Episode 192: Ice Cream and Shark Attacks

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. If you're a person who's interested in getting an updated COVID-19 shot, and you're a little confused about whether or not you can. You're not alone. On August 27th, the Food and Drug Administration approved the updated shots for everyone aged 65 and over, and for those under 65 with underlying health conditions that put them at risk for severe illness. A more limited approval than we've previously seen for Covid vaccines. But that's just part of the story. In some states, pharmacists can't give vaccines to people until they've been recommended by the Advisory Committee on Immunization Practices, which meets today and tomorrow. At this point, it's unclear what the ACIP will recommend. It's possible the recommendations could be even more limited. And if you're under 65 and don't have underlying health conditions, it's unclear if an off-label prescription from your doctor will be enough for your insurer to cover the shot. At this point, there are a lot of questions, and we're going to try to fill you in on what we know and don't know on the September 18th episode of the podcast. We'll also provide a preview of the upcoming ACIP meeting to discuss the ongoing upheaval at the Centers for Disease Control and Prevention, provide updates on COVID-19 and measles, and answer an ID query on Chagas disease. We'll also bring you the latest installment of This Week in Public Health History.

Dr. Osterholm: Thanks, Chris, and welcome back to everyone in the podcast family. It's good to be back with you again after kind of a hiatus, having had our last podcast be that discussion about the new book that we launched. So, it's really great to be here for all of those who might be joining us for the first time. I hope we're able to provide you with the kind of information you're looking for, and that you'll come back and visit us again. And I just have to say to all of the listeners out there who continue to provide us with such important feedback about what we're doing, what we're missing, what we're getting right. What's most helpful to you? Because that in itself right now is a very important part of this. So, thank you. It's good to be back with you again. As they say, back in the old days, this feels like the old bands back together. Before we get started, the topics that Chris previewed. And needless to say, there's a lot of them. I want to take this dedication segment to reflect on the very real and growing concerns families are facing as they send their children back to school. This episode is dedicated to those families and to the children themselves, navigating a school year that feels heavier than it should. For families with young kids, this season is usually about meeting new teachers, picking out school supplies, juggling extracurriculars, and adjusting to the nightly homework routine.

Dr. Osterholm: And while a new school year always brings on its own new set of challenges, this year feels especially burdened by fear, uncertainty and pressure. We know many parents and caregivers are living with heightened anxiety about gun violence, especially in the wake of the recent shooting at Annunciation Catholic School here in Minneapolis and other tragic incidences on school grounds across the country. I've heard from many that this year's rise in measles cases has them worried about declining childhood vaccination coverage and classroom exposure. And of course, there is the confusion over what fall vaccines are recommended for kids and how accessible any of them may be. Families are also carrying worries about their children's mental health. School funding that continues to fall short of the growing needs, and the powerful influence of social media in shaping young people's behaviors, beliefs and self-worth. It's enough to keep any parent or grandparent up at night. To every family facing these realities, we see you. You are not overreacting. You are not alone. The daily choices you make to keep your children safe, healthy and hopeful are acts of deep love and great strength. I often say this because it's the truth. The work that I do is motivated by my own grandchildren and my hopes for their future. Whether you work in healthcare, education, policy or are simply showing up each day for your own family, your efforts matter. So be kind. Spread peace and love and take action because every child deserves a safe, healthy and bright future.

Dr. Osterholm: Now let's move to that lighter part of the podcast. The one for some of you who'd like to excuse yourself for 60 seconds here. Sunlight, I tell you. We're on the wrong side of it right now, but I still enjoy what we can get. Today in Minneapolis Saint Paul. Sunrise is at 6:55 a.m. Sunset is at 7:17 p.m. That's 12 hours, 21 minutes, and 39 seconds of sunlight. We're losing sunlight at the maximum amount throughout the entire year. Today at three minutes and six seconds a day. And then it'll stay at that level of light loss every day through October 2nd, when then it goes to three hours and five seconds. And of course, then at that point the rate of loss will slow down until December 21st, but it will still keep accumulating. And to our dear friends in Auckland, New Zealand, at the Occidental Belgian Beer House on Vulcan Lane. Yep, you're on the upside of it. Today. Your sunrise is at 6:16am. Your sun sets at 6:13pm. You have 11 hours and 57 minutes and two seconds. You're gaining sunlight at two minutes and 19 seconds a day. And just this week alone, you'll be over 12 hours. So, to all of you who are keeping track of that sun, just know that. Yep, we're all going to be about the same pretty soon around the world. But as we get darker, we look forward to our colleagues from New Zealand sharing their sunlight with us.

Chris Dall: So, Mike, let's begin with the status of the updated COVID-19 vaccines. I laid out a brief sketch in the intro, but the issue right now is in the 16 states where pharmacists can't give out vaccines until they've received ACIP approval. And we've heard many reports of people being unable to get Covid shots. Several states are trying to address the issue, but there are still a lot of unanswered questions. Can you fill us in on some of the details? And just a quick note for our listeners. We're recording this podcast before the ACIP meeting, and some things might change based on what comes out of that meeting. Mike, go ahead.

