Episode 190: Courage Over Fear

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. On August 8th, a Georgia man who blamed COVID-19 vaccines for his personal health problems opened fire on the Centers for Disease Control and Prevention's Atlanta headquarters, killing a police officer before dying from a self-inflicted gunshot wound. The shooter had multiple guns and fired nearly 200 rounds of ammunition at the CDC headquarters, forcing hundreds of workers into lockdown. For many who work at the CDC, the shooting was the culmination of years of scorn, invective and threats that have been directed at them over the response to the COVID-19 pandemic, and some drew a link between the shooting and some of the rhetoric that's been used by people who currently lead our nation's health agencies.

Chris Dall: There is a direct line from the vilification of CDC during COVID, and the deliberate lies and mis disinformation that continues today, a CDC official told The Washington Post. Many of the sources of these lies now have a pulpit and the veneer of respectability through their positions in the administration. On this August 21st episode of the podcast, we're going to discuss the aftermath of the shooting and the rhetoric that some CDC workers believe has put a target on their back. We'll also dive further into the controversial decision by the Department of Health and Human Services to abandon mRNA vaccine development. Give you an update on the work of CIDRAP’s Vaccine Integrity Project. Discuss the latest COVID data, review some H5N1 avian flu news, and answer an ID query about vaccine adjuvants. We'll also bring you the latest installment of This Week in Public Health history. But before we get started, we will begin with Doctor Osterholm opening comments and dedication.

Dr. Osterholm: Thank you, Chris, and welcome back to the podcast family. For all those who might be joining us for the first time, I hope we're able to provide you with the information today that you're looking for that's helpful to you. Information that may mean you have to ask more questions, but that's part of the whole scientific process. And for those of you who are regular listeners to the podcast, I think you'll note today that this particular opening and dedication is unlike any I've ever done. And one. However, though I think it's time has come for it to be said. Chris, as you noted, we have a lot to cover today. But before we get into vaccine policy or the latest in H5N1, I want to take a moment to honor and dedicate this episode to the public servants whose lives and safety have been threatened by hate, violence and fear, especially in light of the recent shooting at the CDC. We mourn the loss of the police officer, David Rose, who was killed in the line of duty, and we hold close in our hearts the CDC employees who were targeted simply by doing their jobs, serving the public, protecting health and advancing knowledge. This episode is for them and every public servant who shows up day after day after day with courage and commitment, even when the cost may be high. It won't always look like 500 rounds of fire towards your workplace. Sometimes it's a nasty comment left on social media, or harmful and inaccurate accusations repeated by someone with a bully pulpit or a threatening letter or personal interaction.

Dr. Osterholm: These instances add up, however, the damage is cumulative, and I worked long enough in public service, doing my best to defend science and truth with integrity and compassion, to have received all these types of attacks myself. And when I talk with my friends and colleagues who work in government agencies or lead organizations around the world protecting the lives of not just Americans, but the entire world, I know we are not alone. The fear that the CDC employees felt when they heard bullets hit the windows of their workplace will likely stay with them for a very, very long time. Fear is a natural response to a threat. And in times like these, not only understandable, it's human. Fear tells us that something is wrong, that we're in danger, that we need to pay attention. It shows up in our bodies, our thoughts and our decisions, and it deserves to be acknowledged, not pushed aside or minimized. We honor fear by listening to it and by letting it inform how we care for ourselves and others. But honoring fear is not the same as surrendering to it. Fear can protect us, but it can also distort our view of what's possible. It can shrink our capacity to act and hope. When fear drives everything, it robs us for the very things that we're trying to protect our integrity, our purpose, our community.

Dr. Osterholm: The answer isn't to be fearless. It's to be courageous. Courage is what allows us to keep showing up even when we're afraid. This is a very personal issue for me. As some of you know, from listening to this podcast. When I was a young boy growing up in a small-town household in Iowa. I was the oldest of six children who had to deal with a mentally ill father who, as an alcoholic and his drinking binges would become extremely violent. You don't know how many nights I woke up to the pounding of my father's fist on my head as I slept there as a young boy, how often I was fearful of the dark and the night, and how that stayed with me well into adulthood. I know fear. I understand fear, and I know how paralyzing it can be. But it also means we can't let it continue to paralyze us. What I would say today to you is you are fearful. Know that that's normal. Know that. That's okay. Don't feel like you have to apologize for it. But we all need to seek help. We need to find how we can respond to our fear. Oftentimes in discussions with our colleagues, in some cases, it may even require professional therapy. But don't let it paralyze you. And I hope today's comments are not taken to suggest someone who is fearful or feeling gripped by fear that there's something wrong with you, but fear is something we should understand will occur when we experience these traumatic events in life, and they won't go away.

Dr. Osterholm: I continue to receive the kind of fearful comments or statements that every day make me remember I'm in a constant battle with my fear versus my courage. Just last week, Steve Bannon and Steven Hatfill on the War Room podcast cited me by name, called me a demon and that people like me needed to be snuffed out because of the damage we were doing to the world with promoting these vaccines. Now, did I think that Steve Bannon or Steven Hatfill were going to come after me? No. But do I realize that there are a number of individuals today out there might hear those same words and act? Yes. But I can't let that stop me from doing what I know is important for all of us, for my kids and my grandkids, for your kids and your grandkids. And so, I just hope that from this experience, one, we come to accept that fear is a normal part of what we are experiencing because of what we are experiencing. It is not an isolated event right now in public health, but seek help. So, if you feel that that fear is compromising your everyday life. Talk to your friends. Get professional help. Now is the time for public health to come together.

