Michael T. Osterholm, PhD, MPH, returns to JAMA's Coronavirus Q&A series to discuss the latest developments in the COVID-19 pandemic. He is director of the Center for Infectious Disease Research and Policy (CIDRAP) at University of Minnesota and a veteran of pandemic planning. Recorded September 23, 2020.
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>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. I'm so delighted to have Mike Osterholm back. Mike is the Regents Professor McKnight Presidential Endowed Chair in Public Health, the Director for the Center for Infectious Disease Research and Policy, CIDRAP, at the University of Minnesota. Welcome, Mike.
>> Michael Osterholm: Thank you very much, Howard.
>> Howard Bauchner: So, I just want to remind our listeners and our viewers, when I interviewed Mike about three months ago, he said something that I've repeated may be a dozen times in different interviews, which is Mike said to me, "Could you have me back in two weeks, so I could correct any of the mistakes I'm making today, because of new knowledge?" Mike, that was a priceless comment, so, thank you.
>> Michael Osterholm: Well, thank you, and it still holds true today.
>> Howard Bauchner: So, Mike, what have we learned over the last couple months? What would you say are the highlights of what we've learned?
>> Michael Osterholm: I think the first thing we've learned is that this virus is, in fact, going to continue to do what it's doing without regard to the season, without regard to, you know, these ups and downs we see in these major outbreak areas, and that it's kind of like a big coronavirus forest fire, and if there's human wood around, it's going to burn. In some cases, after we see very, very hot areas like we did in Texas, Arizona, California, Florida, and Georgia, we see the cases trending down substantially because of distancing. But then, as soon as you let up the brake again, they come right back. You know, I think we're going to see a terrible fall, and I worry that we're going to see numbers far in excess of what we even saw in the July peak.
>> Howard Bauchner: Yeah, I saw the numbers again this morning. You know, we dipped down in the 25-30,000 range per day last week, but this morning, I think it was 45 or 50,000 --
>> Michael Osterholm: It is.
>> Howard Bauchner: -- again. So, you anticipate a difficult fall, Mike?
>> Michael Osterholm:. I do. I think what's happening is a combination of, again, the virus is just transmitting effectively, and we as a society, not just in the United States, and in many parts of the world, including Europe, have kind of given up and said, you know, pandemic fatigue has set in. We're going to do what we're going to do. Right now, we're seeing so many outbreaks, for example, in our own state of Minnesota here, in weddings, funerals, social events, parties, bars. I can just go down the laundry list, and it's as if life really hasn't changed from last January. And the virus is taking advantage of that, surely.
>> Howard Bauchner: Yeah, my wife grew up in Maine, and we have a house in Maine, as they had that, you know, that studying wedding in Northern Maine, which has led, I think, to the deaths of seven or eight or nine people, about 120 cases, and it's just been distributed all over the State of Maine, which had very little disease. So, clearly, there's a number of gatherings that have led to an increased number of cases. Two really topical issues that have been in the newspaper almost every day, schools and colleges and vaccines. Why don't we start with schools and colleges? I think it's become increasingly clear that there's going to have to be a more textured response to opening schools. Colleges, clearly, have been problematic, but can you comment on schools and colleges first?
>> Michael Osterholm: Yeah, one of the things I think has been a challenge for us is we talk about kids. We've got to stop talking about kids. We've got to talk about various age groups, because what we're seeing in those under age 10 is very different than what we're seeing in those, let's say, 11 to the 17-18-year-olds or younger adolescents or older adolescents, and what we're seeing in young adults, and particularly, colleges in colleges and universities. It's different in two ways. One is, I think, the dynamics of transmission are very different, as well as, potentially what the health outcomes might be. In those age groups under 10, you know, we're not seeing the massive, big outbreaks in schools that have resulted in serious illness in large numbers, as was, I think, thought would happen by many. And in fact, there's an outstanding article by Laura Meckler today in the Wall Street Journal on that very issue of -- excuse me, Washington Post, laying that very issue out. And, on the other hand, when we get into high school and we get into the college and universities, there the social activities are resulting in very large numbers of cases, and I think that the college university setting, which we've all heard about, with these large parties and so forth, I think are just the beginning. We tried to do some calculations in our group, and we estimate that only 5-7% of college students have been infected to date. So, there's still a lot of college students to get infected, and I think the challenges there we're seeing in both high schools and in college universities is we see a major growth in cases there, and then the spill over into the community. We're already seeing schools with increased number of cases in faculty and staff, and I think that going to be a really major event in igniting this fall peak, which I'm absolutely certain is going to occur.
