Subvariants, Long COVID, and Influenza

Chris Dall: [00:00:00] CIDRAP is proud to announce that the Osterholm Update Podcast, aside from being available on the CIDRAP website and usual streaming platforms, will now also be airing on American Busker iHeart Radio. So stay tuned. Thank you American Busker, iHeart Radio and owner/founder Nancy Hahn. 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. Throughout the COVID-19 pandemic, amid all the suffering and division that has been unleashed by the SARS-CoV-2 virus, there have been some fleeting moments of hope. Hope that facing a common enemy might bring us closer together, that vaccines might lead us out of the pandemic, that the loss we've experienced might help us reevaluate what is truly important, and that our public health system would emerge stronger and better prepared for the next pandemic. Unfortunately, most of those hopes have been dashed, but perhaps none more than the last. In a recent op ed for The New York Times, Dr. Osterholm and colleagues from President Biden's advisory board on COVID-19 wrote, "We are nearly three years into the COVID-19 pandemic, a health crisis so long, disruptive and deadly, it should have transformed the country's preparation for the next public health emergency. Sadly, it has not." On this October 27th episode of the podcast, we're going to discuss why that transformation has not occurred and what has been left undone as we assess the state of the pandemic here in the U.S. and around the world. We'll also provide an overview of the variant situation, discuss the latest research on long COVID, answer a COVID query about the flu, and share a beautiful place of mission 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: [00:02:23] Thank you, Chris, and welcome to all of you back to another edition of the podcast update. As I say so often at the beginning of these podcasts, I hope that we're able to provide you with the kind of information that you're looking for to live with COVID every day and to ask the questions about where are we going in the future with this virus. Needless to say, I also start each podcast often by saying there is still many, many things we do not know or understand about what this virus is doing or going to do in the future. And I'll try to share with you today the updated version of I don't know and what we have learned and what can be useful. Before we go any further, I want to hearken back to one of our recent podcasts. For those of you who are routine listeners, you remember the words that Rebecca shared with us about her family and how COVID not only kills people as a virus, but it kills families from an emotional and personal experience standpoint. And I have had so much in the way of feedback from many, many of you who have also gone through the same thing, who've experienced the pain, the suffering, the anger that has come between families, between friends, between colleagues, and what that has come to mean. And Rebecca, I just want to share again with you a voice of deep gratitude for your willingness to be so acutely honest, to lay yourself out there and to talk about the experience you had at your daughter's wedding. When I think about those things that I have read that have had a real impact on me, have grabbed me emotionally, have made me go back and reread them over and over again. I always felt that the one thing that I could read that would do that to me was the Gettysburg Address. Lincoln said so much in so few words. 272 words, to be exact. Well, Rebecca, your piece was 303 words, not that different from Lincoln's Gettysburg Address. Now, I'm not saying that you wrote the Gettysburg Address, but I hope you realize that your words have been shared around the world and that so many people identified with the pain and the suffering that you are experiencing in your family and what they are experiencing. And if I could say that there's anything today that we are doing such an inadequate job of in public health, in society in general, is how do we heal families, how do we heal friendships? How do we heal the relationship between loved ones? And that is clearly a huge challenge with COVID today. And while I don't have any perfect answers, I can say personally, I'm in that same boat. The need to heal, the need to find a way for us to get beyond this and hopefully not let this be a lifelong legacy of pain, suffering, loneliness, disconnection because of COVID. So, Rebecca, thank you for, in a sense, pricking this horrible boil and for allowing us to have this discussion. So let me move on and just say today's discussion is clearly going to be another challenge in that there are a number of issues we're going to talk about today that have immediate urgency in terms of understanding what's happening and even those which are down the road. But I think at this point, it's fair to say we are, again, in very unsettled, uncharted waters with regard to COVID. I don't know what's going to happen next. I'll lay out for you what I think are the possibilities. And any one of them could surely be a significant challenge to our everyday lives again, despite the fact that most people believe the pandemic is over. So stay tuned for that. And in terms of our dedication today, it's one that is not new, but it's one that I've had the opportunity to think about a lot more over the recent weeks because of personal encounters I've had with individuals who are not only suffering from a world of COVID, but also because of all the natural disasters that have happened throughout the world and what that means to their lives as they try to deal with COVID, whether it's the hurricane in Florida, the forest fires around the world, the large floods that have occurred, earthquakes, all of these natural disasters have meant that people have had to care for each other in a world of COVID, but not because of COVID, unless, of course, it became the very critical health issue of the moment. So for those who have lost their homes, who have lost their livelihoods, for those who have lost loved ones, we dedicate this podcast to you and what it means to have to live in a world of COVID when you're also living in a world of hell for all the reasons that I just shared. This podcast is for you. Now, let me wrap up the opening here with, of course, a very critical piece of information. And that is, of course, sunlight. And I know for those of you who don't find this helpful, now's your time to go get a cup of coffee. Come back in 30 seconds. Today in Auckland, New Zealand, one of my most favorite cities in the whole world, they will experience 13 hours, 26 minutes and 23 seconds of sunlight. That is roughly an increase of 2 minutes in 11 seconds a day. Now, just two weeks ago on the 13th, we actually had only 12 hours and 54 minutes and 43 seconds of sunlight. So you can see this wonderful trend that's occurring here. So basically, in the last two weeks alone, they've gained over 32 minutes of sunlight. As I have shared so many times in this podcast, I, for one, am among those who so welcome the increasing sunlight each and every day. And of course, I want to pay a special tribute to one group that's enjoying that at the Occidental Belgium Beer Huis on the historic Vulcan Lane in Auckland. One of my most favorite bars in the whole world. To the crew there, please know that we're thinking about you, and all we ask is maybe you could just send us the vibrations of that wonderful, wonderful sunlight that is going on there.

