December 28, 2023

In this episode, Dr. Osterholm and Chris Dall discuss the JN.1 variant, the rising levels of SARS-CoV-2 in wastewater, and the low uptake of the COVID-19, RSV, and influenza vaccines. Dr. Osterholm also shares his thoughts on hospital capacity issues in the U.S. and shares the latest "This Week in Public Health History" segment. 

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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 Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. I hope all of you in the podcast family are having a happy holiday season. And since we are in the midst of the holiday season, today's episode is going to be a shorter one focused on COVID-19 and other respiratory virus activity. But before we get started, as always, we'll begin with Dr. Osterholm's opening comments and dedication.


Dr. Osterholm: Thank you, Chris, and happy holidays to everyone. Uh, listening to the podcast, to the podcast team that helped put this together. Uh, I hope that your days are enjoyable, uh, rewarding, filled with wonderful moments. And for those who have been challenged through the holidays, which we know, there are a number of you who have, through illness or other family related events, or just out of work schedule and could not get home for Christmas. That, um, in fact, you are also, uh, getting as much as you can from these holiday seasons. You know, we put such pressure on ourselves to make sure everybody is smiling and happy, and these are the best days of our life. And we know that, in fact, that's not reality. So today, in fact, I'm dedicating this podcast to everyone who over the past several weeks have actually experienced challenges because of the holidays, not, in fact, enjoying them as some of us have had the opportunity to do. I must say that for me, uh, again, one of the highlights of my entire life, every year, is the opportunity to read the Polar Express, in this case in person, to my grandchildren. Uh, what a wonderful, wonderful opportunity. If nothing else happened to me throughout this entire holiday season, that surely was a reason for me to rejoice.


Dr. Osterholm: So today, again, whether it's been because of illness and for some of you, I know this is COVID because I happen to know a lot of podcast listeners right now who are infected with COVID. Uh, if it's for some other health reason, uh, again, we wish you the very best. And this podcast is dedicated to you. Now, it's that time of year where, uh, as I call it in my personal life, the sun's taken a turn for the right angle. And, uh, as you all know who have followed this podcast and thank you for your patience in doing that, um, that I have a love affair with sunlight and, uh, that to me, one of the real wonderful things in life is tracking that there's always hope. Even when the sun length is getting shorter, there's always hope. It's going to turn the corner. Which, believe it or not, every year it does. And so here we are today on December 28th, 2023 here in Minneapolis. Uh, sunrise today is 750. Sunset is 438. That's nine hours and 37 minutes and 15 seconds of sunlight. As I pointed out before, uh, you know, it is not equal sunlight gain or loss on either end of the sunlight spectrum. Morning versus later in the day. Uh, in fact, since December 18th, which was the shortest afternoon of the year at 432, we are now seeing the days lengthen.


Dr. Osterholm: However, the days are still getting shorter on that beginning end of the sunlight spectrum. Uh, we won't see the shortest morning of the year until January 5th, uh, when we hit it at 751. And then after January 5th, all speed ahead both morning and afternoon will be gaining. And we look forward to that. And for those of you who are in Auckland today at the Occidental Belgian Beer House, uh, you had sunrise at 6:01 a.m. and sunset at 842 for 14 hours and 40 minutes of sunlight. Uh, you know, you're enjoying those very best days. Uh, we wish you the best in those sunlight days. And thank you for your willingness to share those sunlight days with us as we will be increasing. And I promise you, in June, we'll we'll pay you back. So, Chris, it's great to be with everyone today in this holiday season. And, uh, all I can say is the podcast family. We understand what that means to be together. And, uh, as we go through the today's podcast, some of the implications that will come through. So thank you all. Uh, we're so glad you're here. And, uh, Chris, I'll turn it back to you.


Chris Dall: So let's start with the latest COVID data. In our last episode on December 14th, we discussed the rising COVID activity here in the US and other parts of the world, and that upward trend appears to be continuing everywhere. Mike, what's your assessment of the situation right now?


Dr. Osterholm: Well, this is one where I have to lead with the single most important perspective on this issue, and that is humility. Uh, anyone who tells you exactly where this virus is going or what it's going to do right now, be careful, because they probably have a bridge to sell you too. Uh, this is a challenge. We are watching this pandemic play out. And while as I've said many times over the past months, we are not going to experience another 2020, 2021, 2022 experience, we're not going to see another Delta or Omicron take off with these incredibly high peaks and cases. But we are going to continue to see substantial action. And we don't understand exactly why. Uh, whether it's waning immunity, whether it's the variant change, whatever. And we'll talk about that today. But so let me just give you the assessment of what's actually happening as we best know it. And I want to add perspective to that in the sense that with the elimination of many of our surveillance tools that we've had in the community. Uh, we don't necessarily know what's going on. I know of a number of individuals with COVID today and who have become infected within the last 7 to 10 days, who took a home test, never reported the case to anyone. And there is no mechanism for reporting many of these cases. So we really are limited in our ability to depict what's happening with cases in our community.


