November 30, 2023

In "The Hospital Capacity Crisis," Dr. Osterholm and Chris Dall discuss the state of the pandemic in the U.S. and around the world, the reclassification of the BA.2.86 variant as a variant of interest, and the surge in pediatric pneumonia hospitalizations in China. Dr. Osterholm also provides an update on influenza and RSV in the U.S. and shares a moment of joy from one of our listeners. 

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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 Dahl, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone to another episode of the Osterholm Update podcast on November 21st, the online reporting system for the International Society for Infectious Diseases, known as ProMED-mail, flagged Chinese media reports about pediatric hospitals in Beijing and other cities in northern China that were filled with children with a respiratory illness marked by fever. The reports quickly raised fears because they were eerily similar to the reports of a mysterious pneumonia in Wuhan in late 2019. Within days, Chinese health officials presented the World Health Organization on request, with surveillance data indicating that the surge in pediatric respiratory illnesses was being caused not by an unknown or novel pathogen, but by an outbreak of pneumonia caused by the bacterium Mycoplasma pneumoniae, as well as an uptick in flu, adenovirus, and respiratory syncytial virus, or RSV.


Chris Dall: The WHO said the increase in these illnesses are not unexpected given the lifting of COVID-19 restrictions in China. The response to this story, particularly the images of hospitals overflowing with sick children, illustrates the heightened level of anxiety we're living with as we emerge from the COVID-19 pandemic. But it also might tell us something about how prepared we are for the next pandemic. This is one of the topics we're going to discuss on this November 30th episode of the podcast, after we look at the international and national COVID trends. We'll also provide an update on the variant picture, look at the latest flu and RSV data, and answer an odd query about long COVID. Bringing you the latest installment of “This Week in Public Health History” and share a moment of joy from one of our listeners. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Dr. Osterholm: Thanks, Chris, and welcome to everyone to this edition of the podcast. In particular, I want to welcome our podcast, family members. You know who you are, we know who you are and we appreciate you very, very much. Thank you for all the cards, letters, emails and so forth. You continue to send us with your wise thoughts and and your support. We appreciate that very much. In addition, for anyone who is new to the podcast, we hope that we're able to cover the kind of material that you find useful. Shirley is somewhat of an eclectic group of facts and figures and moments of reflection that we share with you, but hopefully again, this can help you, not just with COVID and and what we've been through with this pandemic, but as we look forward to what do we need to do to be prepared in the future for public health situations like we've been through now? Today we're going to cover a number of different topic areas, of which some I think will best be described as I don't know in light of the previous dedication around the Thanksgiving and the Christmas holidays, I want to acknowledge a group today that often doesn't get nearly enough recognition that really are the heart and soul of this podcast. You know, you hear my voice. You can agree or disagree. You can find it somewhat discomforting sometimes with what I have to say and hopefully sometimes comforting. But in the first instance, the really good information you get from this podcast is all as a result of the podcast preparation team at CIDRAP. There have actually been ten members of the podcast team, including nine current and one previous member, Maya Peters, who was at the very first days of this podcast a major mover in helping it to come together, who is no longer with CIDRAP.


Dr. Osterholm: However, Cory Anderson, who was also in that same position as was Chris Dall, are still a part of this podcast team and I can't thank them enough for what they've done. In addition, the other members include Sydney Redepenning, Eve Lackritz, Elise Holmes, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat. These ten individuals have clearly made this podcast what it is. I have the good fortune of just being the voice of what they do. So much to prepare. Thank you so, so much. Now to move on to a topic right now that for some of us is a little bit friable. That is sunlight. And today we're going to have a very interesting twist on this, I promise. And it's not going to come at the beginning of the episode. It's going to be at towards the end. But as we all know, here in the northern hemisphere, sunlight has become a real premium and we're happened to be at that time of the year where it is the ultimate premium. So today here in Minneapolis, we have sunrise at 7:29 a.m., sunset at 4:33. That's nine hours and three minutes and 52 seconds of sunlight. Now compare that to June 21st. About six months from now, where it will be 15 hours, 36 minutes and 51 seconds increase of almost six hours and 30 minutes of sunlight. Well, we're looking forward to that. Now, it's interesting to note, and this of course, if you're a weather wonk, as I sometimes have been accused of being, you'll know that the shortest day of the year in terms of total sunlight is actually roughly around December 21st, give or take 12 hours.


Dr. Osterholm: And how that fits in with the winter solstice. But I find comfort in the fact that I will take every opportunity to seize on the light moment. And it is actually right now that between December 5th and December 14th, we will see the sunlight at 4:31. So think of that for nine days. It'll stay at sunset at 4:31 here in Minnesota on December 15th. Will start getting longer at 4:32. What happens is, while the afternoon start to get longer, the mornings continue to get shorter from December 30th to January 5th. Sunrise is at 7:51 the latest. It is on any one day. And so collectively, yes, the shortest day of the year is on the 21st with increasing afternoon sunlight continued decreasing sunlight in the morning. And it is one where at this point I'm going to start to elect to believe that we bottom out on December 5th, just a few days from now. And after that, it's going to be a wonderful ride with more and more afternoon sunlight. So for all of you who have had more than enough discussion of sunlight right now, please do stay tuned because you're going to love. You're going to love the piece at the very end of the podcast. So again, thank you all so much for being with us. We appreciate it. And Chris, let's go to work.


