Episode 205: Disease Waits for No One

Chris Dall: Hello and welcome to the Osterholm Update, a podcast about infectious diseases and public health featuring 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 over 50 years of experience in infectious disease epidemiology to provide straight talk on the latest infectious disease outbreaks, counter misinformation and disinformation about vaccines, and distill the complex and ever evolving public health threats facing our world. 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. In a ruling last week that temporarily halted a year of upheaval of US vaccine policy by Health and Human Services Secretary Robert F Kennedy Jr, US District Court Judge Brian Murphy wrote that there is a method to how decisions about the clinical use of vaccines have historically been made in the country, a method that is both "scientific in nature and codified into law by procedural requirements". Unfortunately, the government has disregarded those methods and thereby undermine the integrity of its actions. Judge Murphy wrote in his decision on the case, which was brought by the American Academy of Pediatrics and other US medical organizations.

Chris Dall: The temporary injunction granted by Murphy, for the moment at least, means that the federal government must restore the vaccine recommendations that were in place when Kennedy took office. But as Doctor Osterholm noted in comments to media outlets, the temporary legal victory won't put the genie back in the bottle. And that's one of the issues we'll be examining on this March 26th episode of the Osterholm update episode number 205. Has the damage from Kennedy's assault on US vaccine policy already been done, and can it be undone? We'll also discuss a leaked report that calls for sweeping changes to how the government tracks COVID vaccine harms. Explore the meningitis outbreak in the United Kingdom, provide an update on COVID, flu and RSV activity. Discuss the latest on measles and avian flu and answer an ID query on the risk of catching COVID in public, and we'll bring you the latest installment of our This Week in Public Health History segment. But before we get started, as always, we will begin with Dr. Osterholm's opening comments and dedication.

Dr. Osterholm: Thank you, Chris, and welcome back to the podcast family. It's good to be with you again. These two weeks seem to take forever, and yet at the same time they seem to happen overnight. So I always enjoy this opportunity to spend some time with you. And for those of you who may be new to the podcast or are someone who comes occasionally, I hope we're able to provide you with the kind of information you're looking for. We have a lot to cover this week. It's a whole mixture of issues of science policy and just, frankly, involves life itself. Now, before I begin, I want to do a shout out that's going to sound somewhat selfish, I'm sure. As anyone who's been listening to this podcast over recent months knows, our heart, souls, and minds have been together with other Minnesotans dealing with the challenges that the ICE invasion brought to this community. And I am so pleased to be able to announce today that earlier this week, we were informed that the John F Kennedy Profile in Courage Award was going to be granted to the citizens of Minnesota for their stand against the federal immigration enforcement activities. Nothing has ever been done like this before with the JFK Profile in Courage Award. This tells you something about how we in Minnesota value life, how we value our freedoms, how we value our obligations, and how we value kindness.

Dr. Osterholm: And so I am really, truly grateful to all of my fellow Minnesotans who stood up during this very, very critical time. We in Minnesota value all of you and particularly this podcast family. Now, let me move to what has always been the traditional dedication and one that really follows on the back of what I just shared with you. This month is the six year anniversary since COVID-19 was declared a pandemic. It's hard to believe it's already been six years, but it's important to reflect on this critical moment in history, a moment that has drastically shifted how we think of health science and the international community at large. A recent study published this month by Science Advances estimates that we greatly undercounted COVID deaths, particularly in the early part of the pandemic. The study was led by a Stanford University investigator who used machine learning, a type of artificial intelligence, to predict unrecognized COVID 19 fatalities. From March 2020 to December 2021, virtually the first two years of the pandemic. The model was trained on US death certificates and according to the study, COVID-19 deaths were underreported by about 19%. The study also found that these predicted deaths disproportionately affected people of different races and backgrounds. The researchers concluded, and I quote "Together, this study indicates the US Death investigation system reported COVID-19 deaths in a systematic and equitable way that hid the true extent of the pandemic mortality and inequality," unquote.

Dr. Osterholm: If you'd like to know more about this study and the implications, CIDRAP's Mary VanBuesekom wrote an article that breaks down the study. It shares with you an important perspective of what was accomplished with this study. We'll link this article to our show notes so you can feel free to go in and easily get to Mary's article. So in short, we're dedicating this episode to all the people who have lost loved ones to COVID, to all the frontline and essential workers who worked throughout the pandemic, including the countless brave nurses, doctors and health care workers. To people still suffering with the consequences of long COVID, and to the incredible scientists and researchers who worked together to create the COVID vaccines. We're thinking of all of you, and we have not forgotten you. Now, let me move to that very special time in the podcast for all of us who are looking forward to this. I have great news. To those of you that do not look forward to this, give me a minute. Come on back. I'm very happy to report on March 26th here in Minneapolis, St. Paul, Minnesota, the sun will rise at 7:04 am.

Dr. Osterholm: It will set at 7:03 pm. That's 12 hours, 28 minutes and 38 seconds of sunlight. This week marks an important part of the sunlight season here in Minnesota, as it's just until Sunday that we continue to see the amount of sunlight increasing each day. Today and every day through this coming Sunday, we will see an additional three minutes and eight seconds of sunlight with that particular day that levels off on Sunday and next Monday, we actually start seeing the increase continue in sunlight, but the rate at which it increases will drop until, of course, we get to that June 21st time period, when then we go the other way. And for all of you in Auckland, particularly those at the Occidental Belgian Beer House on Vulcan Lane, I'm happy to report to you. You're still getting a lot of sunlight today. Your sunrise is at 7:28 am, your sunset is at 7:24 pm. That's 11 hours, 55 minutes and 23 seconds. So you just got below that 12 hour mark. Unfortunately, you are losing about two minutes and 20 seconds of sunlight a day. But let me remind you, we're happy to share our sunlight with you. And we know that in six short months from now, we're all going to have the tables turned, and we'll be looking forward to working with you.