Dr. Osterholm: And that's true for around the world. But let me go ahead and give you my sense of what's happening right now, at least here in the United States, with some context within the international perspective. First of all, all of our metrics that we do measure continue to rise, which is certainly concerning considering the timing with the holidays. As you remember, in the last episode, we discussed much of the COVID activity in terms of wastewater data. At that point, COVID levels were nearing the highest they had been at any point in 2023, and 77% of states were reporting high or very high levels of COVID. Now imagine that high or very high levels of COVID. Now the fast forward two weeks to today, and we're at ending 2023 with wastewater levels as high as they were in January 2023. And I'm not sure when we might see them finally decline. The northeast and the Midwest continue to see much higher levels compared to the South and the West, but activities on the rise across the entire country. And as I'll comment in a moment throughout the world that said, I think we need to be very cautious in interpreting what exactly this rise in SARS-CoV-2 detected in the wastewater really means. These are not cases. Let's take a step back and clarify exactly what wastewater data is.


Dr. Osterholm: When we talk about wastewater data, we're generally referring to the effective SARS-CoV-2 virus concentration or a copies of virus per milliliter of sewage. We get these data from Biobot analytics, though the data briefly came from verily, when Biobots partnership with the CDC ended back in October, we used this wastewater data because it historically has been a good leading indicator of COVID activity in the US. That said, we never really developed an interpretation of exactly how many copies of virus per milliliter of sewage translates into actual numbers of cases, hospitalizations and deaths. And I think things are more unclear now than they've been at any point in the pandemic. Many have speculated that the rapidly spreading JN.1 variant, which we'll talk more about later in the episode, could cause more gastrointestinal illness than previous variants and therefore actually put more viral copies into the wastewater system per case. If this is true, it certainly could contribute to an increased amount of virus in the wastewater relative to the number of clinical cases that are actually occurring. However, anecdotal reports are not the same as actual evidence, and we currently lack any quality evidence supporting or refuting this theory, so it's difficult to say whether this is the case or not. It's possible that the increase of virus detected in wastewater is solely due to an increase in transmission. It's also possible that we're seeing more GI illness with this variant, and thus more fecal shedding of the virus that contributes to increased wastewater levels.


Dr. Osterholm: It's really too soon to say without more data on symptoms associated with the JN.1 variant, but for now, we need to have this possibility in the back of our minds when we interpret the wastewater data with this variant, or any emerging variant for that matter. Moving on to other metrics beyond wastewater, hospitalizations in the US are up 10.4% in the last week. More than 25,000 new admissions occurred during that time. This is the highest number of hospitalizations since February 11th. Let me repeat that. Last week, we saw the highest number of hospitalizations for COVID since February 11th, almost a year ago. Emergency room visits are up 6.6%, with 2% of Ed visits now testing positive for COVID. Unfortunately, deaths are still around 1300 a week, which means we're losing about 186 Americans every single day. This marks a 16th straight. Week in which weekly deaths have exceeded 1000. Think about the fact, as we just talked about the holiday season, using this average number of deaths per week. Almost 200 people died on Christmas Day in this country from COVID. Imagine what those families experienced on Christmas Day. We are a long ways from where we want to be, and I can only hope that people start to consider the ongoing risks that COVID-19 poses.


Dr. Osterholm: I know all of these numbers are not how we want to close out 2023 and ring in the new year. So I do want to provide a little positive news. Data from the recently released preprint from the centers for Infectious Diseases in the Netherlands suggests that the monoclonal xbb vaccine booster is around 70% effective in preventing both hospital and ICU admission in those 60 years of age and older. I've been hearing a lot of discussion about these data over the last week, and giving the sense that this may be the best the vaccine has performed since the beginning of the pandemic. Well, let me just add a footnote of reality. While this is promising news, I think we need to interpret the data with real caution. Remember in 2020, when the first data came out on both the Pfizer and the Moderna mRNA vaccines, which for the data presented to the FDA, they were anywhere from 94 to 96% effective in reducing infection not just serious illness, but infection. But then look what happened at six months and eight months out. Well, the 70% effective number comes from hospitalization data from the Netherlands from October 9th through December 5th of this year, the earliest that anyone in the Netherlands could receive the Xpb vaccine was October 2nd, meaning that all of those in the study who were vaccinated received their dose between one week and a little over two months before hospitalization.


Dr. Osterholm: This suggests for the first couple of months, this vaccine is quite effective in preventing hospitalizations in those 60 years of age and older. But again, remember 2020, this is great news, but I don't necessarily think this means that we're going to continue to see this high effectiveness as six months post-vaccination, or maybe even 3 to 4 months post-vaccination. We need to keep a close eye on this so that we can make the best possible recommendations regarding the timing of future doses, and so that we do not over promise the effectiveness of the vaccine to the public. Our COVID vaccines, including the monovalent Xpb vaccine, which is the one currently available, are really important tools for preventing severe disease and death due to COVID-19. But we need to be clear about the limitations of these tools, which include the durability of their protection by age. We also still have extremely low vaccine uptake here in the United States, with only 18.5% of US adults having received the most recent vaccine, which is actually up one percentage point from our last episode. But that needle is moving very slowly in terms of increased vaccinations. So to summarize what's happening in the United States, it's clear we are seeing tremendous activity. But as we look at the international data, one trend is very important the number of hospitalizations and deaths compared to the total number of cases is much, much lower now than it was in the early days of the pandemic.