>> Howard Bauchner: Now sticking with schools, you know, educators have emphasized that schools provide more than the A, Bs, and Cs. For some, food is provided and important aspects of attention to physical health, nutrition, mental health, and just socialization of what goes on in schools. Do you think we really need to try to make an effort to get children who are in kindergarten, first grade, second grade, third grade, back into schools?
>> Michael Osterholm: You know, I keep reminding everyone that we need to take this year as our COVID year. Do not base it on expectations of what we did last year, and don't base it on expectations of what we hope future years will look like. You know, all we have to do is get through it. If you recall, after Katrina, schools in Louisiana went through a Katrina year where basically not much got done, and what didn't get done, they tried to make up for in the following year. So, I think you raise a very important point, Howard. What we need to do is protect the safety of these children. That's first and foremost, whether it be from the standpoint of adequate food, you know, socialization, abuse, whatever. We need to do that first. Number two is we need to protect them from the standpoint of the virus and what happens there. And then, I think, after that, anything after that's a bonus. Just consider it a bonus and not try to tie ourselves to the rigor of what we did last year. And I think that -- I worry that too many school districts are tied into this is the way we've always done it. So, we've got to get it done at that level. We don't want to leave anybody behind, but at the same time, to try to think that you're living in a community when a house is on fire, or for a virus, or where you have a number of teachers and staff, which 40% in this country do have an underlying risk factor for serious COVID disease, if it's not going just the way you wanted it, just expect that to be the case, and do whatever you can to provide the best education under these conditions.
>> Howard Bauchner: Yeah, I think as we emerge into the spring, and we'll see what will have happened with the educational offerings, K-12, we may have to think of next year as a very different year.
>> Michael Osterholm: I think so too.
>> Howard Bauchner: Yeah, rather than just saying, well, 90% of the children need to go from kindergarten to first grade or from first grade to second grade. I think we shouldn't anticipate whatever occurred in the past will occur in the future until we see how this goes. A couple of my relatives --
>> Michael Osterholm: You know, one thing I think that, you know, you've been a champion for this. So, I just want to emphasize it. One of the things we have to not forget is childhood immunizations. I worry that in the end, we could have more children in the next year dying from measles than will ever die from COVID-19. And so, this was one area, we just have to continue to hit home on is routine childhood immunizations during this time. Whatever else happens, let's do what we can to get our kids vaccinated.
>> Howard Bauchner: Now, Mike, what have you heard and read about vaccines over the last week? Optimistic? Pessimistic? You know, the emergency use authorization has been a huge issue. We've had numerous viewpoints on it. It's also been in the major media outlets. Where you think we stand scientifically and then in the approval process?
>> Michael Osterholm: Let me just say scientifically, you know, I was very involved with the SARS response back in 2003 through the Secretary's Office at HHS and then very involved MERS. I've been on the Arabian Peninsula working on MERS. I was in Seoul for the large Samsung Medical Center Outbreak in 2015. And while I don't consider myself at all a coronavirus expert, a virologist in particular, you know, I hang around some really smart people in that area, and we've known from the beginning of this pandemic that coronaviruses are really complicated when it comes to serving as immunogens. How well do they actually stimulate an immune response in a host that provides normal immunity? So, while I think what's happened with vaccines is remarkable, it will go down as, to date, at least from an R&D standpoint, as a Manhattan-like project effort. But I've worried from the very beginning just what would we get with these vaccines, in terms of durability, of protection and what that would mean? As you're well aware, we're already seeing breakthrough cases right now where we've had second infections with actual isolates from the first and the second infections to show that, indeed, they were second infections, and I think that one of the challenges we're going to have is really understanding just what the long-term population-based impact will be on vaccines. Also, even if we get durable immunity, and really concerned right now about the tenor of the discussion about vaccines in this country. As you know, you've seen recent survey data suggesting over half of the population wouldn't take a vaccine right now if it were available. Well, if you look at these vaccines, and let's just assume, you know, maybe worst-case scenario, I hope that would be the case, that only 50% protection from vaccination. That is similar for what we see with influenza, and surely, FDA has, in a sense, forecasted that they would go ahead and approve a vaccine at 50% protection. Well if only 50% of the population gets it, the vaccine, 50% protection, it's only 25% of the population will be protected. This pandemic goes on raging. So, I think we need to be very, very mindful of what can the vaccines do? How well do they work? How long will they work? And I'm hopeful that we'll see second- and third-generation vaccines, ultimately, that may improve on the immunogenicity of these vaccines. In terms of what I guess you'd call the science politics of this issue, I'm confident, actually, I think, at this point, that the FDA will put in place a process that will not be altered by any political implications, as might be suggested, based on previous FDA actions. And so, we'll see. Today, FDA rolled out additional clarity, in terms of its documents, on what it would require for approval for a vaccine through either emergency-use authorization or licensure, and I think, you know, I've had an opportunity to talk to Steve Hahn. I think he really is committed to making sure that the science rules the day on this issue, and that'll be a welcome relief for all of us.