Chris Dall: Mike, I think everyone who cares about public health and infectious diseases breathed a sigh of relief when Judge Murphy's ruling came down last week, but it is temporary. The administration will likely appeal it and very well could win that appeal. So let's start by explaining exactly what the ruling means for now.

Dr. Osterholm: You're exactly right, Chris. I think there was a collective sigh of relief when the news of the ruling was announced, but at the same time, it was a hesitant sigh, which we'll talk about shortly. But before we discuss the implications of the move, I think in addition to what you mentioned in your introduction, a quick overview of what happened will provide helpful context. First of all, I want to just acknowledge that while the American Academy of Pediatrics has carried the heavy load on this issue and has been the agency or organization seen out in front of it. We also saw the American Public Health Association, the American College of Physicians, the Infectious Disease Society of America, the Massachusetts Public Health Alliance, the society for Maternal and Fetal Medicine, and the Massachusetts chapter of the American Academy of Pediatrics also were all involved in supporting this litigation. Now, it's really important to understand, as you just did, that at the heart of what was going on with this litigation was really to stop the current administration from carrying out the policies that they have put forward that violate official government practice. Now, I want to be really, really clear, though, that as much as we saw this as a victory, we know that this is an uncertain victory and it shouldn't distract us from staying focused on defending health in general. And what do I mean by that? Well, we do have a piece from the Vaccine Integrity Project this past week that addresses this.

Dr. Osterholm: Again, as many of you know, the Vaccine Integrity Project is a very important part of an activity that we're doing in CIDRAP to make certain that we can protect the infrastructure and the enterprise of vaccine availability. And I think as many of you know, the vaccine integrity project is a very key activity inside of CIDRAP to both produce the evidence for why vaccines work and they should be used and how recommendations should be considered in that scientific evidence, as well as the fact of providing important information to the public that otherwise might not be available. In this situation, we did offer a viewpoint that will help you better understand what happened with the legal proceedings of the past week, and what it means for the future. We have put this in our show notes so that you can link right to the article, but let me just read for you the first paragraph or two of that viewpoint, because I think it sets up the situation as well as anything I can do myself. It starts out by saying "In medicine, when patient's signs fluctuate, we do not declare the crisis over because one number temporarily looks better. We look at the whole clinical picture, we examine trends, and above all, we stay focused on the evidence."

Dr. Osterholm: The clinical picture for vaccine policy in the United States suddenly seems more confusing than at any point in the past year. On Monday, a federal judge in Boston blocked the US Department of Health and Human Services newly weakened childhood immunization schedule and indicated that HHS Secretary Robert Kennedy Jr likely violated federal rules when he fired and replaced members of the CDC's Advisory Committee on Immunization Practices. The rulings were unequivocally good news for children's health, but the judge's opinions are unlikely to be the final word in this case. So at this point, there is still no indication of what a substantive course correction will look like. Will there in fact be an effort to bring back the old ASIP? Will there be a third ASIP organization created? Not the original one that Mr. Kennedy inherited or the one he appointed, but another one? What will this all mean? I think the important note here to make is for the public. This particular event, while we see it as a victory, actually just continues to weaken the traditional guardrails of evidence based vaccine recommendations and results in substantial increases in doubt. This is a challenge, and particularly if, in fact, this ruling could be overturned at a higher appeals court level. What will the public think then? Will they think, oh my, the science community is taking on the government in a way that is trying to hold back important and useful information that I should consider when I'm thinking about vaccinating my kids.

Dr. Osterholm: This is going to be a challenge. Now, ultimately we want to win. We want to win all of those. But I think in the meantime, we're going to get bloodied. We're going to get beat up a bit as this goes through the appeals court. So there is a real need for continued vigilance, for urgency, for looking at this as if we didn't win. All we did has got a temporary respite in what's happening. So remember, the disease is not on hold. It is continuing to spread out there. We're going to talk about measles today and the challenge with it. We cannot afford to ever think of the diseases on hold because somehow we have a favorable court ruling. So I think, Chris, the bottom line message from me on all of this is stay tuned, but just know that we're a long ways from being done. We need to keep our eyes on this effort. We need to continue to be vigilant. We need to keep our eye on what will happen with the administration's future decisions. And at this point, just consider all that was reversed, or at least put on hold with this court ruling doesn't change the fact that tomorrow it could become the law of the land, depending on how the courts decide.

Chris Dall: Mike, you just mentioned increased doubt. And that really gets to the bigger question here. Do you think that Kennedy has already undermined confidence in vaccines to the extent that the damage is done? Are you, as parents, ever going to trust the government's vaccine recommendations again? And how can that trust be regained?

Dr. Osterholm: Chris, if I could answer the very important questions you just asked with certainty, I think I should just do that and retire and call it a good career. Unfortunately, I can't. I'm here. I've got to stay here. CIDRAP is going to stay here. We're going to continue to do what we must do to protect the vaccine enterprise, but we can at least begin to understand and address in a way that hopefully helps the situation. In terms of what will the public think about all this happening here? This is where the hesitation. In those sighs of relief we talked about come in. This is why I just cautioned everyone do not be complacent about what happened this past week. As I shared with you, our Vaccine Integrity Project did release a viewpoint on this very issue, and I hope that you'll take the time to go read it. The simple answer to your first question is yes. I think the Kennedy actions have absolutely undermined confidence in vaccines, and damage has certainly been done. As I've said in my New York Times interview, we cannot put the genie back in the bottle, unfortunately. A new poll from Axios and Ipsos American Health Index, released last week, found that from June 2025 to March 2026, public trust in childhood vaccine recommendations fell from 71% to 60%. Incredible. When asked about which source to trust for childhood vaccine guidelines, a third of individuals expressed more confidence in AAPs guidelines.

