Episode 206: What we know about long COVID

Chris Dall: Hello and welcome to the Osterholm Update, a podcast about infectious diseases and public health featuring Dr.  Michael Osterholm. Dr. Osterholm is an internationally recognized medical detective and director of the center for Infectious Disease Research and Policy, or CIDRAP, at the University of Minnesota. In this podcast, Dr. Osterholm draws on over 50 years of experience in infectious disease epidemiology to provide straight talk on the latest infectious disease outbreaks, counter misinformation and disinformation about vaccines, and distill the complex and ever evolving public health threats facing our world. I'm Chris Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back everyone to another episode of the Osterholm Update podcast. We've gotten a lot of questions recently about long COVID from our listeners, and we've heard from people who have personally experienced lingering post-COVID symptoms or know somebody who has. According to the definition of the World Health Organization, long COVID refers to a range of symptoms that persist for at least two months after an initial COVID 19 infection, affecting physical, cognitive, and mental health. But for many people suffering from long COVID, the symptoms have lasted far longer than two months, with significant impacts on daily function and overall quality of life. Here's what one person with long COVID recently told CIDRAP news reporter Liz Szabo. "I have two master's degrees for teaching and administration, and I can't do either one." Today, we're going to try our best to answer a few of the listener questions we received and provide some context about what long COVID is, its potential risks and some of the latest research and reports about it. So long COVID will be our focus for this April 9th episode of the Osterholm Update. Episode number 206. We'll also discuss the CDC's pause on testing for rabies and pox viruses, provide a respiratory update on COVID, flu and RSV activity, and bring you the latest on US measles outbreaks. And of course, we'll have this week in public health history. But before we get started, as always, we will begin with Dr. Osterholm's opening comments and dedication.

Dr. Osterholm: Thanks, Chris, and welcome back to the podcast family. It's always good to be with you. I look forward to these days of recording, and I want to also welcome all those who may be listening to us for the first time. When we started this podcast at CIDRAP back in early 2020, I must admit, at the time I wasn't even sure what a podcast was or how to conduct one. I only knew that on March 10th of 2020 When I was a guest on the Joe Rogan podcast and realized that the following day, more than 10.5 million people had downloaded that particular podcast, I went, wow, this is amazing. And I must give credit to two of our, at that time, younger members of the staff, Cory Anderson and Maya Peters, who convinced me that doing a podcast was a good idea. It was our way of sharing information with the masses. But in fact, even then, with the idea that we wanted to do a podcast was unclear to me just what to do. Well, in some ways, this was brought home to me in a very clear and compelling event. On April 16th of 2020. A very dear friend and colleague of mine died from cancer. Doctor Allan Kind, 84 years old at the time, having been born in June 29th, 1935. Dying on April 16th of 2020 was in fact a major painful moment for me. Allan was not only a dear friend, but he actually illustrated the very nature of his last name kind.

Dr. Osterholm: He was just that. He was my personal physician for several decades, and it was a dear friend to myself and others who in this community appreciated his kind, gentle, but yet very effective leadership. Now, I had an opportunity to see Allen just before he died. Spending time with him at his home with another one of my dear colleague friends, David Williams, and I had to come back to the office that day to record a podcast, and I was in no shape to do it. Emotionally, it was a very, very hard day. But I decided, let's go ahead and get it done. And the podcast changed that day. It received the attention of my emotions as much as it received the attention of my brain, and it was one where I, realizing that we were in for a long, long fight with this pandemic. And that likely many people who I knew would be seriously ill and even die. It just reminded me the humanness of what we do in our public health world. Yes, science is an incredible thing, as you've heard me say time and time again. It's not truth. It's the pursuit of truth. But that pursuit is so important. But there's even more than that. It's all about sharing the emotions, the concerns, the questions, the challenges, the fears, the hopes, the dreams that we all have every day in our lives. And when you're confronted with something like a pandemic, it surely deserves that you recognize all of those.

Dr. Osterholm: And Allan did that for me. He made it possible for me to understand how important speaking from the heart was as much as it was speaking from the head. And while I don't intentionally think about this every time I do a podcast today. It's still there. It's something that is just now a part of me. And I think for some of you who are podcast family members, you've come to appreciate that in some cases or even puts you out. But that's me. That's who I am. That's what I'll always be. And I won't pretend to be anything else. But it was Allan that helped me understand that. So today I want to celebrate the life and the impact that Allan Kind had as part of this podcast. My dearest, dearest thoughts go out to Betsy, his wife of 54 years, who, like Allan, is a very kind and wonderful person. So Alan, this one's for you and thank you for some 200 plus podcasts later. Still trying to live up to the kindness that you so well shared with us. And now let me move to that other part of the early moments of the show. We all have come to recognize how important that light is. And as we get more and more of it right now, it becomes even more of a gift. I am very happy to report that today in Minneapolis-Saint Paul, sunrise is at 6:38 am. Sunset is at 7:51 pm. That's 13 hours, 12 minutes and three seconds of sunlight. Wow. We're gaining sunlight at three minutes and four seconds a day this week. And as much as I appreciate the sunlight change, I do have to admit we still have had pretty erratic weather here in the Upper Midwest. As I have said to a number of friends and colleagues here in Minnesota in April, we live with 90 days of weather could be as much as early March like weather, or it could be as much like late May weather. And we just have to prepare for all of it. And remember, one important lesson when we talk about weather is the fact that there is no bad weather, just bad clothing choices. Think about that. It's very important to never forget that. And now with that, I want to also acknowledge our very dear family and friends in Auckland, New Zealand at the Occidental Belgian Beer House on Vulcan Lane. Your sunrise today is at 6:40 am. Your sunset is at 6:03 pm. You have 11 hours, 22 minutes and 56 seconds of sunlight. Still quite a bit of sunlight, but you're losing it at two minutes and 18 seconds a day. And soon we will see some real differences between us and you. But we're always here prepared to share our sunlight with you, as you are so kind to share with us during our winter. Your abundant sunlight.

