Episode 201: The Twilight Zone of Immunization

Chris Dall: Hello and welcome to the Osterholm update, a podcast on COVID-19 and other infectious diseases 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 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 on episode 175 of the podcast, posted on January 23rd, 2025, Dr. Osterholm and I focused on the Trump administration's announcement that the United States intended to withdraw from the World Health Organization. It was a move that, in retrospect, really represented the removal of the first brick in a public health foundation that the administration has steadily been tearing down ever since. When that announcement was made, it was just the beginning of a year long process. Any country leaving the WHO has to give one year's notice. But last week, the US made it official. And in the process, left behind some unpaid dues.

Chris Dall: Going forward, US engagement with the WHO will be limited strictly to effectuate our withdrawal and to safeguard the health and safety of the American people. Health and Human Services Secretary Robert F. Kennedy Jr. and Secretary of State Marco Rubio said in a joint statement: "All US funding for and staffing of WHO initiatives has ceased." It's a move that Infectious Disease Society of America President Ronald Nahass called "scientifically reckless" and "a short sighted and misguided abandonment of our global health commitments." The US withdrawal from the WHO will be among the topics of discussion on this January 29th episode of The Osterholm Update podcast, episode number 201. We'll also discuss some recent comments made by a CDC official and the chair of the Federal Vaccine Advisory Board on measles, vaccines and individual autonomy. We'll bring you the latest on US respiratory virus activity, discuss some CIDRAP news reporting on how the ICE deployment in Minnesota is discouraging people from seeking medical care and provide an update on mpox. And we have a listener inspired This Week in Public Health History segment. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.

Dr. Michael Osterholm: Thank you, Chris, and welcome back to the podcast family. Uh, it's wonderful to have you with us. And to those who may be listening for the first time, I hope we're able to provide you with the kind of information you're looking for. I promise we do have a wide range of information that we share. Uh, but before I begin, I just have to say that it's obvious to all of you that Minneapolis right now is the center of a great deal of pain and suffering. And you know that it's national news. It's international news. And all I can say is that it has been the worst of times. And I almost feel like I'm on this podcast today in a way, as if you're all my therapists out there helping us as the podcast team, work our way through this situation. As you know, the last podcast dedication was all about the events in Minneapolis. Well, they've devolved since that. I have a heartbreaking update to share with all of you that I'm sure actually many of you probably already know and or have seen. And that is on last Saturday morning, ICE agents shot and killed another person in South Minneapolis. His name is Alex Pretti. He was an ICU nurse at the VA hospital here in Minneapolis and a University of Minnesota alum. Many of his colleagues have taken to social media to share more about this incredible person that he was and that he was an excellent nurse, that he worked on Clostridium difficile trials to improve outcomes for patients, and that he was a good friend, a good son, and a good neighbor.

Dr. Michael Osterholm: There are no words that I can say that can adequately provide comfort to his community as we all grieve this terrible loss. But please know we are thinking of you, the family, the friends, the colleagues every single day. Just as we have not stopped thinking about Renée Good. To our listeners who live outside of the Minneapolis area, we appreciate each and every one of your kind messages of support for our team during this time. Please continue to raise awareness of what is happening here. It's easy for things like this to get lost in the very busy news cycle of life, especially as they go on for weeks and weeks. But please don't turn a blind eye and ignore what is happening here. It could happen to you tomorrow. Your support means the world to all of us here in Minnesota and specifically on this podcast. And to our listeners who live in the area, please know that we're here with you through this devastating time. What is happening right now should never, ever happen. And it's okay not to be okay in the face of the uncertainty and harm in our community. Lean on your neighbors for support when you need it and find ways to help wherever you can. We have seen a community response unlike anything any of us could have imagined in the face of these events. I think I can speak for everyone on the podcast team that it fills us with immense hope to see the thousands and thousands of little ways neighbors, people who don't even know who you are, are helping each other.