Dr. Osterholm: Well, Chris, let me just start out by being honest and saying with great humility, I'm not sure what's happening with these vaccines. As you just noted, we likely will see major decisions being made at this ACIP meeting today and tomorrow that will have real influence on what happens. But let me try to give you my best shot at it. At this point, as you mentioned, there are still so many questions we simply don't have answers to. So, there's a lot of confusion and uncertainty with all of this, which if you're trying to convince people to get vaccinated, it is not at all what we want. On the other hand, if you're trying to keep people from being vaccinated, it's exactly what you're looking for. Just by way of background, and you laid it out very nicely in the introduction. Chris, the FDA did approve the updated Covid vaccine at the end of August. However, that approval was limited to people 65 years and up, or those with certain medical conditions that placed them at risk. Well, that is a significant shift from the previous guidance where basically anyone six months of age and older could receive a Covid vaccine. Remember, we're not talking about mandating vaccine, we just want to make them available. So, on its face, that was the decision that essentially reshaped Covid vaccine guidance for millions of people. And with that, of course, we're seeing a lot of questions and challenges when it comes to access and availability. For example, if you're under age 65 and otherwise healthy, can you receive the updated vaccine if in fact you want to? What does it mean if you're located in one of those 16 states you mentioned where pharmacies can't administer vaccines before they received ACIP approval? Again, so many questions.

Dr. Osterholm: Sometimes the answer is it depends. On top of that, it's not just the issue of can you get the vaccine, but who will pay for it. The number of important factors that come to play there. Specifically what state you're located in. Do you need a prescription? Can it be off label? Will the cost be covered by insurance? Unfortunately, in some cases, people who want a Covid vaccine dose are being turned away, specifically pregnant women. So, we're seeing very real impacts with this. And again, we'll make every effort to keep you updated on that. So now in response to not only this, but everything else that's been happening at the federal level, we're starting to see certain states issue orders or even join together in alliances in an effort to maintain vaccine access. In fact, right here in Minnesota, there was a recent executive order issued by the governor that basically instructs state agencies to work with insurers and payers to limit costs as a potential barrier. The order also talked about ensuring that pharmacies and providers across the state can provide the vaccine without needing a prescription. In theory, this could help mitigate some of the challenges we've talked about. But I have to admit, even here in my home state, I'm still confused about what has happening even here in Minnesota.

Dr. Osterholm: We have a lot more that we have to learn before we can give you the exact information. So, as you can see, there's a lot of nuances with this issue. I think it's still unclear in many states what will it actually mean or look like in practice to be able to get a vaccine with a lot of these issues, there's a laundry list of challenges, whether it's technical, legal, logical, economical or all the above that crop up and need to be resolved. So, it's still a lot of wait and see. And that's basically the case across much of the US right now. Unfortunately, as we wait to get answers, I think we're only going to see more and more people elect to go without Covid vaccine. And if the reason for this is that the guidelines are just too confusing, or being turned away by a pharmacist unexpectedly, or concerns about the cost that didn't previously exist, then this is a sad, sad commentary on the state of public health and vaccines. But again, this is exactly what I believe Secretary Kennedy is trying to achieve. I'm sorry we're all in this place. We are. And right now, at this point, everyone should have access to the Covid vaccine if they want it. The question is, how many barriers will people have to encounter to be able to get vaccinated?

Chris Dall: So, Mike, part of the issue here is that the FDA typically provides broad approval for vaccines. Then the ACIP has their meeting. They decide who the vaccines should be recommended for, and then the CDC typically adopts those recommendations. So, am I right here that the FDA in this case has to some extent usurped the role of the ACIP?

Dr. Osterholm: Chris, you nailed it. There's a lot riding on this current ACIP meeting being held today and tomorrow. And given the capricious nature of some recent federal vaccine decisions, there is considerable apprehension about the outcome of this meeting and what it means in terms of the FDA and the CDC's roles in making sure we have safe and effective vaccines available. In fact, late last month, Senator Cassidy called for this meeting to be postponed, saying any recommendations stemming from this should be rejected as lacking scientific legitimacy. That's his words, not mine. As you know, the FDA typically broadly approves vaccines based on their safety and effectiveness. And the CDC Advisory Committee on Immunization Practices, or ACIP, then decides for whom these vaccines should be recommended. According to the agenda of the meeting today, in addition to Covid vaccines, ACIP is discussing and may vote on recommendations for hepatitis B vaccine and the measles, mumps, rubella and varicella, or MMRV vaccines, including a presentation on what the agenda says will be on fever and seizures following MMR vaccination. Again, we'll provide you with an update on that by Monday. Now, I just want to note that we actually have anticipated what's going to happen at the ACIP meeting, and I'll be coming to this more in detail in a moment, but on September 15th, we actually published a viewpoint from the Vaccine Integrity Project that's on our website that anticipates what will happen at ACIP and what that means.

Dr. Osterholm: This past Monday, following much speculation about whether more science dubious members would be added to the ACIP to sway its decisions, the HHS and CDC announced the appointment of five new members. At least three of these new appointees are clearly vaccine critics, but HHS hasn't said whether they will participate in the meeting. Adding to the concern in an atypical move that would be viewed as observing the role of ACIP, the FDA will present information at this meeting to attempt to link Covid vaccine to 25 pediatric deaths that were submitted to the federal reporting system, VAERS. I will talk more about this report in a moment, but for now, I'll say that I'm incredibly concerned about what it could mean to Covid vaccine access, especially for children, if people actually buy into this falsehood of these deaths. The bottom line is that we don't know yet, based on this report, as well as the beliefs of the new and existing ACIP members and the other planned presentations, whether the ACIP will officially recommend restricting access to Covid or other routine childhood vaccinations. Such a Non-evidence-based decision could further feed confusion, undermine already eroded trust in science and public health, and reduce childhood vaccine access for low-income families. If history is any indication, and amid the recent personnel shakeup at CDC, access to these vaccines may be at very high risk. As you may remember, HHS Secretary Robert F. Kennedy Jr., without input from vaccine experts, announced in June that Covid vaccines were no longer recommended for healthy children and pregnant women.