Dr. Osterholm: So I think this is an important context to say that this disease has now become a much more common everyday infection here in the United States. But fortunately, we're not seeing the same level of severity that we saw in the previous days of the pandemic. It still doesn't erase the number of deaths that are occurring every day with this disease. It still doesn't erase the 25,000 people who are hospitalized with this infection right now. I don't want to for minimize those for a minute because some of them are you some of them are your loved ones, some of them are your friends and colleagues, and they're my loved ones, friends and colleagues. But at the same time, thank God we're not seeing these much higher levels of severe illness and hospitalizations that we've seen before. Now, if we take a look at the international picture, it is not a great one in terms of what we have for data from those countries doing what I would consider to be more comprehensive surveillance. Let's take Canada, for example. This past week, they reported 4687 hospitalized patients. 160 were in ICUs. If you look at the seven day moving average of deaths, it's about 73. This is the highest it's been since May of 2022.


Dr. Osterholm: And at this point, they have now seen a preponderance of JN.1 variant as the causative infection variant. Given the number of deaths that they're seeing and it's going back to those early 2022 days. This is a pretty significant issue. The challenge will be what's happening with vaccination, which has been limited in terms of Canada's uptake of the new additional dose. And what does it mean with regard to which variant is circulating? Let's take another country like Denmark. Where there. The wastewater data in Denmark is the highest it's been since Omicron, which is remarkable. Hospitalizations in Denmark right now are the same as they were in October of 2022, with about 118 new admissions per day. Now, to give you some context, 118 may not sound like a lot, but remember, it's a much smaller population in Denmark. When the alpha variant emerged in 2020, they got as high as 174 hospitalizations a day. So now they're at 118. During Omicron, which was by far the worst hit they suffered in Denmark, they were at 403 hospitalized patients a day. So we're still a little bit more than one fourth of the number of hospitalizations as Omicron. But that is still a very significant burden for at a time when most people thought that COVID was done and over with. The other issue in Denmark, which is something we need to look at carefully around the world right now, in those children two years of age and younger, we are seeing the highest hospitalization rate for COVID since 2020.


Dr. Osterholm: Think of that, the highest number of hospitalizations for those two and younger right now in Denmark than at any time in the pandemic. This is a wake up call to again, prioritize not just those 65 years of age and older to get vaccine, those in Long tum care facilities, but also our kids, particularly young children. Just as we keep focusing on RSV and influenza with our young kids, we should be focusing very clearly on on COVID. And for those naysayers in my public health world who say, oh, kids don't need to be vaccinated, I think the data in Denmark should give you pause. It really is concerning. If we look at what's happening in Italy right now, there's about 7640 hospitalizations right now. This is the highest level they've had since January 2023. And while it is much lower than the 38,000 hospitalizations seen in their worst moments in 2020 is still basically a sizable increase in hospitalizations occurring there. Now, if we look at the Netherlands right now, wastewater levels are at all time high in the entire pandemic. We are seeing about 810 persons hospitalized in the Netherlands per day. This is the highest it's been in all of 2023. The JN.1 variant is predominating.


Dr. Osterholm: The same is true for Austria about 1100 hospitalized individuals a day. This is the most in all of 2023. Now of note there they still see BA 2.86, the precursor variant to JN.1, still causing a most of the cases. So I think this is just a warning that it's not just JN.1, but also this other variant. And let me just conclude with one last country I could spend hours going through a country by country, but this is one I think that is a wake up call. Again, to those who continue to push this concept that COVID has become a seasonal virus, that is simply not true. And I know many of my colleagues want to believe that, because it then makes it possible to come up with a plan for concurrently giving both influenza vaccines and COVID vaccines in the fall. If we look at New Zealand, a country near and dear to my heart, we're seeing some remarkable impacts of COVID right now, even though it's in the middle of their summer during Omicron, the highest level of hospitalizations was about 3.2 hospitalizations per 100,000 people last August. That had gone down to about 0.3 per 100,000 people were hospitalized. Well it's climbing. It's now back up to 1.3 hospitalizations. And that's the highest it's been since 2022. And all the data right now looks like that's going to continue to climb at least for the next few weeks, meaning that it surely could get at least to be half, if not more of the very highest number of hospitalizations ever seen during Omicron.


Dr. Osterholm: Now, anybody who would tell you that this is a seasonal virus will have to explain how, in the height of the New Zealand summer, could we be seeing such activity if this was a seasonal virus? And there's other activities throughout the Southern hemisphere to support this? So the bottom line message for all of this is one, we still have a lot of activity in the United States. Fortunately, with fewer number of severe illnesses per number of people infected. Number two, I don't know where it's going. I don't know why is this happening? Is it because of waning immunity? Is it because the new variant actually is causing more infections to occur? Breaking through the immunity that we have? We don't know. All I can tell you is we're not done with it yet. And for many of us who are trying to live our lives as safe as possible, but at the same time not just shutting ourselves in, we got some real questions about what to do. And Chris, I know we're going to cover that later in the podcast, so I'll I'll wait for that. But I can say right now, globally, COVID is still here, it's still challenging us, and I wish we had better answers.


Chris Dall: Well, so you just mentioned the new variant and let's talk about that some more. Last week, the World Health Organization said that due to its increasing spread, it's classifying the JN.1 Omicron subvariant as a separate variant of interest from its parent lineage, BA 2.86. Mike, what is the significance of that move?