Dr. Michael Osterholm: I know that we're all tired and cold. We're sad, even scared. But please know that showing up for this issue is in fact a gift for our children and grandchildren. If you are in need of support, please don't hesitate to ask your neighbors, your colleagues, whoever for help. No one is meant to get through times like these alone. And fortunately, with the strong community here in Minnesota, no one has to. Let me conclude by just saying this has been the best of times and the worst of times. I cannot tell you what it's like to watch 40 to 50,000 peaceful individuals marching for the safety and security of our community. How many instances have restaurants and other stores put together care packages and delivered them to the homes of those people too afraid to come out? And let me remind you, this is not just about individuals who may be immigrants, people who have green cards or no green cards. Anyone who is Brown or Black right now is being targeted in this community. Individuals who are cops, not on service at the time, are being stopped, pulled over and required to provide papers. We have had many instances of individuals who have been stopped for following an ICE vehicle, only to have them pulled out of the car against their will, windows broken sometimes to get into the car, seat belts cut and then taken to a detention center for 10 or 12 hours and then allowed to leave. Meanwhile, their car sat in the middle of the road with no understanding of who's it was. What happened? It's just now they have to go find their car.  
This is unimaginable. So just continue to stay tough, but stay kind and peaceful. We will win. We will show that we are the Minnesotans who are proud to carry such a title. Let me move on to the actual dedication to someone who has championed around the world as a public health hero, Dr. William Foege, who sadly passed away this week at the age of 89. Bill was instrumental in developing the vaccination strategy that ultimately eradicated smallpox, which is widely recognized as one of the greatest public health achievements of all time, if not the greatest. I shared a statement this weekend about Bill on our CIDRAP website. I'd like to share that with you today. Bill was a dear friend and a colleague of mine. I have so many wonderful memories of interacting with Bill, and one of my most prized possessions is a signed copy with a beautiful inscription in his book, House on Fire: The Fight to Eradicate Smallpox. What I shared on the website was we are deeply saddened by the loss of Dr. William H. Foege, a towering figure in global public health whose visionary leadership changed the course of human history.

Dr. Michael Osterholm: Bill's contributions to the eradication of smallpox, and is one of the most extraordinary achievements in medicine and epidemiology. Under his guidance, a disease that once claimed millions of lives was brought to an end not through brute force but through ingenuity, scientific vigor, community engagement and a profound commitment to protecting the world's most vulnerable. His work did not just defeat a scourge, it redefined what is possible in public health and demonstrated the power of evidence-based strategies to build trust and save lives on a global scale. Bill's legacy is vast and enduring, and his efforts did not stop with smallpox. He inspired generations of public health professionals, strengthened immunization programs worldwide, and served the public with distinction, including leading the Centers for Disease Control and Prevention, then called the Centers for Disease Control, and co-founding the Task Force for Global Health. I'm one of those people who Bill inspired. I benefited from his mentorship and from his insight. For that, I count myself incredibly lucky. A feeling I know I share with many. I also had one commonality with Bill that we often refer to. Bill was born in Decorah, Iowa, a town just 18 miles away from where I was born. We both, in those early days, grew up in that Iowa environment, and that was important in the sense that Bill never forgot where he came from. As much as he was a man of great presence, he was a gentle man. He was someone who always gave everyone else credit.

Dr. Michael Osterholm: Bill's courage, creativity and compassion continues to guide all of us working to improve health across communities and borders. On behalf of CIDRAP, myself personally, we extend our deepest condolences to his family, colleagues and the countless millions, remember I said millions of individuals, whose lives were saved through his work. Bill's life is a testament to the profound impact that one dedicated individual can have on the health of humanity. Dr. William Foege., please rest in peace.  
Now, let me move to that part of the podcast that some of you can take your little break right now and come back in a moment. But for the rest of us, we're holding on tight to this one. Yes, indeed. Today in Minneapolis Saint Paul, sunrise is at 7:35 am, sunset is 5:16 pm. Starting to last longer every day. That's nine hours, 41 minutes, and six seconds of sunlight. We're gaining sunlight at the rate of two minutes and 28 seconds per day. Now to our dear, dear colleagues in Auckland, New Zealand, at the Occidental Belgian Beer House, today your sunrise is at 6:32 am, sunset at 8:34 pm, a whopping 14 hours, one minute and 46 seconds of sunlight. But you are losing sunlight at one minute and 50 seconds a day. Just in a few weeks, when we hit that March 21st date, we will both have the same length of sunlight and then at that point we will be in the ones with more sunlight  and we promise to share it with you.

Chris Dall: Mike, we'll get to the official US withdrawal from the WHO in a moment, but I want to start with some comments made last week by CDC Principal Deputy Director Ralph Abraham, and Advisory Committee on Immunization Practices Chair Kirk Malone. At a press briefing, Abraham said the current US measles outbreak and the potential loss of measles elimination status in the US is, quote, the cost of doing business, unquote, and that we have to respect the personal freedom of those who choose not to vaccinate. Malone, on a podcast, said ACIP was placing individual autonomy over public health and suggested we rethink the need for MMR and polio vaccines since we have better sanitation and less crowding than we did when those vaccines were introduced. Mike, there is a lot to unpack here, but it seems that the theme is a steady undermining of the idea that vaccines play a critical role in public health, and I would even go beyond that to say that Malone's comments seem to be essentially a rejection of the idea of public health itself. Is that how you see it?

