Episode 166: Infectious Diseases Roulette

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. On September 6th, the Center for Disease Control and Prevention announced confirmation of a human case of an H5 avian influenza infection in Missouri. It was the 14th case of H5 reported in the United States in 2024. But unlike the 13 other cases, there was no known occupational exposure to sick or infected animals. The patient, who was identified through the state's seasonal flu surveillance system, was treated with influenza antiviral medications discharged from the hospital and has recovered, though no ongoing transmission has been identified. Missouri has not had any reported H5 outbreaks in dairy cattle, and its last avian flu outbreak was in February. The question surrounding this case will be among the topics we'll tackle on this September 19th episode of the podcast, after we bring you the latest on COVID-19. We'll also dive into a controversial new study on Paxlovid, bringing you updates on developments in Africa's mpox outbreak. Take a look at the latest data on seasonal influenza and measles. Answer an ID query on the updated COVID vaccines and discuss polio in Gaza. And we'll bring you the latest installment of This Week in Public health history. But before we get started, we'll begin with Doctor Osterholm's opening comments and dedication.

Michael Osterholm: Thanks, Chris, and welcome back to all the podcast members. It's wonderful to be with you. And for those who might be listening for the first time, I hope we're able to provide you with the kind of information you're looking for. Is surely our intent to make this a time that you find you invested wisely in getting this information. Before I begin, Chris, I want to take this opportunity to thank a number of the listeners who contacted me in the past week and a half about your challenges of not only locating the Novavax vaccine and being charged for the dose of vaccine as a Medicare patient. As a result of these inquiries, I contacted the Department of Health and Human Services and specifically the Center for Medicare Services, and the director of that program was surprised to learn that Novavax was not being provided free of charge to all Medicare patients. Well, it was an error, a coding error. Within two days, there was an alert that went out from the Center for Medicare Services office to all of the vaccine vendors, those that administer vaccines like Walgreens, CVS, etc., making it clear that in fact, Novavax vaccine should be paid for. So I think we're really at a good point right now in terms of the Novavax vaccine, where it's both available and widely available.

Michael Osterholm: We've checked on that. But in addition, if you're in Medicare, you shouldn't have to pay anything for that. And of course, with any health plan as such, you also should be covered. Well, let me move on now and just state the obvious. Public health has been all over the news lately, despite all the issues that were being raised today in the political world, our economy, etc.. Public health has been surely in the middle of the front row issues, from rising COVID numbers to H5N1 updates. Food safety issues and declarations of public health emergencies. It's been nearly impossible to tune into the news without hearing some mention of public health or infectious diseases. In fact, I can tell you personally from my career standpoint, my head is swimming right now in any number of different emerging infectious disease issues. There's been so much going on that it's hard to narrow down what to cover in our podcast without leaving some important items out. Today's dedication segment comes in response to two of the recent news stories that caught my eye over the past several weeks. First from Gaza. What a tragedy. What a tragedy. But there is an ambitious and complex effort to vaccinate all the children against polio, and it's well underway. I'll have more to share with you on the logistics of the vaccination campaign later in the episode.

Michael Osterholm: But the Herculean effort that the local and global health authorities have initiated their deserves additional recognition. This is a vaccination campaign that's being carried out in the midst of a great humanitarian crisis, and a great personal risk to those who are conducting the work on the ground. And tragically, we also recently learned of the loss of two members of a polio vaccination team in Pakistan who were murdered while carrying out their vital duties. They were targeted by anti-vaccine groups who have stoked fears of vaccines among the local population, and taken extreme violent measures to stop community health workers from reaching those in need in a country where polio remains endemic. Vaccination efforts are critical yet faced major and frankly unimaginable challenges. Another challenge that we really have is what's happening in Afghanistan. It, too, is a country that polio has never been well controlled. Unfortunately, the UN is reporting that this week the Taliban has suspended polio vaccine campaigns in the country. Absolutely devastating news that could undo years of progress to try and eliminate this horrible, entirely preventable disease, public health organizations are working diligently to figure out the next steps in these circumstances, without opening up their workers in these communities to more violence. This is truly an immense public health challenge. These are difficult stories to process.

Michael Osterholm: They remind us of the fragility of global health systems and the resistance that public health still faces around the world. Woven into these stories of frustration and tragedy, however, are also stories of incredible, resilient community health workers, brave vaccination teams and diligent health officials. These individuals work to advance vaccination efforts, leverage limited resources, and respond to outbreaks in the midst of crisis and chaos. They also do it at great peril to their own life. I think they deserve our recognition as the true champions of public health. In this episode, please remember that behind every story, update or research finding, there are a group of people who have worked hard and selfishly for their belief in the mission of public health to improve the quality of life and reduce pain and suffering. Today's episode is dedicated to the polio vaccination teams in Gaza and Pakistan and around the world. Those who live out the mission with great resilience and bravery. Now moving on to that part of the podcast. I happen to love some of you. Tolerate me for that. Thank you. That's what families do. We tend to tolerate some of our family members. Uh, although I have to say this particular episode is a bit challenging for me when I talk about our light. Well, today in Minneapolis, sunrise is at 6:57 a.m., sunset at 715 for 12 hours, 17 minutes, and 49 seconds of that precious light.

Michael Osterholm: This will be the last of the podcast before we dip below that 12 hour sunlight. Now, why is it challenging between now and our next podcast? We will hit the autumnal Equinox, which is on September 22nd. That means we're at the highest rate of loss of sunlight throughout the entire year. Today we will lose three minutes and six seconds of sunlight compared to yesterday, and that will continue to occur right up through the end of September. Now, in terms of our friends in Auckland, you're excited. Those of you who are at the Occidental Belgian Beer House in Vulcan Lane in Auckland, know that today your sun rises at 615. Your sun set at 614. You actually are almost there at the 12-hour mark with 11 hours, 59 minutes and 54 seconds of sunlight. You're gaining sunlight at about two minutes and 19 seconds a day. So yes, we'd all love to be watching the sunrise in Auckland over the next six months, but I know that we can't. So all we can ask you to do is share a little bit of your sunlight. As we've tried in every podcast for the last six months, to share ours with you.