Dr. Osterholm: Adding JN.1 to the list of W.H.O. variants of interest is telling, and that this incredible rise in prevalence has the global health community's attention. But I want to make it clear again that the variants of interest are not the same as variants of concern. Remember, this is a variant of interest. Variants of interest are defined as having two factors one a mutational profile that aids in transmissibility, virulence, or the ability to cause severe disease, antibody evasion or susceptibility to therapeutic agents. Plus number two, a growth advantage over other circulating variants. It may suggest a risk to global public health. Meanwhile, variants of concern are distinguished by adding that they are capable of causing more severe disease, overwhelming existing health systems, or significantly evading all vaccine induced immunity. So JN.1 is classified as a variant of interest at the moment currently lacking the serious red flags I mentioned. Like we've discussed in previous episodes, this variant may be spreading like wildfire, but there is not strong evidence that it causes more severe disease than any other circulating variants, or that it escapes neutralization from the updated vaccine immune response more than the other variants. I hope this new classification encourages those who have not yet received their dose of bivalent mRNA vaccine, or Novavax, to do so with urgency, as I just discussed with the Dutch data, clearly, in those first days after vaccination, there's remarkable protection.


Dr. Osterholm: How long that will last? We're not sure. But having said that, this is still a time when you can avoid that serious illness and more recent data supporting you can avoid long COVID by getting that vaccine dose later. In their statement, the W.H.O. encouraged increased precautions to protect yourselves and others, but most notably, they advise universal masking in health care facilities to limit spread of all respiratory illnesses. While this may sound like a strong recommendation in our current situation, what does universal masking actually look like and entail? Is that a surgical mask or an N95? Is it for a use at all times, or just when conducting an aerosol producing procedure? The W.H.O. has continued to confuse public health and medical officials with these, what I would call conflicting recommendations. We need to see the W.H.O. make a much firmer and more detailed statement on this issue. If we actually expect to see adherence from hospital staff, patients and visitors across the globe, then we need to see them be very specific. We need to be using N95 respirators. They need to be used not just when they're in the patient room, but in areas where patients are out of any kind. Since we are seeing more and more transmission of infection. I just recently had a friend in colleague who had been hospitalized for cancer treatment, and while in the hospital over a period of several weeks, developed COVID and died from his COVID.


Dr. Osterholm: Uh, that was a hospital acquired infection. How did it occur? Was it the staff? Was it visitors? Whatever it was, the use of respiratory protection was not effective. We need clarity on that issue right now. Since the public health emergency ended in the US earlier this year, health care facilities here have relaxed masking requirements to align with individual risk assessment, and I imagine hospitals and nursing homes will struggle to implement new mandates if they attempt to at all. This is a stark reality of our current situation weak recommendations and severe pandemic burnout. I realize they are happening at the same time, but at the end of the day, JN.1, alongside other COVID variants and respiratory illnesses still threaten those who are at higher risk of severe disease and death. And I believe we must try to use every tool that we have to minimize this suffering. This also applies to those at risk people for serious illness in our families and the social settings we get together. We'll talk more about that in a moment about what I recommend doing, but realize again, respiratory protection. As much as the world is over with, it still can be an effective way to avoid becoming infected with this virus. And that's a big deal if you're someone who's at risk for dying from this infection.


Chris Dall: So now on to the other two respiratory viral diseases that we cover on this podcast. Mike, what are you seeing in the latest flu and RSV data?


Dr. Osterholm: Well, Chris, we're seeing a lot of regional variation within the country in terms of respiratory virus activity right now. Overall, RSV cases are slowly continuing to decline, down about 3% over the past two weeks. But it's important to note that most of this decline can be attributed to declining cases in the South. Most of the rest of the country is either seeing slight increases or relatively steady numbers of RSV cases. Similarly, influenza activity is picking up in many parts of the country, while other regions are still seeing very minimal activity. Nine states in New York City are currently experiencing very high levels of influenza virus transmission. 14 states in the District of Columbia are experiencing high levels of activity, up from 12 during the last episode. 11 states are experiencing modern influenza activity, up from eight during the last episode, and nine are still experiencing very low activity. But it's down from 11 last episode. And so from this, you can see that we're in a changing picture for influenza risk right now, depending on where you're at in the country. It's very interesting that we continue to see the most states experiencing high or very high activity in the southern part of the United States. Minnesota, for example, where I sit today, is actually still at very low risk for influenza.


Dr. Osterholm: So we'll see how this plays out over time. I can say that from my long experience dealing with influenza, it is playing out like a typical flu season. At this point, we're not seeing big spikes in cases, and I don't believe that. In fact, we're going to see a sudden takeoff. Looking at the influenza mortality data, the percentage of deaths occurring due to influenza in the US is still fairly low relative to what we would expect to see at the peak of a flu season, at about 0.34% of the deaths in this country, which is about four times lower than we saw with the peak of influenza in the 2022 2023 season. And it was over three times lower than what we saw at the peak of the 2019 2020 influenza season. Pediatric mortality remains fairly low, with three additional deaths reported since our last episode. A majority of the cases this year have been influenza A, and a majority of those influenza cases were subtyped and found to be H1n1 pandemic oh nine strain, which is one of the strains targeted in this year's vaccine. So what does this all mean? Well, it's clear that some parts of the country are in the thick of their respiratory virus season, while others have remained relatively unaffected so far.


Dr. Osterholm: With regard to influenza, it is difficult to say exactly why this may be the case, or if it means that the northern part of the country will experience a milder flu year, or just a later flu season in the southern part of the country. As always, we will keep you updated as this respiratory virus season unfolds and more data become available. Remember, right now we're up against a whole army of infectious agents. It's not just COVID, it's not just RSV. It's not just influenza. It's para influenza. It's metapneumovirus. It's I go down the laundry list. And so we surely have an opportunity to get infected with a variety of different agents right now. But one point that I want to keep emphasizing for the first time in public health history, we have vaccines that can be effective in reducing serious illness, hospitalizations and deaths for three of the primary causes of respiratory illness, namely COVID, influenza and RSV. Use them, use them. And I can't emphasize that enough right now. That could really be a game changer for a lot of people, uh, and in particular for our own loved ones.


