Time for Learning, Not Forgetting

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. As we head into the fall with hopes that the worst of the pandemic is behind us, but uncertainty about what lies ahead, one of the questions that is on many people's minds is when to get the next booster shot of the updated COVID-19 vaccines. In a recent press briefing, White House COVID response coordinator Dr. Ashish Jha said, quote, "Barring any new variant curveballs for a large majority of Americans, we are moving to a point where a single annual COVID shot should provide a high degree of protection against serious illness all year," end quote. But when exactly is the best time to get the new booster? How much more protection will it offer than the original vaccine? And how certain are we that an annual shot will provide a high degree of protection against serious illness all year? These are some of the questions we'll try to answer on this September 15th episode of the podcast as we assess the state of the pandemic here in the US and around the world. We'll also talk about how COVID-19 has impacted the US labor force, give you an update on the monkeypox outbreak and discuss the latest news on polio and share our beautiful place 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: [00:01:51] Thank you, Chris. And welcome back to all of you who are part of the podcast family who routinely listen to these. And welcome to any of you who might be new to the podcast. I hope that we can provide you with information that you find useful and actionable and even in some cases comforting. At this point, it's fair to say that we're all looking forward to the day when these podcasts are no longer necessary, that there's ample evidence that what has happened is behind us. And so I, like you, look forward to that day. At the same time, please know that we and the podcast team never take for granted one moment the opportunity to spend time with you. This has been a remarkable journey we've been on together. We've learned a lot together. We've suffered a lot together, and we've dreamed a lot together. And so I want to never forget that and to thank all of you for for that very point. Today, we're going to cover, again, another variety of topics that I wish I knew a lot more about, that I could share with you with certainty what the right answers are. But unfortunately, the crystal ball just continues to be caked with mud. I will tell you we're in a better place now today than we were just a few months ago. But I don't know where we're going to be in a few months from now, and I'll give you the reasons for that. But to begin with today and today's dedication, as much as I want to look forward, I love looking through the windshield up front, not through the rearview mirror in the back, but sometimes we would be doing a disservice to everyone, including ourselves, if we didn't continue to remember, if we didn't continue to understand the impact that this pandemic has had and continues to extract from us. Today's dedication really comes from a paper that was published last week in the Journal of the American Medical Association by the University of Oxford. In that study, they estimated that 10.5 million children worldwide lost parents or caregivers to COVID-19 from January 1st, 2020 through May 1st, 2022. And 7.5 million of these children were left orphaned, meaning no parent or caregiver available. The Imperial College of London provides a daily updated report on the number of children who have lost a parent or caregiver and the number of children orphaned. As of Tuesday, these numbers are up to 10.6 million who've lost a parent or caregiver and 7.6 million who have been orphaned. 40.6% of these children are in Southeast Asia, 24.3% are in Africa, 14% in the Americas, 14.6% in the Eastern Mediterranean area, 4.7% in Europe and 1.8% in the Western Pacific region. In India alone, there are at least 3.5 million orphaned children because of COVID-19. This pandemic has been a devastating time for so many globally, but I can't even imagine what these children have had to go through. With COVID-19 dedicated funding becoming more and more limited, there's not much being done to support these children who need support now more than ever. So today, on behalf of the entire podcast team, we dedicate this episode to all those children who have suffered immeasurably because they've lost a parent or a caregiver. Now moving on to another ritual of the podcast, something that I promised you would be a surprise. And it is, I hope. After following sunlight length here in Minneapolis, Saint Paul, as we have for so many months through the pandemic, you know, being more and more excited as the days grew longer and feeling somewhat disappointed as the days became shorter and shorter. Today we've decided this is a glass half full day, not a glass half empty. And what I mean by that is one of my most favorite places in the whole earth is in New Zealand. Auckland, New Zealand is a incredibly, incredibly beautiful, wonderful town. I've spent some amazing days there and as they would jokingly say back in my home of Iowa, I spent three weeks there one night some of those days. It was an incredible night. So today we're going to start following the light length in Auckland, New Zealand, as in fact the days are growing longer there as they're coming out of their winter into their summer. And so today in Auckland there'll be 11 hours and 49 minutes of sunlight with sunrise at 6:21, sunset at 6:11. And we are gaining about 2 minutes and 18 seconds a day this week in sunlight there. And by December 21st, our darkest day, in Auckland there will actually be 14 hours, 41 minutes and 36 seconds of sunlight. And so we're going to take the glass half full and every week report how much more sunlight we're seeing among our dear friends, the Kiwis. And as I pointed out, this is a very special place to me. One of the very most special times of my life was a day that Fern, my partner and I spent at the Occidental Belgian Beer Huis on 68 Vulcan Lane in Auckland and the friends we made there, which we continue to have today. So to all of you, this is a shout out and stay tuned. I know we have listeners in New Zealand and we will follow your sunlight and then share that around the world as it gets brighter and brighter every day.

 

Chris Dall: [00:07:15] Mike, let's start where we normally do with the international situation. While cases and deaths continue to fall globally, and much of the world has dropped whatever restrictions still remained, China continues to pursue its zero-COVID policy, and tens of millions have been under lock down condition for weeks, leading to complaints of food shortages in some areas. Mike, what do you make of China's strategy?