Chris Dall: Mike, regardless of what the data are telling us, I think many of us continue to see a lot of family members, friends, and colleagues getting sick with COVID. But with that said, what trends are we seeing in the data? Limited as they may be?

Michael Osterholm: Well, Chris, let me just start out by saying I think we're in the new normal and I'll explain that more in a moment, but just keep that in mind. As you mentioned and we talked about in our past couple of episodes, the data are very limited right now, so it's tough to get a really clear picture of the current trends and situation we're in. The one area that we surely do process information is, as you just pointed out, hearing about friends, family, colleagues, etc. who all are infected right now. And fortunately for most of them it has not been severe, but there's lots of infections going on throughout this country and for that matter, around the world. I'm counting down the weeks right now until November, when all U.S. hospitals will again be required to report COVID hospitalizations as they were at the beginning of the pandemic. This means it will have a more comprehensive and reliable source of data that can serve as both an activity and severity indicator. But for now, I'll provide you what limited data we do have and what it means. Wastewater levels seem to have plateaued now considered high, following several weeks of very high levels. While there has been a decline, it's been very slight, and I hesitate to say with any certainty that overall activity is really decreasing in any major, measurable way. And again, I also want to emphasize that as we look at wastewater data levels, we still are hard-pressed to understand how do they actually relate to number of illnesses in the community.

Michael Osterholm: Regionally, levels in the West and the Midwest are still considered very high, and the West is still experiencing increasing levels of wastewater activity in the South and Northeast is decreasing. Looking at the state-level wastewater picture, the majority of states 37 are still either considered high or very high. So it's difficult at this point to say exactly how many infections are occurring in the community. From these data, however, they surely do tell us there's lots of activity out there. Now, hospitalizations have remained steady, with about 5300 Americans reported to be hospitalized with COVID, and around 12% of those hospitalized are in ICUs. This is consistent with hospitalizations from the previous week, which were slightly lower than the 5350 reported in our last episode two weeks ago. As we wait for November 1st to roll around and again when we will now have comprehensive data coverage for all hospitals in this country. One way to estimate a more realistic picture of how many people are hospitalized across the US is to consider that a third of U.S. hospitals have continued to submit COVID data to get us to this 5300 number. Now, if we assume that nothing categorically is different in terms of the other two-thirds of the hospitals in this country versus the third that are reporting, and I might add, that's a stretch, it may not be the case.

Michael Osterholm: We can conclude there's likely somewhere between 14,500 and 16,500 Americans hospitalized with COVID at the moment. If you look at previous hospitalization data in January of 2021, we hit 130,000 hospitalizations. And then later that year, in September of 2021, we hit 98,000 hospitalizations. And then, of course, as we recall with Omicron in January of 2022, we had 155,000 Hospitalizations. So this is really an important difference here today. As much as we talk about these 5000-plus hospitalizations, even if we add in the other two-thirds of the hospitals, we're still way below the peaks. But this is part of what I was talking about with the new normal. Again, more about that in a moment. Last episode, we discussed the concerning trends that we were seeing when we looked at the age breakdown of emergency department visits. And I just want to give you an update on this. From July 20th 9th to August 28th, those 0 to 11 years of age had the highest percentage of ED visits for COVID than any other age group, peaking at nearly 5% of ED visits in this age group. Having been tested positive for COVID-19 since the last episode, this percentage has declined to about 2%, which is still higher than the national average of 1.66% and only lower than the 65 to 74-year-old age range, which is at a little over 2%.

Michael Osterholm: And of course, the 75-plus age group, which is at 2.9%. What does this all mean? I think what it's telling us is, first of all, kids did see a bolus of COVID activity likely associated with the opening of schools, more kids going back to daycare in the fall. Now that that rush of the virus movement through those schools has happened. We're now seeing the numbers come down quite substantially. Now, if we look at deaths, which of course is by far the worst indicator of all, they do continue to increase. Unfortunately, the 1232 American lives lost to COVID-19 last week marked the fifth straight week with more than 1000 new deaths and the 10th straight week with more than 500 deaths. These are devastating trends, no doubt about it. I want to remind everyone that we have tools so that we can help reduce these numbers. Vaccines. Vaccines. Vaccines. We'll talk more about that in a moment. The updated vaccines are now widely available, including the Novavax vaccine. I want to emphasize that there is plenty of virus circulating out there right now, and I'd encourage you to get vaccinated if you already haven't, especially if you're older or have an immunocompromising condition.

Michael Osterholm: Now is not the time to let up and let me shed more light on. When we talk about who should be among the highest priority members of our community to be vaccinated. If we look at the data for just this last month, these are the CDC data on deaths from August. Fully 91% of all the deaths in this country from COVID were in those who were 65 years of age and older. 91% if you add in the 55 to 64-year-old age group, it's a total of 97% of all deaths occurred in those who are 55 years of age and older. So clearly age is a very, very important issue and I urge everyone listening to this podcast please be up to date on your vaccines. As I've said so many times, these vaccines are good. They're not great, they're good. And what I mean by that is, again, great vaccines would give us durable protection for many years against a wide variety of different variants. We don't see that with the current vaccines. What we do get is 3 to 4, maybe even as much as six months worth of protection against serious illness, hospitalizations and deaths. And I am convinced. But if we were able to, we would be able to reduce these number of deaths substantially by just focusing on these older age populations, focusing on long-term care facilities, getting people vaccinated, as we are now recommending vaccine up to 2 to 3 times a year, this would make a big difference.