Dr. Michael Osterholm: Well, Chris, let me go back and repeat a quote that I have now come to embrace with an understanding I never thought I would. And that was a statement that the late author Tom Clancy once shared with me. And I'll never forget him looking at me and saying, young man, there's one thing you must never forget. The only difference between reality and fiction is that fiction has to make sense. I now feel like I'm living in that world I could never have imagined. Public health leaders, or at least declared as such by the positions they hold in our government, saying the kinds of things they've had about vaccines. It is absolutely beyond reproach to hear a senior official casually state that the US is losing its measles elimination status is only because of the cost of doing business, pains me quite frankly. Having worked in the field of infectious diseases for more than 50 years, I can tell you that earning that status of measles elimination in 2000 was a remarkable public health milestone, and it really stands out as one of those rare moments in my career when everyone, my colleagues, the public could step back and say, this really worked. It felt like the start of a new chapter. It felt like what Bill Foege had previously brought us with smallpox. Let's remind all of our listeners what measles was like before the vaccine first showed up in 1963.

Dr. Michael Osterholm: On average, 48,000 children were hospitalized in this country with measles each and every year. 500 would die. Now, if you look at the rate of serious illness and deaths in children in 1963, it ranged from about 1 to 3 deaths per 1000 cases of measles. Well, in 2025, we had three deaths in 2200 cases of measles, a rate almost identical to that which we saw in the Pre-vaccine era. This is still a very bad disease, not one to take casually. Achieving the measles elimination status was no accident. It was the culmination of decades and decades of hard work, investment and collaboration. And it simply would not have happened without vaccines. So to now see the potential loss of the status treated as something is acceptable or no big deal is extremely disappointing, especially when it comes from officials who are charged with protecting the public's health. This confusion about vaccines leads to great hesitation, which then leads to less vaccination, which leads to more cases and more cases means more hospitalizations and deaths. It's just that simple. Let me remind people also about polio, because that too, was one of the diseases that was dismissed in the discussions by Ralph Abraham and Kirk Milhoan. Let me remind you that, in fact, prior to polio vaccines, there were up to 55,000 cases of polio every year in this country.

Dr. Michael Osterholm: Over 20,000 of those children were paralyzed, often existing in iron lungs. It's ironic that, in fact, Milhoan did not even understand that with better sanitation, polio cases increased, not decreased. Why? Because when poliovirus is transmitted to a young child under the age of one, which was frequently what occurred in a time of less sanitation, the infections were often asymptomatic or very mild. It was the children who were 3 to 12 years of age who were older, who when they got infected, we often saw the paralysis. And that happened when sanitation improved. We saw less early transmission and eventually the children in the community picked it up. Let me just conclude by saying one other thing that worries me is that this is not something we can just wait out. There's at least three more years of this administration. Even if leadership changes, these messages about these vaccines are already out there. They're circulating in the social media world. They're heard by many young parents. These messages are making the rounds and they're sticking. And as I've talked about it before, rebuilding trust once it's been undermined isn't easy. It takes time. It takes effort. It takes lots of listening. It takes wisdom. So it's difficult in a sobering reality, to say the least, to hear our public health leaders talk as they did this past week. Shame on them.

Chris Dall: While we're on the topic of measles, Mike, what is the current state of the measles outbreak in the US?

Dr. Michael Osterholm: Last week, the CDC, for the first four weeks of 2026, confirmed 416 total cases in 14 states. Of the 416 cases, 94% were linked to 49 outbreaks that actually began last year. The US is on track to lose its measles elimination status, which had earned in 2000. In the coming months, as measles cases accumulate, last year, the CDC confirmed 2255 US cases, including the three deaths I talked about a moment ago, the most since 1991. 86% of the 416 US cases so far this year have been in children and young adults, and 25% are in preschoolers. Among all the patients, 94% were unvaccinated or had an unknown vaccination status. South Carolina's upstate measles outbreak this week reached 789 cases, surpassing the 2025 West Texas outbreak, which sickened 762 and killed two. From last Friday to Tuesday, South Carolina confirmed 89 new cases. Currently, 557 people are in quarantine for 21 days. 20 are in isolation and 18 are hospitalized. Of all the cases, 88 are in children. Exposures at public schools with high numbers of unvaccinated students are primarily driving the outbreak, with more than 330 students from at least 20 schools in quarantine. Outbreaks occur when vaccination rates fall roughly below 95% for specific groups. The kindergarten vaccination rate in South Carolina was 91% during the 2024/25 school year. But it's much, much lower in the upstate area. In neighboring North Carolina, health officials confirmed 14 cases as of this last Tuesday, some directly tied to the South Carolina cases. In Union County, 170 people are in quarantine due to exposure to an unvaccinated child in a private school with low vaccination rates. The child's infection was linked to the South Carolina outbreak. Elsewhere in the country. Idaho documented two cases last week, and Maricopa County, Arizona confirmed two cases.  
 