 

Michael Osterholm: [00:07:39] Well, Chris, let me first start out with a quick recap of where things are right now globally. As you just mentioned, the overall totals for cases and deaths reported worldwide have continued to decline. Now, again, I'll add the caveat upfront that we realize that the reliability of case numbers is suspect and that, in fact, there's likely many more than are being reported, not just around the world, but specifically right here in the United States. Deaths are probably a more reliable indicator of activity out there relative to previous death numbers. Two weeks ago, at the time of our last episode, cases were being reported at the rate of about 678,000 a day, and deaths were at about 2,300 a day. As of now, this past Tuesday, cases are just above 500,000, a substantial drop from 678,000. And the death toll now sits at 1,834, down about 400 to 500 cases from just two weeks ago. So finally, we're seeing some noticeable declines when it comes to mortality. Remember, for more than a month now, we've seen case numbers drop going from more than a million a day in early August to about half that level now. Otherwise, progress in terms of deaths has been much harder to come by. In fact, from mid-July to early September, a span of nearly 50 consecutive days, the average number of daily deaths never dropped below 2,000. And of course, included in this time span is a peak of almost 2,600 deaths a day. Think about this. Just since mid-July, we have seen over 100,000 deaths globally from COVID. Hard to say it's over and done. So how should we be interpreting where we're at? Well, as always, I think it has to be realistic. And actually, I think several comments made during the WHO's press conference last Wednesday by Director General Tedros did a nice job capturing what the realistic perspective entails. Here's what he said, "The global decline in reported cases and deaths is continuing. This is very encouraging, but there is no guarantee these trends will persist. The most dangerous thing is to assume they will. The number of weekly reported deaths may have dropped by more than 80% since February, but even so, last week one person died with COVID-19 every 44 seconds. Most of these deaths are avoidable. You might be tired of hearing me say the pandemic is not over, but I'll keep saying it until it is. The virus will not just fade away." So I actually completely agree with Tedros. And as I mentioned in the past, magically stumbling into a fairytale ending doesn't seem at all likely. This is not as if we are experiencing a influenza pandemic where one day we'll just say we're back to the seasonal flu status. We'll talk more about this later in the podcast. So, yes, let's feel encouraged about recent declines, but let's also keep things in perspective. And finally, let's not fall victim to the allure of simply assuming the road ahead of us will be free of any bumps or potholes. If you live in Minnesota and especially in the Twin Cities, you're probably no stranger to road construction. Now, as a driver, is it a pain to deal with? Oftentimes, yes. It is a cheap and quick process. Not typically, no. But imagine the alternative. Imagine a hands off approach where even with the temperature changes the rain, the ice, the snow, the plowing, the traffic, we just collectively come to the consensus that everything would work out. Well, maybe you'd get by, at least for a little while. But odds are, you'll eventually find yourself stuck in an oversized pothole. Same thing applies to COVID. I'm convinced of that. Minimizing its impact requires effort. It requires investment. It requires constant attention. Now, that being said, I really think there's a balance that needs to be struck with all of this. As you mentioned, Chris, in the lead in to your question, most places have dropped any remaining COVID measures that might have been in place. And in some instances, everyone seems eager just to move on. Maybe funding is drying up, maybe programs are being dismantled. Either way, there are places that would like to believe that this is all in the past and this is just wishful thinking. Again, I'll talk about this more later. However, on the complete opposite end of the spectrum, is China, a country that's truly in a league of its own when it comes to the COVID response. Of course, the notion of zero-COVID wasn't solely exclusive to China earlier in the pandemic. Places like Australia, New Zealand, Singapore, Taiwan and others made major efforts to prevent introduction and transmission. In large part, these efforts were maintained until vaccines arrived and were distributed in the population. Otherwise, when Omicron arrived, we saw some of these places acknowledge that zero-COVID was no longer a sustainable goal. Regardless, China's pursuit of this total containment hasn't wavered. Since very early on, I've seen this as a major mistake. As I've explained many times on this podcast and in my writings, I think they're continuing to play an unwinnable game of Whack-A-Mole. Each and every day, the virus makes an appearance there. Sometimes it's a single case in one province. Other times it's a cluster of cases in a city. Either way, the response is the same, lock down the areas deemed at risk and test a lot. Of course, this approach brings with it a layer of unpredictability. As a resident, you might not know when or where you'll be facing restrictions. And while the absolute number of cases are minuscule for a country the size of China, the widespread distribution of these flare ups is resulting in a wide net of restrictions being cast in quite a few different areas. For example, this past Tuesday, China reported a total of 915 cases in 17 provinces, three municipalities and four autonomous regions. Again, in the grand scheme of things, 915 cases doesn't seem like a lot. However, they're in more than half of China's 31 provinces. In fact, even their state-controlled media referred to their situation as the most extensive resurgence of the virus China has experienced in the past two plus years. As a result, there are tens of millions of Chinese residents in at least 30 different regions that are under partial or complete lockdowns. Examples include a city of 21 million, which was locked down the past two weeks. Another city of 6 million where sudden lockdowns left at least 500,000 residents locked at homes with no prior warning. And an area of Xinjiang where some people have been confined to their homes for 40 days or more, there are now reports of major food shortages. We continue to see a wave of social media posts from affected residents describing this lack of food and their inability to seek medical care in a number of areas of China. Obviously, it's not a good situation in these places. And overall, what's been perplexing to me is the continued lack of a comprehensive, outlined strategy by the Chinese. What's the endgame? Are they actually using this time to strengthen their defenses, whether it's through vaccinating more of their elderly population or building up treatment supplies? Or are they just kicking the can down the road, avoiding filling and fixing those potholes? So I, like many others too, have a lot of questions about China and the lack of clear answers, or even the framework of a more comprehensive strategy has me continuing to feel uneasy. And of course on a global basis, we have to understand the economic implications of any of these lockdowns in China with regard to the critical business supply chains that we so very much need worldwide. In summary, we're still in an international dance with this virus, and I'm not sure how that dance ends. If anyone tells you that, they do know be careful. As I've said time and time again, I'm sure they probably have a bridge to sell you too.

