The Current State of Measles

Chris Dall: Hello and welcome to the Osterholm update, a podcast about infectious diseases and public health featuring Dr. Michael Osterholm. Dr. Osterholm is an internationally recognized medical detective and director of the Center for Infectious Disease Research and Policy, or CIDRAP, at the University of Minnesota. In this podcast, Dr. Osterholm draws on over 50 years of experience in infectious disease epidemiology to provide straight talk on the latest infectious disease outbreaks, counter misinformation and disinformation about vaccines, and distill the complex and ever evolving public health threats facing our world. I'm Chris Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm podcast. Before 2025, we didn't spend too much time talking about measles on this podcast. And that's because there wasn't much of a need to. From 2020, when we launched the Osterholm update through 2024, there were a total of 527 confirmed measles cases in the United States. But ever since the measles outbreak in West Texas began in January 2025, it's become a regular topic of discussion with the country now at more than 6000 confirmed measles cases since the beginning of that year.

Chris Dall: Still, it remains something of a shock to say that there have now been four measles related deaths this year in Pennsylvania alone. Last year, there were three deaths. Before 2025. The last U.S. measles associated death was in 2015. Still, the Centers for Disease Control and Prevention has yet to acknowledge these deaths. CDC Director Erica Schwartz is reportedly working with the Council of State and Territorial Epidemiologists to develop a standardized definition for measles death. We're going to discuss the measles outbreak in Pennsylvania and the rest of the country. On the September 24th episode of the Osterholm Update, Episode Number 218. We'll also discuss some potential good news on the Ebola outbreak in the Democratic Republic of Congo. Look at the latest data on COVID and other respiratory illnesses. Bring you an update on CIDRAP Vaccine Integrity Project, answer ID queries about RSV and flu vaccines, and examine an uptick in exposure to rabid animals in the US. We'll also bring you the latest installment of This Week in Public Health history. But first, as always, we will begin with Dr. Osterholm's opening comments and dedication.

Dr. Michael Osterholm: Thanks, Chris, and welcome to the podcast family. It's great to be with you again. I want to thank all of you who routinely provide us with feedback on how we can improve our efforts here. Thank you for that. And I also want to welcome those who may be joining us for the first time and hope that you find the information you're looking for here. And like our podcast family members, we welcome you to join, but also we welcome your feedback. Today, I'm going to dedicate this podcast to something that is very close to the heart of some of you who are listening. I know that personally, and surely it's close to mine. Before we come to the close of this month, I want to highlight that September is Suicide Prevention Month. This is a sensitive topic, so we understand if some listeners would prefer to skip forward. We've included timestamps in the show notes of when you can skip to. With this dedication, with this month in mind, I'm dedicating this episode to anyone who has been affected by suicide. And as I just said, I know that some of you have been. To those who have struggled with suicide personally or to those who may have lost someone to suicide. It can be a dark shadow that is so incredibly difficult to bear. But I want you to know that you are not alone in your suffering.

Dr. Michael Osterholm: The CDC recently published data from 2024, showing that suicide has become one of the top ten causes of death in the United States, accounting for 1.6% of all deaths in 2024. This can be such a heavy topic, but it's so important we talk about it because that's what helps talking about what we're struggling with. There is so much happening every day. It's difficult not to feel weighed down by the weight of the world. But that is even more reason to discuss how we're truly feeling about everything. The conversation can be messy, somber, beautiful, and maybe even a bit irreverent. Whatever it is, it's just important to be sharing with one another. For many of us, our lives are becoming increasingly more isolated. Reaching out and listening with honest, open ears is the first step to. Connection. And connection can lead to healing. Healing also means having access to affordable health care, safe housing, and food security. I also want to dedicate this episode to those who are working in mental health and suicide prevention, many of whom simply volunteer their time to this very, very important cause. Your work is so critical. If you or someone you know is struggling or in crisis, help is available. You can call or text 988 or chat 988 lifeline.org.

