Episode 188: Finding the Light

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. Over the last six months, we've focused on a lot of bad news on this podcast. We've done so not because we enjoy it, but because we know it's important to keep our listeners informed about what is happening in the world of public health and infectious diseases, and how it might affect you. But it's also important to highlight the good news where we can. So, on that note, we want to mention that $400 million in planned cuts to the President's Emergency Plan on AIDS Relief, or PEPFAR, were spared from a resistance package signed into law last week by President Trump. This is the best news ever. The former president of the International AIDS Society said in response to the news.

Chris Dall: I've said this before, and I'm going to say it again. PEPFAR is the most important and consequential contribution to public health, certainly in my lifetime and probably ever, that it is not going away in its entirety. It's a victory for all who've advocated for it. On another positive note, a large study conducted in Denmark found no association between exposure to aluminum adjuvanted childhood vaccines and autoimmune, atopic or allergic or neurodevelopmental conditions such as autism. That study could provide critical in efforts to push back on the anti-vaccine messaging being promoted by Department of Health and Human Services Secretary Robert F Kennedy Jr and his allies. Those two news items will be among the topics we cover on this July 24th episode of the podcast. We'll also discuss the recent limited approval of Moderna's COVID vaccine for children. Bring you an update on the work of Vaccine Integrity Project. Examine the latest COVID data and answer an ID query about West Nile virus. We'll also bring you the latest installment of This Week in Public Health history. But before we get started, as always, we will begin with Doctor Osterholm opening comments and dedication.

Dr. Osterholm: Thanks, Chris, and welcome to everyone listening today. I often call this group our podcast family, and I really do mean that. So many of you have been with us since the early days, when we first started recording during the pandemic. Over the years, you've asked questions, you've shared feedback, you've sent episodes to friends and family, and you've written in to share personal, very meaningful stories with me and the rest of the podcast team. At this point, sitting down to record each episode feels a bit like catching up with a family reunion. We so appreciate that. And like in any family, there are some disagreements or at least friendly debates. One of the most surprising ones. Our daylight update. That short little segment where I share how many hours of sunlight, we're getting in places here in Minnesota or over in Auckland, New Zealand. Some people love it. Others, well, politely, fast forward. But to be honest, it's still one of my most favorite parts of the show, so I guess that counts a little bit, because in the middle of everything we talk about here. Outbreaks, new diseases, long COVID funding cuts and public health challenges. It is a moment where we can get to focus on something simple and good.

Dr. Osterholm: The sunlight. Sunshine isn't just about weather. It's a signal to our bodies and our spirits that we're part of something bigger. It grounds us. It helps us feel awake, present and human. Science has shown exposure to the sun can improve mood, sleep and overall well-being. But sometimes what matters even more is what it stands for. Resilience, renewal and a bit of warmth when we need it most. We've got a wonderful email recently from a listener in New Mexico. She shared that she used to skip over the daylight updates until she took a recent trip to Peru. While she was there, she became close with a family who ran a small bed and breakfast. Since then, they've kept in touch by comparing their local weather and sunlight updates. When it's brown and dry in New Mexico, it's green and vibrant in the Andes. When she's sweltering, they're freezing and vice versa. It's this quiet, ongoing exchange that reminds us in all of us that somewhere the sun is always shining and in time it will always come back around. Sunshine doesn't solve everything. No, not at all. But, boy, I think it sure helps. And our bodies know that. So, wherever you're listening from today.

Dr. Osterholm: Whether you're soaking in bright skies or feeling a little stuck in the clouds. We're dedicating this episode to the light. And to the joy it brings, the healing it offers, and the quiet reassurance that better days are always on their way. I hope you can enjoy the sunlight today. Which then takes us right into that wonderful segment. For those who want to fast forward. Go ahead about a minute. Uh, today, July 24th, in Minneapolis Saint Paul. Sunrise is at 5:50 a.m. Sunset is at 8:48 p.m. 14 hours, 58 minutes and 17 seconds. Wow. We still got a lot of it. But we are beginning to lose sunlight at about two minutes and two seconds a day. Now to our dear, dear friends at the Occidental Belgium Beer House on Vulcan Lane in Auckland, New Zealand. Today your sun rises at 7:25 a.m., your sun set at 5:30 p.m. You only have ten hours, three minutes and two seconds of sunlight, but you are now gaining sunlight about one minute and 26 seconds a day. Pretty soon we'll catch each other. So again, have a very, very sunny day. And to all the podcast family, I say that with great love and affection.

