Episode 203: Somebody to Lean On

Chris Dall

Hello and welcome to the Osterholm update, a podcast about infectious diseases and public health featuring Doctor

Michael Osterholm. Dr. 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, Dr. Osterholm

draws on over 50 years of experience in infectious disease epidemiology to provide straight talk on the latest

infectious disease outbreaks, counter misinformation and disinformation about vaccines, and distill the complex and

ever evolving public health threats facing our world. 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. A little more

than two weeks ago, vaccine maker Moderna shared news that the Food and Drug Administration had refused to

review its application for the approval of its new mRNA based flu vaccine. The reason provided by the FDA was that

the company's phase three trial for the vaccine, which included 40,000 adults, did not provide the best available

standard of care, unquote, for the placebo group. The decision was widely criticized by public health and infectious

disease experts and sent shockwaves through the biopharmaceutical industry, which had already been putting the

brakes on investment in vaccine development in response to the Trump administration's increasingly hostile position

on vaccines.

Chris Dall

There will be less invention, investment and innovation in vaccines generally across all the companies. Dr. Stephen

Hoge, President of Moderna, told The New York Times. The good news is that one week later, the FDA reversed

course, saying it would review Moderna's vaccine after meeting with company officials. But the episode raises larger

questions about what exactly is going on at the FDA and what the impact is going to be on drug development

altogether. Add in the recent leadership shakeup at the centers for Disease Control and Prevention, and there are

even bigger questions about the nation's ability to respond to another public health emergency. The chaos in the

nation's federal health agencies will be among the topics we cover. On this February 26th episode of the Osterholm

update, episode number 203. We'll also discuss the latest news on US measles outbreaks, provide a viral respiratory

update, and answer an ID query about vaccine recommendations for COVID, flu, and RSV. And we'll bring you the

latest installment of our This Week in Public Health History segment. But before we get started, as always, we will

begin with Dr. Osterholm 's opening comments and dedication.

Dr. Osterholm

Thanks, Chris, and welcome back to the podcast family. It's great to be with you again. I had an opportunity over the

past several weeks to meet a number of you that I had not previously met. And again, as we often say here at

CIDRAP, your input is invaluable to us. And so thank you for the information you shared with us. For those who might

be joining today for the first time or only have visited us a few times, I hope again we're able to provide the kind of

information you're looking for in both in terms of the science, but also about life itself and how we're all trying to

manage in these very difficult times. Before I go on, I just want to update you all on what it's like to be in Minneapolis

today. First of all, the days of the ICE movement through the city has surely changed. It is no longer anywhere near

what it was a month ago, but we're still seeing some activity and obviously that's a concern. I also just want to note

that I have never been more proud to be a Minnesotan than I have over the recent weeks. I watched a community,

millions of people come together out of kindness, out of care and concern about their fellow humans and with a

purpose of peace, a purpose of how can we make our communities better? And Minnesota did it.Dr. Osterholm

We stood up and stood out. You know, I can tell you from where I live in downtown Minneapolis, watching 60,000

people parade through the city in -18 degree weather, peacefully chanting for the need to end the horrible scourge of

attacks that we saw in this city. It was a remarkable experience. And so to all Minnesotans, thank you, thank you,

thank you. Standing up for what's right is not easy, but doing it is a gift. And now I'd like to move on to our

dedication. This dedication is really an extension of the comments that I just made. In fact, this week's episode is

dedicated to one of the fastest growing jobs in America, which is certainly one of the most important, but also one of

the most challenging all the health care workers, home health aides, public health nurses, direct support

professionals, nursing assistants and other caregivers who take care of our elders and other vulnerable members of

our communities. These workers help with everything from bathing to meals to making sure folks get their

medications. They drive them to appointments, help them with groceries, and offer a sense of companionship. And in

many cases, they end up treating one of the worst diseases of all society loneliness. And they do that by their actions

and their kind words. Many of us know firsthand how taxing this sort of care can be, whether it's caring for our own

aging parents, relatives, or neighbors.

Dr. Osterholm

This work, although rewarding, can often be physically, mentally, and emotionally challenging. But it is such an

essential skilled work not only to these care workers take on the critical physical health tasks needed to support our

aging population, but they ensure that our elders have a friendly face to talk to and don't have to face illness alone.

Last month, the US saw a surge of people joining the elderly care workforce. The majority of these workers are

women, and over a quarter of the workers are immigrants. In some locations, that number is even substantially

higher. This is another important reminder that immigrants are a part of the fabric of our communities and health

systems, and are under further strain given the recent policy actions. As vital as this work is, it's not always

adequately compensated. Median salaries for home health aides sits around $35,000 a year, and for nursing

assistants, it may be as high as $41,000 a year. But both are well below the national median household income of

$49,500. So this podcast is dedicated to the caring, kind, and compassionate people who show up for our community

day after day. Thank you for your early mornings or late evenings, and for bringing compassion to spaces that can

only feel lonely or overwhelming. We know the work is not glamorous, often goes unrecognized, but we hope you

know you bring immense value to patients and to their families.

