Episode 174: The H5N1 Pandemic Cliff: Are We at the Edge?

Chris: 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. And Happy New Year to everyone in the podcast family, as we begin this new year, we face an infectious disease landscape that is both familiar and unknown. We know that COVID-19 is still with us, that we will likely see peaks and valleys and infections throughout the year, and that new variants and waning immunity will continue to be challenges. But could the virus evolve in ways that surprise us? H5N1 avian flu will also continue to be a challenge for poultry and dairy farmers. But could the virus acquire the mutations that boost its potential to spread in people throughout the year? We will likely talk about the infectious diseases we've discussed on this podcast over the past several years, whether it be mpox, dengue, Marburg, polio or respiratory syncytial virus, just to name a few.

Chris: Will a new virus emerge that we need to add to that list? And finally, could new US health leaders with controversial views on infectious disease and public health reverse decades of progress that the country has made against preventable diseases? There are a lot of unknowns in 2025 when it comes to infectious disease. So, in this January 9th episode of the podcast, we'll start with what we know. We'll bring you up to speed on the latest COVID-19 flu and RSV data. Discuss the latest developments in the ever-evolving H5N1 avian flu outbreak. Answer ID queries on H5N1 in cats and songbirds, and tell you about a new CIDRAP report on Chronic Wasting Disease. 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.

Mike: Thank you, Chris, and Happy New Year to all of the listeners here today. I'm so glad you're with us again to all of our podcast family members. Thank you for returning, and thank you for your many kind and very thoughtful comments and notes during the holiday season. We appreciate that very much. And for those of you who are joining for the first time, I hope you find what you're looking for here. Again, we always welcome your feedback on how to best improve this. And also, I just want to leave you with one last point. I've been asked this question a number of times, and I had expressed in one of the previous podcasts that I now plan on being around at least for four or more years to get us through this potentially difficult time. And nothing has changed that. So, I'm hoping that that's acceptable to all of you. I promise to put my heart and soul into this for at least the next four years, and see where we go from there. For today's episode, we're dedicating our conversation to an extraordinary leader who left an indelible mark on both the world stage and the realm of public health, the late President Jimmy Carter. You have surely all heard by now that the former president passed away on December 29th. Jimmy Carter was many things. First, he was the 39th president, but he was much more than that.

Mike: And in fact, if I could quote from Jonathan Alter, who wrote on Substack, “he was the first American president since Thomas Jefferson who could reasonably claim to be a Renaissance man”. At various times in his life, he acquired the skills of a farmer, naval officer, electrician, sonar technologist, nuclear engineer, businessman, equipment designer, agronomist, master woodworker, Sunday school teacher, land use planner, legislator, door to door missionary, Governor, long shot presidential candidate. U.S. president, diplomat, fly fisherman, bird dog trainer, arrowhead, collector, home builder, painter, professor, memoirist, poet, novelist, and a children's book author and an incomplete list, as he would be happy to point out. That was the Jimmy Carter that we all surely have come to appreciate. Carter was a good and decent person who valued service and community above all else. Those values were instilled in Carter during his childhood on a humble farm in Plains, Georgia, with no running water or electricity. He left Georgia to serve in the Navy and start his family, but returned to take over the family farm in local politics as Governor of Georgia. He focused on government efficiency, educational opportunity, mental health programs, judicial reform, and civil rights for women and racial minorities. As president, Carter promoted moral standards and democratic principles and was recognized for his unpretentious demeanor. His presidential term faced economic challenges and international crises that led to his reelection lost, but not before he created the Energy and Education departments, appointed a record number of women and racial minorities to federal positions, and expanded the National Park and Wildlife Refuge system.

Mike: After his president, Jimmy Carter became known for his lifelong dedication to public service, particularly through the Carter Center, which he co-founded with his wife, Rosalynn. One of the center's most impactful initiatives has been its focus on combating infectious diseases, with special emphasis on diseases that affect the world's poorest and most vulnerable populations. Under Carter's guidance, the center spearheaded efforts to eradicate diseases like guinea worm, a parasitic infection that affected millions, and trachoma, the leading cause of Cause of preventable blindness. When the Carter Center began leading an international effort to eradicate guinea worm disease in 1986, there was an estimated 3.5 million cases worldwide. Today, there was an estimated seven. His approach was groundbreaking, always community driven and rooted in the belief that every human life holds inherent value. Carter's commitment to global health was always deeply personal. He recognized that improving access to health care was not only a moral imperative, but a way to promote peace and stability around the world. His work transcended borders, bringing together governments and non-government organizations and local communities to tackle some of the world's most persistent health challenges. So today, we honor President Jimmy Carter's life, his legacy, and his lifelong fight for the health and dignity of all people. His devotion to humanitarian causes will serve as an inspiration for generations to come, and was quoted by one presidential historian this week.

Mike: “They'll never make him like Jimmy Carter again.” Well, now, let me move on to that part of the podcast that some of you may want to tune out for a minute or more. But for the rest of you, hold tight here today, January 9th in Minneapolis-Saint Paul. I am very happy to report to you that today we have sunrise at 7:50am, the sun set at 4:50pm. That's nine hours and 53 seconds of sunlight. We've gained 19 minutes of sunlight since the December 21st. And tomorrow actually is the first day that the mornings start getting shorter again, not 7:50am, but tomorrow it'll be at 7:49am sunrise. And so, we'll begin to see the numbers really improving from the sunlight standpoint to our dear friends in Auckland, New Zealand, at the Occidental Belgian Beer House on Vulcan Lane. And again, to all the people who have recently submitted pictures or messages to us from the Belgian Beer House in New Zealand, we welcome hearing from you today. Your sun rises at 6:12 a.m. Your sun set at 8:43 p.m. That's 14 hours, 31 minutes and 25 seconds of sunlight. But you did lose a minute and two seconds of sunlight today. But you're still enjoying the very, very bright, warm days of your summer. And we're happy for you. Just know we're coming there, too.

