Episode 187: Stay the Course

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. The first six months of Robert F. Kennedy Jr.’s tenure as secretary of the Department of Health and Human Services has been a time of shock, anger and sorrow for many public health and infectious disease experts, as Kennedy and his colleagues have plowed ahead with efforts to reduce the HHS workforce, cut programs that monitor and respond to infectious disease threats, and remake US vaccine policy to align with his personal views. Perhaps the worst part has been the sense that these efforts can't be stopped, but pushback is emerging. Earlier this week, a coalition of six medical groups sued Kennedy and HHS over his recent changes to COVID vaccine policy, calling those changes arbitrary and capricious.

Chris Dall: He's doing everything he possibly can to undermine vaccine confidence. Doctor Georges Benjamin, executive director of the American Public Health Association, one of the organizations joining the lawsuit, told NBC news: Quite frankly, we've had enough. The lawsuit is the latest in a series of efforts, including CIDRAP’s Vaccine Integrity Project, to defend U.S. vaccine policy and counter inaccurate health information. On this July 11th episode of the podcast, We're going to discuss these efforts and how scientific and medical organizations are stepping up to help safeguard the systems they helped build over decades. As Doctor Osterholm wrote in a recent op ed for STAT. We'll also recap the recent meeting of the CDC's Vaccine Advisory Committee, discuss the lawsuit against Secretary Kennedy and HHS. Update you on measles, COVID and H5N1 avian flu review a paper on the impact of USAID cuts and answer an ID query about RSV vaccine recommendations. 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 to the podcast family. It's good to be with you again. It's always good to be with you. And for anyone who might be joining us for the first time, I hope that the information we're able to provide you is what you're looking for, and we're always welcome feedback from the family members, as well as from those who may be intermittent or new listeners. So please provide us that feedback. I also want to take note today. I just want to thank the podcast team for their ongoing effort here. They really are the ones that make this podcast possible. And Chris, you as the voice of the podcast. Thank you so much for all you do to keep this thing on the tracks. So let me just start by saying we appreciate you all tuning in this week on a Friday rather than a Thursday, so that we could give our staff somewhat I think is very deserved time off for the last weekends holiday. It's hard to believe it's already mid-July, although for most of us around the US, the heat and humidity we've been experiencing has felt like it's a pretty good warning sign. For me, and likely many of you, Shall I bring summer travel time spent outdoors with friends and family, fireworks and grill outs, and of course, enjoying those long daylight hours. But more on that later. In medicine, July has other meanings. July is the start of the academic year, where thousands of young physicians’ step into hospitals with fresh white coats and an eagerness that cuts through the exhaustion, at least for a while.

Dr. Osterholm: I'm dedicating this episode to the new interns and residents beginning their careers this month in clinics, emergency rooms, and hospital wards. I'm wishing you the confidence to rely on your education and training. The humility to say, I don't know, but I'll find out, and the strength to make it through the long shifts and late nights. You may have heard of the idea called the July Effect. It's a phrase often spoken with some apprehension, suggesting that the care might suffer as new doctors begin their training in the month of July. But today, we want to challenge that idea, because the July effect is more than just a moment in medicine. It's also a metaphor for what it means to start anything new. We've all had our own version of the July effect. The first day of a new job, moving to a new city, leading when you still feel like you're learning. Those moments are marked by uncertainty, fear, and self-doubt, but also by the hope of growth. To the new interns, you may feel like you're being thrown into the deep end, and in some ways you are. But you are not alone. You are surrounded by teams, by systems, by mentors, and by patients who, whether you know it or not, are part of your education and growth.

Dr. Osterholm: And to everyone else listening, let the July Effect remind us that we all start as beginners. We all have moments where we step into responsibility, not fully knowing if we're ready. The key is not to avoid those moments, but rather to support the people through them. Whether you're starting a medical residency or just trying to find your footing in a changing world, this dedication is for you. Now to move us on to that very important message about sunlight, which for those of you who want to take a one minute reprieve, please do. But for those who count on this section, like me, I'm happy to report that today in Minneapolis, sunrise at 5:37am, sunset at 8:59pm. That's 15 hours, 21 minutes and 32 seconds of sunlight. We're now losing sunlight at about one minute and 24 seconds a day. But there's still a lot of it. And now for my dear, dear friends and colleagues in Auckland, New Zealand, at the Occidental Belgium Beer House on Vulcan Lane, your sunrise today is at 7:32 a.m., sunset at 5:20 p.m. for nine hours, 47 minutes and 41 seconds of sunlight. But the good news is you gain today about 56 seconds of sunlight, and that will continue to accelerate. So here it is, that season of sun in the northern hemisphere. Enjoy it. Embrace it. And most of all, just remember that there'll be dark days ahead. But then there's also light days after that.

