Episode 193: Fevers, Furloughs, and Falsehoods

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. In the weeks leading up to the recent meeting of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, there was hope that the group would provide some clarity on who would have access to updated COVID-19 vaccines ahead of viral respiratory illness season. But as we laid out in last week's special episode recapping the ACIP meeting, clarity is far from what we got. For those who weren't able to hear that special episode, we're going to recap ACIP's recommendations for COVID-19 vaccines and try to provide a little bit of clarity on what remains a very confusing picture on this October 2nd episode of The Osterholm Update. We'll also take a look at what different states are doing on vaccine access and policy. Discuss some changes the Trump administration is considering for the National Vaccine Injury Compensation Program. Review the latest Covid data. Provide an update on the Ebola outbreak in Africa, discuss the latest US data on sexually transmitted infections, and discuss what a government shutdown could mean for public health. We'll also answer an ID query about the Trump administration's efforts to link autism with the use of acetaminophen during pregnancy, and bring you the latest installment of This week in public health history. But before we get started, as always, we'll begin with Doctor Osterholm's opening comments and dedication.

Dr. Osterholm: Thanks, Chris and welcome back to all the podcast family members. It's great to have you back with me, and I'm going to make a comment about you in a moment. And for those who are visiting us for the first time, I hope that we're able to provide you with the kind of information you're looking for, or if even you come intermittently. We welcome you back anytime and every time. But before I begin today's episode, I just have to reflect on the experience I had in this past month where I was out and about around the country with my book tour. Releasing the new book, as you also well know, is now available, and many of you came up to me and introduced yourself as members of the podcast family. And while we have always thought of this as a family, no matter how close you are to someone, it's great to have that kind of actual physical connection. And I had that opportunity with the podcast family on this tour. I just want to tell you how much it meant to me. What an uplifting experience it was to hear from you, to hear what you like, to hear your suggestions, and just to hear your overall support. So please know how much this meant to me and how much it really put the energy back into my vessels. Keep doing what we're doing, how we're doing it, and even more.

Dr. Osterholm: And I'd also like to say, for those of you that were there for the book tour, I hope that you heard the kind of information you were looking for in the sense of what the big one means in terms of our future preparedness. I encourage you at this point, if any of you have the willingness to do so, I hope you'll leave a comment or two on the Amazon site reflecting on what you thought of the book. It would be very helpful to hear from you in that regard, and that's one way we can systematically collect that kind of information. But again, thank you, thank you, thank you. And now let me move into that very wonderful part of the podcast, the dedication and realize that today's dedication will be a tough one, because I'm dedicating it to a group whose contributions often go unseen but are absolutely essential. The thousands and thousands of government workers who now are facing significant job insecurity and, in some cases, if not many cases, job losses. As we put this episode together, we are watching the country now go into a government shutdown, one where we don't know where it will end, how it'll end, and what it will mean to all of you who are these government workers that are so key to providing the critical services that society needs to move forward? Everything from safety to transportation to health care.

Dr. Osterholm: You provide so many critical services across agencies, departments and institutions. These public servants do the critical work that keeps our country functioning. They support public health, research, safety, infrastructure and so much more. Many of them are the people behind the data we rely on so much in this podcast. The systems we take for granted and the programs that protect our most vulnerable. And they truly earn their titles of public servants by forgoing prestige or profit over their commitment to service. As someone who served for 25 years at the Minnesota Department of Health, I understand what public servants do to make our lives better. The turmoil in Washington has already triggered significant layoffs and forced resignations. For these workers, the cost is deeply personal. Lost income, mounting stress, disrupted families and a growing sense of instability and careers built on service. But the impact doesn't end there. When these professionals are sidelined, so is the essential work they do. Monitoring disease outbreaks. Managing food and drug safety. Processing benefits. Protecting public lands, supporting scientific research, putting out major forest fires, and countless other functions that millions of Americans rely on. These jobs reflect services interrupted, protection weakened, and now communities left vulnerable. Beyond the immediate disruption, these losses carry long term consequences when experienced professionals are pushed out of public service.

Dr. Osterholm: We don't just lose people power, we lose institutional knowledge, technical expertise and years of hard-won experience that can’t quickly be replaced. Rebuilding the capacity will take time, training and resources that many agencies can't afford to spare. In some cases, that knowledge will be lost permanently and, in a moment, when public trust in government is already fragile, hollowing out our federal workforce only deepens the gap between what our institutions are capable of, and what the public needs from them. I realize the importance of all the agencies in the Department of Health and Human Services, the Department of Agriculture, whether they be the CDC, the FDA, the NIH. I think about state and local health departments who will ultimately suffer as the shutdown begins to weigh on them as funding cuts come through that now make it difficult for them to do their jobs. To every government worker holding the line right now, whether you're still on the job or forced to step away. Thank you. Thank you for the work you've done and hopefully will continue to do you reflect the best of our country. And this episode and a piece of my heart is dedicated to you. Now, let me move on to that wonderful part of the podcast that for many of you, you got 60s to go grab a cup of coffee. Today I'm very happy to report on October 2nd, Sunrise in Minneapolis Saint Paul is at 7:12 a.m., sunset at 6:50 p.m.