As we've already discussed today, Immunization with two doses of measles, mumps and rubella is key to curbing these outbreaks and protecting vulnerable people, such as infants who are not yet vaccinated and those who can't be vaccinated for certain health reasons. Increasing vaccine uptake is a community effort, and we all need to do our part to get our country back on track in terms of dealing with measles. Let me just address one last context issue. I'm trying to understand where is measles in the United States going? And I think we have to look to Canada. Canada as a country has many of the same issues with vaccination levels, how the rates vary throughout the country. Remember, Canada throughout all of 2025 went from just a few cases a year to over 5436 cases documented. Think about that. 5436 cases, more than twice what we had. But to put this into context, remember, the United States has 340 million people. Canada has 41 million people. There's more than eight times the number of people living in the United States, than in Canada. If we were to have the same rate of measles as we see in Canada now, that would equate to about 43,800 cases of measles in the United States in one year. I think we could clearly replicate, unfortunately, the experience that we're seeing there. Imagine having so many measles cases that we look back on a time when there were only 2000 and say, boy, I wish we were back there again. So keep in mind, over the next 18 to 24 months, watching what will happen in this country and understanding that Canada surely is a model that we surely don't want to replicate, but one that I think we have to face the facts. We could be seeing in just the months ahead.

Chris Dall: We're going to turn now to the US withdrawal from the WHO. We've obviously known this was coming since it was first announced by the Trump administration last January, but it's no less shocking than it was a year ago. Kennedy and Rubio said in their statement that the United States, quote, will continue to lead the world in public health, saving millions of lives and protecting Americans at home by preventing infectious disease threats from reaching our shores, while advancing global health security through direct, bilateral and results driven partnerships, unquote. Mike, do you think that's possible? And furthermore, how badly is the WHO hurt by this move?

Dr. Michael Osterholm: Yes, Chris, as you said, this moment stems from the executive order issued on the first day of the president's second term, directing the US to leave WHO over supposed mishandling of COVID 19 and the resulting harm to Americans. Throughout the year, WHO officials urged the administration to reconsider, pointing to decades of collaboration that saved lives. The WHO strength has always come from long term partnerships, like the one it had with the US for funding, research, infrastructure, data sharing and emergency response. But the decision was essentially locked in and there was little room for negotiations from the administration. The claim from Kennedy and Rubio that the US will continue to lead the world in public health is delusional at best, and downright deceptive at worst. Our internal capacity has been weakened in the US. For example, there are 25 centers, institutes or offices at the CDC. Different levels of activity. Of those 25 CIOs, 24 currently are vacant in terms of leadership and across the board at CDC, there is no senior public health leadership. It's largely political appointees with no real skill set in public health. If a crisis were to happen today in our own country, forget about the rest of the world, the CDC would be ill prepared to respond. At this point, we no longer have the capacity in this country to respond with a strong technical infrastructure. Cuts across the CDC, NIH, and USAID over the past year have gutted much of that expertise, and externally, effective global health leadership relies on trust and coordination, something far harder to maintain outside the world's central public health body.

Dr. Michael Osterholm: This move isolates the US from critical disease surveillance networks, including efforts to match circulating influenza strains, to the seasonal vaccine. We will pay a price for not being able to stop emerging new outbreaks of potentially very significant and serious public health related viruses that now will spread to the United States, when at one time we could have stopped them in their tracks in some other distant country in terms of impacts to the WHO The immediate challenges are both financial and strategic. The US has historically been the organization's largest donor, contributing over $1 billion in recent years, and the sudden loss of those funds forces WHO to scale back or suspend activities across multiple regions. We no longer are able to provide our US experts to support the WHO in whatever efforts are occurring around the world. WHO leaders have openly stated that the withdrawal makes both the United States and the world less safe. Emphasizing that programs ranging from influenza surveillance to childhood immunizations rely on steady funding and technical collaboration. Although the WHO is resilient and still supported by 193 other member states, the absence of US financial and scientific leadership inevitably greatly weakens its capacity. And Chris, let me add one other point. We are watching the impact of what our leaving the WHO will do, but we also have to understand we did a great deal of damage to global public health with the demise of the US Agency for International Development, or USAID.

Dr. Michael Osterholm: Recent estimates support that about 14 million deaths will likely occur by 2030 that were preventable because of USAID pulling out of these low and middle income countries. Most of these deaths will be in young children. We'll see a major impact on HIV deaths, with an increase of over 65% over what would have occurred had we not pulled out. Or we'll see a 51% increase in malaria and over a 50% increase in neglected tropical diseases. So when you add in what has happened with WHO, and you then look at what we've done with USAID, you can see that the world is in for a lot of hurt. Now one may say, well, but maybe other countries will pick up the slack that we left, notably in Europe, which over the years has also been a major supporter of WHO. We've seen in the last three years there a big change in their allocations of resources to public health. Why? Because they've gone from 1 to 3% GDP supporting defense to now 5 to 7% GDP supporting defense largely as a result of what's happening in Ukraine. Those resources that might have gone to public health have now been diverted ever more frequently to defense related purposes. So at the same time that we're pulling out of WHO, we're also seeing the countries of Europe not supporting WHO with enhanced support. Another example of why we are in big trouble on a global public health basis.