Chris: And, Mike, I, for one, am looking forward to those lighter early mornings. But now to the business of the podcast. And let's start with COVID-19. For much of October and November, we were seeing declines in COVID markers throughout much of the country, but it looks like we are now seeing an uptick. What are we learning from the latest COVID data?

Mike: Well, I'm sure we're all hoping that we could leave COVID-19 in the 2024 rear view mirror, but unfortunately that is not the case. We are continuing to see increasing COVID activity across the country, but with quite a bit of regional variation. The national wastewater level is considered high and this is being driven primarily by the Midwest, which has seen wastewater concentrations more than double over the past two weeks to very high levels. Levels in the West remain low, and the South and Northeast are both considered moderate but increasing. Since wastewater data is a leading indicator, we can expect other indicators of COVID activity to continue to increase in the coming weeks as well. The final week of December, which is the most recent week with complete hospitalization data that includes 85.3% of the hospitals reporting their inpatient bed occupancy, 1.3% of inpatient beds were occupied by COVID-19 patients, which is about 8750 patients. This is much higher, 40% more than the 6220 patients we reported during our last episode on December 19th. During the same week, 78.9% of hospitals reported their ICU bed occupancy and 1.2% of all ICU beds, or about 120 beds, were occupied by a COVID-19 patient. While these numbers are increasing, there are still much lower than what we've seen in previous peaks around the pandemic.

Mike: Notably, in January of 2021, we had 130,000 hospitalizations. In January of 2022, we had 155,000 hospitalizations. So again, we're in a much better place with 6220 hospitalized patients. But nonetheless, it's still a challenge. Along with this increasing inpatient hospitalization numbers, emergency room visits are also increasing, and we're now seeing COVID accounting for 1.2% of all ED visits in the last week. And I'm sure this will continue to increase as long as we're seeing increasing COVID activity. Weekly deaths continue to decline, but remember, they are a lagging indicator that is also a month behind in reporting because it takes time to complete and analyze death records. That being said, the most recent week with complete death data is the week ending December 7th. During that week, we week, we lost 432 Americans to COVID-19. Our grandpas, our grandmas, our moms and our dads. Our brothers and our sisters. And unfortunately, in some instances, even our children. It's a relief to see this number decreasing because it is a sign we are seeing less severe disease, though it is never something to celebrate. We'll keep an eye on these metrics as always, and be sure to keep you updated, especially in the Midwest where wastewater levels are nearing the levels seen in July 2022.

Mike: I'm sure we'll continue to see activity spread, especially considering how low vaccination rates are. With just over 20% of adults and 10% of kids having received an updated dose. And before we move on, let me give a quick variant update. There was a delay in sequencing over the holidays, but as of December 21st, XEC still remained the predominant variant, accounting for 45% of U.S. cases. When XEC first showed up, there was concern that this might cause a big spike in cases. This doesn't really seem to be the be the situation here. While we're seeing increasing cases, XEC is really leveling off. What we now see is KP 3.1.1 making up 24% of new cases, and the new kid on the block LP8, which we discussed in our previous episode, is a variant we're keeping our eye on. It may have a growth advantage over XEC, and has doubled its prevalence in each of the last four variant data updates, which occur every two weeks. However, at this point, it only accounts for 8% of new US cases.

Chris: Mike, anecdotally, there seems to be a lot of respiratory illness activity going on. What are we seeing in the latest flu and RSV data?

Mike: Well, Chris, before I comment any further, I'm sure the audience by now has recognized that both you and I are suffering from respiratory infections. And any of you out there that have had to suffer through me kind of choking up a little bit here, coughing off mic, I apologize. We are clearly members of the of the respiratory infection community today, both in spirit and in reality. So please have patience with us. Thank you. We are seeing a lot of respiratory activity. I already just discussed COVID, but as you'll see in a minute, that's no longer even the number one respiratory pathogen of concern. We are surely experiencing what I consider to be a post-holiday increase in cases. As you noted, the respiratory season is definitely here. And it's not just in the US, it's everywhere. In fact, England is warning that this could be one of their worst winter flu seasons that they've ever seen. With the number of hospitalized flu patients quadrupling from November to December here in the US. Respiratory illness activity is high and we're likely near peak season. One of our best metrics for monitoring flu activity is by looking at the percentage of outpatient visits for influenza like illness. Currently, these levels are considered very high and increasing, with 6.8% of all visits last week. Activity is highest in the in the south and the west, and lowest in the northeast, but it's increasing across the entire country.

Mike: 24 states and the District of Columbia are experiencing very high flu levels. 17 are high. Five are moderate. Three are low. And only two have minimal activity. I also want to draw attention to the age breakdown of this outpatient data we use to measure activity. 6.8% is the average percentage of visits across all age groups, but it is much higher in younger age groups. The percentage of visits for influenza like illness last week are as follows 16.5% for 0- to 4-year-olds, 10% for those 5- to 24-year-olds, 5.5% for those 25 to 49, 4.1% for those 50 to 64, and only 2.9% for those over 65. This is typical for influenza activity, and it emphasizes the importance of parents getting their young kids vaccinated. 16.5% of all visits for those 0 to 4 years of age were for flu. This is a very, very significant issue. Of the 1254 viruses reported by public health labs during week 52 of the final week of December, 1234 were influenza A and only 20 were influenza B 823 of the influenza A viruses were then further subtyped. The majority of the influenza that was reported in Subtyped was roughly 40% H1N1 and 60% age three, in two, according to the CDC flu surveillance reports for the week ending December 28th.