Chris Dall: All right, Mike, so let's start with the international and national COVID data. What's the picture looking like at the moment here in the United States and around the world?


Dr. Osterholm: Well, unfortunately, Chris, we're still stuck dealing with the situation where more and more of the systems and tools we really need to understand what's happening with COVID are being dismantled, literally dismantled. So what we're left with at this point is basically a half broken shell of a system characterized by less testing, less reporting, and as a result, much less data. All the regular listeners have heard me talk about this repeatedly, so I probably sound like a broken record, but I think it bears repeating because we're essentially flying blind, and every month it seems that we're flying increasingly blind compared to the month before. As a testament to that point, let me just start out by sharing some information from the WHO’s latest COVID report, which was published this past Friday, November 24th. Now, you may recall that these reports used to be issued weekly, but starting in September, a couple of months ago, they shifted to monthly. So this latest report from Friday was the first time since late October. And a major reason for that shift, I'd assume at least, is probably the growing lack of data that WHO is consistently receiving from countries, or just the irregularity in the reporting. In the most recent report, which covered the 28 day period from late October to November, only 44% of the world's countries reported even a single case of COVID. 44% just 18% reported a single death and only 13% consistently reported hospitalization numbers. Now, for me, and as many of you have heard me say before, I believe that consistent and reliable data on hospitalizations and deaths in particular is very key right now and understanding what's happening.


Dr. Osterholm: So to recognize the fact that less than 1 in 5 countries are reporting that information to the WHO is truly disheartening, to say the least. And it goes to show that the international picture we have is far from a comprehensive or complete. And so that's a big challenge, because some of the limited data we actually do have available from other countries makes it clear that COVID hasn't just up and gone away. In our last episode, I touched on places like Italy, the Netherlands and Canada. For each, there was a rise in activity that started several months ago and continued on into November. And while I thought that things might have started leveling off in Canada at the time, here we are two weeks later and they've only crept up even higher. With hospitalizations now sitting at 4400, almost triple the reports that we had in August when the increase first began. In fact, for some added context, the current hospitalization levels in Canada actually exceeded the country's highest peak reached during the Delta wave in 2021. Let me repeat that the current hospitalization levels in Canada actually exceed the country's highest peak reached during the Delta wave in 2021, and we all remember how challenging that was. Granted, the one silver lining with this is that the number of Canadians requiring care in the ICU for COVID is just a fraction of what it was during the Delta wave.


Dr. Osterholm: About 150 persons in ICU now versus upwards of 700 during Delta. Still, these hospitalizations are significant and certainly are not a trend we'd like to see. And unfortunately, it's not a trend that's exclusive to Canada. Other places seeing these recent increases include Italy and the Netherlands, Poland, New Zealand, Norway, Finland, Sweden and more. In fact, some of these increases in the Scandinavian countries have been fairly steep. For example, in Sweden, hospitalizations climbed from just over 100in August to almost 1400 as of late. And if you actually adjust that based on population, that's equivalent to having more than 44,000 hospitalizations here in the US. Likewise with deaths, the latest rates from Sweden are equivalent to about 600 deaths a day in the US. In Finland, the latest death peak rate would equate to over 1000 deaths a day in the US. Right now, we're at about 1200 deaths a week in the US, or roughly 171 deaths a day. Now imagine if, in fact, the Finland rate was occurring, we'd be seeing over a thousand deaths a day. So why the increases? As always, that's the trillion dollar question. At this point, I haven't seen anything to suggest that Finland or Sweden are early victims of a new variant. Could it be the result of waning immunity? It could be. Maybe in Finland, at least they've rolled out an updated dose targeting xpb. But I haven't seen data on what the coverage has been, so who knows what's happening anyway, if this is a result of waning immunity or limited vaccine coverage, then we ought to be thinking about what the implications are for other countries and specifically for the United States over the months ahead.


Dr. Osterholm: Speaking of the United States, all of our COVID indicators on the rise right now two following slight declines throughout. September and October. Hospitalizations have once again started to climb the past several weeks, going from 15,000 newly weekly admissions in early November to more than 18,000 new hospitalizations as of late. Emergency department visits are up 1.8%, with 1.5% of emergency room department patients testing positive for COVID. Let me remind you that deaths are a lagging indicator, and is also a number that can take weeks to accurately represent the number of lives lost to COVID-19in any one given week. Because of the time it takes for the death certificate data to be submitted. With this in mind, it is best to look at the last few weeks of death data combined over the past month. COVID-19 deaths are slowly declining. The week of October 21st, we lost nearly thousand 300 Americans to COVID-19. As of the current counts last week, we lost just over 500 lives. Let me be clear that this is nothing to be celebrated, and this number will likely increase and potentially substantially more as the data is coming in regarding wastewater, which is now showing that, in fact, we are beginning to see increases in COVID activity in every region of the United States, with the exception of the South, where there is just stayed steady.


Dr. Osterholm: So where does this put us? Well, I don't think it's time for alarm, and I certainly would not call this the “tripledemic” as many people are starting to claim. Remember how much I dislike that term? Tripledemic. I think it's a misnomer, but COVID-19 is still here and it's still important, although the majority of the public does not believe this. And if you look at all of our activities, you can surely understand what I mean. Vaccine uptake is painfully low, with only 15.7% of adults having received the COVID-19 vaccine as of November 18th. This is concerning, but looking even closer at who is and who is not included in this is especially concerning. A staggering 17% of nursing home residents are currently up to date on the COVID-19 vaccines. Only 17% and only 2% of nursing home staff right now have received the current COVID-19 vaccine. Let me repeat those numbers 17% of nursing home residents, some of the most vulnerable people in our society, and only 2% of the people caring for the most vulnerable are up to date on their COVID-19 shots. This is a population of people who were hit hard, so incredibly hard just the last few years by this virus, and now here are less than a fifth of them are up to date on their vaccines. Another statistic that is of particular concern is that 40% of Americans report that they will never receive a COVID-19 vaccine.