 

Chris Dall: [00:08:34] So, Mike, let's begin where we always do with the international situation. On our last episode, we talked about rising cases in Europe and some parts of Asia. Are we still seeing those trends?

 

Michael Osterholm: [00:08:45] Well, Chris, let me just make it clear that we don't cover the international aspects just because we like to talk about the world. One of the reasons why I cover this at the very beginning of each podcast is so often what happens in the rest of the world is a harbinger of things to come here in the US. So yes, this is a global pandemic. This is a podcast heard around the world. But from an interest standpoint for the United States, I think the international data play a very important role in helping us predict what might happen here. So again, this is why we find the international information so important. But Chris, right now, I think the safest and simplest answer to your question about what's happening is I could again, very honestly offer up to you the question of yes, no, and maybe are we seeing the same trends here in the United States that we're seeing in Europe and Asia. But seeing how that's basically a non-answer and could very well be considered about the furthest thing from a satisfying response, I feel obligated to at least add some context to all of this. So where are we at? Well, as you mentioned, we have been seeing increases throughout Europe and in several parts of Asia. That much is very clear. But at the same time, we really haven't been able to simply explain away these surges by attributing them to new variants. In other words, it wasn't a new variant that caused Europe's weekly case totals to go from 1.1 million in early September to more than 1.9 million a month later. Again, 1.1 million to 1.9 million in a month. And we know that's the case because the sequencing data we've seen during the same time frame ultimately shows that BA.5 is the leading variant, the one that has been around most of the summer. Yes, there are other variants that have gained ground and continue to do so, which I'll touch on more in a bit. But for the most part we have yet to really see them have an impact on the overall trajectory of things, at least from a European standpoint. So why is this worth mentioning? Well, when you look at Europe right now in particular, you can clearly see that many of these countries which have documented recent increases, including Germany, France and Austria, are continuing to report elevated activity, but are now showing signs hopefully of some gradual declines, at least in the past week. For example, Germany has gone from reporting 105,000 cases a day on October 11th to 81,000 cases a day on October 23rd. In France, average daily cases went from 57,000 on October 13th to 49,000 as of October 23rd. That being said, if we compare where they're at now to where they were just a month or two ago, Germany was reporting only 29,000 cases and France was reporting only 16,000 cases. So basically a two and a half to three times lower than their current average. You can see how these are what I consider shifting baselines. When the numbers come down from 105 to 81,000 in Germany, as I just reported, people say, ha ha, we're over the hump or it's not so bad yet they forget it was just a month ago they were reporting only 29,000 cases. And while I fully recognize that any recovery phase following a peak takes time, I'm not entirely sure either of these countries is out of the woods yet or that they really have hit the final peak, reasons being the emerging sub-variants we've discussed. In fact, right now both Germany and France, alongside a number of other European countries, are seeing cases of the sub-variant known as BQ, quickly outpacing BA.5. Now to be clear, Singapore hasn't been dealing with the same BQ.1.1 sub-variant. Rather they're seeing cases of XBB, another sub-variant, so it's not a perfect comparison. However, both of these sub-variants have demonstrated a similar ability to evade immune protection and what XBB has been doing as the dominant variant in Singapore, where nearly four in five residents have received at least one booster dose, really represents what I believe is really the first real world look at the impact that these variants could be having. So in Singapore, daily cases went from less than 1,900 in early September to 8,500 by mid-October, again 1,900 in early September, 8,500 by mid-October. Again, a very clear surge. Only in this case it overlapped with the emergence and takeover of XBB. Remember, these recent surges we've seen in Europe has not yet been linked to a new variant, although they are beginning to show up. So here we have XBB with its heightened immune evasion, driving up activity in a place that ranks among the top ten countries in the world when it comes to the percent of their population that's fully vaccinated and also sits at number 12 in terms of booster dose coverage. In my mind, it's a pretty compelling example of the ability that this virus still has to transmit widely at a population level. And with that transmission, we continue to see mutational changes. And now we are coming to what I've described over the past several podcasts as the convergence of evolution, multiple sub-variants that are actually able to evade the immune protection that has been provided by vaccines and even our monoclonal antibody treatment. And when I say evade immune protection, while it doesn't mean that you have no protection, it may seriously compromise how good that protection actually is. So now if we start to see these sub-variants circulate, what is going to happen? Well, it is going to clearly influence the activity. I'm convinced of that. The question is to what extent. This is especially true in terms of severe disease and deaths. Remember, I've said time and time again, I think we all would settle for COVID affecting every one of us multiple times a year if it was nothing more serious than a mild cold. But if we're going to see hospitalizations, serious illness and deaths, then that becomes a very significant part of a COVID picture. So at this point, I think that it's fair to say if we end up seeing a variant-driven surge play out in places with elevated activity like some of these countries in Europe, I think the direct and indirect cost could be significant. Now, if Europe takes off with the sub-variant activity, it's on top of already having taken off for what we call the behavior-related increases. The same thing could be said for places that might have lower baselines as of right now, like the United States, but also lacks some protection at the population level to effectively blunt any upcoming surges impact on their health care system. And as I just got done mentioning, Singapore saw its cases quadruple in roughly a month's time. They've also seen the number of hospitalizations climb going from 170 in late September to 590 as of last Wednesday. Still, although it is a lagging indicator, it could still continue to creep up. The total number of COVID patients in an ICU there stands at 14. Remember, this is the place that's home