Episode 186: Chaos Reigns

Chris Dall: Hello and welcome to the Osterholm Update, a podcast on COVID-19 and other infectious diseases with Doctor Michael Osterholm. Doctor 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, Doctor 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. As we speak, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, ACIP, is holding its first meeting since Department of Health and Human Services Secretary Robert F. Kennedy Jr. reconstituted the group, removing 17 members and replacing them with eight new members, some of whom have been vocal critics of vaccines. And this meeting is important because it could give us one of the strongest indications yet of where vaccine policy is headed in this country. Among the issues ACIP is expected to vote on in its two-day meeting are the composition of the 2025-2026 flu vaccine and recommendations for a newly approved monoclonal antibody vaccine to prevent RSV in infants. But in a newly added agenda item, the group will also discuss and vote on recommendations regarding flu vaccines that contain thimerosal, an ingredient that anti-vaccine advocates have long been suspicious of. On this June 26th episode of the podcast, we're going to discuss the newly reconstituted ACIP and how this week's meeting could signal the beginning of significant changes in US vaccine policy. We'll also bring you up to speed on some good news regarding federal health agencies, discuss the latest report from CIDRAP Vaccine Integrity Project, update you on measles, COVID and H5N1 avian flu, and answer an ID query. We'll also bring you the latest installment of This Week in Public Health history. But before we get started, as always, we'll begin with Doctor Osterholm opening comments and dedication.

Dr. Osterholm: Thanks, Chris, and welcome back, particularly to the podcast family. You know who you are, how special you are. Thank you again for joining us. And for those who might be joining us for the first time, I hope we're able to provide you with the kind of information that you're looking for, that which is both informative but also actionable, and we will surely work always to give you that kind of information. You know, as anyone who has been a listener to this podcast knows, the opening dedication is something that means a great deal to me. I've always acknowledged that there's a bit of a sentimental side of me that is often captured by these opening dedications, because in fact, they try to reach into not just the world of science, but also into the world of all of us as humans. Today, maybe one of the most difficult of all the dedications I've ever done. But on the other hand, also one of the most very special ones. I'll be starting on a somber note today. I live and work in Minnesota, where we recently suffered a horrible tragedy, and I think it's important to acknowledge the pain and grief that our state is feeling right now. As you've undoubtedly heard, early in the morning of June 14th, the gunman went to the home of Minnesota State Representative Melissa Hortman and her husband, Mark, as well as State Senator John Hoffman and his wife, Yvette.

Dr. Osterholm: Melissa, Mark and their golden retriever, Gilbert, were shot. Both Mark and Melissa were killed. Gilbert was seriously injured and had to be put down by the family. John and Yvette were shot and required lifesaving surgeries, but are expected to recover. All of us here in Minnesota breathed a sigh of relief when it was announced that they captured the suspect and charged him with multiple counts of murder. I'm dedicating this podcast to all those who knew and loved Melissa and Mark, who will miss them not only for Melissa's impact in state politics, but for the dedication they showed to Helping Paws, a nonprofit that trained service dogs. Their lasting friendships, their volunteer work with Habitat for Humanity, and their young adult children who are grieving an unspeakable loss. My thoughts are also with John and Yvette Hoffman, as they recover from their injuries and process this traumatic experience as victims of political violence with their families and loved ones. This is a tough one for me. I knew Melissa. She was a remarkable individual. I shared a number of different activities with her, and I can say with certainty, she is one of the most remarkable people I've ever known in my life. Such a giving, giving person.

Dr. Osterholm: I know what it feels like to be threatened with violence for the work that we've done. The unfortunate reality is that many who work in public service have been targeted with harassment, threats and violence. We cannot let this be the expected price to pay for standing up to serve our communities, or we will not have public servants who are willing to do good, important work. None of us should grow complacent or accept violent rhetoric or inflammatory political speech that evokes fear and encourages violence. In our homes let us engage in productive and respectful debate about the beliefs and values we hold dearly. This is a scary, uncertain, and unprecedented time, and I urge all of us to stay rooted in kindness and compassion as we work for peace and progress. Just ask Sophie and Colin. Melissa and Marc's children. They wrote and shared a grace filled message with the world. So, I'll close this dedication by reading these remarkable words. We are devastated and heartbroken at the loss of our parents, Melissa and Mark. They were the bright light at the center of our lives and we can't believe they're gone. Their love for us was boundless. We miss them so much. We want everyone to know that we are both safe and with loved ones. We are grateful for the outpouring of love and support we have received, and we appreciate your respect for our family's privacy as we grieve.

Dr. Osterholm: Our family would like to thank law enforcement for their swift action that saved others, and for the coordination across communities that led to the arrest of the man who murdered our parents. We especially would like to thank the officers who were first on the scene to our parents’ home, and their heroic attempts to rescue our mom and dad. Our parents touched so many lives, and they leave behind an incredible legacy of dedication to their community that will live on in us, their friends, their colleagues and coworkers, and every single person who knew and loved him. If you'd like to honor the memory of Mark and Melissa, please consider the following. Plant a tree. Visit a local park and make use of their amenities, especially a bike trail. Pet a dog. A golden retriever is ideal, but any will do. Tell your loved ones a cheesy dad joke and laugh about it. Bake something. Bread for Mark or a cake for Melissa and share it with someone. Try a new hobby and enjoy learning something. Stand up for what you believe in, especially if that thing is justice and peace. Hope and resilience are the enemy of fear. Our parents live their lives with immense dedication to their fellow humans.