 

Chris Dall: [00:15:43] Here in the US, nearly all COVID-19 markers continue to show downward trends as we come down from the high plane plateau we've been at for much of the last two months. But as the WHO Director General noted, we can't assume those trends will continue. So, Mike, is it inevitable that those markers will go up again as the weather starts getting colder and people start gathering indoors again?

 

Michael Osterholm: [00:16:06] Well, Chris, I can answer this question quite succinctly. I don't know. And I believe no one knows. But as you mentioned, Chris, over the past several podcast episodes, we've discussed the high plains plateau situation. What we're seeing in the current US, a plateau of cases only now starting to appear to come down to a quote unquote lower case elevation. Deaths are now 8% lower over the past two weeks, with an average of 437 lives lost each day as of yesterday. Hospitalizations are down 10% and ICU numbers are down 8% over the past two weeks. This movement is in the right direction, but we still don't know what this all means. There are just no clues telling us what the virus will do next, rather, with regard to new variants or sub-variants, or what it means with regard to human waning immunity. However, we will continue to hear some public health figures saying that basically the pandemic is behind us. We just don't know. With the new boosters approved and some shots going into arms, people seem to be looking more and more into the future. We've heard of some people making long term predictions about the future of this virus and scheduling of vaccines. But simply there is no evidence informing these predictions. The past two winters have brought along surges in cases, hospitalizations and deaths. But the trends leading up to these surges were nothing like the high plateau we've just seen, and we don't know what variant will come next. Wastewater data indicates that COVID-19 concentrations across the country are slightly increasing, staying the same, and in some areas slightly reduced. It's far too soon to make a prediction about this winter. But let me just share with you where I think the country is not where the virus is, but where the country is. There was the results of a very important survey released this past week, which gives us a sense of where Americans are with regard to the COVID pandemic. These data came from the Axios-Ipsos coronavirus index study, which has been tracking the activity and the beliefs of Americans throughout the duration of the pandemic. And of note, this particular survey data, which had been routinely updated, has now been noted that as of this past week, this is the final regularly scheduled installment of this index, which says they're done with it at Axios-Ipsos. And this began back in mid-March of 2020. So right there, that should tell you something about the signal of what they believe is the current status. The latest results from their survey finds a country that is largely, though not completely moved on from the pandemic. As they quote, "the perceived risk the virus poses in Americans minds has steadily declined since the Omicron surge in the winter of 2022, and Americans have continued to engage in out of home behaviors despite cases rising in the beginning of the summer." If you look at their very specific data, they found that while most Americans say they believe there is still a possibility of them catching COVID, their perceived risk of contracting the virus continues to decline. Many indicate they've already returned to their normal pre-COVID lives. The share of Americans who report being concerned about COVID-19, 57%, is among the lowest captured throughout the entire pandemic. If you look at other data from the survey, it's clear that Americans now are in a holding pattern on mask use, with many choosing not to wear them regularly when leaving home. Of course, there was no clarification of what kind of mask. That said, Americans do report wearing masks in different rates depending on what they are doing out of the home. For those who do report wearing masks regularly, some feel self conscious. The share of Americans that report occasionally or never wearing a mask outside their home has remained constant since June. Around 63% report not wearing or very rarely wearing a mask. It surely is higher than it was during the height of the Omicron wave in mid-January, when only 27% of the population indicated they did not wear a mask. If we look, fewer report wearing mask at all times, or sometimes on a public transportation or ride share only 39%. Finally, the lowest share of Americans report wearing mask at all times or some times are in grocery stores 33% of the time. And when walking into a restaurant to dine indoors, only 27% of the time. The bottom line message here is we have moved on. The country is over with this pandemic. And I just shared with you today, that we're still looking at 430 to 450 deaths a day. At a time where had this occurred two years ago, it would have been a house on fire moment. Let me just conclude this section, Chris, in terms of giving some perspective is, as I said, my initial answer, I don't know where we're going with this, but we're beginning to track some movement right now within the variant sub-variants of COVID that are at least, if nothing else, intriguing, curious, and in some cases concerning. We have not seen anything that has appeared to bump off BA.5, which would say that this is what we've been seeing. This is why we have this plateau. It's kind of in a steady state situation with some downward trend. But now we're beginning to see some new activity with another sub-variant. Originally B.A.2.75 was thought that it might be an important new competitor against BA.5. However, even though in India it appeared that it took off with some extensive energy. We haven't seen it really move, but now we're seeing an additional new sub-variant BA.2.75.2, which actually does have some very concerning activity and very well may be what will replace BA.5. Will it win out or not? I don't know. If you talk to many of the viral geneticists, the people who are tracking this, there are some mixed feelings about it, but many are very concerned that this may be the new variant coming. And as I will talk about later, we not only have the intersection of dealing with new virus variants coming down the pike, but we're also going to deal with the issue of waning immunity in humans. Could this be the perfect storm collision course for at least major increased activity? Not saying we're going back to the big peaks that we had with Alpha, Delta and Omicron, but that it surely could change the game for where we're at right now. So as I conclude this right now, I wish I could give you more conclusive information to say yes, no, this is what we're going. I can't. Just know the virus is not done with us yet. The sub-lineage data is telling us that. The number of deaths continue to be a real challenge. But as you saw from the data on human behavior, we're done with the pandemic. So we'll see where this takes us over the weeks ahead. It's going to be quite a ride. I'm quite convinced of that.