Chris Dall: Mike. The meeting of the CDC's Advisory Committee on Immunization Practices was in progress when we released our last episode, so we've not had a chance yet to discuss the two major news items that emerged from that meeting. One was the recommendation against receiving flu vaccines that contain the preservative thimerosal. And the other was the announcement of two new working groups to review the cumulative effects of the childhood immunization schedule and the use of two specific childhood vaccines. Mike, what did you make of these moves and what kind of impact could they have?

Dr. Osterholm: Chris, the events of this meeting can be summed up in one word unprecedented. The meeting occurred shortly after Secretary Kennedy fired the committee's 17 members and replaced them with eight new members, one of whom dropped out before the meeting even took place. Most of these individuals have little to no expertise in vaccinology and infectious diseases. Some are even outright opponents to vaccines. As you noted, two major items emerged from this meeting, both of which highlight the group's lack of expertise. First, the recommendation against thimerosal containing flu vaccines. And second, the creation of two new working groups, one looking at the cumulative effects of the vaccine schedule and the other looking at the use of hepatitis B vaccination at birth and the use of MMRV, the combined measles, mumps, rubella and varicella vaccine in and young children. I'll start by talking about the thimerosal issue. Thimerosal is a preservative used to prevent harmful microbial growth in vaccines. The use of thimerosal in vaccines is a common talking point used by those skeptical of vaccines, who feel the ingredient is unsafe. Activists against vaccines capitalize on this public fear of complex sounding ingredients and ignore decades of evidence supporting this is not the case. Thimerosal contains a compound called ethyl mercury, although its similarly named, Ethyl mercury is processed very different by the body than methylmercury, which is the toxic compound that comes to mind when people hear the word mercury. Ethyl mercury has one additional carbon chain, that's one carbon atom and two hydrogen atoms. And while this may sound insignificant, it entirely changes how the compound is metabolized in the body.

Dr. Osterholm: Keep in mind that one oxygen atom is all that separates carbon dioxide, the gas we exhale every time we breathe, and carbon monoxide, which can kill after just minutes of ventilation. Stating that ethyl mercury and methylmercury are both toxic because they're both mercury would be like saying drinking water and drinking gasoline are both dangerous because they're both fluids. Very different. Thimerosal was removed from most vaccines over 20 years ago, despite overwhelming evidence supporting the safety, including the absence of a link between thimerosal and autism. It has continued to be used, however, as a preservative in some multi-dose formulations of flu vaccine. Five members of the ACIP voted for the new recommendation against flu vaccines with thimerosal. One abstained from voting and only one voted against this new recommendation. A vote to recommend against the use of a well-studied ingredient with strong safety profiles highlights the lack of evidence-based decision making in this new ACIP. It also sparks a lot of concerns about the methods they may use in future research and decision making. This then brings me to the other major news item that came from this meeting. The formulation of two new working groups to study vaccine safety. One of the groups will assess the cumulative effects of the vaccine schedule, and as I noted, the other will assess the safety of hepatitis B vaccination at birth and the use of MMRV vaccine in young children. I want to be clear; I would not be concerned about a well conducted, good faith studies of any of these topics. At worst, they'd be a waste of resources, considering that we know these vaccines are safe.

Dr. Osterholm: But my concern is that these working groups will not review evidence or conduct studies with scientific integrity. And no matter what the data show, they will conclude that these vaccines are unsafe. Let me give you an example of what I'm talking about. When one thinks about vaccines, you think about antigens, those chemical structures that actually, when injected into your body or taken orally, cause you to have an immune response very specific to that antigen. Well, it's not what it seems. In a beautifully written first opinion piece and stat on June 24th, Doctor Jake Scott, who is an infectious disease physician and clinical associate professor at Stanford, responded to this misunderstanding, if not downright misrepresentation, of what it means to be actually vaccinated in antigen. So let me summarize for you a bit what Doctor Scott said, because as I said, it really did a very nice job of illustrating the confusion that the anti-vaxxers bring to the table about this issue. As I noted, an antigen is any protein or molecule that your immune system recognizes as foreign. Just note that 100 years ago, children received exactly one vaccine. That was smallpox. That was it. That single shot contained approximately 200 different antigens. Today's entire pediatric schedule exposes a child to about 165 antigens, a fraction of the more than 3000 in a single 1980s pertussis shot. What we've done is we've worked hard to make these vaccines safer and more effective over the years of research. Today. The expanded schedule actually includes 16 to 18 different diseases, but the entire antigen count for all of those vaccines is only 165 antigens.