Chris Dall: So, Mike, we have that basic definition of long COVID from the WHO, which is really just the beginning of the story. But let's expand on that. What does the range of long COVID symptoms include, and what are some of the most commonly reported symptoms?

Dr. Osterholm: Well, Chris, before I get into this question, there are several points that I want to emphasize. First, I want to acknowledge how personal this is for so many of our listeners who are currently suffering or have previously suffered from long COVID, or who knows someone who has. Don't forget, I, for more than three months after my only COVID case back in 2021, actually had severe fatigue. There were days that I felt getting out of bed in itself was an accomplishment. So I've been there. I'm very fortunate that my long COVID lasted only 3 to 4 months, but I can at least have some empathy for what many of you have been suffering with for days, weeks, months, and now even years. I also want to acknowledge the fact that we don't have a lot of the answers that we should and must have about long COVID, about why some people develop it, why some people have persistent long COVID cases, what kind of treatment can be done to help alleviate that pain and suffering? Why is it that in fact, we see such different kinds of presentations of long COVID? There are many questions. I won't have the answers. I will just tell you that up front. But I will tell you what I do know and what. In fact, we must strive towards learning so that we can improve upon this horrible situation. I just want you to know we here at CIDRAP promise you that even if long COVID isn't discussed in every episode, we are thinking of you each and every week.

Dr. Osterholm: I know dear, dear friends who are still suffering from long COVID. I know people who have literally had their lives turned around in terms of what long COVID has done to them. So moving on to your question, Chris, it is difficult to describe the symptoms of long COVID because this condition varies so much from person to person. No two long COVID patients are alike in the types, duration, or severity of their symptoms. As you mentioned earlier, the WHO defines long COVID as "a range of symptoms that persist for at least two months after an initial COVID infection affecting physical, cognitive and mental health." That definition, while intentionally broad in order to capture the wide range of long COVID experiences, unfortunately provides little clarity to individuals trying to understand what this condition really is. And as we've discussed before on this podcast, each new study on long COVID adds a new piece to the puzzle. But we are still a long, long way from seeing a complete picture and bringing relief to so many of you. That said, a systematic review and meta analysis published in January in EClinical Medicine provides us with a good picture of what we know so far. For listeners who are unfamiliar, a systematic review is a study that pulls together evidence from previously conducted studies to provide a summary of the data.

Dr. Osterholm: In this case, the researchers also conducted a meta analysis, which pulls together quantitative estimates from different studies. The researchers looked at eight groups of long COVID symptoms. Respiratory, olfactory (these relating to the smell or taste), gastrointestinal, neurological fatigue, muscle, skeletal, dermatological and ear, nose and throat. The most common symptom cluster was respiratory symptoms, which impacted over 47% of patients, followed by olfactory at 41%, fatigue at 37%, neurological at 31%, muscle, skeletal and gastrointestinal, both at 28%, and ears, nose and throat at 19%. And then finally, dermatological conditions at 17%. This really speaks to the variability in symptoms. There wasn't a single symptom cluster experienced by more than half of the long COVID patients. I'll talk more about the general risk factors for long COVID in just a moment, but I want to acknowledge that even within the long COVID diagnosis. Different risk factors and socio demographic factors are associated with very different symptoms. For example, females have a much higher risk of neuropsychiatric symptoms than fatigue, whereas males have a much higher risk of respiratory symptoms. Additionally, Hispanic and Black populations are much more likely to experience respiratory, cardiac and neuropsychiatric long COVID symptoms, whereas the white population were more likely to experience fatigue and muscle skeletal symptoms. I wish I had a clearer answer for our listeners about what exactly what symptoms you can expect with long COVID, and why some individuals experience certain symptoms and not others, but this just isn't the reality of our condition.