Dr. Osterholm

Your kindness and care is the exact thing we need more of in this world at this time. So let me follow through on what

I also consider to be a very bright spot in our community. That is the sunlight. Yep. Today in Minneapolis, sunrise is at

6:55 am, sunset at 5:56 pm. That's a whole 11 hours and 46 minutes of sunlight. We are gaining sunlight right now at

three minutes and four seconds a day, which will increase to three minutes and nine seconds a day from March 12th

to March 25th. And then, while the days will continue to get longer, the actual length of new increases in light will get

shorter. And then after March 25th, the numbers start to drop again. We're increasing sunlight, but just not at the

same rate. So get ready to celebrate. The coming of the sun is actually happening. Now to our dear, dear friends and

colleagues in Auckland, New Zealand, at the Occidental Belgian Beer House on Vulcan Lane, I'm happy to report

today that you had sunrise at 7:02 am, sunset at 8:04 pm. That's 13 hours, one minute and 37 seconds of sunlight

today. Not bad. Now you're losing your sunlight. Yes, we understand that. But as we're gaining hours, we're more

than happy to share with you our dear, dear friends and colleagues at the Occidental with our sunlight.

Chris Dall

Mike, let's start with the FDA's back and forth on the Moderna flu vaccine. It seems like this whole saga is in part a

reflection of the administration's hostility to vaccines, particularly mRNA vaccines. They want to make it harder to get

vaccines approved. And while the FDA's change of heart on the Moderna flu vaccine is good news, it doesn't seem

like the reversal has clarified much. So what does this all mean for vaccine development?

Dr. Osterholm

Well, Chris, let me just begin by putting what's happening right now into some context. I had the good fortune a

number of years ago of working with Tom Clancy, the famous book author. And one night at dinner, I'll never forget,

he looked at me and he said, young man, there's one thing you must never forget. The only difference between

reality and fiction is that fiction has to make sense. Because when you look at what's happening in the overall issue

of leadership messaging, important health decisions being made, this is absolutely a disaster. These rapid reversals

create a confusing case of policy whiplash. But I'll try to walk through what happens chronologically. But hold on.

We're writing a public health ship that absolutely has no rudder. As you noted. On February 3rd, the FDA issued a

letter to Moderna stating that it would not be reviewing the company's application for its new mRNA influenza

vaccine. Importantly, the agency did not cite safety concerns. Instead, it declined to even review the materials

submitted, arguing that the clinical trials did not use what they consider to be the appropriate, quote, state of art

comparator in the control arm. Just to be clear, this idea of a standard of care comparator is a term that is not at all in

any kind of FDA guidance or has ever been used before to discuss vaccine effectiveness. So it was unclear to all of us

what did this all mean? Well, the decision came from the director of the center for Biologics Evaluation and Research,

CBER.Dr. Osterholm

This is Dr. Vinay Prasad. The agency stated that Moderna should have compared its investigational vaccine to a high

dose influenza vaccine. In fact, Moderna did conduct phase three trials, One, comparing his mRNA vaccine to a

standard dose vaccine for adults aged 50 and older. And it also compared from an immunologic standpoint, i.e.

antibody response vaccine, against a high dose flu vaccine in adults 65 and older, according to the company data.

Both the first trial and the immunologic data met primary endpoints and demonstrated superiority over the

comparators. Notably, the FDA previously reviewed and cleared the trial designs even before enrollment began. If

you want a fully detailed review of how these trials were conducted and why this decision from FDA was so

egregious, I encourage you to read Dr. Jake Scott's op ed he wrote for CIDRAP news. We will be sure to include the

link to that article in the show notes. Responding to the FDA's refusal to review letter, Moderna's president Stephen

Hoge stated in an interview with The New York Times that he was confused by FDA's decision, particularly because

the vaccine application had already been accepted for review in the EU, Canada, and Australia. The FDA was acting

completely out of step with regulatory norms, international consensus, and frankly, its own word.

Dr. Osterholm

Of note, we learned that those professionals inside the FDA who have been leading studies of vaccine effectiveness

and safety for many years, strongly supported a review of the Moderna vaccine and the decision not to review it was

based on 1 or 2 people who felt strongly about mRNA technology. Now fast forward to February 18th. A little over two

weeks later, suddenly, in a press release, Moderna described a constructive meeting with FDA officials and said that

the review was moving forward. It's difficult to decipher what brought about the change of heart in the FDA, but

there's plenty of speculation. For example, the night before this new decision was announced to go ahead and review

the vaccine. Secretary Kennedy had met with a group of pharmaceutical industry representatives and stated clearly

that the decision was the right decision and that the vaccine would not be reviewed. Then, some 12 hours later, the

FDA announces no. In fact, it will go ahead and support this and review the vaccine. Now what happened? Politico has

reported that the FDA commissioner, Marty Makary, was called to the white House to discuss the situation. As

midterm elections approach, polling continues to show that vaccines are generally well supported by the American

public, and that HHS actions against vaccines could carry political consequences. White House officials have denied

the claims that President Trump applied pressure on this situation, but there is far too much information available to

support that.