Dr. Osterholm: 8% expressed more confidence in CDC guidelines, 23% had no preference, and 18% said they were not confident in either source. Only a third of individuals in this country expressed more confidence in the AAP's guidelines than the other ones. Only a third. The numbers are alarming, but one finding really stood out to me. 30% of the individuals polled believe that childhood vaccine guidance from federal health agencies mainly reflects the view of the Trump administration. 30% believe it reflects the views of career scientists at public health agencies, and nearly 40% reported being unsure. In other words, we're talking about 70% of the public did not have confidence, in a sense, in what the federal agencies or what public health, as we think of it today, actually is putting forward for guidelines. All I can say, Chris, this is extremely concerning. All public health guidance, including vaccine recommendations, needs to be based on science, not ideology. This is damage that will take decades to repair if repair is even possible. And unfortunately, the consequence of not repairing that or finding at least challenges to repairing that is we're going to see more and more individuals in this country, both children and adults, who will succumb to infectious diseases that our grandparents or our great grandparents feared. Year after year. But our parents and now our children have often been able to avoid. That is going to be the real challenge. And let me just say, I don't know if us parents will ever trust the government's vaccine recommendations again, but what I do know is that there are independent groups, including our own, who are working to provide evidence based recommendations that parents can trust.

Dr. Osterholm: Let me share. Additional information was included in the VIP viewpoint that I mentioned in the previous question, because I think it summarizes how we can regain trust and what we're doing to help. I quote "Those of us involved in efforts to preserve evidence based vaccine recommendations, medical specialty societies, independent public health and academic organizations, and state coalitions can't take our foot off the gas. It's time to intensify efforts." That's what we're doing at the Vaccine Integrity Project. Historically, ACIP's strength derived not from its statutory authority but from the credibility of its process. That credibility was earned through transparency, methodologic rigor, the demonstrated qualifications of its members, and insulation from political pressure. If those attributes continue to be eroded, they must be preserved elsewhere until they can be restored. Disease is not on hold. We can't afford to be either. I'm not sure we can quite conceptualize the extent of the damage the administration has done to public health here. What I can tell you with certainty is that every single one of us here at CIDRAP and VIP is committed to providing unbiased, evidence based science that you can trust, and it is an honor to do so.

Chris Dall: As you noted, Mike, the ruling also meant that the Advisory Committee on Immunization Practices could not meet last week. And basically that group has been essentially disbanded for the moment. But prior to the meeting, there was a story in The New York Times about a report that a federal workgroup was planning to present at the ACIP's meeting on COVID vaccine harms. What do we know about this report?

Dr. Osterholm: Just a day before the judge's ruling on the ACIP petition, The New York Times cited a leaked report prepared for the canceled meeting that a federal workgroup is calling for the creation of a new clinical diagnostic category called, quote, "Post-acute COVID 19 vaccination syndrome," unquote. The so-called syndrome is described as a subtle symptoms involving multiple organ systems lasting at least 12 weeks after vaccination. That can't be explained by any other condition. The group is proposing a new ICD ten diagnostic code, along with clinical guidelines in a national network of specialized treatment centers. At this point, surely sounds like we got a problem. Well, in response, Doctor Jake Scott, one of our very valued op ed contributors to CIDRAP and a professor in infectious diseases at Stanford, wrote an op ed for CIDRAP news on how the proposed syndrome isn't supported by strong evidence, starting with the report's opening summary. The summary says that existing estimates range from 0.003% to the general population to 0.9% of the young and middle aged people. A 300 fold difference, which Dr. Scott points out, is drawn from just one cited paper as he wrote, quote, A clinical entity whose prevalence cannot be estimated within three orders of magnitude, is not ready for ICD ten codification. It is ready for more research. On top of that, the proposed diagnostic system relies on unvalidated tests that won't allow doctors to rule out causes other than what they are considering to be a vaccine injury. But the most important claim in the report is based on an analysis of a Japanese database of 18 million people.

Dr. Osterholm: The paper claimed that the COVID 19 vaccine recipients had a significantly higher risk of death than the first year after vaccination than unvaccinated people, and that the risk rose with additional doses. Sounds very concerning, doesn't it? Well, that is until you realize that the analysis they cited is a three page opinion piece with no original data, no database analyzes and no study of 18 million people. In fact, the same journal published a scathing formal critique three months before the ACIP report was finalized. In addition, the report ignored the EU's vaccine safety data link, which monitor safety signals in both vaccinated and unvaccinated populations. If it had included this data, it would have shown that post-vaccination death is consistently below background rates in every analyzed age group and in fact, separate Vaccine Safety Datalink analyzes have confirmed no increase of all cause cardiac or non-COVID deaths after vaccination with either the Pfizer or Moderna products. These are just a few of the report's fatal flaws, which three of the authors even acknowledged in writing and one refused to sign entirely. Taken within the context of multiple ongoing US measles outbreaks, largely among unvaccinated people. The ACIP report and agenda for the canceled meetings are particularly egregious, as Dr. Scott writes the judge's ruling by his time but doesn't confront the underlying problem, which is that the institutions responsible for setting vaccine policy are now totally unrecognizable, with consequences that are just beginning to unfold. And these consequences are potentially deadly.

