Episode 178: Mixed Messages: Navigating the Unfolding Confusion

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 February 26th, officials with the Texas Department of State Health Services announced the first fatality in a growing measles outbreak in the western part of the state. The death was in a school aged child who was not vaccinated. It was the first death from measles in the United States since 2015, and the first pediatric U.S. measles death since 2003. The measles outbreak in Texas, which now totals 159 cases, cannot be discussed without noting that most of the cases have occurred in children who have not received the vaccine or whose vaccination status is not known, and it's occurring with Robert F. Kennedy Jr, a longtime critic of the measles vaccine and other vaccines, now at the helm of the Department of Health and Human Services.

Chris Dall: In related news, two previously scheduled meetings of federal vaccine advisory committees were either canceled or postponed last week, leaving many to wonder what lies ahead for these committees under Kennedy. Will these committees of vaccine experts be sidelined, scrapped altogether, or will Kennedy replace some of the members with people who reflect some of his anti-vaccine views? Is this all a harbinger of things to come? These are just two of the topics we're going to tackle on this March 6th episode of the Osterholm Update. We'll also update you on flu, COVID, and respiratory syncytial virus trends, bringing you the latest on the H5N1 avian flu outbreak in US poultry and dairy cattle. Discuss how federal health agency cuts are going to affect state and local health departments, and what the dismantling of USAID means for efforts to fight infectious diseases around the world, and will also answer an ID query on measles, mumps and rubella booster shots. And of course, 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.

Dr. Osterholm: Thanks, Chris, and welcome back to the podcast family in particular. We so appreciate your feedback and your support for this effort. And for those of you who may have, from time to time listened in and happened to be listening today, we hope that you find the information you're looking for and that you're willing to consider coming back again. And finally, for those who may for the first time be visiting us, I hope again we too are providing you with the kind of information that you're looking for. Let me start out by saying this is a podcast that could last several hours. It's a podcast that is changing literally by the minute. So, as we record this today, it doesn't necessarily mean what will be happening tomorrow. We'll try to do the best we can to predict that tomorrow, but believe me, it's a challenging situation right now. Let me start at the outset by saying we all are feeling a great deal of angst about where our world is today, whether it's about the economy, whether it's about what's happening with our own personal lives and losing jobs. It's also wondering about what kind of retirement fund I might have if I'm looking at what might be occurring to my 401K right now, if I even have a 401K. There's just many, many challenges before us. And in that light, today we're going to try to bring some clarity to some of those things that will help you better understand what that impact might be on your life.

Dr. Osterholm: But at the outset, I want to make it clear things are happening so quickly that it's hard to anticipate what might be the next shoe to drop. Let me just give you an example. Two weeks ago, we were all in dire straits thinking about the cuts that would be happening at the Centers for Disease Control and Prevention. This included a number of Epidemic Intelligence Service officers, those who are part of the Laboratory Leadership Service, and those who are part of the Public Health Associate program. Well, these officers got spared, but these two other activities were hit hard. Well guess what? The best data we have today says that the Laboratory Leadership Service and Public Health Associate program is going to be reinstated, that, in fact, all the people who were fired are going to be coming back. Every day there is something happening here. And so, when we talk later on in the podcast about what we can and should do to address the things that are happening. We have to understand that what's the reality today may not be the reality tomorrow. And so, we're in here for at least a four-year term. We have to understand what our long-term efforts can and should be to address the public health issues. And that that surely is going to change over the next few weeks to few months.

Dr. Osterholm: In some instances. We probably have a good sense now of what might be happening in other situations. We won't know what's going to happen until the very moment it does. So, we have to stay flexible. We have to stay alert. We have to stay on top of it. But if you don't think that we're doing enough to solve all the problems that are being presented to us right now, you're right. We're not. Because we don't even know yet just exactly what the breadth and the depth of these problems will be. This is where it's a stay tuned moment. This is where stay focused, stay alert, keep track of what's happening out there. And then from that type of understanding, we can launch the kinds of responses that we in public health need to do to, in fact, bring our world the best public health we can. Now, Chris, as you previewed during this episode, we're going to unpack some of the impacts that the recent federal spending cuts and stop work orders will have on critical federal programs and agency work, from shutting down the USAID efforts to contain an Ebola outbreak in Uganda, to canceling an FDA advisory board meeting on flu vaccine strain selection. It's hard to overstate just how far reaching and long lasting the consequences of these changes to federal agencies will be. But before we dive into the programmatic impacts, I want to acknowledge the people whose jobs at federal agencies have been terminated, whose professional integrity has been criticized and condemned, in some cases, whose loyalty to our country has been questioned.

Dr. Osterholm: The very moral character of who these people are has been a point of discussion. These affected employees are not politicians or public figures seeking the spotlight, but rather the quiet backbone of our government working day in and day out to ensure that the systems that support our daily lives function as they should. I've had the opportunity to work with a number of federal employees over the course of my career. People who I found to be outstanding servants, people who cared about what happened to those who live in our country and for that matter, around the world. These are people with such integrity. These are people who care. These are people who are not just on a clock. These are people who really do make a difference in our everyday lives. And it's in that regard that federal employees help defend our rights. They protect our public lands. They ensure the safety of millions of people every single day. They are the steady hands guiding our government to ensure it serves the interests of the public, not just the interests of the powerful or the privileged few. I know people in all sectors lose their jobs daily. I know people in the private sector who do very important work to help improve the lot of all of us, but what I find particularly troubling about these dismissals in the public sector has been the treatment and the rhetoric that accompanied them.