Chris Dall: Now it's time for the US respiratory virus update. Mike, it looks like flu activity may be declining a bit across the country, so that's some good news. What are you seeing?

Dr. Michael Osterholm: That's exactly right, Chris. Flu activity remains elevated across the country, but it is definitely declining. But we're not out of the woods by any means. Overall, emergency department and outpatient visits for influenza like illness are all decreasing and approaching levels. We saw in mid to late December, which was in the middle of the ascent to the most recent peak. Similarly, flu related hospitalizations continue to decline. Now, it rates we were seeing in early December, right near the beginning of the surge in activity. If you look at outpatient visits for influenza like illness, they're down to 4.4%, which is down from that peak of 8.3% just three weeks ago. This is still above the national baseline of 3.1%. And let me remind you that we won't declare the end of the flu season until we are back below 3.1% and it looks stable at that level. I'll add that based on the same metric, only seven states right now are considered to have very high flu levels, down from 25 states during our last episode just two weeks ago. 23 states in the District of Columbia are now considered to have high levels of flu activity, up from 16. Ten are moderate, seven are low, and three are minimal. Bottom line is it's looking good when it comes to flu.

Dr. Michael Osterholm: One thing we are keeping a very close eye on is what is happening with school age children, those 5 to 17 years old. This is the only group that experienced an increase in ED visits, resulting in an influenza diagnosis last week. The respiratory season often is influenced by the spread that occurs with school age kids, and with what looks like could be the beginning of a rebound in ED visits among this age group. I wouldn't be shocked to see activity begin to tick upwards in other age groups as well. There have been 27 new pediatric deaths reported since our last episode, bringing us to 44 pediatric deaths so far this season. Remember that pediatric deaths are often late in getting reported, sometimes more than a month or even longer, before we know that they actually were confirmed. Influenza A continues to account for the vast majority of US cases. About 94% and 91% of those are the Influenza strain H3n2. Pretty much what we've seen all season. I do want to make a note of the fact that while 94% of cases are still Influenza A, that is down from 97% two weeks ago. I bring this up because in a typical flu season, we begin to see more Influenza B cases emerge as we move towards the latter months, and Influenza B tends to cause more severe cases in kids, which is something we have to be aware of and keep an eye on.

Dr. Michael Osterholm: We'll be looking closely at our pediatric populations in the days ahead. If you remember back to last flu season, we experienced what we called a double peak, in which activity seemed to peak right around New Year's and then declined for about 2 to 3 weeks before surging to even higher levels about a month after the first surge. While we're beyond those two weeks of declining activity, this virus has proven itself to be unpredictable. Time and time again, the virus will tell us what it's going to do in the coming months, but it may be given us a hint in the form of increasing Ed visits with kids. This is really a wait and see moment, but what I can tell you is that what happens in the next week or two is going to be very telling. And if we're going to see yet another double peak. Stay tuned for our next podcast episode. We should have a lot more information.

Chris Dall: And what about COVID 19 and RSV?

Dr. Michael Osterholm: In our last episode, I mentioned that COVID was looking like it could in fact be increasing across much of the country. But with the trends we're seeing now, I hope we just had a small flurry of activity that has now passed. The national wastewater concentration is now moderate, down from high and continues to decrease. Concentrations are decreasing in every region, with the Midwest being the only region where concentrations are still considered high and the Northeast being considered moderate. Unsurprisingly, of the 15 states with high or very high wastewater concentrations, 13 are either in the Midwest or Northeast. I'll also note that the West has maintained very low wastewater concentrations throughout most of this recent flurry of activity. COVID hospitalizations have decreased across every age group, and Ed visits resulting in a COVID diagnosis have decreased in nearly every age group, with the exception of the 5 to 17 year old age group. Which, let me remind you, is the same group. We saw the increase in flu ED visits last week. We do have a new variant update from CDC, but the picture remains relatively unchanged from at least one month ago. So for now, I don't think we have any concerns about a new variant emerging that will result in a sudden increase in cases. Now, looking at RSV activities remained elevated. The national wastewater concentration is now considered low as opposed to very low, with concentrations increasing in every region except the South.