Dr. Osterholm: I also want to acknowledge that in addition to variability in terms of types of symptoms people experience, there's also variability in severity and duration of long COVID. For some people, long COVID is a relatively minor inconvenience that resolves on its own within a few months. I think I'd probably put myself in that category. For others, it has turned their lives upside down with no relief after multiple years. You heard today in Chris's question the interview that Liz Zabel had with the patient. That was so powerful in terms of the impact that long COVID has had on that individual's life. I can only hope as further research is conducted, we will have greater clarity into the mechanisms behind these different symptoms that can help us understand how to prevent and treat all of these different manifestations of long COVID. And I'll add on to that and say, once we begin to better understand the immunologic response of the human to the COVID virus, once we begin to realize the complicated nature of these different responses, we're actually going to have an impact on treating a lot of different conditions that today baffle us in terms of why and how they're occurring. And I think from an immunologic standpoint, I witnessed in first person the impact that HIV Aids research had in the 1980s and 90s on understanding immunology and human infections. And I do truly believe that COVID fits that model very, very well.

Chris Dall: So, Mike, as you mentioned, you yourself experienced some long COVID symptoms. Do we have any idea of the proportion of people who experience long COVID after COVID infection? And are there risk factors that make certain people more likely to get it?

Dr. Osterholm: Well, Chris, again, let me just share with you what we know. It will not satisfy many people's questions about the very issues of risk factors and what proportion of people will have ongoing COVID. We do have some ideas, but considering the range of symptoms we just discussed, there is a wide range of case definitions which makes the answers to this question a lot more complicated. But I promised I will do my best to provide a concise answer. There is a fairly large range of estimates from one study. The next. Overall, the W.h.o estimates that about 6% of people who were infected with COVID will experience long COVID. This estimate is based on a 2022 modeling study that defines long COVID as individuals with at least one of the three self-reported long COVID symptom clusters. In other words, persistent fatigue with bodily pain or mood swings, cognitive problems, or third, ongoing respiratory problems. And this is all three months or longer after SARS-CoV-2 infection in 2020 and 2021. Now, before I move on to further discussion of that, I want to add context, though, to even the WHO numbers. And that is, it's very clear that the actual infection with SARS-CoV-2 really mattered in terms of which variant you were infected with. If you look at the early days of the ancestral strain and then the alpha strain, we get into the Delta. Then on to Omicron. It really mattered in terms of how infectious that virus was, and more specifically, what kind of severe illness that it caused.

Dr. Osterholm: Here we are today. COVID is still a real condition within our communities, but it's nowhere like it was 5 to 6 years ago, and we now have enough evidence to feel quite confident that the severity of illness with the virus in of itself is a risk factor for the likelihood of going on and developing long COVID. So there are a number of factors here that we have to keep in mind. So if someone produces results for you that says X, Y, and Z about COVID, my first question is when was the study done? Who were the patients who were enrolled? When did they have their illnesses? How severely ill were they? All of these in and of themselves are independent factors that really have a lot to say about what your long COVID case might look like. So, Chris, let me just share with you some recent data that begins to address this question. More recent studies have estimated higher proportions of cases of long COVID among those who become infected than the WHO study showed. One study, published in the Journal of Gerontology in July 2025, looked back at data from 3.5 million Medicare beneficiaries who had COVID from October 2021 to March 2023. This study found that 3.9%, or approximately 1 in 25 beneficiaries, were diagnosed with long COVID.

Dr. Osterholm: Another study, published in BMJ Global Health in April 2025, included approximately 4700 participants in 13 high and middle income countries. This study found that 25% of patients reported long COVID symptoms, which were defined as the presence of a patient, reported symptoms at 150 days after enrollment. I think we all can agree those are pretty different numbers, which are the right ones. They both could be right. And I'll explain more about why I think that's the case later. Well, I wouldn't say there was a consensus on the proportion of people who experienced long COVID after COVID infection. There is much more of a consensus that there are risk factors. First things first, anyone who is infected with COVID 19 is at risk with long COVID. Make no mistake about it, that's a truism. But to answer your question with more specific risk factors women, older, age, Hispanic or Latino, people with underlying health conditions, unvaccinated individuals and individuals who have previously had infection are all at higher risk for developing long COVID. I want to detail a few important and interesting studies in addition to this list before we move on. First, a study published in JAMA in October 2025 found that serious mental illness defined as schizophrenia, bipolar disorder, or recurrent major depressive disorder, is associated with a higher risk of long COVID. This study was based on the electronic health records of more than 1.6 million COVID 19 patients aged 21 or older from 30 days to six months after infection.

Dr. Osterholm: Researchers found that patients with serious mental illness were at least ten times higher risk of developing long COVID compared with those without serious mental illness. The second study, finding I want to highlight is a study published in Lancet in February 2026 that used data from the NIH, supported researching COVID to enhance recovery studies or known as recover. This study focused on patients under the age of 21 who were infected and reinfected during the Omicron period from January 2022 through October 2023. Researchers found that compared with the first COVID 19 infection, a second infection was associated with twice the increased risk of a long COVID diagnosis. The second infection also tied to a 50% or greater increase in several specific long COVID conditions, including a 3.6 times higher risk of myocarditis, a 2.8 times higher risk of changes in taste and smell, a two times higher risk of heart disease, and over 1.5 times higher risk of acute kidney injury. Generalized pain, arrhythmias, abnormal liver enzymes, and fatigue or malaise. We have identified many factors that increase the risk of long COVID, but there are others I'm sure, that will still be identified with continued research and monitoring. The bottom line is we still have a lot of work to do to better understand this very issue.