Michael Osterholm: And let me close out by just reviewing what we've seen happen on the international level. It gives some sense of why, when I say we're in a new normal here in the United States, that this is actually playing out throughout the world. If we look at the international side of things and again, there are data limitations. There are just as we're seeing in this country. But the W.H.O. released their monthly EPI report this week, which covers the four weeks from July 20th 2nd to August 18th. The report shows a 32% increase in cases from July 20th 2nd to August 18th, and a 44% increase in deaths. While these data represent the picture from a month ago, they are still consistent with the increases we're seeing here in the US. During the same 28-day time period, data from the 45 countries who reported COVID hospitalizations data showed a 3% decrease in hospitalizations compared to the previous month, tipping off the top of that surge just as we think we are here. But the 23 countries reported COVID ICU admissions saw a 36% increase from the month before. So we're still seeing an increase in severe illness and in this case, death. All the more reason why we should focus on laser focus on those who are 65 years of age and older, getting them vaccinated.

Michael Osterholm: Chris, when I responded to you as you asked the question about COVID, I noted that this is, I believe, the new normal. I think we're here. What we're going to see is this constant cycling, and it won't be seasonal. It'll be based on a 3 to 5 month likely timeline where once we get people vaccinated, we're going to see that the deterioration of that immune protection will occur 3 to 5 months out. And then we'll see this ever-changing variant picture with the virus, so that if you combine those two, a new variant emerging reduced protection from either previous infection or the vaccine and we get another surge. I think the big difference now is we're not going to get anywhere close to those big peaks and number of hospitalizations and deaths we saw back during the pandemic. But make no mistake about it, COVID is here. It's going to be a constant part of our lives, and we must figure out what are we going to do to address it. And most importantly, right now we need to vaccinate those who are 65 years of age and older and encourage us with all we might, because in fact, that is going to have by far the biggest impact on serious illness, hospitalizations and deaths.

Chris Dall: I want to ask you about a study that came out last week that suggested the two primary antiviral treatments for COVID-19, Paxlovid and Molnupiravir, have largely been ineffective, and that the recommendations for them need to be reevaluated. I understand you have some issues with this study.

Michael Osterholm: Well, Chris, let me just start out by saying that if the authors of this study were my graduate students, I would have flunked them. And unfortunately, at least one of the authors is a pretty well-known researcher out there. So yes, you're right, I do have real issues with this study. And before I get into the details of the study and provide some perspective on what the findings really mean, I want to mention that a lot of what I'm going to be discussing today was also covered in a recent CIDRAP news article. The story was done by our reporter, Mary Van Beusekom. We will link this in our episode description and I urge you all to read it. It's a wonderful primer on what these drugs can do and how they can help. The study that you mentioned was a meta-analysis of 23 studies, 11 of which looked at Paxlovid, ten which looked at molnupiravir, and two that looked at both. For listeners who aren't familiar with meta-analyses, these are studies that pooled together the results of many other studies to reach one conclusion when conducted well, meta-analyses can provide very helpful information. However, when they are poorly conducted as this one was, they can yield misleading conclusions. And I think that this is exactly what has happened here. In fact, it's one that I consider part of a syndrome called head in the freezer, feet in the oven, and average temperatures just right.

Michael Osterholm: The authors of the study concluded that neither Paxlovid nor Molnupiravir reduce hospitalizations and deaths. It's important to note, however, they did not find any increased risk of hospitalization and death with these medications, but just simply found they were ineffective. Well, the challenge with these results is the authors didn't provide the kind of analysis and specific information on who the study populations were that were included. What's the average age of their sample? How many doses of vaccine had the average person had, etc. but most importantly, they combined studies involving many younger, otherwise healthy individuals, with studies done on older individuals with underlying immune deficiency problems. And we know and have clearly stated for some time that Paxlovid and Molnupiravir really are for those individuals who are at highest risk of serious illness, hospitalizations and deaths, and also, in this case, for long COVID development. And combining those studies and their results with studies that involve mostly younger, healthy adults is again like head in the freezer, feet in the oven and average temperatures just right. And they made no effort to distinguish these types of studies. When you look at those who are older, those over age 50, those with certain underlying medical conditions like diabetes, heart conditions being a current or former smoker and having obesity, in this case, these drugs performed very differently in terms of what they did to reduce serious illness, hospitalizations and deaths and of course, reduce long COVID.

Michael Osterholm: And let me also just remind everyone that while we talk about Paxlovid as the frontline drug, molnupiravir has also independently been shown to be quite effective in terms of reducing serious illness. Remember that Molnupiravir is recommended for anyone who has the same risk factors for receiving Paxlovid, but is unable to take it due to a medical condition, or in some cases, a medication interaction where the individual is taking another drug that they can't stop and that could in fact impact on the molnupiravir. Consider these recommendations. We shouldn't be surprised by the results of this study. If younger and otherwise healthy adults made up a large part of the pooled sample for this meta-analysis. And we shouldn't see the results as a reason to reconsider the current recommendations. Already. I'm hearing from people out there. Well, look at this study showed it didn't work without really understanding the limitations of what they did. In short, this study really should never have been published. And if a decision was made to publish it as it was, it surely needed a commentary or editorial to go with it to point out how bad this study really was. So yes, if you're in that group of increased-risk individuals over age 55, etc., etc., please know that taking these drugs can be lifesavers.

Chris Dall: Let's turn now to H5 avian influenza. Mike, how concerned are you about the case in Missouri that I mentioned in the introduction?

Michael Osterholm: Well, you know, I think some people are going to hear my answer to this question. And in light of some of the other answers I've given over the recent weeks and think I've gone soft on flu. I have not. Unfortunately, it's my 50 years of experience in the business that's coming home to remind me about how often times we thought that the flu virus is going to go left and it turned right, or it was going to go up and it turned down. I think in a sense, we're experiencing some of that right now with H5N1. Remember that the CDC announced on September 6th that a human H5 case without a known link to livestock exposure was detected in Missouri, and at that point, some people immediately jumped to a worst-case scenario. I at that point again emphasized, let's wait and see what the neuraminidase looks like. The end part of that, was it really an H5N1 or could it be H5N2, etc.? Well, last week CDC was able to provide that information with their work to sequence the neuraminidase or the N, and they found out, yep, this really is an H5N1 virus. Now why or how this individual got infected, we'll never know. I wish I could know it just out of my incredible curiosity to understand this, but let me make a couple of points.