Chris Dall: Mike, I'd like to start with that study out of Denmark, which examined the vaccination and medical records of more than 1.2 million Danish children over a 24-year period. What did that study find and why is it important?

Dr. Osterholm: Chris, this is a very important research effort, especially given the current information being spread regarding vaccine safety. As you mentioned, the study was conducted in over 1.2 million children in Denmark born between 1997 and 2018, using data from a very comprehensive nationwide Immunization Registry. It assessed the effects of cumulative aluminum exposure from several childhood vaccines. As a reminder, aluminum is used as an adjuvant in vaccines, a substance that kind of wakes up your immune system so it responds better to the antigens it detects. Researchers looked for an association between the different levels of aluminum exposure and 50 adverse outcomes occurring between the ages of 2 to 5, which included autoimmune disorders, autism spectrum disorder, and attention deficit hyperactivity disorder. The researchers compared the rates of adverse outcomes by each milligram increase in the aluminum exposure. 1.2% of the children in the study had no aluminum exposure through vaccines. Notably not vaccinated. 3.5% had a cumulative exposure up to 1.5mg, meaning up to that point they'd had a number of vaccines that led to this level of aluminum. 57% had a cumulative exposure between 1.5 and 3mg and 37.9%. Those who had more vaccines had accumulated exposure over three milligrams. Outcomes assessed in the study were adjusted for potential confounders that were identified prior to the completion of the analysis, and a priori review. These included birth year, birth season, sex, maternal age, maternal birthplace, maternal smoking, preterm birth, birth weight, and household income.

Dr. Osterholm: Very, very thoughtful design. The results of this study were very clear. Researchers did not find any evidence supporting an increased risk of the adverse outcome studied in association with cumulative aluminum exposure. This is not surprising considering the overwhelming existing data that supports the safety of childhood vaccines. But it's reassuring Nonetheless, the results of this study are particularly important because vaccine skeptics, including Secretary Kennedy, have long cited aluminum exposure as a major reason that childhood vaccines may be unsafe. Earlier this summer, Mr. Kennedy called for studies just like this those looking at cumulative exposure to be completed to give us a clearer picture of the vaccine safety issue. Considering this study's large sample size and very well conducted statistical analyzes, I truly hope that this evidence is accepted by vaccine skeptics who have been asking for this type of research, and that it is reassuring to hesitant parents. Sadly, however, it's unclear if Secretary Kennedy and his team will accept the science and admit that they were frankly wrong. I don't think it's productive to speculate on what they might say if they say anything at all in response to this evidence, but I sincerely hope they take these results seriously and begin to move on from their war on vaccines via the aluminum issue.

Chris Dall: In other vaccine news, the FDA on July 10^th, Approved Moderna's spike COVID-19 vaccine for children six months to 11 years old, but that approval was limited to children who were at higher risk of severe disease. An important caveat that was missed in some news headlines, and it has since been reported that Vinay Prasad, who heads the FDA office that regulates vaccines, overruled fellow agency reviewers in making that decision. Your thoughts Mike.

Dr. Osterholm: That's right, Chris. What could and should have been a positive development in the COVID vaccine world has become yet another example of how this administration is pushing their vaccine hesitancy agenda. For some context, spike facts first receive full FDA approval for adults back in January of 2022 after being available with Emergency Use Authorization, or EUA, earlier in the pandemic. This full authorization has expanded to anyone over the age of 12 As of last year. Infants and young children were still able to receive the Moderna vaccine under the EUA. Moderna recently applied for a full FDA approval for this population. Their submitted application was then reviewed by the Supplemental Biologics License Application Review Team at the FDA. Their group was responsible for forming a recommendation based on their review, before sending it to the director of the Center for Biologics Evaluation and Summary Research at the FDA. This group, also known as CBER, their director, Vinay Prasad, then reviewed the Biologics License Application recommendation and released his own recommendation in an FDA memo which read, quote, the review team has done a commendable job in summarizing and analyzing the submission to date. Nevertheless, I feel differently about certain aspects of their conclusions and instead reach the conclusion described below, unquote. This is where he explains his skepticism about the vaccine. This marks the third time Prasad has overruled FDA reviewers. The first two times were with Novavax and Moderna's next spike vaccine, which we covered a few episodes ago. In each of these cases, Prasad has limited the use of these vaccines to anyone above 65 or those under 64 who are considered to be at high risk for severe outcomes. Let me add that when I read his response, I first of all am challenged by the fact he indicated that he feels differently.

