Episode 179: Remembering Darkness, Sharing Light: Five Years Later

Chris Dall: Hello and welcome to the Osterholm Update, a podcast on COVID-19 and other infectious diseases with Doctor Michael Osterholm. Doctor Osterholm is an internationally recognized medical detective and Director of the Center for Infectious Disease Research and Policy, or CIDRAP, at the University of Minnesota. In this podcast, Doctor Osterholm draws on nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. I'm Chris Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. There's so much going on in our country right now that what might ordinarily be a time for widespread public reflection, the five-year anniversary of the beginning of the COVID-19 pandemic has seemingly gotten lost in the shuffle. I host a podcast that was launched in response to the pandemic, and it's nearly escaped my attention. But a quick look at the COVID-19 timeline on the Center for Disease Control and Prevention website took me back to those days of fear and uncertainty in early March of 2020. On March 3rd, 2020, the CDC reported 60 COVID-19 cases across 12 states. On March 11th, after more than 118,000 cases in 14 countries and 4291 deaths, the World Health Organization declared COVID-19 a pandemic.

Chris Dall: On March 13th, the Trump administration declared a nationwide emergency. On March 15th, the New York City public school system shut down to prevent the spread of COVID-19. The first episode of this podcast aired on March 24th, 2020. I'm sure for many of our listeners, those days are not easily forgotten. For some, it's simply a bad memory. For others, it was when things changed forever and for as much as we have moved on from COVID-19 as a society, the impact of the pandemic still lingers. It has changed us for good and for bad. The five-year anniversary of the pandemic is among the topics we'll be covering on this March 28th episode of the Osterholm update. We'll also update you on what's happening in Washington, D.C., and its impact on our efforts to fight infectious diseases at home and abroad. Provide you the latest information on the Texas measles outbreak. Take a look at COVID, flu and respiratory syncytial virus trends, review some new research on Long COVID and discuss H5N1 avian flu. And we'll answer an ID query about COVID booster shots and bring you the latest installment of This Week in Public health history. But before we get started, we'll begin with Doctor Osterholm's opening comments and dedication.

Dr. Osterholm: Thanks, Chris, and welcome back to all the podcast family, to this ritual that we share, and one that has come to mean a great deal to me to be able to be here on the other end of this microphone, sharing thoughts and ideas, challenges, concerns, dreams, hopes and fears with you and having done that now for five years. For those of you that may be joining for the first time, I hope that we're able to provide you with the kind of information that you're looking for. I trust that if you're here, you've probably already heard that we tend to cover the waterfront of information, both personal and professional. And I hope, if it's possible, you to find part of the podcast family to be to your liking, and you're able to join with us as we share this information. I know that some of you have been with us since the very beginning of this journey, which means you've been listening for five years now. Five years, five years of breaking down the latest public health news, answering your questions, covering the latest medical research findings, sharing your hopes and fears, and trying to understand how to make sense out of all of this. Of course, the five-year anniversary of this podcast also means it's a five-year anniversary of the COVID pandemic. On March 11th, 2020, the World Health Organization declared COVID-19 a global pandemic, and we all remember how our world changed beyond what we could ever have predicted.

Dr. Osterholm: It's a time in history that will shape the way we think about health, science, and the global community for generations to come. The pandemic tested all of us in a very personal and profound way. There's a certain group of people, however, whose experience during the pandemic was uniquely difficult, and that's the front-line health care workers. Many news outlets this past week have asked health professionals to reflect on what they experienced during the early days of the COVID pandemic in light of the five-year anniversary, and I found their responses to be incredibly powerful. One infectious disease physician recalled going from two confirmed cases to over 100 cases in the span of a week. Another physician said wearing full PPE for the long hospital shifts took an enormous physical toll. One nurse mentioned how difficult it was to work with dying patients, then leave the hospital and hear a COVID-19 misinformation spread freely in her social circles. A health commissioner remembered that hospitals needed to figure out where to put the deceased because they ran out of space. One health care professional commented on the trauma and the post-traumatic stress they experienced from watching patients decline rapidly and die alone in rooms because family members weren't allowed to visit.

Dr. Osterholm: These days, it feels like we're living in an era of revisionist history where research and data and lived experiences are seemingly up for debate. But I can't say this strongly enough. We refuse to forget the dedication and sacrifice that healthcare workers showed during the pandemic. It is painful to watch trauma or hardship get swept under the rug in the name of getting back to normal, or satisfying some sort of political blame game. We can't ignore the fact that an estimated 3600 health care workers died from COVID-19 in the US in the first year of the pandemic alone, and that in 2022, a survey of 30,000 nurses found that more than a quarter of them planned to leave the field in the next five years due to pandemic related burnout. Denialism won't prepare us for the next health threat or soften the trauma that people live with every day. Over the five years of this podcast, I've dedicated more episodes than I can recall to healthcare workers, and it's because I can't find enough ways to thank them for the patients they cared for and the personal sacrifices they made day in and day out. On this fifth anniversary of this podcast and the start of the COVID pandemic, I couldn't think of a group more deserving of my gratitude and dedication than these health care heroes.