Mike: There were over 26,000 patients admitted to the hospitals with influenza that week, an increase of 77% compared to the previous week. The last week of December, there were more than 11,550 influenza patients occupying inpatient beds in 85.3% of the hospitals that reported data, and there were 725 occupying ICU beds. So far this flu season, there have been over 63,000 hospitalizations and 5.3 million cases of flu. Unfortunately, there were two additional pediatric deaths associated with seasonal flu last week, sadly bringing the total to 11 pediatric deaths this season and 2700 flu deaths in total. Ultimately, influenza activity is trending similar to the 2019 2020 season, which peaked around the new year, so hopefully we can reach the peak here shortly and activity will start to decline. As far as RSV is concerned, activity is also very high across much of the country, especially in young kids who really tend to get the worst of the respiratory virus season. But hospitalizations are also elevated in older adults. The last week of December, there were 6125 RSV patients occupying inpatient beds, up from 3400 during our last episode. That is double the number we had just three weeks ago. Emergency department visits are also increasing, with the highest ED visit percentages due to RSV being in the south and the highest RSV hospitalization rates being in the northeast. Increasingly, RSV wastewater activity is considered moderate and with wastewater data being a leading indicator of what is likely to come, that could hopefully be a sign that we may see some relief soon.

Mike: This would be consistent with previous year’s peak timing, which varies by region but ranges from late December to mid-January. So let me just tie this all back together. For most of the last several years, COVID has led the way in terms of hospitalizations, whether it be in the winter season, summer, fall, whatever. Well, if you look at where we're at today, let me just summarize. For flu, there is approximately 11,550 people hospitalized. 11,550 for COVID. It's 8750. And for RSV it's 6125. So, flu has surely taken on the lion's share of activity, with almost 45% of all respiratory illness related hospitalizations being due to flu. This is 26,425 people currently hospitalized relative to these three pathogens. That's a significant situation, and we're all hoping to get through this season soon. One last comment about vaccine. I wish I could say go get your vaccine dose. I surely wouldn't tell you not to. But we likely missed the train here. You should have had these in place at least 3 to 4 weeks ago, and unfortunately now not likely that it's going to have a great impact as the season hopefully begins to wind down in the next several weeks.

Chris: Now, the H5N1 topic that continued to be a major national media story over the holidays. On December 18th, you had California Governor Gavin Newsom declaring a statewide emergency due to bird flu. Meanwhile, the CDC continues to state that bird flu is low risk to the public, and we're seeing a number of public health officials critical of the federal response suggesting this virus could result in an influenza pandemic any day. Meanwhile, we are now going on ten months since H5N1 virus was first found in Texas, cattle and the number of new herds infected seems to go up in number almost every day. Mike, what should our listeners believe? Is this situation an emergency, or is the new reality that we have an ongoing dairy cattle infections but low risk to humans?

Mike: Well, Chris, I'll throw a monkey wrench in this and say they're both right. Both California and CDC. But let me explain. I'm going to take a few minutes to cover some background information, influenza that I think seems to be missing from a lot of these discussions. Remember that influenza A viruses can be characterized by their hemagglutinin neuraminidase antigens. The hemagglutinin, which there are were 18 of them, is the lock and key to get inside the cell. So that has to match up into the human cell in order to penetrate. The neuraminidase is, which there are 11, to me I've always thought of them as the hand grenade of the virus. They're the part of the virus that blows up the cell wall once the virus is being made inside that cell, so the virus can escape. And it's that combination of H and N that we've always talked about. If you look at the historic perspective of the last 100 plus years, we have had a series of pandemics, which is when a new avian virus, a virus that has not previously been found in humans, or at least no evidence of person-to-person transmission, changes sufficiently through either reassortment mixing of two viruses together to create a third or mutational changes come along. We have no population-based immunity, or at least limited population-based immunity. It's now transmitted person to person. While voila, you've got yourself a pandemic.

Mike: If you look at H1 virus, we know that was responsible for the 1918 pandemic. In retrospect, we didn't have the ability to isolate viruses at the time, but subsequent studies showed it to be 1918. This virus also returned, by the way, in 1977, in a time when we believe it may have actually leaked out of or been part of at least a program the Russians were investing in in terms of live attenuated influenza vaccines. This was, in a sense, the old 1918 virus that had been around but disappeared back in 1957. And then, of course, we had the 2009 H1N1 pandemic, where we already had a preexisting H1N1 circulating, and then a new one, very different one emerged out of the swine operations of central Mexico. That's the current H1N1 that we're living with today. In 1957, H1N2 Into showed up, which then replaced the original H1N1 that stuck around from 1957 to 1968. And then in 1968, age three and two showed up. That replaced H1N2. And since 1968, we've been dealing with H3N2 and now, of course, H1N1. Now we have seen other largely avian strains of the virus causing illnesses in humans, but without evidence of ongoing person to person transmission. These include H5, which we'll talk more about H7 and H9. And when we look at age five, that history really emerged in 1996 when it first showed up in geese in the Guangdong province of China.