Dr. Osterholm: There shouldn't be any feelings in science. It should be about the facts. Do they support the argument? Do they not? And I find that this is one of the challenges we have right now, is we can't let emotions and feelings become a reason for or for not approving a vaccine. So let me just summarize this new development quickly before I dive into what exactly it means. Moderna's spikeVax vaccine is currently fully approved for anybody over the age of 65, and for anyone six months of age to 64 years who have had at least one condition that puts them at increased risk for severe outcomes for COVID infection. The list of qualifying conditions is broad, including conditions such as depression and as vague as physical activity. But what does this all mean? Well, my biggest concern here are licensing insurance coverage as well as barriers to access. When the EUA for spike VAX expires for all children under 12 and shifts to this full approval, that is limited to kids who qualify as high-risk payers may also limit their coverage to the vaccine. Providers have the ability to prescribe the vaccines, but if the individual does not qualify as high risk, then it is considered off label and insurance providers, payers of any kind could simply deny coverage put in the cost burden back on the patient. Additionally, with these high-risk conditions, it's unclear if the patient will need to first see a doctor to confirm their qualifications, and if so, it adds yet another barrier to vaccine access, which seems to be exactly what this administration is aiming to do.

Chris Dall: Since we're on the topic of vaccines, Mike, can you provide an update for our listeners on what's happening with CIDRAP’s Vaccine Integrity Project?

Dr. Osterholm: Chris, I'm very happy and actually very honored to share with you the incredible work that our VIP team is doing. We are in the process of conducting an incredibly rigorous, systematic review on the safety and efficacy of our seasonal respiratory vaccines: COVID, influenza, and RSV to prepare for two meetings that we are hosting for our subject matter experts where this data will be discussed, we are humbled and honored to have assembled a team that can fill this critical gap during such an uncertain time. When the scientific evidence review by leadership at FDA, CDC, and across HHS is shadowed by ideology. I want to remind listeners that we're not here to replace the ACIP, an advisory committee we feel is of critical importance to be fully restored to its previous position of integrity. However, we are thankful to have the capacity to review and share the most up to date published research so that the Medical Society is responsible for making recommendations around vaccine use Have a scientific brief available to them, which brings them up to speed on all aspects of vaccine effectiveness and safety. This has been an incredibly intensive effort and I'm amazed by the team we've assembled. We have a total of 27 researchers hard at work on this data review process. The team includes physicians from Massachusetts General Hospital, Penn, Montefiore Medical Center, Stanford, and Brown. We also have PhD level students, candidates and researchers from the Marshfield Clinic Research Institute, McGill and Boston University. And of course, we have a strong contingency of 17 researchers from our team at CIDRAP, including our podcast producers and several members of the podcast research team. In less than one week.

Dr. Osterholm: In less than one week This team has screened in duplicate over 16,000 study abstracts for inclusion in their analysis, and by the time that this episode release occurs, they'll have screened over 1400 full text articles for inclusion. Specifically, they are reviewing studies on the epidemiology and vaccine efficacy of COVID, influenza and RSV from recent years, as well as vaccine safety data across an even wider time frame. Data from all of these studies that are screened and will be used in their analysis, that will be completed before the second of the two vaccine meetings in August. This process is an incredibly massive undertaking, and it all goes to show that in tough times, that passion, excitement, creativity and the unwillingness to be fearful allows for this incredible kind of research or activity to take place. I can't say enough wonderful good things about the people who are doing these reviews. They are putting their heart and soul into it for the sole purpose of providing our countries, medical societies, those who will make the recommendations for vaccine use. Having the one scientific brief that is comprehensive and gives them the information they need. If in fact the VIP was not doing this, I don't know where that information would have come from or if it would have come from at all. We will share more about this analysis and the results in coming weeks, but for now, I just want to update all of you to say how proud I am of everything that we as a collective team are doing, and thankful for the opportunity to truly make a difference. It is a remarkable effort to take on what many people thought was a lost cause.