Chris Dall: Mike, I want to return to a conversation we had on the November 30th episode of the podcast when we talked about hospital capacity here in the US. Is that something we need to be aware of? If we start hearing reports of US hospitals filling up with patients amid this uptick in COVID.


Dr. Osterholm: You know, Chris, I have to just say that when I covered this in the November 30th episode, it seemed as if a shocking information to a number of people, and particularly people in the media who had been reporting on this widespread challenge with running out of beds, and that the number of cases was challenging the health care system's ability to even provide care. And when I shared with them the relevant information of comparing actual number of cases of illness over time between locations versus what was happening now, uh, one could see that, well, if you cut the number of hospital beds down dramatically, you cut down the number of staff that you have dramatically, you know, the same number of cases that would have been routine in terms of overall care needs ten years ago. Today could be an incredible challenge. So let me just review this again, and I hope for the sake of the media, at least, they consider this information. And I hope some of my colleagues do, because I saw a number of colleagues who were interviewed in the media who made the case. Oh, you know, we're running out of beds. Uh, and this is a very severe situation right now. Missing the entire point is that they weren't running out of beds per what at one time would have worked much fine. They just had cut their beds. So let me let me try to again provide perspective to this.


Dr. Osterholm: We need to reiterate over and over again when they talk about hospitals overflowing in beds in hallways, this is not a sign of a novel or particularly severe flu season or any other respiratory pathogen. We for the past 20 years, have been decreasing the number of pediatric beds and staffing, especially in rural areas. And therefore you have to take that into account. For example, in a Minnesota Public Radio news story from December 15th, they reported that since 2020, Minnesota has lost almost a thousand pediatric beds, one fifth of all pediatric beds in the state. Let me repeat that. Since the beginning of the pandemic, Minnesota alone has lost over 1000 pediatric beds, one fifth of all the pediatric beds in the state. And if you look at the data on hospitalizations, capacity data as of December 12th, in the Twin Cities metropolitan area, 98% of pediatric hospital beds are in use and 96% of pediatric ICU beds are in use. To put that into perspective, on December 12th of this year, there were only six pediatric hospital beds open in the entire Twin Cities metropolitan area. Think about that. And we were not getting hit. I just got done telling you the flu has not been a serious problem in Minnesota that this year. So when we look at the issue of capacity, it is an issue of supply and demand.


Dr. Osterholm: Last fall winter, we had an early surge in demand. The capacity issues were exacerbated by this decrease in supply of pediatric specialty services over the last 20 years. Remember, this is a financial issue. Unoccupied beds don't make a hospital system any money. Hospital finances rely on a high volume of patients with procedures that create generous reimbursement. Hips, knees, those type of surgical procedures. Pediatric beds generate less revenue than adult beds. Children are more often admitted for observation. They can crash hard and fast when they're sick, so they get admitted rather than undergoing expensive procedures. Just remember that reimbursements for Medicaid are considerably lower than for Medicare and private insurance. If we look at the scale of decrease in pediatric beds around the country from data generated by CMS or the centers for Medicare and Medicaid Services, and these data for from 2020 to 2022, the number of hospitals offering pediatric services dropped by nearly one third, a 32% decline. This was most severe in rural areas and small cities that lost up to 45% of the pediatric hospital care. It includes hospitals that eliminated pediatric services as well as those that closed all together. If we look at an article from the Journal of Pediatrics using American Hospital Association survey data from 2008 to 2018, that ten year period, the number of pediatric inpatient units decreased approximately 20%.


Dr. Osterholm: Nationwide, one quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit, and pediatric units with lower volume and lack of a pediatric intensive care unit were most likely to close. When community hospitals close. It requires families to travel to metropolitan areas, and this is expensive and difficult logistically. It also is what stresses these few last systems that are still surviving. Finally, if you add in staffing shortages during surges, health care systems can find ways to create beds and convertible spaces, but they can't conjure staff out of nowhere. The pandemic resulted in approximately 230,000 providers, physicians, nurses, techs, etc. to quit. Pre-pandemic, approximately 10% of nurses left their job each year. Now that's 20% per year. And why am I emphasizing pediatrics here? Because oftentimes when we see these shortages of beds and the resources to care for the patients, they are pediatric patients. And we have to understand that, therefore, a hospital could quickly become overwhelmed. But there is one last piece. And that is, again, from a health care financing standpoint and the availability of services. We in this country see a number of individuals who are in hospitals who should be in Long Tum care facilities, but there are no beds available, and they end up becoming what we call swing bed patients, where the hospital can't discharge them because there's no place for them to go.


Dr. Osterholm: And so they then continue to also require the services of the hospital staff, because of the fact that there is no place to go, that then takes away from their surge capacity if they need to, for other kinds of infectious agents, such as the respiratory pathogens. So let me just conclude this by saying, you know, our health care system in this country is really in trouble. We know that from a financing standpoint. We know that from an outcome standpoint, we know that from even just trying to provide care. Many of you here listening to this podcast have personally experienced this problem. You know, you need to see a physician. You can't get in for three months, or you need to have somebody hospitalized, but they can't find a bed. And so when we talk about what a respiratory season can mean to a health care system, it is substantial. But it's not because the virus has suddenly become this huge, huge killer of people. Surely I don't want to leave anyone with any confusion. Yes, respiratory seasons can be big trouble, but that's exacerbated by our inability to provide care during them. And I hope that we take into account more about what's happening per number of patients compared to ten years ago, today or in the future. And stop using this idea of, oh, our health care system is overwhelmed today. Yep. It is.