Dr. Osterholm: This tragedy must become a moment for us to come together. Hold your loved ones a little closer. Love your neighbors. Treat each other with kindness and respect. The best way to honor our parents’ memory is to do something, whether big or small, to make our communities just a little better for someone else. What remarkable words from two incredible kids. They are the very best of what Mark and Melissa provided to this community. Thank you on their behalf. And we all are grieving with you. Thank you for the thoughtfulness. Thank you for the ability to see kindness at a moment when many would not. And this podcast dedication will be unlike any others I've ever done. Not because others weren't sincere or that they meant a great deal, but I don't know if I've ever thought about such wisdom and kindness. Such a caring for each other, as this podcast dedication has shown us, in the words of these two incredible kids. For all of us out there, don't lose this moment to grief. Instead, be enveloped by the kindness. Never forget that. Well, it's hard, I must admit, to move into the next segment of the podcast only in the sense that that's the heck of a transition. But you also know how much I love this part of the podcast, in contrast to some of you that tell me all the time to skip it, but there are those of you that insist on it.

Dr. Osterholm: And of course, we're at a magnificent moment right now here in Minnesota. We have just gone through the summer solstice, and we've now lost 27 seconds of sunlight since that solstice on the 21^st. Today in Minneapolis, June 26th. Sunrise is at 5:28 a.m., sunset is at 9:03p.m., and that's 15 hours, 35 minutes and 13 seconds of sunlight. Remarkable. And I might add that the loss of light right now is occurring in the mornings. And in fact, sunset will stay at 9:03p.m., the maximum sunset we've experienced here well into July 3rd. On the other hand, our colleagues in Auckland. Yeah, it's been a little dark, particularly at the Occidental Belgian Beer House on Vulcan Lane. I do know from talking to people who have been there recently, however, it's lit up inside with lots of warmth from our visitors from around the world. Today in Auckland. Sunrise is at 7:34 a.m., sunset at 5:13p.m.. That is nine hours and 38 minutes of sunlight, and they're gaining sunlight at about 13 seconds a day right now. Seems slow, but trust me, it will just be a few weeks before you really start to notice that old sun's coming back.

Chris Dall: Mike, in our last episode, we discussed Secretary Kennedy's removal of the 17 standing members of ACIP and your concerns about that move. As we record the first day of the ACIP meetings has occurred. Your thoughts on the new ACIP and what you heard today.

Dr. Osterholm: Well thanks, Chris. Let me begin first of all, by saying that we are in uncharted territory. In the 64 years of the ACIP and the role that it's played in bringing us safe and effective vaccines that saved lives, we now find ourselves in this situation. You know, rather than go through and critique all eight of the new members, of which at least six I would characterize as vaccine skeptics or anti-vaccine individuals. Let me just summarize what I think this meeting really represents. Earlier this week, US Senator Bill Cassidy, an MD who approved Mr. Kennedy's appointment as Secretary of Health and Human Services, he wrote on X that the following quote although the appointees to ACIP have scientific credentials, many do not have significant experience studying microbiology, Epidemiology or immunology. In particular, some lack of experience studying new technologies such as mRNA vaccines, and may even have preconceived bias against them. Robust and transparent scientific discussion is important so long as it's rooted in evidence and understanding. Wednesday's meeting should not proceed with a relatively small panel and no CDC director in place to approve the panel's recommendations. The meeting should be delayed until the panel is fully staffed with more robust and balanced representation as required by law, including those with more direct, relevant expertise. Otherwise, ACIP recommendations should be viewed with skepticism, which will work against the success of this administration's efforts. Now, this came from the lead Republican senator, an MD, very, very aware of public health practice and the use of vaccines, made this comment.

Dr. Osterholm: I think that says everything you want to say, and I think it was demonstrated in today's meeting exactly that. But let me maybe put this into larger context. Thought a lot about this, and particularly as many of you know, leading the Vaccine Integrity Project. What does this all mean? Well, just think about this. Across all administrations dating back 64 years. We have seen providers, health departments and parents relying on the judgment of the independent experts of the CDC's ACIP to make vaccine recommendations based on data and evidence. This has been endless for 64 years without regard to who is president in the White House. But this ACIP meeting appears to be an effort to de-emphasize vaccine benefits, many of which are largely invisible to the public. And they're taken for granted. And now this meeting is emphasizing potential risks, rather real or imagined. This meeting and today was a classic example of it with so many misstatements of misinformation or in some cases, I believe, outright disinformation. This meeting serves to me as further evidence that the vaccine information and recommendations, at least temporarily, need a new independent home, a home outside the US government. And that's what we are doing with the Vaccine Integrity Project, along with many other medical and public health professional associations and experts are working to find a way forward. So, at this point, all I can say is that my challenge is making certain that the ACIP recommendations that come forth do not become a barrier to payers agreeing to pay for these vaccines that we would otherwise have recommended, but now are no longer recommended.

Dr. Osterholm: And so one of the issues we're taking on at the Vaccine Integrity Project is, in fact, making certain that we can come up with recommendations based on the best science in conjunction with the important associations of societies that use the ACIP recommendation to make their own recommendations for their special populations, pediatrics, pregnant women, etc. and we will work with these payers to determine how we might be able to avoid the what would be a catastrophic finding by the ACIP to take vaccines away from children and to then therefore not have payers pay for those vaccines, and to where we can make certain that the payer community is still able to affirm the vaccines that we have known and come to appreciate so much for what they do. So, at this point, Chris, after a day, all I can say is everything that we worried about is coming true. I can say that, in fact, we do not have a vaccine evaluation system in this country, as we once had in the ACIP of yesteryear, and it is going to be a long three years for us right now. And most of all, it's going to be a very long three years for the children of this country and the vaccines that they may not get just because of this particular activity.

Chris Dall: Mike, another item of note today was that Secretary Kennedy announced that the US would no longer financially support Gavi, which is the organization that provides and distributes vaccines to children in 78 low- and middle-income countries. Secretary Kennedy, in a video sent to the leaders of Gavi, said the group had ignored the science on vaccine safety. Mike, your thoughts?