 

Chris Dall: [00:23:21] Mike, there was a study released earlier this week by the National Bureau of Economic Research about COIVD's impact on the U.S. labor force. And the timing of this is interesting, given that many people are being asked to come back to the office right now. So what can you tell us about that study?

 

Michael Osterholm: [00:23:37] You know, I find this a very interesting, curious and in some cases confusing situation. And what I mean by that is I'm not just talking about workforce in the United States, but when I listen to the media, the pundits, and the public who are rightfully concerned about things like inflation, who are worried about you know, how much will the next meal cost, will they be able to afford it for their families? And you look at unemployment in this very unusual situation of virtually not having nearly enough employees. And you then are looking at what's happened globally and you realize as much as we focus on the United States of America as if we're the only thing that matters in the whole face of the earth, the entire world right now is in economic crisis. I mean, if we think we have inflation bad, there are many countries out there that have inflation levels that are many, many, many times that of the United States. What is the common root issue to all of these? The pandemic. I think people have not fully appreciated yet the impact that the pandemic's had on workforce, on business supply chains, and people's willingness to go into the workplace, as you've just talked about. And so to me, I find you know, our focus on the policies of a single administration, which I'm not here to comment good, bad or indifferent, other than to say that, you know, we seem to be doing a lot better in the US overall than many countries around the world who are dealing with the same pandemic-related crisis. So from that perspective, let me just say that as we know, this virus has impacted far more than just people's health. We know also now we're going to see the economic impact of this pandemic for years and years. And our last episode I touched on this when we discussed the estimates that 2 to 4 million people are currently unable to work due to long-COVID. The study Chris, that you just mentioned that came out of the National Bureau of Economic Research is just one more proof of the long term economic impact that we're going to feel in this country, as well as around the world, estimating that since the beginning of the pandemic, we have here in the US, over 500,000 people who have left the labor force due to pandemic factors such as fear of COVID, child care, and retirement. This means that half a million people are no longer working or looking for work due to COVID. This study estimates that 500,000 person loss from the labor force will only grow until the threat that this virus poses is eliminated. Just look at The New York Times yesterday, front page talking about why the recovery in New York is so challenged right now, because they are short of over 176,000 service and hospitality workers. They're not there. How do you run a city that is all about tourists when you don't have people to actually work in the service and hospitality industry? Now, they were there before the pandemic. What's happened? So when we look at the National Bureau of Economic Research study, data for this study was collected via a monthly household survey given to more than 300,000 workers, and the analysis was primarily based on reported week-long health-related absences. They found that during an average pandemic week, health-related absences were nearly double what they were prior to the pandemic and the rates of health related work absences by demographics mirrored the COVID-19 case rates by demographics throughout the pandemic. I also want to mention that on average, each COVID week-long absence is a loss of no less than $9,000 worth of earnings. This is a significant loss to our economy, and these weeks of lost earnings continue to add up. And analyzing the data of this study, researchers determined that workers who had a week-long health-related absence were 7% less likely to remain in the workforce a year later, compared to those who did not report an absence. Now, individually, these numbers may not seem that significant, but it's important to remember that economic growth does not happen with a diminishing workforce. If we cannot get people to pay attention to COVID because of the health-related risk, both the immediate and long-COVID risk, we can only hope that proving that our economy is heavily, negatively impacted by this virus will help open some more eyes because something needs to change in this country if we want to return to normal. Right now, we don't have a workforce to do that.

 

Chris Dall: [00:28:20] That brings us to our COVID query segment, which gets at some of the issues I raised in my opening about the newly updated booster shots. We've received several questions on this topic, but today's question comes from Amy, and it's a condensed version of her email. But this is what Amy wrote, "Dear Dr. Osterholm, I'm really upset that I'm reading that boosters might be annual from here on out. I'm high risk for a bad outcome with COVID, but I'm not immune compromised or fall into the categories that are talked about as being offered boosters more often. What I fear most isn't death, it's long-COVID. I have fibromyalgia and neurogenic orthostatic hypotension. All of the information emerging on long-COVID confirms in my mind that I don't want this illness. We know efficacy has waned in mere months for the existing shots. Although we have zero information about the new boosters, someone like me is better off assuming they will wane unless it's clearly demonstrated otherwise. This leaves me with a dilemma. For what portion of the year do I go without protection, given that there is no guarantee I can get another booster for an entire year? I don't think saying the shots are annual is going to encourage most people to get them, but it's sure making it hard for those of us who actually want them and want them two or three times a year. I'm so tired of this." So, Mike, what can you tell Amy and other listeners who have similar questions about the timing of booster shots and waning efficacy?

 