to 6 million residents. For context, if you adjust it on a population size differences, the activity we're currently seeing in Singapore would be equivalent to the United States having 780 patients in the ICU. This compares to our actual total right now of 3,200. So you can see we're already still elevated even beyond what Singapore has experienced. So by no means do I want to minimize what's happening in Singapore, which is dealing with a real surge. But to me, a lot of this comes back to the idea of limiting the virus's impact on our health care systems and reducing serious illness, hospitalizations and deaths. And while Singapore didn't avoid this wave, the levels of severe disease that are seen at this point hasn't yet completely overwhelmed the hospitals. But remember, this is a country that has a much, much higher level of vaccination than we do here in the United States. Their health minister recently noted that the situations in hospitals in Singapore could not be considered normal. In France, it actually looks like BQ.1.1 recently overtook BA.5 and established itself as the dominant variant there in just this past week. Otherwise, compared to France, Germany's situation with the new variant is a bit more delayed, but some of the latest growth estimates there indicate that BQ.1.1 is growing at a rate that's around 15% faster than BA.5. So what does this all mean? Well, as I've said time and time again, to be honest, I'm not 100% sure. Nobody wants to predict here in the United States we're going to see another big surge in cases. Again, only now have we reached a point where we might be able to see what the real world impact of BQ.1.1 sub-variants could have on activity. And it's still early. In France where it only became dominant just days prior to this recording, there really hasn't been enough time to see what effect it could have. At this point, we'll have to wait and see. But based on what we know about these variants and their ability to sidestep more of the immune protection that exists, I worry that we'll start seeing more upward trends, even in Europe, where they've already apparently leveled off. As I mentioned earlier, some countries there do appear to be experiencing recent declines. Still, if you look at the list of the 12 countries in the world with the highest number of cases per capita in the past week, nine are in Europe. And these levels are where we see a potential variant-driven surge build off of. So I think we surely could see some challenging times ahead. Again, I know nobody wants to hear that. Right now, France is already dealing with nearly 20,000 hospitalized patients who have COVID. That's up from less than 13,000 at the same time last month. In that same time, ICU admissions have grown from 700 to more than 1,000. Meanwhile, in Germany, the number of patients in an ICU climbed from 650 to more than 1,800 just this past month. In fact, just over a week ago, the head of the German Hospital Association said that normal hospital operations are no longer possible throughout Germany, with nearly half of the country's hospitals having to postpone elective procedures. Why? Well, it's a combination of what COVID has been doing, an uptick of the number of health care workers calling in sick, and additional strain from some other respiratory diseases like influenza and RSV that seem to be making a comeback. So clearly, the conditions of our health care systems aren't equipped for yet another surge. And the baselines that could build off of in parts of Europe only adds to my concern. What if we don't see a BQ driven surge? Well, I, for one, would be very grateful. However, at the same time, I'll be fairly surprised if that doesn't happen. Why? Well, first of all, there's the pandemic track record up to this point, which as at this point speaks for itself. And then, of course, there's the data I've seen on BQ.1.1 itself with its immune evasion properties. And of course, what would happen if we see XBB, the sub-variant that's currently occurring in Singapore, also end up in North America. Let me just put the Singapore experience again in more context. Remember, this is a place that ranks among the best in the world when it comes to vaccination rates. Make no mistake that high coverage is paying dividends in terms of limiting severe disease and death from COVID. When you have a virus that can suddenly take off from 1,900 cases a day to 8,500 cases a day in a month's time, you are still going to see pressure placed on the health care systems. What worries me most is the world lacks the coverage that Singapore has. So a rise in cases might only be accompanied by a steeper rise in hospitalizations and deaths. So what do we need to do to prepare for this? I don't see us taking that into consideration right now. Again, the vast majority of Americans and people throughout the world have moved on from the virus. They're done with it. We're now more than two and a half years into this pandemic, and we're dealing with a virus that's infecting more than 423,000 confirmed cases being reported globally each day. It's the same virus that is killing more than 1,600 people each and every day. And as you know, the number of cases reported is clearly a major under-reporting of activity. As I've said before, no matter how hard you try, you can't wish this virus away and you can't ignore it away. Let me just add one last piece on China that was not in the question, but I think it's really important. In the same vein, you also can't put the genie back in the bottle. Still, we see no signs that China has any plan to move from a zero-COVID strategy to one that's a more sustainable one. Right now, they're dealing with locally transmitted cases in at least 26 of their 31 total province level regions, which include an outbreak in Beijing, recent clusters in Shanghai, and cases in cities that are home to major tech hubs and factories. So in some ways it feels like we're stuck in a rowboat in the middle of the ocean and we've gone from storm to storm, some with 20 foot waves and occasionally even 80 foot waves. Yet in the time that separates these storms, there's still no shortage of rough water. The waves are maybe five, six feet tall. Our boat's filled with water. Everybody's soaking wet and there's still more storm clouds on the horizon. Of course, some people on the boat definitely see it. They felt what happened in these earlier storms and they recognize that could still be out there. However, at the same time, so many people on the boat almost seem convinced they're on a cruise ship without a care in the world. They've got no lifejackets. When it comes to paddling, they couldn't be bothered. Well, that doesn't stop me from paddling and bailing water, because at the end of the day, I don't want to be stuck in an endless cycle of wave after wave after wave. And so with a life jacket, an oar, a bucket and other members of the crew who recognize the situation we're in, I'm going to keep doing what I can to move us into a better, more sustainable position. Not necessarily what we wanted to hear, but I think this is the state of the art.