Dr. Osterholm: Well, first of all, I think we shouldn't be surprised by any action that this administration takes right now to limit or even completely eliminate the possibility of vaccines for many around the world. As you noted, Gavi has been a very critical organization in making sure that low- and middle-income countries had sufficient vaccine. This has been, like PEPFAR, one of the model programs of our country in terms of soft diplomacy around the world. It saved lives, it bought goodwill, and it was cheap to do. Based on this decision to eliminate vaccines for Gavi, we can expect to see a major increase in the number of serious illnesses and deaths and children around the world. In addition, that will only help spread these viruses so that again, we will be dealing with them in high-, middle- and low-income countries, not just the low-income countries that did not have access to the vaccine. In Wednesday's New York Times, in a story about this very issue, there was a statement from Doctor Atul Gawande, a surgeon who has led the global health work in the Biden administration. A true hero to all of us in public health. And he called Mr. Kennedy's remarks about Gavi and the decision to withhold support for vaccines as stunning and calamitous. He went on to say, and I quote, this establishes an official US position against childhood vaccination and its support in the face of demonstration that vaccines are the single most lifesaving technology for children over half a century. He is asserting a position that the US will not support vaccination. This is utterly disastrous for children around the world and for public health. Obviously, this is a sad day to see this now, combined with the withdrawal of support for PEPFAR. And all I can say is, is that we have a lot of work ahead of us.

Chris Dall: So, Mike, when you look at what Secretary Kennedy has done with ACIP and you add in today's news about withdrawing support for Gavi, I think it's safe to say that any thoughts that Secretary Kennedy would back off his anti-vaccine stance is really out the window.

Dr. Osterholm: You know, Chris, you don't have to get hit over the head too many times to realize it doesn't feel good. And we keep getting hit over the head with the issues around public health programs and vaccination. That specifically Secretary Kennedy is in charge of and making certain actually happen. So, when we think about PEPFAR or what we've done to greatly reduce our activities around tuberculosis control or malaria control, and now we look at Gavi, we basically are supporting a major increase in serious illnesses, hospitalizations and deaths in children, in particular around the world, notably those in low-income countries. And I think about what this means, though, for the rest of the world and in a very selfish way, controlling these infectious diseases at their source. In the low-income countries is about everything, about protecting us. But the fact that now that the United States is pulling out of the support for whatever the motivation is from Secretary Kennedy, we have to understand we're not only causing a great deal of harm to low-income countries, but we also are now going to see the blowback in terms of infectious disease transmission around the world, and notably, what's going to happen in high income countries. You know, where I come from in Iowa, they say this is pennywise and pound foolish, and it surely is.

Chris Dall: So, Mike, the whole reason we're talking about ACIP is because the CDC, while not bound to accept ACIP recommendations, typically does. And what ACIP recommends is then reflected in the CDC's recommended immunization schedule. But that all depends on there being a confirmed CDC director in place and at the moment, CDC has neither a confirmed nor an acting director. Mike, what is going on at CDC?

Dr. Osterholm: Well, Chris, in keeping with the answers of our first two questions: chaos reigns. And all I can say is, unfortunately, at this point, I'm not sure anyone really knows. And that's a challenge not only for those of us working in public health, but for anyone who looks to the CDC for clear, science-based guidance. A big reason for that, I believe, goes back to the point you just mentioned, Chris, and that is they don't have a clear, visible leader at this time. Now, what's interesting is that as of this past January, the CDC director position now officially requires Senate confirmation, whereas before they were just appointed by the president. So, the original nominee that the president had announced, Dave Weldon, was eventually withdrawn in late March because they felt they didn't have enough votes for confirmation. Alongside that withdrawal, it was announced that Doctor Susan Monarez, who was named as acting director of the CDC in January, would be the new nominee. She is an immunologist and microbiologist by training who has experience working with the federal government, including the White House Office of Science and Technology Policy, the U.S. National Security Council and the Department of Homeland Security, and most recently, the Advanced Research Projects Agency for Health. And finally, almost three months after her nomination was announced, a Senate confirmation hearing happened yesterday. If she ultimately ends up being confirmed as CDC director, I'm really hoping that will help set an actual direction because as it stands, the CDC as an agency is lost.

Dr. Osterholm: In fact, according to reports from people working at CDC, leadership has basically been invisible so far. And there's confusion about who's officially in charge. For example, even though Doctor Monarez was named acting director by the president back in January. Some of the duties typically performed by the director have been done by others, including the agency's chief of staff, Matthew Buzzelli, who's a lawyer by training and doesn't have any medical or public health experience. And ultimately, the lack of clear leadership for the past six months has been cited as an excuse for delaying action, according to some CDC employees. As we all know, this has real world consequences. Like I've said, right now CDC is a crisis unto itself, waiting for an actual crisis in the community to happen. And it really pains me to see it that way, because CDC has so long served as a global leader and model of public health practice. It's basically been a guiding light for state and local health care providers, policymakers, etc. on so many important issues. Vaccines being one. And I worry that this might no longer be the case if things keep going the way they've been going. That does not take away from the many incredibly dedicated, highly competent and truly professional individuals working there, but it does speak to the leadership and the lack of connection between those two different groups. And the science for moving forward.

Chris Dall: CIDRAP’s Vaccine Integrity Project last week released an interim update. Mike, can you give our listeners a brief summary?