Dr. Osterholm: Federal workers have been maligned, dismissed as bureaucrats. Deep state actors, and even as obstacles to the progress of the country, these accusations have a real human impact. For someone to be told that their work does not only matter and their service is not even valued is not the most cruel of all activities, but it's rather when they get a letter to say they're being let go because they were incompetent at what they did, when in fact they were stellar in what they did. Not to mention, these highly skilled professionals are now facing a shortage of jobs in their sector and steep competition for the positions that do exist. There are unfortunately few places to turn in this saturated job market. Of course, it's not enough to counteract the harm inflicted, but today I'd like to dedicate this episode to all of those federal workers and contractors who have lost their jobs, been dismissed, and in some cases, publicly criticized to the point of ridicule. You are my colleagues and my friends, and the entire podcast team stands with you and thanks you for believing in the value of public service. Now, let me move on to that lighter part of the podcast here.

Dr. Osterholm: So, for those who would like to tune out for a minute, go right ahead. I'm happy to report today, March 6th, here in Minneapolis-Saint Paul sunrise is at 6:41 a.m. Sunset is at 6:07 p.m. a whole 11 hours, 26 minutes and 23 seconds of sunlight. And guess what? We're gaining it at three minutes and eight seconds a day. Only one more second a day will be added on to the rate of gain between now and the spring solstice. And then at that point, at three minutes and nine seconds of new sunlight, it'll start going back down again in terms of addition. But we're going to keep gaining sunlight right up through June. Now, our dear, dear colleagues in Auckland at the Occidental Belgian Beer House on Vulcan Lane. And by the way, thank you to those people who've sent new pictures this week of their time there. Your sunrise this morning was 7:10a.m. Your sun set at 7:53p.m. That's 12 hours, 42 minutes and 14 seconds of sunlight. But you're losing sunlight at about two minutes and 21 seconds a day. Pretty soon, Minneapolis and Auckland are going to cross in the spring solstice time period and where we both have the same amount. And then as we keep gaining and you keep losing, we will, and in the spirit of true international relationships, be willing to share whatever we can in terms of sunlight with you.

Chris Dall: Okay, Mike. So, as you noted, there's a lot we have to talk about and a lot of places we could start, but we're going to start with what is going on at the US agency for International Development. Last week, the State Department terminated 5800 USAID contracts, more than 90% of its foreign aid programs. This goes beyond the funding freeze that was announced in January when Trump took office. These programs are now cut, according to a memo from an acting assistant administrator at USAID that was obtained by The New York Times. Terminated projects include HIV treatment programs, malaria control programs, the main supplier of tuberculosis medications. The list goes on. Mike, we could probably spend an hour on this alone, but big picture what is the human impact of these cuts?

Dr. Osterholm: Chris, it's very difficult to actually talk about this topic because of the magnitude of what is about to unfold. And the fact is, is that it's something that we know is going to happen. We understand that that will result in many, many deaths and it will also bring pain and suffering and frankly, political unrest to many countries. It for me is one of those items where I don't understand how as humans, we can let this happen. This is not about being just right or wrong. This is about being moral. This is about being the leader of a world that cares about all those who are born. So, when I hear people talk about the beauty of life, I think to myself, how can we let happen what is about to happen just because we had an issue with a government agency? So let me elaborate. The March 4th memo that you discussed, Chris, came from Nicholas Enrich, who was the acting assistant administrator for global health at USAID. Shortly after he wrote this, he was put on administrative leave. Chris, let me just begin to share what the impacts of these USAID cuts are going to do and how absolutely devastating they are, according to Mr. Enrich's memo. And it surely bears repeating that the data that he provides has been well documented. What we're going to see happen just in the next year, this is in the next year because of a lack of USAID funding, which again, remember, is less than 3% of our entire government's federal budget is dedicated to this type of public outreach worldwide.

Dr. Osterholm: First, an additional 12.5 to 17.9 million cases and 71,600 to 166,000 deaths due to malaria. This is a 39% increase. We're going to see likely a 28 to 32% increase in tuberculosis cases around the world, including multi-drug resistant TB, which is forever a growing challenge for all of the world, not just for low- and middle-income countries. We're going to see an additional 28,000 cases of emerging infectious diseases like Ebola and Marburg. An additional 16.8 million pregnant women will not be reached for life saving maternity care. An additional 11.2 million newborns will not be seen for critical postnatal care. An additional 14.8 million children will not be treated for pneumonia and diarrhea, which are some of the leading causes of preventable deaths in children under five. And finally, an additional 1 million children will not be treated for severe acute malnutrition. In other words, we'll let these children starve to death. This is the impact over just one year. I can't even imagine these effects snowballing further over the course of four years of this administration. Additionally, if polio eradication efforts remain halted for the next decade, we can also expect to see an estimated 200,000 additional cases of paralytic polio per year over the next ten years.

Dr. Osterholm: In addition to these budget cuts, the funding freeze for the US President's Emergency Plan for AIDS relief will result in over 20 million people losing access to HIV treatment. As I mentioned before, I was very involved with the early days of HIV/AIDS in this country, and there was a period in my life that I will never forget, ever, where in the 1980s, I attended sometimes up to five funerals a week due to HIV, and I never, ever could have believed that we would let that come back again if we had a way to control it. Well, I'm telling you right now, as we take these 22 million individuals off of antiretroviral drug treatments that we now provide, we will start to see the mass number of deaths occurring from HIV/AIDS. And what is so difficult is this program for the last 20 years has worked so hard to stop the transmission from an infected mom to the yet uninfected newborn child. This was accomplished by treatment of the mother right at the time of delivery with the baby. And all I can say is, is that now we are going to see again a generational transmission level of HIV to these young kids. That will be devastating. Now, all of these estimates are truly tragic, but they're real.