Dr. Osterholm

The White House had a major role in the decision to finally review the vaccine. So what are the takeaways from this

fiasco? First, the FDA has once again proven itself to be unreliable and not built upon a foundation of strong science,

evidence and integrity. They have proven that even without explicitly citing a safety concern, they can still send

powerful and confusing signals to the public that can disrupt the credibility of vaccines more broadly. Second, while

the review is moving forward in other major markets across the globe, the American people may be losing out on

important next generation vaccines for a virus like influenza, where especially trying to hit a moving target. These

delays have practical public health implications. And finally, there are some very confusing ripple effects for

innovation. Vaccine development is expensive and high risk when regulatory pathways and anti-science rhetoric

erode the pathway to To implementation companies shift priorities to more profitable or secure product lines. Less

than a month ago, Moderna CEO Stéphane Bancel stated that the company may scale back future late stage vaccine

trials in the US if these barriers persist. This tension in the vaccine policy and development landscape is only

increasing, and if it finally snaps, the damage won't just be limited to companies, it will hit all of us. What a way to

conduct business.

Chris Dall

As I mentioned in the introduction, the FDA isn't the only federal health agency seeing upheaval. In the past two

weeks, the CDC has seen the removal of acting director Jim O'Neill and his replacement with Jay Bhattacharya, who

also happens to be the head of the National Institutes of Health, an agency that has several open director positions.

And just earlier this week, the CDC's deputy director resigned. Mike, this reminds me of the Abbott and Costello

"Who's on First?" routine. But it's not funny. Who exactly is going to be calling the shots if we have some kind of

major infectious disease outbreak?Dr. Osterholm

Well, Chris, the honest answer is we don't really know. And at this point, I am absolutely certain no one really knows.

In terms of the leadership at CDC, we're yet again seeing turnover and shifting of roles. As you mentioned, the

removal of acting director Jim O'Neill was followed up with news that Jay Bhattacharya, who is also the current NIH

director, would now be leading the agency. So in the span of just over a year, we have seen four different leaders

atop of the CDC. At this point, it almost starts to feel like a bit of musical chairs. And that's not what we want. When

you're thinking about preparedness for any kind of major outbreak that could emerge. On top of that, with the latest

change, there is now the added complexity for the same person in charge of CDC also happens to be running the NIH

to help put this into perspective. The CDC has more than 11,000 staff working across dozens of centers and offices

on a wide range of issues, including everything from infectious disease surveillance and outbreak response to chronic

diseases, injury prevention, environmental health, lab science, you name it. And let me remind everyone what's

happening. Also with what I would call the mid-level expertise at CDC. Over 80% of the center directors have left CDC

with this administration. Most of them have been replaced by interim or temporary individuals, not the kind of

leaders that were there prior to the new administration. Now, let me be clear. There are many outstanding people

working at CDC.

Dr. Osterholm

The problem is it's not their leaders. And that is where the challenge begins. And if we're going to have a crisis that

we have to respond to, we not only need staff, but we need critical leaders. They won't be there. Meanwhile, the NIH

has roughly 20,000 employees working across 27 institutes and centers. It's the largest public funder of biomedical

research in the world, supporting hundreds of thousands of researchers nationwide. So clearly, these are very large

organizations, each with different missions, structure and operational demands. Running just one effectively is a full

time leadership responsibility. What is Dr. Bhattacharya doing with both of them? Under his leadership tent, and as I

just noted, beyond the role of the top director, there are other leadership gaps that exist across both agencies and

are also challenging at the time of this recording. There is no director of the National Center for Emerging and

Zoonotic Infectious Diseases at CDC, which plays a key role in terms of outbreak detection and response. And if you

look at NIH, only 11 of his 27 institutes and centers have permanent directors in place as of mid-February, according

to a story published by NBC news. All but two of the 16 current vacancies opened since the new administration took

over last January, so there are real questions about structure, authority and decision making that still need to be

ironed out. And make no mistake, these are questions you want resolved now ahead of a potential crisis and not in

the middle of it.

Chris Dall

And Mike, one final question here on federal health agencies, nature recently reported that staffers at the National

Institutes of Allergy and Infectious Diseases, which is part of NIH, had been ordered to remove the words biodefense

and pandemic preparedness from the institute's web pages. Your thoughts?

Dr. Osterholm

Well, Chris, this is the drumbeat continuing to get louder and louder and louder. I am deeply concerned about this, As

you mentioned, staffers at the National Institutes of Allergy and Infectious Diseases, or NIAID, which is part of the

National Institutes of Health, have been instructed that they must remove the words "biodefense" and "pandemic

preparedness" from their web pages. More importantly, they are also seen work that in the past was done by this

very important agency, no longer supported work that clearly was all about preparing us for a biodefense or

pandemic preparedness event. What we're seeing here is really part of a broader effort to overhaul Niad and its

efforts around these topics. The director of the NIH, as we mentioned just a moment ago now, also, the CDC director,

Jay Bhattacharya, has stated that the agency will shift away from anticipating future diseases and focus instead on

more basic immunology research and current infectious disease threats. While there is nothing wrong with putting

additional funding towards these other topics, we certainly know that immunology research and other infectious

diseases are important. I am very alarmed by the deprioritization of emerging infectious diseases and biodefense,

which completely makes up about a third of the agency's budget. HIV Aids research is also expected to be reduced as

part of this effort, which Bhattacharya referred to as a complete transformation of the agency. I'm sure that my

concerns about this come as no surprise to routine listeners of this podcast. Who knows that the next pandemic is

just a matter of when, not if.Dr. Osterholm

We know there will be future pandemics. So to avoid preparing for them is all but a guarantee that we will not be able

to adequately respond. I also have to point out the irony that an administration so critical of many aspects of the