Dr. Osterholm: Well, Chris, I just want to remind everyone to start with that. You can always get information on the Vaccine Integrity Project website, which sits on the CIDRAP website, and you'll be directed to that specific part of the website for this particular effort. But let me just remind you what I talked about at the last podcast. The Integrity Project was set up knowing that there would be challenges to the vaccine enterprise and everything, plus more that we predicted a few months ago has all come to be true. And so, the need for this project is so important. So, what we did initially, as you may recall, is we had eight focus groups from around the country with individuals who ranged from the basic research and development of vaccines all the way to those whose job it is, is to stick that needle in that last little bit of the way. And we asked them, what would you need? What would you want? If in fact, the CDC or the ACIP or both are compromised in terms of the integrity of their science and the information they provide? And we heard a lot. We all recognize that private sector, nonprofit organizations, academic centers can never replace the government activities of an organization like CDC and that they are, by themselves, capable of doing things under the provisions of law that we can't. And so, I want to make it really clear that what we tried to identify were, what are those things that we can help with.

Dr. Osterholm: And among two of the things, we found, we believe that that's where our Vaccine Integrity Project can be most helpful. One is myths and disinformation and how to address it. We have seen on a continuing basis the myths and disinformation coming from the Department of Health and Human Services about so many aspects of vaccines, and we are, on a daily basis, responding back to these different pieces of information. And you'll be able to see that now on our website. Plus, we're investing a substantial amount into expanding that activity so that as our capabilities increase, we will be able to provide you literally on a daily basis with the kind of information that you can use to counter the myths and disinformation that's out there. And this week, trust me, there's a lot of it that's flowing. But in addition to that, one of the other major challenges we encountered was that of how will we get payers to approve any one vaccine right now for use in the community, and therefore covered under the cost of the payer system. And that's a huge challenge because to date, ACIP has been literally the body that has made the decisions about which vaccines to recommend. And then that recommendation surely goes to the director of the CDC, which in fact almost always agrees with ACIP, as this is the body of real experts from around the country to provide that kind of input.

Dr. Osterholm: So, what we also realize then, is we need to have an alternative way to affirm the actual effectiveness and the safety of vaccines that might otherwise be no longer recommended under the ACIP because of this administration's efforts. And so, we're doing that. We're mounting a major initiative right now to address, particularly the three respiratory viral pathogens that we think of each winter season, namely influenza, RSV and COVID. And we will be holding a meeting in August after a great deal of homework is being done to update and assess any new information about these vaccines since the last ACIP statement. We are working closely with the societies and organizations that currently make recommendations for vaccination. So, for example, ACIP is in fact the body at the federal level. But organizations like the American Academy of Pediatrics, the Infectious Disease Society of America, and others provide additional comment or recommendations to the vaccine recommendations, and we're working closely with them to come up with what we hope will be a largely harmonized set of recommendations for vaccine use, and which the payers could use as an alternative source to make decisions about will we cover a vaccine or not? The worst thing that could happen is to have ACIP literally take vaccines away from us, much as the secretary did with COVID vaccine in his 58 second announcement on X.

Dr. Osterholm: You know, that was a tragic kind of statement with no basis for doing that beyond he just felt he had the power to do it. And so, we are going to make every effort to give payors an alternative source that is part of a harmonized, highly collaborative effort. And we will continue to do that. Also, Chris, with the follow up that we've had with the focus groups and our key informant interviews, we've come up with a number of other kinds of activities that, in fact, we believe that the community and other organizations should and need to consider. And so, for example, there is in a number of things about maintaining the nation's vaccination infrastructure. What happens if the CDC drops out of procurement? How do we safeguard the insurance coverage I just talked about? How do we stabilize the vaccine safety system? Right now the kinds of safety studies that are going on are being paid for by the federal government. Will that continue? How do we provide assistance to state and local health departments on the front lines of helping to deliver these vaccines? How do we make sure that there's a continuing flow of data for decision making about what's happened with vaccine preventable diseases? Isn't it notable there has not been one article on the measles outbreak in this country, published in the Morbidity Mortality Weekly Report in the last four months?

Dr. Osterholm: That's pretty notable. That's an example of absence of information. So, and then how do you build an overarching coalition for strategy and alignment. So, we will help however we can with all of these different issues. But right now, our main focus at the Vaccine Integrity Project is one counter dis and misinformation in real time and with authority. Number two is make it possible so that we can come up with some type of harmonized, updated recommendations for vaccination that take into account all the new information that's been gleaned since the last review by ACIP. And hopefully, if we need, we can use that body of information to support payers who as we all know, there may be very, very effective vaccines with high levels of safety. But if people can't afford them, what good are they? And so, we need to make sure that we have that payer group on board. So, all I would say is stay tuned. We'll continue to share with you what we're doing in the Vaccine Integrity Project. I want to thank all of our collaborators, the team of people that we have working on this right now. Remarkable. I want to thank Alumbra, Christy Walton’s Foundation that has supported this work to date, and we will continue to do our job. Vaccines for all of us are just far too important not to give every ounce of measure that we have to make them available.

Chris Dall: Now let's turn to our update on our nation's federal health agencies. Over the last few months, we've been reporting a lot of bad news regarding the job and funding cuts at the CDC, the Food and Drug Administration, and the National Institutes of Health. But this episode, even though we have been discussing the continuing chaos, we do actually have some good news to report. Mike, what can you tell our listeners?

Dr. Osterholm: Well, I'm going to take this in tranches, because in fact, it may be very different from one situation to another in terms of what's happening. I'm happy to report that the Department of Health and Human Services is now rehiring more than 450 employees that were previously laid off earlier this year by the Trump administration's attempt to reduce the federal workforce. The reinstated staff are part of four different divisions within CDC: the National Center for HIV, Viral Hepatitis, STD, and tuberculosis prevention. The National Center for Environmental Health. The Global Health Center. And finally, the Immediate Office of the Director. We still have a long, long way to go, Chris. Because these 450 workers represent only a small proportion of the federal public workforce that were laid off, but it's definitely a step in the right direction. Fortunately, the good news doesn't end there. Previously recovered the claw back of $11 billion in grant funding by the Trump administration previously awarded to the state. These funds were primarily being used by states to support COVID testing and vaccination, and address COVID-19 related health disparities. However, in May, a federal judge indefinitely prohibited HHS from terminating the 11 billion in public health grant funding set aside for the states. This is a win for state public health departments across the United States, and who rely on these funds to support critical work.