Dr. Osterholm: And they're particularly troubling because these outcomes are all preventable. We have the public health knowledge and tools to do something about these problems, but are now not choosing to fund this critical work. I truly don't see how anyone could look at a program that is preventing this much disease and death around the world as wasteful government spending. I don't know how to say it, other than it's incredibly shortsighted. Though this will primarily impact the countries who are receiving USAID support. We will suffer the consequences of these actions in the United States as well. Our world is incredibly interconnected, so a steep rise in polio or tuberculosis abroad will certainly result in us seeing more cases in the US as well. I hope the government officials see these concerns and reconsider funding these programs. USAID is worth supporting for humanitarian reasons alone. But if that message doesn't get through to the administration, I hope they realize it is in our self-interest to support these efforts as well. This is global public health diplomacy. This is that soft power. This is what has endeared the United States to many individuals around the world. These individuals have looked to us as that shining city on the hill. And now what we're seeing is this tragic, tragic outcome that will unfold. And I don't understand why.

Chris Dall: Well, now let's turn to that measles outbreak in Texas. As I noted in the intro. It's now at 159 cases with one death. For context, there are 285 US measles cases reported in 2024, according to the CDC. And when Kennedy was asked about the outbreak by reporters last week, he said, quote, it's not unusual. We have outbreaks every year. Now, he has since gone on to make some statements taking the outbreak a little bit more seriously. But, Mike, I'd like to get your thoughts on the outbreak itself and Kennedy's response.

Dr. Osterholm: Well, let me try to separate these out because they really are two very different topics. Right now, in the Texas outbreak, we have one confirmed death. This death was in a school age unvaccinated child and reported on February 25th. It is the first U.S. measles death in the last ten years, and the first U.S. measles death in a child in 22 years. This was devastating and infuriating, considering the effectiveness of the measles vaccine in preventing these kinds of outcomes. But the measles cases in Texas continue to grow. As of March 3rd, the Texas Health and Human Services reports a total of 159 confirmed cases. 22 of which have been hospitalized. Approximately 80% of the cases are in kids. 97% of the cases are either unvaccinated or have an unknown vaccine status. Cases are occurring in the South Plains and Panhandle region across nine counties. Most cases are in Gaines County and associated with the Mennonite community with a low vaccination rate. In addition, the adjoining counties in New Mexico are also experiencing increased measles activity. Of the nine cases in Lea County, New Mexico, four in children and five in adults, and they trace back to the outbreak in Texas. While the largest outbreak of measles is currently in Texas and adjoining New Mexico, there are actually cases occurring in other parts of the country as well. As of the CDC update on February 28th, there are now 164 cases and nine jurisdictions. Measles cases in 2025 have now been reported in Alaska, California, Georgia, Kentucky, New Jersey, New Mexico, New York City, Rhode Island, and Texas.

Dr. Osterholm: There are currently less than ten confirmed cases in each of these states outside of Texas. Our current HHS secretary has had an infamous history on measles and the MMR vaccine, and his response to date has not been reassuring. First of all, in a press conference on Wednesday, February 26th, Secretary Kennedy misstated key facts about the outbreak. He said, for example, that patients were hospitalized for quarantine, not severe illness. Most notably, he said, the outbreaks of measles are, and I quote, not unusual. Unfortunately, outbreaks have become more common in the past few years, but ironically as a direct result of his own actions to decrease trust in vaccines and rollback decades of progress in combating the disease. Beyond his statement on Wednesday, RFK continues to provide dubious vaccine and therapeutic information to the media. In his recent opinion piece in Fox News. RFK spoke of the Texas measles outbreak in a way that skirted around the science and hinted at pseudoscience in a few key ways. First, the Secretary's statement does not outright recommend vaccines. He recommends parents, quote, consult with their health care providers to understand their options to get MMR vaccine, unquote. He refers to vaccinations as a personal decision. This is not the message that the highest level of leadership in public health should be given in this moment. Second, the Secretary's statement overstates the role of nutrition and sanitation. He is correct that nutrition and sanitation can take some credit for the drop in measles deaths in the 20th century.

Dr. Osterholm: Rather than vaccines. We can certainly thank improvements in environmental health for many threats like typhoid or cholera. But generally, vaccines are clearly the ones responsible for the sharp drop in cases, disabilities and fatalities associated with measles. The Secretary makes the claim good nutrition remains the best defense against most chronic and infectious diseases. Of course, a balanced diet is very important for health, but a nutrition rich diet alone will not stop the most contagious disease in the world from infecting an unvaccinated child. Third, the secretary opens the door for misinformation on vitamin A as a preventive and therapeutic agent for measles. In his statement, Kennedy says that HHS has updated their recommendations to support the administration of vitamin A with the supervision of a physician because it can dramatically reduce measles mortality. Let me be clear in areas of the world where malnutrition is common. Vitamin A treatment, not prevention. Treatment may benefit the patient in the long term. But in a country like ours, where we in fact have relatively high levels of nutrition amongst our children, the importance of vitamin A treatment during a severe illness may be only but limited. And so, the misconception right now is, is that, oh boy, if you want an alternative vaccination, just take vitamin A. Now, I also want to point out that, in fact, as much as we saw deaths decreasing from measles before the first vaccines were available in the 1960s, it's important to note that one of the other key features that played a role with measles cases was the availability of antibiotics not to treat the measles, but often secondary infections that occurred when you had measles.