Chris Dall: Now let's turn to the good news about PEPFAR. Mike, the removal of that 400 million cut to PEPFAR from the $9 billion recession package doesn't negate all of the cuts that have been made to foreign aid and specifically to USAID. But it is, at the very least, a recognition of how important this specific program has been and how much bipartisan support for it there is. Will this stem some of the damage?

Dr. Osterholm: Well, let me just say at the outset, it's refreshing to finally have a bit of good news in the global health space. It will mean everything to those lives who will be saved in the years ahead. The white House did remove the $400 million in cuts to the President's Emergency Plan for AIDS relief, or PEPFAR, as part of the negotiations on the Trump administration's $9.4 billion rescission package. This is a major win for public health, especially when you consider that PEPFAR has been credited with saving 26 million lives since former President George W Bush initiated the program in 2003. Historically, PEPFAR has had tremendous bipartisan support from both Congress and the white House, including during the first Trump administration. The rescission package, which spared PEPFAR, passed with enough votes in the House and Senate last week and is now awaiting President Trump's signature. Despite the good news about funding for, it is not clear at this point How far will operate internationally. PEPFAR has several implementing agencies in US government, but one of the most crucial agencies for implementing fire support in foreign countries is that of the United States Agency for International Development, or USAID. As all of us know, USAID supported the implementation of PEPFAR programs in nearly 100 countries worldwide and had in-country presence in 50 countries before the Trump administration dismantled the agency earlier this year. Without USAID or additional information from the white House and how it will be implemented. The future of PEPFAR, I believe, is still up in the air, but the restoration of funding is definitely a first step in the right direction. As more information becomes available, we'll be sure to share it with everyone. How are we proceeding on restoring PEPFAR?

Chris Dall: One more item out of Washington, and this, unfortunately, is some bad news. On July 8th, the Supreme Court cleared the way for the Trump administration to go forward with mass reductions in the federal workforce, while challenges wind their way through lower courts, can you just to remind our listeners how these cuts are going to impact agencies like the CDC and the FDA?

Dr. Osterholm: Well, as you know, Chris, just last week, the Department of Health and Human Services finalized the layoffs of thousands of HHS staff, regardless of their status or performance. I call these blanket haphazard determinations using a machete instead of a surgical knife. And they haven't been confined to the CDC and FDA staff at the administration for Strategic Preparedness and Response. The US Department of Agriculture and the NIH and other agencies key to public health security were also purged, and the July 8th Supreme Court ruling allows the Trump administration to continue mass firings, endangering tens of thousands of other federal jobs. These indiscriminate and short-lived dismissals endanger our ability to research vaccines to prevent diseases such as COVID. Prepare for future pandemics. Monitor drug quality and safety, track food safety, and make progress in any number of key public health issues. In fact, in a new study by the Congressional Budget Office at CBO estimates that a permanent 10% budget reduction and a nine-month FDA delay in drug reviews due to the staff terminations will lead to 53 drugs not coming to market during that time. Well, I'm glad to see that the rehiring of some of the staff over the past couple of months. Many programs at these agencies have still been hobbled, and both up and coming and experienced employees who survived the cuts may seek work elsewhere or leave the field altogether. A huge loss for the public health workforce. Thousands of workers have already left their government jobs this summer through retirement buyouts and resignation. And imagine the demoralization of staff who decide to stay in their roles for financial or other reasons, despite the upheaval and the whiplash at their agencies.

Dr. Osterholm: They see the impersonal and inhumane way that HHS terminated people through email and in some cases, simply deactivating the worker security badges. This has to affect even the most disciplined and committed workers focus and productivity, especially when struggling to produce the same quality results with heavier workloads. Let me just give you one example how these cuts make no sense whatsoever. I've had conversations with individuals in various agencies, notably the NIH. There are programs there where they did lose some key staff, but they were able to keep the scientists on board working on these particular very complicated infectious disease issues. But the problem was they let go all of the contracting workforce. So even though they have money, they can't get it out to those researchers that have in the past been using that money to do this important work. And so here they sit. They have no idea when they may actually see a contracting officer come to work in their area. And at this point, it doesn't look like it's imminent. Is that not just a total waste of resources, both in terms of human and financial capital? It just makes no sense whatsoever. So, Chris, clearly staff firing and replacement can also dramatically alter public health policy. For example, as you remember, in June, RFK fired and replaced all 17 technical experts on the CDC's Advisory Committee on Immunization Practices with eight new advisors, including people with conflicts of interest and those who support his agenda to reevaluate and potentially terminate longstanding and evidence-based vaccine recommendations.