Dr. Osterholm: However, we would be remiss not to acknowledge that the disruption to public health programs caused by this unexpected pause in funding, in addition to the inconsistent messaging from the federal government regarding infectious disease surveillance and response. I also want to add some context. Much of the kind of activities we're seeing right now that are basically undoing some of the DOGE related activities are all related to court activity, seeking temporary restraining orders, trying to hold back what, in fact the administration can do. Over 180 such injunctions or temporary restraining orders have been issued that have resulted in this kind of claw back or rehiring that we see. I don't know how long this will last. I assume that the administration will take many of these to the higher courts, and they're they've done fairly well. So, we're going to have to see how this all plays out. I'm not sure. And if we look outside of the Public Health Service and specifically the CDC based activities. Recently, a federal judge ruled the cancellation of several hundred NIH research grants was illegal. Judge William Young stated that the Trump administration's process for grant cancellation was arbitrary and capricious, and that the racial discrimination and discrimination against America's LQBTQ community was behind recent government actions.

Dr. Osterholm: This ruling is a win for science as well as diversity, pay, and inclusion, which are foundational to public health research. One government program we're still waiting for clarity on is PEPFAR. The stop work order issued by the Trump administration in January initially froze all PEPFAR programing and services. In February, PEPFAR received a limited waiver to allow lifesaving HIV services to continue. However, this waiver is limited to providing HIV treatment and care, prevention of mother to child transmission, pre-exposure Prophylaxis for pregnant and breastfeeding women, and HIV testing services that are prohibited include pre-exposure prophylaxis for others at risk groups, general HIV prevention and programing for vulnerable children. A recent survey of W.H.O. country offices found that almost half experienced a moderate or severe disruption in HIV services as a result of the US foreign aid freeze. A study published in The Lancet indicates ending PEPFAR could result in up to 11 million new HIV infections and 3 million HIV deaths over the next five years. Absolutely shameful. The continuation of PEPFAR is critically important to public health on a global scale. We promise to keep you all informed as more information becomes available on the administration's plans for PEPFAR. And let me conclude this by adding a note of optimism that I'm not quite sure why it's there, but it is.

Dr. Osterholm: At a recent meeting, President Bush, who made it possible for PEPFAR to become reality back in the 2003 to 2005 time period, actually said that he was very confident that PEPFAR would return as it was now. I don't know what the basis was for that statement. I don't know anybody that does know, but I do know that President Bush is someone who would not have said that unless he had some kind of information to suggest that there would be support for PEPFAR to be reconstituted as it once was. So, we'll just have to wait and see. But I think the bottom-line message here is that, in fact, we are seeing some improvements on what happened earlier with the DOGE related activity, but it's far from over. The last piece, I would just add that many of us right now are surely concerned about that issue of the immediacy of the DOGE related activities, but we have our eyes firmly focused on the 2026 budget and what's coming forward with that. Because we do believe that there may be very severe cuts coming down in that budget that could be every bit as dramatic, if not more dramatic than we've seen so far with the initial DOGE related activities. So, we'll have to wait and see. We'll keep you posted.

Chris Dall: Now on to our infectious disease updates. Let's start with what's going on in the US measles outbreak.

Dr. Osterholm: Well, Chris, the measles outbreak in the United States is continuing to progress, although it may be slowing down some. As of Friday, the CDC reported a total of 1214 measles cases across 36 jurisdictions in the United States. There's little doubt that we will surpass the 2019 case count of 1274 in the coming weeks, making this our biggest measles year since 1992. Think of that, over 33 years ago. Measles also continues to be a challenge in Canada this year, with 202 new cases reported during the first week of June, putting the country's total case count this year at 3170. Remember, these are pretty dramatic numbers when you realize the population size of Canada is 40 million people, where in the United States is 340 million people. So, when we try to compare a case number to case numbers, it doesn't reflect actually the substantial increased risk we're seeing right now in Canada. Similar to what we've seen in the United States, the epidemiology in measles in Canada seems to be shifting from 28% of the cases reported in those over age 18, 93% of these cases have resulted from exposures that occurred in Canada, and most are in individuals who are unvaccinated or have unknown vaccination status. I must tell you that in a situation like Canada, we're seeing cases of measles that I could never have imagined, a case of what we call congenital measles, where we now have such a large number of young adults who are in childbearing years having children, and they themselves have never been vaccinated or having had measles before.

Dr. Osterholm: Now, if they do get measles during their pregnancy, they may actually, in fact transmit it to the unborn child. Or if a child is infected shortly after birth, again, no protective antibody from mom. And that is really a significant challenge. We are going to see more and more of that here in the United States. Given that we too are seeing this ever-growing proportion of measles cases in young adults. In light of measles continue to spread across the country, and many of our listeners having children in their life that they want to see protected against measles, I want to review the vaccination guidelines that can be a bit confusing to navigate. According to the CDC vaccine schedule, all children are recommended to receive two doses of the MMR vaccine, one between 12 to 15 months of age, and the other between 4 to 6 years of age. The first dose is between 93 to 95% effective, and the second dose raises that to 97% effectiveness against measles and is considered protective for life. However, I know a lot of parents and caregivers of children under 12 months of age, notably a lot of grandparents who are concerned right now about their child being vulnerable to infection, especially if they're in child care settings with low vaccination rates.