Dr. Osterholm: I know you didn't do it to be a hero. You did it because it was the right thing to do. Thank you for everything you did, for the lives you saved and for the hearts you cared for and for the hands you held as those patients died. Well, now, let me move into something a little bit lighter, both figuratively and literally. This is a special day for the light people today on March 20th in Minneapolis Saint Paul. Sun rises at 7:15 a.m., sunset is at 7:26 p.m. We now have hit 12 hours, ten minutes and 28 seconds of sunlight, gaining three minutes and nine seconds a day. Wow, over that 12-hour mark. Now if we're in Auckland, New Zealand, our favorite community in the southern hemisphere, there today, sunrise at the Occidental Belgian Beer House in Vulcan Lane is at 7:23 a.m. Sunset at 7:32 p.m., 12 hours and nine minutes of sunlight. If you remember, we were at 12 hours, ten minutes in Minneapolis. They're at 12 hours and nine minutes. This is the podcast where we cross the boundaries. So yes, it'll continue to get darker in Auckland. It will continue to get lighter here in Minnesota. I love that light. And I promise with the very best of all possibilities. We will share that light with you to our dear, dear friends in Auckland.

Chris Dall: Mike, let's begin with the latest from our nation's capital, where the Trump administration and Elon Musk's Department of Government Efficiency are continuing their efforts to cut workers and funding from the federal government. Now, as I'm sure our listeners know, this is touching all parts of government. But I want to start with the cuts at the US Agency for International Development, because earlier this week, W.H.O director general Tedros Adhanom Ghebreyesus had some pointed comments about the consequences of these cuts. Mike, can you give our listeners a sense of what Tedros said and what you made of those comments?

Dr. Osterholm: Chris, as we've covered in previous podcasts, these cuts to USAID are nothing short of devastating. And I think Tedros comments really highlight that. Tedros called on the US to revisit their decision to cut USAID programs, but also emphasized that if we must cut USAID, we need to do it in a way that does not immediately endanger the lives of those treated by these programs, stating the US administration has been extremely generous over many years, and of course, it's within its right to decide what it supports and to what extent. But the US also has a responsibility to ensure that if it withdraws direct funding for countries, it's done in an orderly and humane way that allows them to find alternative sources of funding. The sudden funding freezes and program cuts are far from orderly and humane, and frankly, it breaks my heart to think of how many people will die unnecessarily because of this action. I also want to highlight some comments that the former Assistant administrator for International Development and Global health at USAID, Atul Gawande, a dear personal friend and someone who has been a hero to me for many, many years. Atul provided these comments in an interview with The New Yorker. In that interview, he explained that over 20 million people, including over half a million children, have not received HIV treatment in six weeks because of the dismantling of the USAID programs.

Dr. Osterholm: He estimates that in the next year, we could see an additional 160,000 malaria deaths, hundreds of thousands of additional HIV/AIDS deaths, and a million additional deaths due to vaccine preventable diseases. The fact that anyone could celebrate this as a victory is absolutely unthinkable. A tool also sheds some light on why some Americans might still perceive these cuts as a positive thing. The average American drastically overestimates the amount we spend on foreign health aid, according to a recent KFF survey. Americans estimate that, on average, that 26% of our federal budget is spent on foreign aid. The actual amount spent is just 1%. The researchers found that after learning the actual foreign aid budget amount, the percentage of Republicans that feel that the U.S. spends too much on foreign aid drops from 81% to 50% for Democrats. This drop was from 29% to 15%. I hope that this administration hears the warnings from Tedros and Atul and reconsiders the incredible, harsh and reckless cuts they are making to these lifesaving programs. The money we spend to improve the health of people around the world is far from wasteful government spending. It's worth every penny. And as I mentioned earlier, the consequences of dismantling these programs as we are doing is simply devastating. This is a machete going after a problem that, if very least, might need a scalpel.

Dr. Osterholm: This is an issue that is changing by the day, so I'm sure that we will have more to share with you in the next episode in two weeks. But let me just offer a perspective. You know what? We're all going to die. All of us. And we're always going to have a top ten causes of death. And I can say that, you know what? If you substitute the current ten with ten new ones, I'm not sure it'll be any better. But I can say for certain, as a public health practitioner, that it's all about how you live your life, and the fact that we'd all love to live long, healthy, disease-free lives. And then suddenly one day we're done. What we're doing here with these programs that we are taking people at the prime of their life. We are taking people who could have a much healthier long life, but not allowing them to have that now because of the kind of cuts we're making. So I can only hope that we understand what we're doing here, is helping the world be a better place by these programs. And let me just conclude by saying, the fact that I even have to address a question like this is simply breaking my heart, but it also hardens my resolve not to give in or to give up, I won't.

Chris Dall: Regarding the impact of Trump administration policies on U.S. federal health agencies, things are still very much in flux at this point, even after buyouts and the termination of probationary employees and in some cases, the rehiring of those employees, it appears more layoffs are in store. But there have also been a lot of policy changes, and I want to focus on another recent item from KFF, which reported that National Institutes of Health officials have urged scientists to remove all mentions of mRNA vaccine technology from their grant applications, a move that suggests NIH may not fund any type of mRNA vaccine research over the next four years. Mike. Aside from the question of why, how is it going to impact our efforts to prepare for the next pandemic?

Dr. Osterholm: Well, Chris, this is going to greatly hinder our prevention efforts for several infectious diseases and seriously set us back even further in terms of pandemic preparedness. As you mentioned, NIH officials have told scientists to remove any mention of mRNA vaccine technology from their grant applications, pending grants that are intended to study mRNA vaccines have already been flagged by the NIH, and it's unclear what the future holds for mRNA projects that have already been approved to receive funding. This is incredibly disappointing, considering that millions of lives saved by mRNA technology during the COVID pandemic. But it's also disappointing in the sense that this technology has been studied for several other diseases as well. mRNA vaccines for influenza, HIV and even pancreatic cancer have been shown promise in clinical studies. And now the future of these vaccines is uncertain. Let me remind everyone that right now, if we had an influenza pandemic emerge, we have the capacity to make enough doses of vaccine to vaccinate fully 2 billion people in the first 12 to 18 months of the pandemic. Remember, that's only a fourth of the world. The egg-based vaccine production methods we use for influenza are outdated, antiquated and need to be changed. At this time, I don't see that happening for years to come, but mRNA technology could rapidly escalate the amount of vaccine we have following the emergence of a pandemic and could save millions and millions of lives.