Dr. Osterholm: And so that too contributed If we were today to say that vaccine didn't exist, and take what I would consider to be kind of the best-case scenario, we would still see 600 to 1000 deaths from measles every year in this country, 600 to 1000 deaths. Now that's a lot less than 6000 deaths, or 10,000 deaths a year that we saw before vaccines were available. But would any of us say that 600 to 1000 deaths a year are acceptable in children? No. That's why the vaccines do remain a very important part of the prevention. And please don't be fooled by the idea that it was just the improvement in sanitation and overall nutrition that led to this decrease in deaths out there in the country. And finally, I just want to add that on Tuesday, Mr. Kennedy did an interview with Doctor Marc Siegel on Fox News. I have done numerous interviews with Doctor Siegel. He's a very thoughtful, very well-informed individual who on Fox News presents some very important and factual information on things like infectious diseases. But I found it interesting, just to give you an idea of how you can trust or believe whatever happened, Doctor Siegel asked the Secretary to discuss what happened with the fact that Thomas Corey, the Assistant Secretary of Public Affairs, the lead person for public relations at the Department of Health and Human Services, after two weeks on the job, quit after he clashed with Secretary Kennedy and his principal deputy chief of staff, Stephanie Speer, who had served as the press secretary for Kennedy's presidential campaign.

Dr. Osterholm: Two weeks on the job and he quit. And it was largely over the messaging on measles. Well, why that's interesting, because Mr. Kennedy, when being questioned by Doctor Siegel, said he didn't know Thomas Corey, had no idea what this was all about, when in fact a picture was published of them at a staff meeting earlier in the week, with Thomas Corey sitting just one seat away from Mr. Kennedy in the meeting. And yet he said he didn't know him. Now, maybe you can say that's a minor point, but it goes to a pattern. It's a pattern of what do you believe he says. And what does it mean? So going forward, I remain very concerned about the consistency of message from the Secretary, such as the one he did for Fox News, where he kind of melds in a little bit of what appears to be public health science as we know it, but a lot of it comes back and says, oh, well, by the way, but you can just take your vitamins. It's one of these mixed messages that is going to confuse the public so much. And I do believe we will continue to see major challenges in the messaging to the public that will result in people becoming infected, people becoming severely ill, and even some of our children dying.

Chris Dall: Since our last episode, there have been two moves made by the Department of Health and Human Services that have raised concerns about what Kennedy may have planned for U.S. vaccine policy. On February 20th, we got news that a meeting of the CDC Advisory Committee on Immunization Practices ASAP, scheduled for February 26th, had been postponed with no word on when it will be rescheduled. Then, on February 26th, members of the FDA's Vaccines and Related Biological Products Advisory Committee were told that their March 13th meeting to recommend strains for next season's flu vaccine had been canceled. Mike, what did these moves mean, if anything, for the future of these advisory groups under Mr. Kennedy?

Dr. Osterholm: Well, just as I noted earlier in the podcast, clearly there is a situation of things changing almost on a daily basis. Now, to be fair. It's important to note that in previous presidential administration changeovers, where it went from one president to another, it took a while to get their sea legs underneath them, to be able to actually use the apparatus of government to do their jobs. And one can argue that the cancellation of these two meetings were more in keeping with their just trying to get their sea legs than not. I think there's much more to it. But let me say what did happen. First of all, understand that these committees do absolutely essential work for the public health world. The Advisory Committee on Immunization Practices, for example, as many of you know, is responsible for recommending and maintaining the CDC's vaccine schedule, which determines which vaccines the public should receive. And when VRBPAC does the critical work reviewing safety and efficacy data of vaccines and biological products so that the FDA can determine which vaccines should be approved and for what groups. Though there is some sense that this administration would rather not have either of these groups providing input or information. Our past history says they are invaluable. It is of note that late last week, Secretary Kennedy's office announced that they were no longer counting on public input when it comes to these advisory committees, which has been a very important source of information to be considered when making such decisions. Shutting off input, canceling meetings is not the way to run a national advisory group that is there to try to support the federal actions being taken.

Dr. Osterholm: So, you may say that canceling meetings is a good thing in terms of wastefulness and so forth, I don't agree. Now, does it mean because these two meetings were canceled that will be set back? I don't think so. I think the issues that ACIP surely can be addressed if that committee stays intact. However, we're also concerned about what will happen to these committees’ long term. Already, we are understanding that there are meetings taking place within the administration to reconsider the entire roles, in some cases, the existence of some of these committees. So, at this point, I don't want to overstate the case. I think the OPEC meeting that was canceled last week to determine which strains should be recommended for the influenza vaccine for 2526 for the 2526 season, still can go ahead. And in fact, FDA has taken under consideration the information that came from the World Health Organization meeting last week that actually addressed this issue of what should be the new strain. And I think that they're going to take that piece of information and use that to help advise manufacturers for vaccine distribution in the 2526 season here in the United States. So, the bottom line is that the cancellation of these meetings, while concerning, still doesn't define their full future, but this is one we're going to watch very carefully. We surely have made the case in public health that these committees are very important, and they shouldn't be approached as an adversarial group to this administration, but one that can provide very important input from the public sector.

Chris Dall: Now let's turn to H5N1. Last week, new USDA Secretary Brooke Rollins announced a five-step plan to battle avian flu in poultry. Mike, what's the latest on the outbreak and what do you make of the new USDA plan?

Dr. Osterholm: Well, Chris, among all the distressing news coming down around us, I wish there were more positive things I could report on with regard to this topic, but unfortunately, it's not the case. H5N1 continues to circulate in various animal populations and serves as an important source of exposure to humans. Let me just update you on several of the animal categories. Poultry. The number of affected poultry birds continues to soar in the US, reaching 12.7 million inches the last 30 days and 166 million birds cumulatively. These outbreaks affect all types of facilities, but the most front and center are those connected with commercial egg laying farms. Since our last episode, two more facilities in Indiana and three more in Ohio have been hit, affecting an estimated 6.1 million egg laying hens. These losses are devastating to the industry, and the main reason for why egg prices continue to rise. With an egg shortage. Now, in terms of dairy cattle, the most current published total we have is 976 infected dairy herds, with the most recent detections coming from Nevada, two farms and California one. Additional farm detections are seeming to slow down, either due to one a decreased testing and reporting to a lack of ability or willingness by the USDA to publish detections to the public, or third, an actual decrease in the number of newly infected birds. Perhaps all of these possibilities can at least partially be true, but right now we just don't know.