Dr. Osterholm: If you're in this position, please talk to a health care provider. Hopefully, you actually have access to your child's health care provider, of which I know many do not have that kind of relationship. Wherever you get vaccines, it's hopeful that those providers will take into account that you are likely eligible to receive an early dose for one of your children if they are over six months of age and either traveling internationally or living somewhere where measles transmission is occurring. It is important to note that this early dose does not count towards the two-dose regimen, so that they will still need an additional dose of 12 to 15 months of age and at least 28 days after their previous dose. For example, if your infant is traveling somewhere with an active outbreak and is vaccinated at nine months of age, they would still need two additional doses after their first birthday, spaced at least one month apart to have completed the recommended series. I hope this helps clarify what you can do as a parent or a grandparent to keep your child safe, especially if they are below the ages of measles vaccine recommendations. As always, we will keep you informed as this measles outbreak continues to unfold.

Chris Dall: Let's turn now to COVID. We've been keeping an eye on the NB.1.8.1 variant, and there's been some media reporting on some of the symptoms that have been reported with what's now being called the Nimbus variant. Mike, what can you tell us?

Dr. Osterholm: Well, Chris, the media is picking up on what we've been discussing over the past month. So, while there is attention being drawn to this variant and its rise in prevalence in the US, there isn't much new information on this variant severity or spread that has changed the picture much since our last episode. And let me just make one comment I recognize for many of our listeners, these numbers and letter combinations get all jumbled. So let me just try to be clear in terms of what variants we're talking about and why are they important. The first variant, which is known as NB.1.8.1, I'll just call it 8.1 for the rest of this presentation. It's also been known as the Nimbus variant by a group of professors in Canada. I don't think that that's an appropriate term and we will not continue to use it. But this particular 8.1 is now the predominant variant, accounting for 43% of cases in the US. It surpassed LP.8.1, One, which makes up 31% of US cases. XFG, which we discussed in our last episode regarding increasing activity in India caused by both 8.1 and XFG, accounts for 14% of all US cases. The W.H.O. is not yet considering XFG a variant under monitoring, but many variant trackers are watching it and have been calling XFG the Stratus variant. Again, we will not continue to use that term, but I want to make sure you are aware of it. Increasingly, the CDC's traveler based genomic surveillance program, which collects specimens from travelers arriving at several major U.S. airports, provides a slightly different picture. This surveillance places XFG ahead of 8.1 for the first week of June. That week, XFG accounted for nearly 33% of cases, and 8.1 accounted for nearly 28%, compared to 19 and 48%, respectively, in the previous week.

Dr. Osterholm: These two variants seem to be battling for the dominant spot, though neither are causing significant surges or more severe disease. There have been reports of a new symptom of the 8.1 variant being called razorblade throat, which is described as an extremely sore throat that feels like swallowing broken glass or razor blades, as well as gastrointestinal symptoms. Despite the scary sounding razor blade throat syndrome, neither 8.1 or XFG have caused more severe disease. That's an important point. We're not seeing increases in hospitalization or people seriously ill. While both have been shown to be more transmissible compared to previous variants, any surges they have caused have not surpassed previous year's surges. Here in the US, as both 8.1 and XFG increase in prevalence, the national wastewater level for SARS-CoV-2 is still considered low but is slightly increasing in every region. Emergency department visits for COVID remain very low, but are also now increasing. Weekly deaths, which are a lagging indicator, continue to decline and are at the lowest we've seen at any point in the pandemic. Let’s celebrate that point! The week of May 24th, which is the most recent week with complete data, we lost 181 Americans to COVID-19. We won't forget them, but the numbers are surely much better than they were just even two years ago. Both 8.1 and XFG are increasing here in the US, and only time can tell how it's going to impact the national situation. We are months out for many people receiving their latest COVID vaccine dose in the typical respiratory virus season, so I do worry about waning immunity, leading to a rise in cases, but I'd love to be proven wrong.

Chris Dall: Mike, it feels like things have been fairly quiet on the H5N1 front in recent weeks, at least here in the United States. Is that trend continuing? And if so, what do you make of that?

Dr. Osterholm: It's true, Chris. H5N1 news in the US has been eerily quiet over the past few weeks, with very few reported detections among poultry and dairy cattle. Since our last episode, only two backyard flocks in Arizona and Idaho have tested positive, affecting just 50 birds, and there hasn't been any new positive dairy cattle herds reported since June 3rd. Listeners may recall that H5N1 had a major impact on four commercial egg facilities in Maricopa County, Arizona, at the end of May. The USDA estimates that over 5.5 million birds were affected among those sites. The calling of such a large number of animals is no small task and likely required hundreds of personnel. It's incredibly important to consider the acute and long-term health impacts for these workers, many who are migrants. A recent article in The Guardian reported that only 50 people with known exposures to H5N1-infected animals have been tested since the federal layoffs affecting avian influenza response teams at the FDA and CDC on April 1st. None of those individuals tested positive. But considering the scale of the outbreak, millions of birds across 17 states, it's hard to believe that the current surveillance is capturing more than just a fraction of the exposed farm workers and response teams. Has there truly been little activity in humans? Are we just missing something, or is it something in between? One possible explanation for the low case numbers is that proper PPE and biosecurity measures are effectively preventing infection. However, as we discussed last fall, adherence to these protocols can be inconsistent, especially in extreme heat. Another factor that's difficult to ignore is the potential effect of increased Immigration and Customs Enforcement activity, which may discourage any immigrant and migrant farm workers from seeking out available testing options.