Dr. Michael Osterholm: We have also left some important resources in our show notes. Remember, you are not alone, especially not in your sadness, grief, or despair. Check in on each other. Silence is not the answer, but connection is. And now, moving on to a lighter part of the podcast, and one for which we still do have some light today here on September 24th in Minneapolis/St. Paul, two days after the official start of fall, I can say that we are surely experiencing that reduction in light today. The sun rises at 7:02 am, sunset at 7:06 pm, 12 hours, three minutes, and 45 seconds of sunlight. We are now losing sunlight at three minutes and six seconds per day, and that will continue to stay at that level until October 2nd. To our friends in Auckland at the Occidental Belgian Beer House on Vulcan Lane. You are warming up today on the 24th of September, your sunrise was at 6:08 am, your sunset at 6:18 pm. That's a whole whopping 12 hours, ten minutes, and 27 seconds of sunlight, a little bit more even than we have. But each week now you will get brighter and brighter. And so we wish you all the best with that and just remind you that we shared our light with you. I hope you'll continue to share your light with us.

Chris Dall: Mike, last week, officials in Pennsylvania announced two more measles related deaths one in a 40 year old woman and the other in an 18 year old. Pennsylvania now has nearly 800 confirmed cases in 39 counties. Are these deaths an indication that this outbreak is much larger than the official numbers? And what's your assessment of how the Pennsylvania Department of Health is handling this outbreak?

Speaker 3: Well, Chris, it is very likely that there are a number of unreported cases occurring in the community. We surely know within at least one group of individuals that have been infected that with additional follow up cases of measles that were not recorded, had actually occurred in family members. So how many more cases? I don't know. But when we look at our past experience with measles, on average, about one person would die for every 1000 cases. Now that did depend on the age group of which they were involved. For example, the very young, those under five years of age and those older, such as teenagers and older, actually have higher rates of death than those who are actually the typical school age child. And so when I look at this one per 1000 and compare that to the almost 800 cases in Pennsylvania, I think, yeah, we have people we're missing that would actually drive that number much closer to one per 1000 deaths, which would mean 4000 cases could be half that. But cases of measles are clearly occurring across different age groups and throughout a number of counties in Pennsylvania that are not getting counted in terms of how are the Pennsylvania health departments handling this, I will have to tip my hat to them. I think they're doing an amazing job. I've had the good fortune to actually consult with them on this issue, and have seen the kind of expertise that they've brought in to support them. They are handling this as well as any state could, and I might congratulate them on the fact that they've actually greatly increased the level of vaccination in the Pennsylvania counties affected by measles by a substantial number over the course of the last month. So thank you to all that. The public health teams in the state of Pennsylvania are doing. And all I can say is, is that, unfortunately, we're going to see more and more of these kind of scenarios play out state by state by state. As we get further into the winter and an increased period of transmission time for the measles virus.

Chris Dall: Health and Human Services Secretary Robert F Kennedy Jr has repeatedly said that the US is doing a better job at controlling measles outbreaks than any other country in the world. Mike, what do you make of that claim?

Dr. Michael Osterholm: Well, Chris, it reminds me a bit of that old saying, never let the truth get in the way of a good story. And I'm afraid that's what we're dealing with here. Despite Mr. Kennedy's claim that the data itself paints a very different picture. Let's start with the international comparison he keeps making. For months now, whenever he's asked about measles, Mr. Kennedy has claimed that the U.S. is doing better than any country in the world at controlling it. And he typically points to the same three countries to make his case Mexico, which he says has more than ten times as many cases as we do, Canada with four times as many, and the United Kingdom with twice as many. So basically, his message is that our situation isn't so bad compared to what's happening in other places. And to be fair, it's true that Mexico, Canada and the UK have been dealing with higher rates of measles per capita than the U.S. this past year. If you're a regular listener of this podcast, you've probably heard me personally reference the higher rates in Canada on more than one occasion. Although my reference to that has always been from the standpoint of what we could eventually be dealing with here, if we don't get on top of this outbreak and we have the same experience that Canada has had, but Mexico, Canada and the UK are the exception, not the rule. Just last week there was a really good piece published by factcheck.org. It dug into Mr. Kennedy's claim, which I encourage listeners to read if you want more detail. The link to this document is in the show notes.