Michael Osterholm: [00:29:46] Amy, I can sense your frustration here, and I think many of us in public health share it. I personally very definitely share it. And so I'm going to tell you right up front, there are no magic bullet answers to your question. But let me try to lay out what I believe is the situation, as you have done a really good job of doing. You do understand the challenges confronting us. I'd like to first address the issue of influenza vaccine, and you'll see why in a moment, because that actually helps illustrate some of the challenges we have with COVID vaccine, so that the two connected as such may not appear obvious, but you'll see in a moment. I think they are very definitely connected. We will provide a link to you here for an article that written by Helen Branswell with STAT News. That was simply an excellent piece this past week on the difficulties of timing for influenza vaccines and balancing the duration of immune protection. Her article correctly referenced studies performed on the duration of protection for influenza vaccines from several different sources, including the Kaiser Permanente Vaccine Study Center and the Harvard School of Public Health, showing about an 18% decrease each month in flu vaccine's effectiveness after their administration. A similar study from CDC shows the vaccine protection against hospitalization from influenza wanes 8 to 11% each month. This tells us that a typical influenza vaccine will maybe give us 3 to 4 months of some measurable protection. The follow up question then has to be, when is the flu season most active so people can match that 3 to 4 months with the most likely times that they'll be infected? While there is certainly variation each year in the United States, the peak for flu season is largely from mid-December through the end of January. However, it's not unheard of for influenza activity to peak in February. For those getting vaccinated in early September, their protection has likely waned significantly by the time they encounter this virus. I personally get my influenza vaccine in late October unless I know that activity is picking up early. In that case, I get it right away. But I know many people rely on the pre-planned vaccination events in their work or school that may fall in September or early October. If it's a matter of getting your influenza vaccine in September at an event or not getting one at all, go ahead and get it in September. But for those of you who have flexibility around the timing and want to optimize the window protection, waiting another month is probably a good idea. Of course, consult with your health care provider, especially if you or anyone in your household has extenuating circumstances like being immunocompromised or living or working in a congregate setting, as that may impact the timing as well. Now, remember, the administration has just put forward this idea of two arms, get a flu shot and a COVID shot at the same time. These data speak against that. And I think that that was an unfortunate I call unforced error, where they should have really looked more closely at the recommendations around influenza and not have been inconsistent about the fact with waning immunity. That's flu. You know where it's at. You know what I think about when you should get your flu shot. And we've done a lot of work on the vaccines and I feel confident in what I just said to you. So now let's bring it back to COVID boosters and the question of how long we may have protection from each dose, which is exactly Amy, what you were going towards. When and how do I get it relative to giving me long term protection? Remember, this is also the same guy you've heard me say over and over again, We can't boost our way out of this pandemic. We just can't. And while influenza is mostly seasonal in the northern and southern hemispheres and we can plan a time limited vaccine around peak activity, COVID-19 is the opposite. It's ongoing and completely unpredictable. As we've discussed previously robust trial data for BA.4 and BA.5 vaccines or the most recent formulation boosters from Pfizer and Moderna are really lacking. We did see some additional information presented at the September 1st meeting of the CDC's Advisory Committee on Immunization Practices that sheds a very critical insight into how long it takes for boosters to wane. Now we're talking about COVID-19. CDC presented data from the Vision Network, which includes electronic health record data across ten different states. Researchers assessed vaccine efficacy against hospitalization, comparing factors such as age, number of doses received, number of days since last dose of vaccine, and the dominant variant during the study period. I will have to say that this was a very well done study as well as can be done given the kinds of health record collection we have today. Considering the current time period when BA.4 and BA.5 are dominant for immunocompetent adults, meaning people who are 18 years of age and older, not just the oldest, and for people who did not have any identified underlying immune compromised condition with three doses of vaccine their protection against hospitalization was close to 50% near the time of their recent dose. However, after three months, they had approximately 35% protection against hospitalization, a 15% point drop. Preliminary data for adults over age 50 with four doses show approximately 60% protection near the time of their vaccination, but dropping about five percentage points after 60 days. None of these data looked at the issue of those who are over 50 or over 65 or immune compromised, which we surely can assume that the data aren't nearly as good for those groups as they were for looking at all those 18 and older and immune competent. So this should give you a real pause to think about the fact that we will be seeing waning immunity. Imagine at this point now, if I tell somebody, if you are fully vaccinated with four doses of vaccine, now this is before the BA.4 BA.5 dose is administered. But if you have four doses of vaccine on board and at roughly 100 days out, only 56% of you are protected against hospitalization. That's a challenge. I think there are really two important things to note here. One of these is that those who are vaccinated with as many doses they're eligible have significantly more protection than those who are unvaccinated who haven't received all of their booster doses. Two, is that there is evidence of considerable waning of immunity after three months of vaccination. What this tells me is that vaccination is an important tool. Boosters are providing some time-limited protection, especially in older populations, against severe disease and death. But this is not a long term strategy. The protection from these doses wanes quickly. And as much as I wish it was, COVID-19 isn't going away in the next three months. I understand how people are trying to time these boosters to offer the best protection during potential travel, the holiday season, visiting family and friends, etc. I wish I had more evidence for best practices here, but we just don't have the data. And I believe unfortunately our government, as well as many others around the world have just moved on. They want you to believe that this is now a seasonal coronavirus infection, seasonal influenza infection, and we're going to handle the two the same way. And I just don't think that's the case. I don't think that's going to work. So we'll have to see. So I'm sorry, Amy, this isn't the answer you wanted to hear. We are, unfortunately, still a ways out from being done with this pandemic. To be able to have more confidence in our immune protection provided vaccines, we've got to develop the technology that has higher, broader and longer protection. And of course, we have to actually get those shots in arms. In the meantime, we're in a dance with this virus, and we have to understand that. And we have to understand that means the virus itself and how it changes over time will be critical. And it also means how our immunity holds up over time will be critical. And the intersection of those two events will determine what the future looks like with COVID amongst all of society.

 

Chris Dall: [00:38:25] Now onto the monkeypox outbreak. Two preprint studies have now been published showing some mixed signs on the efficacy of the JYNNEOS vaccine. Mike, what can you tell us about those studies and what they mean for the intradermal vaccination strategy that has been implemented to stretch the supply of the monkeypox vaccine?