COVID 19 pandemic response would choose to deprioritize funding for future emergencies if they found our response

to COVID so inadequate. Why wouldn't they want to put more funding into improving our response infrastructure

rather than less. It's tough to make any sense of this. This is exactly the worst fears of what I wrote about in my new

book, The Big One, that we would not learn from the past pandemic and understand how we could take the lessons

from that pandemic to make ourselves much better prepared for future events. That has all gone out the window in

this administration. Additionally, this is just one item on a long list of disruptions this agency has faced due to this

administration. It started with the firing of director Jeanie Maurizio, the successor to Tony Fauci, who served in that

role for 38 years. As more and more individuals with leadership were fired, we saw political appointees, often with

little or no expertise, coming in to replace them. At best, these individuals lacked the experience to do these jobs

effectively, and at worst, many came into these agencies with clear anti-science agendas. Then we saw the workforce

reduced by about 4000 people, 20% of the agency staff.

Dr. Osterholm

Next grants were clawed back, followed by back and forth in the federal court system, in which some grants were

reinstated and others weren't. Even for the grants that were reinstated, the lost time due to stop work orders and

uncertainty regarding future funding was very disruptive and detrimental to research. Among the research that has

been defunded over the past year was $500 million in mRNA vaccine research, which was a critical component of

future pandemic preparedness. I don't bring this up just to rehash old concerns, but rather to contextualize these

most recent events. These actions are not occurring in isolation. They are just one piece of a very complex effort that

this administration has taken on to dismantle our public health systems and the future pandemic preparedness. And

let me just leave you with might call one parting shot here. As much as we might want to diminish the whole issue of

biodefense and the potential for future pandemic, some of us are watching very closely as AI today is on its own,

generating a tremendous amount of information about infectious agents that could be new weapons of tomorrow. I

worry that one day we're going to wake up and realize we're being attacked by some now AI generated virus, and

we'll have no preparedness whatsoever for it. None. As much as this may be very important, it's also one that is

being completely ignored, if not totally buried.

Chris Dall

Let's turn now to the continued measles outbreaks in the United States. What are the current hotspots? And I also

want to note that Maryland last week reported an increase in mumps cases over the past month. Is that something

we're likely to be hearing more about from other states?

Dr. Osterholm

Similar to early measles outbreaks in Canada, we're beginning to see large outbreaks and in some cases, smaller

ones, but large numbers of clusters popping up in new states. The two biggest outbreaks remain in South Carolina,

with 632 cases, and Utah, which has 117 cases reported. I do believe that these numbers surely may be an

underestimate of actual disease occurrence in those communities. So far this year, and we're not even two months

into the year, we have logged 982 measles cases, all but six of them locally acquired in 25 states and New York City.

We've seen seven new outbreaks this year, leading to 73 reported cases. The remaining 797 cases are associated

with outbreaks that began last year. In comparison, 2281 cases and 49 outbreaks were reported in all of 2025. Let

me repeat this. If you look at all the cases reported in 2025, the worst year for measles we'd had in decades. That

only amounted to 2281 cases. Here we are, not even two full months into the year, and we're already at 982 measles

cases. We will far outstrip the number of measles cases this year compared to previous years. And where that ceiling

is on those numbers, I think is very difficult to know. In 2026, 4% of measles patients have been hospitalized, with 6%

younger than five years old and 7% in adults. In comparison, last year, 11% of patients were hospitalized, with 18%

in the youngest age group and 12% in adults.

Dr. Osterholm

Three people died, two of them children. Also, I want to emphasize that I do believe in 2026, the actual reported

number of patients who have been hospitalized or have had serious illnesses is truly underreported. We already have

evidence about this from South Carolina, where, for example, there is no mechanism for necessarily reporting for

how many people are hospitalized with measles. The epidemiology of measles has been changing in North America.

Before vaccination became available in the United States in 1963, virtually everyone contracted measles by age 15

and therefore had lifelong immunity if they survived the infection. Measles cases in adults were rare, but in 2025,

29% of those 2281 US infections in 2025 were among adults aged 20 and older. And of the 982 cases so far this year,

15% are in that age group. This is problematic in a couple of ways. First, just to understand that the reason we are

seeing these cases now is that these children were not vaccinated 20 years ago, and over time, there were enough

individuals vaccinated to keep measles from circulating. And therefore these unvaccinated individuals did not

become infected with measles virus, but now that's changed. This is an important issue in that we are going to see

more and more cases in adults, just because they have now made it into this age without having previously had

measles or measles vaccine. That's going to change. This is problematic in a couple of ways.Dr. Osterholm