 

Chris Dall: [00:23:18] We'll get back to the variants in a moment. But I want to talk about the US situation. So the declining cases, hospitalizations and deaths continues here. But it appears to be slowing. And we're also getting reports of increasing hospitalizations in parts of the country. Mike, what's your read on the current situation in the US?

 

Michael Osterholm: [00:23:37] As you mentioned, Chris, we are seeing national COVID numbers continue to decline, but these declines are slowing. Deaths are 6% lower than they were two weeks ago, sitting around 360 lives lost every day. That still is a real challenge when you think about the fact that we're talking over 2,500 people a week dying in this country from COVID and hospitalizations have decreased 1% over the past two weeks. But I'm not sure that these past records reflect what the records of the next month or two will look like. I've stayed away from sharing case numbers because they are a significant underrepresentation of the true case numbers. You've heard me say that time and time again. However, I want to draw attention to some trends that I'm concerned about. Currently, we're seeing an average of just below 38,000 reported cases in the US each day, which is 7% lower compared to two weeks ago. This seems like a good thing. But again, as we take a closer look at certain areas of the country, I start hearing alarm bells ringing. One place in particular is New York City, which was once the epicenter of the pandemic. We all are so familiar with the painful days of that situation. Cases in New York City have remained relatively steady this past several weeks, but now they've seen hospitalizations increase slightly about 10% over the past two weeks. This is alarming, especially considering hospitalizations tend to follow case patterns by about two weeks because there are lagging indicator. It's even more alarming when we consider that it is estimated that now a quarter of new cases in New York are the new BQ.1 or BQ.1.1 variants, which could very well be a driving factor behind this new increase in hospitalization experience. Regardless of the flat reported case numbers. We'll discuss this new variant a little more later in the episode. But for now I want to dive into a little deeper into the national hospitalization rate. Currently, 24 states are seeing increasing hospitalizations. 12 states are seeing double digit increases, five of which are above 20%. These states are New Mexico with a 44% increase. Hawaii with a 40% increase. Vermont a 38% increase. New Hampshire a 34% increase. And Montana with a 24% increase in hospitalizations over the past two weeks. Yes, when we are dealing with small numbers, a small increase may appear to be a large increase, but I think these increases are significant enough to warrant concern. Six of the 13 states with double digit increases are also seeing double digit hospitalizations per 100,000 population. These states are Vermont, New Hampshire, New York, New Jersey, Massachusetts, and Ohio. And there are eight other states and the District of Columbia with hospitalization rates per 100,000 in the double digits as well. Delaware and the District of Columbia have the highest rate in this country, with 18 hospitalizations per 100,000 population, followed by Maine at 17 per 100,000. And New York, where there are now 16 hospitalizations per 100,000 population, double the national rate. These numbers might seem relatively low compared to what we've seen in the past, but I am still concerned what they might be signaling for our future, particularly in the next several months. As we seeing in New York City new variants, including BQ.1 and BQ.1.1 are accounting for more and more of the new cases, and if these variants are the true driving force behind the increase in hospitalizations, we are going to be in for some rough months ahead. With COVID hospitalization numbers on the rise, coupled with the dramatic increase in pediatric hospitalizations for respiratory illnesses, which we'll cover later in this episode, and a potential rise in flu hospitalizations, I worry that we're heading straight into a perfect storm where our hospitals can be overwhelmed yet again. And I worry for our health care workers who have been called on nonstop for nearly three years now dealing with this ever increasing challenge. So ultimately, Chris, my current read on the situation in the US remains the same as it was during the last episode. I'm very concerned about the direction we're heading, even though the overall national picture at this point appears we're heading in the right direction at this moment. This virus is unpredictable and turning a blind eye and pretending it's done with us is going to do nothing but set us up for failure. As I've said in repeated podcast episodes, we now see a US health care system that is desperately, desperately being taxed, meaning that we have very, very little excess capacity right now to handle anything that might even be nothing more than a minor increase in case numbers with influenza, respiratory syncytial virus or, of course, COVID. So we'll have to wait and see where things are at. But I think at this point, if I were planning now for what might be with the experience in our communities in the months ahead, I've got to be planning for how am I going to staff our hospitals, how are we going to take care of these very sick patients with even a moderate, let alone a major increase in serious illnesses?

 

Chris Dall: [00:28:48] So let's dive a little deeper on the variants. Mike, are we still looking at a scenario where multiple immune evasive Omicron sub-variants gain ground and cause surges in different parts of the world at different times? And do we have any information on whether any of these variants cause more severe disease?