Mike: 1997 it caused an outbreak in the markets of Hong Kong with 18 human cases, six died. The markets were basically completely wiped clean of these birds, the farms supplying the birds to the markets. All those birds were also euthanized and the sense was waloo, we've stopped a pandemic from happening. Well, in fact, H5N1 showed back up again as early as 2001, and particularly in 2003, we started to see major increases in cases occurring in humans in contact with birds, primarily in Southeast Asia. And then, of course, as you know, we went through this history since that time with this virus, from 2003 to 2009, worldwide, there were 468 human cases documented of H5N1 without evidence of person-to-person transmission. Of those 468, 282 died, or 60% of the individuals died from 2010 to 2019. There was a total of 393 documented H5N1 human cases. 173 of those individuals died, or about 44% after 2020 and with regards to the pandemic, things really begin to change. We saw very few cases occurring. We didn't really at this point think of H5N1 much at all in terms of humans. And then, lo and behold, a new clade of virus showed up in 2021. This is kind of like the big family name. And this is the 2.3.4.4b clade of H5N1. And in short order, we saw widespread infection spread through bird populations around the world.

Mike: From there, it got into a number of different mammal species. If you look at what the sampling has been done here in this country, the US Department of Agriculture, as well as the Department of Interior, have worked on this issue and have determined there have been over 100 isolates out of wild birds. And of course, the 917 dairy herds and at least 130 million poultry in the United States have succumbed to H5N1. One. The concern had been all along in 2021 that this might spill over into humans. We saw very little evidence of that until we actually saw the first activity around the beginning of 2024, with the dairy cattle throughout the country. And then, of course, we continue to see poultry outbreaks happening then and now this week. As you know, we have had a death in human here in the United States, an individual in Louisiana who was over age 65, who actually had underlying health conditions and died from their H5N1 infection. I can tell you over the course of the last several days, I've had all kinds of calls from the media thinking, is this it? Does this mean it's now going to happen? Remember, I just shared with you all the deaths that have occurred with H5N1 to date? This one death does not tell me anything about what the risk is of this virus becoming a person-to-person transmitted virus, nor does the serious illness that occurred in the adolescent female in British Columbia, who also had his underlying risk factors obesity and asthma.

Mike: Now, in both those cases, the Louisiana case and the British Columbia case, those would be cases. If it was H1N1 or H3N2, you would expect potentially to have serious illness. I mean, I've already shared with you, you know, the number of deaths that we've seen already this flu season in this country. So, I don't want to minimize these cases, but they do not make the case for the fact that this is now changing into a different virus. And I think this is where we really are at a loss for understanding this. Anyone that tells you they know that there will be a pandemic resulting from H5N1, you know, be careful because they probably have a bridge to sell you to. We have to be honest and say, we don't know. I was in Southeast Asia in the early days of the 2004 2005 time period, working on H5N1. I was on the National Science Advisory Board in 2012 when two very distinguished researchers brought data to our group saying we are only 1 or 2 mutations away from H5N1, causing the next pandemic. I very closely followed what happened in the Nile River Valley in 2014-15, when we saw a big spike in cases in humans who were duck farmers.

Mike: And again, a large number of deaths. And then, of course, we saw what happened in 2000 to 2005. Now we have these additional cases, 66 cases in 2024 with seven probable cases coming up to now, what people are estimating to be 73 or 74 total cases, only these this particular case that I mentioned in Louisiana have been classified as severe cases in this country. What does this all mean? Well, let me just be really, really clear that we don't know what the combination of mutations or reassortment might be necessary. I liken this from an analogy standpoint of it's like a tumbler on a safe. You first have to go to the right to a certain number, hit it, then you got to go back to the left and hit a certain number. Then you go back to the right again, and then you go back to the left a second time. And it's got to be the right numbers in the right order. Exactly done that way for that safe to open. And I think that's what we're looking at with this virus. It's going to have to make certain changes that would then allow the virus to enter into the cell and get out of the cell, and then cause this major problem. So, I just said a moment ago, is this a crisis or not? Is this an emergency? Is CDC got it wrong? Well, from a standpoint of California, their declaration around this virus activity was really all about an administrative decision of how to move money under emergency circumstances to the agricultural community to work on this.

Mike: Okay. It wasn't about the fact that there was some imminent public health threat to the residents of California could be in the future, but at least that wasn't what was happening. In terms of what CDC is telling you is this is where I think, unfortunately, some of my colleagues really don't do a good job here of helping the public understand what does low risk mean? Imagine right now you're walking down a very flat, beautiful piece of land, and you just can keep walking as far as your eyes can see. And you walk and you walk and you walk. That's what we've been in with H5N1, kind of that low risk. We've not had evidence at all of person-to-person transmission, but then all of a sudden you go 18 to 22 in too far, you hit a cliff and you didn't see it. And that cliff is five miles straight down. That's a bad, bad, bad place to be. So, you go from the flat land of low down. That's what's going to happen with the pandemic. There's not likely to likely to be any early warning signs that tell us, oh my.

Mike: This is happening right now. We got to stop it. I have, of course, been of the mind for some time and I surely was with COVID. We will never stop a respiratory virus transmitted pandemic. Once it starts, it will move far too fast. Far too many people will get infected and we won't stop it. I discussed this at great length in my new book that's coming out later this year. So, at this point, I can only say that if I look at what's happening in the animal population, in the dairy cattle, which is in addition to the clade, also the genomic data showing it's a, B3.1.3, which at this point has not caused serious illness in humans, nor have we seen it transmitting person to person. Now the poultry virus, the D1.1 and D1.2, that particular virus I think maybe has more potential. It could possibly acquire more activity to become the next pandemic strain, but we don't have any, any clue that that is actually what's going to happen. You know, I said to some people back last May when we saw what was happening. Don't be surprised if we don't see human transmission, at least person to person from this virus. I've been here too many times with the H5N1 data. You know, when I heard the CDC present the data on the ferret and what it did to ferrets with isolates related to this most recent episode, and thought to myself, those are the very same data I heard back in 2012 when it was presented to the NSABB that, in fact, you know, this was an imminent risk.