Dr. Osterholm: In late May, he went back on his word not to take any vaccines away from the public when he announced the COVID vaccines are no longer recommended for healthy pregnant women or children. Despite that, these groups, including newborns, are also at risk for severe outcomes. The FDA has announced that routine COVID-19 vaccine approvals would not be restricted to adults 65 and older and younger people with underlying medical conditions. Not only does this remove access to large swaths of the population, but it also sharply reduces the likelihood that health insurance companies or other payers will cover non ACIP approved vaccines for these groups, ending access for those who cannot afford them. This also makes it much more difficult for health care providers to discuss the critical nature of vaccines with families, and the government's overall distrust and regard for scientific evidence, and the importance of both vaccines and of seasoned medical professionals. And some providers, especially financially strapped rural areas, may opt not to stock vaccines. They are not required to keep on hand. That's why the CIDRAP’s Vaccine Integrity Project is so fundamental to safeguarding U.S. vaccine use, so it stays grounded in the best available science, free from external influence, and focused on optimizing protection of individuals, families and communities against vaccine preventable diseases. I invite you to follow our work and read the media stories about our efforts on the CIDRAP website.

Chris Dall: And for more on how the federal job and funding cuts are having an impact on state and local public health agencies. You can read the recent article I wrote on this topic, and we'll have that link on the podcast page. Mike, let's now turn to the latest COVID data. Are we seeing any impact yet from the NB1.8.1 variant or any of the other variants of concern?

Dr. Osterholm: Well, Chris, overall, nationally, we're not seeing a significant impact yet. But when you look at a more granular scale, we surely are seeing some hints of activity in a few states and regions. The national SARS-CoV-2 wastewater level is still low, but it's increasing. The West and South have seen increases in wastewater concentrations, with the West now considered moderate and the south not far behind those still considered low. Hawaii's wastewater concentration is very high and six states are high. California, Florida, Louisiana, Nevada, South Carolina, and Texas. Emergency department visits result in a COVID diagnosis are increasing, but still considered very low on a national level. Florida and Hawaii have both seen notable increases in their ED visits recently. So, we keep in a very close eye on these trends. The week of June 14th, we had the lowest weekly death total since the beginning of the pandemic, when we lost 153 Americans to COVID-19, a sad reality. We still had to lose 153 individuals to get to the lowest weekly death total. Our thoughts and prayers go out to those families who have lost loved ones. Unfortunately, the week of June 21st, which is the most recent week with complete data, there was an increase. And now we're up to 168 lives lost. I'm hoping this was just a one off.

Dr. Osterholm: And we continue to see the downward trend we've been seeing since the beginning of the year. Though I want to emphasize that these numbers are nothing to celebrate because, as I just noted, they're just not numbers. These are people's loved ones. We still do not have an updated variant data from the CDC. It's been a month since the last update. However, we do have variant data from the CDC's travelers based genomic surveillance program. The traveler-based data is showing that the XFG accounted for 52% of the cases the week of June 22nd, while in NB.1.8.1 was 19%. This is compared to 43 and 24% respectively the previous week is what we reported during our last episode as well. Even with the XFG surpassing NB.1.8.1, I'm not seeing any indication at this time to ring alarm bells, but we'll continue to monitor the situation and we will update you in our next podcast as we hopefully will have more data. Let me just add one other caveat on this issue. I discussed the COVID vaccines earlier, but I want to point out again another challenge that we have. I'm getting lots of questions from listeners about. Is it time for me to get a new COVID vaccine dose? Many of them have now been out 4 or 5 months since their last vaccine.