Dr. Osterholm: Remember, we're talking about the fact that with the DTP vaccine in the 80s, they were getting 3000 antigens. So, to say that they're somehow this antigen burden is increased dramatically with more doses of vaccine is absolutely not true. In the piece, Jake actually quoted vaccine expert Paul Offit and colleagues where they calculated that a baby could theoretically respond to 10,000 vaccines simultaneously before even using 1% of their circulating B cells. Those important immune cells that somebody might argue were being overloaded by vaccines. Let me repeat that 10,000 vaccines at one time, and they would still only involve about 1% of circulating B cell. So, this whole idea that there's this overburden of the immune system with all of these new vaccines is just absolutely wrong. But again, it goes to the very point of what this group is trying to do. They're not trying to present facts. They're trying to prevent scary information. And if I heard about all these new vaccines we got, I might think, oh my, what are we doing to the human body? But when you actually look at the data, you say, wow, is that all that the body is responding to and all the vaccines we recommend today? There is no hint at all. There is no suggestion. There is no theoretical basis for suggesting there is an immune overload with these vaccines. And yet now we have a group at ACIP that's going to study this. And you and I both know what their conclusions are likely to show.

Chris Dall: Mike, in the stat op ed that I mentioned earlier, you said that the Vaccine Integrity Project is not going to be a, quote, shadow ACIP. It is not going to stand in for government bodies. You wrote, quote, its mission is simple and urgent to ensure that vaccine use in the United States remains grounded in the best available evidence and focused squarely on protecting the public. Can you explain how VIP is going to do that?

Dr. Osterholm: Well, first of all, let me start out by saying I have been simply overwhelmed by the amount of support that has come forth from the medical community, the public health community, from funders, etc. to help us really deal with what is a very timely and unfortunately extremely dangerous, challenging issue, the availability of our vaccines for the future. So, Chris, let me be really clear that I want to ensure our listeners that they have this crystal-clear understanding of what the Vaccine Integrity Project here at CIDRAP is and aims to accomplish in the coming weeks. The dismissal of all the previous ACIP members, along with the controversial elements of the June meetings, understandably raised serious concerns about the integrity of the newly formed committee and its recommendation. In response, we've developed a process to independently and systematically review the latest evidence published. Or if we can get our hands on unpublished data. We will do that too, since the last trusted guidance came out from ACIP. Given the urgency of the upcoming fall respiratory virus season, the VIP is mobilizing three key groups to deliver timely, evidence-based recommendations specifically for these vaccines. First, a team of leading infectious disease researchers are conducting a systematic review of the most recent published literature or also unpublished literature. If we can get access to that on COVID-19, RSV and influenza immunizations, their workers, culminating in a comprehensive science brief that reflects the current state of virology, epidemiology, vaccine effectiveness and safety data for this fall's respiratory virus season. This science brief will then be reviewed by additional experts with backgrounds in pediatrics, geriatrics, obstetrics, and immunization science. They'll ask tough questions to ensure that the findings meet the highest scientific standard.

Dr. Osterholm: Following the presentation of the science brief and expert discussions. Representatives from major medical societies, who also have historically provided recommendations on vaccination for their specific populations, will present their respiratory virus immunization guidelines for their corresponding subpopulations. Specifically, the American College of Obstetricians and Gynecologists, known as ACOG, will focus on guidelines for pregnant individuals. The American Academy of Pediatrics, the AP on children, the Infectious Disease Society of America, IDSA on immune compromised and high-risk populations, including older adults, and the American Academy of Family Physicians on healthy adults. As I emphasize in the stat piece, this initiative is not a shadow ACIP. The ACIP role, particularly its authority to interface with federal health insurance programs and payers, is inherently governmental. We sincerely hope the official committee's credibility can be restored, but in the meantime, we must act to provide clinicians with the evidence-based guidance they need to protect Americans from respiratory viruses that hospitalized and killed tens of thousands each year. In addition, we must ensure that there is a system for individuals to receive these vaccines. And one of the areas that we're concerned about is if, in fact, payers no longer will support the payment of certain vaccines, that may not be recommended by the ACIP. Is there, in fact, a way that we can work around that to work with payers to now actually make those vaccines available to many who could otherwise not afford them? This is truly an evolving activity here at CIDRAP. And again, I just want to acknowledge the many individuals who are working with us so closely to make this a reality.

Chris Dall: I know you're not a legal expert, Mike, so I'm not going to ask you to weigh in on whether the lawsuit against Secretary Kennedy and HHS will be successful. But can you explain for our listeners what the lawsuit is charging and why it's important?