Dr. Osterholm: By the way, that was done on a 58 second X video. And then late last month, the FDA approved updated versions of the vaccines, but released narrower approvals for updated Covid shots. The new approvals restricted Covid vaccine use in adults younger than 65 to those with underlying medical conditions, and limited the use of Pfizer's Covid vaccine to children older than five years. Removing the only Covid vaccine approved for all children in the US. I gotta tell you, that sure sounds like they're somehow restricting vaccines to the public. Even though Mr. Kennedy promised in his confirmation hearing he wouldn't do that. This decision was children leaves younger kids vulnerable to the virus, which presents the highest risk to those aged 6 to 23 months. Shortly after, the CDC updated its immunization schedule to partly reflect Kennedy's position, it now recommends Covid vaccinations for most adults and says parents of kids six months to 17 years should discuss the benefits with the health care provider. Well, how many people in this country have a routine health care provider? They can just get in and have this discussion with. It's going to be another barrier. The moves earned backlash from public health experts, medical societies, physicians, concerned parents and adults worried they won't be able to get vaccinated against an infectious disease that could sicken or kill them.

Dr. Osterholm: In the following days, organizations such as the American Academy of Pediatrics broke with the CDC recommendations, issuing their own guidelines. In August, Kennedy announced the dismantling of the US mRNA vaccine development programs, the same innovation that allowed rapid scale up of COVID-19 vaccines during the public health emergency. And by the way, let me mention that saved likely over 3 million lives. The Biomedical Advanced Research and Development Authority, or BARDA, terminated just under $500 million in mRNA vaccine development contracts. The move hobbled our ability to respond to future pandemics with timely vaccine development. A tragedy. Today's ACIP meeting will be the second one with the all-new membership, which includes several vaccine skeptics Kennedy appointed after firing the 17 sitting members in June at the first meeting in June. The new members made controversial announcements. First, they said they planned to revisit recommendations for hepatitis B and the MMRV vaccines, which are recommended for young children. They also recommended that Americans receive flu vaccines only in single doses that don't contain the mercury based preservative thimerosal, despite extensive research finding it presents no health risks. These are perilous times for both access to lifesaving vaccines and public health in general. We can only hope that the ACIP will make right decisions today to guarantee vaccine access for people who need and want it again. I don't trust it.

Chris Dall: All right. So, let's dig into that presentation by the FDA at the upcoming ACIP meeting that you mentioned. So, The New York Times and Washington Post both reported last week that FDA officials will present data at the meeting that allegedly links COVID-19 vaccines to more than two dozen pediatric deaths. And that presentation is reportedly going to be based on information from the Vaccine Adverse Event Reporting System, or VAERS. Mike, can you remind our listeners what VAERS is and why information from VAERS needs to be handled carefully?

Dr. Osterholm: Chris, as I alluded to earlier, I'm extremely concerned about what this report of VAERS data could mean for vaccine access. And not because of the data itself, but because of how Kennedy's ACIP might interpret it. Before I get into my specific concerns about this report, I want to take a step back to talk about what VAERS data is and what it really means. As you mentioned, Chris VAERS stands for Vaccine Adverse Event Reporting System. It was created in 1990 to meet the reporting requirements laid out by the National Childhood Vaccine Injury Act of 1986, which created the compensation system for which those impacted by adverse events related to vaccines could be readily compensated. It simply created an alternative to the traditional litigation process to protect both consumers and manufacturers. VAERS collects data on adverse events that occur following vaccination. What you decide to call an adverse event is really up to you. Anyone can make a report to VAERS if they believe they've experienced some type of unintended health problem following a vaccination. Additionally, providers are required by law to report certain events, including death, that occurs following a vaccination, regardless if they believe the vaccination to be the cause. The catch all system for reporting, including unverified and potentially duplicate events reported by individuals and providers, creates an incredibly sensitive, but not at all a specific way of gathering information. In other words, this is meant to have a very large net, so nothing that could be an adverse event could get through.

Dr. Osterholm: And this system is monitored regularly to see if, in fact, there might be evidence of something happening that we otherwise couldn't have picked up. VAERS will raise red flags and when investigated further, will allow us to understand. Is there something going on? This is a way to prevent even rarer side effects from flying below the radar. The unfortunate trade off to this, however, is that the VAERS report database is filled with cases of people's reported health problems that have not at all been a direct result of vaccination. And remember, association does not mean cause and effect. Do you know that there's an association between the number of shark attacks in the United States and the consumption of ice cream? Well, why is that? Is it cause and effect? Ice cream consumption makes you more likely to get attacked by a shark. No, it's because it's both are summertime events. And so, when you see shark attacks go up, it's also in more ice cream is sold. VAERS is very much like that. You can't take and assume a one piece of data tells you a cause and effect. To give you an idea of VAERS working at its best, I'll use the example of Johnson and Johnson's Covid vaccine.

