infected is a tragedy. And hospitals around the country have learned from what happened in Dallas and the intent of avoiding similar tragedies in the future. But these two cases among health care workers do not compare to what occurred in West Africa or what is currently happening in Uganda, where at least ten health care workers were infected and four have died. We have the resources here to provide health care workers with all the necessary PPE to protect them from Ebola and to provide patients with the best supportive care possible. Health care workers are, for the most part, asking their patients about their recent travel history so we can identify any potential cases as soon as possible. We are screening potential contacts and symptomatic cases at airports, and that doesn't mean that we won't see a case of slip through the cracks or our screening process. And it doesn't even rule out that we could see a patient transmit the virus to family members that may be caring for them or even an improperly protected health care worker like we saw in Dallas. But it does mean we won't see widespread transmission and death like we've seen in West Africa and likely we're currently seeing in Uganda. The bottom line is that we should be concerned about Ebola here in the United States, but that concern should really be focused on the people of Uganda and what they are going through, not about the virus causing widespread disease and death here.


Chris Dall: [00:51:14] Mike, I think this week's Beautiful Place submission provides a little bit of hope in showing how the pandemic has actually brought some families closer together. What can you tell us about it?


Michael Osterholm: [00:51:26] Thanks, Chris. I do think that this beautiful place today is just what we need. The right place and right time, given what we've been commenting on throughout this podcast, including the very powerful but painful statement from Rebecca. This is from Lynn, and she wrote, "Hello, friends. Thank you for all your hard work. Your podcast has been my touchstone throughout the pandemic. Many times I've thought of sending you photos of the beautiful place where I live on the north coast of California. We've been isolated and protected while having the Pacific Ocean and redwood forest to explore largely alone. I became infected in July 2022 and was quite ill for two weeks. But here's where my story takes a surprising turn. After recovering, my sense of a beautiful place had shifted from the coastal village where we retired happily eight years ago to the faces of my children and grandchildren. Suddenly, I knew without a doubt that I wanted to be near my family, who live 500 miles away, sharing vacations with them twice a year was no longer going to cut it. I wanted to be running errands and walking the dogs together, being in the lives of the grandchildren, not a face on a screen to an infant. Thank you again for the information, the current science, and the heartfelt touches throughout. I usually tear up at least one during each podcast, and for that I thank you. I'm attaching photos of the beautiful place that got me through the first two and a half years of COVID, and the next beautiful place that will carry me into the future. Sincerely, Lynn." Lynn, thank you. We needed this. We needed this note very, very much. I'm sorry that you ended up developing COVID infection, but I'm also very happy that you're at this new, beautiful place. As some of you know, I had the opportunity to serve as the grand marshal of the 2022 University of Minnesota homecoming parade. And it may have been one of the highlights of my life, not because I was in the parade, but my five grandchildren were all with me throwing candy to all the participants along the route and being with those five grandchildren and of course, their parents, my children in tow. It was one of the most gratifying, wonderful experiences of my life and one that happened right during the pandemic. So to you, Lynn, I say congratulations. Thank you for your kind words. And most of all, to the listeners, please look at these photographs. They're beautiful, Lynn has shared with us of her North California coast. We really do appreciate it. Please keep these beautiful places coming in. We need them. We need them.


Chris Dall: [00:54:08] And just a quick reminder to our listeners that if you want to tell us about the beautiful place that helped get you through the pandemic or share a celebration of life for a loved one friend, neighbor or coworker who died during the pandemic, please email us at osterholmupdate@umn.edu. Mike, what are your take home messages for today?