 

Michael Osterholm: [00:29:08] Well, clearly, as you mentioned, Chris, we are continuing to see this pack of the latest Omicron sub-variants, many of which possess this immune evasive mutation, crop up and enter into the footrace to succeed BA.5. For the first time, most places are still in a position where BA.5 is dominant, including right here in the US. At the time of our last episode, so two weeks ago, around 80% of infections in this country were likely to BA.5. Fast forward to now and BA.5 accounts for only 60% of the cases here, still the majority, but it appears to be rapidly fading away. At the same time, we've seen the proportion of cases that identified as BA.4.6 more or less remain the same throughout the past month, sticking it around 10%. Otherwise, the variants that have made the most gains in this country are as of late, BF.7 and most notably the BQ variants. So both BQ.1 and its offshoot BQ.1.1. In their latest estimates, which accounts for last week's case totals here in the US, the CDC found that around 9.4% of cases were BQ.1, 7.2% were BQ.1.1, and 6.7% were BF.7. Thus, together, these three sub variants of great concern accounted for almost one in four new infections. However, if we compare these current levels to what we saw in the previous week or even previous month, you can get a sense for their different speeds. For example, in the case of BQ.1, the 9.4% reported most recently it was up from 5.8 the week prior and just 1.2% almost a month ago. With BQ.1.1, the 7.2% we're seeing right now is up from 3.6% last week and 0.5% last month. So we've doubled in the past week. Otherwise with BA.7, which currently accounts for 6.7% of the cases, the proportion last week stood at 5.4% and last month was 2.1%. So even with the head start that the BF.7 had in the US, it's already been outpaced by each of the BQ variants. In fact, in the northeastern region of this country, including New York and New Jersey, almost a third of the cases are now linked to one of these two BQ variants. Again, let me remind you, these are the ones that are highly immune evasive, which means that the challenges we could experience from having protection both from vaccine and previous infection, may very well be limited. And based on what we know about them, this shouldn't be surprising. If you look at both BQ.1 and BQ.1.1, these are actually descendants of BA.5. However, what distinguishes them are a number of mutations they possess. I've talked about this in past podcasts, but remind you again, they're all associated with greater immune evasion. And as I've also noted in the past, some of these same mutations are also showing up independently in several other sub-variants like the XBB that I just talked about with regard to Singapore. In fact, some of the latest data on BQ.1.1 and XBB, which used blood sera collected from individuals with three doses of Sinovac, one of the inactivated vaccines produced by China and a breakthrough infection with BA.1 showed virtually no neutralization activity. In other words, the antibodies present weren't capable of neutralizing BQ.1.1 or XBB, which suggests that these same people would be vulnerable to reinfection. Now, of course, the vaccine that they used was Sinovac, and that's not the mRNA vaccines we're more familiar with here in this country. But I think it raises some concerns about continued susceptibility to infection. I don't know how well the mRNA vaccines are going to respond. I will say just in the past week, I've known a number of different individuals who were vaccinated with the new Bivalent vaccine, which included BA.4 and BA.5 4 to 6 weeks ago who subsequently developed infection this past week. Now, I can't speak to how severe these people were as they're still ill, but it does raise the question as just how well will these vaccines protect us? Now, please do not use this as a reason not to get vaccinated, just like me have my all my booster doses on board. It surely may limit the ability to. It may limit the likelihood of severe illness, hospitalizations or deaths. But it is raising a red flag. Will it actually prevent infection? And we just don't know. In fact, in Europe, CDC has just issued a report that predicts the reasons we'll see the BQ variant take over and drive up case numbers there. Otherwise, XBB seems to be doing the same in parts of Asia. Earlier in this episode I mentioned the Singapore experience. However, that being said, let me get to the second part of your question, Chris, which addresses severity. So far, evidence has not shown that any of these variants I just mentioned are associated with more severe disease. This is good news, but it's very preliminary. We will continue to look at this very carefully to ask ourselves, is it not only that this virus can evade immune protection, but will that result in more severe illness and in particular among those who are most vulnerable to severe illness? We just don't know. So to conclude, the best advice I can give all of you at this point is get all the vaccinations and boosters you're eligible for. While breakthrough infections can and do occur and might even increase with the BA.1.1 vaccines, we still have evidence that vaccines and boosters considerably lower the risk of hospitalizations and deaths. Getting shots in arms needs to remain a focus in our national and global health messaging, despite the fact that most people do not believe that they need the vaccines at this time.

 

Chris Dall: [00:35:11] So, Mike, let's discuss The New York Times op ed, which I quoted in the intro. In the piece, you and your coauthors write about the many opportunities that would have permanently improved American health and the public health system that have not yet been pursued. What are some of those missed opportunities?

 