Dr. Osterholm: As many of you recall, back in 2021, Johnson and Johnson had a single dose Covid vaccine on the market. But the administration of this vaccine was paused after six reports of thrombosis with thrombocytopenia syndrome, or what we call TTS, a rare but serious condition that can cause blood clots that are sometimes fatal. Out of the estimated over 18 million people who received the J&J vaccine, ultimately 60 individuals were found to have developed TTS, nine of whom died. This is obviously a risk that one must consider, but look at it this way it's much lower, for example, than the risk of TTS associated with taking oral contraceptive pills. Just to put it in context, I'm not minimizing any of the serious illnesses or deaths that occurred. But in real life, every day, women who take oral contraceptives are at a much higher risk of developing TTS. So, in fact, this J and J vaccine issue demonstrated what it was that this system could do and how it could pick it up very early. The follow up research to the initial VAERS reports concluded that the rate of TTS is higher than what we'd expect in the population, meaning there was a link between vaccine and TTS. Administration of the J&J vaccine was paused and later resumed following thorough investigation, but with the recommendation it should only be used for those who cannot or will not take a Pfizer or Moderna vaccine.

Dr. Osterholm: It was later discontinued entirely in June of 2023. Those 60 TTS cases that were identified, which led to changes in recommendations of vaccine, were identified through the VAERS system. This truly is an example of the system working at its best to identify even very small risks associated with our vaccines, ensuring that we are never compromising on safety. However, not all VAERS data are created equal. As I mentioned, anyone can submit reports to VAERS, which means that they're often misguided and sometimes even ill intended and outright fraudulent. Let me give you some examples. One VAERS report claims that the vaccine turned the gentleman into an incredible Hulk. Other complaints of dodgeball injury that occurred in a gym class in a child who was vaccinated days earlier. Others have claimed that vaccines have caused mites, fleas and bedbug infestations in their houses. And then there's the third category of VAERS reports those made in good faith by concerned individual physicians who are required to report certain events but that still are only coincidences, are associations, and not signs of true elevated risk of vaccination. This often is the case with deaths reported to VAERS, as physicians are required to report any deaths following vaccination, regardless of whether the vaccine was a probable potential cause. For example, there are VAERS reports of children who have died in car accidents following vaccination simply because they occurred during the required reporting window.

Dr. Osterholm: This is why we have additional thorough safety studies for our vaccines, to ensure that we understand the difference between deaths that occurred following vaccination due to chance alone, and those that may actually have a signal of an increased risk for an adverse event. The tragic reality is that people die every day, and because people also get vaccines every day, some of them are going to die within a fairly short time period after getting vaccinated. But that doesn't mean the vaccine was the cause of death. That is why the VAERS data, while useful, needs to be interpreted with a lot of caution and scrutiny. My concern is that this administration will not take the rigorous statistical approach needed to properly approach these data, and that they're likely to make their conclusions about these 25 pediatric deaths before they even started their analysis. The bottom line is, I don't think we can expect honest, rigorous science from this report. And I think it will paint an accurate picture of the safety of these vaccines. Oh, yeah, it will make headlines. 25 kids died from Covid vaccine. We will keep you updated after this report is released. But in the meantime, please be prepared to interpret these results with a very, very healthy amount of skepticism. Using VAERS data is frankly, just intellectually dishonest.

Chris Dall: And Mike, as you noted earlier, CIDRAP's Vaccine Integrity Project does have a viewpoint on this, correct?

Dr. Osterholm: Yeah. Thanks, Chris. Actually, we published this on September 15th this past week, and we have a link to it in the show notes. I would urge you to go and take a look at this viewpoint, because we really try to flesh out the issues that are going to be before the committee, as today and tomorrow, what that might mean in terms of public policy statements. So, as you know, the Vaccine Integrity Project, part of CIDRAP is doing everything we can to keep our audiences in the public informed, as listeners know. In August, we hosted a live streamed webinar featuring presentations from four esteemed professionals covering our findings from an evidence review of the safety, effectiveness and epidemiology of Covid, RSV and influenza vaccines. Since then, our team has been working to finalize the late stages of our review, and we will be publishing all of the results in their entirety. Chris, let me just spend a minute summarizing what this new viewpoint in the VIP program that we published this week has to say about where we're at. First of all, there were four major points that we addressed. One, as I just discussed a moment ago, reports to the VAERS system do not prove causation. VAERS that incredibly useful surveillance system, but interpretation of the data should come with the understanding that the data is subject to extreme bias. Second, and an important point. All evidence is not created equal. The current administration within the HHS and a new roster of ACIP members has chosen to abandon the rigorous evidence to recommendation framework, leaving major questions about the integrity of their claims.

Dr. Osterholm: Any information not supported by peer reviewed literature or vetted by career scientists should be approached with caution, if not outright rejection. Yet that's going to happen today and tomorrow. Third, we want to again emphasize that serious adverse events following Covid mRNA vaccines are very rare for children, pregnant women, healthy adults and older adults. Despite what some vocal anti-vaccine advocates would like you to believe. Millions of people have received these lifesaving doses without any issues and gain robust protection against serious illness, including hospitalization and death. The benefits still far outweigh the risks here. That's why I get my shots. Finally, it's becoming clear that the next vaccine under the anti-vaccine microscope is the combination measles, mumps, rubella and varicella vaccine or MMRV. When it comes to the MMR vaccine, frankly, what's old is new again. In 2008, there were safety signals identified by the CDC for an increased risk of febrile seizures among children 12 to 23 months of age who were vaccinated with this vaccine. The ACIP swiftly responded to these concerns and changed their recommendations accordingly. Though parents still have the option to have their child receive this combination as opposed to receiving the MMR and varicella separate shots, there haven't been any new developments on the associated risk, so rehashing its use on the federal level is redundant and it just tries to cloud the situation with confusion.