Chris Dall: Mike, earlier you mentioned the low uptake of the latest COVID shot. And on the day that our previous episode was released, the CDC issued an alert to health care providers warning them of an urgent need to increase vaccination coverage for COVID, flu and RSV amid the reports of increased respiratory disease. And one of the reasons the CDC cited for low vaccine uptake was lack of provider recommendation, which surprised me. So a do you think that's where the problem is? And B, can the CDC leverage that Dr. patient relationship to boost vaccination rates?


Dr. Osterholm: Well, Chris, anyone who believes they have the answer to this question, be careful too. They probably have a bridge to sell you. Now, there are some things we can surely address in terms of why are people getting vaccinated or not getting vaccinated, or why are they vaccinating their children or not? And we've talked about that many times on this podcast. At this point, with vaccination rates as low as they are. I think the CDC is right to leverage all the tools in their toolbox to boost vaccine uptake. One of those tools is the health care alert focuses on is having health care providers recommend vaccination to their patients. Primary care providers have always been a source of critical clinical and personal support to patients as they navigate vaccine decision. Adults who received a provider recommendation for the COVID-19 vaccines were much more likely to be vaccinated and have a positive perception to the vaccine's efficacy and safety, so that's the positive. We know that provider recommendations can really help increase vaccine uptake, yet we are still seeing low vaccination numbers. And it's not a failure of the primary care docs, but we need to take a look at is why are we seeing this very, very low vaccine uptake and in many cases an absolute rejection of vaccines? Well, let's just start by looking at how Americans view their medical providers and see if that's the answer.


Dr. Osterholm: In 2020, the Pew Research Center published data showing that although 74% of Americans have an overall positive view of medical Dr.s, only 49% believe they do a good job of providing recommendations all the time. 42% believe they do a good job of providing recommendations some of the time, and 9% believe that they do a good job of providing recommendations only or little of the time. To be clear, I'm not placing blame on any one group here, but it's clear we need to strengthen the Dr. patient relationship in order to help people trust the recommendations made by the providers. Now, one of the challenges we have here, though, is that people come in with already formed preconceived notions on vaccines. How many primary care providers have had to go well beyond the allotted time suggested for a visit, because one of their patients wanted to argue with them about the safety or the need for a vaccine, and they came in armed with all their printouts from the internet showing why this, in fact, was the wrong thing to do to give that child a vaccine. We live in a world today where alternative facts are common. We live in a world today where the authority figures, or those who are trusted in the past to provide us with information that could help save our family members from serious illness, hospitalizations and deaths.


Dr. Osterholm: And today, these people are not appreciated or respected. We've even seen this spill over into the veterinary community, where today veterinarians are having a very difficult time in many places to get dogs and cats vaccinated because people do not want to be told what to do or how to do it. We've talked about that on this podcast before, so I think we're at a time where we need to take a step back as public health and medical care providers and say, what is the reason for this anti-vaccine consideration and what can we really do about it? You know, this is not just providing information when alternative facts rule the day, and it doesn't matter who else is providing factual information. This is a challenge. So I just want to make it clear the CDC needs to be out there and promoting these vaccines. Many of you know, Dr. Mandy Cohen, the current director of the CDC, has been very actively going throughout the entire country trying to promote the vaccine uptake and look what's happened very little. And that is not in any way, shape or form of fault of Dr. Cohen's. I appreciate what she's trying to do, but it really is signaling to us we're in a new age of vaccine and how they're used. And so from my perspective, Chris, I don't know what to do. And I think we need to really hone in on this issue and try to address what is it about society today.


Dr. Osterholm: And I might add, this is not just in the United States. We're seeing this throughout the world. Europe is having a terrible challenge right now with the very same issues that we are on vaccine uptake. So in all my 50 years in public health, I've never, ever experienced anything like this where just what has been well understood, well appreciated and time honored vaccine programs that have saved so many lives are now being challenged as somehow being the work of the devil. That's just crazy. And I don't mind saying that. And so we need to understand that it's not enough to go out and preach. It's not enough to go out and say, I'm the right. You know, I'm the one with the right information. Okay, we've got a lot more work to do. And I applaud anyone right now who is willing to take this issue on and to try to understand at this point, you can't change it until you understand it. We don't understand it right now. So. So this is going to be a challenge for the future. And for the sake of my grandkids, I hope. I hope we can find answers and approaches that will change the current mindset of vaccine uptake and what that means.


Chris Dall: So Christmas Day has come and gone, but we are still in the holiday season and many people, especially those with large extended families, have gatherings at different times of the season. So Mike, how would you advise people to protect themselves right now?