Dr. Osterholm: But now we're not doing the research to understand how mRNA vaccine technology could help us with influenza. That's just a classic example of one that is so misaligned for what the public health needs are. But, Chris, I'd like to add one more log to the fire here. And that is this past week, the NIH also announced to its investigators that they will no longer fund research dealing with vaccine hesitancy. It's no longer allowed. Yet we've been talking on this podcast from its very beginning about the challenges with the public understanding, the tools that we have in public health and specifically vaccines and the vaccine hesitancy issue is front and center right now in what's happening with measles in the United States. So, the fact that we are both taking mRNA vaccine technology research off the table, and we're refusing to fund any kind of work that's done with vaccine hesitancy, a major, major mistake. And again, the way that will be ultimately realized is in lives lost.

Chris Dall: As our listeners know, we've been closely following the confirmation process for the people who've been nominated to lead our federal health agencies. And last week, there was a bit of a surprise the nomination of physician and former Congressman Dave Weldon to lead the CDC was withdrawn by the Trump administration just hours before his confirmation hearing. Mike, your thoughts?

Dr. Osterholm: Well, Chris, this was certainly an unexpected turn of events. Dave Weldon's nomination was withdrawn hours before his confirmation hearing because he lacked enough votes to be confirmed. This was surprising considering some of the other nominees who had been approved, but I think most of us in public health are feeling a great sense of relief knowing he won't be leading the CDC. Following the withdrawal of the nomination, Weldon released a very concerning statement explaining that Republican Senators Susan Collins and Bill Cassidy were both considering voting no at his confirmation hearing because they perceived Weldon to be Anti-vax, which he denied. He then elaborated to say that Big Pharma was likely behind the removal of his nomination as well. The rest of the statement contains some very alarming anti-vaccine rhetoric. First, Weldon suggested that the CDC manipulated safety studies on thimerosal, a preservative formerly used in childhood vaccines, which has been shown repeatedly not to be harmful. Then, even more concerning, he went on to defend Andrew Wakefield, the British researcher who conducted the since retracted and widely debunked study linking the MMR vaccine to autism. The fact that Weldon was even close to becoming the CDC director is deeply concerning. I'm relieved that Senators Collins and Cassidy were willing to vote against Partisan lines to do the right thing. The consequences of having Weldon lead the CDC could have been devastating. The Trump administration has yet to announce a new nominee. So, stay tuned on this. We will likely have more to share in our next episode. The bottom line who leads these organization matters, and we need to follow this very closely and wherever we can, provide our expert input as to who might make the best candidate for that position.

Chris Dall: Let's turn now to the measles outbreak, which continues to grow. Mike, what are the latest numbers out of Texas and New Mexico? And does this outbreak show any signs of slowing down?

Dr. Osterholm: Well, Chris, let me address the Texas and New Mexico situation. And then I'd like to elaborate a bit more on the measles situation and put it into perspective. And you'll see what I mean by perspective in a moment. Unfortunately, this measles outbreak is absolutely not slowing down and there is no clear end in sight. As of Tuesday, March 18th, the Texas Department of State Health Services is reporting 279 confirmed cases of measles in the West Texas outbreak, and 36 patients have been hospitalized. We have every reason to believe that there are a number of additional cases in Texas not being confirmed because they are not seeking medical care. New Mexico is reporting 38 cases connected to the outbreak just across the state's border. There is one confirmed death of a child in Texas and one death under investigation of an adult in New Mexico. This is certainly the largest outbreak in the U.S. right now, but it's not the only place measles is spreading. As of Friday, March 14th, the CDC has confirmed cases of measles in Alaska, California, Florida, Georgia, Kentucky, Maryland, new Jersey, New York City, New York State, Pennsylvania, Rhode Island, Vermont, and Washington. Of course, this includes both Texas and New Mexico. Also, outside of those areas, there are fewer than ten confirmed cases in each of the other jurisdictions I just noted. What happened in Texas was the introduction of measles to a highly unvaccinated population, where it takes off like wildfire. We know these pockets exist all across the country, and it just takes one exposure for things to get out of hand in this outbreak.

Dr. Osterholm: The majority, or 75% of the infections have been in children, and all but two cases have been in individuals who have no evidence of measles vaccination. As we all know, vaccination is our best tool against measles, and we have to make sure we get that message out effectively and ensure that there is vaccine readily available. I've been careful here to talk about confirmed cases. As I just noted, I don't want to spend much more time speculating, but I think it's quite likely that there are far more cases out there, especially in this West Texas outbreak. We know that this population is hesitant to seek formal medical care, so mild cases may be going undetected. It can take up to two weeks for someone who is exposed to show symptoms. So, we won't know this outbreak has settled down until there's at least a sustained period without new cases. Based on the way this outbreak is unfolding, I don't see that happening anytime soon. Let me add a perspective also about how bad things could get. And when I say that, all I do is look across the Atlantic Ocean to Europe. Europe as a whole has about twice the population of the United States in 2024. They had 127,350 cases of measles, including 38 deaths. Let me repeat that 127,350 cases with 38 deaths.