Dr. Osterholm: That is nearly half of America. Now, I know that these people are most likely not listening to this podcast, and I also know that they are not going to change their minds. But if they happen to be listening, I please ask them if you know you're infected. At the very least, try to avoid transmitting the virus to others for 5 to 10 days, and especially to high risk individuals like the 83% of nursing home residents who are unvaccinated. I also just want to emphasize the importance of testing for COVID, especially as we gather with friends and family throughout the holiday season. I know we all want to move on. We want this to be our post-pandemic Christmas. I want that too. But one of the easiest ways to reduce COVID-19 transmission is to know that you're infected in the first place. COVID-19 is still very much a part of our lives, whether people want to acknowledge it or not. Fortunately, the government is again offering more free tests to all Americans who are going to COVID That is COVID We have two great tools in our fight against this virus vaccines and tests. If 80% of our population is not utilizing the vaccines, they should at least be using tests as the other tool and there is no excuse when it is as easy as going to the website, entering your address and grabbing the test at your front door.


Chris Dall: The Who last week reclassified the Omicron variant BA.2.86 and its offshoots as variants of interest. Now, we first heard about this highly mutated variant back in August, but haven't heard much since then. So Mike, what does this mean?


Dr. Osterholm: Chris is. Anyone who's listening to this podcast knows we have followed emerging variants from the very beginning of the pandemic, and the closer we look at these variants, the more we realize how important they are in determining what the clinical picture of illness may look like in any one given community. But at the same time, it's not completely predictive. Yes, we knew that the alpha variant and the Delta variant and the Omicron variants were much more infectious. They were more likely to beat the limited immune protection we might have had from previous infection or early vaccines. But beyond that, it's hard for us to know what's happening right now. And so again, let me just start out by saying, from my perspective, variants are very critical in terms of determining what we might be facing in the days ahead. But at the same time, I consider each new variant innocent until proven guilty. How many times have we heard individuals say, oh no, this new variant is going to completely disrupt all the immune protection we have. The vaccines won't work, your previous infections won't protect you, and that may not be the case. At the same time, you heard me say earlier in this podcast that in fact, what we're seeing in Europe may be in part tied to the emergence of the BA.2.86 or JN.1 variants. We don't know. We find it fascinating from a scientific perspective that some countries appear to be responding with increased cases to the presence of these new variants and other countries.


Dr. Osterholm: Not so, I don't know. So let's just take a look at what we know about the original BA.2.86 variant. This parent variant has an array of mutations forming a strong fitness profile, but did not take off as rapidly as once expected. Unfortunately, as I just noted, the same cannot be said for further mutated BA.2.86 descendants. JN.1 has been linked with increases in cases in some European countries, but not in others. Since our last episode, this situation has changed and there are more countries globally facing the BA.2.86 lineage and this driving Gen one variant. This past Monday, the CDC published an update on BA.2.86 following its addition to the CDC's variant surveillance estimates. We have linked this report in the episode notes. According to these weighted estimates, the BA.2.86 variant group accounts for between 5% to 15% of cases, with the best estimates sitting somewhere right around 9 to 10%. However, there are limitations in interpreting these data, since there is a lag in analyzing the small amounts of viral sequences and the samples may not be nationally representative. Sound familiar in terms of concerns about surveillance? Ultimately, evidence is still limited surrounding BA.2.86 and its descendants, and there is no way to know for sure what the short and long term impact will be as a result of JN.1’s accelerated rise.


Dr. Osterholm: I'm waiting to see how quickly JN.1 is distinguished from its parent's lineage, and it hits its own 1% threshold in the United States. As I said a moments ago, I've always maintained that variants are innocent until proven otherwise. But the suspicion is mounting against some of these key players here. That all being said, BA.2.86 lineage is still accounting for a smaller proportion of cases than other variants. We're seeing a continuation of previous reports indicating a rise of cases attributed to Omicron HV.1 variant. The EPI data suggests infections caused by HV.1 result in similar symptoms to other recently circulating variants the typical sore throat, congestion, cough or fever. From the data coming out of our labs, it looks like HV.1 is good at immune evasion, but clearly weaker at ace binding. Knowing that less than 20% of adults, even fewer children have received the updated vaccine, targeting the Omicron variants leaves me with real concerns about the ongoing community transmission heading into the holiday season. Bottom line, all the variant information says we may see increases here like we're seeing in some countries in the world that will be in part tied to people coming together in the holidays, not being vaccinated and this new variant. So one of the things you can do about that, if you particularly are going to get together over the holidays, please get vaccinated with that dose of vaccine now.


Chris Dall: Now to the surge in pediatric respiratory illnesses in China, which I'm sure our listeners were all over when those first reports came out. As I noted in the intro, Chinese officials have provided an explanation that the WHO and many infectious disease experts appear to support. So, Mike, what do you make of what's happening in China, and what role do you think immunity debt is playing?