Dr. Osterholm: Christmas really is a follow on to the question you just asked me about how to get vaccine uptake. It's one about what will the public do based on what information you can provide them, and how will they choose to act on that information that might provide for a safer experience for their loved ones, particularly those who are at increased risk of serious illness, hospitalizations and deaths? And we have to be practical. We have to be honest and we have to be realistic. So, for example, I do not believe today that a masking recommendation, particularly using N95 respirators, will be taken seriously by most people in society. We have an almost impossible time getting health care facilities to take it seriously. And these are the Dr.s and the nurses and the others who are dealing with vulnerable patients who are in the hospital. So I want to be really clear here, because I know somebody will come back and say, I'm anti-masking. I am not, I am not, I am not, but I'm being a realist. So I don't believe that a masking recommendation on a wide scale public basis will have much impact. Now, I do believe within your own individual power, if you're someone who has increased risk of serious illness, hospitalizations or deaths, you can still use your own N95 respirator to protect yourself when you're in certain circles. But you know, how does that go when you're at a holiday party and Grandpa and grandma have an N95 on and all the grandkids want to kiss them or hug them or whatever, you know, will that really take place? I don't think so.


Dr. Osterholm: I wish it were, but it's not going to. So what's the next best step? And that's where I've said time and time again minimize the risk in a secondary manner if necessary. One if you have any symptoms of a respiratory illness, don't go to a public event. Don't go where there's others there that might be at increased risk of serious illness. And I know that's hard to hear, but it's it's really a what I believe is an honorable approach to protect those that we love or care about. Now, in addition, if you can test before you go, that also adds another level of protection. Now, the tests are not perfect. They will not always pick up the virus infection in the first 24 to 48 hours necessarily. But if you have symptoms and you test positive, that's absolute proof you shouldn't be there. If you have symptoms, test negative. I would still not go because it could be that you are positive. It's just that the test has not turned positive yet, and that's one way that you can surely help others. And on top of all of this, just get vaccinated so that if you do become infected, you have a much lower risk of serious illness, hospitalizations and deaths.


Dr. Osterholm: And as we saw today with the data from the Netherlands, even in those first weeks, it will prevent you from getting infected, potentially, at the very least, keeping you from getting at any kind of illness. So get vaccinated. Everyone should be vaccinated in this holiday season, in particular against COVID, RSV and influenza. So from my perspective, Chris, it's about being practical. So all those who think that I'm an anti-masker based on these comments, I'm not I'm not, I'm not I don't think anybody's probably had a, you know, a more vocal public record on masking than I have, but it's got to be effective masking. And if people aren't going to use it, then what's the next best thing we can do? What can we recommend? And I think it's the issue of illness history and testing for COVID with tests. Before you go to these events and just know that you don't want to be the person who came to a party and infected the rest of the party there. And one of those family members died because of their infection. And I personally know of experiences just like that. I'm telling you, the guilt that comes with that is forever and it's painful. Don't put yourself into that place. I know you love your loved ones. You don't want to see them become ill, but you don't also want to be the person responsible for doing that.


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


Dr. Osterholm: Well, Chris, we have a great story this week and in fact, an incredible feat of engineering to make improvements in public health, but not without some downstream consequences. Pun very much intended here, as you'll see in a minute. Today, the Chicago River is a destination for riverboat architect cruises and transformed to the color of green during the annual Saint Patrick's Day celebration. At the height of population growth and industrialization of the mid-19th century, it became a dumping ground for sewage and debris from homes and businesses. The Chicago River at that time flowed into Lake Michigan, which was the city's source of drinking water. The river was spreading infectious waterborne diseases like cholera, typhoid, and dysentery to the city's source of drinking water, Lake Michigan. To remedy this problem, the Sanitary District of Chicago was formed to carry out an extraordinary task reverse the flow of the river. Construction began in 1892 to create a 28 mile canal connecting the Chicago and the Des Plaines River. The canal would divert waste water from Lake Michigan and instead run it into the Illinois and subsequently the Mississippi River.


Dr. Osterholm: As you can imagine, communities downriver from Chicago weren't too pleased about the idea. Rushing to completion. Before a Missouri lawsuit could be filed, workers officially opened the canal in the dead of night, 1st January first, 1900. Again January 1st, 1900. The ground was so frozen even dynamite was ineffective at making the final connection. Finally, a work was able to break through with a dredge to open the flood of water. This enormous project improved water quality in less than infectious disease threats for residents of Chicago, but the flow reversal was not without consequences. Connecting Lake Michigan with the Mississippi River subsequently altered its ecosystem and accelerated the introduction of invasive species like Asian carp. The continued impacts of climate change and severe weather events can result in flooding, both in the city and from the surrounding rivers. So this January 1st, especially if you're downtown in State Street, looking at the holiday windows or ice skating in Daley Park, take a moment to appreciate your sources of clean drinking water and all the effort that was taken to build and maintain them.


Chris Dall: Now we'd like to take a moment for a little bit of business before we wrap up this episode of the podcast. This podcast family has been so important to us over the last three years, and we hope that you have come to appreciate all the timely information, support, and positivity that we've been able to provide you through the Osterholm update. And that's why we're asking you for your help as we near the end of the year. Please help us continue to provide updates and perspective on COVID-19 and other infectious disease threats by supporting the team you trust, respect and depend on. Any amount of financial support is extremely appreciated and will ensure we can continue to offer this podcast going forward. Your support means more to us than you'll ever know. To contribute to this podcast and everything we do here at CIDRAP, please visit to make it easier for you. We'll put that link in the podcast page. We so appreciate your support, trust and continued partnership. Mike, any closing thoughts or take home messages for today?