Michael Osterholm: [00:35:29] Here's something to be really clear that the op ed piece, that Zeke Emanuel, David Michaels, Rick Bright and I wrote, all of us having served on the Biden Transition Team Advisory Board, was really written not just about this administration, but about where the whole world is in better understanding and transforming us to a more prepared world for the rest of this pandemic and for future pandemics. It's clear at this point that most of the world is done with this pandemic. Politicians around the world do not want to know that COVID could continue to be a major threat. They want to be over it and move on. And it's not just the United States government. But clearly, in the last three years, we should have transformed our country's preparedness for the next public health emergency. And having said that, it's sad, but we have not. And in this piece, we really laid out. First of all, what are some of the things that we have done and done well? You know, getting the vaccines as early as we did, the ability to do at home testing and even wastewater surveillance. But, Chris, there have been many challenges in areas that we have done little to address and particularly prepare ourselves in a better way for a future pandemic. For example, at home testing, there is no way to report these results today. And we do know that some of these tests are challenged by their sensitivity and the ability to pick up infections. There is no national plan for wastewater surveillance. Right now, I think that wastewater surveillance could be one of the very wonderful outcomes of this pandemic that gave us this new tool to know what's going on in an entire community without trying to invade into people's personal lives just by monitoring what's happening in our wastewater. In terms of the whole issue of protection, yes, vaccine is the foundational rock for that protection. But as we also know, air quality is everything, too. And you've heard me time and time again on this pandemic address the issues of both air quality in indoor buildings and personal respiratory protection. And we've done little to address that. Our indoor air ventilation has not improved really in any meaningful way in this country and around the world. And surely we have not seen any improvement in personal respiratory protection either from the design of comfortable and accommodating respiratory protection devices that can be reused, cleaned, etc.. And we clearly have not done anything to educate the public about the appropriate use of N95 or KN95 respirators so that in fact people can have effective protection, not just a piece of cloth on their face. Now, there's a lot of reasons why we're not seeing advancements in these areas. Look at our government in Congress. Congress is basically done funding COVID-related work. They said enough money has been put out there. Yet I just shared with you air ventilation, which could be a huge, huge help in trying to reduce indoor transmission of viruses, not only COVID, but many other indoor respiratory transmitted viruses. And there is no appetite today for moving any further into this area, trying to develop new national standards, trying to retrofit the ventilation of our schools. So many of our buildings where people work indoors. And so what we really were trying to highlight is we've learned enough from this pandemic to know where we have fallen short. And we have. And so we really owe it to future generations. And let me be clear, the next pandemic could very easily happen well within the next decade. What are we doing to prepare for this? Remember, the world right now is in terrible, terrible economic straits, inflation, recession on the doorstep of many countries. When you go back to the root cause analysis, it was the pandemic. Yes, the war in Ukraine surely added to the petroleum-related cost, but overall it was the countries of the world trying to respond to the pandemic that basically has put us here. What would we pay as an insurance policy against that happening again? What would we do to make the impact of a new pandemic virus much, much less because of what we could do around better testing, better vaccines, better surveillance, dealing with indoor air and better respiratory protection? So our piece was all about, please don't consider the pandemic over done, get it behind us, we don't want to hear about it again because we will be doomed to repeat many of these same challenges if we don't. So I have to give the Biden administration a great deal of credit for many of the things that they've done. And I have very much appreciated the opportunity to work closely with what I believe are very committed public health officials in this regard. But there is still so, so much more to do. And if the rest of the world doesn't take it on, doesn't mean we shouldn't, because, again, it will help us as a country, which hopefully will then translate to global efforts to reduce the impact that a future pandemic might have.

 

Chris Dall: [00:40:58] So, Mike, one of the things you mentioned in that op ed is the limited research that's been done on long COVID. As you well know, long COVID is a topic of great interest to our listeners. But there was an interesting study that came out of Scotland recently about people who continue to experience symptoms 6 to 18 months after infection. What did we learn from that study?

 

Michael Osterholm: [00:41:19] Well, Chris, as our listeners know, long COVID is a very complex puzzle, and we're still a long, long ways from showing the whole picture. But every study that gets published is giving us one more puzzle piece. Getting us a little bit closer to understanding what this condition is doing on an individual level and to our society as a whole. It's of note, just in the last week, again, I've actually encountered several individuals who are suffering from a long COVID who, based on their description of it, felt helpless as to what they could do and how can they move beyond long COVID. The study that you mentioned was published last week in Nature Communications and it followed a cohort of 33,000 individuals with laboratory confirmed SARS-CoV-2 infection and 63,000 individuals who were never infected. Participants completed detailed health questionnaires at six, 12 and 18 months into the study, and these questionnaires have given us a lot of information about what patients previously infected with COVID are experiencing in the months and now even years following their infections. Of the 33,000 individuals with laboratory confirmed infections, 31,000 had symptomatic infections. Of those with symptomatic infections, 6% reported they had not recovered and 42% reported they had only partially recovered at their most recent follow up. That is nearly half of the infected individuals that either partially or not at all recovered from their infections. Rates of non-recovery and only partial recovery were higher in women, those with preexisting conditions and those who were hospitalized at the time of their acute infections. Recovery status was constant for a majority of individuals in the study, but about 13% reported improvement and 11% reported deterioration or relapse. The most common symptoms reported by individuals in the study who previously had COVID were tiredness, headaches and muscle aches and weakness. After adjusting for confounding factors including age, gender, ethnicity and baseline comorbidities, the researchers found that individuals who had been infected with COVID reported higher rates 24 out of 26 symptoms than the individuals who had not been infected. The largest differences were seen with changes in smell and or taste, breathlessness, chest pain, palpitations and confusion. Vaccines provided some protection against some of the long COVID symptoms looked at in the study. After adjusting for confounding factors, the study found that unvaccinated people who had COVID had 1.7 times the odds of reporting a change in smell or hearing problems, a 1.6 times the odds of reporting a change in taste, a 1.4 times the odds of reporting low appetite balance problems and confusion, difficulty concentrating, and 1.3 times the odds of reporting anxiety and depression compared to vaccinated people who had COVID. One more reason why you want to be vaccinated. Finally, I want to mention one more really concerning finding from this study. As I mentioned earlier, long COVID can have devastating impacts not just on individuals but on our society as a whole. Not only are the individuals suffering from this condition and a great deal of physical and often mental pain, but they're also unable to complete the everyday tasks that they did before getting infected. After adjusting for age, gender, ethnicity, preexisting conditions, variant period, and vaccination status, people in the study who were previously infected with COVID had about twice the odds of being unable to work, study and complete household tasks and chores. This is heartbreaking enough when we think of the impact that this has had on individuals, but on top of that, this is having a major impact on our economy. With nearly half of the people not fully recovering from COVID and infected people having over twice the odds of being unable to work as those who had not been infected. This has major implications on a global scale where millions of people have been infected and will continue to get infected in the future with this virus. There's absolutely no question that this is contributing to the labor shortage that is causing global economic turmoil. While much of the long COVID puzzle remains incomplete, this study did help us piece together a little more information about what it is and what it's doing. And sadly, the findings weren't all that hopeful. But I do think that this study may raise some more awareness to the things that can still be done about this issue. First, please take this as another reminder to get every dose of vaccine you're eligible for. While the protection provided by vaccines may not be as much as we'd like it to be, it is certainly better than nothing. And of course, the best way to prevent long COVID is to never get infected in the first place. Second, we need to dedicate more funding to this issue so we can find a way to effectively treat these patients. We owe it to the millions of people that are suffering to find these answers. And our economy depends on it, too. We just simply cannot afford to ignore the issue of long COVID.