Chris Dall: So, Mike, we know the role that COVID 19 vaccines have played in preventing severe disease and death. But one of our listeners wanted to know, is there evidence that vaccination mitigates long COVID, including neurologic symptoms?

Dr. Osterholm: Chris, the preponderance of observational research strongly suggests that vaccines do reduce long COVID rates, perhaps by preventing severe illness. I acknowledge this may be confusing in terms of some of the differences between study findings, but overall, I think the weight of the data support. Yes, they do. A large observational UK study published in 2022 in BMJ suggested that COVID 19 vaccination after infection lowers the chances of long COVID and health care workers, with a 12.8% initial decline after the first dose and an 8.8% drop after the second. Another observational study published in JAMA suggested that the long COVID rate was 41.8% in unvaccinated participants, 30% in those who received one vaccine dose. 17.4% after two doses and only 16% after a third dose. Likewise, a large study in Nature Medicine suggested that US veterans who were vaccinated and then infected were at a 15% lower risk for lingering COVID symptoms than their infected, unvaccinated peers. Now, this may seem like a lot of numbers to you, but the data contained in this paragraph, in short, support that vaccination and more vaccines actually do reduce your likelihood of going on and developing long COVID. Now, a 2023 study in Antimicrobial Stewardship in Healthcare Epidemiology estimated that the three doses of vaccine were 69% effective against long COVID and two doses were 37% effective against long COVID.

Dr. Osterholm: The next year, a study of 1 million US kids published in Pediatrics showed that COVID vaccines can prevent 35 to 45% of long COVID cases. Other research on more than 20 million vaccinated and unvaccinated people from three countries concluded that vaccines were 29 to 52% effective against long term symptoms. And finally, a study of US veterans in the New England Journal of Medicine estimated that the risk of long COVID has ebbed over time, most likely due to vaccination. But a Mayo Clinic study published in Open Forum Infectious Diseases suggested that vaccines had little effect in preventing long term symptoms. That research found that about 7% of infected patients were later diagnosed with long COVID, with no difference between unvaccinated patients and those who received two or more doses. I share the results of this study with you because you will likely hear about it. But I, like others, believe that the study sample size, the homogeneous population, and the expected healthcare behavior surely skewed the results here, and I believe that this study has to be put in context that it doesn't fit the main body of research data, and I think there's some methodological challenges with it.

Dr. Osterholm: Similarly, in a 2020 study in brain communications involving 1300 hospitalized and non-hospitalized long COVID patients, Northwestern University researchers concluded that vaccination before infection doesn't affect rates of virus neurologic effects. Well, that may be true for neurologic effects, but again, it does not address the issue of long COVID itself. And the other manifestations. All of this is to say, we know that COVID vaccines can reduce the risk of hospitalizations and death. These findings are clear and compelling and have not changed since the day that the vaccine arrived here for use among the public. However, the findings of the studies I just shared with you also suggest a potential modest reduction in long COVID symptoms among vaccinated participants, though the evidence is still not entirely clear. I hope we have more answers for you on the exact role of vaccination in preventing long COVID. But in the meantime, please continue to stay up to date on your vaccines to give yourself the best chance to not only avoid long COVID, but also severe disease, hospitalizations and deaths. I can tell you that even in a what some might call a mild year for COVID, I still maintain my current vaccination status as a yes with COVID.

Chris Dall: What people with long COVID want more than anything else other than answers, is something that will help relieve their symptoms, which in some cases, as you noted, Mike, are really debilitating. On that note, CIDRAP news reporter Liz Szabo wrote a story last week on a study in Brazil that investigated whether the antidepressant fluvoxamine had any effect on long COVID symptoms. What did that study find?

Dr. Osterholm: Well, first of all, Chris, I highly recommend that the listeners check out Liz's excellent work for CIDRAP news. Her article, which we will link in the show notes, has a really touching but heartbreaking testimonial from someone who has experienced long COVID symptoms since 2020. It really helps paint a picture of how disruptive some of these symptoms can be. One of the most common symptoms of long COVID is fatigue, which is exactly what this study targeted. The researchers found that an antidepressant called fluoxamine could help with fatigue and quality of life in people with long COVID, at least in the short term. The study, published last month by Annals of Internal Medicine, used a randomized clinical trial of 390 people from outpatient facilities across Brazil. Prior to treatment, all the participants reported experiencing significant fatigue, persisting for at least 90 days after being infected with COVID 19. Over 60 days, participants received either the antidepressant fluvoxamine, the diabetes drug metformin or a placebo. You might be wondering why these drugs. Well, research shows fluvoxamine can reduce inflammation and lower the risk of hospitalization in people acutely infected with COVID 19. Meanwhile, as we discussed in previous episodes of the podcast, metformin has been previously shown to prevent long COVID in randomized trials. After 60 days, the people randomly assigned to take fluvoxamine were nearly 50% more likely to report lower levels of fatigue and better quality of life compared to those assigned to placebo. The study's coauthor, Jamie Forrest, told CIDRAP news that fluvoxamine is worth trying in people with long COVID. He could also be the jumping off point to find more effective drugs in the future. Now, the challenge is what happened with metformin. Studies conducted right here at the University of Minnesota showed very different results. Well, this is where it becomes quite important to understand the study design It out, which was the drug treatment study led by the University of Minnesota, actually found that when they gave a 14 day course of metformin during the acute phase.