Dr. Osterholm: Now, given that they are about twice the size of us, if we were to have the same kind of situation occur here, we'd be talking about 63,000 cases in the US, not hundreds. Now, could that ever happen here in the United States? Absolutely it could. And why? Because Europe too did not have numbers of measles cases like this until the last several years when, because of a great deal of misinformation, we saw vaccination rates drop dramatically in children and particularly in some countries. All it takes is the continued unwillingness to vaccinate your children that will ultimately drive a measles outbreak to grow much larger. And just to compare it, this is not a low-income country situation I'm talking about in Europe. I'm talking about standards of living just like ours, but also countries that make up Europe that have been heavily influenced by mis and disinformation about vaccines and vaccine safety. So again, I hope people understand we are not in the worst shape of what we see happening to other countries around the world. But we could be, and I worry that one day we might come back and say, boy, it was only 300 cases of measles when it now is in the thousands and thousands and Europe is our model. Don't forget that. Remember what I just said, 127,000 cases last year They're on track to have even more in 2025. That could be us in the near term.

Chris Dall: While health officials in Texas and New Mexico have been very clear and consistent in saying that the MMR vaccine is the best way to protect your child from measles, we have yet to hear a full-throated endorsement of the vaccine from Department of Health and Human Services Secretary Robert F. Kennedy Jr, who instead has promoted alternative treatments and continues to suggest that there are safety issues with the vaccine. Mike, Kennedy repeatedly said during his confirmation hearing that he wouldn't prevent people from getting vaccinated. But isn't sowing doubt about vaccines just as dangerous?

Dr. Osterholm: Chris, I'm going to go a step beyond that. Make no mistake about it, RFK Jr. Isn't just sowing doubt about vaccines. He's outright untruthful. He is untruthful about the seriousness of the outbreak and the best medical evidence we have for treatments and about the vaccine safety and effectiveness. And we predicted this. Go back to the podcast of the last six months. This is not unexpected. When the media asked me, what questions should the senators ask Kennedy as initial confirmation hearing, I said on the record, it wouldn't matter to me because his words mean very little. During his confirmation hearing, Kennedy said, and I quote, I support the measles vaccine. I support the polio vaccine. I will do nothing as HHS secretary, that makes it difficult or discourage people from taking either of these vaccines. For anyone who took him at his word, I hope you're beginning to come around that this is just untrue. The most egregious lie from this past week was when RFK appeared on Fox News with Sean Hannity on March 11th, and stated, regarding the measles vaccine, it does cause deaths every year. It causes all the illnesses that measles itself causes, encephalitis and blindness, etc. and so people ought to be able to make their choice to vaccinate for themselves. I want to be very clear. We do not have any evidence. None. Zero of a properly administered MMR vaccine causing death in immunocompetent individuals.

Dr. Osterholm: There are adverse events associated with this vaccine, but they're far more rare than the consequences of measles infection itself. For example, there is a very small risk of encephalitis from an MMR vaccine about 1 to 2 per million. In contrast, primary and post-infectious encephalitis from a measles infection occurs in one out of every 500 cases of measles. Compare 1 to 2 per million for the vaccine to one out of every 500 with actual measles. This is 2000 times higher risk from measles infection as opposed to the MMR vaccine. In addition, one topic that has not received much attention and one that I remember very well in my early days in public health, is a condition that's known as subacute sclerosing panencephalitis. Big words. Subacute sclerosing panencephalitis or SSP. This is a rare complication due to persistent measles infection after one has their initial infection. It usually occurs in early adolescence, some few years after actually having had measles. If you're vaccinated, it virtually prevents 100% of the time developing SSP. In the days before measles vaccination, we would see SSP cases about 4 to 11 cases of SSP for every 100,000 measles cases. What happens when one is first infected with the measles virus? There is a type of immunosuppression that continues for some months and may leave someone at increased risk for other infections.

Dr. Osterholm: When we see SSP occur, it usually, as I said, several years later, and it usually starts out with certain neurologic symptoms, including seizures. There is no treatment for SSP. 95% of the people who get SSP following their measles infection die. To give you an example, between 1956 and 1981, in the United States, when measles was much more common, there were actually 634 cases of SSP and documented here. Now, we have hardly ever seen it in the modern day of public health. Why? Because we've had so few measles cases. But just as I pointed out with what happened in Europe with measles, we will begin seeing SSP come back as we have more measles cases. So again, here is an example of where Mr. Kennedy didn't even understand that. As I've stated, vaccines are our best means of preventing and combating measles outbreaks. But RFK Jr has continued his misinformation campaign, understating the risk of infection and overstating our ability to treat it. In his interview with Hannity, he claimed that becoming infected with measles provides more lasting protection compared to a vaccine and that it can later protect against heart disease and cancer. Well, this is entirely untrue. And what he doesn't tell you is, even if we all got measles to develop protection, that means we would expect, based on historic norms, 500 to 600 deaths a year in this country from measles.

Dr. Osterholm: Is that a price we want to pay to have potentially even a little bit better immune response? He also speaks to the benefits of antibiotic steroids and cod liver oil to treat measles. RFK Jr. has been in contact with at least two doctors in Texas, who appear to be frontline sources of information on this issue. One doctor, Richard Bartlett, has been disciplined by the Texas Medical Board in the past for his non judicious use of antibiotics and steroids, the same antibiotics and steroids touted by Kennedy. Not only is this against best practices treatment recommendations from doctors who are board certified in pediatric infectious diseases, but it's also widely dangerous from an antibiotic stewardship perspective. It's outright hypocrisy for Kennedy to be promoting these vitamins and medicines for measles that have substantial risks and no benefits, while leaving out the incredibly effective vaccine with extremely rare adverse events. A small part of me is hoping that the Weldon confirmation falling through is a sign that these anti-vaccine views are being recognized by policymakers and the public for what they are deadly. We need to continue to call balls and strikes on leadership, spreading misinformation and putting people's lives at risk, especially the lives of young children who have no agency in this matter at all.