Compared to infants, adults are much more likely to experience measles complications such as pneumonia and

encephalitis, and therefore more likely to be hospitalized. And because adults are also generally more mobile than

children, they may be more likely to spread the virus to other people. Also becoming more common is congenital

measles, something I could never even imagine seeing when I first started my career in public health. This is a

condition that was virtually unheard of until recently, because adults rarely are infected with measles in a highly

vaccinated population. But the pockets of under-vaccination we've been seeing have resulted in congenital measles

cases, putting newborns at risk for complications such as pneumonia, encephalitis, and death. At least six babies

were born with congenital measles in 2024 and 2025, in Canada, with at least one dying from their infection. Measles

infection in pregnancy can also lead to miscarriage and stillbirth. This is going to become a much larger problem this

year. 94% of measles cases in the US have been in people who were unvaccinated, or had an unknown vaccination

status. These infections were so unfortunate because they are preventable given the two doses of the measles,

mumps and rubella, or MMR vaccine, which is about 97% effective against measles and rubella and about 86%

effective against mumps. Yet in its latest update, CDC said only ten states and Washington, D.C., have maintained at

least 95% uptake of the MMR vaccine among kindergartners, which is a level needed to prevent outbreaks.

Dr. Osterholm

While we don't hear as much about rubella, it's no longer endemic in the US. It can still be imported from abroad and

circulate here. Rubella is less contagious than measles and causes mainly mild symptoms in adults, but it's very

dangerous in pregnancy and for a developing fetus, it can cause miscarriage, stillbirth and a number of serious birth

defects known as congenital rubella syndrome, that can have lifelong consequences. Congenital rubella syndrome is

rare, with 15 babies born with it in the US from 2005 to 2018, but it is almost 100% preventable with vaccination.

Women should be vaccinated before pregnancy, as the vaccine shouldn't be given to pregnant women. To highlight

the success of the MMR vaccine. Before measles vaccine became available in 1963, 400 to 500 Americans died each

year, 48,000 were hospitalized and 1000 developed encephalitis. Think of that again. Before vaccines were available,

400 to 500 Americans die each year from this. After the vaccines roll out, infections plummeted and the disease was

declared eliminated in the United States in 2000. Only recently resurging as a result of vaccine skepticism and

misinformation. In summary, the United States will lose its measles elimination status shortly. That will be an

unfortunate finding. But let me just be clear. It is just the beginning of what I believe is going to be a very significant

few years of major measles activity throughout this country.

Chris Dall

COVID?

Now it's time for the US respiratory virus update. Mike, what are we seeing with flu, respiratory syncytial virus and

Dr. Osterholm

Well, we're actually seeing more of the same across the board. Chris, let's start with flu where activity remains

elevated. We've been in somewhat of a holding pattern for the past five weeks without patient visits for influenza like

illness increasing one week and then decreasing the next week. These numbers have bounced between 4.4% and

4.7% of those presenting with influenza like illness, which is still higher than our national baseline of 3.1%. When we

can declare the end of the flu season. So, in other words, the flu virus just continues to hang on. This past week was a

decrease week, putting us at 4.5% of visits to doctor's offices with influenza like illness. It's to note that the 0 to 4

and 5 to 24 old age groups both experienced some increases in outpatient influenza like illness last week. Currently

at 11.7% and 8.6%, respectively. But all the other age groups remain steady or dropped. The school age population

of 5 to 17 year olds continues to experience the highest percentage of emergency department visits, resulted in a flu

diagnosis, and that percentage has increased every week over the past month as we continue through the latter part

of the flu season. We're seeing influenza B activity pick up, as we would expect. Remember, we have both influenza A

and influenza B occurring in our community.

Dr. Osterholm

Influenza A is the one that we often think of early in the flu season, with large increases in cases, and the one type of

influenza virus that can cause a pandemic. Over the last week, influenza B accounted for 18.5% of specimens

submitted to the CDC, and influenza A accounted for 81.5% of the subtyped influenza A specimens. 83% were H3n2,

which is what we expected to see, and 17% were H1n1. My take on the flu situation is that we are likely to see a

continued downward trend for flu, and that we're really past the flu season, as we might otherwise have considered it

in January. That's good news. It's not done, but it's good news. COVID remains relatively quiet across much of the

country. The national wastewater concentration is moderate and increasing slightly on the national level, as well as in

the south and the northeast. The concentrations in the Midwest remained high, but are decreasing in every age

group. Hospitalizations have decreased, and Ed visits resulting in a COVID diagnosis have remained steady. In terms

of monitoring variants for COVID, it turns out that there's nothing that really suggests that we're going to see any

uptick in activity in the near future.Chris Dall

Speaking of flu, RSV and COVID, that brings us to this week's ID query. Now, this is essentially an amalgam of emails

that we've been receiving over the last few weeks, but I think it reflects the lack of vaccine guidance that Americans

are getting from the federal government. So, Mike, what are the current recommendations for children and adults on

COVID, flu and RSV vaccines?