Mike: So, I don't know what it means, but let me just say, what I do know is we are woefully underprepared for the next pandemic. I can't say that enough times. And so, I don't want people to think that. I don't think that this is an urgent crisis. One thing I would say is we have to do what makes a difference. I keep seeing some of my colleagues promoting vaccinate the workers around them. With the H5 vaccine we have meaning in the dairy, etc. do they realize that these vaccines do very, very little to stop transmission or even infection itself? You know, the data for the United States, just published this past week showed last year against seasonal flu. The vaccine reduced hospitalization by about 40%. That was it. Now that's great. I get my shot because that's still worth it to me, 40%. But that's hardly going to stop transmission from animals to humans if that becomes what we're going to begin to see. And so, you can vaccinate workers, I think it will have very little impact at all. Also, more testing. Well, you know, we are testing those at highest risk, those in the interface with these birds.

Mike: The only other population we can be testing is the whole general population. And as far as exposure, you know, yes, someone could get exposed to a bird virus out there that's floating in the air from dust that's been blown up on a nearby field or from a bird feeder. But in fact, we're testing who we should be testing right now, I believe, and what I want to expand it more, possibly some, but it's not the same as what was happening with COVID. And when I see some of the public health voices out there saying, well, remember COVID, we didn't do enough testing, this is a totally different situation. Back then, we didn't know anything about this virus. We didn't know where it was going. We know a lot more about this virus here. So, at this point, I would just say that the challenge we have is we have a vaccine for this virus that has made in 2022 H5N1. We don't know that this vaccine will actually be effective against this virus. CDC hinted in the statement they made about the patient from Louisiana that, in fact, the virus that was seen there was closer to a candidate virus, meaning one that had already been considered for vaccine but had had no production whatsoever. Well, why is that important? Because right now, in this world, we have the capacity to only make 6.8 billion doses of vaccine a year.

Mike: 6.8 billion. And in that first year of the pandemic, we wouldn't see a vaccine for the first six months. If you look at the 6.8 billion doses of vaccine, remember it's a two-dose vaccine. That means less than 2 billion people would have access to that vaccine in the first, you know, 6 to 18 months of the pandemic. And what would happen to the rest of the world? We need to do so much more to improve on our vaccine work. And we will provide a link to you on our website for the influenza vaccine roadmap work that we're doing, trying to track where new vaccine research is at and what's available, and how can we look at future vaccines. But right now, we're a long way off from more effective vaccines. First of all, my message continues to be we need to stop 5 in 1 transmission and dairy cattle because of the potential for reassortment where we could have a human virus and a bird virus in the same udder and reassort. No question about that. And the USDA has really been challenged to provide us with the leadership we need in that area. We need to fast forward overall research and development around flu and coronavirus vaccines. We need to build manufacturing capacity that may sit idle sometimes, but in fact, during a pandemic, we need it and we need it now.

Mike: We need to look at mRNA vaccines. Will they, in fact be an answer that could help with the flu vaccine shortage, both in terms of the actual level of protection, but also will the public accept it? So, I think that I just want to come back and say, yes, this case that just occurred is something we should be concerned about. But just remember, today, 11,550 people are hospitalized in this country with seasonal flu, 2700 have already died, including 11 pediatric cases. That's a focus we can't forget. But we also have to be much, much better prepared for the next pandemic. And we're not. And whether it will be H5N1 or not, I don't know. I don't know that. But it surely could be. But right now, nothing I see tells me that that is what's going to be the imminent threat today, tomorrow or next week. So, I hope this is helpful. I'm sure some will disagree with me vehemently of the statements I've made. I've been living flu for 30 years. I've been working it hard. And I have to acknowledge to you, I probably know less about flu today than I did ten years ago. But I think having learned what I have learned, I also have this great respect for this virus. And you can expect it to do the unexpected or maybe do nothing at all. We just don't know.

Chris: That brings us to our ID query. And this week we have two H5N1 related questions. The first is from our listener identified as Elle, who asks, could domestic cats become a vector for this virus to spread to other mammals, including humans? Then we received this email from Wendy who wrote, I just finished listening to the latest podcast in which he spoke about H5N1 in the wild bird population. I asked that you be specific about which birds are implicated in the spread of this disease. As I understand it, it is spread almost exclusively by waterfowl, not by songbirds, birds of prey, or any other type of bird. Birds are the one type of wildlife that we see on a daily basis, and an estimated one third of Americans identify themselves as bird watchers. 57 million Americans actively feed birds, but many are concerned about doing so for fear of spreading or catching bird flu. This fear is unwarranted, but sustained by speaking in general terms of bird flu in the wild bird population. So, Mike, let's start with that second question and talk about H5N1 in the wild bird population.