Dr. Osterholm: Well, first of all, Chris, thank you for that message you just delivered. Um, as everyone on the podcast knows from my previous comments, I'm terrible at asking people for money. So, uh, I appreciate you doing that, but please know how important that, uh, support is to us as we try our very best to provide you with high quality information, free of charge, open access to everyone. And that really is a challenge when there are so many needs that we have today. And I also want to say thank you to the listeners of this podcast. You know, some people think it's kind of corny that we talk about a podcast family, but you know what I'm talking about for those of you who are part of that family, you know, we need each other. We count on each other, we support each other. And I can't tell you how much that means to me. You have given me personally and professionally so much over the course of the pandemic and in this past year, and for that, I will never be able to adequately thank you. Uh, your feedback, the support, uh, the questions in some cases, questions that are challenging but very important. So I just want to personally say thank you. And to all of you who have been so negatively impacted by COVID personally within your family, whatever. You know, we're still here. We're we're not done. I don't want COVID to go on one day longer, uh, than surely it could. But at the same time, as long as it's here, we'll be here. And I promise that into the future. So thank you. In terms of my message today, I just want to say, uh, number one, I don't know where this COVID situation is going.


Dr. Osterholm: Uh, this JN.1 one variant, waning immunity. What this all means? Uh, if you had asked me, would we be in the same place today that we are? Six months ago, I would have said, I don't know, I hope not. Um, at the same time, you know, I continue to challenge that notion about seasonality of the virus. It has not become a seasonal virus. I just gave you the example from New Zealand. So I don't know. And I think that's an important message with humility and honesty to say. But as we learn more, we'll share it with you. Second vaccine vaccine, vaccine. I can't say it anymore, okay? It's not perfect. These are good vaccines. They're not great. Influenza and COVID in particular are good but not great. But man, they save lives. They make the world a safer place. And so please avail yourselves to these vaccines. In terms of RSV. This one is one that is much more effective even. And it can have a big impact, particularly for our younger kids and our older adults. Finally, let me just say that, uh, in terms of the issue of vaccination and getting people vaccinated, we do know that we have a lot of work to do, and we're going to be learning over the course of weeks, months, years about why the public perceives vaccines as they do, and how can we do a better job of sharing the message of these important tools? Uh, I don't expect any miracles overnight. I think the political and social challenges that we have right now of getting people to come together, arm in arm, to take on a common enemy. In this case, a virus is a challenge. But at the same time, we've got to move forward.


Chris Dall: And your closing thoughts, Mike?


Dr. Osterholm: Thanks, Chris. Well, clearly my closing thoughts today are wrapped up very much in this holiday season. And again, wishing you all the best. And for those who have been challenged by this holiday season, I'm thinking of you and and wish for you the best. Today I'm going to go and revisit something I shared with you in episode 37 back in December 23rd of 2020. Hard to believe that long ago, the podcast title of that day was Now Is the Time. And it's a very personal experience for me, and I will again try to summarize it for you in terms of what it means. As some of you already know, on Christmas Eve 1970, uh, my father's boss and editor of the local newspaper in my hometown of Waukon, Iowa, sent me a passage from a book that was yet unpublished by Mackinlay Kantor, Iowa's poet laureate. This was a horrible time in my life, as I had literally physically removed my father from our house as he almost killed my mother in one of his drunken rages in October of 1970, as he took a broken beer bottle to her. Um, I kicked him out of the house that night. Physically, uh, we never saw him again as a family. My father's employer went by her family name, Nana. She and I had grown very close over the years, and she was a source of great strength for me.


Dr. Osterholm: She also had struck up a distant relationship with Kantor, and they had exchanged numerous letters. He sent her a passage of his new book before it was published. It was entitled I Love You, Irene. This was a story which was a blend of autobiographical discussion yet written as a novel. It told of his relationship with Irene, his wife, and it described very painful challenges that they experienced together. He wrote the following book passage, and Nana shared it with me on that wintry Christmas Eve in 1970. The passage my child, you will see many strange things. You'll watch holly berries wither and freeze while the nettles are pressed tenderly. The good dear will starve in icy thickets. When the rats grow portly amid his corn, you'll see the inspired creator neglected and his smug imitators extolled, heroic, ignored and presumptuous, cowered feeted richly. These you will observe. The shyster shall dwell long in luxury. The diligent and dependable will fall early and on the dole. A kindly nation may shiver in terror of the iron harshness adopted by its neighbors. Bright universe eclipsed black tar and gilded by a prominent sun. You see your future so. And yet in their season the candles will be lighted again. The cone smell pungent. Men may sing with the tongues and throats of angels.


Dr. Osterholm: Amid the saintly as frost. There is time now for consideration of the noblest fairy tale of all. If one be willing to believe, God rest ye merry. In the midnight clear. On that Christmas Eve night, when I read Cantor's beautiful words, I still struggle as the oldest child of a family without enough money to buy groceries or pay the heat and light bills. They were just words. They didn't put food on the table that night, or buy even a single Christmas present. For my five younger siblings. I thought at the time the pain would never go away. But like Cantor's words, I did learn over time that it would, and I begin to believe the candles could be lighted and the cone smell pungent one day. And so on. This holiday season, for all of you who are listening to this podcast, I wish you the happiest holiday experiences. But know that if you're challenged feeling life's harder realities for whatever reason, don't give up. Don't give up. Don't forget that one day there will be a time when you will see the candles being lighted and the cone smell pungent again. So happy holidays to you and thank you for being part of such a very, very important group. This podcast family is priceless. Happy holidays!


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 Homes, Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.