Dr. Osterholm: In terms of wild birds, we know that the true incidence of H5 among waterfowl and a few species of passerine birds or songbirds is difficult to estimate, but we know they're out there in mass detection scattered across the country, including New Mexico, North Dakota, West Virginia, Pennsylvania, Connecticut and Massachusetts just in the last 30 days indicates that the virus is circulating over a wide geographic area and will continue to infect susceptible species, including poultry flocks held in facilities with inadequate biosecurity to prevent exposure, which I'll address in a moment. And then finally, domestic animals and pets. There are several cats that have tested positive for H5N1 in Oregon and Washington after consuming West Coast raw brand pet food, now recalled contaminated with live virus. The best way to protect your pets from H5N1 exposure and infection is to not feed them raw pet food, including raw meat and milk, and keep them away from potentially infected dead birds and bird droppings. Remember, as the Audubon Society and other groups dedicated to bird watching will tell you, the greatest enemy that many bird species has today is, in fact, domestic cats that prey on these birds throughout the year. When they eat a potentially sick bird, then they themselves, as cats can become infected. And I believe that that likely is a source for a number of these cats that have become infected.

Dr. Osterholm: Now, shifting to the new USDA plan, I'm not surprised that this administration is taking an economic focused approach to addressing H5N1. One. I'll start by summarizing the plan and then give listeners my $0.02 worth. This $1 billion plan includes five prongs centered largely on increasing biosecurity and benefiting farmers. Remember, biosecurity are all those steps you take to keep the virus out of the barns. The first prong of this plan is to provide up to $500 million to be invested into gold standard biosecurity measures for all U.S. poultry producers. Again, as I pointed out in previous podcasts, in our work continues to show I do believe that airborne transmission of virus into these barns from the wild bird population that may be adjacent to in fields and so forth, with the dried feces actually being blown just like dust into these barns is a real issue. How much of the transmission in these barns can be accounted for this way? I don't know, but as long as you have these loose, open barns where air just moves through quickly and easily, I think you're still going to have a problem. The second prong provides $400 million for additional farmer indemnification and to encourage repopulation. In other words, get the birds back in there so that they can produce.

Dr. Osterholm: The third one is to remove unnecessary regulatory burdens on egg producers and to allow for market expansion. Well, I have to tell you, without further definition of that, that to me is an ingredient for disaster in terms of what are you going to do differently that will somehow increase the bird population, but not, in fact also put them at risk for infection. The fourth prong, which I'm going to come back to in a moment, is to provide up to $100 million for vaccine and therapeutic R&D targeted at birds. Finally, the fifth one import eggs from other countries to increase our national supply in the short term. Well, at first glance, let me just say that the fourth prong for me is an immediate red flag. What am I talking about? Well, in this case, the USDA has talked about vaccines, which may have some role and surely have been used in other countries. And these are vaccines for the birds. But now they're talking about therapeutic agents. The only effective therapeutic agents we have today that are readily available are those we call neuraminidase inhibitors, like Oseltamivir, Baloxavir. These are the drugs that we count on in human medicine, particularly for severely ill individuals. Why am I concerned about this? Because back in 2004 to 2005, when H5N1 took off in China, with H5N1 spreading widely among the poultry operations there, the Chinese government made a decision to start using the amantadine drugs.

Dr. Osterholm: These are the drugs that basically were at that time the most effective drugs for treating influenza infections. They use these drugs widely within the poultry industry. They used him as what we call prophylaxis. Meaning that they were given to the birds even before they might become ill, so that they don't become ill. Well, within short order. We saw widespread resistance develop in these drugs, and within several years, the amantadine basically became useless in the treatment of influenza because of the high level of resistance. But now we have this new class of drugs that we use. But again, just like with amantadine, I'm convinced if we see widespread use of these drugs in the poultry industry to try to keep the egg production up, we are going to pay a hell of a price. And I can't say that any more strongly. I think any kind of therapeutic agents that's used in these birds has to be first considered. What are the implications for human medicine? And I have not seen that happening. So, to date, let me just say that that really, I continue to be very concerned about H5N1. I realized that we're now over a year into the dairy cattle outbreak and the first recognition of that.

Dr. Osterholm: We've continued to see widespread transmission and waterfowl and then onto other animal species. We have not seen really any activity in humans recently, and I do believe that that is likely a reflective of less infection, not just the fact that it's an artifact of surveillance. But the bottom line is we don't know what's going to happen next with H5N1. And as I've said many, many times, the pandemic clock is ticking. We just don't know what time it is. And will H5N1 be the cause of the next pandemic? I don't know, could be, but I don't know can. In fact, we expect that some virus and the influenza family will come forward and cause the next pandemic? You betcha we can. And so, we need to still do a lot of work. Now, one of the areas I just want to point out that I'm very concerned about is with the NIH’s restriction on NIH work and funding. We're setting back in a major way new influenza vaccine research and development, finding better vaccines, more durable vaccines, safe vaccines, vaccines that can be given and provide protection for an extended period of time against any number of different influenza strains. That work is all going to get set back in a very, very big way in the days ahead because of decisions being made about how we're doing our cuts.