Michael Osterholm: First of all, I am convinced that there all possible logical sources of exposure were examined by the Missouri Department of Health. You know, this individual did not have known contact with any animals, was not in a setting that would have put them at increased risk for H5N1 in terms of human contact with someone who either worked on farms or with chickens or dairy cattle, whatever. On and on. But in fact, they got infected. And you know what? We've actually had this very same experience before with other influenza variants that are of animal origin, for example, with H3N2 variant, a type of influenza virus that we see often in the summertime Time associated with county fairs and contact with swine, and in the original outbreak of H3N2 variant back in 2012, there were 306 cases of H3N2 variant that were documented in humans in ten states. And interesting enough, five of these individuals absolutely had no risk factors whatsoever for how they picked it up. They did not have contact with swine. They weren't near swine. They didn't have contact with any other animals. They were not around someone who might have been infected. As a human, we don't know where it came from.

Michael Osterholm: And again, in short order, the virus stopped being transmitted in the community. And as the fairs closed and we went back to kind of, quote unquote, the fall season and normal life, H3N2 numbers dropped precipitously. So it's not surprising that we might see this happen with an N1. Now what? I have been concerned if we'd had other cases around them. Yes. And some people say, well we did. Well not really. This is where it gets complicated in what can be shared publicly from public health agencies. But let me suffice it to say that this particular case was hospitalized for an illness that was clearly not influenza and was only picked up through what was routine surveillance for influenza virus in hospitalized patients. This patient was only hospitalized for a very short period of time, and then was released and did just fine. Someone very close to this person also had an illness during that time, but it turned out that in fact, it was not a respiratory illness and no evidence that it was influenza. So in that case, again, that was a kind of a red herring. And then finally there was concern expressed because the health care worker who did develop mild flu like symptoms following exposure to the case, but ultimately tested negative for influenza virus.

Michael Osterholm: Remember, there are lots of other viruses floating around out there right now that cause a similar illness. So to answer your question, Chris, I'm always concerned about influenza. H5N1 is one that I have had major concerns in the past. I still have real concerns now, but I think I'm becoming more of a believer that somehow H5N1 will never climb over that bar to sustain human transmission. I hope I'm right. Could be wrong, but I just see, after all these years of tracking H5N1, there's something about it that no matter how many times it gets to throw at the genetic roulette table, we just have not seen it come up a winner. And we'll have to see what happens here. But so to answer your question, I don't think that the Missouri case changes anything. You know, we'll continue to look for other cases in the community, try to tie back exposure sources. And if one day we come on this podcast and there's just been a couple of clusters of H5N1 with likely human-to-human transmission, you're going to hear a very, very different voice from me. But for now, I'd say it's not one that I would put in the front windshield of worry.

Chris Dall: I also want to ask you about a letter in the New England Journal of Medicine regarding widespread detection of H5N1 in wastewater from ten cities in Texas. The authors of the letter called the findings troubling. Do you agree?

Michael Osterholm: Well, frankly, I've been troubled by a lot of things since the whole H5N1 in cattle situation started earlier this year. But I can't say that these wastewater detections are keeping me up at night. For context, let me quickly summarize the New England Journal of Medicine piece, the Texas Epidemic Public Health Institute, which, by the way, I give great credit to them for what they've done with wastewater monitoring activities, has been monitoring wastewater throughout cities in Texas since May of 2022, up until March of 2024. H5N1 had never been detected in any of the wastewater systems, but between March and July of 2024, it was detected in ten of ten cities that were monitored throughout the state. A few weeks after the earliest detections, the USDA announced that they had detected high-path avian influenza in Texas dairy cattle. The authors of this piece are troubled because they suggest there could be multiple animal sources and suggest the sequencing of wastewater be expanded. I don't know what caused these big spikes in H5N1 activity in these cities. When it occurred, it was not sustained, meaning it didn't last for weeks and weeks and weeks. When public health agencies followed up to learn. Was there evidence of increased human activity consistent with influenza seen in these respective metropolitan areas? And the answer was no. Whether it be emergency room visits, hospitalizations, test results, etc. so there's something, however, that's driving these positives in the wastewater. We just don't know what it is. Could it be other animal inputs? Could there be a way for animal waste to get into the human waste stream, meaning anything going into the local sewage treatment plant? I don't think that that's likely, given that animal waste in itself is so substantial.

Michael Osterholm: There are very few major metropolitan waste treatment systems that would allow that kind of waste to come in. What are the alternatives? Well, humans, could it be humans? It could be. But that means that virtually everyone was mildly ill at most and largely asymptomatic for many others. And I think that that just doesn't explain also where they would have gotten infected and how. So the bottom line message for me is, is that we as a country have not been serious about investigating this work. We should be looking at wastewater detection data from around the country in states with cases in dairy cattle states. Without it, we should be looking constantly to try to match up what we're seeing with the wastewater data results with human illnesses, outpatient settings such as emergency rooms and urgent care, as well as looking at hospitalizations. So what does this all mean? I don't know, there's something going on with H5N1. I do have confidence that the test results that the Epidemic Public Health Institute has been providing are, in fact very reliable. But at this point, I don't think we have any clear evidence that what we saw was an increase in human infections associated with the concurrent increase than in wastewater data. But I'll be darned if I can figure out what's happening and why. And we do need to understand that.

Chris Dall: Mpox vaccine doses have begun arriving in the Democratic Republic of Congo, but according to a recent Reuters story, fewer than 4 million doses have been pledged for donation out of an estimated 18 to 22 million that are needed to vaccinate 10 million people over the next six months. Mike, how are African countries going to curb this outbreak if they don't have enough vaccine?