Dr. Osterholm: Remember, you're eligible for vaccine two months after a previous dose or three months after a previous infection. We have learned that the mRNA vaccines from both Moderna and Pfizer will have the updated LP 8.8.1 in the vaccine. This is good news. Novavax will continue to have the JN1, a variant that is, in a sense the grandfather of the LP 8.8.1. The challenge with this is that at this time, these vaccines are not yet authorized to be given because they need, in fact, the blessing of the ACIP, which at this time is not scheduled to have another meeting. So, I could see us getting to September 1st when these vaccines would be available. In other words, the companies are in the manufacturing position right now to provide vaccine on September 1st. I don't know what's going to happen. I personally, and this is my personal approach, not to be taken as medical advice, but I'm now more than five months out since my last dose of vaccine. I'm thinking to the fact that if I wait, maybe I'll be able to get the new improved vaccines. But I don't know that that is actually going to be the case. In the meantime, I just shared with you that there's some increasing occurrence of activity right now, and within the next couple of weeks, we may find we're starting to see a sizable increase in cases in this country.

Dr. Osterholm: Well, I won't be nearly as protected, but the vaccine I got at that point six months ago versus a recently acquired one, although I want the new one, but I have no evidence that it's going to be available in September 1st. So, what I'm considering doing is getting vaccinated again now, soon with the current vaccines, and then two months from now, I'll be eligible again. And hopefully at that point, the updated versions of the Moderna and Pfizer vaccines will be available. Don't know if that's going to happen, but then at that point I would get vaccinated again some two months after my current dose. So, we'll keep you posted on what's happening. There really is no leadership at this point coming out of CDC. No leadership in this issue coming out of FDA. And we'll try to do the best we can to combine the issue of risk, what's happening in the community with what is available for vaccine and what you can do about it. But this is clearly a time when we could use really science-based recommendations for vaccine use, and I don't think we're going to see it.

Chris Dall: Now It's time for our ID query. This week we received a question about West Nile virus from Michael, who wrote. Hi. I heard that West Nile virus was detected in 15 New York City zip codes. Is it possible that it hasn't yet been detected in other zip codes? Do I need to be worried about this virus? And Mike, I remember when West Nile virus was first detected in New York City in 1999, and it was a pretty big deal then. And we hear about it off and on. What's going on with West Nile virus?

Dr. Osterholm: Thanks, Chris, and thanks to Michael for reaching out. I want to provide a quick overview of West Nile virus as an agent before going over the transmission patterns in New York and factors linked to a sign going spread. As some of our listeners know, West Nile virus is a mosquito borne what we call flavivirus, first identified in Uganda in 1937. It has since spread beyond Africa, in the Middle East, across the world. The virus typically does not cause severe illness in most humans, but about 1 in 5 infected individuals will develop symptoms, and unfortunately, about 1 in 150 will develop what we call neuro invasive illness, such as encephalitis. The first outbreak of West Nile in the United States. As you noted, Chris occurred in New York in 1999 and was linked to 62 known cases among humans. It is also notable that in 1999, New York was actually experiencing a significant drought. And you would argue, well, don't we need rainfall to get the mosquitoes to be responsible for transmitting the virus into humans? And in fact, what had happened was with the drought, the storm sewers of New York, for example, were not being flushed out with rainfall. And one specific mosquito species actually was propagating in the storm sewers. And therefore, the population had continued to grow substantially in the absence of a flushing out rain event. In addition, this was also a time when there was financial stress in our communities, and a number of homes were for sale in the New York area that had swimming pools that, in fact, were not being cared for as people had abandoned the homes and the swimming pools with organic litter, such as leaves, became another example of a hotspot for mosquito growth.

Dr. Osterholm: So, I just want to point this out because people will often relate the risk for a mosquito borne disease with lots of rainfall. And depending on the type of mosquito species, it can actually be just the opposite. So, to get back to the New York outbreak, CDC scientists, along with those from the New York City Health Department, conducted what we call sero-surveillance, taking blood samples in the Queens borough and found that the incidence of human infection to be 2.6% in this area. The number of human clinical West Nile cases remained below 100 until 2002, when there was over 4000 cases, followed by nearly 10,000 in 2003. The catalyst for this comparatively massive outbreak was the virus, using a new, more efficient species of mosquitoes as its transmission vector. The mosquito family Culex is actually widespread throughout the United States, and there are different species of Culex mosquitoes, such as the primary vector Culex pipiens. And this population of Culex is now a very important factor in the ongoing transmission into humans. Case numbers vary by year, and it should be noted that West Nile is now considered endemic in the New York State. As we are in the thick of the mosquito season, I'm hearing lots of chatter about West Nile in Pennsylvania, Oregon, Georgia in addition to New York. To get back to our original question. The virus has been detected in mosquitoes across 15 New York City ZIP codes and 4 or 5 boroughs, all but Manhattan. This surveillance works by testing mosquitoes harvested from water sources, knowing to be the breeding grounds for this Culex mosquito.