Dr. Osterholm: By the way, I might note these are still daylight times, and when those change, we'll see some significant adjustment of hours of sunrise and sunset. But for now, we have 11 hours and 38 minutes and nine seconds of sunlight. We're losing sunlight at about three minutes and five seconds a day, which is just under the maximum loss of three minutes, six seconds a day. The actual rate of losing sunlight will, in fact, start to decrease until we get to December 21st, when in fact, at that time it will start going back up again. Now for our dear friends and colleagues in Auckland, New Zealand, at the Occidental Belgian Beer House on Vulcan Lane, your sunrise today is at 6:55 a.m. Your sun sets at 7:25 p.m. Wow. You have a whopping 12 hours, 29 minutes and 45 seconds of sunlight and you are in that wonderful position of gaining. Today, you will gain two minutes and 20s of sunlight. Just think, in the next week you'll gain over 15 minutes of sunlight. And so, at this time of what many would consider a period of darkness, just keep coming back and reflecting on the sun. It is there for us. It follows us every day. Gosh, how we love that sun.

Chris Dall: Mike, let's begin once again with the status of updated COVID-19 vaccines. In brief, the ACIP voted to recommend COVID-19 vaccines for those 65 and older and those ages six months to 64 years, based on shared clinical decision making with the provider, which includes doctors, nurses and pharmacists. But what exactly does that mean? Also, the recommendation for people under 65 did not appear to be limited to those who are at increased risk for severe illness, which theoretically makes it broader than the FDA approval. So, what does this mean for our listeners who want to go get their updated COVID-19 vaccines?

Dr. Osterholm: Well, let me start out with a statement that will obviously make all of you wonder what I'm thinking about these days. I will go through exactly what we learned from the ACIP meeting, but at the very end, after I get all done with them, I'm going to tell you I'm not sure it matters. And what do I mean? Well, yes, the ACIP recommendations have only further muddied the waters in terms of Covid vaccine eligibility, the shared clinical decision making you mentioned implies you have to discuss your individual potential health benefits and risks with your healthcare provider, but it's unclear what that means. For example, who in healthcare can be considered a provider for this process? Is it restricted to doctors and nurses? Well, we know how long it might take to get in to see them, to even get a prescription. Or can pharmacists provide that service to. Well, in some states it's likely they can't. In fact, previous ACIP members have tried to move away from shared clinical decision making exactly because it prevents barriers to vaccination. Fortunately, at least for now, the ACIP rejected a proposal to recommend that states and local jurisdictions require a prescription for the administration of a COVID-19 vaccine, which would further limit access. Note that this particular vote was 6 to 6, with the tie going to the chair's vote, which was not to recommend prescription. This is one that I believe HHS is going to reconsider, and I'll talk about that in a moment. In short, don't be surprised if in the end, a prescription is actually required.

Dr. Osterholm: If that happens, it will just create another barrier to obtaining a Covid vaccine. Because, as I just noted, how many of us can readily get in to see a healthcare provider for a prescription? How many of us don't have a provider? They can give us such a prescription. And how will we interpret what shared decision making consists of in terms of time required and the aspects of vaccine risk and benefits covered? And the other two ACIP votes the group recommended that the CDC add more language about the risks and uncertainties of COVID-19 vaccines to the information statements that individuals receive when receiving a vaccine. This is the same information that healthcare providers are meant to cover with patients who seek vaccination. As you noted, Chris, the FDA has approved this year's Covid vaccine only for people aged 65 or older and those at high risk for poor outcomes, which again, is still a wide-open category. What does that mean? While ACIP has previously recommended the use of vaccine outside of its FDA approval, which is called off label use, it is rare and usually restricted to small groups of people with special indications. In a press release shortly after the vote, HHS that allows vaccination coverage through all payment mechanisms. But the challenge is that in a number of states, pharmacists may have more restrictions on what they can provide off label compared to a physician. Note that for ACIP's recommendations to become official guidelines, the CDC director has to approve them.

Dr. Osterholm: But we don't know yet what or if that will happen. For now, we can hope that most states will step up and safeguard access to vaccines, such as those against SARS-CoV-2, which is still causing infections, hospitalizations and deaths throughout the US. And of course, the world Now let me take all I just told you and throw it up in the air. Why? Because I believe that in the end, Secretary Kennedy will likely make his decision on how to play out each of these different votes that were taken by the ACIP. Not only can he reject them, but he, in the end, can actually decide whatever he wants. Like, for example, making prescriptions mandatory. So, anything I just told you about what ACIP did is totally up for grabs right now, when in fact, or if in fact, the Secretary's office makes any statements. Remember, if the CDC acting Director or the Secretary of Health and Human Services does not accept any of the vote tallies from the ACIP member, they're just stranded. They're left. There is no recommendation. So, we have a lot to learn yet in the days ahead about what will HHS do? Will they bury what was really the outcome of the ACIP meeting? And in fact, will they even consider taking up the issues that were raised there and just letting them die on the vine, making that by itself a decision as to what is recommended and what is not.

Chris Dall: Mike, given the lack of clarity from the federal government on Covid vaccines, which you've just so nicely outlined, several states have been issuing their own policies. Can you give our listeners a sense of what different states are doing?