Michael Osterholm: Well, Chris, let's break this down into two different components. First of all, what is the immediate response. And I think this is a huge issue right now where we have both clade two and clade one outbreaks occurring. And remember, clade two is what we saw several years ago that really began to spread globally in men who have sex with men. This was not an infection that was spreading widely outside of this group of men who have sex with men. And then along comes the clade 1B specifically, which has a higher case fatality rate. And this is one where we've seen most of the cases in children. And when you think of that, you'd say, well, what's unique about kids? Well, they're the ones that are having contact with wild animals, you know, in the wild, you know, mice and so forth. But also remember that almost half the population of Central Africa is 14 years of age and younger. It's a remarkable concept to think about in terms of what's happening with global population. And to put more perspective to this, there have now been 18 African nations which have experienced cases of mpox, specifically clade one. And if you look at where the highest activity is right now, it's in three countries of DRC, Congo and Burundi. DRC has had almost 20,000 cases, the Congo has had 162 cases and Burundi 702. And then you look at the needs for vaccine in these areas and defining what you mean by needing vaccine.

Michael Osterholm: Well, there's no really good way to determine how someone's going to be infected from the wild, meaning from contact with animals as opposed to contact with another human. And as the number of individuals born in the country aged to the point of where they're out and about, you know, doing what kids do to have contact with these animals, the question becomes, isn't this going to be a lifelong vaccination issue? It's not one time to go in and clean up one outbreak. We now have this large population that has constant exposure to what is a wildlife reservoir. And just to even give you a sense, in DRC alone, last year there were 4.1 million births in DRC. And think about that. In contrast with a population of 111 million people now back up to today and say, “But what’s our short-term plan?” And when you start putting these together, what you find is, is that we're basically debating about how much vaccine we can supply to these African countries from three major manufacturers of vaccine. One is Bavarian Nordic Company, located in Denmark, which has probably the best of the vaccines, the Jynneos vaccine. And it is in a situation right now where even full-fledged production, they can only put out about 10 million doses a year. So yes, we've got some that's in stockpile right now, but it's going to hardly touch this outbreak in any meaningful way. Then we have ACAM2000, which is a live virus vaccine produced here in the United States and was going to be used primarily for a smallpox attack.

Michael Osterholm: And the problem with this vaccine is that you cannot give it to those who are immune compromised in any way because of the live virus vaccine. The kind of reactions that could occur are really substantial. And so now you really eliminate this vaccine from use in much of Africa. And then the third one is a company in Japan for which we know some about it looks like it's a quite effective vaccine. But again they have limitations in what they can produce. I've tried to come up with some rough calculation, and I think if we get 30 million doses of vaccine a year from our current capacity, that's going to be a lot. And remember, with the Jynneos vaccine, you need two doses. So if I tell you they're making 10 million doses of vaccine, that's only 5 million people vaccinated. In short, I think this discussion and sometimes bordering on debate about what's taking so long to get vaccine to Central Africa to help begin a process of kind of ring vaccination around cases, around locations where cases have likely been exposed to wild animals that were positive, etc.. Yeah, that's important, but that's just the start. And what I mean by just to start, we really need to be vaccinating large segments of the African population. And we're nowhere close, not even close. So I really believe that over the course of the next two years, we're going to see major challenges with impacts.

Michael Osterholm: It's going to continue to spread around the world. It is going to be a real challenge in Central Africa. And by the way, it's going to spread around the world, not as a virus with wings, the kind that cause the pandemics we talked about, like influenza and coronaviruses. But nonetheless, it's still going to be present. And all these locations are going to want vaccine and need vaccine. So stay tuned on this one. Uh, you know, a couple of weeks ago in a podcast, I shared with you an article that Mark Olshaker and I had written for Foreign Affairs on why we are so concerned about what would happen if we had an influenza pandemic. Again, because of the lack of manufacturing capacity in a timely way to cover much of the world. Well, this is a deja vu all over again moment. We do not have the capacity worldwide to make vaccine anywhere close to what we're going to need to address this issue. And so as such, we're going to continue to see lots of transmission spread widely throughout much of Africa. And with number of cases occurring throughout the world, we have got to see the international prioritization of mpox vaccine development and the fact that we see the kind of manufacturing capacity come online as soon as possible, that can help provide the vaccines that we desperately need.

Chris Dall: Although it's still early. We're getting to that time when we need to start thinking about seasonal influenza. Mike, have we started to see any uptick yet in seasonal flu activity?

Michael Osterholm: Well, remember that when we talk about infectious diseases of seasonal diseases, one of the most reliable seasonal diseases we have is influenza, whether it be in the Northern Hemisphere from that period of early winter through early spring, or whether it be in the Southern hemisphere during their winter and spring seasons, we can count on flu to come. What we can't tell you is exactly when it's going to come and when it's going to peak. So today I'm going to try to address that issue as it relates to the vaccine. But in short, Chris, the answer to the current activity is no. We are not seeing any major uptick yet in cases. According to the CDC, 1.9% of the outpatient clinic visits last week were for influenza-like illness, which is well below the 2.9% national baseline, which indicates increased activity. All 50 states are currently experiencing minimal levels of influenza activity. I can tell you that, in fact, COVID and RSV still dominate in terms of the respiratory illnesses we're seeing in the District of Columbia is experiencing some moderate levels of activity, making them the sole outlier in terms of laboratory-confirmed influenza cases. So, in short, all of the markers, whether it be laboratory-confirmed cases, influenza-related hospitalizations and influenza deaths are all continuing to remain steady. With this in mind, it is still, I believe, far too early to get your flu vaccine this year. I know it can be tempting to get it now. Surely a lot of advertising says get your COVID shot, which we do want you to do, and get your flu shot now. But remember, just because it's being advertised at every pharmacy and offered by providers at medical appointments. It's just too early. As we have previously discussed on this podcast, protection from influenza vaccine wanes significantly over just a few months, so it's important to time your vaccination so that you can be protected.