Dr. Osterholm: I think we all should be part of an informal therapy group, helping each other talk about this and helping each other to understand it's okay to be fearful, but don't let it take you over. And I struggle with that myself today. As here I am, a 72-year-old man, and I'm still living with fears from my earlier part of my life. So let me just conclude by saying, if you're a listener who works in public health, education, public safety, government affairs, the legal system or social services or any other kind of public service role, I hope that you will find the ability to let your courage shine bright. But please take care of yourself. Honor the fear. Honor it and honor the uncertainty that we have for our future. We still have a job to do to protect the lives of all of the citizens of this world. We need to find a way to allow us to do our jobs. And if that means seeking help, do it. I hope all of us can continue to do our jobs with courage, constantly mindful of our fears and taking time to help support our colleagues. Now, if there was ever a time to be kind, to be understanding and listening to our colleagues, it's now. Now I'm about to make a rather critical transition here. After speaking about the courage and fear to give you some incredibly good news. I do want to take this opportunity to congratulate one of the producers for this podcast and advisee of mine.

Dr. Osterholm: Sydney Redepenning, who successfully defended her PhD dissertation last week and is now Dr. Redepenning, CIDRAP is so proud of you Sydney. We're excited to see what kind of lasting impact you leave in the world of public health. I have no doubt it will be huge. Now let me move on to that part of the podcast that some of you will want to tune out. But today I am very happy to report it's going to be a sunny day in Minneapolis-Saint Paul. We have sunrise at 6:22 a.m., sunset at 8:08p.m. That's 13 hours, 46 minutes and 23 seconds of sunlight. Still a bright day out there, but I will have to acknowledge we're losing sunlight at about two minutes and 53 seconds a day. On the other hand, our dear friends and colleagues at the Occidental Belgian Beer House on Vulcan Lane in Auckland, New Zealand. Your sun rose today at 6:57 a.m. It will set tonight at 5:51 p.m. That's ten hours, 54 minutes and 32 seconds of sunlight. Yeah, we've still got you beat by a few hours, but you're actually gaining sunlight at two minutes and five seconds a day. Won't be long and will be about the same sunlight in both locations. And then after that, we will count on you to share your sunlight with us.

Chris Dall: Mike, I want to start with a topic that we discussed briefly in the last episode because the news was occurring as we were recording that episode. And that is the decision by the Department of Health and Human Services to cancel 500 million in contracts for development of mRNA vaccines against respiratory viruses. Secretary Kennedy said in an HHS statement, quote, BARDA is terminating 22 mRNA vaccine development investments because the data show these vaccines fail to protect effectively against upper respiratory infections like COVID and flu. We're shifting that funding towards safer, broader vaccine platforms that remain effective even as viruses mutate, end quote. In a video posted on YouTube. Kennedy also said HHS had determined mRNA technology poses more risks than benefits for these viruses. Interestingly, a week later, National Institutes of Health Director Jay Bhattacharya wrote an op ed in The Washington Post saying the administration was pivoting away from using mRNA technology for vaccines for broad public use because the platform had failed to earn the public trust. Mike. Can you address and respond to some of these claims by the head of HHS and the head of NIH?

Dr. Osterholm: Well, I would just remind everyone again to a quote that I have used before in this podcast that was shared with me a number of years ago by the late Tom Clancy, the author. And he said to me, never forget that the only difference between reality and fiction is that fiction has to make sense. I now finally understand that in ways I never did before, because in fact, that's exactly what's happening here. First, let me say that the statements Mr. Kennedy and others at HHS have made about this are highly misleading, to say the least, and it's really added so much unnecessary confusion to this issue. The truth of the matter is that mRNA technology is, in fact, an area that is ripe for scientific breakthroughs that could be game changing. But now, instead of taking a leading role in this work and being on the cutting edge, it looks like the US is basically going to be stepping away and for no good scientific reason. I've said this in the last episode, but I think it bears repeating the decision to move away from mRNA technology is dangerous, irresponsible, and has absolutely no basis in legitimate science. Let me just highlight one of the most important aspects of mRNA technology that we're now losing. If we were to see the emergence of an influenza pandemic in this world, we would be in terrible, terrible trouble right now in terms of vaccine availability. The current methods that we use to make influenza vaccine embedded chicken egg is one that would take us many years to have enough vaccine produced to cover the world.

Dr. Osterholm: Right now, we estimate in the first 15 to 18 months of the pandemic, we could probably actually produce enough vaccine for about a quarter of the world's population. That is obviously terribly inadequate in the face of a severe influenza pandemic. On the other hand, we know that mRNA technology holds great potential to provide us with a vaccine that's every bit of equivalent to the current chicken egg vaccine in terms of its ability to protect. But we could also make much, much more of it, likely being able to provide enough doses of vaccine for the world in the first year of a pandemic. Now think of the contrast one without mRNA technology and one with. Now, do I believe that the world will stop using mRNA technology because we are no. And if there is going to be any advantage to having mRNA technology for an influenza pandemic, it will come from production in other countries. So even though we keep hearing about America first, this puts America last. We won't be at the head of the line to get vaccine. We will be at the end of the line. I can't emphasize enough. This issue alone should be enough to move mRNA technology back into the front row of research priorities. Let me just also talk about some of these misleading statements. First, the claim that mRNA vaccines fail to protect effectively against upper respiratory infections like COVID and flu. Let's be clear. Did the mRNA vaccines stop every COVID infection? No. Clearly, with waning immunity and a virus like SARS-CoV-2, which is constantly mutating and spinning off different variants or subvariants, breakthrough infections happen.