Chris Dall: Mike, let's turn now to a growing bacterial meningitis outbreak at the University of Kent in England, which has risen to 20 cases with two deaths now. Meningitis outbreaks are not uncommon on college campuses, but they can be very serious. So, Mike, can you provide our listeners with some basics on meningitis?

Dr. Osterholm: Well, Chris, unfortunately, I can provide some basics. And I will mention this at the end of my answer. I actually led a major outbreak response for a large meninge outbreak that occurred here in Mankato, Minnesota, back in 1995. And that particular experience still haunts me. But for background, meningitis refers to the swelling of the meninges or the protective layers around the brain and spinal cord. It can be caused by viruses, bacteria, or even from autoimmune conditions or certain medications. When we hear about meningitis outbreaks in high school or college students, we're typically referring to meningococcal disease caused by the bacteria Neisseria meningitidis. This is the form that progresses quite quickly and can be fatal or cause lifelong disability. Some may be asking, don't we have vaccines for meningitis? And you'd be correct. We do. However, it isn't as simple as one shot for lifetime protection. There are multiple strains or serogroups of meningococcal bacteria in the US. The routine vaccine given to adolescents covers four of them A, C, W, and Y. There's also a vaccine includes serogroup B, often referred to as Menb but because of serotype is relatively rare and the vaccine's protection wanes quickly over 1 to 2 years. It isn't given population wide, however. Meningitis B is a nightmare scenario for college and high school students, and that seems to be the case in this situation in the southeast of England.

Dr. Osterholm: The outbreak began in nightclub areas in the Canterbury area and soon began to occur throughout all of Kent. The bacteria are transmitted through close contact, usually through sharing drinks, cigarettes or vapes. Quite frankly, swapping saliva is the main way in which we see this transmission occur. Early symptoms can be nonspecific and appear like the flu or even a hangover, but progress rapidly, sometimes leading to death in under 24 hours. The parents of one of the old teenagers described their child beginning to vomit early in the morning, taking her into emergency care and then passing away within 12 hours. The local area is responding with more than 12,000 doses of antibiotic prophylaxis and 8000 doses of meningitis B vaccine so far. However, news sources are reporting long lines and supply challenges, putting strain on their ability to respond to the many people at risk at the university and the surrounding community. The somewhat reassuring piece here is that while meningococcal disease is very serious, it is not broadly a concern for the general public across the globe. This is not something like novel influenza coronaviruses that's going to take off via airborne transmission and cause a global pandemic.

Dr. Osterholm: I mentioned earlier that I have lived through a very serious and challenging meningococcal outbreak here in Minnesota in 1995. Ten cases of this infection occurred in college students and several members of the community in Mankato, Minnesota. It was one that continued over the course of ten days and ultimately resulted in us vaccinating more than 30,000 individuals in the Mankato area, for which we also provided antibiotic prophylaxis. They're doing all the right things in this outbreak in Kent. The one challenge I would have is, even though we ended up doing the entire community for vaccination, I'm not sure how important that was relative to bringing this under control. While I surely wouldn't fault anyone from being able to vaccinate an entire community, what I wouldn't want to see are young adults, teenagers who might otherwise be at risk for contact with someone, or they may share a pop bottle or a glass, cigarettes, whatever. I would not want to see them not being able to get vaccine because there's not enough Meningo B vaccine is not readily available throughout the world. And so for them to get additional doses is going to be somewhat of a challenge. The antibiotics are common for which can actually provide prophylaxis initially. And my recommendation is if you're going to do a vaccine campaign, these individuals should also be on antibiotics at the same time.

Dr. Osterholm: There has now been enough evidence to suggest if you vaccinate someone who has low level antibody, you may tie up that antibody in the first several days after vaccination, as it basically combines with the incoming antigen from the vaccine, leaving you now vulnerable to any kind of infection that you wouldn't have been had you not had the vaccine a week prior. I also just want to make it clear that it is a devastating disease. I was there for a 15 year old individual from Mankato who died, who basically went from an evening where he was hungry, couldn't wait to eat after hockey practice, to being dead by the end of the following morning. I've seen it. I've been there. It's a horrible, horrible situation. But again, I want to just add context here. It doesn't mean you can't travel to the Kent area. It doesn't mean that you have to worry that somehow by being in the United Kingdom, you're going to be at risk for this disease. Again, it'll stay localized. It will stay largely within individuals who know each other. And as I pointed out early, who are willing to swap spit.

Chris Dall: While we're on the topic of outbreaks, let's talk about measles. The outbreak that was centered in the upstate region of South Carolina appears to be slowing down. While the number of measles cases in Utah is rapidly growing, fueled in part by low MMR vaccination rates in parts of the state. So, Mike, what's going on in both those states?

Dr. Osterholm: Yes. There actually is some good news in upstate South Carolina. The outbreak climbed to 997 confirmed cases. But for the first time in months, health officials report that things are stabilizing and no new cases are reported. But zooming out to the rest of the country is a lot less reassuring. We're now approaching 1500 confirmed cases of measles in the US just since January 1st, and it's only March. Considering we had nearly 2300 reported cases all of last year, and that was considered a heavy burden, now we're on track to surpass that number quite significantly. As you mentioned, Chris, Utah is experiencing a surge in cases, but measles certainly isn't isolated in the southwest. There are outbreaks reported this year across 31 different states and New York City. Let me repeat that. 31 states and New York City. Texas alone has reported nearly 150 cases, more than 100 of which are located in detention centers. There are little fires everywhere, and not nearly enough staff, public buy in and political will to get things under control. Much of the focus for the measles issue is on prevention, notably vaccination. And that makes sense. Vaccines are the tool that brought us to the elimination status in the US, and the drop in vaccination rates is the driving factor for all these recent outbreaks. But I also want to recognize the reality of treating measles or, more accurately, providing supportive care. There was an excellent piece in the New York Times last week from Doctor Jennifer Reich, a sociologist who studies vaccine hesitancy. She points out something clinicians see regularly families who are wary of vaccination are often still willing to seek care if their child becomes seriously ill or needs to be hospitalized. Now, there are certainly exceptions to this, some of which we've seen in these measles outbreaks in isolated communities.