Chris Dall: I want to turn now to what's going on at the Centers for Disease Control and Prevention. Since our last regular episode, we've seen new CDC Director Susan Monarez fired less than a month into her job by President Trump, reportedly for refusing to agree to HHS Secretary Robert F Kennedy Jr's request that she approve all ACIP recommendations ahead of time. Her firing was followed by the resignation of three top CDC officials. Mike, how concerned are you about this chaos at CDC?

Dr. Osterholm: Well, Chris, I'm extremely concerned, and I can't state that strongly enough even when I say I'm very concerned. It's kind of like saying the Grand Canyon's just a big ditch. I'm extremely concerned. I think anyone who wants or expects science-based information coming from our nation's leading public health agency should be very concerned, too. Right now, this is an agency that's not just in turmoil, but it's also a house burning down. Clearly, I think the horrific shooting that happened there just last month is still front and center in everyone's minds. And of course, that alone is deeply troubling for so many different reasons. But now, on top of that, we're talking about a situation where the CDC director, Susan Monarez, according to her own account, was fired just 29 days into her tenure for ultimately refusing to preemptively rubber stamp ACIP recommendations about vaccines. In an op ed published in The Wall Street Journal, she stated that she was being pressured to do so and wouldn't agree to do it. Now, typically, the CDC director has the power and discretion to adopt or deny ACIP recommendations, and that was her expectation, reviewing recommendations thoughtfully on a case-by-case basis and ensuring that they are steeped in legitimate science and data. But in her own words, she was, quote, fired for holding the line, unquote.

Dr. Osterholm: Think about that. She was fired for following standard protocol and prioritizing science over political ideology. In response to her termination, three senior officials at the CDC also resigned. These are individuals with decades of experience in leadership and in statements and follow up interviews. They basically said it was clear to them that ideology had overtaken science as a driving factor, and they could no longer serve at the agency. They also referenced various examples of Secretary Kennedy forgoing briefings by CDC experts, making major vaccine policy changes over social media without consulting or even notifying CDC staff ahead of time, and elevating vaccine opponents to high level positions. Finally, in a truly unprecedented move, nine former CDC directors who served both under Republican and Democratic administrations wrote in The New York Times that Mr. Kennedy's actions are, quote, unlike anything they've ever seen at the agency, unquote, and actively endangered the health of every American. These are individuals I know well who really represent the best and the brightest when it comes to public health. I can tell you right now to see this kind of public, bipartisan consensus from so many former leaders of the CDC demonstrates how serious this entire situation is. So, to your question, Chris, again, I'm extremely concerned about what's happening in CDC, and I worry a lot about what this all means moving forward.

Dr. Osterholm: The ripple effects are huge. State health departments rely on CDC. Providers rely on CDC. Vaccine manufacturers rely on CDC. Even international partners rely on CDC. When they can't trust the agency, we end up exactly where we are now with states and medical societies going their own way, because they no longer believe the federal government is providing reliable direction. So, this is not just an internal chaos issue. It's a fundamental crisis of leadership at CDC, and it's a crisis for the world. It has real consequences for vaccine uptake, outbreak preparedness, and the ability to protect Americans from emerging health threats. And let me add with one last caveat. As critical as I am about CDC right now, please understand there are many outstanding professionals who have spent their lives doing what they can to protect the public's health, who are still there. They are expert, and if we could actually get their input, their comments, their statements, I would completely change my opinion. But right now, what we're hearing from is the appointed political leaders whose statements are not science based. And therefore, unfortunately, we just can't trust the information coming from the CDC or the FDA.

Chris Dall: With all the discussion about Covid vaccines. It's a good time to talk about the latest COVID-19 data. Mike, what is Covid activity looking like around the country right now?

Dr. Osterholm: Activity has actually been documented behind a number of areas in the country. However, there have been some reports suggesting activity may have peaked for this wave. If you want to call it that, the national wastewater concentration is high and increasing, and concentrations are across every region. The Midwest and Northeast are looking moderate, while the West is high, the South is very high. Looking at the state level, wastewater concentrations are considered very low in two states New Mexico and Missouri. Low in five. Moderate in 15, including Minnesota. High in nine and very high in 18 states in the District of Columbia. Now, emergency room visits are still considered low and seem to be starting to decline, with 1.5% of ED visits last week resulting in a positive Covid test. This is down from 1.7% the previous week, which was the highest it had been in a year. Weekly deaths are increasing, with about 250 Americans lost to Covid the week of August 16th. This comes after a two-month period of weekly deaths below 200. These are someone's loved ones, and therefore it's very hard for me to celebrate about only 250 deaths. Based on what I just shared with you. You might be confused and say, wait a minute, is it going up or is it going down? Well, remember that we can actually have activity occurring with virus circulating in the community that could be coming down from where it was 2 or 3 weeks ago.