Dr. Osterholm: It happens with influenza vaccines. But the more critical question is do these vaccines help reduce severe disease, hospitalizations and death? And the answer is a resounding yes. In the US alone, it's been estimated that vaccines prevented more than 18 million hospitalizations and 3 million deaths from COVID. Without them, it would be a very different impact with regard to the COVID pandemic. So, to frame the vaccines as failures because they didn't completely block transmission is intellectually dishonest. And I might add, we'll be talking about this in a moment when we talk about the Vaccine Integrity Project. But all of our recent work and the information we have provided publicly clearly demonstrates the protective action of these vaccines against COVID and the fact that they are also very important in reducing severe illness, hospitalizations and deaths in groups like pregnant women who are infected. In terms of the data that the HHS officials cited, it's a similar story. In fact, Doctor Jake Scott, who's a brilliant and highly respected infectious disease physician who has been involved with our CIDRAP’s Vaccine Integrity Project, went through all the HHS reported data and summarized it in an op ed published by STAT news. Long story short, the data they cite doesn't support their claims. In fact, a number of the studies they referenced explicitly state that vaccines are preferable compared to infection. Other evidence they cite relies on test tube experiments or animal model studies that have limited real world application. In many cases, they took studies that looked at the effects of spike protein specifically from infection, and then unfairly extrapolated that to vaccines.

Dr. Osterholm: And coincidentally, they just so happened to leave out that the numerous studies supporting the safety and effectiveness of these vaccines. Let me just read the concluding paragraph of Jake Scott's op ed, because I think it captures it so well. I quote there are real discussions to be had about rare side effects, risk communication and policy tradeoffs, but those require honest representation of evidence. What Kennedy has done is different. Most papers found infection related harms evidence that actually supports vaccination, yet he is wielding it against vaccines. He citing sources that explicitly support vaccination while claiming they oppose it. This isn't scientific disagreement. It's either a staggering incompetence or willful misrepresentation when half $1 billion decisions affecting pandemic preparedness rests on such foundations, the scientific community must respond clearly. Kennedy is using evidence that refused his own position just to justify dismantling tools we desperately need when the next pandemic arrives. Finally, on the HHS promise of safer, broader alternatives, let me be clear I'm all for better vaccines. We need them. Our center has been leading the world with its influenza and coronavirus vaccine roadmap work and the landscapes. But the alternative whole virus vaccine that HHS is now promoting is almost certainly not the answer. Now, let's also be honest about timelines and capacity when it comes to the speed and scale of production, particularly on a global scale. The whole virus vaccines don't even hold a candle compared to mRNA platforms. And in a pandemic, as I just noted, we know that any delay in vaccine availability translates directly into illness and death.

Dr. Osterholm: So, moving away from the mRNA platform really leaves us grossly underprepared. A week later, we heard from Jay Bhattacharya, who indicated that the real reason why they had decided not to support mRNA technology research was the fact that the public no longer had faith in this vaccine. And so why invest in its research? Well, that is like somebody who is going through the neighborhood, setting houses on fire and then coming back and complaining about the fact that this is an unsafe neighborhood for the vast majority of the public. They do support these vaccines. Those that don't, in many instances, have been informed by the misstatements and the outright dishonest statements by the Secretary and those people who work in or around him. So, it's really important to understand that, yes, there surely is going to be some challenge in these vaccines because they're hearing from the Secretary of Health and Human Services. They're not safe. They're not beneficial. So, to leave this where we're at today is one of great confusion. Again, we cannot let that decision rest about the support for mRNA technology. And it holds such promise not just for influenza or coronavirus infections. It also holds promise for a number of different infectious diseases, a number of different cancers. We will be at the end of the line again globally, relative to any breakthrough that might occur in medical sciences with mRNA technology, and who will pay for that? We will. As a society, we have to understand that this is a very, very dark time in science.

Chris Dall: Let's stay with COVID vaccines, because it has been reported that the FDA may not renew an emergency use authorization of Pfizer's COVID vaccine for children ages six months to four years. Now, Mike. Correct me if I'm wrong, but if that happens, wouldn't that mean there is no available COVID vaccine in the US for healthy children in that age group?

Dr. Osterholm: This is correct, Chris. If this emergency Use authorization or EUA is pulled, healthy children under five will not have an option for vaccination. But I also want to emphasize that this does not actually change what we expected to see when we finally get a formal recommendation from ACIP and CDC. The vaccine approval and recommendation process has several steps to break it down. Simply, it begins with FDA approvals, which should be based strictly on scientific evidence about the vaccine's efficacy and safety. The ACIP then forms a recommendation which considers both scientific evidence and the public health impact. The CDC then makes the formal recommendation, which typically aligns with the ACIP recommendations. Nothing is happening as expected these days. Remember, in May, the Secretary Kennedy stated that COVID vaccine recommendations were being removed for healthy children and pregnant women. I bring this up because even if the FDA renewed the Pfizer EUA for healthy children, the ACIP has made their position clear that they do not plan to recommend vaccines to healthy children regardless. To clear up any confusion about this news, let's quickly go over what approvals looked like at this time last year and then where things stand currently. at this time last year, both Pfizer and Moderna vaccines had full FDA approval for anyone over the age of 12 and UAS for kids six months to 11 years.