Dr. Osterholm: Well, of course, I first want to acknowledge that the fear that many of our listeners may have experienced when headlines emerged last week about the spread of an undiagnosed pneumonia in China. The last thing that any of us want to hear is that we could be experiencing the start of another devastating pandemic. Fortunately, this is not what we're seeing here. And in fact, what we're seeing in China right now is exactly what we should have expected during this respiratory virus season. On Thursday of last week, the World Health Organization published a news release clarifying that this rise in pneumonia cases is a result of several circulating pathogens, including SARS-CoV-2, influenza, RSV and Mycoplasma. And for our listeners who are not familiar with mycoplasma, it's a bacteria that typically causes mild lung infection but can cause severe infections in children. The crisis that is happening in China is not at all surprising and is largely a product of two things what we call immunity debt and hospital capacity issues. I'll get to the hospital capacity issues in a moment, but for now, I want to provide some context on the issue of immunity debt. If you look at the early history of the pandemic, we often talk about the world being in lockdown. Well, let me just be really clear. The United States, for example, never really was in a lockdown. The idea that a major restrictions of contact between individuals, access to the public diminished, if not denied, all of those kinds of issues that really make for a true lockdown.


Dr. Osterholm: In the United States. 40 different states enacted some type of stay at home orders in March of 2020. If you look at those 40, within eight weeks, all of them were basically lifted. More importantly, many of them were basically screen doors on a submarine in terms of what they accomplished. In Minnesota, for example, the governor had in place a stay at home order except for essential workers, but 82% of our workforce was defined as essential workers. We never really had a lockdown here. There may be individual companies or organizations that decided not to have activities or be open, but it wasn't forced on it. And remember, the pandemic lasted more than three years. In that sense, this was 6 to 8 weeks at the beginning of the pandemic, when at that point, fewer than 5% of all the cases had occurred. So we get into these debates about lockdowns and what happened. This is just an emotional issue. There was never really any activity that was a lockdown as far as I'm concerned, in this country. Now that's different in China. China was in a real lockdown there. They actually used the force of government to keep people from being in public places, had all kinds of civil liberties issues, all kinds of challenges.


Dr. Osterholm: In terms of what it meant, people denied access to health care because they couldn't get to an emergency room for an appendicitis case because they weren't COVID. I mean, all kinds of things happened that were really tragic. And some of you may recall, in January of 2022, Zeke Emanuel and I actually wrote an op ed piece in China's zero-COVID policy. Is a pandemic waiting to happen. And what we meant by that was they did suppress transmission of the virus, as well as all the other infectious respiratory pathogens at the time because of these extreme lockdowns. But when they finally released them, what they hadn't done is vaccinated much of their population, particularly older individuals, against COVID. And so all of a sudden it was like the dam broke and all these people were highly susceptible who had not been exposed to the virus throughout the entirety of the pandemic. Now were. And we saw within a month over a million deaths in China. It was incredible what happened. Well, think of that population now. Today, they are highly vulnerable to these other infectious agents because they too did not transmit during the period of these major lockdowns. And now the immunity debt, as it's been called, is basically where the last 3 to 4 years, no one was infected with these viruses.


Dr. Osterholm: All the ones I mentioned before, you know, influenza, RSV, Mycoplasma, etcetera. And so now they're catching up. They've got almost four years of individuals, kids who were born who have not previously been infected. So we would expect to see this happen now in the United States. We never really, with our non-pharmaceutical interventions, had much impact in slowing down transmission. People will say that all the time, and it's just dead wrong. And what happened in the United States is we saw widespread transmission of SARS-CoV-2. Well, that was being transmitted. There surely was a potential for transmission for all these other pathogens, too. Non-pharmaceutical interventions didn't selectively keep influenza and mycoplasma and RSV down, but not COVID. And when you look at what happened with COVID, it was remarkable the amount of transmission. Look at what Omicron did. Okay. And so if. Those viruses were here, they could have been transmitted. What was different was that you've heard me say over and over again was viral interference. It wasn't NPIs. You know, if you go back to 2009 and you look at the H1N1 pandemic for over a year, we saw almost no other influenza activity, H3N2. We saw no influenza B activity. We saw very limited RSV activity. All of those things were absent, too. And remember, in the H1N1 pandemic of 2009, there were no restrictions put into place on movement. We did nothing to try to use a non-pharmaceutical intervention.


Dr. Osterholm: And yet those other viruses stopped. It wasn't because of masking. There is something that happens that we don't understand yet, that when viruses like this circulate in the community and predominate, much as we saw with SARS-CoV-2 now or the pandemic H1N1 and 2009, it just stops transmission from occurring for these other pathogens, whether it's interferon related, I don't know what it is, but the bottom line, we to have a situation in the United States now where we're going to start seeing more and more catch up in that immunity debt, meaning that we had kids that did not pick up these viruses out there, not because the NPIs prevented transmission. It's because I think that somehow we had this kind of viral interference. Bottom line is, most of the world is in a situation today where we're going to expect to see some rough flu RSV seasons ahead of us, and that's what China's experiencing now. Now we'll talk more about in a moment. How do we judge how bad those are. And unfortunately, one of the things we often use is how are the hospitalizations looking and what does that mean for capacity? And when hospitals are overrun, a word that gets used so often. Let's take a look at that and find out. Does that really tell us what's happening in our community?