Mike: Well, first of all, I want to thank Wendy for her very thoughtful comment. It was a very important one, and I look forward to adding some clarification to that issue. Let me just start out by saying, with the ever-changing landscape of what we know about this virus, I can only address these topics with currently available information, and without necessarily having what I would consider to be a good, definitive answer. As I just said in the previous question and answer, I always say I know less about flu now than I did five, ten, 20 years ago, and I'm afraid that's the case here. But let me just back up and first of all, support the point that Wendy made about the predominant bird species involved are migratory waterfowl or poultry. And that has continued to be the case. However, there has been a number of species of passerine birds, the songbirds, 23 of them to date where the virus has been isolated from them and they in fact had died. And so, it appears that the house sparrows, for example, birds like this, can get infected occasionally. And what role they play in potentially transmitting this virus to humans or other animals, birds, etc. is unclear. So, at this point, the recommendation from the USDA and Aphis in general is no. Go ahead. You can use your bird feeders, keep them clean to be additionally safe.

Mike: Make sure you wear gloves. You may even wear a mask if you're trying to clean the bird feeder out. At this point, just know that pastoring or the songbirds are going to be a low-risk situation. Clearly, the category of ducks, geese, swans, shorebirds they will continue to be the dominant source of virus being spread around by birds. And we're seeing that right now. We've had major outbreaks on the East Coast and the Midwest. These are all occurring in poultry operations that are still coming in contact with migratory birds. People say, well, wait, migratory birds is so late in the season. We have many locations in this country that because of warm water activities, meaning either industrial related agricultural farm ponds from dairy operations that are still wide open, or rivers or lake areas that may be open where we're still seeing these birds existing, they won't migrate if they have open water. And so, from that perspective, yeah, we're still seeing that activity. To answer your question, Wendy. Yes, passerine birds have been infected, but at a much, much lower rate than we see with the migratory waterfowl. And all I can say is that I think if you had your bird feeder and cleaned it, as we just discussed, that would put you at very low risk. Now, as far as the cats, let me just remind you that felines have been involved with H5N1 dating back to the early 2003 2004 time period in Asia.

Mike: The Bengal tigers at several different zoo locations in Thailand were heavily impacted, with a number that died in 2003 and four, after they had been fed culled poultry from flocks that had H5N1 infection. Thinking that that would not be transmitted on to the cats. And then there was some additional evidence that, in fact, the cats transmitted to each other, for some of them had never had these culled poultry, and they too got infected. And almost universally, in every case, it was fatal. Well, we've continued to see that with cats, domestic cats. We've seen it with the big cats. Just in the last few weeks, additional deaths have been reported at zoos and so forth. So just know that the virus can be transmitted from feline to feline. But we have at this point, no evidence that we've seen transmission from an infected feline to a human. Whether that will continue, I don't know. But at this point, I would have to say that I don't think this is a high-risk situation for humans. But anyone who is a cat lover and you have your pet cat, you recognize just how difficult this situation is in terms of the risk of your cat picking up H5N1.

Chris: Now on to some other infectious disease news. This week, CIDRAP published a new report on a Chronic Wasting Disease, or CWD. Mike, CWD is a disease that you've been concerned about for many years. Can you remind our listeners what CWD is, why CIDRAP is focusing on it, and what the main takeaways are from this report?

Mike: Well, Chris, you're right, Chronic Wasting Disease, or CWD has been a concern of mine for some time, but I guess most of the public are not familiar with it. CWD affects members of the Cervid family, which includes deer, elk and moose, and is distributed across free ranging cervid populations now in 35 U.S. states, four Canadian provinces, Norway, Finland, Sweden and South Korea. It's caused by a unique bionic infectious agent called a prion, which is that misfolded form of normal protein that can set off a domino effect of more and more misfolding. Unfortunately, the immune system can't do much about these prions, and eventually they aggregate and migrate to the central nervous system. The accumulation of prions in the brain causes spongiform encephalopathy, leading to a neurodegenerative symptoms that worsen until the infected animal eventually dies. CWD is a major concern to the hunting community, both for their interest in the health of deer and elk populations, as well as concerns that consuming venison from CWD positive animals may result in a spillover incident that could infect humans. While there is no direct evidence of human transmission of CWD to humans to date, the concern stems from parallels to bovine spongiform encephalopathy, or BSE. Some listeners may remember BSE as mad cow disease, which was a prion disease that led to a massive fallout in the UK cattle herds in the 1980s. Years later, a cohort of young people began developing highly unusual neurodegenerative conditions, which were then linked to the consumption of food products with sick cows. Mad cow had far reaching impacts on livestock agriculture. Are we prepared to face those challenges again? If CWD were to transmit to a human or to a production animal? The answer to that question is a resounding no, which is why CIDRAP set out to complete our spillover preparedness work.

Mike: This involved working with 67 of the world's leading experts in human health service and production, animal health and prion biology and disease diagnostics, carcass and contaminated item disposal, and wildlife health and management. These multidisciplinary experts participated in a total of 25 different meetings over the past year and a half to discuss the current state of management and science, as well as gaps in research and readiness to respond to a spillover case. Just yesterday, January 8th, we released a report that summarizes the critical findings from these 25 meetings. The report, entitled Chronic Wasting Disease Spillover Preparedness and Response Charting an Uncertain Future, is an in-depth characterization of what is known and unknown about the disease, the threat of a spillover, and the requirements of a spillover response. Most importantly, the report includes nine recommendations aimed at improving human and animal health agencies capacity to respond to a spillover event. Examples include securing dedicated multiyear funding for research and management, strengthening work partnerships among wildlife managers, agricultural experts, neurologists, the basic research community, and human health providers. More robust outreach to improve surveillance and prion disease. Reporting by primary care physicians. Estimating carcass disposal capacity needs. And expanding and standardizing CWD disease surveillance. You can find the report on our website, we have a link in the show notes that you'll be able to get right to it. This is truly one of those other conditions. Where will it ever happen? I don't know, could it happen? Absolutely. If it does. Oh, my. This could be a major, major challenge.