Dr. Osterholm: Well, Chris, let me start out, first of all and say we are not a part of this lawsuit and have not been involved in the discussions about it. But let me share with you what I can. You are right. I'm not a legal expert and certainly won't pretend to be that. But I'll do my best to provide a summary of this because I think it's worth following. The lawsuit was filed in federal court in Massachusetts this past Monday, July 7th, by six medical and public health societies or organizations and an unnamed pregnant physician who works in a hospital. I should note that the medical and public health societies and organizations we're talking about here are quite prominent. They include the American Academy of Pediatrics, the American College of Physicians, the American Public Health Association, the Infectious Disease Society of America, and the society for Maternal Fetal Medicine. They are suing Mr. Kennedy and HHS for what they describe as unlawful and unilateral vaccine changes. In particular, they focus on his announcement, made in late May, that COVID vaccines would no longer be recommended for healthy children and pregnant women. They argue that this decision was made without even attempting to follow the standard processes, which, as they allege, violates the Administrative Procedures Act. Essentially, this act is a federal law which establishes the systems and procedures that agencies like HHS are required to follow. Otherwise, the lawsuit basically explains that Mr. Kennedy didn't consult with the CDC or ACIP before his announcement that COVID vaccines would no longer be recommended for healthy children and pregnant women. They go on to say that the announcement directly contradicted COVID vaccine guidelines announced just days prior by the FDA, which designated pregnancy as a risk factor for severe disease.

Dr. Osterholm: And they allege that no clear and compelling basis was provided to justify this change. In other words, there was no specific data or evidence presented towards this decision as a result of this recommendation being removed. The plaintiffs claim that the public trust in vaccines has been damaged. They point out that doctors are now stuck in a position where they are either advising patients on what they believe is the proper standard of care, or adhering to conflicting federal guidance. And alongside the added confusion and distrust, they state that the decision immediately exposes vulnerable populations to a serious illness with potentially irreversible long-term effects and in some cases, death. Specifically, the unnamed pregnant physician I mentioned who is part of the filed suit, alleges that this change in recommendation creates barriers to accessing the vaccine, and she is worried not only for her own health but for the health and well-being of her unborn child as well. So, with all that being said, the lawsuit ultimately wants the courts to declare that Mr. Kennedy's directive no longer recommending COVID vaccines to healthy children and pregnant women is unlawful, and they want to have the original recommendation reinstated. Again, this is something surely, we keep in our eye on because depending on how it shakes out, this could set an important precedent when it comes to vaccine policy in this country and how it is shaped. We must anticipate the possibility that, in fact, the suit will fail, which will only embolden the administration in terms of the recommendations that it unilaterally makes regarding vaccines. Our hope is that is not what happened, but we must be prepared for that eventuality.

Chris Dall: In other legal news, the Supreme Court this week announced that the Trump administration can move forward with its plans to cut the federal workforce, which could have implications for the nation's health and scientific research agencies. Now, this is not the end of this story, because the plans are still being challenged in lower courts and could be ruled illegal. But, Mike, as you said before, this isn't any way to run a business. Your thoughts.

Dr. Osterholm: Chris, This could have likely will have devastating consequences. Note that again, as you pointed out in your introduction, this is a rolling issue that each week, new decisions are being handed down by the court on any number of areas that affect public health. And so, each week it will be an update of public health practice and what the courts are saying in a way that I've never experienced before. But before I get into discussing the impact of this recent court decision, I want to take a step back and clarify what this order is all about. Back in February, the Trump administration issued a detailed plan titled Implementing the President's Department of Government Efficiency Workforce Optimization Initiative. This outlined a reduction in force that could impact tens of thousands of workers across the federal government, including an estimated 20,000 employees at HHS, nearly a quarter of their workforce. This includes about 80% of the workers at NIOSH, the National Institute for Occupational Safety and Health. All of the regional employees collecting data, and opioid and other substance abuse within the Substance Abuse and Mental Health Services Administration, and many individuals with the National Institute of Allergy and Infectious Diseases. On May 9th, a judge at a federal district court in California paused these plans. The pause was initially intended to last two weeks, but was then extended as the judge ruled that the pausing of these essential services was an urgent threat and unconstitutional due to a lack of congressional approval. The Trump administration quickly appealed this ruling. The case was then escalated to the US Court of Appeals, which upheld the lower court ruling that these reductions in forced plans were not legal.