Dr. Osterholm: Without more data on the populations involved in this response, we're flying blind. Now, I might add, however, there is one piece of information that does suggest that maybe we have seen the major thrust of H5N1 from the last 18 months in a way that is different now. And what do I mean by that? If we look at the wildlife populations, we're seeing many, many fewer reports right now of all kinds of wildlife species actually developing H5N1 infection and dying from it. For example, raptor centers around the country are reporting that raptors are still coming in after having been hit by cars, but not with H5N1 infection. They do have evidence of immunity in many cases with antibody. What does that mean? And I think that again the whole issue with migratory birds will be important. We'll see what happens on the fall migration track going south again. What that will do to bring more cases. But right now, we just don't really know for certain what's going on. Maybe we are seeing a reduction in transmission occurring. I just want to note we've also been monitoring the international human cases of H5N1. The most recent involved a 52-year-old man in Cambodia who died from severe complications. This was one of six reported human cases in the country where the 2.3.2.1c clade to the virus is endemic. While it's unclear if that clade caused the latest case, the individual reportedly had contact with poultry and cattle. Both domestically and globally, the lack of coordinated information sharing and response remains a major barrier to pandemic preparedness and actually understanding what's going on with H5N1.

Chris Dall: Now it's time for our ID query. And while this isn't specifically about an infectious disease, we've received a few emails over the past few months regarding autism and Secretary Kennedy's long held belief that the rise in autism diagnoses in the United States is linked to the MMR vaccine and/or other environmental factors. So, Mike, what do we know about the rise in autism diagnoses and the studies that have examined the potential links to the MMR vaccine?

Dr. Osterholm: Well, let's just start out with one very obvious and important fact. Mr. Kennedy has made numerous false claims about the causes of autism and the abilities of autistic people. His issues with the MMR vaccine have been central to this discussion, which is our area of expertise - infectious disease issues. Study after well-designed study continues to show there is no association between MMR vaccine and autism. I don't know what it will take to put this myth to rest, but I know that many people with autism and their families are sick and tired of fighting it and seeing research dollars being devoted to investigating it, when they could be better allocated to the causes that would truly improve the quality of their lives. But I also want to acknowledge the field of neurodevelopment has some incredible experts that have been published on the rise in autism diagnoses in recent decades. Based on information from those most knowledgeable in the field, there are two distinct things to consider regarding the rise in reported rates of autism. The first, and continue to be the most significant rise in numbers, is the expanded reported diagnoses themselves. And the second is a true rise in the actual incidence of autism in the population. Almost 60 times as many people are being diagnosed with autism today compared to 30 years ago. Notable number.

Dr. Osterholm: The diagnostic label once reserved for more profound cases of cognitive disability, has now been significantly expanded with new additions to the Diagnostic and Statistical Manual, the book of guidelines that clinicians use to diagnose patients in mental health and developmental fields. Additionally, the American school system offers significantly more supportive services to those with the diagnosis, providing an incentive for those on the fringes of seeking a diagnostic label with the potential for more structured support in educational settings. Finally, greater public health awareness autism increases individuals and parental understanding of the development milestones to ask their providers if they may fit someone along the autism spectrum. There is an investigation occurring. Actually, rigorous science about the biological determinants of autism. We understand that approximately 80% of autism is likely genetically determined, and other factors like parental age may also play a significant role. But the more we belabor the myth about the link between vaccines and autism, the less attention and funding scientists and clinicians can have to learn more about the neurodevelopment and find more effective supports and services that actually improve the lives of people with autism and their families. There are many notable individuals in the autistic community.

Dr. Osterholm: People who I actually know and respect very much. One of them is Doctor Holden Thorp, the Editor-in-Chief of Science and Professor of chemistry and medicine at George Washington University. He is a remarkable individual who I have enjoyed a relationship with for many years and has appreciated his academic excellence. He has written in a number of high-profile publications The New York Times, STAT, and Science, on the dichotomy between further understanding the science behind autism and the historic context of eugenics that seeks to eliminate marginalized communities under the guise of science. In one of his most recent opinion pieces, New York Times, Doctor Holden, as someone with autism, reframes the increasing diagnoses of autism not as an epidemic to be alarmed about, but a recognition of people's neurodiversity, an opportunity to lessen stigma and allow for those across the entire spectrum to get the care and support they need. HHS has claimed that they will make major discoveries in this field by September. I have a feeling that there are conclusions already been written, and any additional research will do nothing to change those. We'll have to wait and see. But mark my word, I think it was going to be a challenge.

Chris Dall: Finally, it's time for your favorite segment in mine. This week in public Health history. And Mike, I believe we are continuing with the vaccine theme today.

Dr. Osterholm: Chris, you nailed it. Vaccines have been a primary theme this episode, so we're carrying that over into our public health history segment. Benjamin Waterhouse was born on March 4th, 1754, in Newport, Rhode Island. And let me warn you, this guy was a real character, as they would say in Iowa. By the age of 16, he was an apprentice to a local physician. He then traveled to Europe in his 20s to study medicine. Notably while living in the Netherlands, he was roommates with John Adams, the future president of the United States. Doctor Waterhouse returned to the U.S. in 1782 and became one of three founding members of the Harvard Medical School. He kept in touch with a physician in London who introduced him to Edward Jenner, the creator of the smallpox vaccine, which of course, as you know, was cowpox. While the product was being introduced across Europe, it had not taken off yet in this newly minted United States. Doctor Waterhouse was determined to change that. After receiving sample doses of the vaccine from Jenner himself, Waterhouse conducted a few somewhat and frankly very reckless experiments. First, he vaccinated his own five-year-old son, then a local 12-year-old boy, who he delivered to the Massachusetts Smallpox Hospital, where he was sure to be exposed to the infection.

Dr. Osterholm: To Waterhouse's delight, neither child became infected. Waterhouse advocated widely for the use of the vaccine across the US, and was supported by his close contacts of John Adams and Thomas Jefferson. However, many physicians at the time were skeptical of its efficacy. At that time, there were still infrastructure challenges of delivering the vaccine in a sterile manner and keeping it appropriately refrigerated, therefore reducing its effectiveness. Physicians also had significant conflicts with Waterhouse's arrogant demeanor. Waterhouse himself was protective of the vaccine and wouldn't allow others to distribute it. Seeking to keep all the profits for himself, he later departed from Harvard Medical School over clashes with other faculty and tried to start his own rival school in the area. Ultimately, smallpox vaccination did become widespread in the US, and by 1900 the disease was virtually eliminated from the country. The Waterhouse story offers several major public health lessons. First, it reminds us that even historic figures who made major contributions aren't always perfect role models. Second, newly discovered vaccines don't make an immediate impact if they don't become shots in the arm. It takes time to distribute, and that requires reliable infrastructure and community buy in. This is a lesson we continue to learn today. Third, the idea of holding vaccines hostage for personal gain is simply unacceptable.