Dr. Osterholm: Novavax vaccine was fully approved for individuals 12 to 64 years of age, with at least one immune-compromising condition and anyone over the age of 65. The approval picture has changed in recent months. Moderna has recently received full approval rather than EUA for their vaccine in children six months to 11 years, with at least one immunocompromised condition. Not healthy children. As such, this means their vaccine is fully approved for anyone six months to 64 years of age, with at least one immunocompromised condition or anyone over 65. Novavax full approval was renewed, meaning it is approved for those over age 12 with at least one immunocompromised condition or anyone over 65. There have been no official reports about Pfizer's full approval for 2025-2026 vaccines. As it stands today, two months since ACIP is meeting. We still don't have a formal recommendation for this fall, but we expect that anyone over the age of 65 and for those six months and older with at least one immunocompromised condition, will be able to get a COVID vaccine. So, if you're healthy and under 65, your options may be very limited.

Dr. Osterholm: And the decision to pull the Pfizer EUA for children under five would seal the deal for young, healthy children as well, though again, I would not have expected the ACIP to recommend this anyway. I must note that just earlier this week, the American Academy of Pediatrics issued their recommendations for vaccination. The VIP program worked closely with the AAP to support their recommendations, and they do recommend vaccines for those six months of age or older to have at least two doses. Now we're in a world of confusion. What vaccines will be available? Which ones can be given based on consultation with your physician, what's available, what's not? Who will pay for what? is such a mess. And it doesn't have to be. It wasn't before and now it is. Stay tuned. We'll try to give you as much information as we can. In the meantime, I just want to give a shout out to the AAP and the leadership in that organization for doing what they're doing right now with vaccine recommendations. They're based on good science. They're based on care for kids, and they're based on what we need to do from a public health perspective.

Chris Dall: Mike, this is confusing for those of us who follow this. It's not going to be any less confusing for the general public.

Dr. Osterholm: Confusion is a normal word here, and this, I believe, is an actual effort being made by HHS to do that. Because by creating confusion, something as simple as why is a vaccine not being recommended or it is, is because it doesn't work. It's not safe. Is it because the public doesn't like it? I mean, what's the reason? If you look at the issue of how well these vaccines work, we have demonstrated clearly in our own efforts here with the Vaccine Integrity Project, that the data of the past two years only continues to support the recommendations that were in place before this new administration came in. So, I can only say stay tuned. We will try on a every other week basis to give you the most updated information in terms of what's happening, but if you're frustrated, if you're confused, welcome to the crowd. We don't know at this point how this is going to play out.

Chris Dall: Mike says he just mentioned VIP. This is a good place to get an update on the work of CIDRAP’s Vaccine Integrity Project. You held a big live stream announcement this week. What can you tell us?

Dr. Osterholm: Well, first of all, I just want to say that I've had the opportunity in my 50-year career to work with a number of really amazing public health efforts, ones where the teamwork was job, one where critical issues were confronted and dealt with. And this particular effort has without a doubt been one of the highlights of my career. I can only say I feel so fortunate to have worked with this group. It is really a remarkable effort. Let me just say that the VIP has been a bullet train from the start, and these last few weeks were no exception to the fast-paced progress. We knew in terms of timing, we had to get information to the medical societies, making recommendations for vaccines and for the community in general, and how to use these vaccines. The fall viral pathogens are here. The vaccines that we use to protect ourselves against them are here. How are they going to be used? For that reason, we actually embarked upon what some called an impossible effort to, within a period of almost eight weeks, bring together an overview of more than 17,500 abstracts, hundreds of studies, to come up with a very detailed, comprehensive review of what has been learned about vaccines since the ACIP last issued their reports 1 to 3 years ago. Let me just say, as we approach this respiratory virus season, I think all of our podcast listeners know that it's more important than ever that people have clear, trustworthy information to make informed decisions about immunization.

Dr. Osterholm: That's why the Vaccine Integrity Project embarked on this work, to provide a source of scientific evidence to use, as needed to inform medical societies, physicians and the public. By the time this episode comes out, as you noted, we are now two days out from the live stream that VIP put on. Entitled From Data to Decisions the Evidence base for 2025 fall Winter immunizations. This was live streamed on Tuesday afternoon, and we have included a link to the recorded session in our show notes for this week's episode. The presentation included findings summarized from a thorough literature review led by a team of experts in epidemiology, infectious diseases and evidence review looking at the recently published body of publicly available data concerning vaccine safety and efficacy for flu, COVID and RSV immunizations. During the live stream, the scientific research team presented findings on the effectiveness and safety of COVID-19 and RSV immunizations in pregnant, pediatric and immunocompromised populations. Coupled with a panel led Q&A, some of the top line findings grouped by population of interest from the review were the following. We'll start with the immunization during pregnancy. Our review found there was no significant new epidemiologic data for COVID-19 and RSV in pregnancy. One new study supported the effectiveness of influenza vaccination and pregnancy to reduce medically attended infection and pregnant women. The only safety concern our review found was one that was already established for RSV, and that is the potential increased preterm birth risk, which led to CDC timing recommendations for 32 to 36 weeks gestation.