Dr. Osterholm: Then, the administration filed an emergency application with the Supreme Court, leading to the order released earlier this week allowing agencies to move forward with layoffs. As you mentioned in your question, Chris, the Supreme Court order is not a final decision. However, it was made because the court felt that the government is likely to succeed on its argument that the reduction in force plans were legal. This comes shortly after the Supreme Court ruled in favor of this administration. Other lawsuits challenging the legality of the president's actions, including a ruling that limits the ability of federal judges to use nationwide injunctions to block policy. So, this is not entirely surprising. Nearly 2000 US State Department employees, whose layoffs have been on hold since the preliminary injunction will be affected immediately, and tens of thousands of additional federal government employees will likely be impacted in the coming months. It's worth noting that Elon Musk, the former head of the Department of Government Efficiency who played a major role in these reductions in forced plans, is no longer working at the white House. It's unclear at this point if anything will change in the reduction in force plans in Musk's absence. Finally, I want to acknowledge all the workers who have been or will be affected by this decision. These employees are doing essential work that keeps our country safe and healthy, and we will all suffer the consequences of this dismissal. But I don't want to forget the personal side of this either. Hard working people who are trying to help the public who are being terminated despite strong performances. These employees surely deserve better. And we, the public, want and need their services.

Chris Dall: Now let's turn to our infectious disease updates, and we'll start once again with what's going on with the US measles outbreak. As of Wednesday, this week, the US has now recorded the most measles cases in a year since the disease was eliminated in 2000. Mike. This is not a milestone we wanted to hit.

Dr. Osterholm: Chris. We have finally surpassed a sad milestone that we all knew was coming. We have officially seen more measles cases in 2025 than we have in any year since 1992. The total case count in the US of 1288 cases exceeds the 2019 case count of 1274 cases. And we're only halfway through the year. The multiple outbreaks occurring do appear to be slowing somewhat, with fewer cases being reported each week now compared to what we were seeing at the peak back in March. But we're certainly not done with this situation by a long shot. Even more concerning than the activity in the US is the continuing outbreak in Canada, which has reported more than 3700 cases. As we discussed in our last episode, these numbers are especially concerning due to the relative size of Canada's population 40 million compared to the US population of 340 million. Canada's situation should serve as a warning to the US. Since 1998, Canada has had about 32 measles cases per year, and their highest yearly count prior to this year was 752, in 2011. We have no reason to believe that this sudden, sharp increase in measles cases in Canada couldn't happen here, especially if vaccination uptake continues on a downward trend.

Dr. Osterholm: Additionally, as we've discussed in several recent episodes, declining MMR vaccination rates don't just pose a danger for measles outbreaks. A resurgence of mumps and rubella is also possible since measles is more infectious than these viruses. It's not surprising that we're seeing a rise in measles cases first, but there is no reason to believe that without herd immunity, we aren't at risk for outbreaks caused by mumps and rubella as well. This is especially alarming considering the risk during pregnancy. If someone contracts Rubella during pregnancy, particularly during the first trimester, can result in severe birth defects, including low birth weight, developmental delays, heart defects and glaucoma. We need to continue stressing the importance of MMR vaccination not just for children, but for any unvaccinated adult as well. Measles, mumps and rubella infections can have tragic consequences, but they are preventable. Even one case of measles encephalitis or congenital rubella syndrome is too many. As always, we will continue to keep you updated as this situation unfolds in the US and internationally. But until we see improvements in vaccination uptake, we should expect this challenge to continue.

Chris Dall: Let's turn now to COVID. I feel like it's been a really long time since I uttered the phrase summer surge, but we are in that time of year. Mike, do we have any indication yet that the NB.1.8.1 variant will cause an uptick in COVID cases this summer?

Dr. Osterholm: Chris, we currently have no indication of an uptick in COVID cases this summer. The national wastewater level is considered very low and is stable. Concentrations in the south and northeast, however, have increased slightly over the past week. Concentrations in Hawaii, Louisiana, and Texas are considered high and are very high in Nevada. Emergency department visits for COVID also remain very low, but are increasing. weekly deaths, which are a lagging indicator, are the lowest we've seen at any point during the pandemic. The week of June 7th, which is the most recent week with complete data, we lost 178 Americans to COVID-19. Again, we acknowledge the loss of these individuals to their family and friends. But we do have to admit we're in a lot better place than we were 3 or 4 years ago. We unfortunately don't have updated variant proportions to report since our last episode, when the NB.1.8.1 accounted for 43% of the US cases and XFG accounted for 14%. We do, however, have updated variant data from the CDC travelers based on Genomic surveillance program, which collects specimens from travelers arriving on international flights, has several major U.S. airports, as well as airplane wastewater from planes at several major international airports. The week of June 8th, FXG accounted for 43% of cases, and NB.1.8.1 accounted for 24%. I'll be interested to see if the US variant proportion start to shift to look more like this Glimpse into the international variant picture. Regardless, I don't think we're seeing any indication that NB.1.8.1 or XFG will cause an uptick in COVID activity this summer. But things can change, and that also does not mean we can't see an uptick come this fall.

Chris Dall: On Monday, the CDC said it was ending its emergency response to H5N1 avian flu, citing a drop in cases. Based on what you've been seeing, Mike. Was that the right decision?