Dr. Osterholm: Let me emphasize, during the acute phase, it had a 42% drop in long COVID. More specifically, if the drug was given within three days of onset, the drop was 63.9%. Overall, it also reduced the viral load by 93%, consistent with reducing the seriousness of the illness. So these studies actually aren't in conflict. Remember that the study conducted in Brazil actually required people to have had significant FPG for at least 90 days before they gave them the medication. So fluvoxamine may work days to weeks after you've been infected. But in fact, metformin really is a drug that has to be given, much like we think of an antiviral drug at the time of the illness. So I don't see any inconsistency in these results at all. I think that the power of metformin is clear and compelling, and one that I think really is a very, very powerful part of treating COVID patients. So in summary, let me just say that these results really do suggest that fluvoxamine could begin to offer a glimmer of hope for some folks suffering from long COVID when treatment begins, even months after the onset of the long COVID. Meanwhile, metformin still, I think, is a very important drug that should be given immediately with a diagnosis of COVID, with the idea that that's when it will be most effective. Ultimately, as always, is the case, we need more research with a broader, more diverse group of people over a longer period of time before we can come to a firm conclusion.

Chris Dall: Finally, Mike, what is the current state of long COVID research and are there good resources we can provide our listeners with to keep track of long COVID research?

Dr. Osterholm: I'm glad we got to focus on this really important topic today. It's one that is at best confusing for. Therefore, it often leads people not to want to deal with it, but it's very important and it is one that we need to invest much more in than we are. I have seen several economic studies that have been conducted recently suggesting the cost of long COVID to this country's economy is substantial in terms of worker performance. The cost of care, etc. is truly a challenge. Chris, the state of long COVID research has always been a little abstract due to the novel and evolving foundation. At first, the field was focused on gathering evidence to support this condition as a real and tangible diagnosis that affects more people than the public realizes. Lately, the research question has shifted to characterizing the diversity of long COVID experiences and trying to understand the scientific mechanisms that cause the often debilitating and long term symptoms. As we discussed already today, we know now that long COVID is a multisystem disease with a heterogeneous presentation. And as I made a point earlier, I am absolutely convinced that solving the long COVID condition from a standpoint of diagnosis and the ability to treat the condition will enhance our ability to treat a number of post-infection syndromes. I look at chronic Lyme disease. I look at any number of post-infection chronic syndromes that actually have similar mechanisms as we see with long COVID, and I believe that we will provide a great benefit to society by solving long COVID for the long COVID patients themselves. But for others who are suffering similar kinds of situations.

Dr. Osterholm: In terms of the ongoing research landscape, we know there are observational in some clinical trials producing strong evidence where the gap exists really is reliable and available diagnostic tools. While there have been some interesting studies on immune signatures among those with this condition, these are still in the research phase and there is no FDA approved biomarker to help practitioners identify long COVID in their patients. Long COVID is now exactly at the stage where coordinated, well-funded, translational work really matters the most. That is why recover the NIH supported effort has been so important. This initiative stands for Researching COVID to Enhance Recovery, and it created the infrastructure needed to support characterization of the complicated topic. Recover received funding from the NIH initially in 2021, with additional appropriations invested in February 2024. I don't think I need to remind listeners that since the new administration took office, budget cuts, termination and harmful rhetoric from government leadership have wounded the NIH as a prestigious research institution. Grants were terminated or frozen, and new awards have been slow to move through the approval process. If they do it all, that means that fewer new labs are entering the field and fewer studies are initiated. Long COVID research is uniquely vulnerable to these cuts because the disease is long term and complex, involving truly interdisciplinary work. Despite this uncertainty, recover remains active and ongoing, although with many more delays and less risk taking. Interested listeners can still access their range of resources on their website. I want to see this initiative in the field as a whole succeed, but the ongoing political climate surely does concern me.

Chris Dall: Well, that wraps up our segment on long COVID. But to our listeners, please keep sending us questions and we will try to answer them in future episodes. So now on to some other infectious disease news. Last week, it was reported that the centers for Disease Control and Prevention had paused testing for rabies and poxviruses, including Mpox. Mike, given what's going on at the CDC over the past 14 months. There's a tendency to view news like this as another step in the dismantling of the agency. Is that what's going on here or is this much ado about nothing?

Dr. Osterholm: Well, Chris, it's not a simple answer. Let me be clear about that. As you know, I've tried very hard to make certain that we call balls and strikes in anything we say about this administration or anyone else working in this area. Several weeks ago, when it was announced that we would not be evaluating our measles elimination status until November of this year as opposed to originally scheduled April date, many people immediately leap to the fact that this was obviously an effort to avoid this discussion before the election, and therefore a political ploy. Actually, in following up with the experts at CDC who are doing the measles investigations and all the genetic work to determine is that one strain of virus, or several strains of virus that have continued to occur across the United States, which is an important piece of information for deciding whether or not you lose your elimination status. And it turns out that the CDC professionals actually said we need that much time. It had nothing to do with a political answer. And so I very much support that decision and realize for what it is, it's really about the science. So now let me take a look at the laboratory issues that we're confronted with. As you just described, coming from the infectious disease world, I always felt like, you know, the people in our lab at the Minnesota Department of Health or at the CDC were like twin brothers of different mothers or twin sisters of different mothers.