Dr. Osterholm: All other pregnancy outcomes examined the risk of adverse outcomes with COVID-19 sphere influenza, immunization and pregnancy was similar to or less than receiving immunization during pregnancy. Next is pediatric populations fanning birth through 18 years of age. Our review found there was a moderate volume of new data regarding the epidemiology of COVID-19, RSV, and influenza among children of all ages. There were several studies providing new data regarding the influence of RSV immunizations on pediatric hospitalization, consistently demonstrating protection in children under age two. There were several studies providing new data investigating the potential association between COVID vaccination and Guillain-Barre syndrome, or myocarditis, among children. Though no new safety concerns were identified. Three studies assessing the Pfizer mRNA vaccine re identified that myocarditis risk was around two cases per 100,000, and more common after the second dose in adolescents. Findings which have been previously established. I should note that the additional Pediatric Vaccine effectiveness safety studies and Co administration analyzes are ongoing. And lastly, we did not identify any studies that made it to the final phase of our review that reported vaccine associated outcomes related to autism spectrum disorder. I know the casual risk has been all over the news, but we did not find any evidence of association in our extensive review. Finally, we conducted a review of COVID-19 RSV and influenza vaccines in immunocompromised adult populations for the overarching population of immunocompromised adults. Vaccine effectiveness for COVID-19 vaccines was comparable in effectiveness to that of immunocompetent individuals.

Dr. Osterholm: Very good news they are working in immunocompromised patients. Among stem cell transplant patients, we found that RSV vaccination was somewhat less effective than in healthy adults, and one study resulted in increased risk of Guillain-Barre syndrome in those over age 60. However, the risk of severe outcome of RSV infection in immunocompromised adults is large and must be considered when assessing personal risk. Lastly, influenza vaccines were found to be protective against hospitalization but with lower effectiveness, and more data is needed to compare outcomes influenced by dosage. The key takeaway from Thursday's meeting was that the respiratory viruses pose a risk to everyone, and immunizations for COVID-19, RSV and influenza with strong safety and efficacy profiles are effective in reducing the risk of severe outcomes across several key populations. And as I previously noted, our partners at the American Academy of Pediatrics agree. The medical society released its own evidence-based immunization schedule for children this past Tuesday, with some clear deviations from the recent statements by HHS. The AAP news release is comprehensive, and I will point listeners directly to their page, which again, will be linked in the show notes for this webcast. This is not the last. You will be updated on this review. We're continuing to analyze COVID-19 randomized controlled trials, along with additional data on older adults and a comprehensive evaluation of results involving healthy adults. Bottom line these vaccines are working. They are safe. We must use them.

Chris Dall: That brings us now to our COVID update. CDC data suggest COVID infections are rising in most states. Mike, are we finally starting to see the hints of a late summer surge in cases?

Dr. Osterholm: I'm not sure I'd go as far to say that it's a surge quite yet, but there is certainly an uptick in activity across the country. And quite honestly, I'm not surprised by that. Wastewater concentrations are increased in every region, but still moderate in the south and west, and low in the Midwest and Northeast. The national level has risen from low to moderate since our last episode. Six states have high concentrations, including. Alabama, California, Connecticut, Florida, Louisiana, and South Carolina. Five states Alaska, Hawaii, Nevada, Texas, and Utah are considered very high. Emergency department visits are still considered low but continue to increase, especially in children in the 0 to 11 age group whose percentage of ED visits with a COVID-19 diagnosis being more than double the percentage of any other age group. All other age groups, including other school age groups both 12 to 15 and 16 to 17 years old, have followed a very similar trend. We have to keep an eye on those, particularly those under 11, as we start the school year. Again, these data support why we want to have vaccine available for children and what this means. Weekly deaths on a nationwide basis have remained fairly steady, hovering around 158 to 179 deaths for six straight weeks, most recently with 167 deaths the week of July 19th.

Dr. Osterholm: We're in a much, much, much better place than we were at any other point in the pandemic. But that does not minimize that those are people's loved ones. These are not just numbers. There is still no updated variant data from CDC, but the most recent CDC trailers-based surveillance shows that for arriving international travelers, XFG accounted for 50% of samples the week of July 20th, down from 61%, and the NB1.8.1 accounted for 28%, up from 18%. Remember, the NB1.8.1 is now the new emerging variant that we saw throughout much of Asia in other parts of the world. So, what does this all mean? I think we're still in a wait and see moment. I expect activity to increase, but so far signs are not pointing to a huge surge, particularly in severe illness. And that's the important note here. We are seeing a number of infections in the community, but only rarely are we seeing severe illness. Now could that change? Absolutely. But in fact, at this time, I think again, this is still good news.

Chris Dall: It's been a while since we've discussed H5N1 avian flu, and you could say that is good news, but there was an interesting preprint study that came out recently that examined different ways the virus may be spreading on dairy farms. Mike, what did we learn from that study?

Dr. Osterholm: Well, let me begin by first saying that the more I learn about H5N1, the less I know about it. I feel convinced of that. This is no exception. Of note, the study that you referred to Chris has not yet been peer reviewed. It involves sampling of air, farm wastewater and aggregated milk on 14 farms with H5N1 avian flu detections in two California regions last fall and winter. The research, which posted at the beginning of this month, found that live H5N1 virus, including variants in air and wastewater and H5N1 viral RNA, which isn't infectious in the air during milking, and the exhaled breath of a row of 15 to 30 cows and head restraints. Analysis of cow milk indicated a high prevalence and high viral loads in H5N1 positive cows, which appeared healthy, and wastewater analysis review of H5N1 viral RNA at every sampling point, including manure lagoons where migratory birds congregate and fields where cows graze. The study author said that these findings suggest H5N1 is likely transmitted in multiple ways on farms, including contaminated milking equipment, aerosols generated during milking, and the contact of teats with contaminated water used to clean pens. The researchers recommend the dairy farm workers wear respiratory and eye protection, especially in milking parlors, something that we realize has been very difficult to accomplish.