Chris: Finally, Mike, I'm sure some of our listeners want to know what's going on with president elect Trump's nominees for various health leadership positions. We talked a lot about this in the episodes leading up to the holiday. Is there anything you want to say on that topic?

Mike: Well, first of all, I just want to reassure everyone. We are still very much on top of this. And as I promised you right after the election, we will stay connected. This has been a period of somewhat quiet period, in the sense that we still really haven't seen any of the appointments for those positions at the second, third and fourth levels of agencies. Everyone is still focused on the actual secretary for that given agency, such as Robert F. Kennedy Jr. for Health and Human Services. We do know now, as we talked about in a previous podcast to the nominees are for director of CDC, the NIH, the FDA, etc. and we'll continue to stay on top of that. Clearly, after the inauguration and the announcement of the next set of leaders, that will be really on a day-to-day basis, leading these organizations will have a much better sense of what the challenges are and will be able to provide to you, the listeners, what our take is about, what can and must be done. But in the meantime, I wanted to give you a sense of what I had shared with you some weeks ago about how it is oftentimes this second, third, fourth level leaders that have by far the greatest impact on what an agency does. If you're the Secretary of Health and Human Services of $2.2 trillion organization, you don't have a lot of time for micromanaging. But on the other hand, your leaders at that second, third and fourth level do. And I just want to share with you, I think one example in the Department of Health and Human Services, one of the individuals who is in the senior vetting team, meaning the person doing the interviews and doing the follow up and making decisions about who will hold certain positions at HHS is Aaron Siri.

Mike: Aaron is a lawyer at the firm of Siri Grimstad. He is most noted for his work on the various petitions that have been filed with the FDA in the last several years to remove certain vaccines from of the availability here in the United States. For example, in 2022, in a petition that he filed to the FDA requesting that FDA withdraw or suspend the approval of inactivated polio vaccine for infants, toddlers, and children until a properly controlled and properly powered double-blind trial of sufficient duration is conducted to assess the safety of the product. Well, he is way off base on this one in terms of what these studies have already been done and what they've told us and how much was done. A couple of years earlier, in 2020, he actually filed another petition to the FDA to withdraw or suspend the approval of Engerix B or Recombivax hepatitis B vaccine for infants and toddlers and tell a double blind, placebo-controlled trial with sufficient duration is conducted to assess the safety of these products. Again, absolutely does not understand what studies had been done, how they had been done, and the fact that you can't, for example, use a placebo-controlled trial when you're actually dealing with a population at risk for the disease. But you have other ways to evaluate comparison wise between the vaccine recipients of A and the vaccine recipients of B, the previous vaccine just totally off base.

Mike: He filed a third petition in 2021 that actually asked the FDA to withdraw 13 vaccines from the market, which prevented a wide range of diseases. The issue was the adjuvant aluminum, which enhanced the immune response to a variety of vaccines. He claimed that based on studies in Europe, that in fact the quantity of aluminum was far too high and was a health risk and danger. This is the guy right now who is vetting the people to hold the senior positions at HHS. Can you imagine someone with experience in vaccine research and development or delivery? How they would do in a vetting situation with this guy? So, this is the kind of thing we're tracking. We will keep track of this for you. As I said, probably in the next four weeks, we're going to have a lot more information about what the implications are with the administration. Leadership changes what you can do or must do in terms of your community. How will this begin affecting not just national policy or national laws regulations, but how will it impact your schools, how it will impact your states? These are all going to be issues that we'll continue to continue to follow. As I said before, I'm committed to this one for the next four years. This is far too important for my kids and grandkids not to put everything I have in my heart and soul into this effort.

Chris: Now it's time for this week in public health history and for this segment, we're going to return to where we started this episode with former President Jimmy Carter.

Mike: Well, this moment in public health history is a very personal experience that I had with Jimmy Carter. It turned out that back in 1995, the University of Minnesota School of Public Health was celebrating its 50th anniversary, and we had a large week-long celebration topped off by a dinner with hundreds of people attending. And I was one of the co-chairs of this particular event, along with the former Commissioner of Health at the Minnesota Department of Health System, Madonna Ashton. We all came to the agreement that the speaker that we liked more than anyone was doctor Bill Foege, who had been former head of the CDC. Clearly one of the masterminds of smallpox eradication. A hero of heroes among public health and who had gone on and become the director of the Carter Center, working very, very closely with President Carter on many of these initiatives I talked about. So, I contacted Bill, secured his services months in advance, and we were all very excited about having him there. If you've never heard Bill speak before, you've missed a piece of art. He is an amazing speaker. Well, about five days before the event, I get a call from Doctor Foege telling me that he could not attend the event because that, in fact, President Carter had just basically bartered a peace agreement, a temporary cease fire in the Sudan to actually deliver, at that time, vaccines for children and guinea worm related treatments, and that he was being charged by President Carter to go to the South Sudan and actually oversee this particular truce.

Mike: And oh, here we are, big speaker. So, you know, I had a conversation with him and I said, do you have any suggestions? And he said, let me think about it. Well, he got back to me the next day. He said, you know, I know Art Buchwald, who is a humorous columnist many people will be familiar with from back then, one of the most entertaining people you could ever imagine and somebody who had a vast knowledge of many topics, etc., he said. I think that he would be great for that. He said, you know, I can actually have the president call him and actually enlist him to come do this in five days. And that was four days. And so, I said, well, thank you. Anything you can do will be great. Well, a day later I get a phone call at the health department, and it is an administrative assistant from the Carter Center saying that President Carter wanted to talk to me.