Chris Dall: Now it's time for an update on the latest respiratory virus trends. And as we did last episode, let's start with what has been one of the worst flu seasons in recent memory. Mike. Are our flu trends getting any better?

Dr. Osterholm: Fortunately, flu activity has declined for two straight weeks, which may indicate that we're past this season's peak. Now, I do hesitate to say this with 100% confidence, because the last time we said that activity was decreasing. It then increased dramatically. But activity is right now decreasing across the board from. Outpatient visits, emergency room department visits and hospitalization rates. Outpatient visits for influenza like illness or Ili is now at 5.8%, down from 7.8% two weeks ago. This is still much higher than the national baseline of 3%, which is when we consider the flu season to be over. We have quite a ways to go until then. Flu activity is still considered very high in 17 states, but that's down from 35 states, while 22 states and the District of Columbia are still high. Eight now are moderate and two are low. In the past week, 36,500 patients were admitted to hospitals for influenza, a 27% decline compared to our last episode. Also, since our last episode, there have been an additional 30 pediatric deaths, bringing the total for the season to 98. Such tragedy. These 98 pediatric deaths have contributed to an estimated 21,000 deaths across all age populations this flu season. The activity continues to be driven by influenza A strains, with 60% of subtype specimens being H1N1 and 40% being H3N2. This has remained consistent throughout much of the entire flu season. And finally, I want to discuss recent reports of influenza associated acute necrotizing encephalopathy, or A&E in children this flu season. Acute necrotizing encephalopathy is a rare but very serious condition with a high mortality rate. It causes rapid and severe neurological damage, often starting with symptoms such as seizures and an altered mental status, often resulting in a coma.

Dr. Osterholm: I've heard from a number of physicians across the country about anecdotal reports of increased incidence of A&E in pediatric influenza patients this season, but for several weeks, the CDC remained silent on the issue due to their very limited ability to release information at that time. Fortunately, they were able to release a report last Thursday in the MMR. So, we now have a bit more insight into what is going on. According to the CDC report, 13% or nine of the kids who have died from influenza in this country had influenza associated encephalopathy or encephalitis. While this alone is alarming, I'm also concerned because I'm sure whether these numbers really reflect the total burden of encephalopathy out there. I actually know of several hospitals in the United States that collectively have more cases than are being reported here for the whole country. This also points to why CDC surveillance and communication is so critical. We need them. What is a good sign that the CDC was able to release this report? We know that further reduction in their staff and restrictions on their communications will greatly hinder their ability to determine why these cases might be occurring at the rates they are, and to share information with health care providers who are treating these patients. Last but not least, public awareness is a huge issue. Parents recognizing early signs and symptoms of what may be A&E need to get their children to medical care immediately. That information right now is not found out there in the public domain. We are continuing to monitor this and I hope we know more in the coming weeks. But suffice it to say, these deaths are truly a tragedy.

Chris Dall: And how about COVID and respiratory syncytial virus?

Dr. Osterholm: Well, this is one that I'm actually happy to report on. The US has seen decreases in every metric that we typically use to monitor activity for both COVID and RSV. Starting with COVID, the national wastewater level is considered moderate and is decreasing. Wastewater concentrations are decreasing in every region, with the Midwest and South being considered moderate and the northeast and the West being low. Emergency department visits for COVID are or low and decreasing, and hospitalizations are also decreasing. In the most recent week, with hospital capacity data, 1.3% of inpatient beds or almost 9000 patients and 1.3% of ICU beds, or about 1300 patients, were occupied by a COVID patient. This is an 11.7 and 12.7% decrease, respectively. Weekly deaths also continue to decline. The week of February 1st, there were 850 COVID deaths. This is still much higher than I hope we could ever see, but I'm hopeful that we'll see this number only continue to decline at this time last year, weekly COVID deaths were just below 2000 and decreasing. So, you can see that surely, we're in a better place this year. At 850 deaths. The variant tracker has been updated and as we expected, LP.8.1 has become the predominant variant, accounting now for 42% of US cases.

Dr. Osterholm: XEC, which has been the dominant variant since early December, now accounts for 31% of the cases. I don't anticipate this shift to have a significant impact on the COVID picture, but we'll keep you updated if that changes at any point. And as I noted in the last podcast, again, I'm not sure what this new variant information really means, as we've not seen big swings in case surges or case drops related to the most recent variants. And now looking at RSV, there really isn't much to update. The national waste water concentration is still considered low. Emergency department visits for RSV are moderate but are decreasing. Less than 1% of inpatient beds are occupied by RSV patients, a 9% decrease from our last episode. 1% of ICU beds are occupied by RSV patients, a 15% decrease. But since the beginning of the respiratory season, there has been an estimated 7700 to 18,000 RSV deaths. It still is a very important viral pathogen. Now summarizing both the data for flu, COVID and RSV, I'm confident that we are watching this seasonal respiratory disease picture improved substantially and that, in fact, most of the 24-25 season is likely in our rear-view mirror.

Chris Dall: Now it's time for our ID query. And this week we received many questions from listeners prompted by the measles outbreak in Texas about the potential need for a measles, mumps, rubella, or MMR booster shot. Here's what Ivonne wrote. Could you comment on the recommendations for adults to determine if they might need to get an MMR booster? Is there a date of birth range that would be helpful? So, Mike, first of all, is this really something people need to be thinking about?