Michael Osterholm: [00:54:26] Again, Chris, I have three take home messages that I think cover the breadth of today's podcast. This is a hard podcast today. I wish I could have shared with you more positive prospective news. As you know, this virus just doesn't give us that opportunity, at least not yet. And that's my first take home point. It isn't over with yet. This thing is not done. I don't know what the next 4 to 6 months are going to bring. But I do believe that there will be real challenges. I think the combination of the immune evasive strains, the situation we see with waning immunity and with behavior change, where we're back to a pre-pandemic activity level doesn't lend itself to a good future with regard to COVID. I think the Europeans are giving us a taste of that early on. So the reason I tell you this is not to be a downer, but to say just prepare yourself for a little bit more. Just a little bit more. Let's get through this phase. Hopefully by the end of this phase, this virus will come into a much more steady state relationship with us. But the bottom line is we're not done. Number two, Rebecca, thank you. Thank you. And thank you for your incredibly courageous, thoughtful and very heartfelt note. So many of us have been in or are in the same place that you are, and we feel that pain something fierce. It's one thing to have someone die in your life physically and be gone. It's another thing to have someone die in your life, but they're still alive. And I'm not sure which pain is more painful until we understand that this pandemic has surely given us far, far, far too many casualties of that latter category. But I do really believe that that pain with time, with love, with being kind, having hope, all four letter words are on our side. And that's what we have to keep looking to and looking for. And I at this point believe that only by acknowledging the pain can we begin to address it in a way that gives us hope. And finally, the third thing is please still get vaccinated. I know today I laid out why there may be challenges with the vaccines, but they're our best tool right now for keeping you out of the hospital, becoming seriously ill, and dying. And I don't know how long they're going to last. I don't know what this protection will look like, but I can tell you'll have a much better chance in the days ahead getting vaccinated. And if you're, again, in one of those high risk categories for serious illness, hospitalizations, or death and you still have been vaccinated, you can do more to protect yourself. Do what I do. I'm out in the world right now, and I am not bashful about wearing my N95. I do not take it off. I give talks in it. I obviously don't go to restaurants unless they're totally outdoors, distant from any other people. But I live my life. My family lives their lives. My kids live their lives. My grandkids. We're going to get together. We make sure that nobody has any symptoms and haven't had for the last 2 to 3 days. We make sure we don't have any known exposures to anyone with COVID in the last three days. We know that we test ourselves to make sure that even though while it may not be perfect, it's one more layer of protection. That's when we get together. So I think if you take these kinds of messages, there's still so much we can do. We don't have to live in fear of this virus, even though it has given us every reason to be fearful of it. But this is our way to go forward and to be protected and to live life. I think that is such an important message. So these are my three summaries of the day. We always welcome your feedback. I learn a lot from you. Sometimes I say things and I think I hear them a certain way, you hear them a different way. And frankly, your sharing that different way is very helpful to me in understanding how did I miss that point or why didn't I cover that point? And so I always welcome your feedback.


Chris Dall: [00:58:40] And Mike, do you have a closing song or poem for us today?


Michael Osterholm: [00:58:45] I do. And this one was chosen actually kind of a group activity from our podcast crew here at CIDRAP, a group that I can never say enough about, never say enough about. This podcast crew, including you, Chris, are remarkable in helping to put this activity together and for keeping me on the straight and narrow and sticking to the facts where at all possible. Today's song is actually by John Mayer, an American singer songwriter that many of you know, and it comes from the album "The Continuum," which was released in September 12th, 2006. And this particular album actually as some of you know, debuted at number two on the Billboard 200, selling more than 300,000 copies just in the first week of sales. It ultimately reached the top ten of several other countries and sold over 5 million copies worldwide. Of note, only five of the songs on the album actually were released as singles. And this one was not even though I think it's an amazing piece of work. The song I'm going to share with you today was sung and written by John Mayer. The title is "The Heart of Life," and I think you'll see why we picked this song, given today's podcast. "I hate to see you cry lying there in that position. There's things you need to hear. So turn off your tears and listen. Pain throws your heart to the ground. Love turns the whole thing around. Now it won't all go the way it should. But I know that the heart of life is good. You know, it's nothing new. Bad news never had good timing. But then the circle of your friends will defend the silver lining. Pain throws your heart to the ground. Love turns the whole thing around. Fear is a friend who's misunderstood. But I know the heart of life is good. I know it's good." John Mayer. Thank you, everyone, for spending another day with us. I hope that we provided you with some useful information. Again, reminding every one of us that we talked about a lot of numbers today. But every podcast you must never forget, these are our moms and dads, our brothers and our sisters, our grandpa and our grandmas. Think about the 20% of children who have lost a loved one or a family member in this pandemic. Think of the pain and agony that has caused. We must never forget that. And that's why we will continue to take this virus on. We'll take it on with our hearts and our souls and our heads. And I'm so glad you're with us to do that. Be kind, be safe. Go out and be kind today. You know, just make somebody wonder what's going on here. Just be kind. Start an epidemic of that. It's so important.


Chris Dall: [01:01:46] Thanks for listening to this week's episode of the Osterholm Update. If you're enjoying the podcast, please subscribe, rate, and review, and be sure to keep up with the latest COVID-19 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/donate. The Osterholm Update is produced by Cory Anderson, Meredith Arpey, Elise Holmes, Sydney Redepenning, and Angela Ulrich.