Dr. Osterholm: It's possible that it's present, but not yet detected in other ZIP codes, including Manhattan. In fact, I believe it's likely there have not been any other clinical human cases of West Nile reported this year. However, it is critical to protect yourself against mosquito bites to reduce your risk. Preventative measures, including wearing bug spray with DEET long clothes, ensuring window screens are properly installed without tears, and reducing the amount of standing untreated water in your surroundings. The final point that I'll make is that climate change is likely playing an increasing role in West Nile transmission and geographic spread. Warmer temperatures and milder winters allow mosquitoes to survive longer and expand into new regions, while also creating more favorable conditions for viral evolution. Additionally, extreme weather events like droughts, heavy storms, and floods influenced breeding patterns of the mosquitoes. Likely, climate change is altering the timing and routes also of bird migration, which can lead to additional West Nile activity. Remember, the way that the virus increases in the community is the mosquito feeds on the nestling birds in nests. Birds that can't fly away. And at that point, they become infected. More mosquitoes come and feed on those birds. They then get infected. They then go infect other birds in nesting situations. And that's the amplifying factor that occurs. So altogether, these climate driven changes are surely making West Nile more of a year-to-year public health concern. It's no longer just the rare instance of West Nile in our communities. You're going to end up seeing it become a much more common event.

Chris Dall: Finally, it's time for this week in public health history. And Mike, this is a timely one given the recent news of a death from pneumonic plague in Arizona. Who are we celebrating today?

Dr. Osterholm: Well, our topic is actually a suggestion from a listener today. We do listen to you. As a reminder. We always appreciate your listeners suggestions to our podcast email, which is linked to the show notes. We just can't respond to every message. But I want you to know the team does read every single one of them. They have a big impact on us doing our job. Mary wrote in to mention that the recent pneumonic plague death, as well as share her experience at a small museum in Vietnam where she learned more about our historic figure we're covering today. Alexander Yersin. Alexander was a Swiss French physician scientist who studied under the renowned Louis Pasteur in France. He was briefly invited to assist Pasteur with the development of the rabies vaccine. That which we covered in our last podcast episode. Alexander ended up needing to administer the serum to himself after cutting himself during a cadaver dissection of someone who had died from rabies. At the later name Pasteur Institute, he also played a central role in the discovery of diphtheria toxin. In addition to his collaboration with Pasteur en Roux, Alexander also studied tuberculosis alongside renowned German bacteriologist Robert Koch. Yersin eventually left Europe and traveled to French colonial Asia. In Hong Kong, he studied an ongoing epidemic of pneumonic plague, where he eventually isolated the causative pathogen. These unique bacteria, eventually named Yersinia pestis, was also discovered to be hosted in and transmitted by rodents.

Dr. Osterholm: From there, Yersin spent most of the rest of his life in Vietnam working towards a serum against the deadly bacteria. He was likely the first person in Hanoi to own a car, and established a medical school and multiple laboratories in the country. He is also credited with acclimatization of type of tropical trees from South America that could produce quinine, a quintessential anti-malarial. As for all of Indochina, he is still remembered fondly by the Vietnamese people. As Mary mentioned, the country hosts numerous structures in his honor, including a museum, statue, and university. Now, some may be concerned about a resurgence of plague here in the United States after this recent death in Arizona. The mention of plague certainly paints a gruesome picture of what we know as the Black Death sweeping across Europe in the Middle Ages and taking out roughly half the population of major cities. However, nowadays, infections with Yersinia pestis can be treated with antibiotics, if caught early, and is limited to having close contact, particularly with rodents such as prairie dogs. Avoiding that will keep you from acquiring plague. So, I want to end by thanking Alexander Yersin for his hard work in bacteriology and global health. Our fight against bacterial illness is certainly not over, but we have him to thank for lessening some of our burden.