 

Michael Osterholm: [00:38:44] Well, Chris, let me take a step back and do a minor tutorial, you might say. And that is, what does it mean to be vaccinated using the intradermal route? Well, if you look at how we normally think of immunizations, we think of the needle going into the arm. And what it does is it goes through the epidermis, the dermis, the subcutaneous fat and then into muscle. That's what all of us have on all of the architecture of our skin that we often just think of as skin. Well, when you do a intramuscular administration of the vaccine, you put it deep into the muscle, almost a 90 degree angle down. Now, there are immune cells there, but not nearly as many that reside at the level of the epidermis, this very thin layer of skin that's right in the top that you see, as you look down at your arm or your foot or wherever. The dermis is slightly deeper and there to get you basically an injection into the dermis, you're actually talking about about a 25 degree angle, not a 90 degree to get it in. It's a very thin layer. Then underneath that is a subcutaneous fat and that basically requires a injection, often somewhere right around 45 degree angle. Now, this may sound complicated. It kind of is, because you've got to hit the right spot. It's kind of like being at the county fair. And when you throw the ball, you've got to hit it just right to knock over the the bottles. So when we look at the very top level of what we often think of as skin to muscle is the epidermis. To get an intradermal injection into that very thin layer means the angle of the needle is about 10 to 15%, and it's very thin to get it into. But the good news is, in the epidermis, there's actually a very high concentration of immune cells where if you present the vaccine or a live virus for that matter, or whatever, the immune system's response to that will be heightened compared to what it is if the injection is actually in the muscle. So this is the concept behind intradermal vaccination, where if you can do it correctly, you can actually use much less of the antigen or the vaccine to still get a very robust immune response. So when people are asking the question, now, what is this all about? The intradermal means getting it into this very thin top level of what people often think of as skin in such a way that it puts itself in the presence of these high concentrations of immune cells. So that is not easy to do. And if you're not trained on it, it can be very difficult in learning how to do that. Intramuscular actually is much easier. Just let it go down deep, okay. So with that background, let me just update us where we're at. Right now, the monkeypox outbreak continues to be a challenge with 59,179 cases reported as of yesterday. Over 22,000 have been in the United States. Cases have now been reported from 102 countries, including seven countries where monkeypox has historically been reported. The JYNNEOS vaccine is a critical tool in helping us fight this virus, but it's not perfect, especially when used differently as directed. Two preprint studies that looked at the subcutaneous administration of the vaccine showed somewhat mixed results in immune response. Now, again, this is not intradermal. This is that next level down. This is actually below the epidermis, below the dermis, and now into the subcutaneous area. The first study published on September 1st looked at antibody responses four weeks after first and second doses of the JYNNEOS vaccine. And concerningly, they found that there was little antibody response four weeks after the first dose of vaccine and four weeks after the second dose. The study was small, had other limitations, but it ultimately did not provide the results we hoped to see. The second study was published last week on September 9th and based on data from Bavarian Nordic, the vaccine manufacturer. The study looked at neutralizing antibody responses in participants that were not previously vaccinated for smallpox that received one dose of JYNNEOS or two doses of JYNNEOS four weeks apart. And that antibody responses in patients who had been previously vaccinated for smallpox and received one dose of JYNNEOS. All three of these groups still had neutralizing antibodies six months after their most recent JYNNEOS dose, with neutralizing antibodies returning to baseline levels within two years of vaccination. It is important to note that the neutralizing antibody response is not the same as effectiveness in preventing disease. But in the absence of an outbrea, it is the best data we have to understand whether or not this vaccine is working. I also want to emphasize that in this study, the vaccine was administered subcutaneously and not intradermally, the dose-sparing route of administration that I just talked about. Still, this data are certainly promising and should give us some hope about this vaccine after seeing the alarming results from the September 1st preprint. The bottom line is that these mixed signs are just another example of why we need more data on the JYNNEOS vaccine, especially regarding the use of dose-sparing approaches like intradermal and single dose vaccine administration. Though the second study, which was much larger than the first, showed very promising data from the vaccine manufacturer. It still has not been peer reviewed, and we can never rely entirely on a single study to tell us everything we need to know about a vaccine and how well it works. We also need data in the real world efficacy of these vaccines, including efficacy data and intradermal and single dose vaccine administration, not just data on immune response. I want to remind everyone that dose-sparing approaches have been used to get more people vaccinated in a short period of time for other diseases, including yellow fever and in many instances considered equally effective. Now that more doses of JYNNEOS are becoming available, we need to encourage people to get their second doses and ideally one day, not through intradermal administration, once we have more vaccine. Finally, I want to remind everyone that all of these discussions are about efficacy, not safety. All these studies have provided evidence that this vaccine is safe and unlikely to cause serious side effects. So in short, let me just emphasize that as much as I just discussed all about the process of vaccination and the challenges of that, remember, a vaccine is not a vaccination. Vaccines mean nothing if they don't turn into vaccinations. And I think, Chris, we're going to address that next.

 

Chris Dall: [00:45:47] Yes. On that note, Mike, here in the US there continue to be problems in getting the JYNNEOS vaccine to communities of color, particularly in the southern states. How do state and local public health officials fix this problem?