Dr. Osterholm: Well, Chris, first of all, we need to put this whole situation into perspective of what's happened over the past year. You know, as you may recall, it was a year ago right now that I noted, I wasn't sure how this H5N1 situation in cattle and poultry and of course, as we talked about wild avian species would actually play out. I'm not surprised by this. At the same time. I can't tell you what's going to happen tomorrow. What I mean by that is don't forget we've been here before with H5N1. in 2015 and 2016 We saw over 50 cases of H5N1 serious illness in duck farmers in Nile River Valley, and at that time, everyone thought, this is it. It's coming. The pandemic is just around the corner and within months that literally ended. We no longer have seen that problem in River Valley with H5N1 and duck farmers. Why? I don't know. So let me just couch my comments here by saying H5N1 could cause the next pandemic starting yesterday, but it might not ever cause a pandemic. We don't know. This is one of the really humbling aspects of being in this business. I would just say right now, as we've discussed in previous episodes, the USDA report showing that H5N1 detections in monitor animal populations have declined significantly. Some of that surely has to be associated also with reduced testing. The most recent confirmed positive dairy cattle herd was reported on June 24th in Arizona. In the past month, there's only been one reported outbreak in a commercial flock, a game bird facility in Pennsylvania affecting about 30,000 birds. And there hasn't been a confirmed human case since February. Now, let me comment on the human case issue.

Dr. Osterholm: I think we could be missing a number of mild conjunctivitis like infections with H5N1. I don't think we're missing any kind of large number of cases of severe respiratory pneumonia, like illness with this virus. I think those would be picked up, even given the issue right now with migrant workers, undocumented individuals in the country. When you get severely ill with H5N1 and pneumonia like picture, either you die and people will know that or you're severely ill in a hospital. So, I think the tip of the iceberg of cases in the severe side really gives us some reason to think that, in fact, yes, there has been a significant drop in transmission. I will say, however, by folding H5N1 into routine flu surveillance, we risk deprioritized in pandemic influenza preparedness. The shift creates blind spots in our monitoring system just when we need to be most vigilant. This virus doesn't wait for headlines. It will continue to mutate, infect new species, and adapt in ways we may not detect until transmission has taken hold. So, in the emergency response now I think sends the wrong message. It suggests we're in the clear when in reality we don't know what the future holds for us. The bottom line is we don't know the full picture of H5N1, and we haven't really known it for the past 20 plus years. And now reducing visibility is not necessarily the solution. So, what does this all mean? We still have to keep our eye on the ball of flu viruses and the pandemic potential for them. Whether H5N1 is yet I don't know. But we can't take our eye off that ball either.

Chris Dall: Now it's time for our ID query. And this week we received a question about RSV vaccination from John, who wrote. Should individuals in identified high risk groups receive a second RSV vaccine a year or more after the first vaccine? The CDC website says in an April 25th update approved by RFK Jr. on 625. At this time, RSV vaccination is recommended as a single dose Only. persons who have already received RSV vaccination are not recommended to receive another dose. John went on to write the current HHS director is not qualified by education or experience to make such a recommendation. Will the Vaccine Integrity Project look at the data and make its recommendation? Mike. Now, John is essentially asking if he can trust the CDC on this recommendation. So, is it in line with what other medical groups and other countries are recommending?

Dr. Osterholm: Well first of all, John, thank you for this very thoughtful question and the context of which you presented in. It's really important. The update that John is referring to is the CDC's recommendation for adults 50 to 59 years of age, where increased risk of severe RSV disease receive a single dose of RSV vaccine. This recommendation was approved by a majority vote at the ACIP meeting that took place in April of this year. The key word here is April. This means that the vote took place prior to Secretary Kennedy removing all the prior ACIP members, an unprecedented action which we have covered in detail on prior episodes. Since this recommendation was approved by the prior ACIP members. I have a lot of confidence that is grounded in science. Specifically, the data that drove the recommendation came from a phase three clinical trial assessing the safety and immune response of the RSV vaccine in individuals 50 to 59 years of age with underlying medical conditions. Normally, after ACIP recommendations are passed by majority vote, those recommendations are confirmed by the CDC director to become official CDC recommendations. However, there was no active CDC director in April and we still do not have one today. Therefore, the RSV vaccine recommendation was confirmed by Mr. Kennedy to become an official CDC recommendation. An important component of this recommendation is the identification of groups at high risk of severe RSV disease. Included with this recommendation was a note that CDC will publish clinical considerations that described chronic medical conditions and other risk factors for severe RSV disease for use in this risk-based recommendation.