>> Howard Bauchner: I do think it's an example of the scientific community speaking with a single voice. Sometimes we don't have enough data to necessarily speak with a single voice, and there can be differences of opinion. I don't think there's been any differences of opinion about what needs to be the approval process for a vaccine, right? I think, you know, I think some are uncomfortable with an emergency use authorization, but I think most are comfortable with it, as long as the FDA scientists are allowed to make an independent recommendation, based upon data, and I think Steve's worked hard to insulate the FDA for vaccines. We can talk about hydroxychloroquine or convalescent plasma, but particularly around vaccines, from any political pressure. Is that your impression?
>> Michael Osterholm: Absolutely. I agree, and I think as difficult as the hydroxychloroquine/plasma issues were, I think they were also learning opportunities for the FDA to make sure that everything that needs to go right with the vaccines will. They've learned. And so, I actually more confident here, and I think this will be a successful review. I think the challenge will continue to be, of course, is even if they're approved, how do we communicate that to the public the way that they feel confident, because there already is this mistrust that's occurred? And it's there. And so, I would hate to have a tool that could be very important in dealing with this pandemic and not have it used. That would be a real tragedy.
>> Howard Bauchner: Yeah, no, you know, there will be two challenges, obviously. One communicating the effectiveness and safety of an approved vaccine, and then, secondly, the infrastructure that we'll to distribute it. It will be very different than anything in my lifetime. Before the starter, we talked about a new term that we both learned, "long haulers." I said, when I first read about it, I said, what's the story with truckers? And I've come to recognize that it's a new language about people recovering from COVID-19. Could you talk a little bit about what we know about people who've been exposed and actually survived?
>> Michael Osterholm: Well, you know, this is an area that I think is going to receive much more attention over the days ahead, because I think it's a much more significant public health situation than we realize. And we've always known that individuals who spend an extended period of time in intensive care unit, when they finally do survive and get out of the hospital, they have sometimes a long row to hoe. But what we're seeing now is a very different kind of long row to hoe for patients, often young, healthy adults, who get infected, who have only mild illness, at most, in those first days, and then just kind of never recover and then go downhill from there. I mean, I personally know of individuals who, you know, were sick for five, seven days, not severely ill, came back to work, but just had this ongoing issue with fatigue and a whole series of nondescript symptoms that by week four or five are at home on oxygen with some pretty bad looking lung pictures and some real challenges from a cardiac standpoint. And we're now recognizing that this may be occurring as much as in 10 to 20% of young adults having this condition. It's kind of a, you might say, a chronic fatigue syndrome-like picture on steroids. And so, I think we have a lot more work to do to understand this, and most importantly, we've got to communicate this in a way that, you know, says to the young adult to say, "Ah, I'm not going to get sick with it and be in the hospital. Hardly anybody ever does. You know, nobody my age dies from this." Kind of that ongoing perception. Well, this could really be a serious challenge to your health over time, and we don't know what the long-term consequences will be. So, long haulers are going to be getting a lot more attention paid to them in the short and long-term, and it's all the more reason why you don't want to get infected with this virus.
>> Howard Bauchner: Mike, when you look at the international community, have there been countries that have had prolonged successes, you know, four or five months with very little flares, or are most countries really struggling with the periodic flares? I'm just curious, what's your sense of the international landscape?