Dr. Osterholm: We always had to work closely on any outbreak or even disease surveillance in general. Without the laboratory, we had no likelihood of defining what was happening in our communities, and a laboratory that could not then provide the data for the kind of public policy and emergency response actions. What good was it to have that in the laboratory? Well, I think we have a situation here where we got a little of both. We surely have a situation where what CDC has been doing over the last several years to improve its laboratory capacity has kind of gotten us into this situation. But then I'll comment in a moment about the number of people at the workforce. But again, another story in CIDRAP news. April 3rd, Sarah Boden, who is new to the CIDRAP news team, welcome, Sarah. What a way to start out on your second day of work to hit a grand slam home run with the story. State public health lab step up as CDC pauses testing for various pathogens, including rabies and mpox. The story is linked on the show notes. I'd urge you to go read it. It's an outstanding effort and having talked to several leaders in lab science, they said that it really is the best reflection of what's happening. So the agency did temporarily pause testing for a host of infectious diseases, including poxviruses, several parasites and rabies.

Dr. Osterholm: And this is obviously a very important issue because when you need definitive testing for rabies, you need it. Well what's happening? Well, in short, the CDC has been working to improve the quality of its lab testing, and they provide hundreds of different kinds of tests for any number of different infectious agents. And so there have been pauses, as the CDC has been making a concerted effort dating back to 2024 to improve on its lab services. This is really something that we all should applaud and thank them for doing this. And in the process of reviewing this, sometimes these programs literally have to come offline. And so there was nothing sinister about this. Now, on the other hand, CDC has been hit hard in the laboratory area in terms of the number of people who have been let go. And we do know right now that there are challenges in terms of their ability to meet the needs of our national public laboratory situation. So from that standpoint, we have to continue to look closely at that and realize that we are operating on a razor thin margin right now in terms of professional capability at CDC. So what does this mean? Well, fortunately, we have had two state health departments in particular really pick up the slack.

Dr. Osterholm: The CDC is leaving behind. One is the Wadsworth Laboratory in New York, and the other one is the California Department of Public Health and their laboratory, both outstanding laboratories. And that can actually help provide support. And that's what they're doing right now. So no one will be denied a rabies test or a poxvirus test, whatever it may be, delayed slightly, and sending it to the state that for which they then at Wadsworth or at California can in fact confirm. So this is a wake up call that we surely do need to continue to improve on the quality of the lab testing. And I congratulate CDC for doing that work. And that work was started, by the way, before this current administration came into office. And it's going to be on going for several more years. At the same time, there is a warning sign here for us that, in fact, the capacity of a public health agency, whether it's a laboratory, epidemiologist, statisticians, whoever is always going to be a very important indicator of how prepared we are for anything coming down the pike. And when you don't have the kind of staffing you need, you can expect that eventually there will be a collision course between Mother Nature and us, and Mother Nature will have the upper hand if we don't have the people to respond to it that we desperately need.

Chris Dall: Turning now to measles. In its most recent update, the CDC reported 1671 confirmed measles cases in the United States, a pace that puts us on track to surpass the 2286 confirmed cases in 2025, and we are just a little more than three months into the year. So, Mike, what are the measles hotspots in the US at the moment?

Dr. Osterholm: Well, again, Chris, we actually have some good news, but we also have some bad news in terms of what's happening with measles at the current time. The good news is that South Carolina's outbreak appears to be wrapping up. Now, the outbreak can't be officially declared to be over until April 26th, assuming no further cases are reported. Remember, April 26th would mark the 42 days after the last reported case. Why 42 days? Well, that's the magic number we've come upon because it marks two full incubation periods of the virus. So if we did miss it in the first incubation period, the second one should surely show up. And if you've got two negative incubation periods together, that's always great news. So at this point it looks like South Carolina is over its measles epidemic. We got our fingers crossed and we're all trying to stay calm in South Carolina for the next several weeks. The bad news extends to the rest of the country. Utah is the biggest concern right now, as the CDC last reports in April 3rd. There are 667 confirmed cases in the state. While this began in some more isolated communities, the virus moved quickly into the broader population. Exposures are being reported in grocery stores, churches, elementary schools and college campuses.

Dr. Osterholm: Unlike South Carolina, cases in Utah are expanding rapidly, with parts of eastern Utah reporting cases doubling in a single week. Meanwhile, Chicago's reporting a different type of measles risk. O'Hare International Airport, one of the busiest airports in the world, had a reported measles exposure on March 24th. Although it's still a difficult task, public health is well practiced at responding. If someone carrying a highly infectious agent is on an airplane. There are protocols to follow up on contacting affected people and communicating next steps for their safety. What is far more difficult are the thousands of people within the airport traveling all across the globe. And it's a prime example of why vaccination, or a lack thereof, is a public health measure that protects everyone, regardless of where you live. And let me just conclude this section by saying we are far from done with measles this year. I think that we may see a somewhat slowing of new cases as we get into the early summer months, but I believe that by fall it fall, it'll come roaring back. And I think now is the time for us to step back and say, what do we need to do to begin to address when measles cases come roaring back?