 

Michael Osterholm: [00:46:02] Well, let me repeat what I just said. A vaccine is not a vaccination. And if there was ever a time to understand and appreciate that it's now. This vaccine will only be effective if it's actually used. So this is a very important question, Chris. And sadly, this feels somewhat like deja vu all over again for me. We talked about racial disparities in vaccination rates and antiviral treatment rates with COVID-19. And we're in the same place again with monkeypox. Currently, black men make up about 38% of monkeypox cases, yet they represent only 11% of Americans vaccinated for the virus. One of the first steps to fixing this problem is to acknowledge why it's happening. We are seeing overwhelming rates of vaccine hesitancy in the black community, just as we did with COVID-19 and as we have talked about many, many times, there is a lot of really tragic history behind this very feeling about vaccines in the black community. This is why it's absolutely critical that the state and local health departments support black gay community health workers in creating and sustaining vaccination campaigns within their communities. A Washington Post article published earlier this week titled "Inside a City's Struggle to Vaccinate Gay Black Men for Monkeypox," really highlights the importance of this and shares the story of Johnny Wilson, a black gay health care worker in Charlotte, North Carolina, who has been working to establish more vaccine confidence within his community and advocating to ensure that anyone in his community who wants a dose of monkeypox vaccine is able to access it. We will provide a link to this article in our episode description, and I urge you all to read it to understand the importance of this work and the great impact it can have converting a vaccine into a vaccination. So, Chris, we have a long way to go in addressing these racial disparities. And as you all know, it does not start or end with monkeypox. Supporting community health workers in the black gay community will be a critical first step in a long effort to break down systemic barriers in health care and even in public health. We must rebuild as much trust as we can if we are going to effectively reduce the impact of this situation with monkeypox.

 

Chris Dall: [00:48:23] Earlier this week, the CDC announced that because of the polio viruses recently found in New York, the case of paralytic polio, and the positive samples in wastewater from four counties that the US has been added to the WHO'S list of countries with circulating vaccine-derived polio virus. So Mike, first, just your reaction to that news, but secondly, does this mean that we could expect to see more polio cases?

 

Michael Osterholm: [00:48:50] As you mention your question, Chris, polio virus has now been found in samples from four counties in New York and in New York City. In total, 57 samples of concern have been detected from wastewater in those locations, 50 of which are genetically linked to the paralytic polio case that was reported just a few months ago. The fact that we are finding these positive samples in more and more counties suggests that the transmission of the virus is continuing to occur. This is not surprising as three of the counties where polio virus has been detected Rockland, Orange, and Sullivan counties have polio vaccination rates around 60%, much lower than the state's vaccination rate of 79%. Many zip codes within these three counties have lower vaccination rates, the lowest in an Orange County zip code, where just 15% of the children are vaccinated for polio. Since most cases of polio are asymptomatic or cause only mild flu like illness, it's very difficult to say how much transmission is occurring. All of the polio samples in New York wastewater have contained either vaccine-derived polio virus type two or a variant of this vaccine derived strain. About one in every 1,900 polio type two infections results in paralysis. So it's not surprising that we've not seen a widespread outbreak of polio cases to date. That said, if polio virus continues to circulate, we should expect to see a number of new cases. And while one in every 1,900 polio cases may not seem like enough to warrant a state of emergency declaration, I want to put this number in perspective. There are nearly 2.6 million children over age two in New York State, and 21% of them are not vaccinated for polio. If even half of these unvaccinated children were to contract the virus, we would expect to see over 140 cases of paralytic polio. And if half the children under two were not able to be fully vaccinated due to their age also get infected, that'd be an additional 120 expected cases. Again, if just half of all the children in New York State that are not fully vaccinated against polio contracted this virus. We could expect to see up to 260 cases of paralytic polio reported, and that's just in children. We would certainly expect to see a lot of adult cases as well, just as the original case reported here in this situation in New York was a young adult. Luckily, we have no reason to believe that the current transmission levels are even close to the levels where half of susceptible individuals would get infected. Individuals who are already vaccinated are like rods in a reaction when in fact they're inserted, they slow down the transmission. So the more people we have vaccinated, the greater the likelihood is, is that we can suppress transmission in the community. I hope these numbers help everyone get a sense of why this is still such a very concerning situation. We have well established and reliable tools needed to control this outbreak before we get to the point of seeing dozens of cases of paralytic polio. And I hope that we can convince the public to use these tools, these vaccines, before it is too late.

 

Chris Dall: [00:52:11] So now the fun part of the podcast, Mike, where is this week's beautiful place submission from?

 

Michael Osterholm: [00:52:18] Chris, this is actually truly a beautiful place of mission in the finest sense of the word. This comes from Adam, and we are so appreciative for what Adam has shared with us by way of pictures as well as text. I encourage you to go to the podcast link on our website and take a look at what Adam has shared with us. He wrote, "Dear Dr. Osterholm, As public school teachers, my wife and I, a 13 year brain cancer survivor, have found your podcast as an essential guide through the foggy terrain of these pandemic years. We continue to find ourselves in a spin cycle awash in crosscurrents of confusing COVID policy and vitriolic culture war. Your show has been a breath of fresh air to help us see through the toxic cloud that has descended on our educational communities. During wave after wave of COVID, we found ourselves drawn to the waves at Ocean Beach, San Francisco. Ocean Beach is not what one would expect of a California beach. There are no palm trees and usually no sun. Most days, Ocean Beach stretches off into a haze of fog, running both directions. It's as if we are in our own little pocket universe, our own little bubble. Other figures amble along the beach shadow-like in their own fog bubbles. The Pacific stretches out endlessly dark and frothy, with surfers dotting the horizon alongside squadrons of pelicans surfing along the air currents mere feet above the waves. It feels more like the Scottish Moors in California. And we love it. When your feet hit the waves it's bracing as if a dull razor has pulled across your ankles. The intense cold acts as a warning, as if to remind you that this is one of the most dangerous beaches anywhere. There are unexpected rip currents that have pulled folks out to their death. And so when you leap in, you need to respect the waves, respect the ocean. It requires all of your attention. When you dive in, when your whole body is submerged the first time, it's like a cold lightning bolt strikes. All other thoughts, feelings, worries and what ifs, they disappear into the break, into the Pacific. And all that's left is the present moment. And then you emerge and the world looks fresh. The pelicans, the surfers, the whitecaps, the silhouettes of fishermen, sprinting dogs, walking couples. They all look more real, more vivid, more concrete, more alive, even as they are cloaked deep in a bank of San Francisco fog. That's what Ocean Beach has given us, as has your podcast. A reminder to stay present. Do not try to fight the waves as they come, but rather to work with them, to respect them. Whether we are on the beach or in the classroom. Then in those moments we see the beauty and not the fog of our fears. Thank you, Adam and Corinne." Thank you both to Adam and Corinne for this very beautiful submission. As an old English Channel swimmer, I can tell you, I can feel that cold water in those waves more than I could ever put into words. So thank you very much for sharing this beautiful place. And again, I encourage you all to go take a look at the pictures that accompany this submission. Thank you, Adam. Thank you very much, Corinne.