Dr. Osterholm: But as a whole, an assumption remains if a child gets measles or another vaccine preventable disease, the health care system will be there to catch them and treat them. But there are a few very real problems with this assumption. First, there is no antiviral drug for measles. We can provide supportive care for dehydration, fever, managing pneumonia, etc. but there is no pill that can make the measles virus go away. Second, and the part that keeps me up at night is that the entire infrastructure for pediatric health care is under immense strain. Today, when you ask a parent who's their child's health care provider, very few can say it's a pediatrician more, but still very few can say it's a family practice physician today. Often these kids fall through the cracks. It's going to a local pharmacy to get your vaccines, not a standard health care provider. We've covered this in some previous podcasts, but pediatric care in the US is an expensive endeavor that is reimbursed at lower rates compared to adults, especially considering that almost half of all children are on Medicaid from 2002 to 2023. Nearly 30% of pediatric inpatient beds were closed, predominantly in rural areas. Measles outbreaks could quickly overwhelm a hospital system, not to mention possible resurgence of other vaccine preventable diseases like hemophilus, influenzae, meningitis, rotavirus, varicella, and more. So measles remains the focus for now, which is understandable given the rise in outbreaks. But we need to keep our eyes on the horizon. Public health and healthcare systems need a long term strategy to make sure our children are protected from what comes next, because it will happen.

Chris Dall: Turning now to avian influenza, 16 elephant seals, along with a sea lion and an otter at a state park off the coast of California, have died in recent weeks from avian flu. So, Mike, we've talked a lot about avian flu infections in mammals in recent years, and there's always the concern that these infections could be a signal of mutations in the virus that could make human infection more likely. But none of those fears have come to fruition to date. Anything different here?

Dr. Osterholm: Chris, let me just say, this is one area of my professional efforts for which I feel very, very unqualified to comment on. Why do I say that? Because I knew a whole lot more about influenza 25 years ago than I do today. I feel like the more I've learned, the less I really know. You may recall almost two years ago, when H5n1 first emerged in the dairy industry and we saw bovines who were infected and remained infected for some time. At that point, many in the flu community were crying out that we were just literally a mutation away, likely from a new pandemic. I was not quite on that bandwagon, and for many people, I think they thought that was a bit odd, that somehow I was now going from being someone who kept crying out about the risk of a pandemic with influenza, to one now is somehow don't worry about it. But in fact, that latter point was not true. I am very concerned about an influenza pandemic because I know it's going to happen, and I know it could be bad. But this story, while having gotten news coverage over the last week, I don't think it provides the public with the kind of information that we need. So since we haven't covered H5n1 for a while, let me try to provide some perspective. Highly pathogenic avian influenza has circulated among susceptible bird populations, the late 1990s, evolving along the way as influenza viruses do.

Dr. Osterholm: I've talked about this many times on this podcast and how I actually spent time in Southeast Asia working on H5n1, convinced that it was just a matter of time before we would see a devastating pandemic around 2020. We saw a more significant shift with the H5n1 clade 2.3.4.4 b emerging and quickly becoming the dominant strain. Due to the migratory nature of birds, the disease can spread very quickly wherever they fly, which unfortunately tends to be just about everywhere. The USDA documented for the first case of this clade in the US among wild birds in January 2022, followed shortly after by a positive poultry flock in February of the same year. This clade has persisted migration season after migration season, with year round activity now documented in wild birds. Remember, we have seen over the course of the last 30 years a constant challenge with H5n1, where one moment it appears to be increasing, changing its host capability and even potentially the serious illness that it causes. And then it goes away and then it comes back and then it goes away. So I think at this point, we don't know what's going to happen. I just read a paper this past two weeks from some of my colleagues who I have great respect for, who make the case that this new virus may very well infect humans in a way that we hadn't fully appreciated.

Dr. Osterholm: It could happen. If that could be true, and we could see this virus not only infect humans, but be readily transmitted by humans, we're in a different ball game. Just remember that from a virologic standpoint, having the actual viruses. If you look at the pandemics, the last 150 to 200 years, we only have data on more recent ones. We don't have it on 1918. To understand what was happening with the H1n1 virus that was circulating for several years before that particular pandemic emerged or wasn't circulating. We do know that in 1957 and 1968, pandemics. The virus wasn't circulating widely among humans before the pandemic strain emerged. And of course, that was exactly the same thing that happened in 2009 with the H1n1 strain that emerged as the pandemic virus there. So is there something here to be told about this rapid change in the virus that then causes it to be a pandemic virus, where a virus like H5n1 will continue to cause us great concern. It'll give us every reason to be in a constant preparedness mode. But in fact, 20 years from now, just like the past 20 years, will still not have caused an influenza pandemic.