Chris Dall: Mike, let's turn now to H5N1 avian influenza. What's the latest?

Dr. Osterholm: Well, Chris, I'll start my usual recap of recent detections by saying I'm becoming less and less confident. We are getting the full picture of H5N1 from government sources. We are seeing fewer reports of H5N1 in commercial poultry operations and dairy herds, which makes me question the validity of interpreting the available data. Now, I surely believe as the migration season slowed down over the past several months. In fact, that could be a reason why we're seeing this reduction in activity. I also think we're still missing some of the activity that's occurring out there. And remember, spring is here. We're going to start seeing the northern migration of birds occur in the near future. Stay tuned. This observation, with regard to reduced occurrence in both dairy cattle and poultry, follows news of a presidential executive order earlier this month that eliminated two key food safety committees within the USDA, the National Advisory Committee on Microbiological Criteria for foods and the National Advisory Committee on Meat and Poultry Inspection. These committees provided guidance to the CDC, the USDA, and the FDA on food safety related matters, and it's concerning they've been dissolved in such a critical time in the H5N1 era. All that being said, there are updated numbers that have been reported since the last episode. There have now been three more detections in commercial poultry facilities. Six more detections in live bird markets and nine more detections in backyard flocks.

Dr. Osterholm: In the last 30 days there have been a cumulative 66 high path influenza positive flocks across 23 states, affecting an estimated 3.8 million birds, depending on the type of flock, they can range from single digits to over a million birds impacted. The cumulative national total number of positive dairy herds is 986 across 17 states, with the most recent detection originated in California, bringing that state's total to 755 herds. Of note, one California herd tested positive for the B3.13 strain with a unique mutation called PB2E627K. There's also a cluster of high path influenza infected cats in New Jersey with this mutation, but interestingly, they were infected with the D1.1 viral strain, not the B3.13. These mutations alone are not cause for immediate concern, but its presence has been associated experimentally with facilitated transmission in mammalian models. This, of course, may include humans, so it's critical for health care providers in affected areas to monitor any unusual respiratory illness, even as flu season draws to a close. We will continue to monitor this development in the weeks to come. It's critical to watch out for sustained spread among pigs and more clearly defined human clusters. I do not believe we're at this point yet. I hope we never get there. But the US simply is not prepared for a pandemic tipping point anytime soon.

Chris Dall: Well, what about human respiratory virus trends? And let's start again with flu, which has been the main storyline this winter.

Dr. Osterholm: Well, flu trends continue to improve across the board, and I think we're nearing the end of the flu season, but we're not quite there yet. Outpatient visits for influenza are currently at 4.3% and decreasing, down from 5.8% two weeks ago. This marks 15 weeks above the national baseline of 3%. When we drop down below 3%, we can declare the flu season over. I anticipate that we will be there within the next month. Activity is decreasing in every age group and also in every region of the country. There are still six states Louisiana, Maine, Michigan, New Mexico, New York and Ohio that are considered to have very high influenza activity. 17 and the District of Columbia are considered high. 14 are moderate, seven are low, and five are minimal. The percentage of emergency department visits that ended up with an influenza diagnosis is down from 5.2% two weeks ago, during our last episode, to 3% this week. New hospital admissions are down 37% compared to our last episode, with approximately 22,800 new admissions last week. Unfortunately, since our last episode, there have been 36 new pediatric deaths, bringing the season total to 134 pediatric deaths, which have contributed to the estimated 23,000 deaths this season. Every time I hear about, read about, or think about these pediatric deaths is so painful. Throughout this flu season, activity has been 97% influenza A, both H1N1 and H3N2 and 3% influenza B. As expected, with a typical flu season, subtyping has shown a higher percentage of influenza B in recent weeks. This is a rather unusual event in a typical flu season for B cases to follow after major activity with influenza A last week. Influenza B accounted for 5.5% of cases. This shouldn't have any impact on activity trends, but is something worth pointing out? This flu season isn't quite done with us, but I do really believe we're getting close. So, hang in there for just a few more weeks.

Chris Dall: And how about COVID and RSV? 

Dr. Osterholm: Similar to flu, we're seeing improvements across the board. Nationally, the COVID wastewater level is considered low and decreasing. There was a very small increase in the Midwest over the past week, but it's still moderate as it is in the South. The West and northeast are considered low. Emergency department visits are low and decreasing, and hospitalizations are also decreasing. Over the past week, 1.1% of inpatient beds and 1.1% of ICU beds were occupied by COVID patients. It's important to note for inpatient beds, the current number of 7763 patients is actually down from 8978 patients we talked about in our last podcast. This is about 13% lower than it was during our last episode. COVID deaths have decreased for five straight weeks now. The most recent week with complete data was the week of February 15th, when we lost 673 Americans to COVID. While a decrease in weekly deaths is the trend we want to see, what we really want to see is no weekly COVID deaths. We also recognize that infections that don't result in deaths will still have an impact. People experiencing Long COVID are still looking for answers. We're going to cover that in a bit more detail later in this episode. Finally, I will note that the COVID variant picture hasn't changed much with LP8.1 continues to grow in prevalence, now accounting for 47% of US cases, while XEC accounts for 25% of cases.