Dr. Osterholm: Also, the milking equipment should be disinfected between each milking of a cow. Milk from sick house is treated before disposal. Waste streams are treated before they are used on fields, and infected cows are identified and isolated regardless of clinical signs. Ten days after the study was published, CIDRAP News published a story on an unusual increase in H5N1 avian flu outbreaks on United Kingdom commercial poultry farms, with more than ten reported over the past two weeks, and a smaller outbreak in Ireland in a backyard flock. For comparison, last year the UK did not report any poultry outbreaks from March to early April and before the recent detections had lowered its H5N1 threat level after no detections surfaced in five weeks. Mike Coston, who publishes the infectious disease news blog Avian Flu Diary and someone who I have tremendous respect for and have learned a lot from reading his work over the years, was quoted as saying. While this map of summer outbreaks could prove to be a little more than a transient event, it represents a change in the typical summer pattern and is worth at least keeping an eye on, unquote. Other countries have also reported recent H5 detections in poultry over the past few weeks, including Taiwan, Canada and Cambodia, the latter of which announced its 15th human H5N1 infection of the year on August 6th.

Dr. Osterholm: Nearly all of them in people who had contact with sick or dead poultry. Tragically, seven of the 15 cases were fatal for a death rate of 47%. Since 2005, Cambodia has reported 87 human infections, including 50 deaths, for a death rate of 58%. The latest human cases have involved an assortment between the older H5N1 clade that have circulated in Cambodia since 2014, and a newer clade circulating globally, the rise in human infections in that country began at the end of 2023 and has accelerated this summer, with 12 reported over the past two months. The US reported its latest H5N1 outbreak in early July, with involved a game bird farm in Pennsylvania. All of these cases and deaths highlight the importance of vigilance in monitoring H5N1 circulation around the world. While the US hasn't seen an outbreak for a month, the assortment and high death rate in Cambodia show that the virus still can pose a grave threat as it mutates and circulates among dairy cows, people, birds and other animal species. Bottom line message from me that I don't know what's going to happen. And I've been saying that for the better part of 27 years, and its so far work. I hope it stays that way.

Chris Dall: Now it's time for our ID query. This week we received an email from JJ about vaccine adjuvants. He wrote. On the last episode, Doctor Osterholm talked about aluminum adjuvanted vaccines. Forgive me, but I was always under the impression that people were concerned about mercury adjuvanted vaccines, not aluminum adjuvanted vaccines, specifically thimerosal adjuvanted vaccines. Did I miss something? Or aluminum adjuvanted vaccines and mercury adjuvanted vaccines the same thing. And Mike, this is a good question because it's something we've been hearing a lot about lately and we will continue to hear about in discussions over vaccine safety.

Dr. Osterholm: I want to thank the listener for this very thoughtful question. It's one that we're hearing about, and it also just adds to the ongoing confusion of fact versus fiction. I hope I can clear up for you any confusion about vaccine ingredients. Our listener pointed out two of them aluminum, which is used as an adjuvant or a way to actually boost the immune response, and thimerosal, which is used to prevent growth of bacteria in the vaccine vial when it is a multi-dose vial. Let's talk about aluminum-based adjuvants first because they are widely used. Currently recommended vaccines that use aluminum-based adjuvants include the RT. Acellular pertussis vaccines HPV, pneumococcal, meningococcal hepatitis A and hepatitis B vaccines, and more. As a general reminder, adjuvants are used in vaccines to enhance that host response. A strong immune response is necessary in order to protect the recipient from disease for a sufficient period of time. Adjuvants allow for lesser quantities of the vaccine and fewer vaccine doses overall. Importantly, the amount of aluminum used within these vaccines is minuscule. Aluminum is one of the most common metals found in nature and is present in air, food, and water, according to the Children's Hospital of Philadelphia. Or CHOP, infants received more aluminum through breast milk or formula in the first six months of life than they received through all the vaccines they received. Adults ingest more aluminum every day through food and beverages than is included in vaccines using aluminum-based adjuvants. Long story short, aluminum-based adjuvants have been used in vaccines safely and effectively for a very long time, Chris. This is not a real public health issue, but again, another attempt to obscure the truth about vaccine safety.

Dr. Osterholm: Now let's shift gears to thimerosal, which contains ethyl mercury. Notice I said ethyl mercury. This specific type of mercury is very different from the mercury found in the environment, which can be toxic to people at high levels. Ethyl mercury is cleared from the human body much more quickly than the other type of mercury, and therefore is not likely to cause any harm. However, thimerosal was taken out of childhood vaccines in the US out of an abundance of caution in 2001. There was no evidence to indicate any harm besides the typical minor reactions to vaccines that we are all familiar with. Like redness and swelling at the injection site. Prior to ACIP recommendation to remove thimerosal from influenza vaccines in the US in June of this year. Thimerosal was still used in some influenza vaccines to prevent contamination. Specifically, it was used in multi dose vaccine vials to prevent the growth of germs like bacteria and fungi, which can occur when a syringe needle enters the vial as a dose of being prepared for administration. This is different from an edge of it, which enhances the immune response. However, there has been no evidence that either thimerosal or aluminum cause any harm when used in vaccines. We will continue to follow the evidence when it comes to vaccines and vaccine ingredients, and encourage our listeners to do the same. Vaccine safety is too important of a topic not to be based in science when doing research or making public health recommendations.