Dr. Osterholm: I don't know, and I think that unfortunately, everyone wants to know that. And the more the time that goes since the first emergence of the virus in bovine and now in the aquatic mammals are all convinced that somehow we may have been crying fire in a crowded theater. This is not going to be a problem. My assessment: it could be. My assessment: it might not be. But my assessment is absolutely certain there will be another influenza pandemic coming down the pike. And right now we are simply not prepared for that. And we need to be reminded of that constantly, that we are way, way, way behind in preparedness for an influenza pandemic, whether it be what kind of vaccines we'll have available, when we'll have them available. What plans do we have that might very much look like what happened with COVID? I don't know. So Chris, to summarize, yep, these sea mammals are a real challenge. I'm sorry to see that. I think they're magnificent creatures, but at the same time, I'm not sure that they're telling us that. Yep, the influenza pandemic is on the road right now, coming to a neighborhood in your town, and we'll have to wait and see whether that's it. But we don't have to wait and see to get ready for the next pandemic, because it will happen.

Chris Dall: Mike, what is the latest on COVID, flu and respiratory syncytial virus?

Dr. Osterholm: Well, I'm actually really happy to report things are moving in the right direction across the board. Did everybody hear that? I'm happy to say that things are moving in the right way. I can't be all bad news, Mike. Okay. The national COVID wastewater level is low and levels are decreasing in every region, with the South and the Midwest being considered low and the West and Northeast considered very low. Emergency department visits will result in a COVID diagnosis, and hospitalizations for COVID continue to decrease overall, as well as in every age group. The monthly variant report was released last week and did not show many notable changes since the last update in February. Fcg and FCG Sublineages continue to account for over 55% of the cases. However, we have seen a new variant emerge throughout the world and this 1BA 3.2, is truly quite different than what we've seen with the other Omicron lineage and viruses. This is a heavily mutated Omicron subvariant that is different than the other one. Now, I've heard many of my colleagues say, aha, this could be a big game changer in terms of the incidence of COVID in our communities. What I've seen so far from late last year and early this year in parts of the world, were this particular BA 3.2 has been circulating. I've not seen evidence that there has been a big increase in human illness. So could that happen? Yes, it could, but I don't think at this point I'm really concerned about that. We now know that it's in.

Dr. Osterholm: At least 23 countries have originally been detected in South Africa in November of 2024. We know that the first US detection was in June of 2025, so it's been around at this point, I would continue to say that COVID is not likely to become a major challenge for us any time soon, relative to what it might be if we saw a totally new variant. That leads me to my next point. I am worried about that. Just remember, in the early days of the pandemic, where no one had yet been vaccinated or had prior infection with COVID in such a way as to have made antibody? We did see new variants suddenly emerge. We went from the ancestral to alpha to beta to delta to Omicron. And each time one of those major changes occurred is when we saw substantial activity. I don't have the evidence to prove it, but I believe it very much is. We're going to probably one day wake up to a new variant like Pi, something that is going to be at a major level change that overlaid upon a population that is only becoming less and less protected because of waning immunity. And then I think we could see a major surge of COVID. Will it be like the pandemic? No. Could it be like a very, very bad year for influenza on steroids? Yes, it could be. But so right now, I think we're kind of in a quiet period with COVID. And in that sense, I feel confident that we're not going to see the devastation from COVID that might yet still be ahead of us.

Dr. Osterholm: Now, let me move on to RSV activity because it remains elevated, but it seems that we may have peaked out over the past several weeks, which, let me remind you, has occurred much later than we'd normally expect to see. The national wastewater concentration is considered moderate and is increasing. The West, which is considered moderate, is the only region experiencing increasing concentrations. Concentrations. RSV in wastewater in the South, Midwest and the northeast continue to decrease. ED visits associated with RSV are also decreasing overall and have either decreased or remained the same in every age group. RSV hospitalizations are decreasing in average age group as well. Lastly, for that highly anticipated flu update, we're seeing improvements in every metric. Let me repeat that. We're seeing improvements in every metric, but we're not quite able to declare the end of the season yet. Hopefully very soon. Last week, 3.3% of the outpatient visits were for influenza like illness or ILI, down from 3.9% during our last episode. Remember that we don't declare the end of the flu season until we're below the national baseline of 3.1%, but I anticipate we will be there by our next episode in two weeks. Influenza related ED visits and hospitalizations are decreasing overall as well in every age group. Sadly, since our last episode, there have been 25 additional pediatric deaths, bringing our season's total to 115. I'll also remind you that as the end of the flu season is coming into sight, influenza B activity continues to increase while influenza activity decreases, which again, we expect to see.

Dr. Osterholm: Last week, influenza B, which tends to cause more severe cases in kids accounted for nearly half of the samples in public health laboratories and 76% of the positive tests performed by clinical laboratories. Before I move on, I also want to quickly circle back to the discussion we had during our last episode about the Strange selection meeting, and provide the update that the FDA did, in fact accept the W.H.O. recommendations and that the meeting went as planned. This was the best case scenario, but was certainly not a guarantee. And let me just also conclude on the differential impact that the flu virus can have on kids. You know, we talked about the severe year here that right now we're up to 115 deaths in kids. Remember last year we had 289 deaths in kids in this country. This year's numbers will not get anywhere close to that. And we don't really understand exactly why this happens. But I can tell you whether you're losing 115 kids a year or you're losing 289 kids a year, vaccination is in fact a wonderful, wonderful gift to your child. Does it guarantee they won't get infected or sick? No. Does it substantially reduce the risk of serious illness, hospitalizations and deaths? An absolute 100% yes. So I do hope that next flu season, when it's time to get that flu shot, you do definitely get your child vaccinated. It could be the difference between life and death.