Michael Osterholm: During the peak of the influenza season, we typically see activity picking up around late October or early November, so this will likely be the best time to get your vaccine to prepare you for a late December to early February peak. Once you've been vaccinated within two weeks, you actually have quite good protection. However, as I've pointed out before, from a date standpoint, when it arrives, when it peaks, and when it ends can vary from year to year. I'm sure that many of our listeners recall two years ago that we had a very early flu season, which led us to recommend getting your vaccine much earlier than usual. So please stay tuned to this podcast as we see what this year's flu season brings, and we'll keep you posted on when you get your shot to maximize protection that you can. And I want to add one additional point. There was some very sobering information shared this past week by the CDC about flu deaths. And to give you some perspective on not just when to get vaccinated, but who needs to get vaccinated. Last year in the 2023 to 2024 season. So last winter, flu deaths in children hit 199. These are kids in the first year of life to the 17 years of the 158 cases who were eligible for a flu vaccine. 83% or 131, were not fully vaccinated. So I do urge that parents strongly consider vaccinating their kids just with the idea that even if it doesn't prevent them from getting flu, it can go a long ways in reducing the risk for serious illness, hospitalizations, and deaths.

Chris Dall: I want to turn now to measles, because here in Minnesota, we're in the midst of an outbreak that began in May and is now at 40 cases. Mike, what does the national situation look like?

Michael Osterholm: Well, every indication we have right now is that measles is really turning out to be a public health mess. And unfortunately, I think we still need to brace ourselves because there's much more to come. As you mentioned, Chris, we are currently dealing with an outbreak here in Minnesota. While 40th May not seem like a lot of cases, the real concern is that increasing number of these cases do not have a recognized exposure, meaning that there is obviously more measles transmission occurring in our communities that we're missing. I know case numbers in the 40s don't sound like a lot, but this disease can spread like wildfire and can have devastating consequences, especially for young children. I worry that these numbers that we're seeing now will be multiplied many times over in the months ahead if we don't do more to get children vaccinated. In the year 2000, measles was declared eliminated in the United States, meaning that there was an absence of spread of the disease for more than 12 months. We can attribute that to a really effective vaccine. We were able to get to young kids to prevent disease and interrupt transmission. But vaccination rates are dropping, and we're back to being at high-risk today in 2024. So far, we've had more than 250 confirmed cases of measles in the United States. 96% of those cases were in people who were not fully vaccinated, meaning these individuals were either unvaccinated or only had received one of the two recommended doses. In the last ten years, the US has faced a few significant and prolonged outbreaks.

Michael Osterholm: I think it's likely we'll lose our status soon as having measles been eliminated if really dramatic action isn't taken to improve vaccination rates, especially in some of these pockets of tight-knit communities. There are numerous daycares and charter schools in the Twin Cities metropolitan area, where less than 25% of the kids are vaccinated against measles. You get just one case there, and I promise you it'll spread like wildfire and it's just a matter of time. Now, why is this happening? There's all kinds of potential explanations, but the key one is we are seeing a generation of young parents who no longer want to be told what to do. They will make their own decisions about their health outcomes and that for their children. And as a result of that, we're seeing them choose not to get their children vaccinated for a number of reasons, of which safety is just one of many. Really, we need to help educate our population about the importance of these vaccines and what it would be like to go back again to a world like I saw growing up as a young child, where we had no measles vaccine and outbreaks took lives every year. This is such an important issue and for all the grandparents who are listening to this podcast, please, if you can, I know it's difficult. Help your children, the parents of your grandchildren to really, really consider the potential implications of not getting their kids vaccinated.

Michael Osterholm: Now, in terms of measles on a global basis, let me just add that this is what we might be looking at if we don't do more to get our children vaccinated. The UK lost their eliminated status in 2019 and have faced climbing case numbers since. This year, they're facing an all-time high almost 2500 cases. Measles infections, especially in young children, can cause lifelong medical complications in high-income countries. The fatality rate for measles is approximately 1 in 5000 cases. But in lower-income countries with fewer health care resources, the fatality rate can be as high as 1 in 100 cases. Places like the Democratic Republic of Congo and Pakistan have faced especially deadly outbreaks in recent years. It really is devastating when you consider that these cases are entirely preventable. No one should be getting measles in this day and age. We actually have a very, very highly effective vaccine. That should be the takeaway. I wish all of our vaccines could perform as well as the measles vaccine does. Some of today's teens and young adults may not have received it when they were infants due to misinformation spreading in the early 2000 time period. Some children may have missed doses during the earliest years of the COVID pandemic. If whatever the reason is that someone isn't fully vaccinated, it's time to catch it up now. It's not too late, and hopefully, your actions will mean it never is too late.

Chris Dall: It's time now for our ID query. As our listeners know, we've talked a lot in recent episodes about when updated vaccines are going to be available and when people should get their next COVID shot to maximize their protection. But now that the new vaccines from Moderna, Pfizer, and Novavax are available, we have a lot of people asking which one they should get. Mike, what's your response?

Michael Osterholm: Well, the single most important answer is get it? And as you know, we cover this issue virtually in every podcast right now, particularly for those who are older over age 65. Now is the time to make sure you get that updated dose. And again, we'll put a CDC document summarizing who is eligible for and what doses on the podcast website. But the important issue is get the vaccine. It can save lives, particularly for those who are at high risk for serious illness, hospitalizations and deaths. At this point, which of the vaccines to get? Well, this is not official recommendations or information because all three of them, whether it be Moderna or Pfizer or Novavax, are recommended. Now, it's more than anecdotal information, but I've heard from a number of individuals who have had some kind of reaction to the mRNA vaccines, where they were in bed for a day or two after getting their shot, and they've decided they're never going to go through that again. Well, the good news for you is we've had a relative absence of anyone experiencing a similar type of reaction by getting the Novavax vaccine. Now, as you've heard, the Novavax vaccine does not have the most recent variant as part of the vaccine as compared to the mRNA vaccines.