Dr. Michael Osterholm: The South has the highest concentration, followed by the Northeast. Both are considered moderate. Four states, Louisiana, Maryland, Massachusetts, and Virginia, are considered very high in five states Arkansas, Connecticut, Georgia, Hawaii, and Kentucky, as well as the District of Columbia, have high concentrations. Overall, ED visits for RSV have declined, but noting that there still have been increases in both the 1 to 4 year olds and the 5 to 7 year old age groups. Similarly, over the last week, hospitalizations for RSV have declined overall, with the less than one year old age group having the highest rates of RSV hospitalization. Ultimately, I'll say that it is most definitely respiratory season. Chris. COVID and flu are both showing some signs of decline, but they're also hinting at potential rebounds based on the increasing ED visits in school age kids 5 to 17 years of age, and it's notable that RSV levels are still elevated. All you can do is continue to monitor activity and encourage everyone to take precautions, like staying home when you're sick or wearing an N-95 respirator when you're in public. Those are the things you can do right now to help best protect yourself. It may be a little bit too late for vaccine to have much impact.

Chris Dall: It should be no surprise that hospitals in Minnesota are very busy during the winter respiratory season, and that's no different this year than for many other year. But what some of our listeners might not know is that the deployment of nearly 3000 Immigration and Customs Enforcement officers in the state is leading a growing number of people to cancel important and even life saving medical appointments. Can you fill our listeners in on some of what we're learning about this?

Dr. Michael Osterholm: Chris, this is just another heartbreaking example, the way our community has been impacted here. As you mentioned, Minnesota residents are delaying medical care due to fears about the ongoing ICE operations in our state. This includes not just undocumented immigrants, but also citizens and other immigrants that are here under work permits, permanent residency status or other legal routes. On top of all of that, anyone who has Black or Brown skin right now can easily be targeted for a stop. Pulled over, Asked to see papers supporting the fact that they're actually US citizens. This has even happened to off duty police who are from communities here in the Twin Cities that have been stopped and asked for proof of their citizenship. This is so painful, but this is the underlying feature of why we're talking about this issue with the medical care system. These fears come after reports of ICE present in hospitals and clinics throughout the state, sometimes with a judicial warrant and other times without. This is to detain patients and staff among these hospitals where ICE has been present is the Mayo Clinic in Rochester, Minnesota, which serves some of the nation's most medically complex patients, often those with rare diseases who have few options for treatment outside of the Mayo Clinic. And it's not just being at the hospitals and clinics themselves that pose a risk. Simply getting to appointments has proven dangerous for some individuals, including a US citizen named Aliya Rahman, who was pulled out of her car by ICE agents on her way to a medical appointment at a traumatic brain injury treatment program in Minneapolis two weeks ago. She was pulled from the car. They used a knife to cut her seatbelt, and despite her pleadings to say she was on her way to this important medical appointment, she was detained and not allowed to make that appointment.

Dr. Michael Osterholm: These threats to patient safety that have led to delayed medical care have devastating consequences. Just let me give you a couple of examples. Two weeks ago, a Minnesota child suffered a severe case of appendicitis that could have been treated much earlier had his family not feared bringing him to the hospital. A US citizen and a mother of nine children has canceled routine well-child visits for her newborn due to fears of being detained by ICE on the way to the clinic. These examples are so important in helping us understand that everyone impacted is not a number, but a person with a story. One of our CIDRAP news reporters, Liz Sazbo, did an outstanding article about this issue that was posted to our website last week. We will link it for you in the show notes, and I encourage you to read it to get a better sense of what is happening in Minnesota and how it is impacting the health of our state. I want to be clear. What I just said is not about partisan politics. This is about public health. Public health is grounded in the belief that health is a human right, and no person should be afraid to seek medical care. What we're seeing right now in this state is the antithesis of core values that ground our work every day. And just as we've spoken out about other recent attacks on public health, we must continue to speak out on this one. It is simply tragic.

Chris Dall: We haven't discussed mpox in a while, but there has been some news recently. What can you tell us?

Dr. Michael Osterholm: Although we haven't covered mpox in a while on the podcast, it still remains a threat to global public health. A study published a couple of weeks ago in the Journal of Infectious Diseases determined that neutralizing antibodies against mpox declined substantially within two years of vaccination or infection. In this study, researchers followed 90 men, 48 who had had prior mpox infection and 42 had received the vaccination and measured the impact specific antibodies more than two years later at the two year mark. Antibodies were low or undetectable in both groups. For mpox, cases occurred during the study follow up period, all of which occurred in vaccine recipients, indicating that we may need to consider booster doses in the future for those at high risk of infection. This will be a very important point of consideration in the days ahead. There are currently multiple strains of mpox circulating globally. As a reminder to our listeners, there are two major clades of mpox clade I and clade II. The global outbreak that started in May 2022 was caused by clade two, and that strain of mpox is still circulating worldwide today. In the US, there are over 100 mpox cases reported in December 2025, most of which were clade II. The other clade, clade I, has been found less frequently outside of Central Africa, where it is considered endemic and is associated with a higher mortality rate.