Dr. Osterholm

Well, Chris, let me first start by saying that I understand where the confusion is coming from, regardless of whether

we consider them seasonal viruses or not. All come with different guidelines and who should receive the vaccines and

when. Also, the mixed messages coming from the federal government regarding vaccine policy are only adding to

this confusion. I'll do my best to break down the current recommendations for you, our listeners. Let's start with

COVID vaccines. The CDC currently recommends the 2025 2026 COVID vaccine for all people ages six and older,

based on individual decision making. Remember that term, that whole thing about individual decision making? So

somehow you're supposed to talk to your healthcare provider, whether it be a physician, a nurse practitioner, a

pharmacist, whoever, and come to some agreement on whether you should get vaccinated or not. I find this useless

information only in the sense of saying that I think you should stay current on your COVID vaccines based on the

most recent information showing how COVID vaccine. Even at times when COVID is not ravaging a community, there

is still real benefit to reducing one's risk of serious illness, hospitalizations and death. So the CDC recommendations

go on and say those who are moderately or severely immunocompromised are eligible for additional doses at least

two months following their last dose of the COVID vaccine.

Dr. Osterholm

So you can get one dose, and if you are moderately or severely immune compromised, you're eligible for an

additional dose at least two months following the last dose of COVID vaccine. There are several different COVID

vaccines available in the US, and eligibility depends on age range and the presence of any underlying conditions. This

area can be very confusing and let me just say at this point, it's more important just to get your COVID vaccine dose

than to worry about which one you got. The Moderna vaccine Spikevax, is available to everyone six months or older.

The Pfizer vaccine is available to anyone five years or older. More recently, a new Moderna vaccine has become

available to anyone at least 65 years of age or older, and for those 12 through 64 years of age who have at least one

underlying condition that puts them at high risk of severe COVID 19 outcomes. The main difference between the two

Moderna vaccines is that M next spike has one fifth the dose of the Spikevax vaccine, and yet results show that you

get a better response. In fact, with the lower dose vaccine and there are fewer side effects. Lastly, there is a Novavax

vaccine available to anyone 12 years of age and older which uses traditional recombinant protein technology instead

of mRNA. So there is no reason why not to get vaccinated, even if you believe that mRNA technology is a challenge.

Dr. Osterholm

Now let's discuss flu vaccine recommendations. Now we're really talking more about seasonal illness. And one

question is if the flu season is almost over, do we still need to be vaccinating? Well, the CDC currently recommends a

yearly flu vaccination for people six months of age and older. The 2025 2026 flu vaccines are trivalent, which means

they are formulated to protect against three main seasonal influenza strains. There are standard dose influenza

vaccines, which are recommended for most people and grown in eggs. Those with an egg allergy can receive a cell

based influenza vaccine, although there is technically not a medical contraindication for those with egg allergies.

Since the amount of residual egg protein is too low to elicit a significant reaction. Both the standard dose and cell

based influenza vaccines are approved for use in anyone six months of age and older. There are high dose and

adjuvanted influenza vaccines approved for those 65 years of age and older. These are designed to elicit a stronger

immune response. Lastly, there is a live attenuated influenza nasal vaccine called Flumist. This is approved for use in

those 2 to 49 years of age, but this excludes people who are immunocompromised, pregnant, or have certain

underlying conditions. Finally, last but not least is RSV vaccines.

Dr. Osterholm

The CDC recommends a single dose of any licensed RSV vaccine for all adults 75 years of age and older, or adults 50

to 74, at increased risk of severe RSV. Additionally, RSV vaccination is currently recommended for pregnant women

at 32 to 36 weeks of gestation from September through January. Protect their newborns against severe RSV. Unlike

cold and flu, RSV is not an annual vaccine. However, the CDC website currently states that additional surveillance

and evaluation activities are ongoing to determine whether adults might benefit from receiving additional RSV

vaccine doses in the future. We promise to keep you, our listeners, updated if the current guidance changes. One last

question. I am sure some of you will have. I've referred back to the CDC recommendations repeatedly for these three

vaccines, and the question may be, well, wait a minute, can I trust the data from the CDC to actually support the how

these vaccines are used? And I would say, yes, you can. I've surely disagreed that we must consider COVID vaccines

based on individual decision making. It is one where you still can get the vaccine. So generally speaking, yes, the

current recommendations of CDC actually do reflect largely what the current recommendations are from the medical

societies who are now, I believe, the authorities on vaccines use in this country.

Chris Dall

Mike, can you give us an update now on CIDRAP Vaccine Integrity Project?Dr. Osterholm

Chris, more than ever, I'm inspired by the Vaccine Integrity Project's ability to rise to the occasion as the state of

federal vaccine policy continues to deteriorate. The first thing I want to update listeners on is what we have kicked off

in terms of the 2026 2027 Respiratory virus immunization evidence review. Our ultimate goal is to ensure that

clinicians have access to credible, up to date evidence to inform immunization against COVID 19, influenza and RSV.

We are building on our 2025 2026 evidence review covering the same viruses. However, this time around, the major

difference is our collaboration with the American Medical Association, which we will work alongside for convening,

outreach and more. The first stage of this process involves information gathering from professional medical societies,

subject matter experts and the state public health practitioners so that we may hear what the evidence gaps they

need to address as they prepare to write their seasonal immunization recommendations. We feel this early and

frequent communication with stakeholders is critical to defining the key policy questions. Next, in our rigorous

process, our ongoing expert panels and briefings, literature review, comparative analyzes and presentations of our

findings, we are very excited about this work and look forward to sharing more about our progress in the months

ahead. A few episodes ago, we also told listeners about the launch of our HPV Systematic Evidence review. As a

reminder, the Vaccine Integrity Project, including several of the researchers who were on our podcast research team,

is conducting a review of the vaccine safety, efficacy, effectiveness and immunogenicity following the receipt of an

HPV vaccine in the US.