Chris Dall: And finally, what's the latest on COVID flu and RSV?

Dr. Osterholm: Well, I always like it when I can start with good news. And I'm happy to say I have good news. Chris, we now are back below the national baseline of outpatient visits for influenza like illness or Ili, which means we can declare the end of the flu season. Everybody here that we're declaring the end of the flu season. Bring out the bells and whistles. This does not mean the virus has disappeared, but just that activity is no longer elevated. Last week, 2.6% of outpatient visits for Ili was down from the 3.3% during the last episode. New Mexico is the only state still considered to have high influenza like illness activity based on outpatient influenza like illness visits, outpatient visits for influenza like illness, influenza related Ed visits, and influenza related hospitalization all decreased in every age group. Last week, influenza B accounted for the majority of the samples that state health department laboratories at 54% and as well as the vast majority, 84% of specimens at clinical laboratories. As we see less and less flu activity in coming weeks, we can expect to see the proportion of cases that are influenza B increase. Since our last episode, there have been 12 additional pediatric deaths, bringing us to 127 deaths so far this season. According to the CDC, approximately 85% of these pediatric deaths have occurred in children who have not been vaccinated against influenza.

Dr. Osterholm: Now, shifting over to COVID activity continues to decline as well. The national COVID wastewater concentration is now considered very low and continues to decrease. Concentrations are very low in every region except the South, where it's just considered low, and there have been slight increases in concentrations in both the South and the northeast over the past week. COVID related emergency department visits and hospitalizations continue to decline in every age group. In our last episode, we discussed the newest variant, B 83.2, which was first detected in South Africa in November 2024 and has since been detected in 23 countries, including the United States. We don't have an updated CDC variant report, but they do monitor variant concentrations in wastewater, which allows us to have a better idea of what the variant picture looks like from week to week, as opposed to those monthly reports. Their data show the average relative proportions of SARS-CoV-2 virus variants in wastewater. At the national level, variants constituting less than 5% abundance are characterized as other. During the last week of March, the new Ba432 variant accounted for 7% of the virus variants in wastewater at the national level. We will continue to monitor this situation will keep you all updated each episode, but suffice it to say, at this time I do not see Ba432 causing a major new increase in COVID cases in our community.

Dr. Osterholm: Finally, RSV remains elevated but seems to have peaked in much of the country. Rsv wastewater concentrations are now considered low nationally, down from moderate during our last episode. Concentrations are low in every region except the Midwest, which has seen a spike in concentrations over the past week. It's now considered high there. The South is also experienced increasing wastewater concentrations over the past few weeks, but is still considered low. Rsv hospitalizations have decreased in every age group, and the emergency department visits for RSV have decreased or remained unchanged in every age group. Despite this, declining activity is still elevated compared to the typical RSV season. Usually, by this time of the year, we've actually seen RSV begin to drop off substantially. For that reason, most states have now extended their eligibility window for vaccination for eligible infants and toddlers from the end of March to the end of April. What this means is that the monoclonal antibody by Fortas still should be highly considered for any child born during this current period, and that monoclonal is approved for those less than eight months of age. And if you're high risk for serious illness with RSV up to 19 months of age in the first year of life.

Chris Dall: And now it's time for this week in public health history. Mike, what are we celebrating this week?

Dr. Osterholm: Well, Chris, this is a big week. This is National Public Health Week to celebrate all those who are active members of the public health community, including those in the general population, that help support public health. This past Tuesday was World Health Day, which commemorates the founding of the World Health Organization back on April 7th, 1948. The WHO emerged when the United Nations was first forming in 1945. It was at that very convention where representatives from Brazil and China first proposed creating a global health organization. Over the next couple of years, a constitution was drafted and eventually signed by 61 states. During the 1970s, the WHO slogan became "Health for all." The organization advocated that health for all not only meant having access to health care, but truly leading a life of quality. This meant pushing the medical and public health measures, but also for literacy and public housing. Over the decades, WHO has had an enormous impact on global health. They led the successful eradication of smallpox in 1980, marking the first and only infectious disease in humans was eradicated by public health efforts. I also might add, for those who are wondering just how important that was, even though smallpox was only in limited parts of the world in the early part of the 20th century, between 1900 and 1950, it still caused more than 250 million deaths in the 20th century before it was eradicated in 1978-79. Think of that just merely getting rid of this virus once and for all saved many millions of lives since 1950 to 1960.