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

Dr. Osterholm: Chris, let me start out, first of all and just say that we're watching COVID very closely right now. Again, we're in one of the best positions we've been in with COVID since the beginning of the pandemic, but it looks like we could be seeing some increase occurring in the days ahead. We will keep you posted and will also help you work through the vaccine schedule issue and what that means for you. And for those wondering, should I get another dose of vaccine now? We'll hopefully have better information for you in our next podcast. Second of all, I just want to acknowledge the number of people working on VIP right now that bring such expertise to the table and who are doing it out of goodwill because they want to help. They want to take on this challenge we have right now of an ACIP not capable of providing such information, and yet we need it to understand how to make the best vaccine recommendations. We'll keep you posted on our findings and what we're doing in the days ahead, but just know that the VIP is here and it is working. And finally, I want to acknowledge the hope that I feel with regard to PEPFAR after taking and literally dismantling and destroying one of the most important and effective agencies in all of the federal government. It's sad to think that we're now talking about rebuilding, but at least the fact that we're even talking about rebuilding, I believe, is also a very positive issue. We will keep you posted where PEPFAR is at, what it means with other program areas. Just know that over the upcoming weeks, we'll see many challenging situations arise over the current approach to government and responding to infectious diseases, but that we'll keep you posted.

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

Dr. Osterholm: Well, I almost thought about asking everyone to guess before I actually tell them. Remember the dedication? So, if you think about that dedication, maybe you might think, huh? Might it be tied to that? Well, I am very honored to report that this particular song we're using today has been so popular, so important. It's been used four previous times on this podcast. On November 6th, 2020, an episode 30 A New dialog on November 4th, 2021. In episode 76 vaccines in the World of Delta. On May 26th, 2022, in episode 105 COVID-19 Monkeypox and Pediatric Hepatitis. And then finally on April 6th of 2023, in episode 128. Light at the end of a tough two weeks. Well, think about it. It's been almost two years and three months since we last used this song, but that's surely an oldie but goodie that we all love. We're talking about tomorrow, the show tune from the musical Annie, with the music by Charles Strouse and lyrics by Martin Charnin. I must also add that I had one of those moments that just happened to occur in life you never forget. In January of 1981, I was asked to appear on Good Morning America. At that time, we had just released our results of the Toxic Shock Syndrome study that we did here in the Upper Midwest.

Dr. Osterholm: And our results were not consistent necessarily with what CDC had been reporting about the risk of toxic shock, cinnamon, certain tampon use. And so, I found myself my first trip to New York, you know, Iowa farm kid, overwhelmed by what I saw there. But the reason I tell you this is because the other guest on that morning with me was Eileen Quinn, a young lady who was one of the 9000 girls that auditioned for the movie Annie. And Eileen Quinn was the one selected, and we were in the same green room together. So, I've always had a very favorite spot in my heart for Annie. So today it's about son, it's about tomorrow Moral and what that all means. So here it is. Tomorrow the sun will come out tomorrow. Bet your bottom dollar that tomorrow there'll be sun. Just thinking about tomorrow. Clears away the cobwebs and the sorrow. Till there is none. When I'm stuck in a day that's gray and lonely. I just stick out my chin and grin. And say. The sun will come out tomorrow. So, you gotta hang on till tomorrow. Come what may. Tomorrow, tomorrow I love you tomorrow. You're always a day away. When I'm stuck in a day that's gray and lonely. I just stick out my chin. And I grin and say.

Dr. Osterholm: The sun will come out tomorrow. So, you gotta hang on till tomorrow. Come what may. Tomorrow. Tomorrow. I love you tomorrow. You're always a day away tomorrow. Thank you so much for being with us again. I hope that we're able to provide you with the kind of information you're looking for, maybe even provide you with a light moment here and there. And at this point, I just want to continue to emphasize the fact that we're in this for the long haul. We need all of you to help rally the public health message again on our show notes for this show. We will post information about organizations that are working in your community to promote vaccination, to help move the science message forward. And I hope that you'll think about getting involved. And let me just conclude with the fact that now more than ever, do I appreciate the importance of kindness. If anything, now's the time takes an unplanned moment. Walking down the street, you see someone say something nice to them. You're in a grocery store alone. Somebody is having a challenge getting their groceries under the belt. Help them out. Just say, you know, have a nice day. It's amazing what that can do. I hope that you will consider that. So be good. Be kind. 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.