>> Michael Osterholm: Well, you know, I think that, again, I come back to my analogy of a coronavirus forest fire. There are those countries that, basically, like we, in April, were a house on fire, major fires, and they locked down, that horrible term, as we did, to limit contact between people, and, you know, we got to the end-of-May time period and said, "We're done," even though we only had gone from 32,000 to 22,000 new cases a day, and we saw what happened with that pandemic fatigue set in, and we went to 67,000 cases a day. Many other countries in Europe, as well as in Asia, actually kept the break down and kept it going down to the point where many of them got below one case per 100,000 population per day, and they have actually done a pretty good job of controlling it through most of the summer. Then, unfortunately, they seem to have learned the lessons that we had, unfortunately, showed them is they let their foot up way too fast. And so now, if you look at Europe, for example, Eastern Europe is really in serious trouble. Western Europe is too, France, England, Spain, etc. Even in Sweden, which people keep using it as the benchmark now, they were averaging 200 hundred cases a day a month ago. Today, they're over 1,200 cases a day. And so, I think what we all are reminded of is as long as we put the brake on, and in a measured way, we can control this. If you don't, it's coming back. The same thing is true in Asia. The one area I think that people miss talking about, Howard, is New York. The State of New York has been nothing short of remarkable since its disastrous opening days in March and April. I think they're now on like day 40-something of less than 1% positivity. They've days with no deaths in the entire state. Even right now, today, they announced that they're seeing some slight increase in certain areas of New York City, and they're all over it. So, they have shown us that while the economy is not fully back. You know, workers are not in full force in New York, they have taught us even as one of 50 states surrounded by a lot of activity, how to control it, and I think that's the lesson we should be learning right now, because we're not going to get out of this thing overnight, and I think we're going to see a lot of places, whether they're in Europe or the United States or Asia, continuing to have real challenges with this virus.
>> Howard Bauchner: It's interesting, because I think the notion of kind of testing, tracking, tracing, and quarantine is almost impossible with 50,000 cases a day. I don't know of any country other than, perhaps, China, could locked down 50 million people, right? But when you have a limited number of cases, then I think many states, or cities, will have the capacity to track and quarantine, but when the number's overwhelming, we lose that capacity, and I think that's what New York has shown us.
>> Michael Osterholm: I think you're right. You know, I have likened it to where you have these very large number of cases when you're trying to, basically, achieve control through testing and tracking is kind of like trying to plant your petunias in a category five hurricane. It's not easy to do. At the same time, what New York has taught us is you can do it, just as you said. If we get the numbers down, which is that's the first thing you have to do. Then you really pay very careful attention to what's going on. You know, and New York's had several instances in the last couple of months where numbers started to creep up in one area of the state. They were on it immediately, and I think that that's, you know, they've had to tighten up, in some cases, their closure issues, and so forth. But they taught us a lot about managing this virus until, hopefully, a vaccine can provide us more of a tool. But, so, I am more optimistic about what can be done if we decide to do it. Where I'm extremely pessimistic is the American, and in some cases, other countries' ideas, we're just done with this virus long before the virus got done with us.
>> Howard Bauchner: Now, Mike I think today's the first day of fall. It's still a beautiful day in Chicago. I don't know what it is in Minnesota, but you live in a chilly state, and it's going to begin to get cold. That will drive people inside. I think we're going to begin to see the end of outdoor dining or it will be far more limited. I don't know how many heaters each restaurant can put outside. What will be the keys to the fall? Obviously, the flu vaccine, that you can mention, but what's going to be the keys to the fall in cities like Chicago or Minneapolis when it gets very cold?
>> Michael Osterholm: Well, you know, as they say in the real estate business, "location, location, location." I think, as they're going to say the COVID business, "indoor air, indoor air, indoor air." We just know that, in fact, the transmission of this virus is enhanced when groups are together in indoor air where, unfortunately, the air circulation is far, far short of what would be needed to remove the virus quickly, like we see when it dissipates in outdoor areas, and we actually saw some of that this summer, even in the South, where indoor air, because of air conditioning, brought people in. And so, I think this is going to add to the challenge of a combination of, you know, I don't seem to worry about this problem. You know, I'm happy to go do certain social events and not worry about it, and then, being indoors, it's going to only enhance it. So, I think that's why, you know, some of us are very concerned about the what, I think, will be very substantial impact of this disease in the fall months into the winter.