Chris Dall: And that brings us to this week's ID query. This week, we heard from a listener who wanted to know about the risk of catching COVID in public. L Clement wrote, has COVID receded to low enough levels that the risk of catching it in public is fairly low at the beginning of the pandemic. There were all sorts of lists defining riskiest behavior to least risky. Are there any current resources to help navigate risk?

Dr. Osterholm: Well, let me just start out by saying this is a really great question. So thank you for your thoughtful question because in many ways, this question reflects just how much things have changed over the course of the past six years as we've gone through this journey with COVID. To start out, as we discussed in our last episode, the overall burden of severe outcomes were seen today with COVID is not what it was earlier in the pandemic. Just consider this there was a stretch from December 2020 into January 2021, where more than 20,000 Americans were dying of COVID a week for eight consecutive weeks. 20,000 Americans dying during a week for eight consecutive weeks. Think about the more than 187 deaths from COVID in the span of just two months. Now consider the annual number of COVID deaths in all of 2025 was just below 21,000. Now don't get me wrong, 21,000 is still a very difficult number, but in fact it is very different picture than it was during the pandemic. So clearly the risk today is different than what we were dealing with in those early years. However, it doesn't mean the risk is trivial. In fact, we're still talking about a virus that's causing hundreds of thousands of hospitalizations and tens of thousands of deaths each year. And remember, COVID didn't replace the other respiratory diseases. We have to think about. Influenza and RSV are still here and causing a lot of damage also. But now COVID is layered on top of that. So we are still dealing with the added burden and risk of another respiratory illness that ten years ago didn't even exist. With that being said, when it comes to the risk of catching COVID in public, there certainly are still higher risk and lower risk behaviors and situations, but has really been the context that has largely changed.

Dr. Osterholm: When COVID first emerged in those earliest days, there was very little population immunity. So we saw the novel virus spread very quickly and overwhelmed healthcare systems in places that had been hit hard. On top of that, this was a time when there was a lot of fear and uncertainty. And so a lot of messaging focused on risk and what people could do to help mitigate it and stay safe. Well, fast forward to today, and most people have had at least some level of immunity, whether it's from prior infection or vaccination or both. And although that protection does wane over time, even for severe outcomes, it shifted the overall risk landscape. Alongside that, we really haven't seen any new game changing variants that have reshaped things. And finally, we of course have tools that can help with vaccines and antiviral. Given this reality and the latest trends, I think there's been a tendency for some to look at COVID now, almost like we look at seasonal influenza in terms of burden. Let me just give you some perspective on what it means to die from COVID today compared to other events in our community. Right now, on average, about 6.2 people per 100,000 population die from COVID each year. That's with COVID. Meanwhile, if you look at recent years with influenza, that's about 14.2 per 100,000 die from flu. That's over twice the level that it is for COVID. If you look at RSV, that number is much lower than it is for flu.

Dr. Osterholm: At 4.2 deaths per 100,000 people, similar to what it is for COVID. And let me just give you one last one that I think helps set the tone. In fact, if you look at automobile accidents, the rate of deaths per 100,000 there averages about 17 per 100,000 per year, with a low year of around nine per 100,000 deaths, with a high year as high as 24 per 100,000 deaths. Now, do we in fact not go in our cars? Do we decide not to take that risk because it surely is substantially higher than the risk of COVID? So what does this all mean when it comes to navigating risk? Well, I think a key point is that it's very context dependent. One big piece is how much virus is circulating in your area, what types of settings you're in clearly don't have the same kind of surveillance and case reporting that we once did. But there are still useful indicators like wastewater data and hospitalization trends, that can provide a sense of what's happening with activity. And finally, an important piece is understanding your own risk profile and even the risk profile those around you. We know that certain groups face higher risk of severe outcomes, including older adults, infants, and individuals with certain underlying health conditions. There's also the risk of long COVID, which we plan to talk about more in our next episode. So your tolerance for risk may look very different depending on your own situation and circumstances. But again, one of the great equalizers in all of this is vaccine. I hope you're all consider using it.

Chris Dall: So Mike, just to reiterate, as you said, we've received a lot of questions and concerns recently about long COVID. So we'll be tackling that topic next episode. So make sure you tune in with us in two weeks. If you have a question about long COVID, please email us at Osterholm.Update@umn.edu. And Mike, now it's time for our favorite segment this week in public health history. Who are we celebrating this week?

Dr. Osterholm: Well, first of all, you're absolutely right, Chris. This is one of our most favorite segments that we do. And listening to the podcast family, I've also learned that you like this one too. I've gotten more very favorable comments about that. So please continue to let us know that. But more importantly, if you have people that you think should be noted in the public health history part of the podcast, please let us know. Okay. We welcome that information. Well, Chris, this week marks the last full week of March, which is Women's History Month. So today I want to honor some incredible women you may not have heard of before the Granny Midwives. And let me tell you, this one's going to tug at your heart. I promise this. This is the nickname given to the countless Black midwives who provided care to women living in poor and rural areas in the American South during a time when hospitals were not accessible to them. For some context, before the 1930s, the majority of people were born at home, not in a hospital. Midwives helped pregnant women and their children during labor, as well as long before and after the birth. They administered medicine, provided emotional support and ensured proper hygiene. Of course, there have been Black midwives for millennia. They persisted throughout enslavement and Jim Crow, providing essential care for Black women. Despite the harshest restrictions of slavery and segregation in the 20th century, gynecology and obstetrics became a medical specialty. However, one that was dominated by white men. There were even campaigns targeting lay midwives across the US, particularly the Black Granny Midwives.