 

Chris Dall: [00:46:27] Now for our COVID query segment, which this week is not about COVID but about influenza. Here's an email that we received from John, who wrote "I know Dr. Osterholm personally waits until later in the flu season to get the vaccine unless cases are increasing locally. I've been monitoring the weekly flu reports and it seems like they are increasing early this year. I'm in North Carolina. Is it time to get the vaccine yet? Otherwise, I also usually wait until later." So, Mike, what can you tell John? And more broadly, while flu has not been as much of an issue the last two winters, largely because of COVID-19, is this winter going to be different and do we need to be concerned about other respiratory viruses like RSV?

 

Michael Osterholm: [00:47:09] Well, John, you are 100% right. Flu cases are on the rise in the US and we're seeing an earlier increase this year than in a typical pre COVID-19 influenza season. Right from the top, let me just be clear. I've just got my flu shot and I encourage all the listeners to get this year's flu shot as soon as possible, because it does now appear that influenza cases are occurring earlier this year than previous years. Remember, I had recommended waiting until we first saw flu activity so that you didn't find this diminishing protection over time to be an issue should it first show up in January or February. Well, it's here now. There are regions of the US that still have low activity, but we're seeing regions around the country with high levels of influenza like illness activity, particularly in the south and southeast, as well as what appears to be emerging in the northeast. So far, Influenza A, H3N2 viruses are predominant in the US, but it's too early to tell what viruses will dominate for the season. The Southern Hemisphere may give us some insight to what we could expect to see this year. As I've shared before in Australia, we saw activity there plateaued and they experienced an earlier and shorter 2022 influenza season as compared to historic trends where nearly all the specimens over 99% were Influenza A H3N2, making up 91.3% of the subtype specimens. The Australian Department of Health and Aged Care reports of vaccine efficacy is on the lower end of the moderate range from preliminary estimates in 2022. This is challenging the fact that this vaccine is actually quite well matched this year to the virus strain circulating, but points out also why, yes, get your flu vaccine. It's still better than not getting it, but at the same time we need new and better flu vaccines. So when we look across the other countries in the southern hemisphere, it doesn't really give us clear and compelling evidence of what is going to happen. Many countries saw very, very limited activity with flu in the southern hemisphere. But at this point, I think it's fair to say be prepared for flu. Now, I will continue to put forward the idea that when you have close circulating respiratory viruses like influenza and COVID, that one of them will dominate for reasons we don't understand why. There's something going on there that can't be just attributed to personal protection, distancing, etc.. So get your flu shot now. The other respiratory pathogen we're getting more concerned about this season is respiratory syncytial virus or RSV. This is a common respiratory virus that usually causes mild cold like symptoms. And by common I mean that virtually all children get RSV infection by the time they're two years old. And reinfection is very common. As our listeners who are parents of young children probably know, RSV is characterized by coughing, wheezing and fever. And it's the most common cause of bronchiolitis or the inflammation of the small airways and the lung and pneumonia infections of the lungs in children younger than one year of age in the United States. Unfortunately, 1 to 2% of children under six months with RSV infection may need to be hospitalized and require oxygen, intubation or in the most severe cases, mechanical ventilation. There is substantial protection that happens by repeated exposure to RSV. So especially young kids may be a bit more vulnerable than during a typical season due to decreased exposures and circulation over the past few years. This means it's likely that this will be a more challenging winter season with RSV. RSV typically causes seasonal outbreaks in the northern hemisphere. These usually occur from October or November to April or May with a peak in January or February. However, this year RSV started in April, not October, November, as usual. And we're now seeing case numbers that are more typical of mid-winter levels. Currently, many children's hospitals across the country are reporting nearing capacity as cases of respiratory illnesses, especially RSV increase early. Here in Minnesota, data suggest RSV hospitalizations have doubled since the last week of September to levels that were typical of peak months prior to the pandemic. So, Chris, this is clearly a stay tuned and be prepared moment for RSV and influenza as this season in the northern hemisphere could be a real challenge. Do what you can and get your flu vaccine as soon as possible and stay tuned. We'll keep you updated on this and what appears to be a war between COVID, flu, and RSV.

 

Chris Dall: [00:51:50] So now it's time for our beautiful place to mission. And Mike, I believe this week's is from down under.