>> Howard Bauchner: Now you and I both have many colleagues at the CDC. It's been a difficult few weeks, few months for the CDC. Do you want to make any comments about what appears to be intrusion into their editorial and scientific independence? I think it's been painful for many of us to see.
>> Michael Osterholm: Yeah, you know, the CDC issue is one that, first of all, let's just take a step back. They are such a critical part of the public health landscape for the whole world, not just the United States. Their expertise and their capability of responding to crisis has been legendary. You know, I care very much about many, many of the people at CDC who are among the world's experts in what they do. I think what's happened is that caught up in both the, as you talked about, the deep reach of the political arm of Washington DC into CDC science and policy has been a challenge, but I also think they've made some mistakes, and that leadership should be taking responsibility for and correcting and making clear what they're going to do to correct it. And this most recent one on aerosol issue is not the long arm of Washington reaching down to Atlanta but was an administrative there that if, at a time when they're under such scrutiny, should never have happened. You know, basically, check twice before you do something. And so, I think, you know, I'm very careful about this because I want to -- but I think some of the leadership at CDC right now has to ask themselves should I be here doing this, because I'm not doing the agency necessarily the service that it deserves? And, you know, I come back to one last thing. It's not a red or blue issue. It's a COVID-color issue. We need the CDC's expertise. They have that expertise buried within that agency in a very important way. So, I think leadership has either change who they are, or they have to change what they're doing, and I don't see that happening right now, and that's what really concerns me.
>> Howard Bauchner: With such as shining light in public health nationally and internationally, it's one of the jewels in the crown of the federal scientific effort. So, I think it has been disappointing. I think the inconsistency often from the WHO and the CDC has been beyond just that there's uncertainty about the data, which I think people can survive if the message is clear. I think Dr. Fauci, Tony's, done a wonderful job saying, you know, trying to be steadfast in what we know and don't know. The crystal ball is foggy. You made that clear the first time, but people really want to know what spring of 2021 and the fall of 2021 is going to bring. I think people have come to recognize, if we see a vaccine on the side of January 1, that would be surprising. Certainly, it won't be widely distributed until the first quarter of next year, based upon some recent statements, and that's assuming it's a successful vaccine. There's numerous ones. But, you know, the vaccine's not really going to roll out to tens of millions of people until after the first of the year. Do you have any sense of what the spring of 2021 or the fall of 2021 will bring?
>> Michael Osterholm: Well, I can say with certainty, we're still going to be very much involved with this virus at that point. I think the challenge is, is again, how well will the vaccine protect? How many people will get the vaccine, and how long will that protection last? Finally, is how well do we roll it out, not just to the United States or other high-income countries, but how do we roll it out to the middle-income countries and lower-income countries? Remember, with 8 billion people on the face of the earth, and this virus is still, you know, is ravaging parts of the world, we're going to see that virus moving back into United States time and time again challenging us here. In other words, we now are one big global pot of COVID-19. And so, I think the issue is going to be how well we take care of the world will also dictate how much pressure we'll have with that virus constantly entering this country. So, we need to do both. We need to protect the United States, but in doing that, we need to protect the world, because that's also what will protect United States, and I think we'll just have to wait and see. I can promise you one thing for certain, that again, I will need to come back on here in a couple weeks and, you know, try to correct the mistaken statements I made based on new knowledge and what we've learned, and so, 2021, there's going to be several iterations between now and then of understanding what's happening.
>> Howard Bauchner: Given that it does now appear that vaccines will be delayed until 2021, are monoclonal antibodies likely to bridge to vaccines for high-risk individuals?
>> Michael Osterholm: You know, that's a really important question, and again, we'll have to wait and see what the data provides us, and then we'll have to look at the logistics. How you deliver monoclonal antibodies, particularly to the highest-risk people, which, as we know, part of that is racial inequities? Would we be able to put monoclonals in a successful way into communities around the country that are already, you know, suffering from poverty and other challenges and racial disparity. I don't think we know at this point what that possibility is, and the first thing I'd love to see is just what the data show us, relative to monoclonals and just how well they work.
>> Howard Bauchner: Yeah, I think, as difficult as the distribution of a vaccine may be, it will be equally as difficult with monoclonal antibodies, and also, I think the government seems to be committed to making sure that the vaccine is available for every individual, either through insurance or free if they're uninsured, but I don't think that same commitment has been made around monoclonal antibodies.