Mike: So, I get on my phone and here is Jimmy Carter telling me that he had talked personally to Art Buchwald and that Art Buchwald would be more than happy to come and do that as a favor for Bill and the president, and that he would personally make sure everything was taken care of. Well, to make this long story short, Bill went off to the South Sudan and as he had done so many times before, it was a hero. The ceasefire held. The public health services were delivered. Amazing impact. Art Buchwald came to the University of Minnesota celebration. He was a hit upon a hit. He had people in stitches, and yet they were really very substantive points he often made about public health. And so, I will never forget that act of kindness on Jimmy Carter, who basically made up for having Bill Foege go to the South Sudan. And we had a wonderful night because of that with Art Buchwald. It was all due to the president's willingness to actually engage Art Buchwald, and I'm sure it was very hard for Mr. Buchwald to turn down Jimmy Carter for a request like that.

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

Mike: Well, my first take home message, Chris, is, I hope that both of us do a little better with our upper respiratory infections and get our voices back for the next time. For all those who had to put up with our scratchy voices today, we're sorry. Okay, my first real point is, is that H5N1. None of us, none of us know what the next shoe will be to drop with that virus. We just don't. I do know that there's going to be additional influenza pandemics. They could be horrible. We're not prepared for them as we need to be. We've learned very few lessons from the COVID pandemic, and for now, we need to do much more with H5N1 just to keep reassortment from occurring in some cow's udder or some on some dairy operation in this country. And from that perspective, the USDA has to continue to step it up. Step it up. We cannot continue to have this ongoing transmission. The next couple of weeks will be surely an increased time for upper respiratory infections. We know that if you are someone who is older, who has underlying health conditions, please avoid sick people if you can.

Mike: And if you are someone who is sick and you have an older family member or someone with underlying health conditions, be considerate. Don't go. You know, I know this has been hard this holiday season, but we've had multiple occasions where individuals, they felt like they had to go to a family event, whatever. And then lo and behold, an outbreak occurs. And finally, the message, I just want to leave with you. We are still all over this issue of what's going to happen with the new administration and public health. We will keep you informed. Again, we're kind of in a quiet period because we don't really know what the policies are going to be, who the leaders are going to be in those policy related positions that can make policies change. But as soon as we get that information, we will share it with you and we will come up with ideas about how we can become engaged and what we can do about it. Whether it's at your local school board meeting or whether it's petitioning on a national level.

Chris: And what is your closing song for today?

Mike: Well, for all of us who have ever known of Jimmy Carter, we know of his love and that of his wife, Rosalynn, for the habitat for humanity program. Very few people in this world have done more over the course of the past 25, 30 years supporting this program and in fact, even not just in the United States. But, you know, his work that he did building a neighborhood in Thailand. Amazing work. Well, there was a book published in October 13th of 2009, of which it actually had President Carter's compelling anecdotes in this book. It's a joy to read. And the title of the of the book, if I Had a Hammer Building homes and Hope with habitat for humanity. And so, while I don't have any evidence that the songwriter Pete Seeger actually was close to Jimmy Carter, as any of us know, the late Pete Seeger had a song that fits just perfect with this if I Had a hammer. That he and Lee Hays wrote. It was written in 1949, in support of the progressive movement. It was recorded by a number of different acts over the years, and went on and became one that is familiar to many. It was often said that the song if I Had a Hammer was a freedom song of the Civil Rights movement. It had a tremendous impact on the American youth of the 1960s who protested against American culture.

Mike: It helped to spark the hippie movement. And it was all about building. So today I've chosen if I Had a Hammer Again, written by Pete Seeger and Lee Hays. This is Jimmy Carter, basically with his hammer in hand. If I had a hammer, I'd hammer in the morning. I'd hammer in the evening. All over the land. I'd hammer out danger. I'd hammer out warning. I'd hammer out love. Between my brothers and my sisters. All over the land. Ah, if I had a bell. I'd ring it in the morning. I'd ring it in the evening. All over the land. I'd ring out danger. I'd ring out a warning. I'd ring out love. Between my brothers and my sisters. All over this land. If I had a song, I'd sing it in the morning. I'd sing it in the evening. All over the land. I'd sing out danger. I'd sing out a warning. I'd sing out love. Between my brothers and my sisters. All over the land. Well, I've got a hammer. And I've got a bell. And I've got a song to sing. All over this land. It's the hammer of justice. It's the bell of freedom. It's a song about love. Between my brothers and my sisters.

Mike: All over this land. It's a hammer of hammer of justice. It's a bell of freedom. It's a song about love between my brothers and my sisters all over this land. Pete Seeger and Lee Hays. If I had a hammer. And Mr. Carter, you had a hammer that was much larger than anyone could ever have imagined holding in one hand. And you did that through your entire life. So, thank you all so much for being with us. I hope we were able to provide you with the information you're looking for. I know we got into the weeds a bit on the influenza issue. This is one that I don't think I can ever go deep enough in the weeds to actually understand exactly what's happening, but hopefully you got a sense of at least where I'm coming from on this issue. I hope you all have had a happy holiday season, and that the days ahead also are ones that as the light gets lighter, that you enjoy and appreciate and we'll stay in touch with you and keep you posted on what we see happening. Thank you so much for being with us. And take your hammer out there and sing out love between your brothers and your sisters. We need that right now. Be kind. Be thoughtful. Thank you so much. Thank you.

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