Chris Dall: Okay, so in our podcast meeting, you told the team that this episode has had you thinking a lot about hospital capacity and how unprepared we are for seasons where respiratory illness activity is higher than normal, not just in China, but here in the US and elsewhere. So, Mike, when you see images of Chinese hospitals filled with kids getting IV drips or hear about a hospital here in the US being overrun with patients. Does that tell you more about the severity of the illness or the novelty, the pathogen? Or does it tell you more about the capacity of the hospital?


Dr. Osterholm: Well, Chris, first of all, it's important to note that this topic must be discussed more openly and it needs to be shared with the public as to why we actually see these stressful moments in our health care system. It's not because of a major surge in respiratory virus transmission, although that can surely happen. What this is all about is capacity as an issue of supply and demand. If we look at where we are today with capacity for caring for people in our communities who need hospitalization, who are seriously ill, and compare that to where we were even 10 to 15 years ago. It's the difference between night and day. And I wish the media would pick up on this and stop using the terms like hospitals are overrun, because that gives a sense that somehow this is an infectious disease challenge that is unique, or that is really serious in a way that we've not seen before, when in fact, it may actually represent fewer cases today than it might have been adequately handled 10 or 15 years ago. For example, if you look at the issues from a financial standpoint, unoccupied beds don't make a hospital system money. Hospital finances rely on high volumes of patients with procedures that create generous reimbursements. That is true worldwide. Pediatric beds generate less revenue than adult beds. Why? Because children are more often admitted for observation. They can crash hard and fast when sick rather than undergoing expensive procedures.


Dr. Osterholm: Approximately 40% of children are covered by Medicaid. Reimbursement for Medicaid is considerably lower than Medicare and private insurance. If you look at the scale of decrease in pediatric beds, it says it all. From an analysis in the Washington Post, from data gathered from the US centers for Medicare and Medicaid Services data from 2000 to 2022, the number of hospitals offering pediatric services dropped by nearly one third. This was most severe in rural areas and small cities that lost up to 45% of their pediatric hospital care. This includes hospitals that eliminated pediatric services as well as those that closed altogether. In a study published in the Journal of Pediatrics using American Hospital Association survey data from 2008 to 2018, the number of pediatric inpatient care units decreased approximately 20%. One quarter of US children experienced an increase in distance to their nearest pediatric intensive care unit. Pediatric units with lower volume and lack of pediatric intensive care unit were most likely to be the ones that closed when community hospitals closed. It requires families to travel to metro areas, which is expensive and difficult logically, and they may surely have other children to take care of, in addition to the fact that they have to take off work, find hotels, etcetera, etcetera. On top of all of this, with regard to whether pediatric or adult beds, staffing shortages have become a very serious challenge. During surgeons, systems can find ways to create beds in convertible spaces, but can't identify staff out of nowhere.


Dr. Osterholm: For example, the pandemic results in approximately 230,000 providers. This includes physicians, nurses, techs, etcetera to quit the health care profession. Let me just repeat that 230,000 providers to quit the health care profession. Pre-pandemic, approximately 10% of the nurses left their jobs each year. Now it's over 20%. Especially concerning for a lack of staff specializing in young children, including nursing and respiratory technicians. The bottom line is that around the world, we have a health care delivery challenge where what we once had doesn't exist anymore. On that supply and demand issue. So when I hear about a hospital being overrun, my first question is how many actual individuals are being hospitalized or seen at that institution and how many were actually seen? Ten years ago for the same illnesses, and by the way, didn't create the overall crisis because there was more capacity. And this is an important consideration in terms of we can surely knock down our health care system for cost containment to the bare minimum, but when the surge occurs, what are you going to do? You know, you can have a much easier funded fire department in your community if you only have one fire truck. But if you need 3 or 4, you know what happens when you need them. You can't go out and buy them. Then you can't go and make them. And this is what's happened in health care today.


Dr. Osterholm: So please take any information about overrun or, you know, hospitals at the breaking point and ask yourself, is this really a function of a major increase in occurrence of illness in our community, or is it a function of the inability of our health care system to respond to even a slight increase in cases, or is it both? It could be both. And I think that the challenge we have today is understanding that so that we can prepare for the future so that we can be in a place where seasonally, we don't have this major challenge. I look at what happened in China recently, and we have reports, excellent reports from places like the BBC, where they have major clinics for infectious diseases in the community that have 2 or 3 professionals that are responsible for thousands and thousands of patients. Of course, that's going to be overrun if that's all you have. And at the same time, it doesn't give the sense, though. Then what can we do about that to make sure it doesn't happen again? So I hope anybody, particularly from the media who's listening to this, please think about this. Stop reporting about what's happening in hospitals as being overruns or being placed in the hallways. Ask yourself, what is the actual number of hospitalizations? How does it compare to the past, and why are we not better prepared today to handle these even minor surges in cases that occur?


Chris Dall: So with that in mind, what are you seeing in the latest US data on RSV and flu? And is it looking like our hospitals are going to be getting crowded in the next few weeks?