Chris Dall: One last item here, Mike and I bring it up because this is a topic that's at the heart of your forthcoming book. In an article for a website called Think Global Health, the former chief of staff for the Office of Pandemic Preparedness and Response Policy under President Biden wrote that the office is currently without a leader and has essentially been gutted. How concerned are you about this?

Dr. Osterholm: I'm incredibly concerned about this issue of pandemic preparedness and the lack of a response center within the government, as you mentioned, Chris. The question are we prepared for the next pandemic is the theme of my upcoming book, The Big One. And while I'm at it, I want to quickly give listeners a heads up that we have a special episode coming up in two weeks that will focus on the book, which comes out on September 2nd. But let's come back to your question, Chris. Nikki Romanek, who led the Office of Pandemic Preparedness and Response Policy, or OPPR, along with retired Major General Paul Friedrichs, wrote a really thoughtful article summarizing this issue. For context, OPPR was created in 2022 through the Prevent Pandemics Act, which I'll add passed with bipartisan congressional support. According to the now archived OPPR website, the office of more than 20 people was created to be a permanent office in the executive Office of the president charged with leading, coordinating, and implementing actions related to preparedness for and responses to known and unknown biological threats for pathogens that could lead to a pandemic or a significant public health related disruptions in the United States. OPPR will take over the duties of the current COVID-19 response team at mpox team at the white House, and will continue to coordinate and develop policies and priorities related to pandemic preparedness and response. Let me just add a personal comment here that I have known and work closely with Major General Friedrichs for a number of years. He is one of the finest government employees I've ever met in my career. Highly qualified, very committed and wise. And so, from my perspective, this article takes on even more critical concern of note, OPPR was created to fill a critical gap in our country's pandemic preparedness efforts that was clearly evident through the COVID-19 pandemic.

Dr. Osterholm: Let me be very clear. This is not COVID or mpox specific. This is about everything from avian influenza, RSV, influenza, Marburg and whatever novel pathogen may cause the next outbreak or even pandemic. This is about biosecurity, biodefense and the national stockpile. Abandoning this office is doing nothing to move forward and better prepare for future pandemics. It is setting us back so far and quite frankly, preparing us for major failure. I want to share with you a final paragraph in which you summarize the issue at hand, because she captures it perfectly. She writes, If the United States is no longer the first call in a crisis, the global system for outbreak detection and response weakens. This issue is more than reputational. It's practical. When global health leadership fades, threats abroad are more likely to reach Americans at home, with bio surveillance fragmented across agencies. The likelihood of early detection and containment diminishes. The emptying of OPPR signifies more than a staffing gap. It's a hemorrhage of institutional knowledge. OPPR brought hard experience from past pandemics. Interagency coordination, global partnerships, and biosecurity policy. The team understood the system, knew the players, and had the trust of international counterparts. That expertise is gone when the next crisis hits the United States, rebuilding from scratch without the muscle memory, the relationships or the policy playbooks needed to respond quickly and effectively, unquote. I can't say it any better. We have just put ourselves in harm's way in a totally unnecessary decision. Why are we not recognizing how unprepared this leaves us in the future? And it is not a question. Will we see more major infectious disease crises in the future? Absolutely, yes. But now we can anticipate a true total lack of preparedness for that response.

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

Dr. Osterholm: We have an upcoming birthday to celebrate this week. August 26th, 1906. A Polish medical researcher was born who had changed the trajectory of infectious diseases forever after immigrating to the United States at age 15, Albert Sabin settled into life on the East Coast. His uncle offered to pay for his college at New York University under the condition he studied dentistry. After two years of study, Sabin knew he was more interested in medicine, particularly virology. Although he lost his uncle's financial support, he was able to piece together enough scholarships and odd jobs to finish his schooling and then attend medical school at NYU. After a brief stint in England, he joined the Rockefeller Institute for Medical research and honed his expertise in infectious diseases and vaccinology. However, World War Two redirected his focus as he joined the US Army Medical Corps. There, he focused primarily on insect borne illnesses and vaccine development for Japanese encephalitis, dengue, and sandfly fever. Sabin returned to the US after the war to begin vaccine development for a disease reaching epidemic levels around the globe. Polio. Sabin began working at the Cincinnati College of Medicine and Pediatrics to study and develop a vaccine against this debilitating disease. We've mentioned Jonas Salk on this podcast multiple times, and many of you remember him as being a key figure in vaccine development for polio as well.

Dr. Osterholm: To clarify, Salk developed the first inactivated polio vaccine delivered by injection, which was licensed in 1955 and was targeted at preventing paralytic polio. Sabin's vaccine took a different approach. Instead of a dead virus, Sabin's vaccine used the weakened version of a virus delivered via oral drops. This was meant to target the virus in the intestines, where it first replicates before traveling through the bloodstream to later infect the nervous system. Sabin's vaccine could be more easily distributed and administered compared to an injection. A common picture for this period are children receiving sugar cubes that has received drops of polio vaccine on top. Many countries around the world still use oral polio vaccines for ease of use and good performance. Both Salk and Sabin developed incredible vaccines, each of which have their benefits and limitations. But together their efforts have limited polio in most countries across the globe. Public health organizations are working tirelessly to meet a goal to fully eradicate polio from the world. When this happens and we can only hope it will. Albert Sabin will be one of the many people we can thank for that accomplishment.