Dr. Osterholm: As of July 9th, we are still waiting on this list of clinical considerations from CDC. There is currently a banner at the top of the CDC RSV immunization webpage, indicating that it will soon be updated in alignment with current recommendations. However, based on RSV vaccine recommendations for other age groups, we know that this list of high-risk groups is likely to include those with chronic cardiovascular or respiratory disease, moderate or severe immunocompromised conditions, and other conditions that put individuals at increased risk of complications from viral respiratory infections. Notably, the world's first RSV vaccine was approved in 2023. Since this is a newer vaccine with clinical trials ongoing in different risk groups, many countries have yet to make official recommendations on RSV vaccine use and the 50- to 59-year-old age group. However, it is recommended for those 60 years of age and older and during pregnancy in many countries around the world for one dose only. And for our listener John, if you're looking for a reliable source of information on vaccine recommendations outside of CDC, I would also suggest following some of the major medical societies as they are bringing the best scientific evidence to their organizations, including groups such as the Infectious Disease Society of America, the American Academy of Family Physicians, and the American College of Physicians. As always, we promise to keep everyone informed as more information becomes available on RSV vaccines.

Chris Dall: Like we've previously discussed your concerns about the impact of the dismantling of USAID on global health. Last week, The Lancet published a paper evaluating the impacts of two decades of USAID interventions and the potential effects of USAID defunding on mortality. What did that paper find?

Dr. Osterholm: Chris, the authors of that paper project that more than 14 million people worldwide, including 4.5 million children under age five, could die of preventable infectious diseases in the next five years if the US continues to withhold USAID funding. to calculate their dire estimations. The researchers first measured the tremendous impact that USAID funding has had in preventing dust and 133 countries from 2001 to 2021. They found that over those 20 years, USAID financing prevented 91.8 million deaths, including those with 30.4 million children under age five, mainly in sub-Saharan Africa. This translates to a 15% reduction in all deaths, and a 32% cut in the deaths of young children. USAID slashed deaths from HIV Aids by 65%, malaria by 51%, and neglected tropical diseases by half, and contributed to significant declines in deaths from tuberculosis, malnutrition, and mortality during pregnancy, delivery, and postpartum. As you probably know, USAID has been the world's largest funder of humanitarian and development efforts. But in January, the Trump administration suspended nearly all foreign aid programs, and in March, it canceled 83% of the USAID program, a simply deafening blow to global public health. The funding cuts are being challenged in court, but their fate is still unclear if these program calculations stand. The study authors say that they could include an 88% cut in support to maternal and child health, 87% cut to epidemic and emerging disease surveillance, and 94% cut to family planning and reproductive health programs.

Dr. Osterholm: I think the authors of the study best described the grim effects of continued defunding on poor countries when they wrote. The resulting shock would be similar in scale to a global pandemic or a major armed conflict. Unlike those events, however, this crisis would stem from a conscious and avoidable policy choice, one of whose burdens would fall disproportionately on children and younger populations, and whose consequences could reverberate for decades to come. To put U.S. contributions to USAID into perspective, each citizen contributes about $0.17 a day, or $64 per year, to these programs. It seems to me a very small price to pay to ensure the health and well-being of millions, in addition to the many soft power benefits to the US as we build economic and political relationships abroad. I wish our country leaders could see it the same way. I would also issue to them a warning if we see unbridled transmission of many of these infectious diseases occurring in the countries that USAID has worked so hard to prevent those infections. We're going to see blowback into the United States and other high-income countries. International travel, as we have talked about over and over again, will bring these infectious diseases to our doorstep. Again, this is all about being strategic. Why are we not understanding that as it relates to preventing these infectious diseases?

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

Dr. Osterholm: Well, Chris, we're continuing our theme of vaccines this week. We truly can't overstate the impact they have had on both human and animal health. For this episode, we're featuring a disease that has been recognized for centuries as universally fatal once symptoms appear. In July 1885, a mother in France begged two local scientists to help her son, who was bitten by a rabid dog 14 times. The scientist Louis Pasteur had been testing their live attenuated vaccine candidate on dogs, but were wary of using it in humans, at least not yet. However, with the boy's life in the balance, they initiated a series of 12 shots over ten days. The result? The boy never developed rabies, and the world had its first successful rabies post-exposure prophylaxis and vaccine. News spread quickly, and patients across Europe lined up for treatment at the newly formed rabies vaccination center in France. Soon enough, similar centers were developed around the world that used a live attenuated vaccine protocol involving multiple shots over multiple days. But one critical component of this story is the concept of one health. The one health approach acknowledges that human, animal and environmental health are dependent on one another and requires thoughtful consideration and interdisciplinary collaboration. Mass vaccination for rabies and pets began in 1908, and is still a leading strategy in reducing rabies infections and deaths in both animals and humans around the world. In the 1960s, the US began mandatory vaccination of pet dogs for rabies, which led to an elimination of the canine strain of rabies in the US in the early 1990s.