Dr. Osterholm: Well, it's been wonderful to see so many states stick to the science and try to maintain broad access to Covid vaccines, despite the actions of Mr. Kennedy. As of September 22nd, 26 states within the US have announced policy updates that will provide broader access to Covid vaccines in the current federal recommendations. Note that there is a significant divide between red and blue states with these policy updates. For example, of the 26 states announcing broader access to Covid vaccines, 23 of the 26 have Democratic governors. This does include Minnesota, where pharmacists can now administer Covid vaccines to those aged three years or older. The Minnesota Health Department commissioner and the state epidemiologist stated, quote, we're following the science, and the science is clear. COVID-19 vaccines prevent severe illness and death for people of all ages, and we want to ensure access to vaccination. Unquote. 13 states have moved to require state regulated health insurers to cover Covid vaccines, at no cost. In states that have not taken this step to require continued coverage of Covid vaccines, it is still unclear whether individuals may have to pay out of pocket. I'm hopeful that more states will move towards guaranteed continued coverage. KFF has been tracking policy changes to vaccine access for individual states, so be sure to check out their website if you have questions about a specific state. We promise to keep our podcast community updated on Covid vaccine accessibility as new information becomes available.

Chris Dall: On the topic of vaccines, Bloomberg News reported last week that Health and Human Services Secretary Robert F Kennedy Jr is considering ways for people with autism, which he has long believed is linked to vaccines, despite no evidence to seek compensation through the National Vaccine Injury Program. Mike, can you explain what this program is and what it would mean for the program if such changes were made?

Dr. Osterholm: You know, Chris, that when I wrote the piece last November in the New York Times shortly after the election, detailing what I thought it meant to have Robert F Kennedy Jr potentially serve as the Secretary of Health and Human Services, that, in fact, one of his major efforts would be to take the vaccines away from us. A lot of people were skeptical. A lot of people didn't think that would really happen. Now we're seeing, in fact, what is happening, and it's a huge challenge. Well, let me just tell you that what we're about to discuss here has even more significance in a way than anything about him taking away vaccines through his administrative power. I can't tell you how much I worry about this very topic and what it means, so let me try to give you some perspective. We're talking about the National Vaccine Injury Compensation Program. This program was actually first set up back in the 1980s, and it was in response to a wave of lawsuits being filed against vaccine manufacturers, in particularly those making the DTP vaccine. At the time, these cases were being tried in civil courts, where the judge and jury were given the task of deciding whether a vaccine caused a particular outcome. And as you can imagine, causality is not easy to determine, even for the researchers who live and breathe this type of work, determining whether a medical condition is truly linked to a vaccine can be extremely complicated.

Dr. Osterholm: What that meant in practice was the vaccine makers were facing the risk of massive payouts. Any time someone came forward with a claim that resulted in some companies determining it wasn't worth the risk and leaving the vaccine market. This left the US and the world facing a very real possibility of major shortages for certain vaccines, because they just were no longer being manufactured. And that's where the vaccine injury compensation program came in. The program works as a kind of middle ground between vaccine developers and the public. Rather than going through a civil court. People believe they were injured by a vaccine can file a claim through this program. Each claim is then reviewed by an independent judge, referred to as a special master. And if the evidence supports it, compensation is awarded to cover medical costs, lost wages, and pain and suffering. Notable, this is funded by a small tax of $0.75 on every vaccine dose is given, and ultimately the program accomplishes two important things. First, it gives the people who experience a rare but real side effect a place to go for help. At the same time, it gives vaccine manufacturers the protection they need to stay in the market and keep producing these vaccines without the fear of being sued out of existence.

Dr. Osterholm: In fact, since it started, the program has paid out more than $5 billion in claims to the public. Now, that being said, it is not a perfect system. The program is understaffed and the process can be slow, which can understandably frustrate anyone trying to navigate through it. So, changes to help resolve these issues, such as adding more special masters and staff, would be extremely beneficial. But that's not what we're talking about here. What we're talking about, in this case, with the idea of adding autism to the injury list for this program, is extremely concerning. Why? Well, let's first be clear. There is no reliable evidence proving that vaccines cause autism. It's just simply not the case. This has been studied extensively and I, along with a whole heck of a lot of scientists who do this for a living, can tell you there is no causal link between autism and vaccines. But if the government were to now suddenly say families with autism can seek compensation for this program, you can imagine how people would interpret that. For many, it would look like an admission that vaccines do in fact cause autism. And this would only further reinforce a myth that has already done a lot of harm to public trust.

Dr. Osterholm: However, there is a practical matter of addressing the additional adverse event. Roughly 1 in 31 children are identified with autism spectrum disorder by age eight in this country. If you made this eligible for compensation, there would be tens of thousands of new claims made overnight for a system that already struggles to keep up with around 1200 claims per year. This would effectively drown and bankrupt the program. So rather than fixing the system, we'd be breaking it. And what's left after that. Well, I worry very, very much that it would be used as a means or justification to do away with the current system. I'd be concerned what that means for vaccine supply and access in this country, because I believe we would see the last few remaining vaccine manufacturers saying the risk is just too great. We're out of the business. That would be the ultimate challenge, not just that we are trying to convince people to be vaccinated, but now saying you can't be vaccinated. We don't have any vaccines. That, ladies and gentlemen, is a real possibility. I can't emphasize that enough. I don't want to wake up one day and say, how did we get here? What does this mean? It could mean a lot.

Chris Dall: Let's turn now to the latest COVID-19 data. Mike, what is Covid activity looking like around the country at the moment?

Dr. Osterholm: Well, we seem to be on the other side of this most recent wave. Wastewater concentrations are now considered moderate nationally and every region is reporting decreasing wastewater concentrations, with the exception of the northeast, which has seen a slight increase in the last week. Only four states Connecticut, Delaware, Nevada and Utah are considered very high, but down from 18 states during our last episode, a big drop. 15 are now considered high 13, moderate, 15 and DC are considered low, and two Missouri and Michigan are very low. I'm happy to report that emergency department visits are low and decreasing, with now just 1% of ED visits resulting in a positive Covid test. This is down from the peak of 1.7% a month ago, but it's still higher than the 0.3% we were seeing in May. We hope we can continue to see that number drop. Weekly deaths, which I want to remind you, is a lagging indicator, meaning that this reflects the activity of 3 to 4 weeks ago. And now we're actually unfortunately, seeing those numbers continue to increase. But that shouldn't be unexpected given that we did see that earlier peak in actual clinical cases and again, realizing the lag period to occur for people to get sick or die and that information be reported. During the last week of August, we lost 337 Americans to Covid.

Dr. Osterholm: The following week, which is still considered to be incomplete data, we lost 386 Americans, but this number is likely to rise somewhat. It always seems discouraging to see this weekly death total rise, and we can only hope we'll start to see a decline soon. I predict that by the time of the next podcast recording, we will see these numbers begin to level off and drop. XFG continues to assert itself as the dominant variant, accounting for nearly three quarters of the US cases, or 72%, from August 3rd to August 30th. During the same period, NB.1.8.1 accounted for 11% and LP.8.1 made up just 8% of cases. CDC’s traveler-based surveillance has been pretty consistent with this US picture. The week of August 31st, XFG accounted for 84% of samples from international travel, compared again to the 72% here in the United States. In addition, NB.1.8.1 accounted for 12% and LP.8.1 accounted for just 1% of the international travel isolate. Before we move on, Chris, I just wanted to add that I'm starting to get asked about flu shots for the season. Please remember, I'm not providing medical advice, but I will tell you what I know from all my years of research with influenza vaccines and what I do.

Dr. Osterholm: The best way to ensure I am protected for as long as possible through the flu season is to get the vaccine as close to the time that flu activity begins to increase. Why? As I've pointed out before, we can see waning immunity of 2 to 8% per month of flu vaccines in protecting you after you get the dose. So why would I want to get a dose 4 or 5 months in advance of the flu activity, knowing that that could result in 20 to 30, 40% reduction in how well that vaccine worked. So currently, the activity remains very low and we typically start to see an increase in mid to late October. We'll be sure to keep you updated with what you need to know, as well as when I decide to get my dose. We'll make sure all of you know that, and that will be the time that I'm beginning to see flu activity pick up. And I will then get my dose, which will then give me maximum protection for what will be an increasing number of cases.

Chris Dall: Mike, let's talk briefly about measles. So, the United States right now has more than 1500 cases, which is the largest number in more than two decades. We just recently had the president of the United States saying he didn't think that parents should give their children the MMR vaccine. He said it should be separated into separate vaccines. What are your concerns about measles in this country and where we are headed?

Dr. Osterholm: Well, I think as everyone listening to this podcast probably is aware of is that the president did put out a social media statement last Friday, basically indicating that in his recommendation, every dose of MMR should be given individually, not together. And that that should be how we approach this issue. Well, that's not going to happen, because first of all, you'd have to change the manufacturing capacity to make single doses, which would mean three jabs as opposed to one. And which would only further deter people from likely getting their children vaccinated. So, you've seen a rather widespread response to this statement from a number of medical and public health groups. But let me just talk about what's happening right now. Remember, measles virus is a little bit like the influenza virus in terms of its seasonality. We've always seen measles cases rise during the late fall through the early spring. And so, we're coming into that season again, which likely enhanced transmission. And just in the last several days we've seen an uptick in cases by states. We now have four states that have recently had new activity Arizona, Utah, South Carolina, and now our home state of Minnesota. In addition, the New York state health officials have documented a measles virus in wastewater this past week in the Oswego, New York region, suggesting that there is transmission of the virus going on in that community.

Dr. Osterholm: I think having seen these different locations for measles activity just points out the fact that it is going to be throughout the country and wherever there is someone or groups of someone's who are not vaccinated or not previously infected and therefore protected are going to be at increasing risk of having measles cases in their communities. So, it's really important to remember. This is an ongoing battle. Getting the Texas outbreak under control was great, but we're going to be faced with that day after day after day. It's just like the fact if you put out one forest fire, it doesn't mean you put out all the forest fires for the next year. Each one is a new one requiring additional activity. So, we'll stay tuned on that. I do want to add that this past week, it was notable in Israel that six children have died from measles, four of them during the past week. And just is a really important reminder to all of us what can happen with measles. And we are going to see more of these severe cases in this country with some of the children dying. And it's important for parents to understand that they don't want their children to be part of those numbers.

Chris Dall: The CDC last week issued some provisional data on sexually transmitted infections in the United States in 2024. It was a bit of a good news bad news report. What can you tell us, Mike?

Dr. Osterholm: I should first mention that it was your reporting CIDRAP news, Chris, that led us to cover this topic this week. Thank you for that. Every year, the CDC publishes a report summarizing the previous year's surveillance of several key sexually transmitted infections for what we call STIs, including chlamydia, gonorrhea and syphilis. The provisional data presented here represent 2024. Let's start with the good news highlighted by the report. Across the three agents, there was an 8.5% decrease in diagnosed cases from 2023 and a 5.9% decrease from 2020. Chlamydia was by far the most common, followed by gonorrhea and then syphilis, although the burden is still higher than what we saw ten years ago. Steady declines are obviously a good sign. I believe there is no single driver of this success, but changing behaviors and new interventions are likely contributing. Now for the concerning part of the report. Congenital syphilis continues to rise. Nearly 4000 cases were reported in 2020, for a 1.6% increase from the previous year, and 81.8% increase since 2020. And simply a staggering almost 700% increase since 2015. This form of syphilis occurs when a pregnant person transmits the infection to their baby during pregnancy. It can lead to miscarriage, stillbirth, or serious health complications for the newborn. The good news is that syphilis is treatable and prevention hinges on timely testing, reducing exposure risk and prompt treatment. But let me just add a sobering note here.

Dr. Osterholm: When I first got into the business 50 years ago, the idea of any occurrence of congenital syphilis was an indication of the failure of the system that you had in your community for, in fact, detecting STIs and making sure that the prenatal care was adequate to never allow congenital syphilis to ever occur. Well, look where we're at now. We have been backsliding for the past 50 years, and this is a real concern. One of the areas that we have to keep in mind is access to affordable health care. It's critical in managing and preventing STIs. This brings me to my major concern that recent Medicaid funding cuts are expected to have serious consequences. The law slashes $990 billion from Medicaid over the next decade, potentially leaving millions without or more limited coverage. Clinics that provide STI testing and treatment, especially in underserved areas, are at risk of closing. And with fewer people able to afford care, we could see STI rates climb again, much beyond that of what we see now with syphilis. Finally, I am concerned that the CDC's report does not break down data by race, ethnicity, income, or geography. This lack of granularity makes it difficult to target resources to communities most affected by STIs. Given that these infections disproportionately impact marginalized populations, we need more detailed data. It's essential for equitable public health responses. At this point, we don't have access to that.

Chris Dall: So, Mike, as I mentioned in the introduction, we would provide our listeners with an update on the government shutdown and its potential impacts on the agencies that oversee public health. As we speak, we are now in that government shutdown. As we know from the past, these things can sometimes last just a few days. Sometimes they go longer. The most recent one in 2018-2019, was 35 days. But for now, what do we know about how this shutdown is going to impact federal health agencies? And Mike, let me just add, the US, FDA, in a post on social media, said, I'm going to read their whole post. All FDA activities related to imminent threats to the safety of human life or protection of property will continue. This includes detecting and responding to public health emergencies, and continuing to address existing critical public health challenges by managing recalls, mitigating drug shortages, and responding to outbreaks related to foodborne illness and infectious diseases. It also includes surveillance of adverse event reports for issues that could cause human harm. The review of import entries to determine potential risks to human health. Conducting for cause and certain surveillance, inspections of regulated facilities and related regulatory testing activities and criminal enforcement work, and certain civil investigations. So that is what the FDA right now is telling us about how they're going to be impacted.

Dr. Osterholm: Well, Chris, let's just be clear. This is a very, very sad day. We are watching government come to this dysfunctional place. Some would say even more dysfunctional place than we've had before. I think it's important to understand that this particular shutdown could change in nature as time goes on. If we get a rapid resolution to this, I think we can all say let's move forward. Only limited impact has occurred to our country because of it. On the other hand, if it is prolonged, I think we're going to see real challenges, in terms of programs being able to maintain even their critical safety nature. Let me just say that at this point, and according to an HHS fiscal 2026 contingency plan and was updated this past weekend, it was highlighted in STAT, 32,460 HHS employees will be furloughed, with 79,717 employees retained to perform essential services. Don't know, though, who's in fact going to be furloughed. We don't know what necessarily those essential services will be. Also, there had been discussion over the past several weeks of a massive firing of workers if in fact, the shutdown went into place and that has not been discussed in the last two days. So, I don't know what that means, but obviously we'll continue to follow that very closely. One point to note that at least at the NIH, it's also reported in staff that care of existing patients will continue, but no new patients will be admitted to the clinical center, while NIH grant making and basic research is also going to take a pause.

Dr. Osterholm: This is a huge hit. My heart goes out to those family members who are on the kinds of protocol studies at the Clinical Center at NIH, and who are basically desperate for the kind of care that they can get there now, no longer being able to get it. This is going to be really a huge, huge issue. So, all I can say everyone stay tuned. We're going to try to keep you updated on this. This is a very, very unfortunate development, but one I think that we could see coming. There surely did not appear to be any olive branches extended over the past week to bring this to a much more successful conclusion. Stay tuned. I'm certain that this is going to be a very rough ride in the days ahead. And I think, Chris, it's an important subtext here that remember all the previous shutdowns that have occurred when we were at full force and government employees, we already have a very unfortunately diminished federal resource team in many locations of the federal government. And so how this will actually play out, on top of all the people who through DOGE, have been riffed or have retired because of that. And so, this only, I think, accentuates what we've never seen before in terms of, of a manpower issue with federal government, namely a DOGE related purging. And now this on top of that.

Chris Dall: So, folks, stay tuned. If this continues, we will have more about it in our next episode of the Osterholm Update. Now it's time for our ID query, which this week is tangentially related to infectious diseases but involves an issue that has gotten a lot of attention recently. The warning from President Trump. Secretary Kennedy and other federal health officials that use of acetaminophen, the active ingredient in Tylenol during pregnancy, may cause autism. Will remarks about autism and Tylenol be forthcoming? In particular, I am seeking to know if Doctor Osterholm has made remarks regarding the source of that information. Doctor Andrea Baccarelli, Dean of faculty at the Harvard School of Public Health, and a note for our listeners. Doctor Baccarelli was the senior author of a meta-analysis of 46 studies that found an association between prolonged acetaminophen use during pregnancy and the development of neurodevelopmental disorders, including autism. Mike, your thoughts on this controversy?

Dr. Osterholm: Well, Chris, let me just begin by saying that we could spend an entire podcast digging into all the implications of what happened in the past week with this issue. Let me just remind everyone that Secretary Robert F Kennedy promised us all in the early part of the summer, that by September, we would actually have an understanding of what causes autism. In fact, by September, we had several groups come forward showing how the anti-vaccine activists had actually manipulated the data to provide what would be considered a link to autism. So, what happened? Well, now September comes along. Not having that smoking gun answer that he promised. So, he had to come up with something. And in fact, it was what happened last week with this link with Tylenol. Well, let me just say I'm not an expert on the issues around Tylenol use and its impact, but I actually had the good fortune over the past week to have several conversations with someone who I highly respect, who really does have a very good handle on understanding and interpreting data. Doctor Jessica Stier Chapin, who is considered one of the premier science communicators, actually spent time with me sharing what her thoughts were about this issue. So, I want to share with you what she shared with me, and I know that she is working on developing a publication on this issue, and I can't wait to see it. But in the interim, thank you, Doctor Stier Chapin, for allowing me to share with the audience what it is that you believe about this issue. And also, thank you for your incredible work.

Dr. Osterholm: Well, first of all, let me just be really clear and remind everyone. As we've talked about before, associations are not causality. What do I mean by that? I've used the example that if you look at the relationship between shark attacks and ice cream consumption, you can find they're actually pretty closely linked, but it's not really a link that's anything to do about, cause it's about the fact that we are more likely to go swimming in the ocean in the summertime, and you're more likely to eat ice cream when it's warm out. So that relationship between them gives us no information on why shark attacks occur, or in fact, how good the ice cream is. So, in fact, we need to have the kind of studies that actually are what we call controlled trials, where pregnant women with fever or pain are assigned to a treatment or a placebo, meaning some get the actual drug. In this case it would be acetaminophen and some get a placebo. But it's really impossible to do a study like this because it would be unethical to hold back fever-based medication for a pregnant woman who has a fever, because we know, frankly, that fevers can actually significantly increase the risk of bad outcomes with your newborn, including both neural tube defects and heart defects, and in some cases, oral clefts. What we have today are studies that are basically based on what we call a case control approach. Well, what's new? There was a recent publication in August that reviewed 46 different studies, and it showed that 27 of these studies showed some association between acetaminophen and neurodevelopmental issues.

Dr. Osterholm: And in fact, the lead author was very clear and said, and I quote, we cannot answer the question about causation. This is very important to clarify. So now looking at the review of these studies, what can we in fact understand? Well, why do pregnant women take Tylenol? They take it because of fever. And as I just pointed out, fevers are associated with bad outcomes during pregnancy. And so, one of the things that we're really working on right now is to try to understand what is cause and effect and what is actually association. Now, there was one study that was done that was actually not highlighted by either the president, the HHS staff, or for that matter, even those who have been studying this issue, putting forward the possibility of a relationship. That's a study in Sweden where they looked at over 2.5 million children every birth in Sweden, literally over a two-decade period. They looked at the data in several different ways, but they appeared to find was a very weak association, with only about 5% increased autism risk with acetaminophen exposure. They then compared siblings for these families where one child was exposed to acetaminophen in pregnancy and one wasn't same mother. And they found at that point, basically the entire association vanished. Same parents. The risk dropped to zero. So let me just say that at this point, I do not see any compelling information to show cause and effect. And I do know that when women are experiencing fevers while pregnant, you have to do what you can to reduce that fever.

Dr. Osterholm: And that is why a number of organizations have come out, such as the College of OB-GYN saying how important it is to continue to use Tylenol during pregnancy as low level as you can, but you need to control that fever, and I can't wait to get a more comprehensive review of this issue from Doctor Stier Chapin. She really will provide us with the kind of information that we should share with every parent, every doctor, everyone who studies this topic. If you're a mother today thinking that your child is on the autism spectrum because of something you did, please give yourself the benefit of knowing that's not the case. At this point, I worry that we have created a sense of regret and remorse among the parents who somehow feel like responsible for this based on this kind of information. And I would urge you, under all conditions, follow the leadership of organizations like the College of Obstetricians and Gynecologists and their recommendations. They are looking at this from a full vantage point of the data. Do not follow what the president suggested. This unfortunately was another one of his bleach moments. Remember during the Covid pandemic, he said, maybe we should inject bleach to kill the virus. We would never recommend that. So, I'll leave it there and just say, stay tuned. It's not done yet, but in fact, what you heard last week is just factually incorrect. And the relationship that was painted between acetaminophen usage and autism is absolutely not established, and very well may never be. And we look forward to more information forthcoming.

Chris Dall: We're going to turn now to some international infectious disease news and talk about Ebola. And we haven't discussed Ebola much on this podcast because it's been a while since there's been a major outbreak. But we now have an outbreak underway in the Democratic Republic of Congo. Mike, what can you tell us about what's going on with Ebola?

Dr. Osterholm: Well, Chris, you're correct. It's been quite a while since we discussed Ebola. As the outbreak we saw earlier this year in Uganda was declared over back in April. But sadly, the virus has reemerged, this time in the Democratic Republic of Congo, DRC, which has been home to many outbreaks over the years. Sequencing data from the viruses suggests that this outbreak originated from a zoonotic spillover, basically animal to humans. This is typical of Ebola outbreaks, with the first case here being reported in a 34-year-old pregnant woman who then transmitted the virus to a lab technician and a nurse while receiving treatment in the hospital. This healthcare worker associated transmission is tragically common for Ebola outbreaks, as healthcare workers often have contact with the blood and other body fluids of infected individuals. As of Thursday, September 21st, 57 cases have been reported, including 35 deaths, yielding a case fatality rate of 61%, which is within what we would expect for an Ebola outbreak. Though on the higher side, epidemiologic data suggests that the funeral attendance for Ebola patients who died from the virus may have amplified the spread. This is not surprising, as we have seen this in several previous Ebola outbreaks, particularly because Ebola viral load remains high after death and because funeral traditions in the DRC often involve washing or touching the body of a deceased person, which creates a perfect storm for transmission.

Dr. Osterholm: Fortunately, many efforts are underway to control this outbreak. Nearly 2000 doses of vaccine have been administered as part of the outbreak response so far, and more vaccination efforts are underway. Additionally, Doctors Without Borders and other partners worked with the W.H.O. to open an Ebola treatment center two weeks ago, which will be critical for improving patient outcomes and protecting healthcare workers. Finally, I just want to remind our listeners, as I have in the past when we've discussed previous Ebola outbreaks, that while it is normal to be concerned when we hear about cases of this terrible virus infection, the concern should be focused on those in the affected areas in the DRC, not about the virus causing widespread disease and death here in the United States. The Ebola virus is devastating, but it lacks wings to transmit efficiently enough to be a pandemic causing agent. I say this not to minimize the tragic effects of this virus, but to help you all put this information into context so you know how this will, or in this case, won't affect you. As always, we will keep you updated as this outbreak continues to unfold and we will be keeping the healthcare workers and affected individuals in the DRC in our thoughts.

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

Dr. Osterholm: Well, Chris, rather than celebrating our public health hero this week, we're going to be reflecting back on what I would consider a dark time in our country's history, both from a public health and a national security perspective. On October 4th, 2001, just weeks after the devastating 9/11 attacks, a case of inhalational anthrax was confirmed in Bob Stevens, a journalist for the tabloid magazine The Sun in Florida. This is a particularly memorable day for me because it was on that day, I happened to be sitting in the 60-minute studio at CBS in New York City, recording a program to show that following Sunday on, is there a risk of a bio attack following the 9/11 plane attack? Of note, there were three other individuals on the panel with me, and when we were confronted with this information, we were all asked, does this mean there's an attack that's happening? And of course, based on a single case, we could say, no, we don't know. But I'll never forget learning about that at that point. Well, this one case surely did raise some red flags. Though cases of anthrax can be naturally occurring. Bacillus anthracis, the bacteria that causes the disease, is found in soil in many parts of the world. A case of anthrax is rare and severe enough to prompt further investigation. Stevens tragically died just a day after the case was confirmed, and soon after anthrax was found in his office.

Dr. Osterholm: The following day, an NBC employee in New York City tested positive for anthrax. Days later, anthrax was found in Senate Majority Leader Tom Daschle office. In the days to come, several other infections would be reported. A seven-month-old who visited his parents’ office at ABC news, a CBS news employee, and postal workers in new Jersey and Washington, D.C. it had become clear that the country was facing a bioterror attack at a time when we were already deeply vulnerable to fear, panic and unrest. It was confirmed that anthrax was being sent through the US Postal Service to multiple news organizations and government offices Officer. By the end of the attack, 22 people were infected with anthrax, 11 of whom had inhalational anthrax, the most severe form of infection, and tragically five people died as a result of their infection. An additional 32,000 potentially exposed individuals were given a 60-day course of antibiotics to prevent any spores they had inhaled from creating an infection. An intensive FBI investigation into the attack was quickly underway. Unfortunately, it has some difficult periods of starts and stops in terms of who they were investigating. It wasn't until February of 2010 that the FBI concluded their investigation and determined that Doctor Bruce Ivins, an anthrax researcher for the US government, was responsible for the attacks.