Dr. Osterholm: We have a powerful counterexample in Jonas Salk, the creator of the polio vaccine, who famously put affordability and access above profit and famously chose not to patent his vaccine. In my book Deadliest Enemies, published in 2017, I actually described an event where Doctor Salk was being interviewed by then the very famous broadcast journalist Edward R Murrow. On April 12th of 1955, in what became one of the most famous quotes of the decade, Edward R Murrow, asked on live CBS program, See It Now, “Who owns the patent on this vaccine?” Well, with matter of factly, modesty and a shy smile, Salk replied, “well, the people, I would say there is no patent. Could you patent the sun?” That was it. Just as Salk showed us, public health leaders can have such an impact on our community. That's especially relevant today, as many of the former ACIP members, dedicated scientists and clinicians have been unfairly accused of serious conflicts of interest. While transparency and accountability in public health are essential. These false accusations only serve to distract and undermine trust, driven by a federal administration more focused on sowing doubt than promoting science. Now, more than ever, we need to stand with those who fight for public good over personal gain.

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

Dr. Osterholm: Well, first of all, this isn't necessarily a take home message, but I hope it's a sense you come away with listening to this podcast, and it all goes back to the dedication. When you can understand such kindness and thoughtfulness, both before that terrible event happened and afterwards in the voices of Melissa's and Mark's children. Just that there is so much good in this world and it's up against so much bad. But I have always believed just as light wins out over darkness, kindness will always win out over those who are intent on doing harm. And I think now more than ever, we just need to never forget that. So that leads me to my first point on summary today. Never before have we needed an organization like the Vaccine Integrity Project, as we do now. Nothing over our 61 year your history has ever led us to understand the need for something like the Vaccine Integrity Project, and we are here. We will not leave. And as you've heard me say multiple times in the past, our motto in CIDRAP right now, front and center, we will bend, but we will not break.

Dr. Osterholm: And I think that's an important conclusion. Again, I want to emphasize how important it is for you to get involved. Last week, I left you with locations in the vaccine world where you could become involved as community members of a number of different activities. We're going to repost those same links in this week's podcast notes so that you can, in fact, again, reach out to one of these organizations and they could use your help. Please do that. And finally, let me just say I'm not sure what COVID is going to do when we listen to the information about these variants. I know how confusing it gets. And frankly, I get confused over all these different numbers and so forth. The bottom-line message is we will see rises in COVID again. How much? What will it mean? I don't know. I'm somewhat encouraged by the fact that what we are seeing in Asia has not been a major increase in serious, life-threatening infections, even when milder infections have increased substantially. Hopefully that will continue to be the case.

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

Dr. Osterholm: Well, Chris, I'm actually very pleased to share with you a song that I think fits the time. And it also was suggested to us by one of our listeners, Eileen. The song I've chosen is Arlo Guthrie’s song in Times Like These is recorded live on March 10th, 2006 at the Singletary Center for Arts in Lexington, Kentucky, in collaboration with the University of Kentucky Symphony Orchestra. It was later released in an album, In Times Like These on July 10th, 2007. The song really reflects on social, political and personal uncertainty. I have always loved Arlo Guthrie. His song Alice's Restaurant Massacree has always been one of my favorite songs. And of course, City of New Orleans. How could you not have been raised without knowing the words to that song by Steve Goodman? I might add that Arlo Guthrie is still alive and well. He’ll have a birthday coming up in just a couple of weeks. July 10th. He'll be 78 years old. So here it is. In Times Like These by Arlo Guthrie. Just remember how this fits with today's message. In times like these, when night surrounds me, I am weary and my heart is worn. When the songs are plain, don't mean nothing. Just cheap refrains. Play on and on. The storm is here. The lightning flashes between commercials are taking names The singers run to where the cash is. Just another link in the slavery's chain. I see the storm clouds rise above me. The sky is dark and the night has come. I walk alone along the highway. Where strangers gather one by one. When leaders profit from deep divisions. When tears of friends remain unsung. In times like these it's good to remember. These times will go in times to come. I see the storm clouds rise above me.

Dr. Osterholm: The sky is dark and the night has come. I walk alone along this highway. When friends gathered one by one. I know the storm will soon be over. The howling winds will cease to be. I walk with friends from every nation. On freedom's highway. In times like these. Arlo Guthrie, thanks again for spending your time with us. We know you have a lot of other priorities in life, and you have a lot of other sources of information. We're humbled that you're with us. I want to also, again, thank the podcast team, and I want to thank all of you who have been supporting CIDRAP. You have made a big difference and made it possible for us to do the kind of work that we're doing right now. And I never want you for a second to think that we don't take that support with such, such appreciation. It means everything to us. It's not just the fact of the support, but it means we're doing something right for you. And that's what we're here for. And that's something we never forget. So, in light of the discussion today and particularly the dedication, please, please do something kind in the next week. Just reach out and do something you would not normally do for someone and see what happens when you do that. It's a remarkable thing. So, thank you. We'll keep you posted. Anything new in late breaking, of course. It's going to be covered on CIDRAP news. I hope you sign up for that. Free of charge. Never will there be a paywall in CIDRAP. No way, no how. It's always going to be available. And, we just appreciate you so much. Thank you. Thank you. Be safe. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoy 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.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to cidrap.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.