Dr. Osterholm

We targeted this platform following the news in early January that the Department of Health and Human Services

alter the childhood immunization schedule and reduce the number of recommended HPV vaccines from two doses to

one. Mind you, they did this without going through the long, trusted, thorough ACIp process and instead just based

off of what other countries do. And we anticipated HPV might have been a topic of discussion at the February ACIp

meeting, which may have led to the spread of more confusion and false claims from the panel. So we felt it was

needed to provide an independent and scientifically sound, evidence based, built upon previous reviews so that

medical societies, practitioners and the public could make their own informed decision. And although the ACIp

meeting has been postponed, clarity is imperative. In times like these, the Vaccine Integrity Project will continue to

take on these issues for as long as necessary. I've always said that we wish we weren't in this position, and that

instead the US government was doing its job and acting in the public's best interest. But it's clear we are not there

now and we won't be anytime soon. But VIP will be there.

Chris Dall

Mike, this is also a good time to take a moment to remind our listeners about CIDRAP collaboration with Unbiased

Science, a group that specializes in scientific communication. You mentioned that collaboration a few episodes ago,

and part of the collaboration is a series called The State of US Vaccine Policy, which tracks everything that's unfolding

with vaccine policy in the United States. It's a fantastic resource, both for reporters like me and the general public.

We'll post a link to the most recent update on the podcast page. I also want to let you know about a new three part

series on antibiotic overprescribing in dentistry by CIDRAP news investigative reporter Liz Szabo. If you've ever been

prescribed an antibiotic by your dentist and wondered if you really needed it, you're going to want to read this series.

You can find all three stories by going on CIDRAP homepage and clicking on the Antibiotic Aftershocks link. And that

brings us to this week in public health history. And today, rather than celebrating, we are marking the passing of a

man who's been hailed as a titan in the field of prion diseases. Mike, what can you tell us?

Dr. Osterholm

Well, Chris, this week in public health history, we're honoring an accomplished career of a dear colleague, Dr. Byron

Caughey, who passed away last week at the age of 68. Byron's tenure at the National Institute of Health, Rocky

Mountain Laboratories began in 1986, where he specialized in the unique area of infectious disease research of prion

diseases. We've talked a little bit about prion diseases on the podcast before in discussions of chronic wasting

disease, a lethal degenerative brain disease circulating in deer, elk and moose. Prion diseases affect humans, too,

and a disease known as Creutzfeldt-Jakob disease or CJD. CJD is rare in humans and often not diagnosed, if at all,

until the patient reaches an advanced age, which is why it is often misinterpreted as old age or dementia. Without

Byron's early work on the basic biochemical characteristics and mechanisms of infectious prions, the field would

likely not be where it is today. Byron and his lab colleagues at the Rocky Mountain facility went on to pioneer in vitro

replication systems for prions. While this may sound esoteric to listeners, this work is the foundation for critical

research, assays and diagnostic tests. The crown jewel, if you will, of all these ultra sensitive tests is one known as

Rt-quic, which is a rapid test for prion disease diagnosis that works when the patient is still alive. While a positive rt-

quic test result certainly isn't good news.Dr. Osterholm

Receiving a diagnosis while the patient is still alive allows families to make concrete plans for end of life care. In

addition to Rt-quic, Byron's legacy in the field also includes his breakthrough publication of the first cryo-EM structure

of a prion. When researchers can see the structure of prion, it allows them to better understand prion strains, species

barriers, and transmissibility. While Byron was widely recognized for his scientific achievements, his colleagues agree

that his greatest legacy may have been his generosity and collaborative spirit. He trained numerous scientists to

implement RT quick, and his lab became a trusted hub where researchers could turn for hands on guidance and

open, supportive troubleshooting. His humor, humility and generosity were known by many, including us here at

CIDRAP. Byron was a co-chair of the working group we organized to address the gaps in chronic wasting disease

spillover preparedness. He led his working group with expertise and curiosity and contributed greatly to our final

report on the topic. As we reflect on Byron's life, reminded that the true measure of a scientist is not only the

discoveries they make, but the people they inspire and the communities they strengthen. Byron leaves behind a field

that is more connected, more collaborative and better prepared. We are thinking of his family, friends and many

colleagues during this difficult time. Thank you Byron, for all you did for us.

Chris Dall

Mike, what are your take home messages for today?

Dr. Osterholm

Well, Chris, like so many of our podcasts that we share, it's a challenge because there's a lot of things that I think we

could be covering. But first of all, clearly the federal leadership or lack thereof, regarding infectious diseases and

specifically vaccines is truly a tragedy and one that we have yet to really see unfold in its full impact. I believe we are

literally one public health disaster away from CDC becoming a disaster itself. It is not prepared for much of what is

needed to respond to future biologic events. I also wanted to come back to a point that I made earlier in the podcast.