Michael Osterholm: I actually think from talking to a number of colleagues who are real experts in this area of immunology and vaccines, that because the Novavax vaccine has this unique adjuvant, a chemical that actually enhances the immune response to the vaccine, as well as its protein nature, that in fact, that may be the ideal vaccine to get to boost your previous immunity that you've had from prior infection or from a previous mRNA vaccine. Personally, that's the vaccine for me and Novavax vaccine. So it's up to you. The most important thing, though, is to get one of them, as we've talked earlier in this podcast. Yes. In fact, case numbers are starting to come back down again. But this vaccine will help give you protection well into the holiday season if you get it now, if you've not been infected in recent months and you've not been vaccinated in the previous two months, then now is your time to get this vaccine. I do want to make one comment about something, Chris, that I find absolutely appalling. And, you know, I try not to use too strong of words on this podcast. But last week, the State Surgeon General, basically the person head of the health department in Florida, Doctor Joseph Ladapo, put out guidance that basically said based on the high rate of global immunity and currently available data.

Michael Osterholm: The State Surgeon General advises against the use of mRNA COVID-19 vaccines. Any provider concerned about the health risks associated with COVID-19 for patients over age 65 or with underlying health conditions should prioritize patient access to non-mRNA COVID-19 vaccines and treatments. Well, let me just say without any doubt this is absolutely irresponsible information. It is anti-public health. It's anti-science. And frankly, it scares people into not getting a vaccine that could save their lives. There are no data out here to support this kind of conclusion. Uh, again this is such a challenge as we've seen throughout the COVID pandemic. The red states, the red counties in this country have seen a dramatically increased loss of life due to COVID because of a resistance or reluctance to get vaccinated, in part due to statements like Doctor Ladapo has just made this is irresponsible, absolutely irresponsible, and I hope that those living in Florida do not take this information that he's provided with any kind of validity. It literally could cost you your life.

Chris Dall: Now for some other infectious disease news. And Mike, this ties into what you were talking about in your dedication and yet another reminder that outbreaks of infectious disease can cause additional suffering in regions already traumatized by war and conflict. Gaza's Ministry of Health in mid-August reported the first case of polio in 25 years in a ten-month-old child. That has prompted a subsequent vaccination campaign that aims to reach more than 90% of the 620,000 children under ten in Gaza. Mike, will this be enough to prevent an outbreak there?

Michael Osterholm: Chris I can only hope. I can only hope. This is a very ambitious campaign and the stakes couldn't be higher. Remember the conditions by which these public health workers are working to get this vaccine to these children. Think about the families who have already lost many loved ones in the Gaza war, and how they're living their lives right now, often with unreliable access to safe water. Sewage all over the environment because of a loss of wastewater treatment. All the conditions that you would think of as ideal for spreading the polio virus. Now, the first round of the vaccination campaign just concluded. And who has reported that approximately 560,000 children under ten years of age in Gaza were vaccinated from September 1st through the 12th? The coordination of this effort is massively impressive, and it speaks to the resiliency and dedication of community health workers and vaccination groups in this region. It also says a lot about parents who will do anything they can to protect their children. Despite early success, a number of operational challenges remain. A second round of the campaign will follow in about four weeks to provide a second dose of the vaccine to the children in Gaza. Reaching these children again will certainly be difficult given the conditions in Gaza, including destroyed infrastructure, limited fuel access issues and frequent population movements. It's also important to remember that we're still talking about almost 10% of the population under age ten has not been vaccinated, even in the first round. That is more than enough to sustain an outbreak in a concentrated area like Gaza under the living conditions which they find themselves.

Michael Osterholm: While public health officials wait to begin the second round of vaccinations, officials are currently traveling throughout Gaza to confirm the percentage of vaccination coverage achieved in the first round. Only after a second round of immunizations is performed and officials can capture data on a complete vaccination coverage. Will we be able to characterize the success of this effort? Besides vaccination efforts, officials also need to pay very close attention to the evidence of the virus circulating in the population or present in wastewater sampling. At this point, it's just too early to say whether these efforts will be successful in stopping an outbreak from spreading. And let me remind you, there is a birth cohort of children born every day in Gaza. Despite the incredible conditions upon which families find themselves, we will not be able just to go in with a one-time campaign to vaccinate. This is going to be something. Now, once we do a catch-up, we're going to have to be certain we also vaccinate all the newborns each year. Then we see an increased number of children not even born yet today being the reason for an outbreak in the future. Polio eradication is a global effort and setbacks in one region can have implications for others as the virus spreads quickly. This situation highlights the need for continued support for vaccination programs worldwide, and the importance of addressing both health and social-political challenges to achieve global health goals. It will be important to monitor the situation closely and provide ongoing support to ensure the success of this vaccination campaign today, tomorrow, and frankly, forever.

Chris Dall: Now for this Week in Public health history. Mike, who are we commemorating this week?