Dr. Michael Osterholm: In it, they actually looked at the WHO's measles data through mid-September and ranked countries by measles incidence, meaning the number of cases per million population reported so far this year. Let me acknowledge up front, for some countries, surveillance is obviously more limited than it is in our country, so there are a number of fewer cases surely could in part, be due to the lack of surveillance. But on a whole country by country, the data are pretty darn good for us to compare our data with. And what they found was, out of the 169 total member state countries listed, the U.S. had the 65th highest rate. In other words, more than 100 countries had lower per capita cases than the US. It's also worth noting that the number of cases included in the WHO data for the US was 3,074 cases. Now, CDC's latest count stands at 3,471, an increase of almost 400 cases, which means our rate is even higher. Now, sure, you can always cherry pick a handful of countries with higher rates, but I don't know how you look at that list and come away thinking we're doing better than everyone else. And honestly, I don't think other countries are the right comparison anyway. One of my close colleagues, Dr. Jennifer Nuzzo, who directs the pandemic center at Brown University School, stated, quote, let's compare ourselves to ourselves, unquote. In 2023, the U.S. reported a total of 59 measles cases in 2024, there were 285. Last year, there were 2,289 cases and three deaths. And as of last week, the 2026 total stood at 3,471, including the four deaths in Pennsylvania, with three months still ahead of us in this year. That's the most we've seen in over 30 years, and we're all but guaranteed to lose our measles elimination status in November. When PAHO meets and reviews the data, which is a status that we've held since 2000. The same piece also looked at Mr. Kennedy's claim that once CDC gets involved, outbreaks are brought to an end overnight. Well, they're simply not. The outbreak in West Texas lasted around seven months. In South Carolina, it was about six months. And Utah has been reporting cases for more than a year now. To be clear, it's worth remembering who actually does this work. Much of the measles response work is led by state and local health departments, with CDC on occasion providing a supporting role when asked. In Pennsylvania, which is the latest hotspot for measles activity in the U.S., state health workers have set up almost 150 pop up vaccine clinics since late April. Add in the EPI investigations case, follow ups, contact tracing, etc. and I can tell you that this is a massive undertaking which requires a lot of resources, and far too often the public health systems in place at the state and local levels are already stretched thin. Even without a measles outbreak. As someone who has been in this business for the past 50 years, what frustrates me the most is that none of this is inevitable. Instead of deflecting the claims that simply aren't true, I'd much rather see our federal health leaders follow the data, speak with one voice. And right now, we're not getting that.

Chris Dall: While we're on the topic of measles, there was a Reuters Ipsos poll last week that showed 76% of U.S. respondents trust the safety of the measles mumps rubella vaccine, down from 85% in 2020. The results were released two days before Secretary Kennedy spoke at a conference hosted by Children's Health Defense, an anti-vaccine group that he helped start. While he didn't discuss the MMR vaccine, he spent a good portion of his speech casting doubt on the safety of childhood vaccines in general. Mike. Many people were concerned that Kennedy might do things to block access to vaccines, but it seems his goal really is to get more people to question vaccines. Is he succeeding?

Dr. Michael Osterholm: Unfortunately, Chris, I do think he's succeeding both at making it difficult to get vaccines, as well as the fact of creating doubt among those who would be vaccinating their children, starting with those polling numbers you mentioned. Trust in MMR vaccine safety is falling nationally. Now, I still want to note that the majority of Americans, 76%, still trust vaccine safety. But that drop is still concerning. As you mentioned, Secretary Kennedy didn't get up on the conference stage and directly tell people not to trust vaccines. The strategy was much more subtle. If I had to sum up what's happening with Kennedy and other anti-vaccine leaders right now, it's one word segmentation. There are two entirely different communication strategies running at the same time in settings with the general public, where again, the majority of whom believe vaccines are safe and effective. The language is careful and technical. Informed consent choice asking questions. This reads as more measured to many casual news consumers. Then there is a second strategy for the more committed base that has followed Kennedy for years, and that children's health defense audience is the clearest example. The group itself referred to as appearance as a full circle moment. As they welcomed its founder back to the stage, Kennedy received a standing ovation in the midst of the worst U.S. measles outbreak in decades. He shared a speaking lineup that included Andrew Wakefield, the author of the discredited study that first proposed a link between the MMR vaccine and autism, who has fueled much of the modern anti-vaccine movement? So what actually did he say to this audience? There are a few specific areas he seems to be targeting that I think we need to keep an eye on. One was when he held up the package insert for the hepatitis B vaccine to point to a list of post-marketing adverse events.