 

Chris Dall: [00:55:31] Just a reminder to our listeners that 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: [00:55:50] Chris, I have to come back to a theme that has been a take home message with so many of the recent podcasts, a theme that I can't wait to actually not have to use anymore. But number one, we don't know where we're at in this dance with this virus versus us. We just don't know. What does our future look like? I already emphasized today the uncertainty around where the variants or sub-variants are going. I emphasized the uncertainty around immune protection, but at the same time I highlighted the fact that the case numbers, as we've seen previous in the pandemic are much lower. But aren't we really talking still about a very unacceptable number of deaths each day, not only in this country, but around the world? So I don't know where we're at with this virus versus us. I do know where we're at with us versus the virus. And what I mean by that is how we're responding and reacting to the virus. As I pointed out in the Axios-Ipsos survey, you can see that we're moving on beyond the virus. Doesn't matter anymore. And yet for many of you listening to those podcasts, it matters a lot. You're immune compromised, you're individuals who are at risk for severe illness. You worry how well will that vaccine protect you from hospitalization some five, six months out? We don't know. We need to get those answers. And so you're going to have to stay tuned. Anyone who tells you that we're beyond this, that it's over with and done, that we can go to seasonal vaccine approaches. I don't think they get it. I just don't think they do. We don't know that. Maybe it could happen, but we don't know that. So we really have to understand, number one, we don't know we're out with this virus. Number two, we are at a very critical time for learning, not forgetting. One of the things that I think is most important right now is all the things that have happened. What have we learned from all of these experiences we've had so that we are better prepared for the future, even trying to deal with the situation right now? How many times do we have to be wrong about what this virus is going to do in the weeks and months ahead to understand the critical need for humility and just to say, we don't know. This is what we do know. This is what we don't know. So we want so badly to move forward. Oh, boy, do I want to move forward so badly. But we have to acknowledge we can't at this point with what we know. And finally we will recover, but we're going to have some rocky roads ahead. We have to be prepared for that, whether it's monkeypox, polio, antibiotic resistance. I can go through the laundry list. We can't forget, as we talked about in previous episodes, the impact that this virus has had, whether we look at life expectancy, we look at what it's done to the workforce. We have to understand these things. We'll move forward, but we have to still address a number of critical issues. So these to me are the primary take home messages, messages that continue to ring through week after week. And it's our job to get you better answers so that we can give you a better messages.

 

Chris Dall: [00:59:13] And do you have a closing song or poem for us today, Mike?

 

Michael Osterholm: [00:59:17] Well, I'm very happy to report that in fact, we actually have a quote today that I think is very, very appropriate for the time and very helpful. And it came from a very special person who shared this with us. They weren't the one who wrote it, but they shared it with us. This quote was submitted by listener Sherry. We've received a number of wonderful emails from her over the course of the pandemic. They were wonderful, and we actually used her beautiful place that she submitted about her mother in March of 2022, in Episode 93: What the World Needs Now. And she has suggested that we use a quote by Nikki Banas. Nikki writes and publishes letters through printed collections and online. Her writing shares her experience through different life seasons and helps readers learn to share their own light with others. I think this quote is so applicable for today. So here it is from Nikki Banas. "You never really know the true impact you have on those around you. You never know how much someone needed that smile you gave them. You never know how much your kindness turned someone's entire life around. You never know how much someone needed that long hug or deep talk. So don't wait to be kind. Don't wait for someone else to be kind first. Don't wait for better circumstances or for someone to change. Just be kind because you never know how much someone needs it." Nikki Banas. Thank you, Nikki, for those beautiful words. I hope our listeners can identify with this message as this is something we surely have tried to promote through the course of these episodes. And if nothing else, from today's podcast, I hope you remember these words, because right now I think we're at a time where kindness has never been more important. Where what we need to do is not forget what Nikki so very nicely illustrated about the importance of a smile and kindness. I want to thank all the listeners. Today, I want to acknowledge for many of you who are experiencing long-COVID how challenging this is. For those of you that continue to try to protect yourself from getting infected because your underlying health status, how challenging that is and how I wish we had better information. Amy I feel like I just mungled that question with you because of the fact I couldn't give you the answer that you wanted. I wanted, everyone wanted, but thank you for asking it. I want to thank the podcast team for your invaluable support in making this podcast possible and for all the input that you provide. And I want all of us just to take a step back and say we're in this very, very gray period where we don't quite know is it going to get brighter and brighter? Might it get darker someday? But we're there and we will continue to do our best to learn, to understand. But in the meantime, hopefully, we never forget to be kind. Finally, I just want to thank all of you who have provided us with wonderful emails, letters. Your thoughts are so important to us, and I wish we could have a conversation with each and every one of you. We can't but know that we read every one of the comments you submit and we learn from them. We do learn from these very important messages. And thank you. So be kind. Be safe. We'll see you soon. Thank you very much.

 

Chris Dall: [01:03:05] 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.