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

Dr. Osterholm: Well, Chris, I'm sure I could almost do another podcast on take home messages, but I have a feeling our audience is ready to call it for the day. So let me summarize for you the three areas that I think are of note. One is the fact that we are watching a vaccine enterprise in this country under threat, unlike anything that I think anyone could have imagined. There is that possibility we are going to see more and more restricted access to vaccines, and that companies themselves will ask the question, do we want to stay in this business making vaccines, given the challenges that in fact we're witnessing? We cannot overstate the importance of this issue. Elected officials, local officials, the public needs an outcry to say, this is dangerous and we cannot let it happen. This is where again, write your letters to the editors. Talk to your elected officials, whether at the local, state, or national level. Let them know how dangerous the path that we're taking right now with the vaccine enterprise system is. Number two, is COVID still in the not sure territory for me. And what I mean by not sure is we are going to see an increase in cases, I think, associated with the new variant as well as some waning immunity.

Dr. Osterholm: But what will that increase in cases look like? Some people want to continue to call it a surge. I don't think we'll see a surge. In other words, a big increase in cases I think we will surely see over the next several weeks increasing cases. This also, for me, is an issue where I would want to consider getting my booster dose of COVID vaccine if I'm older, if I'm immune compromised. I think also for children who have not yet seen this virus for the first time, you'd rather have it be vaccine than the virus itself. And again, we have seen an increase in severe illness in kids. Finally, the third one is one I didn't really cover, but I wanted to close with this one because it's always an annual issue that comes up. If you've been watching your advertising world out there, whether it be TV, radio, or even print, you'll see that the influenza vaccine is being pushed heavy right now with the idea that seasonal vaccine is now available. Go get your shot. Well, I don't agree with that and I haven't agreed with that for years. I understand why, from a standpoint, we can't wait until the last minute to get everybody vaccinated.

Dr. Osterholm: But we know that influenza vaccine loses its protection over time. So, in some cases, 6 to 8% per month. Well, if the real flu season is going to be till January or even December, why get vaccinated in August? It surely coincides with going back to school or things like that. But we have literally no flu activity of note in this country now, and all you're going to do is have a vaccine protection that wanes over time. I always time my vaccine to when flu activity begins to pick up on a local area. And we'll let you know that if you follow this podcast, we'll tell you influenza activity is picking up. Now's the time to get your dose of vaccine. You know, 2 to 3 weeks before you really are at increased risk for getting influenza. Actually, I don't want anyone to come away thinking I'm anti influenza vaccine. Hardly. I get my shot every year, but get it closer to when you're going to really be at risk and you have more protection because of that, as opposed to getting vaccinated now, encountering the virus in January and realizing, wow, I lost some of my horse power because of waning immunity.

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

Dr. Osterholm: Well, this one was a hard one to identify just by the nature of what we discussed in the dedication and the challenges we're seeing in terms of vaccine preventable diseases in this administration. So, at a time when we in public health surely recognize a renewed sense of fear in what we do and how we do it, just by the very everyday roles that we play in our communities. I wanted to cover something that basically empowers us at a time when we're not feeling empowered. And this song is really dedicated to all the public health people out there, all the people who are involved in the care of our children and vaccines. It's by Andra Day, the R&B singer. It was issued in 2015. It was a Grammy nominated hit. It's rise up, you're broken down and tired of living life on a merry go round. You can't find the fighter, but I see it in you. So, we're going to walk it out and move mountains. We're going to walk it out and move mountains. And I'll rise up. I'll rise like the day. I'll rise up. I'll rise unafraid. I'll rise up. And I'll do it a thousand times again. And I'll rise up high like the waves. I'll rise up in spite of the ache. I'll rise up and I'll do it a thousand times again for you. When the silence isn't quiet. And it feels like it's getting hard to breathe. And I know you feel like dying. But I promise will take the world to its feet and move mountains. Bring it to its feet and move mountains. And I'll rise up I'll rise up like the day.

Dr. Osterholm: I'll rise up, I'll rise unafraid. I'll rise up. And I'll do it a thousand times again. For you. All we need. All we need is hope. And for that we have each other. And we will rise. We will rise. Andrea De, thank you very much for joining us again. I hope we were able to provide you with the kind of information that you're looking for a lot of challenges these days, but I have such great confidence in the public health community and what it can do. And even in this period where it is under attack, literally and figuratively. So please, please know that you know, if you're feeling the fear, if it's if it's compromising your ability to do your job or even in your personal life, seek help. Public health community start organizing the discussion groups that we all could be a part of to talk about how we feel. Call it group therapy. I don't care what you call it, but we need to talk about this and we need to acknowledge it, and we need to embrace it. And we need not to be afraid to own it. This is a tough time. Now is the time for us to help each other. All I can say is please be kind. His toughest things are right now. Be kind. Be thoughtful. Think about what's ahead of us. We have all of our kids’ grandkids going go to school soon. Another new school year. What a wonderful time to celebrate the youth of our world. So just be kind. Thank you very much.

Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoyed the podcast, please subscribe, rate and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease news by visiting our website. This podcast is supported in part by you, our listeners. If you would like to donate, please go to cidrap.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Meredith Arpey, Leah Moat, Emily Smith, Clare Stoddart, Angela Ulrich, and Mary VanBeusekom.