Dr. Osterholm: Well, Chris, this is actually a great question and it is an important one. My bottom line is that this question is best discussed with your own health care provider, so you can review your vaccination record and risk factors. Many of you who are older may not even have a vaccination record, and so you'll have to base your decision on not knowing. But I do still want to provide some guidance so you can get the basic picture. I'll start with some important historical context and then get into the recommendations. The first measles vaccine was made available in 1963, but efforts to develop improved vaccines continued in 1968. A more effective vaccine with fewer adverse events was introduced, and the 1963 inactivated vaccine was withdrawn. That being said, if you were vaccinated between 1963 and 1968, you may want to check your vaccination records to confirm whether you were one of the 600,000 to 900,000 people who received the lowest effective vaccine. Now, as I just noted, many of you may not have those records. In that case, I would assume that you got the less effective vaccine, frankly, just to be certain. If you were vaccinated between 1968 and 1969, you may have only received one dose because it was standard at that time. The first dose is considered 93% effective, which is very good, but a second dose can raise that to 97%. Prior to a vaccine being available, measles was so prevalent that it was assumed that everyone had it during their childhood. So, if you were born before 1957, you are considered to have had natural immunity. If you're unsure about your immunity status, you can have a laboratory test done to show proof of immunity, and you can also receive an additional dose of the vaccine.

Dr. Osterholm: The MMR vaccine has an excellent safety profile, and an additional dose of vaccine does not pose a significant risk of any kind. Fast forward to today. The current recommendation is that every child received two doses of the MMR vaccine. The first dose is given between 12 and 15 months, and the second between the ages of four and six. While that is the recommended timeline, the second dose can be given earlier, as long as it's at least 28 days after the first. The first dose protects between 93 and 95% of children, and the second brings that up to 97% of kids being fully protected. With these two doses of vaccine, you are considered protected for your entire life. Infants as young as six months of age are eligible to receive a dose of MMR vaccine if they're traveling internationally, but that dose does not count towards their standard two dose regimen if it is given before their first birthday. This may seem long winded, but I think the context as to why there are so many layers to this answer is helpful. So let me summarize this. If you were born before 1957, 69 years of age or older, you are assumed to have natural immunity. You can seek vaccination if you want, but it's not necessary if you are vaccinated with two doses of vaccine after 1969, which should apply to anyone younger than 55. You are considered protected for life as long as both doses were given after your first birthday. If you were born after 1957 and vaccinated before 1968, you should consider revaccination. And clearly, this is something you should talk to your individual physician about.

Chris Dall: And one last item here, Mike. We talked a lot last episode about the mass firings at several federal health agencies like NIH, CDC, and FDA. But I know one of the things you're really concerned about is how the fallout is going to affect state and local health departments. How much damage do you think this is going to cause?

Dr. Osterholm: Chris, the audience should be aware of the fact that I spent the first 25 years of my 50-year career at the Minnesota Department of Health, as well as being at the University of Minnesota. I bleed local and state public health in everything I do. And so let it be said that my concern here is surely potentially biased. But at the same time, it's also hopefully quite informed. I'm extremely concerned about state and local health departments. Last week we talked about how the Louisiana Department of Health is moving away from vaccine promotion. And while I'm concerned about an increasing number of health departments making political decisions like this, I'm even more concerned about the threat that will impact all health departments, regardless of their state politics. And that is a loss of federal funding. State and local health departments receive substantial funding through a variety of sources, including state and local taxes, grants from a variety of different groups, both public and private, and the federal government. That reliance on federal funding has led to a lot of uncertainty for state and local health departments. If we look right here at Minnesota, one of the finest health departments in this country, 55% of our health department budget is supported by federal funding.

Dr. Osterholm: More importantly, for much of the infectious disease, work that's done, as high as 95% of that is supported by federal funds. If we look nationwide, 23% of the local health departments, the cities and the counties, and their funding comes from federal investments, though this varies greatly by department. Again, I want to avoid speculation about what might happen with funding with these groups, but I want to acknowledge that we have a right to feel very concerned about the future of these departments and their ability to continue doing the critical work they do. I wish I could say state governments will be responsive and that, in fact, legislatures and the governors of those states will provide additional support for state and local public health. I'm not optimistic. I fear that we will be seen major losses in public health capacity in the immediate months ahead. And if that were to be the case, expect even more problems with infectious diseases.

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

Dr. Osterholm: Chris, this week we're going to cover two historic outbreaks of measles in the post-vaccine era. I want to make sure we dispel the myth that measles is just a usual occurrence a harmless childhood illness. Measles is not harmless, and I think those two previous outbreaks make that very clear. In the fall of 1990 through the spring of 1991, Philadelphia experienced an especially significant outbreak of measles. From November through June, the city confirmed 938 cases of measles. The outbreak was concentrated in two churches that taught congregants to forgo medical care and rely solely on faith healing. Out of the 201 students at Faith Tabernacle School, 134 contracted measles more than two thirds of the students in the school. The most devastating part of this outbreak is that it resulted in nine deaths, all of which were in children. Part of the reason this outbreak was so deadly was that not one of the severely ill children in the church received medical care after coming down with measles. Not only could these cases have been prevented in the first place with vaccination, but deaths and complications may have been avoided with proper medical care. Another notable outbreak of measles occurred in the island of Samoa. In 2013 the island's rate of vaccination for MMR was about 90%. Could use improvement, but still quite substantial. Unfortunately, in July of 2018, a one-year-old child died as a result of an improperly prepared MMR vaccine. A nurse had accidentally mixed the powdered vaccine with an expired liquid muscle relaxant instead of sterile water. An absolutely tragic situation that resulted in immense backlash of vaccine hesitancy.