Dr. Osterholm: Well, Chris, it's safe to say that the winter respiratory virus season is in full swing here in the United States. The percentage of outpatient visits for influenza like illness is increasing currently at about 3.7% of all outpatient visits, which is above the national baseline, about 2.9%, but still far lower than what we've seen in peaks of previous flu seasons, which range from 5 to 7.5%. Excluding, of course, the 20 2021 season. During our last episode two weeks ago, we reported that zero states were experiencing very high levels of influenza, three were experiencing high levels of influenza, four were experiencing moderate levels of activity, and nine states and New York City were experiencing low levels of activity, and the rest of the country was experiencing minimal influenza activity. Well, let's move forward. Two weeks today. Two states as opposed to zero, are experiencing very high levels of influenza activity. Eight states in New York City are now experiencing high levels of activity. Nine are experiencing moderate activity. Seven are experiencing low activity, and the rest are still experiencing minimal activity. So in a sense, we're kind of in a transition period where we're seeing some areas pick up the flu activity. None in in a way that would suggest a major epidemic this year occurring surely could worsen over the days ahead, but nothing yet to support that. That's the case. Globally, we're seeing varying amounts of influenza transmission throughout the northern hemisphere. Influenza activity has remained below baseline levels in most of Europe and Central Asia. Activity in East Asia has increased, mostly due to the increase in transmission in China and South Korea.


Dr. Osterholm: In South East Asia, influenza cases are currently declining after an apparent peak a few weeks ago. As I've said in the last few episodes, now is the time to get your flu shot if you haven't already. It's not too late, and though the vaccine is not perfect, it can greatly reduce your risk of being hospitalized or dying of influenza. As for RSV cases, they are continuing to increase in the US, up 40% from just two weeks ago. Just as with influenza, the South is currently being hit the hardest with their RSV numbers, similar to what we saw at the peak of last year's RSV season. I'm beginning to sound like a broken record, I know that, but just as with influenza, just as with COVID, now is the time to receive your RSV shot if you're eligible and have not yet received the vaccine. Finally, I want to acknowledge that though we are not yet at the peak of our respiratory virus season, and though we are currently on track for a fairly normal flu and RSV season, this season may be particularly challenging in some parts of the country due to the hospital capacity issues that I just discussed a moment ago. This hospital capacity issue is truly a crisis, and it leaves us incredibly vulnerable to these seasonal illnesses. Not to mention the challenge that this will bring with the next pandemic. And as listeners of this podcast know, there will be another pandemic.


Chris Dall: That brings us to this week's query. We've had several listeners ask us about a recent New York Times article that cites Census Bureau data showing that more Americans are now reporting serious cognitive problems than at any time in the last 15 years. And what they want to know is how much of this can be attributed to long COVID.


Dr. Osterholm: Well, Chris, this rise in serious cognitive problems is really a concern. I myself personally can attest to that. After having had almost four months of what I call brain fog after having had my COVID last March. The New York Times article mentioned “Can't think, can't remember. More Americans say they're in a cognitive fog.” By Francesca Paris provides an excellent breakdown of this issue. We will link the article in our episode description. The article covers some alarming data from the US Census Bureau showing that immediately following the start of the pandemic, the percentage of Americans reporting cognitive issues like remembering things, concentrating and making decisions increased dramatically and has continued to increase over the course of the pandemic. There has been a particularly large increase in these types of issues among younger adults, those 18 to 44 years of age, though I do want to note that the percentage of individuals in this age group experiencing cognitive issues is still relatively small, at about 4%. That said, I also want to acknowledge that for those 4%, these symptoms can be devastating and have significant impacts on quality of life. So this rise in cognitive symptoms is certainly a major concern. There is no question that long COVID is a factor here. The estimates of the number of Americans experiencing long COVID vary significantly by study, but recent estimates suggest that 20 to 30% of those infected with SARS-CoV-2 experienced symptoms of long COVID that may persist for multiple months. Now, we also understand that that may vary by which of the variants you are infected with at the time, and with the idea that some of the earlier variants we saw actually may have caused increased occurrence of these cognitive issues, whereas we're seeing less of them now happening with the people who are being infected with the most recent variants of COVID.


Dr. Osterholm: Many of these long COVID patients have reported a number of cognitive symptoms, often referred to as the brain fog, which I just mentioned, which we discussed in previous episodes of this podcast and I lived with for months. With so many Americans experiencing SARS-CoV-2 infections that result in long COVID, there is no question that long COVID is a major contributor to the increase in cognitive issues that we're seeing, including in younger adults. That said, as mentioned in the article, there are some additional factors that could partially explain the rise in cognitive issues. The first is the increased prevalence of mental health issues that we've seen over the past few years. Rises in depression and anxiety may partially explain the rise in cognitive issues, and these can occur with those conditions. In some cases, these cognitive symptoms could also be the side effect of medication prescribed to treat mental illness, which again has been on the rise since the start of the pandemic. Additionally, there has been an increase in the awareness of mental illness and neurodiversity, particularly among younger adults, which could be contributing to the increase in self-reported cognitive symptoms in this group. The bottom line is that this rise in cognitive issues is something that we will have far reaching consequences, and at least some of this increase can be attributed to long COVID. I know that many of our listeners have experienced these challenges with their own COVID infections, and I hope that one day we can provide some more useful information for you. But for now, this just highlights the importance of continuing to support long COVID research. We owe it to everyone struggling to find these answers, particularly for those who we love, who we care about, and who we work with every day.


Chris Dall: Now for this week in public health history. Mike, who or what are we honoring this week?