Dr. Osterholm: To become infected and actually be seen in an emergency room is a delay of a few days. But more specifically, deaths often are delayed 2 to 3 weeks. So, the fact that we're still seeing deaths come up actually may be a reflection of what was happening in early August, whereas right now the wastewater data is more likely to tell us exactly what's happening with the virus in our community. What I take away from all of this is that we really have hit this lower-level peak, not a big peak like Omicron or Delta, but this lower-level peak and that in fact we are starting to see the activity come down. Based on this, I would predict within the next 3 to 4 weeks the number of deaths will also start coming down as again, that delay will catch up and will be actually reporting out deaths from this time period now in the middle of September, in somewhat of an unexpected twist. Chris, for the first time since the end of June, we have a variant update from CDC. I do want to note that while they updated their variant proportions, they also changed their reporting from two-week periods to four-week periods.

Dr. Osterholm: In doing this, they removed a significant portion of the existing variant tracking data. But back to the newly updated variant picture. This new update shows that for the four-week period from July 7th through August 2nd, XFG accounted for 60% of the US cases, while LP.8.1 and NB.1.8.1 each accounted for 15%. When we last reported new variant proportions from CDC at the end of June, XFG accounted for only 14% of the variant. Now again, it's up to 60%. What this really tells us is we're continuing to see the evolution of this virus through the different variants that come in, seem to take over a certain portion of the population and then recede. To me, there's nothing significant here suggesting that we're going to see more severe illness or that we're going to see a new surge in cases. It's really, I think the virus is doing what it's going to continue to do in the future. So, while we're in a much better place than we've been in previous peaks, and we're seeing some signs that the activity may have peaked, I don't think we can say with certainty that we're on the tail end of the peak yet. Could be getting closer. Is this virus has proved itself unpredictable time and time again. So, hang on for a little longer, and we'll continue to keep you updated on what you must know.

Dr. Osterholm: These data still give me reason to tell you to get your Covid shot. If you've been out 2 to 3 months, depending on whether your last exposure was due to illness or it was actually due to a vaccine. I also want to just note that I've been asked a number of times in the last two weeks, should I be getting my flu shot? Now everybody's advertising in the pharmacy world. Come in and get your flu shot. We know that the flu vaccine is most effective when it's given close to when the time, you're likely to be exposed. In other words, over time, you have waning immunity from the vaccine protection. And right now, we're seeing really zero flu activity in this country. When we start seeing an increase in that flu activity, I'll tell you now is the time to get your dose. But I wouldn't yet. I'm waiting on mine. And I could easily see going into mid late October, maybe even a little longer before I get mine. So, if you've gotten yours already, good. You've gotten it. You'll start to see a reduction in protection over time. I wouldn't worry about that. But if you have the opportunity to get one closer to real flu season, you'll be better off.

Chris Dall: The increase in US measles cases has slowed significantly since the spring, but there have still been 1454 confirmed cases this year, the highest number since measles was declared eliminated in the US in 2000. Mike, is it possible we could see an uptick in measles again now that kids are back in school?

Dr. Osterholm: That's certainly possible, Chris. In the US, we saw a small uptick in weekly measles cases during the month of August. We know that multiple recent cases in Utah were exposed at a high school cycling league race on August 16th. There are over 2000 people in attendance, and the state epidemiologist recommended all participants check their MMR vaccination status. On September 11^th, it was reported that a school aged child in Los Angeles tragically died of a rare complication from measles, subacute sclerosing panencephalitis, or SSPE. This condition is a progressive brain disorder that causes seizures and other neurologic symptoms and is fatal in almost all cases. SSPE can occur years after the initial infection and recovery. In this case, what happens is the measles virus actually incorporates itself into the nervous system of the host, much as some of the other viral infections do up to several years later. We then see the onset of SSPE with this residual virus in you. There is no known cure or effective treatment. It's rare about 1 in 10,000 people who develop measles will later develop SSPE, but the risk is higher for those infected with measles and infants, where the rate is about 1 in 600 infection. In a recent press release, Los Angeles County Health Official Doctor Muntu Davis stated this case is a painful reminder of how dangerous measles can be, especially for our most vulnerable community members. Vaccination is not just about protecting yourself, it's about protecting your family, your neighbors, and especially children who are too young to be vaccinated. Among the 1454 cases in the US so far in 2025, 92% have been unvaccinated or had an unknown MMR vaccination status, according to the CDC data. The MMR vaccine is still our best defense against measles virus, and we should all do our part to protect the most vulnerable in our communities.

Chris Dall: Mike, we should also note that Canada has seen more than three times the number of measles cases compared with the US. Do you have a sense of why the Canadian outbreak has been worse than what we've seen here?

Dr. Osterholm: Chris, this podcast is obviously just an audio format, but I really wish I could put up a graph for our listeners just to show how steep and concerning this rise in measles cases in Canada truly is. As of the latest reporting from the week of September 15th, Canada has reported 4902 measles cases in the country and the number continues to grow. Cases are concentrated in Ontario and Alberta, but ten out of the country's 13 provinces and territories have experienced cases this year. I also want to remind you to put this number of 4902 into context. Canada only has only 40 million people compared to the United States 340 million people. So, from a rate standpoint, you can see just how absolutely high these rates of measles actually are. I don't think there's a single straightforward answer to why the Canadian outbreak has taken off more than in the US. One major factor driving outbreaks of vaccine preventable diseases are these smaller pockets of under vaccination. We've discussed this at length in the podcast before. That idea your heads in the freezer, your feet are in the oven. On average, your temperature is just right. You know, you may have 92% of your state's children vaccinated, but there's communities where less than 40% are vaccinated. It's a real challenge. One key factor, again, in addition to these pockets is that the virus is highly infectious when introduced. It takes off like wildfire. In the US, this often occurs in communities that are relatively self-sustaining, as was the case in the largest outbreak from this year in West Texas. Therefore, once the full community is exposed, the outbreak eventually dies down. What appears to be different in Canada is the presence of a super spreader event in 2024, in New Brunswick, in which individuals then dispersed and brought cases to numerous unvaccinated pockets across multiple provinces, which introduced the disease to their own under vaccinated subgroups in the community, and it continued to spread.