>> Michael Osterholm: It has not, and you're right on the mark with that. That's a key issue.
>> Howard Bauchner: And so, that may become particularly important. As you look to the future for individuals, is it still social distancing, masking, keep your activities outside with limited numbers of people? I mean, that messaging, I mean, people have really tried to deliver it sometime since March or April. Is it still the same overall message, Mike?
>> Michael Osterholm: It is. I think I would offer one friendly amendment, which I know you will agree with, is I try very hard not to use the term "social distancing." I hope we never social distance. Let's stay close together, but physically distance, yes. I think that that's still the real effort here that we need to do, and when you look at what's happened when people get back together in large groups and somewhat carelessly, that's when transmission occurs. And so, again, if you're at a high risk of having serious illness, in particular, you've got to distance yourself. And, you know, wearing a mask of face cloth covering will likely reduce the risk of that, but you can't count on that as being a stopgap. You've got to really understand if I am in that crowd, if I go to that wedding or that funeral, which is a challenge, because we're hearing of more and more people, "You know, my granddaughter's getting married. There's going to be a large wedding. I'm 74 years old. I have underlying risk factors. Should I go to that wedding or not?" And you know what? We're seeing people go to them, and then, unfortunately, they're ending up dead three weeks later. So, I think this is going to be a huge challenge is how do we maintain society in a way that is acceptable and something people will comply with, but at the same time respectful of the need for distance, particularly for those who are at increased risk of serious disease.
>> Howard Bauchner: For those that are at particularly high risk, do you want to weigh into the debate, the discussion, the challenge of face shields versus masks?
>> Michael Osterholm: You know, I think, again, the aerosol issue, I think, is well-established, and so, from that perspective, I fall into that camp loud and clear. I think one of the things that's been challenging is the epidemiology of this disease is very, how shall I say it? Uneven. And what I mean by that is we've already demonstrated that a large proportion of individuals who are infected with this virus will transmit very little, and if you're in that household setting with that individual, that makes it seem like it's all droplet, and you can understand that, and there, face shields could be very important. On the other hand, if you're in that other 20% of patients who transmit, likely, to 80% of the new cases, aerosols are very critical. And so, if you're in that environment, you say, well, of course. Droplets may play some role, but they're not that important. It's all about aerosols. And so, the message is both are important, but I think from the standpoint of the face shields, we have outbreaks now where we have had people who wear face shields only and not masks, who are infected at a substantially higher rate than those who wear face shields only. So, I think that, you know, the evolving science here is important. You know, I'd want, from a respiratory standpoint, if I could, in an ideal world, I want my N-95 anytime I'm public, which, of course, is not recommended, because we need to save these for healthcare workers. Right here in our state, we still have a shortage of N-95 respirators for the healthcare workers who are on the front line.
>> Howard Bauchner: That leads to the last question, and I'm anticipating a surge of cases in the fall. Do you know if the supply chain around PPE and masks has gotten better, because I do realize -- but let's put testing aside, which is debated every day how much better that is, although it doesn't seem debatable for the NBA or the NFL, which always I'm struck by. They seem to be able to get tested every hour, but PPE and masks, do you have a sense if the supply chain is better for the coming fall?
>> Michael Osterholm: It's better but that doesn't tell the full story, meaning that if we had a surge right now, which I suggest we're going to have, we will fall far short again. We were already down in many of our hospitals in this state to less than five days of gloves. We have a similar situation in N-95 respirators. Gowns have been a challenge. And so, you would think that we should have been able to catch up some over the course of the last six to eight weeks, given the decreasing number of cases, and yet, we have, at best, caught up some but not at all in a way that puts a lot of this PPE in storage so that we can use it during the surge capacity. I think this fall, we're going to run into major challenges on PPE.
>> Howard Bauchner: This is Howard Bauchner, Editor-in-Chief of JAMA. It's been Conversations with Dr. Bauchner. What a pleasure to talk with Mike Osterholm again. Mike is the Regents Professor McKnight Presidential Endowed Chair in Public Health at the University of Minnesota, one of the country's leading experts on epidemics and pandemics and always humble in his presentations and discussions with me. Mike, thanks so much for joining me today.
>> Michael Osterholm: It's great. I appreciate very much being here with you. Thank you, Howard.
>> Howard Bauchner: Stay healthy, as usual.
>> Michael Osterholm: Thank you.
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