Dr. Osterholm: As I pointed out in the past podcast, I don't believe that these variant numbers really mean much to us anymore. In terms of predicting, are we going to see more or fewer infections in the community? At the risk of sounding like a broken record, but a welcome, broken record. RSV is improving across the board. The national wastewater level is low and decreasing, nearing the threshold considered to be very low. Emergency department visits for RSV are low and decreasing. Hospitalizations are decreasing, with less than 1% of both inpatient and ICU beds being occupied by RSV patients last week. 0.6% of inpatient beds were occupied by RSV patients last week, which is a 23% decrease from our last episode. 0.8% of the ICU beds were occupied by RSV patients, an 18% decrease from two weeks ago. To date, there have been an estimated 8600 to 20,000 RSV deaths this season and between 160,000 and 310,000 hospitalizations. Ultimately, things in the flu, COVID and RSV worlds seem to be improving, and we'll hopefully get to experience this relief for some time before we inevitably have another surge in activity. Hopefully not until next winter.

Chris Dall: It's been a while since we've discussed Long COVID, and I think our listeners have been letting us know that we haven't covered this topic in a while, and it is a fitting topic, it being the five-year anniversary of the beginning of the COVID-19 pandemic. So, Mike, is there any Long COVID research that's caught your eye recently?

Dr. Osterholm: Chris I'll just say at the outset, there's never enough Long COVID research. We need to do so much more. But you have raised a very important question. I do know it's been a while since we last covered Long COVID because there's not been a lot in the news. But in light of Long COVID Awareness Month and the five-year anniversary of the beginning of the pandemic, I want to share results of two recent Long COVID studies. The first was conducted among a cohort of over 2700 COVID patients in Spain. They found in that study that 1 in 4 COVID-19 survivors went on to develop Long COVID. Among these individuals have still experienced symptoms two years out from their infection. The researchers classified Long COVID into three subtypes one mild neuromuscular Long COVID, which accounted for half of the Long COVID cases. Two mild respiratory Long COVID, which accounted for about 20% of cases, and the third of severe multi-organ Long COVID, which accounted for about 30% of cases. Risk factors identified in the study were similar to those identified in other Long COVID studies. Being younger than 50 years of age. Being female. Severe acute infection.

Dr. Osterholm: Low socioeconomic status. Obesity and a history of chronic illness. Protective factors were also similar to those identified in other states. Vaccination. Being physically active and sleeping 6 to 8 hours per night. The second study I want to cover is one that looked at the economic cost of Long COVID on a very important point that is often glossed over. The researchers created a model to estimate the financial burden of Long COVID. They found that Long COVID cases cost U.S. employers somewhere between 1.9 billion and 6.5 billion annually due to productivity losses. While the suffering of patients alone is a good enough reason to fund research for Long COVID treatments. I hope that this study can provide additional motivation for government organizations and other groups to fund this critical research. Finally, I want to offer some words of support to all of those who are still suffering from Long COVID. Though we aren't able to cover Long COVID in every episode, please know that we are always thinking about it and reading your stories. We know that you are facing more uncertainty now than ever, and we will continue to advocate for better funding for Long COVID research.

Chris Dall: Another topic we haven't covered in a while for good reasons is the origin of the COVID-19 pandemic. But the topic has come back with a recent opinion piece in the New York Times. Is there anything new here, Mike, or is this just a rehashing of the argument we've been hearing for the last few years?

Dr. Osterholm: Chris, this is a difficult topic for me because I find myself in the position that no one seems to agree with. And what I mean by that is, is that, as most of the podcast audience knows, because I've talked about this on multiple occasions, I have been extremely concerned for almost 20 years about the issue of laboratory leaks or intentional releases with biologic agents. In 2012, when I was on the National Science Advisory Board for Biosecurity, the federal committee brought together to oversee the safety of research in the United States. And I wrote a letter at that time in relationship to a specific event that occurred around H5N1 influenza vaccine research, stating that we were just not prepared to deal with the potential for laboratory leaks and how we would police them, how we would assure that, in fact, research is not done that is dangerous. And at that time, I said, all we're doing is kicking the can down the road. We're not really solving this problem. That was not a very popular letter to write. A number of US government officials were not real happy with me because it did get some notoriety. Well, I sit here today and tell you that here in 2025, we're not any better prepared to deal with this same issue than we were in 2012. Now, what's important to understand here is we will continue to have this debate literally, I think, forever as to what happened in Wuhan.

Dr. Osterholm: Was it a laboratory leak or was it, in fact a spillover? And my point is, it doesn't matter. And what I mean by that, it doesn't matter. We'll not ever know. But what we can know is that both of these have the potential to happen in the future, and we're not preparing for either one of them. We're spending all of our time debating about how many angels can dance on the head of a pin, when we ought to be saying lab leaks are real, they're very important. And how are we going to police these, not just in the United States, but around the world, because a lab leak in some obscure country, anywhere in the world could be the agent that affects all of us tomorrow. So, we have a national and a global interest on this issue in terms of what happens with the spillover, how well are we prepared for the future to handle another big pandemic? We're not you know, I've completed writing my next book, The Big One, which will come out this summer. And this is not a plug for the book, but it explains why I care so much about this. I tried very hard to put together lessons that should have and could have been learned with COVID, and that we haven't understood that we haven't brought together in a cohesive way to say we can be better prepared for the future by understanding what went wrong or could have been done better in COVID.

Dr. Osterholm: And so, I sit here and say to everyone, stop debating this as if somehow there will be some kind of answer. I have to say, I was somewhat chagrined when I saw that the CIA switched their assessment of what happened in terms of how the virus entered into the general public these past several months. They went from a likelihood that it was a lab leak from a status of it was a spillover, but both of them were with low confidence. Well, what that means is you might as well just flip a coin for either one of them. I don't know why there's any difference between the two. So, at this point, all I can say, Chris, is I know we're going to continue to keep hearing about this. We'll have journalists who will do long exposés on who covered up what, when and where, who didn't do what. And let me just say, I think that the evidence from my perspective still favors potentially that it was a spillover then rather than a lab leak. But I don't know, and no one else will. So, let's get on with it. Let's get on with getting ourselves better prepared for the future, for both. Let's make both of them high priorities, lab leaks and spillovers. And the world will be a lot better off if we do that.