Dr. Osterholm: A key point I want to make, Chris, is that this situation in Canada is not out of the realm of possibility for us in the United States, with decreasing vaccination rates across the country. It is completely possible, perhaps even likely, that measles is introduced at the wrong place and at the wrong time and as a result, takes off in this country as well. Increasing vaccine hesitancy and refusal just adds kindling to that possible fire. And Chris, I also want to add that this isn't uniquely a North American phenomenon. We've covered this on previous episodes of the podcast as well, but it's worth a reminder that Europe has also seen substantial decreases in measles vaccination and increasing outbreaks. In 2024, the European Center for Disease Control reported more than 35,000 cases and 23 deaths from measles in that region. While most cases in the region are occurring in Eastern Europe, where in countries like Romania, recently elected officials across three political parties all espoused anti-vaccine views, the western part of the continent has not been spared. France has also experienced a notable increase in measles, including two deaths. Just for a rough comparison, the EU has a population of approximately 450 million, compared to the United States 340 million. If the US experienced a similar increase in cases. That would equate to more than 27,000 reported cases in the country each year. An entirely preventable disaster. It is truly astonishing how quickly these things can occur in a country that eliminated measles spread entirely just 20 years ago.

Chris Dall: Now it's time for our ID query. And this week we received an email from Glenn about Chagas disease. He wrote: Chagas disease, long considered only a threat abroad, is established in California and the southern US. Can you share more about the risks?

Dr. Osterholm: Well, first of all, this is a disease that suddenly is getting some real notoriety. This past week, the CDC actually published a piece in its Emerging Infectious Disease journal on Chagas disease, and it was covered by Doctor Sanjay Gupta on CNN. But thank you to our listener for the question. Chagas disease is caused by a parasite called Trypanosoma cruzi and is found in 21 countries across North and South America. It's most commonly spread via a vector with a cheeky name, the kissing bug. Unfortunately, their kiss is actually a bite. The parasite itself can infect a human host through the bite wound, or if the bite is scratched and the same hand touches your eyes, nose, or mouth. There are two phases of Chagas disease acute and chronic. Most people, about 70 to 80%, don't show symptoms, but those who do enter the acute phase may have a notable bite mark, swelling in one eyelid, fever, headache, cough, and abdominal pain. Early treatment is crucial to prevent progression to the chronic phase, which can cause serious damage over time, especially to the nervous system and heart. About 30% of chronic cases develop these severe heart issues. As important as it is to treat people in the acute phase, Chagas disease often goes undiagnosed and disproportionately affects those with low socioeconomic status. Unfortunately, these factors have contributed to the continued spread globally. That brings us to Glenn's question.

Dr. Osterholm: Yes, kissing bugs or tritoma insects carried the parasite that causes Chagas disease are common in the southern half of the continental US have been identified in 32 states. At least 17 states have reported infections among mammalian reservoirs like raccoons and possums, and at least 23 states have reported cases among domestic dogs. Finally, most of the human cases reported in the US come from international exposures, primarily Latin American countries, where the disease is more common. Eight states, however, including California, Arizona, Texas, Tennessee, Louisiana, Missouri, Mississippi and Arkansas have reported locally acquired Chagas disease in humans. For example, in Texas, locally acquired cases have not exceeded ten per year since 2013, with the caveat that there is likely to be a considerable amount of underreporting due to the often-asymptomatic nature of the disease. Other methods of transmission can include blood or organ transplants from an infected person consuming uncooked food contaminated with T cruzi parasites, and vertical transmission from mother to fetus. If you live or travel to a place where kissing bugs live in cases of Chagas disease have occurred, there are preventive measures you can take to help reduce your risk of infection. These include applying personal insecticide, wearing long clothing, and avoiding raw foods, especially unpasteurized juices and undercooked meats. Be vigilant about your environment and seek treatment if you suspect you've been exposed.

Chris Dall: Mike. On our last podcast, we discussed your new book, The Big One, with your coauthor and research fact checking team. The book has been out now for a few weeks, and you've been doing a lot of media appearances. What's the response been?

Dr. Osterholm: Well, I have to say, the response has been very gratifying in many ways, and I say that because the people I look to for response, first and foremost are my colleagues. Any author who writes a book like this, the first thing they want to know is, what did I get wrong? And you know, I'm happy to report that much like with Deadliest Enemy, so far, Mark and I have not gotten any feedback of anything that we got wrong. The fact of the matter is, is that people may not always agree with any points of view we take, but at least from a factual basis, we seem to have done okay. This book was heavily footnoted, and so hopefully we can provide the kind of information that would allow people to make that decision. I think at this point, though, it's clear that as we talk about preparedness for the next pandemic, based on what lessons we should have learned from the previous experience, we're being somewhat drowned out right now by just the very nature of local and state federal public health and how it's surviving the current moment, which is unfortunately, a very, very dangerous period of time for public health. And so, you surely can't be prepared for the big one long term if you're not even prepared for what could happen today here in this country. And that's the state of the art. You know, it's a sad commentary for me, having been in this business for 50 years. I've never seen the public health system so at risk as it is right now. We'll continue to push the big one as an agenda item. Hopefully with it. We can also see the short term immediate public health preparedness improved, but for right now, we have neither short term or long term.