Dr. Michael Osterholm: However, in the fall of 2025, community spread of clade IB mpox was reported in multiple regions outside of Central Africa, including the US and European countries. More recently, an inter clade recombinant mpox virus, meaning a novel strain of mpox composed of both clade I and clade II gene sequences, was detected in England in a traveler returning from Asia. Although the risk to mpox to the general public in the US remains low, it is clear that this virus is continuing to spread and evolve, and we should remain vigilant of mpox as an emerging public health threat. A study published in Eurosurveillance in 2025 determined that the primary mode of transmission of clade IB mpox, in the Democratic Republic of Congo was through household exposure, not sexual contact as was previously thought. Although overall mortality reported in the study was low less than 1%, it was more than five times higher in infants, indicating that certain populations are likely at higher risk of severe disease and death. Chris, as we continue to learn more about the mpox virus, high risk groups and potential changes to vaccination recommendations will keep our podcast audience informed of these important updates.

Chris Dall: Now it's time for this Week in Public Health History, which we are combining this week with our ID query segment. This mashup was inspired by an email we received from Michael, who wrote: "My family and I are traveling in East Africa over the holidays, where we learned about the profound ecological and socioeconomic devastation caused by the introduction of the Rinderpestvirus into cattle and wildlife in Africa. We've also learned that as of June 2011, Rinderpestwas declared only the second viral illness to be eradicated by vaccination. I found myself thinking that a highly abbreviated Rinderpeststory might be a good topic for this Week in Public Health History segment. So, Mike, what can you tell Michael and the rest of us about Rinderpestand its eradication?

Dr. Michael Osterholm: Well, Chris, let me be really clear. When we talk about the word eradicated that is reserved for the fact that a virus no longer circulates in the population, meaning it is not in a reservoir animal population somewhere. It's not in humans. Eradication applies to when in fact there is no other source of the virus except what might possibly be in a laboratory. The only other disease for which we actually had that happen was smallpox in humans, for which the virus only circulated in humans. As we'll discuss in a moment, Rinderpest only circulated in certain animal populations. The term Rinderpest comes from the German phrase for cattle plague. Rinderpest is caused by the Morbillivirus, which falls under the same genus as human measles. In fact, scientific evidence suggests that measles may have been the result of a spillover of Rinderpest virus from cattle to humans as far back as the sixth century B.C.E. Rinderpest virus is highly contagious and often fatal in cloven foot mammals like cattle and buffalo. While it does not infect humans, the loss of entire herds were catastrophic for human health, driving famine, food insecurity, and economic collapse in 18th century Europe. Outbreaks were devastating, perhaps exceeding 200 million deaths in cattle by 1871. There was a convention in Vienna to determine how to best control infected herds and avoid transporting infected animals across the continent, but European imperialism only amplified this problem. Around the same time, imported Rinderpest began decimating cattle herds across Africa, taking out more than 90% of the animals in key regions.

Dr. Michael Osterholm: Many other wildlife, including wildebeast, antelope and buffalo were affected, making quarantine measures nearly impossible. This was especially devastating to the many pastoralist communities who lost both their food source and livelihoods. The loss resulted in human famine and an entire ecological shift due to fewer grazing animals. But the veterinarian public health communities recognize the scale of the threat and were looking for ways to stop this deadly disease. Although the responsible pathogen had not yet been identified in the days prior to virus isolation, it didn't stop scientists from creating inoculations. Some of those created for rabies and smallpox. Progress was slow, and early vaccines had limited success. By the time World War II began, global concern shifted to North America. Rinderpest virus had not only taken hold there, but there were major concerns of biological warfare introduction of the virus to further deplete food supply access to the Allied nations. Ultimately, defeating Rinderpest required an unprecedented international cooperation. The founding of the United Nations provided a new structure to bring scientists together for the common good, for global health and veterinary health. Over the following decades, improved vaccines were developed, quarantine and isolation procedures drafted, surveillance measures deployed, and veterinarians trained. After decades of sustained global effort, Rinderpest virus was finally declared eradicated in June 2011. The Rinderpest story reminds us that while basic scientific discovery and clinical research are essential, we also need systems to coordinate and work in harmony. Infectious diseases do not care about national borders. Therefore, our efforts must always remain globally interconnected.

Chris Dall: Mike. One additional item here. This week, CIDRAP announced a collaboration with two groups the Evidence Collective and Unbiased Science to support independent, evidence based vaccine information.