Chris Dall: Now it's time for our ID query. And this week we received many questions from listeners about COVID shots. Many of our listeners got their updated COVID shot in the fall and are now near or at six months from that shot. So, should they get another shot with the current vaccine or wait until the updated shots come out next fall? Will there even be an updated COVID vaccine in the fall? Mike, maybe we should start with a refresher on the CDC's current guidance on COVID vaccination.

Dr. Osterholm: Sure, Chris. Let's start with a refresher of the current guidance. The CDC recommends that everyone six months or older receive a 2024-2025 COVID-19 vaccine, which became available in August of 2020 for the Pfizer and Moderna vaccines, are approved for anyone six months or older, and the Novavax vaccine is approved for those 12 years and older. A second dose of the 2024 2025 vaccine is recommended for people ages 65 and older, and for anyone who is moderately or severely immunocompromised. The second dose is recommended to occur six months after the first, but at a minimum can be given up to two months apart. On top of these two doses, additional doses are recommended for those with immunocompromising conditions based on discussions between the patient and their doctor. We're coming up on the six-month mark since the updated vaccine became available, so I'm not surprised we're getting a lot of questions about this. If everything goes as planned, we would expect an updated vaccine to become available in about six months in August or September. That would mean for those that are eligible, receiving the second dose now would turn out well. Buying them six more months of coverage and ready for an updated dose in six months When they're ready.

Dr. Osterholm: I want to remind everyone that the studies are consistent. These extra doses of vaccines do significantly reduce hospitalization, deaths and the onset of Long COVID. Now, are they perfect? No. We may get 30 to 40 to 50% protection over time for these, but boy, that's a lot better than zero. Unfortunately, there's a lot of uncertainty about what will happen this fall and when. The CDC's Advisory Committee on Immunization Practice meeting that was scheduled for February was postponed, but a new date has not yet been announced. The draft agenda for this meeting includes discussions about considerations for the development and use of the 2025-2026 COVID-19 vaccine. This obviously begs the question of whether or not delaying these conversations will also delay the availability in the fall. The answer is we just don't know. For now, I can tell you what my plans are. As someone who is over 65 and is now just turning six months out from my most recent dose. Please remember, this is not medical advice. This is just what I am personally doing. I am getting my additional COVID dose very shortly and I'm very happy to be getting it.

Chris Dall: Now it's time for this week in public health history, and this is where we're going to return to where we began this episode, the five-year anniversary of the COVID-19 pandemic. Mike, you've been as busy as anyone else, but have you had time to reflect on this milestone from a public health perspective? Are we in a better place or a worse place from our experience with COVID-19?

Dr. Osterholm: Well, Chris, thank you for that question. And it's one that this podcast has made me take a step back and think about where am I with all of this? Remember that I've been deeply involved with considering, planning for, worrying about, and trying to respond to pandemic preparedness dating back almost 30 years. In my 2017 book Deadliest Enemies, I spent several chapters laying out what an influenza pandemic of some nature might look like, and you could take the words right out of that 2017 book and cross off influenza and put in a coronavirus, and it's what happened. So, I tend to be more on the side of always thinking about pandemics and how we can be better prepared for the future. But I think in the end, what means more to me than anything is much as my experience with HIV/AIDS. It's losing the personal and close friends, the colleagues, the people who I care about. And from that perspective, it is something I do think about a lot about where are we and are we in a better place? We've all been through a lot since the earliest days of the pandemic. Most notably, we've lost over 7 million people to COVID globally. I believe that's really a true undercount of the number of people who actually did die from COVID 1.2 million of those are right here in the United States.

Dr. Osterholm: These were our friends, our neighbors, our colleagues, our parents, our grandparents, and tragically, in some cases, even our children. An estimated 400 million people experience chronic symptoms due to Long COVID that left many people out of work, leading to both individual and societal economic crises. In addition to these cases and deaths. We've seen unprecedented levels of health care worker post-traumatic stress and burnout as a result of the pandemic, leading to critical staffing shortages. That leaves us unprepared to handle a regular flu season, let alone the next pandemic. We've seen public health become an increasingly partisan issue. Public health has always been policy related, but not truly political. While it does rely on government funding, it's all about influencing public policy with the best science, with the best information. Never before have I ever seen it become such a partisan political issue. We even saw partisan differences in COVID mortality rates after the vaccine became available, because uptake of the vaccine was heavily associated with political affiliation. We've watched the public lose trust in public health as the pandemic unfolded, though this mistrust is more common among Republicans than Democrats. It is far more than just a partisan issue. This mistrust is widespread among all political parties. We've spent five years on unproductive debate on the origin of the pandemic, as I just noted, while doing little to prioritize the funding and actions needed to reduce our vulnerability to both spillovers and laboratory leaks, and perhaps most concerningly of all, in recent months, we've watched our current administration dismantle the public health system that keeps us safe and dramatically reduces the amount of morbidity and mortality that we experience throughout the past pandemic.

Dr. Osterholm: And while that pandemic was devastating, it is not the big one. Trust me. It is not. There could be pandemics that are much worse. As I mentioned in a previous podcast, we've now uncovered a new MERS like virus in China in a bat cave that also has certain receptor sites that would allow it to be transmitted as readily as we saw with SARS-CoV-2. But we also know that MERS virus can kill up to 35% of the people who get it, not just the 1 to 2% of people who got COVID-19. All of that said, I would like to end things on a more positive note, reflecting on what we've gained over the past five years, namely you, the podcast family. We are approaching the fifth anniversary of the podcast on March 24th. Now, at our 185th episode of the podcast that includes 179 regular episodes and six special episodes during that time, we've shared with you not just the science, but also the more personal human side of the pandemic, beginning with our very first dedication to the late Doctor Alan Kind in our fifth episode in April 2020.

Dr. Osterholm: That was a turning point for this podcast. After that dedication, this podcast was no longer just a professor lecturing to an audience. It was all about a discussion with the podcast family. Since then, we've continued to share our heartfelt dedications, our minutes of sunlight, our closing songs. We've had the joys of reading your emails and cards and social media comments, which has gotten us through some of the most challenging times of the pandemic. We've answered your questions, or at least we've tried. We've listened to your feedback, and we've learned. And we even had the opportunity to share our beautiful places, moments of joy and celebrations of life. And hopefully, our plug of our favorite bar in New Zealand gave them a little bit of business. The podcast has changed the careers of our producers and research team for the better, and it's all thanks to you, our incredible podcast family. Thank you for being our silver lining during the very dark times of the pandemic. You have made a difference in our lives. Thank you.

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

Dr. Osterholm: Well, Chris, I couldn't decide which of 742 priority points here to leave the audience with today. So let me try to distill it down to three. First of all, we have to realize chaos is reigning supreme and human lives are in the balance because of this. Now is the time to stand up. Now is the time to be counted and to state clearly that this is unacceptable. Now, how you do that is unclear. Yet we're all working on trying to figure out what the right answer is. Remember three weeks ago we were talking about these major layoffs of key government employees. While that still has continued to happen at some level, now we're seeing many of these employees’ positions restored. It's unclear what's happening when, where and how. Just know that for the next few weeks, I think as the administration and the courts begin to settle on who has what jurisdiction over what issues and what can happen or can't happen, we in fact, will then see how we can have more impact as a public health community. For example, just today, there has been substantial discussion how USAID was literally dismantled as unfortunately, Mr.

Dr. Osterholm: Musk put into the wood chipper that may have been illegal. We'll see what the courts say this next week. And could a USAID actually come back into existence? I don't know. But number two, right now, I would urge all of you to focus on local issues, supporting your medical community and your public health agencies with vaccine education and practice. It's really important that local communities are supporting vaccine efforts there, and not allowing a few of the anti-vaccine community to take over and dominate meetings. So go to the school board meetings. Go to the city council meetings. Go to wherever you can. Have influence and stand up for what we need to do right now to minimize the pain and suffering of vaccine preventable diseases. And finally, the third point. I'm happy to report that the incidence of flu, COVID and RSV are dropping in all of our communities. But I also want to remind you, if you're eligible for that additional COVID vaccine, now's the time to get it.

Chris Dall: And Mike, what is your closing song for today?

Dr. Osterholm: Well, Chris, in light of the five-year anniversary of the pandemic, I wanted to choose a closing song that honors the traumatic experience that healthcare workers had during the pandemic, particularly in those very early days. This isn't a song that we've used before on the podcast, but it is one that our producers and research team were excited to use. Epiphany by Taylor Swift. It was released in July 2020 on Swift's eighth studio album, folklore. Written by Swift and producer Aaron Dessner. An epiphany. Swift compares the experience of healthcare workers in 2020 to her grandfather's experience as a soldier in World War Two. In an interview with Vogue about the song, Swift stated, my grandfather never talked about it. Not with his sons, not with his wife. Nobody got to hear about what happened there. So, I tried to imagine what would happen in order to make you never be able to speak about something. I realized there are people right now taking a 20-minute break between shifts at a hospital who are having this trauma happen to them that they will probably never want to speak about. I just thought this is an opportunity to maybe tell those stories five years later. This message about healthcare worker trauma still resonates with so many of us who remember the incredibly challenging early days of COVID. So here it is. Epiphany by Taylor Swift. Keep your helmet. Keep your life, son. Just a flesh wound. Here's your rifle. Crawling up the beaches now, sir. I think he's bleeding out. And some things you just can't speak about with you. I serve with you. I fall down, down. Watch you breathe in, watch you breathing out, out. Something med school did not cover. Someone's daughter. Someone's mother. Hold your hands through plastic now, doc, I think she's crashing out.

Dr. Osterholm: And some things you just can't speak about. Only 20 minutes to sleep, but you dream of some epiphany. Just one single glimpse of relief. To make some sense of what you've seen with you I serve with you I fall down, watch you breathe in. Watching you breathe out, out. Taylor Swift, thanks again for joining us on this fifth anniversary. I have to say again, thank you to all of you who hang together with us here. We appreciate you more than I can put into words. I know that this podcast family has been something special for so many of us, and you have made it that way. And so all I can say is hang with us. We're not done. We've got a lot of work to do in these next few years, and we're going to do it. And I'm hopeful that we're very close to making some announcements and future podcasts about what kind of work we're going to do to specifically take on issues related to what's happening right now in our public health world. I hope all of you are beginning to enjoy that sunlight. Enjoying spring. I know that this is a tough time. This is the time to reach out to people. This is the time to be kind. This is the time to not let the shock and awe make you feel as if nothing can be done. It's going to be. It can be. We must do it. And at this point, all I can say is I'm in the best company in the world with all of you to help get that done. So be kind today. Please be kind. And most of all, remember we need each other. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoy the podcast, please subscribe, rate and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease news by visiting our website cidrap.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to cirdap.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.