Michael Osterholm: Chris. September 18th, 1915 marks the death date of an incredible woman in public health history in this country. Susan La Flesche Picotte was the first Native American medical doctor and a strong advocate for her community. Susan's father, Joseph La Flesche, was the last recognized chief of the Omaha tribe. Their family lived on a reservation in northeast Nebraska and faced many challenges trying to balance living their cultural values and traditions in an ever-increasing white-dominated society. When she was eight years old, Susan stayed at the bedside of an elder in her community who was in severe pain. The family had called the white doctor in town four times. Each time, the doctor said he'd be there soon. Unfortunately, the woman passed without ever receiving any medical care. Looking back at this time, Susan recalls, “It was only an Indian. It didn't matter.” Susan was an exemplary student and finished second in her undergraduate class at Hampton University, and then first in her class at the Women's Medical College of Pennsylvania. While she was officially a medical doctor as a woman in 1889, she could not vote as a Native American, she was not considered a US citizen. After graduating, Doctor La Flesche returned to the Omaha Reservation and became the sole medical doctor for over 1200 people, serving an area of over 400mi². She relied on house calls that could mean hours on horseback between appointments, and she traveled in all kinds of adverse weather. She advocated for improved water, sanitation, and hygiene practices, window screens to manage insects, and resources for those facing substance abuse and mental health challenges. Before her death, she was able to secure funding for a hospital in the area that would serve both the reservation and the surrounding community. She is memorialized today in a statue in downtown Lincoln, Nebraska. Her words are inscribed in a plaque reading, “I shall always fight good and hard, even if I have to fight alone.” What an incredible message and something we can all strive to live by. She represents to me the very best of the human spirit.

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

Michael Osterholm: Well, of course, it wouldn't be a take-home message day if I didn't continue to emphasize COVID, COVID, COVID again, we're in a much better place with COVID right now than we've been. And for many people in our communities. Another COVID case is going to be a mild, flu-like illness. And they're going to all wonder, oh, why is this such a concern? If you're among those younger individuals in our community that when they become infected with COVID, it often is nothing more than a quote unquote mild influenza-like illness? But on the other hand, if you're among those 1200-plus Americans who lost their lives to COVID last week, it is a big deal. So what we have to figure out is how we're going to live in this new normal of COVID, where we do everything we can to protect those who need most protection with vaccine, specifically those older age population groups. And at the same time, while recognizing that we would rather have no one be infected, there will be an increasing number of younger individuals infected, for which there will be some severe cases. There will be some deaths, but proportionally, compared to the activity we see in older individuals, it will be very, very different. So number one, COVID, we got to get people vaccinated who are older.

Michael Osterholm: We got to get into long-term care facilities, etc.. Number two H5N1 infection I don't know what's happening. And I'm convinced that anyone that tells you they do be careful because they probably have a bridge to sell you to. It's still a concern what's happening with H5N1 and cattle in this country. I am convinced that there is much, much more activity than we already are picking up, and that largely is associated with farmers not wanting their herds to be tested, even when they know that there is some illness going on in that herd. So stay tuned on this one. Finally, really, we need to take a step back and look at these infectious diseases that really can cause great disruption in our communities and ask ourselves, why do we not have enough vaccine to address a program that would, in fact, target that very issue of making sure the availability of vaccine was not a limiting factor, and we just don't do it. It was I laid this out in the Foreign Affairs piece several weeks ago that around influenza vaccine, we're now seeing it with mpox vaccine. And we just continue to want to respond to crisis. That doesn't work.

Chris Dall: And how would you like to close today's episode?

Michael Osterholm: Well, Chris, today I want to close on a high note. We need some good news. I've considered, you know, songs and so forth, but I thought there was even a better way to do that today. And that's to actually highlight one of the true public health heroes of the last 150 years for the world. And the person I'm talking about is Doctor Jonas Salk. And for some of you, you will recall that name because it was associated with the very first polio vaccine available in this country and ultimately throughout the world. Doctor Salk became an international hero for his work at a time when polio was running rampant throughout the world. And I have two different quotes from him that I want to share today that one speak to his absolute belief in affecting the health of humans, and how we could do that in a very positive way, and something else that we desperately need today. And that's a good dose of humility when we find ourselves in these situations and do not understand fully what they mean, we need to tell the public that. The first one let me take is an interview that Doctor Salk did in 1991 with the Academy of Achievement, and he was asked the following question where do you think your sense of wanting to do something for humankind came from doctor Salk responded. “I believe that this is part of our nature and part of our ancestral heritage. That's how we got to be where we are. People who performed or functioned that way, or had that drive, or that desire or ambition, which I look upon as a natural phenomenon. Some people are constructive if you like. Others are destructive. It's this diversity in humankind that results in some making positive contributions and some negative contributions. It is necessary to have enough who make positive contributions to overcome the problems of each age.” With Salk's famous work on polio vaccine, he became an instant international star. As I mentioned in our book Deadliest Enemies, we published an experience that Doctor Salk had in terms of responding to a media question. Imagine now this is in April of 1955, when his vaccine was rolled out and it was clear that it was preventing what had been major outbreaks of polio. And let me read for you the passage in our book, to give you a sense also of who Doctor Salk was on April 12th, 1955, and what became one of the most famous quotes of the decade. Legendary broadcast journalist Edward R Murrow asked Salk on the live CBS program See It Now. Who owns the patent on this vaccine? With matter-of-fact modesty and a shy smile. Salk replied, “Well, the people, I would say there's no patent. Can you patent the sun?” That was it.

Michael Osterholm: The apoptosis from man to immortal. Jonas Salk was every patient and selfless deliverer from fear. And so today, I want to emphasize that there are those people who are so constructive who are making a difference, and there are those who are the true heroes, those whose whole lives are all about helping others without concern about what money they make or what contracts they get or whatever, just assaulted. And I think that when we think about where we're at today, if we've ever needed a dose of humility and we've needed a dose of dreaming, this is it. And Jonas Salk gave us both. Thank you again for joining us today. I hope that you were able to get some of the information you were looking for. Thank you to the listening audience for being with us again today. We appreciate that very much. I want to acknowledge again those who contacted us about the challenge with the reimbursement for the Novavax vaccine and the fact that your efforts actually played a real role in getting that taken care of. So thank you so much for being with us. It's very crazy right now. It's a tough world. So do your part to add a little kindness to the world. Reach out to someone today if even if it's been months. Reach out to someone today. Be kind. Be thoughtful. Thank you.

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 CIDRAPumn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP.umn.edu forward slash support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddard, and Leah Moat.