Dr. Osterholm: WHO and UNICEF attempted to intervene as vaccination rates plummeted, but the damage had already been done by the end of the year, MMR vaccination rates for infants was down to 31%. In the summer of 2019, Robert F. Kennedy Jr. actually visited the island and met with the anti-vaccine advocates, applauding them for their work. Unfortunately, this led to a perfect storm for this outbreak. While Secretary Kennedy debates how this all unfolded and his role in it, there are many witnesses that can say his role in the anti-vaccine advocacy was very important in keeping the levels of vaccination on Samoa at this very low level. In August of 2019, a traveler from New Zealand brought measles to the island and it spread like wildfire. By December, Samoa experienced more than 5200 cases and 79 deaths. This impact was predominantly in children. It is estimated that 20% of the infants in Samoa between 6 and 11 months of age, contracted measles, and 1 in 150 infants in this age group died. In total, 90% of the deaths from this outbreak were in children. This is gut-wrenching. The impact on these families and their communities will last for years to come, as they grieve their loved ones and manage the ongoing complications for survivors. I hope these historic outbreaks, in addition to the news of the measles outbreak in Texas, makes it clear that this isn't a harmless childhood illness. The measles virus is incredibly contagious, and it can be deadly and disabling. Take it seriously and make sure your family, your friends, and your community do, too.

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

Dr. Osterholm: Chris, at this point, again, I think most of our listeners want to know what can they do to help at this time. And I've promised you we would give you some roadmaps for that. But then it is still early. We're still watching the confusion unfold. We're watching contradictions right in front of us. For example, people were fired, but they're called back. And so, we're really waiting to get a better sense of some of the major public health actions. What will actually happen with the CDC, NIH, and FDA budgets? What will happen in terms of support for local and state public health agencies? What will happen with infectious disease research with the direct and indirect funding issues from the NIH? So, at this point, we have to understand that at the national level, the most important actions that are taking place are taking place in the courts, and there are organizations and groups that are actually working on that. But in the meantime, at the state and local level, I want to note that we can follow very closely what's happening with vaccine policies and practices in your community. Get involved. Find out what is happening in terms of school boards, what's happening at city council meetings, what's happening in the state and local health departments, and keep track of that in a way that allows you to become a voice.

Dr. Osterholm: If, in fact, these vaccines come under attack right now, that's an important point. There will be more to do later as we get a better handle on what's happening. But you don't have to just say to yourself, there's nothing I can do. This is clearly an important area that you can begin to work in. And next, let me address H5N1. It's still very unclear what's happening with that virus. It's unclear what the proposed program from the USDA to deal with poultry related infections is going to do. What is the risk of using certain therapeutic agents in sacrificing them for our own human use one day? So, stay tuned on that. And finally, the one piece of good news while influenza, COVID, and RSV are still taking lives every week and we must never forget there are moms and dads and our grandpa and our grandmas, our brothers and our sisters. And unfortunately, as I've shared with you in pediatric influenza, some of our children are dying. But the good news is it's getting better and it's getting better and it's getting better. So, stay tuned on that one. We'll follow that closely, but I think we're likely in the next couple of months to be potentially in the best place we've been with all three of those simultaneous infections, and we've been possibly in the last five years.

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

Dr. Osterholm: Well, Chris, actually, I'm not going to use a song. I'm going to use something that I thought long and hard about this week. I probably put as much thought into this one as I have any of my closings, and it's one that I wanted to really feel right for the times, and it's one that had to be full of mixed emotion, but also with a message that we need to hear. And so, I'm going to do an oldie but a goodie. It's one that I use in episode 158 back in May 30th of 2024. What I want to share with us today are words that will never grow old. They will never, ever, ever grow old. They are the words of one of the most important figures in American history, Abraham Lincoln. What I'm choosing today is to share with you, I think, one of the greatest speeches of all times. It's one that still is relevant today. Short, succinct, and to the point. The Gettysburg Address. Think of this in the context of not just on the battlefield. The soldier's true and important, but also on the battlefield of life and all of the potential public health preventable deaths that we have to deal with. And then how this particular speech concludes and sends us a message for the time. So here it is. Lincoln's Gettysburg Address four score. And seven years ago, our fathers brought forth on this continent a new nation, conceived in liberty and dedicated to the proposition that all men are created equal.

Dr. Osterholm: Now we are engaged in a great civil war, testing whether that nation or any nation so conceived and so dedicated can long endure. We are met on a great battlefield of that war. We have come to dedicate a portion of that field as a fitting resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this. But in a larger sense, we cannot dedicate, we cannot consecrate, we cannot hallow this ground. The brave men, living and dead, who struggled here have consecrated it far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us, the living rather to be dedicated here to the unfinished work which they who fought here have thus so far nobly advanced. It is rather for us to be here, dedicated to the great task remaining before us, that from these honored dead we take increased devotion to that cause for which they gave their full last measure of devotion, that we here highly resolve that these dead shall not have died in vain, that this nation under God shall have a new birth of freedom, and that government of the people, by the people and for the people shall not perish from the earth.

Dr. Osterholm: Abraham Lincoln can't imagine anything that's probably more timely right now than these words. Thank you all so very much for being with us again. A lot of information we covered right now. I feel like we all are swimming in a tsunami of information. And each day it seems to change. Each day it has new implications. We'll do our best to keep you informed. I want to just thank all of you who continue to write to us to share your thoughts, your ideas, um, what this podcast means and how we can make it better. On behalf of the podcast team, a group that is simply remarkable. Absolutely remarkable. You know, we remain committed to giving you the best information we can. We remain committed to never having one thing on our CIDRAP website ever, behind a paywall. We want to make certain you have access to the information that is most important for you to think about on the day-to-day basis of what's happening. So, thank you again and just know that we're going to be here. We're in here for the long haul. And we are glad you are too, because we all need each other right now very much. And just remember those wise words of Abraham Lincoln. Thank you. Thank you. Be kind right now. Oh, my. Please be kind. 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 cidrap.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to cidrap.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.