Dr. Osterholm: Well, you know, I've said this in the last podcast and I'll probably say it in every podcast in the future. I love this week in public health history. As someone who has now been in the business almost 50 years feeling ancient myself, it's fascinating to go back and rediscover the amazing things that people did in the name of public health over the decades, before we got what you might call the modern science world. We have two events with similar themes this week, Chris. Both highlight the role that the environment plays in human health. The first event is the Great Smog of London, which took place from December 5th to the 9thin 1952. This event is depicted in the popular Netflix series The Crown Season one, episode four, and does a great job of portraying how all encompassing this event was on the city. For centuries, London had experienced air pollution events from coal smoke and sulfur dioxide, sometimes appearing yellow or green. Londoners would call these smog events pea soupers, but this occurrence in December of 1952 was one of the most severe on record. The combination of unusually cold weather and an anticyclone which circled air around the city caused the significant decreases in visibility and devastating health impacts.


Dr. Osterholm: Estimates of deaths from respiratory complications range from 4000 to nearly 10,000. In the following years, the UK passed legislation to make improvements in central heating rather than relying on open coal fires. This brings us to our next event almost 20 years later, on December 2nd, 1970. The Environmental Protection Agency, or EPA, was established in the United States. Environmental issues related to water and air quality were becoming an increasing concern to the public. While there was some legislation in place like the National Environmental Policy Act, there was not a dedicated agency to coordinate the work and enforce regulations. Since its creation, the EPA has had a number of successes, including reducing auto emissions, restricting the use of lead paint, banning the pesticide DDT, reducing companies ability to dump chemical waste into oceans, and establishing drinking water standards. While significant improvements have been made in the last 50 years in environmental health, we still have a long, long way to go. 1 in 4 people worldwide lack access to clean drinking water. 6.7 million people are estimated to have died as a result of air pollution last year. We can and should be doing better for ourselves and future generations.


Chris Dall: Finally, we have a moment of joy from one of our listeners. Now, technically, it was not presented to us as a moment of joy, but this email we received serves as a reminder to us that joy can sometimes be found in the most unlikely places. Mike, what can you tell us about it?


Dr. Osterholm: Well, Chris, this will kind of turn things on its head, okay? Because as anyone who's listening to this podcast knows, I celebrate the sunlight. But you know what? I'm always open to alternative explanations or belief systems. And this one from Janet I thought was just beautiful. And Janet, thank you so much for sharing this. It was brave and it actually made some sense. Anyone who's a little romantic might actually identify with this one. So this is what Janet shared with us. She said, I know there has been some controversy over the segment of the show each week where you discuss the hours of light, and that the consensus was that most listeners enjoy that segment and wished it to continue. I am among those who do look forward to hearing you talk about the light, but for reasons that are polar opposites of how you present it, I am someone who enjoys the winter and the dark season, unlike you and most of your listeners. Rather than dreading the days when dark hours outnumber light. I look forward to it. There are many reasons for it, but some are that to me, there is nothing more satisfying than curling up in front of a fire with a blanket, a book, and a hot cup of something. Coffee, tea or hot chocolate? Apple cider, whatever.


Dr. Osterholm: The brisk, cold air of the winter is more inviting to me to spend time outdoors than in summer, when the unrelenting sun, which wakes me up at ungodly hours in the morning, saps my energy when outside. Although I'm certain I'm in the vast minority with this opinion, I can't believe that I'm alone in it. So the next time you discuss the dimming light as we approach the solstice and the darkest days of the season, know that rather than being despondent about the lack of light some of us are reveling in this season. Janet, I love this. Janet had made sense, I get it, and it also just addresses the idea that, you know, the plurality of who we all are in this world is such an important gift, and I can appreciate the wonderful walks that you probably have, because you know how to dress warm, you know, as we have in our household, always said, it's not a function of bad weather, it's bad dressing for that weather. And so I think you probably have that down to a science. So thank you very much. And to all those celebrating the dark days right now, enjoy it. And the rest of us will still hope for June.


Chris Dall: Just a reminder to our listeners that we have not abandoned our moment of Joy segment. So if you have a moment of joy that you would like to share with us and the Osterholm update listeners, you can share it with us at Mike, what are your take home messages for today?


Dr. Osterholm: Crushed. My first message really is all about perspective. What's happening in the world with regard to infectious diseases, particularly COVID, all the other respiratory pathogens. And we have to acknowledge that we have limited information. And so we'll continue to try to do our best on this podcast to give you what we think is the best estimate of what's happening out there. But know that we're challenged right now, given that we've dismantled so many of the systems that we had in place to better understand what's going on and why is that important? Because I know that for many of you, you actually act upon what you do to protect yourselves or those of your loved ones based on what's happening in the community, is are we seeing lots of increases in cases, lots of hospitalizations, and we'll try to do as good a job as we can going ahead here in the In the Future podcast, to give you a sense, you know, where are we at this week? Is this one that now is the week? If you could reduce your indoor activity with people at high risk might be a very positive thing. So number one is how do we decipher the data. Number two is I wish we would better understand the health care systems of today around the world and their fragility relative to what they can do to respond to even slight increases in cases in a community, you know, you don't see big surges of cancer cases, you don't see big surges of heart attacks, you don't see big surges of neurologic disease.