Dr. Michael Osterholm: Well, Chris, this is really an exciting partnership to support independent, evidence-based vaccine information. I think most of our listeners will surely recognize immediately that the Evidence Collective, co-founded by doctors  Katelyn Jetelina and Jess Steier, has a very important role in promoting scientifically sound information and taking head on that mis and disinformation that continues to be a challenge. The Evidence Collective is a consortium of 25 plus scientists and clinicians, with combined monthly reach of more than 150 million people. At the same time, Unbiased Science is a science communication organization that reaches up to 30 million people monthly, backed by an interdisciplinary team of public health professionals, clinicians, immunologists, epidemiologists, and toxicologists. This team makes health science feel human using social media, infographics, video, podcasts, and long form storytelling to connect with general audiences, not just to talk at them. This is led by Dr. Steier, who I believe is one of the single best public health communicators that we have fighting the issues of the day. So we're very excited to be working with these groups. They already have done amazing things, and we hope our partnership between what we offer at CIDRAP and what they offer together can enhance this whole idea of promoting independent, evidence based vaccine information. Stay tuned. You're going to hear a lot more about this in the future.

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

Dr. Michael Osterholm: With each podcast? You know, I try to come up with three main points that I think are really important takeaways. This particular podcast, I think I have about 187 take home points, but I'll try to summarize about 880 of them in one bullet. We are in the Twilight Zone of immunization. Another way to describe it. This is the Twilight Zone. In reality, much of what we're seeing happen today falls under that rubric of "I can't believe this just happened." This past week the discussion by two senior HHS appointed leaders is absolutely mind blowing. To think that they could suggest that maybe we should just postpone measles, mumps, rubella and polio vaccines for a couple of years to see what happens. I can't put my reactions in words that adequately express my frustration, my concerns, and frankly, my anger. We are playing with our children's and grandchildren's lives. It's straightforward and simple. We are in the Twilight Zone of immunization. In terms of our second point, yep flu and COVID and RSV are still there. Uh, we're going to be waiting to see if we have a rebound effect with flu and maybe COVID in the next couple of weeks, but if not, uh, hopefully on its way down and out.

Dr. Michael Osterholm: And finally, measles. We are going to have a huge challenge over the course of the next year with measles. No other way to sugarcoat it. And I worry that we could be a replay of what's happening in Canada, which would put our cases of measles into the tens of thousands of cases. We will look back one day and say, boy, things weren't so bad at a couple hundred cases, which in fact, of course, if that had happened two years ago before we were close to losing our measles elimination status, we would have said, wow, a couple of cases of measles was really bad. So at this point, all I can say is, hang in there, we're here. We'll keep informing you of what we know. Our Vaccine Integrity Project is continuing to take head on the issues of vaccines in this administration. We will not stop. As I've said time and time again about our activities at CIDRAP and the Vaccine Integrity Project, we will bend and we will bend, but we will not break.

Chris Dall: Mike, in the dedication to Dr. Foege, you mentioned his 2011 book House on Fire, and I believe you look to that book for some inspiration for this closing.

Dr. Michael Osterholm: Chris, in fact, the book that I have in my hand at this very moment is a signed and inscribed copy of Bill Foege's House on Fire: The Fight to Eradicate Smallpox. A book of wisdom, a book of humility, a book of honor, and a book of vision. That was Bill Foege. And by the way, for those who had never met Dr. Foege, and I know many of you have. At six foot seven, he was a towering giant. And yet when he was in the room, he made everybody feel bigger than him. That was one of his gifts. That was one of his unique talents to be able to make so many things happen for so many people in the public health world, but I thought that the closing to Bill's book really captures the moment, both in terms of the eradication of smallpox, his death, and what we're experiencing in our communities today. So here it is. Bill Foege's closing comments in the book House on Fire.  
"This is a cause and effect world. As smallpox disappeared because of a plan conceived and implemented on purpose by people. Humanity does not have to live in a world of plagues, disastrous governments, conflict, and uncontrollable health risks. The coordinated action of a group of dedicated people can plan for and bring about a better future. The fact of smallpox eradication remains a constant reminder that we should settle for nothing less." -- Bill Foege. 
 
Well, thank you all for being with us again, this, uh, podcast. Uh, a lot of hard information. Uh, but we're trying to do our best to take it on, share it with you, but also do what we can to change the course of what we're talking about. I just can't emphasize enough right now how important it is to be kind and thoughtful. I emphasize that again, in light of what's happening here in Minnesota and seen what all of those very peaceful but committed individuals in our communities are doing to take on this horrible situation. They're doing it with kindness. They're doing it with purpose. They're taking care of those in our communities that need that. Please think about your own lives right now and what you can do to help, even if you're not in a Minnesota community anywhere in the world right now. What can I do to help respond to this terrible situation we find ourselves in? So thank you. I hope that in two weeks I can report much better news. And in the meantime, we're just going to keep going at it. And we will not give up, as I've said before. Be kind, be thoughtful, and thank you so much for being with us and being a part of this podcast family. I feel like I got my therapy session in today. It meant a lot. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm update. If you enjoyed 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. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP. Support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Meredith Arpey, Leah Moat, Emily Smith, Claire Stoddart, Angela Ulrich, and Mary VanBeusekom.