Dr. Osterholm: The WHO also made significant strides in curbing polio cases, thanks to To vaccination and programs that are supported, as well as reduce the number of malaria cases and deaths over the decades. According to the WHO. 2025 Malaria report, 2.3 billion malaria cases and 14 million deaths have been averted worldwide since the year 2020, including 1 million lives saved in 2024 alone. The WHO legacy also includes their response to the COVID 19 pandemic, when they helped deliver over a billion doses of COVID 19 vaccine internationally. Yes, for many of us, we did have challenges with how W.H.O. performed in the pandemic. I think that they surely were an obstacle to the early recognition and declaration of the pandemic. They held us back, unfortunately, in a major way with regard to respiratory protection and its use in community, etc., etc. but on a whole, they did offer a major service to the world in terms of responding to the pandemic. As some of you know, the US withdrew from the WHO back in January of this year. This had a snowball effect, which prompted the WHO to announce their staff would shrink by nearly a quarter by the summer. That's about 2000 jobs gone, which has had devastating international implications. It's unclear what the future holds for the WHO, but we can take this week to honor some of the incredible work they've done over the last 80 years. Let me just conclude by saying all for health and health for all.

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

Dr. Osterholm: Well, I hope based on the overall information provided on long COVID, everyone can appreciate that long COVID still remains a major challenge. Even when the pandemic of COVID is in the rear view mirror, we have so much to do to really understand long COVID and provide the kinds of Treatments that can help individuals overcome these horrible symptoms. Second of all, the lab situation at CDC reminds us all that it's the unseen part of public health that often gets hurt when budget cuts come through, personnel cuts occur. These are not people you see on the front lines. These are not people you see every day in your community. They're in the laboratory doing really important work. And so we need to continue to support these individuals. The CDC labs, the state labs, even local labs all provide a critical service that we must never forget is so important to us. And then finally, I just want to thank Allan Kind for living up to his namesake kind. He was an incredible man who inspired many of us to help each other be better in every way possible. Six years ago. Hard to believe, Allan. That's when I last had a chance to say goodbye to you. And you have never left me. However, over these last six years. Thank you very much.

Chris Dall: And finally, what is our closing song for today?

Dr. Osterholm: Well, we actually have a new one. No repeat today. No golden oldie. We're looking for one that reflects the season. It reflects the time. Some would not be surprised when they learn of what song I picked, given my fixation on the thing called the sun. So in fact, to the greatest singing group in all of history, together with the season and what's happening with the sun. We picked "Here Comes the Sun", a song by The Beatles from their 11th studio album, Abbey Road. This was released in 1969. It was written and sung by George Harrison and is one of his best known compositions. Harrison wrote the song in the early 1969 at the country home of his friend Eric Clapton, where Harrison had chosen to play truant for the day to avoid attending a meeting at the Beatles Apple Corps organization. The lyrics reflect his relief at the arrival of spring, and the temporary respite he was experiencing from the band's business affairs. The Beatles recorded Here Comes the Sun at London's EMI Studios in July and August of 1969. It was led by Harrison's acoustic guitar, which he had introduced to the band's sound after acquiring an early model of the instrument in California. Reflecting the continued influence of Indian classical music on Harrison's writing, the composition includes several time signature changes. "Here Comes the Sun" has received wide acclaim from music critics throughout the world, and today I'm happy to share with you as we all think about the sun. "Here Comes the Sun", the Beatles, here comes the sun.

Dr. Osterholm: Doo doo doo doo. Here comes the sun. And I say it's all right. Little darling, it's been a long, cold, lonely winter. Little darling, it feels like years since it's been here. Here comes the sun. Doo doo doo doo. Here comes the sun. And I say it's all right. Little darling. The smiles returning to the faces. Little darling. It seems like years since it's been here. Here comes the sun. Doo doo doo doo. Here comes the sun. And I say it's all right. Sun, sun, sun. Here it comes. Sun, sun, sun. Here it comes. Sun, sun, sun. Here it comes. Little darling, I feel the ice is slowly melting. Little darling, it seems like years since it's been clear. Here comes the sun. Doo doo doo doo. Here comes the sun. And I say it's all right. Here comes the sun. Doo doo doo doo. Here comes that sun. It's all right. It's all right. The beetle. Thank you so much for spending your time with us today. We appreciate it. I hope the information we've provided on long COVID can be of some help. I tell you, we have a lot more information that's desperately needed to really take us to a place where we can say we're in front of the long COVID situation, not trailing behind it. I also just want to thank all of you for your wonderful support of our efforts. I can't tell you how much your comments mean to us, and we do read every one of them. It means a great deal to us. I want to thank the podcast team. This group has, week after week after week, worked hard to help bring this information to you. And it means a great deal to me to be a part of it. So enjoy spring as it comes. Everyone recognizes we're in a very precarious time in this world, and all we can keep doing is looking forward. Being kind. Being thoughtful. Being thankful. So thank you so much. Be kind. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm update. If you enjoyed the podcast, please subscribe, rate and review wherever you get your podcasts. And be sure to keep up with the latest infectious disease news by visiting our website, CIDRAP. Edu. This podcast is supported in part by you, our listeners. The Osterholm update is produced by by Sydney Redepenning, Elise Holmes and Ruby Guthrie. Our researchers are Cory Anderson, Meredith Arpey, Leah Moat, Emily Smith, Clare Stoddard, Angela Ulrich, and Mary VanBeusekom.