Dr. Osterholm: What you see are big surges associated with infectious agents, particularly those respiratory transmitted agents. And our health care systems are just not in good shape anywhere in the world to deal with those. And so we've got to really emphasize that when we talk about what's happening in our communities, is it scary? Is it a bad thing, what's happening right now? Or is this just, in a sense, a media story that says, yes, these are happening, but they're the same as we saw 5 to 10 years ago. It's just today we are not as prepared to handle them. So we'll continue to add perspective to that issue. And the final point, I'm sure, which everyone already knows what this one is vaccine, vaccine, vaccine. You can do so much to reduce the likelihood of becoming seriously ill. Even being in bed for a few extra days. If you get your vaccines right now, COVID, flu and for those eligible with RSV, get it. I think that we could have some tougher days ahead with COVID if we see what's happening in Europe and even in Canada, as it might play out here, particularly among the unvaccinated. I hope the data I shared with you today on nursing home vaccination levels was a little shocking, because I think it is shocking that we have so few people vaccinated in our long term care facilities, and even more so the people who work there. So vaccines still can play a key role. Please, please protect yourself. Protect your loved ones. Get those vaccines.


Chris Dall: Mike. Instead of a closing song for this episode, we've asked you to share some of the thoughts you expressed in an email that you sent to CIDRAP staff on Thanksgiving. Now, you send this email every year on Thanksgiving, but this year's message struck many of us as particularly meaningful. Can you share some of your message with our listeners?


Dr. Osterholm: Well thank you Chris. I'm humbled to be asked to share this. And thank you to the CIDRAP staff for the feedback on this. I find that for me, one of the ways that I exist in this world, professionally and personally, is is communicating with those that mean the world to you in a way that shares with them the most important message you have, and that is how important they are to you in your life. And that's true not just for who I work with, but in particular at CIDRAP. You know, I would have a hard time trying to define in a couple of words what it's like to be as a part of CIDRAP. We have an amazing team of people who are outstanding professionals, literally at the top of their game internationally, but they're also kind, good people. It really is special to work there. It's a gift and I never forget that. And so I every Christmas and every Thanksgiving, write a note that they all have to read. And I have to say that I appreciate the fact that as as members of the CIDRAP team, they they humor me and let me share those thoughts every, every Christmas and Thanksgiving. And this year's message really reflects more of what I've been thinking about, what's important in my life, including them. And so I will read an excerpt from it that you asked me to do. And for all of you out there, this, I hope, can resonate with you, too. Because as you'll see in a moment, you are part of this very message.


Dr. Osterholm: So I wrote our lives should never be all about our work, with everything else filling in after that. I've developed a philosophy that my life is a 24 over seven juggling balls act. At least that's how I see my life these days. I'm juggling lots and lots of balls at any one time. If I considered every ball equal in importance, I'd quickly be exhausted to the point of dropping them all. So I've come to categorize my juggled balls into four buckets. The first contains balls made of lead, and they just weigh me down and quickly exhaust me. The second bucket contains snowballs that if they drop, they crumble, but the snow is easily repacked into new balls in a sense. No harm, no foul if dropped, and the third bucket are tin balls, but if dropped, get dented and scratched, leaving permanent scars. But they can be added back to the juggling routine if needed. And the fourth bucket contains beautiful, fragile glass balls that, if dropped, are broken forever and are extremely difficult, if even possible, to replace. We can all identify the lead balls in our lives, those negative relationships based on abuse of power, insensitivity and pain. I have learned to never allow lead balls in my juggling activity. The second bucket of balls are snowballs are optional, being potentially interesting people or activities, but they're never critical in my life. I love going to a Minnesota Twins game, but it is never a critical activity.


Dr. Osterholm: The third bucket of balls are the ten ones. They are important in life but can withstand being dropped, even though doing so leaves a scar. Some relationships or dreams are like that. A ten ball for me was my quest to swim the English Channel 30 to 35 years ago after three attempts. I never made it, but I still have a dream now of maybe one day being the oldest person to achieve it. Yep, my channel ten cup is still in the juggling routine, but if I drop it, my life goes on even if I've never accomplished it. The fourth bucket of balls are simply my highest and really my only priorities. My glass balls are all relationship based. First and foremost is my family. Yet for many of us, some family members will not actually make this category because by their choice, they have decided to be lead balls. I never have a legitimate excuse to drop one of my family glass balls. Never. Second are my dearest friends, some of whom are also trusted colleagues. These are people who I love and would do anything within my power. For in a time of need, without judgment or an expectation of reward. And finally, there are those colleagues who may not be my dearest friends, but our work binds us to a deeply meaningful cause mutual respect, appreciation, and the knowledge that our personal connection will always trump a professional consideration is our strong bond. So I hope that this message can resonate with you.


Dr. Osterholm: I truly try to live by this message. I want you to know that. Where does this podcast family fit? Even though I've never met many of you personally, I know you and you know me, and I will have to say that you clearly are one of my glass balls. I never forget that. Never forget that you will always be important forever. No matter whether this podcast goes on, only a few more versions or it goes on and on and on. No. That this experience we've been through together is all about juggling glass balls. And I'm so blessed that you have been with me. Thank you for that. So thank you again for being with us. I want to remind all of us one more time. Not that any of us need to hear this, but remember that when we talk about all these numbers today and we share what's happening in very objective numerical terms, these are our mothers and our fathers, our grandfathers and grandmothers, our kids, our neighbors who are all cases of these terrible diseases. And unfortunately sometimes die from them. We can never forget that part of this podcast ever. And again, I want to say thank you for being with us. Remember, you are a very precious glass ball in our lives, in my life, and I appreciate you so much for that. Thank you. Be safe. Get those vaccines if you haven't, and we look forward to talking to you in a couple of weeks. Thanks a lot. Bye.


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 This podcast is supported in part by you, our listeners. If you would like to donate, please go to The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat