Episode 171: Serious Challenges Ahead: RFK Jr and a New HHS

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 Dahl, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of The Osterholm Update podcast. Over the last two episodes of the podcast, we've discussed concerns about how public health could be impacted by the administration of president elect Donald Trump, while noting that we can't get too far ahead of ourselves, because there's still a lot we don't know about how things will play out. Now, with last week's announcement that Robert F Kennedy Jr has been nominated to be the secretary of the Department of Health and Human Services, we have a little more clarity. While he will need to be confirmed for this position by the US Senate on its face, the nomination of a well-known promoter of anti-vaccine and other health related conspiracy theories to run a sprawling department whose divisions regulate the nation's food, medications, vaccines, medical treatments and public health insurance programs is deeply troubling. In the days since the nomination was announced, countless medical and public health professionals have expressed concern about the damage that Kennedy could do in this role. On this November 21st episode of the podcast, we're going to talk about the RFK Jr nomination, what exactly he would be in charge of as the head of HHS, and what the concerns are. We'll also examine the latest developments in the H5n1 avian flu outbreak. Discuss the latest COVID-19 data and bring you updates on the Marburg virus outbreak, measles and sexually transmitted infection incidents in the United States. And we'll 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 podcasts, family members, anyone who might be joining us for the very first time and for those who have joined us from time to time, I'm glad you're back with us, and I hope for all of you that we can provide the kind of information you're looking for. I want to take this opportunity to just thank the podcast family members who, over the course of the past several weeks, have shared with us numerous emails and notes about our podcast, what we're doing, how we're trying to come together here, and what is certainly a very uncertain time and your input has been invaluable. Not just that which tells us, yeah, you're doing a good job or yeah, we want to be part of this. But even even providing us with insights about how we can improve what we're doing. So thank you so much. We're incredibly grateful. And in that light, I also just want to start out by saying thank you so much to the podcast team Chris, Elise Holmes, and Sydney Redepenning, the co-producers of the show, as well as all the research staff at CIDRAP that helped participate in this effort. I just want to thank you. If there was ever a time for gratitude and appreciation for those things which are good, those things which are positive, those things which give us reason to believe in the future, now is the time to also recognize them.

Dr. Osterholm: So at this point, please know you're recognized out there in the podcast land. As you noted, Chris, the medical community is abuzz with the news that the president elect, Donald Trump, has selected Robert F Kennedy Jr to be secretary of the US Department of Health and Human Services. For many, this nomination raises deep concerns about the direction our nation's public health policies might take and how it could affect everything from vaccine accessibility to trust in evidence based medicine. In this episode, we'll be diving deeper into what it will require for RFK Jr to be approved as secretary and the potential implications of him holding such an influential position. Hopefully, I can say with some clarity on what we know and what we don't know at this point in the nomination process. And let me just remind you, if there was ever a time right now to be steady, to be thoughtful and to be committed, it's now. There will be much that will play out in the days ahead, some with some surprises. And today I'll try to share with you a sense of what I think some of those might look like. But to start, I want to offer some words of encouragement and perspective to those who are feeling anxious about what this nomination means for the direction of public health and for your trust in government institutions.

Dr. Osterholm: I want to acknowledge those concerns. Whether you're a healthcare professional, a parent, or just someone who's passionate about science and health equity. Your worries are valid. The future of public health is truly on the line. This is like no other time I've seen in my 50 year career. But let me remind you yet of another truth. Public health is bigger than any one person. It's a collective effort. It's about communities coming together, advocating for policies that protect everyone, and continuing to demand transparency, evidence based decision making, and accountability from our leaders. It's about pushing for a system that prioritizes access to care, addresses health disparities, and continues to adapt to emerging challenges, whether that's infectious diseases, mental health, or chronic conditions. So to everyone out there questioning what this nomination could mean for the future of public health policy, we want to say we hear you. I also want to be honest and say that this is just the first of a number of nominations which will be coming forward, where agency directors or commissioners will be also named in the days ahead, which will have some impact and in some cases, significant impact on what we may see in terms of public health leadership out of Washington. And while we may not have all the answers right now, I can promise you that our group at CIDRAP and this podcast family, we will keep asking the tough questions.

Dr. Osterholm: We'll keep holding our policymakers accountable, and we'll keep pushing for a healthier, more equitable future for all. Now, whether you're feeling hopeful or anxious or just trying to make sense of what's going on, this episode is dedicated to you. It's dedicated to the people who care deeply about the future of public health. It's dedicated to those working on the front lines and labs and communities, and in government fighting for better, more effective solutions. And most importantly, is dedicated to everyone who believes that no matter the challenges we face, Our health and well-being always will be worth the fight. Remember in the last podcast I committed to you for the next four years I will be here. This podcast will not go away and we will call balls and strikes without fear or favor. And hopefully we can help you and the entire community get through these next four years. This is our last episode before Thanksgiving. I want to extend my gratitude to all of you for continuing to listen and support this podcast. Thank you for sending us your questions, your feedback, and for sharing these episodes with your family and friends. More than anything, thank you for continuing to spread kindness.

Dr. Osterholm: I am certain we need that more now than ever. Thank you for being here and being part of my family. Thank you to the podcast team, that family. Now let me move in to the darker days, if that could be the case. Uh, today, November 21st, 2024 in Minneapolis Saint Paul. Sunrise sunrises at 7:19. Sunset at 4:38. Only nine hours, 18 minutes and 57 seconds of sunlight. We're losing about two minutes and four seconds a day. But I wanted to inform you that we're only 13 days from the shortest afternoon of the year, December 4th, here in Minneapolis, when the sun will set at 431. And that means shortly thereafter. We're back on the upside. What a wonderful feeling that is to know that now, if you're our dear, dear friends and colleagues at the Occidental Belgian Beer House on Vulcan Lane in Auckland, New Zealand, you today got to see the sun rise at 559. Sunset at 8:14, 14 hours, 15 minutes and 48 seconds of sunlight. You're gaining sunlight at one minute, 35 seconds a day. So if you could just share a bit of that with us for the next few months to help us get through. We'd appreciate it, but just know it's always darkest just before the dawn. Remember that it's going to be the darkest day soon, but then we're on the upside.

Chris Dall: So, Mike, let's start with the nomination of Robert F Kennedy Jr to be the secretary of the Department of Health and Human Services. And before we get into your concerns, some of which you have laid out already, I think it would be helpful for you to lay out for our audience what HHS encompasses, those 13 agencies you mentioned and what kind of power the Secretary of HHS holds.

Dr. Osterholm: Well, Chris, I think it's actually of some note that most people have no idea that the Department of Health and Human Services is by far the largest department in all of our federal government, including that of the Department of Defense. If you look at the annual budget right now for the Department of Health and Human Services, it's about $1.8 trillion a year. When you compare that, for example, against the Department of Defense, which has a budget of about $880 billion, you can see in size how it absolutely dwarfs even the Department of Defense. It's a very large bureaucracy of well over 80,000 employees. They're dispersed nationally across 13 different operating divisions or agencies. And as I noted, they control about $1.8 trillion in federal spending. My own personal experience, having worked for Secretary Tommy Thompson after nine over 11 for almost three years and spending a lot of time in the inner sanctums of HHS, I learned a couple of things. First of all, anyone who is the secretary of HHS is not in the position to be, as I would say, micromanaging any aspect of this large conglomerate activity. They usually are constrained in this case by potential regulation or case law, president and even statute. In a setting like that, no president can come in and actually suddenly change many of the policies that exist. And so, in fact, they find themselves often a bit frustrated trying to change the ship of government.

Dr. Osterholm: In one area that they do have control over is that with policy prioritization, communication approaches, and then just the overall personnel decisions among those at the highest levels, these can be of real importance. However, again, they're not the same as being able to just suddenly change laws, statutes or otherwise the policies that exist. One of the things that I want to be very careful about is the fact that there is so much speculation going on right now as to who will do what with what. By the time you hear this podcast, there may be new additional names put forward for the various agencies within HHS. And at this point, I think it doesn't do any good to say John Doe or Susan Thomas or whoever is in line for this position or not. I think we could be very surprised, but just know that this is not just about Robert F Kennedy Jr as the potential and I say potential Secretary of Health and Human Services. It's about all the other appointments that will occur at that senior level. And that's what we're keeping track of, because that will have tremendous impact on how agencies are run and what they prioritize and how they respond to the issues of the day. And let me be clear, it's not certain yet that, in fact, Mr. Kennedy will be confirmed as the Secretary for HHS. It's very possible, maybe as likely in the minds of many.

Dr. Osterholm: But again, some of the challenges that you've seen that have arisen over the past week and a half to two weeks about his previous positions on a number of health issues, do raise some concerns. Now, do I think that a Republican Senate, uh, particularly when requested by the president to approve a appointment like this. It surely likely to happen, but I think we have to be very careful. I'm not jumping to conclusions yet, and I say the same about all of the potential appointees to the senior leadership positions in HHS. In the meantime, I think it is worth noting, though, that there are areas where, in fact, we can immediately expect to see some real impact. This is not an exhaustive list, but it's one that I've kind of prioritized to say, this is what I'm going to be looking for. If Mr. Kennedy is confirmed as Secretary of HHS, he will have a platform second to none. You know, he's occupied a major platform throughout the world over the past decade with regard to the issue of vaccines and all the misinformation and disinformation he has shared about that. That will now put this on steroids and he will be able to say to many people in the public who don't understand his lack of scientific rigor when it comes to vaccine preventable diseases will in fact, now say, well, here he is, the secretary of Health and Human Services.

Dr. Osterholm: You know, he's he must be someone that we can all believe in. And we know that he is, in fact, an anti-science individual who, unfortunately, from time to time, does have bits of information he puts forward which are legitimate. And one could argue that would be something to really have a detailed discussion about. But then he mixes that in so often with just clear, frank disinformation misinformation. And we know that he knows better than that. I likened it in an earlier interview I did this past week to trying to nail him down, and what he actually believes is like trying to nail Jell-O to the wall. And in that regard, this is a challenge. He is a communication expert from how he presents what he believes, but at the same time it is often couched in this situation of not being truthful. So he's slippery. You know, when he says he's not an anti-vaccine guy, he tries to convince you that he's just out there to protect you. He's just trying to find the truth, when in fact there is no truth to that whatsoever. So that's number one is going to be just how do we deal with his disinformation? Number two is all about the topic that I shared with you last week. Title 42. Title 42 is the job classification used to attract many of the senior leaders throughout the agencies in the public health Service and bring them into the federal government, as salaries that are much higher than otherwise would be available for a government position.

Dr. Osterholm: Today, if you look across the number of HHS agencies CDC, FDA, NIH. All these agencies are literally led by individuals who are in the classification of title 42. Now, there is some debate about this, and this is again why I want to be clear about let's not speculate too far ahead of our headlights here, but in fact, there are some who have concluded that these are the individuals that the president could summarily fire on day one of his job. And there have been threats to that, as you know, uh, Mr. Kennedy himself has said, you know, pack your bags at FDA, get out. You're done. Um, and there may be a reason for which they need to be concerned about that. If this were to happen, it would be like cutting off the head of our body and then saying, well, the rest of you just continue to function. These are the senior leaders. When I go to meetings of, you know, at the highest levels in government, um, dealing with issues around vaccines, with outbreak control, etc. it is dominated by really talented title 42 employees of these different agencies. I can't imagine if they were all suddenly gone. We need to follow this one very, very closely. And let me just conclude, there is no plan that we have seen that has been put forward to how do you replace these individuals? What do you do to to account for suddenly losing their expertise? It was interesting.

Dr. Osterholm: I heard one European researcher, a very prominent researcher, note this this past week that in fact, now would be the time for the Europeans to try to hire some of the very best scientific expertise in the world because they're likely to be fired from their jobs they have now. That's that's a very sad and unfortunate comment, but it's maybe very real. What is it going to have in terms of agency impact? Well, as I just noted, the secretary doesn't have the ability on a day to day basis to get down into the weeds, but they do have the ability to affect certain programs. Let me give you one. I think you're all aware that most vaccines, and particularly vaccine manufacturers, have protection against lawsuits, and they have had for the last 40 years for potential adverse events with their vaccine. The National Childhood Vaccine Injury Act of 1986 was put into place because at the time, we were beginning to see manufacturers get out of the business. We were really concerned about a major shortage of vaccines in general, and that was because of lawsuits that were filed after potential and I say potential adverse events associated with the vaccines. There are some that are real. We have to acknowledge the very rare safety issues that do occur from time to time.

Dr. Osterholm: And so with the National Childhood Vaccine Injury Act of 1986, there was actually a system set up such that there was a 75 cent a dose tax on all vaccines that were manufactured that would go into a fund with a system set up within HHS to adjudicate these questions about, did the vaccine actually cause this adverse event and to then be subsequently compensated? And it was amended most recently December 13th, 2016. We still know that there's more that can be done to better address the issues of potential, uh, adverse events associated with vaccines. But the bottom line is, is that this is a program that the secretary could impact. This program is guided by an advisory commission on childhood vaccines. Uh, nine individuals from outside of government. And right now, only two of nine members of this commission have membership terms that go through 2026. In short order, it's very possible that the Secretary could appoint at least seven new members to this, uh, and could dramatically change the whole approach of how this is taken. Remember, Mr. Kennedy has said multiple times that there today is no way for a individual to sue a vaccine manufacturer for an adverse event potential. Well, we've already agreed that, yes, this is now part of this other program that was set up so that we wouldn't drive vaccine manufacturers out of business, but at the same time, be certain that we take care of those few people who have adverse events.

Dr. Osterholm: Now, the last point is the other appointments that I mentioned, this is number four. We'll have to wait and see. You know, as I said, I could sit here and speculate with you who some of these names are, the ones we've all heard have been of grave concern because, again, what I would consider their anti-science approach, uh, the issues that they've raised. And we'll just have to wait and see. This is what we promised to share with you over the days ahead when new appointments occur. What does this mean? Uh, when new programs are were initiated. What does this mean? And we'll continue to try our best to make sure that you're kept up to speed. The bottom line message is don't go off the cliff right now. I can't say that any more clearly. And I know I have that feeling sometimes myself, like, oh my. But right now we just need to be mindful of what's happening. We need to keep a 360 degree view of the world, and as individuals are confirmed and assume their leadership positions in these agencies, it will be our time to keep very close track of what's happening, to keep you informed and as a public health community, to be prepared to respond to anything that we believe is challenging better public health.

Chris Dall: So now back to our regularly scheduled programing. And let's start first, Mike, with the H5n1 avian flu outbreak, because there's been a lot more news on that front in the past week, starting with news from Canada that a teenager in British Columbia with an H5n1 infection is in critical condition. Mike, what do we know about this case and where does it fit in with the wider outbreak that we've been covering?

Dr. Osterholm: Well, Chris, let me just be very clear. I think I know less about influenza today than I did ten years ago. And as you know, I have done a lot to study the issue of influenza, its epidemiology, its virology, its the vaccine related issues. And it seems as if this virus and Mother Nature just keeps throwing curveballs at us that make calling balls and strikes impossible. And it's one that I think we all have to have a high dose of humility here. So let me just kind of paint the picture. At the time of this podcast, the case you mentioned, Chris is still in critical condition and our thoughts are with their family during this time, navigating a sick loved one and sharing information with health officials. We know that this teenager was otherwise healthy and had no preexisting underlying medical conditions. They were hospitalized last week with a severe respiratory infection, presenting with cough, fever, and conjunctivitis. The symptoms worsened and the patient was tested for a range of acute respiratory illnesses as part of a routine surveillance, which first indicated that he or she was infected with an H5 influenza virus, presumed to be H5n1. Genomic sequencing of the viral isolates from this patient point to the relatedness to wild birds and poultry, not to dairy cattle. To provide further information to clarify what this genomic sequencing data means, if we look at the current clade of H5N1, that big family of H5n1, the virus that is dominating across the world, whether it's in poultry or it's in dairy cattle, is one that's 2.3.4.4b.

Dr. Osterholm: But then in addition to that, the cattle Related of genotype is AB3.13, and the genotype for the virus isolated from wild birds and poultry is D1.1 and actually D1.2. Both have been seen in recent weeks. Now why is this important? Because the changes we've seen genetically in the wild bird viruses, the D1.1 and D1.2 actually caused us to have more concern about how these mutations are developing and what might they actually increase the likelihood that this virus could cause infection in humans in such a way as to create a classic influenza and potentially spread the virus? Now, the case that we're talking about here in Canada, there's been no evidence that this individual has transmitted the virus to anyone else. Yes. It's unclear whether they actually picked it up. I'm quite convinced it had something to do with wild birds breathing in the virus that wild birds shared. Somehow, some way is just not clear. At the same time that we're also hearing this week about a second case, maybe somewhat similar, occurring in California. Again, waiting for further confirmation on this, but at the time of this recording, it was clear that it was an H5 virus. It's unclear whether or not it's the same D1.1 genotype. What I'm really looking at carefully right now are these bird virus infections in humans, as opposed to concentrating solely on the dairy industry.

Dr. Osterholm: Don't get me wrong, it's surely possible that tomorrow the H5N1 we see in dairy cattle could in fact go through a reassortment event in an udder and give us a brand new virus that we're very concerned about. But let me just be clear. The virus that I'm hearing from my colleagues who are the real experts in viral genetics, viral sequencing of influenza viruses, will tell you they're more concerned about the D1.1 in the birds and this case that occurred in Canada. And we'll wait to see what the one in California is like. That could be a harbinger of things to come. Now, when we look back over the past year, we've had at least seven reported cases of severe illness, including death in individuals around the world who have had H5N1. And one of the issues is, well, that's been happening since 2003. What's different now? It hasn't led to widespread transmission. And that's true. What this all comes down to is we need to be much better prepared for a potential influenza pandemic. Right now, we are inadequately prepared with vaccines. We're inadequately prepared with antiviral drugs. We are inadequately prepared for the kind of testing issues that would be confronted with if we had an influenza pandemic. So that is my bottom line. It doesn't matter whether we're talking about the dairy cattle, we're talking about wild birds.

Dr. Osterholm: We are going to see an influenza pandemic in the future. We just don't know when. And as we used to say over the years, the pandemic clock is ticking. We just don't know what time it is. Now, let me just do add that I still am concerned about what's happening in dairy herds. Just this past week. California has contributed again a number of new dairy herds. 335 dairy herds have now been infected with H5N1 in California, a total of 549in the whole country. And by the time you listen to this podcast, it could very well be up another 30 or 40 farms. So we do have a lot more work here. We don't want flu viruses transmitting anywhere, particularly between animals and people for what they represent, but will, in fact the dairy industry be the source for the next pandemic virus? I don't know. I don't think anyone knows. And the real question is, will the wild bird virus that moves with migrating birds and then causing these illnesses and humans that we've just talked about or transmitting to large poultry flocks, will that be the source? I don't know, but all I can tell you is it is going to happen someday. We're not prepared for it. And in the meanwhile, we're going to keep talking about this, even though we're going to watch a world that is doing little to get better prepared.

Chris Dall: And now on to COVID. Mike, you mentioned last week that we would be getting data on COVID hospitalizations now that US hospitals are required to report numbers of patients hospitalized with COVID-19, flu and respiratory syncytial virus. What are we seeing in that data and in other COVID metrics?

Dr. Osterholm: That's right. Chris. We've been making assumptions about hospitalization data for months, and the day is finally here in the first hospitalization update since the November 1st transition. 84.1% of hospitals, rather than a third of hospitals, are now reporting their data. We expect to see that number increase to close to 100% in the near term, while even the 84.1% is not perfect, it sure is providing us with a more complete picture. That 30% we were seeing in the weeks prior, the week ending November 9th. In these, 84.1% of the hospitals were reported data, just slightly less than 1% of the hospital beds, 6184 were occupied by a COVID-19 patient. Let me remind you that in last week's episode, we estimated there were around 6500 patients hospitalized with COVID-19 in the last week of October. So it seems that our assumptions were not too far off, and this is a good place to be compared to. To what we've seen during other points in the pandemic. Don't forget that here we sit here today talking about hospitalization of around 6000. If we go back to January of 2021, when Alpha was just emerging, we saw 130,000 hospitalizations that week. When we saw Omicron emerge in January of 2022, we had 155,000 hospitalizations in a given week. So clearly we're in a much, much better place than we ever were during the pandemic.

Dr. Osterholm: But yes, we know we can and must do better. Aside from the new hospitalization data, not much has changed since our last episode in terms of other COVID metrics. Wastewater levels remain low across the country, and the slight increase we had seen in the Midwest has leveled off. One state, New Mexico, did report very high viral activity, so we'll keep an eye on that in the coming weeks. Weekly deaths continue to decrease with 675 deaths in the most recent week, with complete death data, which marks the 19th straight week above 500. As you remember with last week's podcast, I went into some detail about the number of deaths and what this means. And as we look at 675 deaths, there's still a lot of preventable deaths in that. Were we able to get particularly older individuals vaccinated? And in that regard, the adult vaccination rate went up from 14.6% last week to 17.4%. I'd love to see it much higher. It is notable that this is still ahead of what we saw last year at this time. The vaccination rates in kids increased from 6.2 to 7.9%, which is just about where we were last year. Now shifting over to flu and RSV, which is also now included in the hospitalization data updates as well.

Dr. Osterholm: Of the 887,000 inpatient beds reported for the week ending November 9th, about 0.2% were occupied by influenza patients. This is still low and consistent with the minimal wastewater concentrations we're seeing across the vast majority of the US. Every state, with the exception of two, are considered either minimal or low. California is considered moderate and Rhode Island is considered very high, so we'll be sure to keep an eye on that. Despite this low activity across the country, there has been a slight increase in flu activity in kids. Now is the time to get your flu shot. The RSV picture is very similar. The same percentage, about 0.2% of inpatient beds were occupied by RSV patients for the first week of November, and wastewater concentrations are considered minimal across the country. Washington, D.C. did report very high RSV levels in their wastewater, and Hawaii and Maryland were moderate, while the remaining states were all either low or minimal. We'll keep an eye on the respiratory pathogen picture and keep you updated, but for now, we're in a pretty good place heading into Thanksgiving next weekend. One last plea. As I noted earlier about vaccines, please get up to date on your COVID shot, your flu shot and your RSV shot. It surely could be something that could save your life.

Chris Dall: Given that we've been talking about the nomination of a man with well-known anti-vaccine views to be secretary of the Department of Health and Human Services. It seems worth mentioning that the World Health Organization and CDC last week reported that there were an estimated 10.3 million measles cases globally in 2023, a 20% increase from the previous year. Furthermore, only 83% and 74% of children received their first and second doses of the measles, mumps and rubella vaccine last year, respectively. Why are those numbers important? Because coverage of 95% or greater of two doses is needed to prevent outbreaks caused by this highly contagious virus. Mike, how concerned are you about this global backslide on measles?

Dr. Osterholm: Chris, the short answer is that I'm very concerned. And while it's certainly alarming, it's not surprising. Measles, mumps and rubella vaccination have been in steady decline over the last two decades. The MMR vaccine is highly effective, and I think its success has almost been its downfall. It has put measles so far in the rear view mirror that the public has lost touch with how big of a threat it really is. In 1912, when health care providers in the US were first required to report measles, there were an average of 6000 deaths per year in a population about one third of what we have today. But this isn't purely an issue of mortality in the mid-20th century. Approximately 48,000 people were hospitalized with measles each year, and over 1000 suffered from encephalitis, or swelling in the brain. By the early 1960s, it was estimated that between 3 to 4 million people were infected with measles in the US every year. For comparison, in 2023 there were 59 cases in the US. You heard that right 59 cases. This is an incredible success that we can attribute to a highly effective vaccine with a very strong safety profile. There are a number of reasons why MMR vaccine rates have declined, but I want to call out three in particular. The first is a targeted disinformation campaign about the safety of the vaccine from leaders, including RFK Jr.

Dr. Osterholm: That has led to an erosion of trust in all vaccines, but especially MMR. We have an overwhelming amount of data to show that it is not linked to autism or other neurodevelopmental outcomes, but misinformation persists. Second, a global pandemic and multiple other humanitarian crises in Ukraine, Gaza and the DRC have made it more difficult to ensure children are getting all their scheduled doses of these critical vaccines. Finally, the public sentiment around vaccine mandates has made the public more antagonistic towards public health guidance on what they should or shouldn't do regarding their health. This was accelerated rapidly following the rollout of the COVID-19 vaccine and the associated mandates. This is a frustrating reality that I can only anticipate will worsen given the country's new leadership. However, we can fight misinformation. We must encourage our family and friends to get all loved ones vaccinated. People may not want to read a fact sheet on a CDC website, but they might listen to a trusted voice. If you as a family member, a neighbor, a health care provider, if you can help share the truth about these vaccines, both their benefits and what happens when you don't get vaccinated, hopefully this will be what moves the needle. No pun intended, on this very important issue, one that is all about, again, life and death decisions.

Chris Dall: Now for a little good news. Last week, the CDC reported a 1.8% decrease in sexually transmitted infections in the United States. That's a small decline, but it's noteworthy because the numbers have only been going up for nearly two decades. Could we be turning a corner on STIs?

Dr. Osterholm: This is right, Chris. While 2.4 million sexually transmitted infections, or STIs in the US in 2023 isn't exactly worth celebrating, it is a step in the right direction when we consider the context of what we've been seeing over recent years. Since 2011, there has been a 42% increase in STIs in the United States. However, 2.4 million cases of syphilis, gonorrhea and chlamydia mark a 1.8% decrease overall in the number of STIs from 2022 to 2023. Looking closer, there was a 7% decrease in gonorrhea cases, bringing case numbers down below pre-COVID levels and driving the overall decrease among STIs. After several years of double digit increases, syphilis cases only increased by 1%. The 209,000 syphilis cases marks the highest number of cases reported since 1950. I want to dive into these numbers a bit more, because this picture looks a little different when you consider each stage of syphilis from 2022 to 2023. There was a 10.2% decrease in primary and secondary syphilis. In other words, more recent infections, which is the most infectious stage when lesions and or symptoms are present. There has been a 5.9% decrease in early non-primary secondary syphilis, which is when there are no signs or symptoms of primary or secondary syphilis, but the initial infection occurred within the past 12 months. However, there was a 12.8% increase in cases of unknown duration or late syphilis, which means the infection occurred more than 12 months ago or the time of initial infection could not be determined. Finally, and most frustratingly, there was a 3% increase in the number of cases of congenital syphilis, which is when mothers pass the bacteria causing syphilis to their fetus or infant during pregnancy or childbirth. There were 3882 cases of congenital syphilis in 2023, which is the highest number of cases since 1992.

Dr. Osterholm: That is, 3882 cases of a completely preventable infection, easily treated with antibiotics during pregnancy that can lead to serious lifelong complications. Unfortunately, there were 279 congenital syphilis, stillbirths, and neonatal infant deaths reported. These cases shouldn't have happened. Yet in 2023, we're studying nearly a 30 year record. Overall, it is definitely a good sign to see a decrease in recent STIs. Despite the disappointing increase in congenital syphilis cases, there are a few factors that may have contributed to this decline. There are newly authorized at home STI tests, which make knowing your status and seeking treatment more accessible. There has been a national response to the syphilis epidemic. Additionally, a treatment regimen called doxy Pep doxycycline post-exposure prophylaxis, which is recommended by the CDC for high risk groups. Doxy Pep is the use of the common antibiotic doxycycline within 72 hours of sex to reduce the chances of getting syphilis, chlamydia, and potentially gonorrhea in high risk groups. I have some concerns about this approach when it comes to antibiotic resistance development, which gives me the perfect opportunity to plug our other CIDRAP podcast, Superbugs in You, which we will link in the podcast bio. It's also quite timely as this week is World Antimicrobial Awareness Week. Overall, I think we're finally in a first in a while hopeful spot when it comes to syphilis, but I hesitate to say that we're truly turned a corner. With the ongoing concern of antibiotic resistance coupled with drug shortages, including a recent months long shortage of syphilis drug Bicillin earlier this year. I don't want to get ahead of ourselves and celebrate a win when we've just seen a 70 year high in syphilis cases.

Chris Dall: And finally, we've also had some good news on the Marburg outbreak in Rwanda. What can you tell us, Mike?

Dr. Osterholm: Well, Chris, it's been a few episodes since we last covered Marburg, and I'm really happy to report that we have some great news to share. There's been no new cases of Marburg associated with this outbreak since October 30th. The last patient who was in isolation for the virus had a negative PCR test on November 9th, which means that there are currently no known infectious patients in Rwanda. If there are no additional cases reported, the outbreak will be declared over on December 21st, which is 42 days. Or in other words, two incubation periods from when the last patient was no longer infectious. This would bring the outbreak to a total of 65 confirmed cases and 15 deaths, yielding a case fatality rate of 23%. This is on the lower end of what we would expect to see for Marburg virus, but I think can be accounted for by the excellent health care that was provided by the Rwandan government. I want to acknowledge the incredible work that's been done by public health officials and the health care providers in Rwanda to control this outbreak. I think it's fair to say that we all needed some good news. So I'm glad that we're able to share this positive update with you all today. It's also a reminder when you invest in infrastructure, the payback can be enormous. And that's exactly what happened with Rwanda. They made real investments in their public health and health care systems and it showed. It really showed.

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

Dr. Osterholm: Chris with every podcast. I really love this particular section and this one that we've chosen today has some what I consider to be significant connections to the modern world of what we're living in. We've spent quite a bit of time talking about the current nominee for HHS secretary, so I thought it'd be appropriate to go back in time to learn about the first person in that position. Patricia Roberts Harris was born in 1924, in Mattoon, Illinois. Her father was a waiter on a railroad dining car, and she was raised by her mother and grandmother. She was a bright student and attended Howard University, where she graduated summa cum laude. She was active in fighting for civil rights, and participated in one of the first diner sit in protests in the country in 1943. Harris attended George Washington University for law school and graduated top of her class. Harrison's intelligence and passion for social change led her to achieving many firsts for black women. Harris was the first black woman to serve as Dean of Howard University School of Law. First to serve on the board of a fortune 500 company, and the first to enter the presidential line of succession. Patricia Roberts Harris held numerous high profile legal and advocacy roles across the District of Columbia, which gained the attention of multiple U.S.

Dr. Osterholm: presidents. President John F Kennedy appointed her co-chair of the National Women's Committee for Civil Rights. President Lyndon B Johnson appointed her as the U.S. Foreign Ambassador. President Jimmy Carter appointed her as Secretary of Housing and Urban Development. She was highly successful in this role by rehabilitating housing and bringing businesses back into struggling neighborhoods. She was then appointed by Carter to bring her expertise to the largest government agency at the time, health, education and welfare legislation. Organizational changes made it clear that a split was necessary to organize all the work encompassed in this agency. Therefore, two departments were made, the Department of Education and the Department of Health and Human Services. Harris therefore became the first Secretary of HHS, which she led with integrity despite financial and political challenges. Harris passed from breast cancer in 1981 at the age of 60. She leaves a powerful legacy, including an induction into the National Women's Hall of Fame in 2003. I hope her story is inspiring to those who strive to fight for common good of a country and the world, and someone who was an exemplary leader.

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

Dr. Osterholm: Well, Chris, it's pretty simple. We got to stay the course. Now is the time to keep our heads. Now is the time to keep in touch with everything that's going on around us, but not go off in tangents because someone noted that this person might get this job, or they get that job, whatever. We've got to be strategic and thoughtful. We've got to be steady and we've got to support each other. I think that right now is by far the most important message we can deliver. Let us know what's going on around us before we make decisions and how to act. Number two, we want your input. We really need your input. How can we better focus this podcast to give you the kind of information that you want and need as it relates to what's happening with this administration and public health in general? We are open to your input. We need your input. We appreciate your input. So please let us know. How can we do a better job? The entire podcast team is committed to that. And we know that with your advice, we can even do a better job.

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

Dr. Osterholm: Well, this is what I would call a favorite knock off song. What is that? Well, you all are very aware that Bill Withers Lean on Me has been a very popular song on this podcast. I've chosen it four times to use it as a closing first on June 10th, 2020, in Episode 11, then in April 22nd, 2021 in Episode 52, and October 28th of 2021, we used it in the 75th episode, and finally we used it on November 16th, 2023, almost a year ago in Episode 144. And why did I bring up this song Lean on Me by Bill Withers? If I'm not going to use it? It's because, in fact, the song that we have chosen was one inspired by Bill Withers Lean On Me, and it conveys a very similar message of offering support and a safe space to a loved one. The song We've chosen, written by Chris Stapleton and several of his colleagues. Weight of Your World was from his 2023 album higher. The melody of the verse subtly hints at that. Lean on me and I think you'll. If you were to hear it sung by Chris Stapleton, you'd catch that. I just want to say thank you to Chris. I think this is a very, very meaningful song and one for the times, one we need. So here it is. Chris Stapleton, Weight of Your World I want you to know wherever your road wants to go I'll never be far.

Dr. Osterholm: I'll always be right where you are. If you lose your way. If your hope is gone. I'll be the light that leads you home. Give me your darkest hour. Give me your darkest fear. Just give me a call and I'll be here. Give me the bars and the chains. That won't set you free. Give me the weight of your world. And lay it on me. There will come a time when all the words don't seem to rhyme. Please lean on me until you find the harmony. When it's hard to breathe. When the right seems wrong. I'll be the hand that helps you along. Give me your darkest hour. Give me your deepest fear. Just give me a call and I'll be here. Give me the bars and chains that won't set you free. Give me the weight of your world. And lay it on me. Wherever you go. Wherever you've been. Any time you need a friend. Give me your darkest hour. Give me your deepest fear. Just give me a call and I'll be there. Give me the bars and the chains. That won't set you free. Give me the weight of your world. Lay it on me. Just lay it on me. Chris Stapleton. Weight of your world. What a beautiful song. And I hope that all of you today listening.

Dr. Osterholm: Got the kind of information you are looking for. If not, do let us know how we can improve on that. I hope this closing song has some meaning to you. Makes you all take a moment to think about what's really important in the world right now. Thank you so much for your support. I have to tell you, you know, because some of you know, already listening to this podcast, I can't help but share a bit of my heart now and then as much as my head. The last couple of weeks have been hard for all of us. They've been very hard. Wondering what will happen, what it means for our world and coming together as we do around this podcast has been a gift to me. I want to thank you for that, and I want to thank the podcast team and just know, as I shared with you before, we're here, we're committed for the next four years. You're you're you're locked in with us and we're going to make a difference. So thank you very much. Have a very good safe Thanksgiving holiday. Enjoy that food. Be careful how you prepare it. No foodborne outbreaks. Okay. And and we look forward to seeing you in two weeks. And most of all, just thank you. Thank you so much. Be kind. As Chris Stapleton said, just lay it on me. Be kind.

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