As much as we're critical of our federal agencies right now, it's not because there still aren't many dedicated

professionals who are trying to do their best to keep public health as strong as possible. This is true for the medical

research at the NIH. But when we talk about what is a problem with these federal agencies is because the leaders,

which are largely political appointees, are not scientists with expertise, have now taken over the decision making

process that is in itself makes the agency almost disqualified to provide science based information. And so we always

think about our colleagues who are still holding out in the trenches of public health to do their jobs and feeling the

criticism which is unwarranted for them, but rather for their supervisors. And that's a challenge. Second point I'd take

home is measles continues to grow as a public health problem. And I'm afraid in some dear future date we're going to

look back and say, boy, I wish we only had 2000 cases in the last two months. I think the number of measles cases

has the potential to grow substantially over the next 12 to 18 months.

Dr. Osterholm

Then only then maybe, will some people realize just how dangerous measles is. When we see more and more

children in our communities dying from you, more and more adults also severely impacted. And my third take home

message is yes, the vaccine situation is a bit confusing right now this flu season, and to a certain degree, the RSV

season I think is beginning to wind down. So the question is getting a vaccine now, should I? I would never tell you

not to if you haven't had one, because you could be the person the fourth week of March that develops a severe flu

case and becomes seriously ill. But the return on protection from the vaccine is going to decrease in the immediate

weeks ahead. If you didn't get it this year, at least, please consider getting it next year. In terms of COVID vaccine, as

I mentioned, I really don't see this right now as a seasonal disease, even though we've lumped into that category.

Cases just continue and continue and continue. And so I think it's always a good idea to stay current on your COVID

vaccines. And for those who have not been vaccinated this year, I would get it. We have seen the benefit in all age

groups from being vaccinated. If you've already received one dose, but you are immune compromised of other

underlying health conditions, that puts you at higher risk for serious illness. Definitely get your second dose anytime

two months after your previous dose. In conclusion, I guess I would just say public health has a lot on his plate right

now, and it's unfortunate that some of the biggest challenges are not the bugs themselves, but the people who are

running the systems right now in our federal government.

Chris Dall

And like, if I'm correct, I think your closing song today is going to tie back to our dedication.Dr. Osterholm

Thanks, Chris, for that very thoughtful note. Indeed, the song that I've chosen today is really fitting for our dedication

today. The healthcare workers, the home health care aides, the direct support professionals, the nursing assistants,

the public health nurses, all those who give care a very, very, very special group. And this song is really about and for

them, this is a song that we've used a few times already. It's by the late Bill Withers. Lean on me. Lean on Me was

the first single from his second studio album. The track was released in April of 1972. The song is often used as the

first song to teach children to play the piano, because of the position of fingers doesn't change. Lean on Me won a

Grammy Award in 1987 for Mr. Withers as the writer and for the best R&B song. And now, in terms of how we've used

the song, there's a bit of a trivia question here. Can anybody imagine what the first song was used on a podcast? In

fact, it was Lean on Me, which was in the June 10th, 2020 podcast. In episode 11, driven by the data, we had not

used the song in the first ten episodes, so this was kind of the breakthrough with the second time we used it was on

April 22nd, 2021.

Dr. Osterholm

In episode 52, A Balancing Act continued. The third use was on October 28th, 2021, in episode 75, Evolving Science.

The fourth use was on November 16th, 2023, in episode 144, a slow motion tsunami. And finally, the last time it was

used was on November 21st, 2024, in episode 171 Serious Challenges Ahead arcade JR and The New HHS. That

sounds interesting how that ties in today. Here it is, a song that I believe is deeply meaningful to many of us. By the

late Bill Withers. Lean on me. Sometimes in our lives we all have pain. We all have sorrow. But if we are wise, we

know that there's always tomorrow. Lean on me. When you're not strong. I'll be your friend I'll help you carry on. For

it won't be long. Now I'm going to need somebody to lean on. Please swallow your pride. If I have things you need to

borrow for. No one can fill those of your needs that you won't let show you. Just call me brother when you need a

hand. We all need somebody to lean on. I just might have a problem that you'll understand. We all need somebody to

lean on. Lean on me when you're not strong. And I'll be your friend I'll help you carry on.

Dr. Osterholm

For it won't be long So I'm going to need somebody to lean on. You just call me brother when you need a hand. We all

need somebody to lean on. I just might have a problem that you'll understand. We all need somebody to lean on.

Thank you again for joining us. I hope we've been able to provide you with the kind of information that you're looking

for. It's a very complex, ever changing world of public health right now. And all I can say is, is that we'll do our best to

stick with the facts and stick with the moment in such a way that you know what's going on. I want to thank our

podcast crew for their work putting this podcast show together. Chris, thank you again as you do such a great job

moderating. I love it when people who talk to me and know about the podcast say so, you know Chris Dall? Wow. Uh,

that's a that's a real honor for me. So I hope all of you have a good two weeks until we're back together again. So

thank you again for being with us. It means the world to hear from you. We appreciate our podcast family very much.

Be kind. Be safe. 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. This podcast is supported in part by you, our listeners. The Osterholm Update is

produced by Sydney Redepenning, Elise Holmes, and Ruby Guthrie. Our researchers are Cory Anderson, Meredith

Arpey, Leah Moat, Emily Smith, Claire Stoddart, Angela Ulrich, and Mary VanBeusekom.