Dr. Osterholm: Now, wild animals account for 90% of rabies cases in the United States, primarily from skunks, bats, raccoons, and foxes. While great strides have been made in reducing rabies cases and death in humans and animals, the rest of the world, primarily Africa and Asia, still faces major challenges managing the virus. In fact, today, the W.H.O. estimates that over 60,000 deaths in humans occur each year and more than 150 countries because of rabies contrary to the US, 99% of rabies deaths internationally are due to dog bites. These deaths occur primarily in children and in rural areas where vaccines and post-exposure prophylaxis are still limited. That incredibly stark difference in mortality rates across the world highlights the critical need of health equity and public health work. We know what to do to save lives. What we need is political will and resources to make this a reality. So, I will close by saying, thank you, Louis Pasteur, for kicking off this progress with their development of the first rabies vaccine. We hope to spread your innovation further into parts of the world that is most needed. We cannot accept 60,000 deaths a year in this world of human rabies. Just because we didn't have the political will to make sure that these people were protected.

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

Dr. Osterholm: First of all, Chris, let me make it very clear. We are in a very dangerous period with regard to public health and public health practice. I can't put it any other way. We will continue to see both international and national programs attack slashed and, in many cases, done in. And of course, we will see more decisions coming from the courts in terms of what that means. I also want to make note that we will be sharing with you in the days ahead what the 2026 legislation that just passed Congress and signed into law by the president means for public health programs and budgets. I'm extremely concerned that we're going to see major gutting of funding support for state and local health departments, as so much of what we do in this country today is supported by federal dollars to state health departments. At this point, we're unsure what this new legislation will mean, but everything that we've seen so far looks like it could be disastrous. The second point is we can't give up or give in. This is about the lives of our children. It's about the lives of our grandparents. It's all the things that make us human that should make us also want very much to counter the kinds of changes that are occurring.

Dr. Osterholm: And as I've said before, get involved. We already have on our website locations where you can get involved actively promoting vaccines in your community. You know, you can be at the school board meetings, at the city council meetings, even have state legislative hearings trying to promote good public health at the state and local level. So, find a way to outreach to these groups and organizations. And please give of your time. If nothing else, for those of you listening today who have grandchildren. Please do it for them. Finally, at a time when things are so right with anger and disagreement, just continue to remember one thing. Now's the time to be kind. You know, I saw a quote the other day that really hit home. He said, in a world where you can be anything. Thing. Be kind. Think about that. In a world where you can be anything. Be kind. And right now, that's a hard thing to do, particularly when you feel under attack or you feel threatened by some of the actions being taken. But it's never a bad time to be kind. Never.

Chris Dall: And, Mike, what is your closing for today?

Dr. Osterholm: Well, Chris, I'm sure everyone's waiting for the song of the episode, but rather what I want to share with you today is a quote from Winston Churchill through the fall of 1942. Things looked very bleak and dark for the Allied troops and forces throughout Europe and northern Africa and the Mediterranean region. Finally, in November of 1942, the Allied forces scored a major victory in Egypt in the Second Battle of El Alamein. At that time, people were excited, celebrating the fact that they thought that the tide of the war had changed from one of almost defeat to one of now they could win. But Churchill understood there was still a long way to go to save the world from the Nazis and the fascists. And he gave a quote, a talk that really laid out that sense. And this quote was, now, this is not the end, is not even the beginning of the end, but it is perhaps the end of the beginning. And I want to remind people today that we are still really very much in the beginning. And if anything, maybe we're getting to the end of the beginning. But we've got a few more years to go of having to respond to the conditions that we just talked about in this podcast. We can't give up. We can't be overly optimistic by one victory. We can't be defeated by one loss. And at this time, this is going to be stay the course, stay the course, stay the course.

Dr. Osterholm: And that's what we're going to do here at CIDRAP. We're going to stay the course. The Vaccine Integrity Project three, four months ago. And I proposed that people thought, what a crazy thing. Today we're doing it, we're doing it. And I think we all have to have that kind of faith right now. So just remember, we are not at the end. We're not even at the beginning of the end, but we perhaps may be at the end of the beginning. And that's what this is all about. So, thank you very much for your time today. I hope we're able to provide the kind of information you're looking for. Again, I want to thank the podcast team. I want to thank all the listeners who continue to send us cards and notes and emails and how much that means to us. We read every one of them. They get circulated among the staff is so important. So, thank you. And as I noted in one of my concluding comments today, find a way to intentionally be kind. Don't let it happen by accident. Reach out to someone. Be kind. And right now, overlaid on otherwise a very complicated public health world. That may be the oil that keeps our hinges in good condition to allow us, day after day, to open that door to better public health. Thank you. Thank you. 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.