 

Michael Osterholm: [00:51:57] Well, since I started the dedication with sunlight in down under, there is no reason why I just shouldn't continue this trend. This week's Beautiful Place is from Lisa. Thank you so much. It was really quite beautiful. And this is from Brisbane, Australia. Lisa wrote "Good day CIDRAP team. It's been a while since I've written, but I listen every fortnight. I'm a proud Coloradoan who is lucky enough to call Brisbane, Australia home. Only a three hour flight from Auckland. I can assure you that all the Aussies I know are loving the longer days we are now enjoying. Even though it means hotter days are ahead. The jacaranda trees are coming into full flower and what a sight they are and a sure sign that summer is near. I'm sending along some photos from one of my most beautiful places here. This little piece of paradise, less than seven kilometers from Brisbane, has been a real haven throughout this time. I've been walking in this bushland for 20 years and it never looked more beautiful. Thanks to good rains and the dedicated work of volunteer bush cutters, of which I am one, I hope you like them. Thank you for your care, dedication and work in helping me make sense of this very strange time. Even in Australia we've lived under very strict rules and regulations during the height of COVID. It feels like everyone has moved on. Your podcast is very much appreciated in this continuing, uncertain time. Best regards, Lisa." I urge you to please go take a look at these pictures, the jacaranda trees, and also there's a special surprise photo of an animal that I think you'll want to see. So thank you very much, Lisa. Keep sending in the beautiful places. We need beautiful insights right now into a world that is otherwise challenged.

 

Chris Dall: [00:53:41] Yes, we love getting those beautiful place submissions. So if you want to tell us about the beautiful place that has 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: [00:54:01] Well, Chris, again, three messages I think, that hopefully resonate from this presentation. The very first one comes in part from the dedication. We have to pay attention to what we can do to heal families, friends and colleagues in what has been a very difficult and painful time. Isolation, loneliness, anger, accusations. And again, thank you so much, Rebecca, for highlighting this in a way that we all can very clearly understand the pain of this COVID isolation. So any time you have an opportunity to help respond to that, to help bring people back together again is going to be every bit as important as we move forward as understanding how did COVID kill, how did COVID hurt us from a long COVID standpoint? The mental health aspects are huge. Number two, the next month is going to be really interesting. Hold on. Fasten your seat belts. I surely have mine tight. I don't know what's going to happen in this country or through much of the world as these new sub-variants that are very highly immune, evasive take off. I don't know what's going to happen. I just know the more people that are vaccinated have a better chance of not having serious illness, hospitalizations and deaths. That's important. And finally, the last thing is protect yourself. You can do that. You know, I have been out and about, been traveling. I'm still uninfected. But you know what? Besides having all of my doses of vaccine, I religiously wear my N95 in public places. When I give talks, when I even go to receptions, I wear it. I don't take it off to go drink or to eat in the way that some might say, well, you're missing the experience. But I also don't want to experience getting infected in a large crowd, or for that matter, even in a smaller crowd. Again, Fern and I take every effort to continue to stay socially connected to our friends. To do that for an evening dinner of a very small group, you've got to have three days with no known exposure of someone with COVID, you can't have any symptoms of respiratory illness of any kind including allergy like symptoms, and you got to test negative on the day of. And so far, I think that's working. So I want to emphasize to everyone, don't shut down, turn on, but turn on the right way, the best way to keep yourself protected and live with this virus and make sure that you win.

 

Chris Dall: [00:56:35] And do you have any closing songs or poems for us today, Mike?

 

Michael Osterholm: [00:56:40] I do. Thank you. And this one actually comes from a dear, dear friend and colleague. One of the people I do research for in my books. Anne, and Anne, thank you so much for pointing this out. This is actually a song written by Ben Harper and sung by Mavis Staples. It's a song that I think is very apropos to the moment. It's from the 14th studio album by the R&B and gospel singer Mavis Staples. It was released on May 24th, 2019. And I think it really hits a very important note for the time. So here it is, the lyrics from "We Get By," written by Ben Harper and sung by Mavis Staples. "We get by on love and faith. We get by with a smile on our face. We get by with help from our kin. We get by through thick and thin. We get by, we get by. No matter what happens, I'll be there for you. We get by. Was just the other day I heard from my old friend. She was going through some changes once again. Matters of the head, matters of the heart. Maybe too early to tell, but it's never too late to start. We get by. We get by. No matter how long I'll be waiting here for you. We get by, we get by, we get by. No matter how long I'll be waiting. We get by. Day by day, line by line. If you don't have yours, you sure got mine. We get by, we get by day by day. We get by in our own way We get by, we get by. No matter how it happens, I'll be there for you. We get by. No matter how long I'll be waiting here for you. We get by. No matter how long I'll come running. We get by. I'll be waiting. Oh, no matter what happens, I'll be there for you. What happens? I'll be there for you." Mavis Staples. Thank you again for joining us. I appreciate so much all of the feedback that we get regarding the podcast. It's very clear that you all have lots of good ideas for material for us to cover. I appreciate the fact you're not afraid to tell us exactly what's on your mind. We welcome that. We read all of these emails and all the kind things that you share with us. All the things that you share also that where we can learn from. And so please keep the cards, the notes, the emails coming. And finally, let me just say that we're coming to another unsettled time with COVID. I know the world is done with it. Almost all your friends and family are done with it. I wish that were the case, but and I don't know what to tell you is going to happen. I worry very much about these immune evasive strains, What that means, what will happen, I just don't know. But I do know one thing acts of kindness, the ability to never forget who the names and the faces and the hearts and the souls of the people who have died from COVID. The ability to be there to support those with long COVID. Being patient. Being there to hear of their trials and tribulations. That's what we need to do right now. So thank you for joining us. We will continue to be here for you. We will do whatever we can to give you the information that we know, and we'll do it as straight shooter as we can. So thank you, be kind, be good. And we look forward to talking to you again soon.

 

Chris Dall: [01:00:20] 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.