Dr. Osterholm: Sadly, by the time it was determined that Ivins was responsible, he had committed suicide. Now, let me just point out that some people still dispute the fact that Bruce Ivins was, in fact, the perpetrator of this particular attack. All the evidence I've seen surely convinces me that, in fact, that was the case. This attack was a turning point in public health history and emergency preparedness. The federal government funded significant bioterrorism preparedness efforts to reduce our vulnerability to attacks like this in the future, some of which I have been deeply involved with. This was a truly tragic event in public health history, but we wanted to reflect on it so that it isn't forgotten. As an example of a time that real public health change was made in response to a tragic event. I hope we can get back to a place as a country where we can learn from outbreaks like this, rather than set ourselves up to repeat them. And finally, let me just say I will never forget shortly after 9/11. As many of you know, I had the opportunity to split my time between Minnesota and serving as a special advisor to Secretary Tommy Thompson at the Department of Health and Human Services. I was extremely involved with the anthrax investigation follow ups. And I must tell you, it was a challenging, challenging time to be in Washington, D.C.

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

Dr. Osterholm: Well, Chris, I've got a number of them, but I'll try to distill them down to three. First, Chris, I just want to remind everybody that science is not truth. Science is the pursuit of truth. It's always learning. It's getting better. It's understanding what is happening through example, through research and observation. All I can tell you right now is that science is under a major attack. Today I talked a bit about the vaccines. I talked about the kind of scientific studies looking at acetaminophen and the autism spectrum. These are real issues that affect people's lives, not just politically, but from a very personal health standpoint. And we must continue to use as the basis for how we proceed as science. It's all about the pursuit of truth. Second of all, here we are in the shutdown, and I have no idea where this is going to take us. I worry desperately about the fact that the threats of mass firings within the federal government may be realized in the next few days. If that's the case, agencies that are already down to the bone, such as the CDC, will only further be compromised in what they can do and how they can do it.

Dr. Osterholm: Stay tuned. This is going to be a major challenge in terms of doing good public health with the shutdown. Finally, I'm happy to report that we're seeing lower Covid activity. And in fact, RSV and flu also are at very low levels. It's still too early to get your flu shot. I'm convinced of that. But I want you to get it. It's important to get and we'll let you know when we start seeing flu activity increase. And of course, if you can get your Covid shot, get it now. The new vaccine is out, which surely appears to be superior to the previous vaccines out there. And then finally, I just want to say thank you again for your incredible support on the book tour. It was so good to meet you, you took the time to introduce yourself, and I just so much appreciate your feedback. Again, I welcome that feedback. If you have ideas, thoughts, comments, criticisms on the book, you can go to Amazon and put those in and we'd appreciate that very much.

Chris Dall: And what closing song have you chosen for us today, Mike?

Dr. Osterholm: Well, I was trying to find one that fit the mood, but then I had to figure out what was the mood and what are we experiencing right now? You know, I feel like we live in a world of whiplash emotionally whiplash day after day. So, I kind of went back to an oldie but goodie, a favorite one that, for me, shares a message of what I hope we can better experience right now. This song has been used three times before. I guess we like it. On July 10th of 2020, in episode 15, a coronavirus forest fire on February 10th, 2021, in episode 43, a realist adjusts the sails and then on January 20th of 2022, an episode 87 Hope is not a strategy. Anybody have any ideas what this might be? It is Bridge over Troubled Water. It's a song that is familiar to all. I'm sure most everyone here. Written by Paul Simon. Sung by Art Garfunkel. It was released in January 1970 as the second single from their fifth and final studio album, Bridge Over Troubled Water. This song continues to mean a great deal to many of us who come from that era of the 1970s, but in addition, even since that time, who have understood the importance of what it means to live in a world where there is a bridge over troubled water. So here it is. Paul Simon, Art Garfunkel, bridge over troubled water. When you're weary. Feeling small. When tears are in your eyes. I will dry them all. I'm on your side. When times get rough. And friends just can't be found. Like a bridge over troubled water, I will lay me down like a bridge over troubled water I will lay me down. When you're down and out.

Dr. Osterholm: When you're on the street. When evening falls so hard I will comfort you, I'll take your part. When darkness comes. And pain is all around. Like a bridge over troubled water, I will lay me down. Sail on silver girl. Sail on. By your time has come to shine. All your dreams are on their way. See how they shine. If you need a friend I'm sailing right behind. Like a bridge over troubled water, I will ease your mind. Like a bridge over troubled water, I will ease your mind. Paul Simon and Art Garfunkel. Thank you again for being with us. We appreciate all of you so very, very much. Continue to provide us with that feedback. It helps make us better at what we're doing and we want to make sure we're meeting your needs. If there was ever a time right now to be kind. It's right. It is right now. This world is surely in a challenged place. But it's one that we can continue to try to make better. I just want to add that we're actively working 20 hours a day on the Vaccine Integrity Project. We'll be making some major announcements about our findings in the next couple of weeks. And we're excited to say that we are continuing to put forward the kind of science that our federal agencies once did. And we're now trying to step in and help out however we can. So, stay tuned for that. So out for a walk. Say hi to somebody you wouldn't normally say hi to and give them a smile. That's the kind of days we need right now. Thank you again. Be well. Be safe. 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.