Dr. Osterholm: But these women still persisted despite their odds. Women like Margaret Charles Smith, a prolific midwife from Alabama, Miss Margaret was born in 1906 and only completed a third grade education. However, in 1949 she became one of the first official midwives in Greene County, Alabama. Miss Margaret delivered over 3000 babies during her career, including twins, breech babies and preemies. She often helped mothers who were in poor health and had very few resources. Despite all of this, Miss Margaret lost almost none of the babies were mothers during childbirth. This is especially extraordinary considering infant mortality rates were about eight times higher back then in the 1940s than compared to today. Miss Mary Francis Hill Coley of Albany, Georgia, also helped deliver thousands of babies over her career. She didn't just help with deliveries, she often stayed for days after the birth, helping families with cooking, cleaning and filling out paperwork. She helped both Black and white mothers, which was truly a radical act of care at the time in the segregated South. Miss Mary's warmth and care can be seen firsthand in the 1953 documentary "All My Babies", which follows her work as a midwife. The film was produced by Georgia's Department of Public Health and was eventually added to the Library of Congress's National Film Registry for its cultural and historic significance. If you're interested in watching, we've linked the film in our show notes. Today, we honor Miss Mary, Miss Margaret, and all the incredible Granny Midwives throughout history. They deserve our respect in so many ways.

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

Dr. Osterholm: Well, first of all, again, I just want to thank the entire podcast family for being with us today and those who might be visiting as guests. I want to also thank the podcast team that puts this podcast together. Your input, insights, and support is priceless. And I can't say enough times how much we all owe you for your efforts. Let me just start out by saying that the past week and a half has been very difficult to interpret relative to what's happening with public health policy and vaccines and this administration in the courts, uncertain victories mustn't distract us from staying focused on defending the health. I think we're going to see some real challenges yet with the administration's going to come back with alternative approaches that surely the courts may beat down again, but they'll be out there for some time. And so we cannot rest on the fact that we got a favorable decision from the courts. It simply is not going to last for long at all. Second of all, I'm happy to report the respiratory season is on its way down and way out. COVID will likely only become a temporary Lion King again as we see a major variant show up, one that is very different than what we've seen to date.

Dr. Osterholm: We still, with the influenza season, have some cases ahead of us, but I think that too is on the wane. And again, just remind ourselves get that flu shot late next fall again. And finally, you know, each week we talk about all the challenges that we have in public health and infectious diseases and public policy. And I'm just always reminded we are not prepared for a big one right now, whether it's influenza or coronavirus, whatever. We are just not prepared. And I see nothing as doing that to get us there. And so some of us are going to continue to beat on that drum, even though we know the immediate need is to get prepared for today, which we're not prepared for that either. So I think it's going to be a challenge. But I just want to remind people that on my list of three, not being prepared continues to still come up high on that list.

Chris Dall: And Mike, I understand we have a canine themed closing today.

Dr. Osterholm: Well, this is going to be a hybrid in many ways. For those of you who have been around the podcast for some time, you know that I have a very, very soft spot for dogs. If you're a dog owner and that dog loves you with unqualified love. You know how fortunate you are. And actually, the canine is too. Today I'm going to blend an oldie and a new one into kind of, you might call a contemporary oldie. Back in Episode 150 on February 8th of 2024, I talked about the Nome to Alaska Serum Run, that famous dog sled effort that got the antitoxin for diphtheria to Nome, Alaska and saved many, many lives. It was a remarkable experience. At the very least, it involved over 20 mushers and about 150 sled dogs to relay this emergency supply of antitoxin starting near Fairbanks. The trip would be over 1000km in Arctic conditions, reaching below 85°F windchill. And there are some really notable details of that trip that I talked about in the podcast. But let me just remind everyone, the 20 pound package made its way to Nome in five and a half days. Not a single ampulla was broken. Unfortunately, multiple sled dogs died in the process and mushers running the relay faced severe injuries. What a remarkable story. Well, today we celebrate with what has now been several iterations of that run through what we call Iditarod. I think most of you have probably heard of Iditarod. It's an annual race held each winter in Alaska. And I want to close a little story about that. This year, musher Jessie Holmes won for his second year in a row thanks to his pups, Polar and Zeus.

Dr. Osterholm: Together, they finished the race in nine days, seven hours, and 32 minutes and 51 seconds. Jessie hopes his win is a beacon of hope for others. At a press conference after this amazing feat, he said "What means to me the most is that I can use my story to inspire others. It doesn't matter where you start, it doesn't matter where you finish. Never lose hope and always keep pushing forward." Well, congratulations to Jessie, to Zeus and to Polar. We're definitely taking your hopeful spirit with us as spring inches forward. And we never forget that a world where kindness rules the day is a world that I want to live in. And I know that many of you do too. So thank you to the Iditarod message. Thank you for that great memory. And for those of us who are dog lovers, thank you for keeping those pups nearby. And just know how much I appreciate spending the time with you. So please, if you have questions, comments, ideas, let us know. We're always open to making certain we can do this better. And in the meantime, in the next two weeks, be kind. Be helpful. Just one time a day. Do something that you would normally never do by reaching out to someone or something and watch the smile on their face. Watch what that means. And if everybody could just do that. Wow. We could have a better world. Meanwhile, enjoy spring. Be kind. Be good. 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.edu. This podcast is supported in part by you, our listeners. The Osterholm update is produced by Sydney Redepenning, Elise Holmes and Ruby Guthrie. Our researchers are Cory Anderson, Meredith Arpey, Leah Moat, Emily Smith, Clare Stoddard, Angela Ulrich, and Mary VanBeusekom.