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

Dr. Osterholm: Well, there was actually some foreshadowing earlier in this episode, and I don't think it'll take too long for listeners to catch on to our topic for today. Scientists estimate that this pathogen was likely introduced to South America 7 to 10 million years ago, which evolved in early terrestrial mammals. The earliest evidence of human infection was found in a 9000 year old mummy from the coastal region of Peru and Chile. More recently sequenced with PCR technology. But it wasn't until the early 1900s that a researcher made the epidemiological and clinical connection from disease to pathogen. Carlos Chagas was a Brazilian physician scientist born in 1879. His original research interest in medicine was malaria, where he focused on opportunities to prevent infection through use of an insecticide, pyrethrum. During his work combating mosquito borne illness, Doctor Chaga also noticed an infestation of a strange insect in rural homes that community members described as kissing bugs. Based on their tendency to bite people's faces while sleeping, Doctor Chagas was able to ascertain blood samples from infected mammals and humans in one village and tested them for parasites. He then discovered the presence of a flagellate protozoan he named Trypanosoma cruzi in honor of his mentor for medical school, Oswaldo Cruz. Through additional research, Chagas found that the infection with the parasites could cause severe heart disease, later known as Chagas myopathy.

Dr. Osterholm: During the 1920s, Chagas served as the director of the Department of Health in Brazil and made notable contributions to improving prevention and treatment of tuberculosis, influenza, leprosy, and other infectious and non-communicable diseases. Doctor Chagas significant contributions to describe the organism vector and clinical picture was remarkable, but not always met with significant acclaim. He was nominated for the Nobel Prize in both 1913 and 1921, but he did not receive the award. There is much ink spilled on why he did not receive this recognition, but there was a suspected element that the quality of science emerging from places outside the United States and Europe was perceived as being of lower quality and impact. Doctor Chagas passed in 1934, but his legacy on vector borne illness in South America continues on today. World Chagas Disease Day is recognized April 14th each year to recognize his discovery of T cruzi in his honor. I hope the world can also appreciate the incredible contributions the scientists across the global South have made and continue to make, especially regarding neglected tropical diseases that lack the research, attention and funding to mitigate.

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

Dr. Osterholm: I have a number of take-home messages, but let me just tell them down into three. I don't know how else to say it, but we're in the darkest days of public health that I've seen in my career. The challenges that we're seeing within the United States are remarkable. But it's not just the United States. We're seeing reduced funding right now in the European countries for public health programs with the money that once was Benton Public Health now going for defense spending. It's a challenge. What can we do here in this country? Contact your elected officials at all levels of government, and make it clear that this should not be a political issue. This is a public health and scientific issue. And that what's happening right now in the federal government is, frankly, a true disaster unfolding. Second, stay tuned for what's happening at the ACIP meeting today and tomorrow. As I noted earlier, we'll have an additional update provided on the website in terms of what happened at ACIP and what does that mean? But most of all, let me be clear. If you hear data that supports that 25 children have died from Covid vaccine, it is simply not true. And finally, get your Covid vaccine now if you can. We'll try to provide you with more information by Monday on just what the ACIP has decided a four recommendation. It could be quite interesting. Stay tuned and we'll give you that information.

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

Dr. Osterholm: Well, in keeping with the dedication, I wanted to kind of bookend the podcast today with the song. That means a great deal to me. Uh, and it's one that I see my family through the eyes of the words of this song. What I've chosen is sunrise. Sunset, a song from the musical Fiddler on the roof, written in 1964 by composer Jerry Bock and lyricist Sheldon Harnick. The song was performed at the wedding recital, and it's one that, uh, is a father. Uh, you never forget when you see the movie or the play. And this particular song. So here it is. Sunrise. Sunset. Sunrise, sunset is this little girl I carried. Is this little boy at play? I don't remember growing older. When did they? When did she get to be a beauty? When did he grow to be so tall? Wasn't it yesterday? They were small. Sunrise, sunset. Swiftly flow the days. Seedlings turn overnight to sunflowers. Blossoming even as they gaze. Sunrise, sunset. Swiftly fly the years. One season following another. Laden with happiness and tears. Sunrise. Sunset. Such a wonderful song. And it is all about us and our kids and our grandkids. And, uh, what this all means to us. So thank you so much for joining us again this week. I hope we're able to provide you with some of the information you're looking for, and we will continue to keep you updated. Again, check back on the site on Monday. You'll also get push emails about the update. We so appreciate the opportunity to be with you. This is a tough time, a really tough time, but now is the time when it is tough to do the right thing. Be kind, be helpful if you can, and surprise someone with a hi or a thank you. Just be kind. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm update. If you enjoyed the podcast, please subscribe, rate and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease news by visiting our website CIDRAP.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, Meredith Arpey, Leah Moat, Emily Smith, Clare Stoddart, Angela Ulrich, and Mary Van Beusekom.