Dr. Michael Osterholm: While he stated the severe events are very rare in the same breath, he cited evidence of vaccines fueling a chronic disease epidemic. Despite the historic measles outbreaks in the US, Kennedy only briefly mentioned the issue, saying, and I quote, you care about every child who dies from measles. They get the headlines, unquote. This shifts the focus from the disease itself and its devastating impact to suspicion of the news media and their alleged desire to sensationalize. He also framed these deaths as attributable to complications rather than the disease itself, which we touched on earlier in the episode. And of course, this event couldn't conclude without mentioning one of their anchoring pieces of misinformation on the supposed but entirely false link between vaccines and autism. While Kennedy did not explicitly state vaccines cause autism, he discussed a major federal study into the autism epidemic, which he initially had promised to have answers for last September. So here is my key takeaway from this event, looking at this alongside the other recent public appearances by Kennedy and other HHS officials. It's not one talking point or false claim doing most of the damage. It is the broader framing of uncertainty that no one knows about the risk profile or long term impacts of vaccines, despite the fact there are multiple systems and scientists tracking and reporting these issues on a daily basis. But this strategy is in some ways more effective than a Wakefield style claim, because it isn't tied to a single myth that could be picked apart or disproven. He cast doubt on the whole system, which is meant to provide reliable information and reassure us pediatricians, family physicians, nurse practitioners, vaccine scientists, even federal advisory groups and those weeds of distrust are much harder to uproot.

Chris Dall: The Wall Street Journal reported last week that states haven't been able to obtain COVID-19 shots from the CDC, which is causing delays in the vaccines for children program. Do we have any idea what the holdup is?

Dr. Michael Osterholm: I wish the situation surprised me, Chris, but we can add it up to the list of ways that this administration has worked to create questions about and limit access to vaccines, in this case, specifically COVID vaccines for pediatric population. The vaccines for Children program, or VFC, is a program that provides free vaccines to children who are uninsured, underinsured, Medicaid eligible, or American Indian or Alaska Native. Nearly half of American children receive vaccines through this program. CDC purchases vaccines from the manufacturers at a discount and distributes them to state and local VFC program providers. So far this season, the VFC providers have not been able to place orders through CDC for COVID vaccines and as of last week, still had not received the typical communications from CDC regarding the ordering process. Your question here, Chris, was if we have any idea what the holdup is. And the answer is we don't know for sure. HHS spokesperson Emily Hilliard stated the decisions were being finalized by CDC and also stated that because of the different seasonal pattern from flu and arbitrary September date should not be treated as a public health deadline for COVID 19 vaccine procurement. Let me just add a of footnote that at this time, we are seeing in parts of the country locations where COVID cases are increasing. And just to remind everyone that we just demonstrated this in our recent evidence review for COVID vaccines, that young children are at increased risk for serious illness, hospitalizations and deaths with COVID. And that first dose of vaccine can be very important in making the difference between a child who is critically ill and a child who has a milder infection. Chris, I know this still does not answer the question at hand, but to be quite frank, we don't know with certainty what the hold up is.

Dr. Michael Osterholm: But we have our suspicions. Both Pfizer and Moderna have said there is no shortage of vaccine doses, so that can be ruled out. The VFC website, which has a bullet point at the top, stating, and I quote, VFC is one of the most important contributors to vaccine access, unquote, and says that the VFC automatically covers vaccines recommended by the Advisory Committee on Immunization Practices and approved by the CDC, which includes vaccines for children ages 18 years or younger. I suspect because there is not an ACIP recommendation due to the lack of a functioning ACIP. This holdout may continue. I sure hope this was not the case, and it can be restored quickly, but it's hard to have faith in this administration to do the right thing and fulfill the VFC role as one of the nation's most important contributors to vaccine access. And let me add, with regard to the lack of an ACIP recommendation. Again, with the Vaccine Integrity Project efforts and those of the medical subspecialties, the American Academy of Pediatrics did come out with this recommendation, which strongly supports these vaccines for this age population. So now we're denying these kids a vaccine that at least the American Academy of Pediatrics saw fit to say, was really an important vaccine. We know these vaccines are incredibly important, especially considering that children less than one year of age have the highest COVID-19 related hospitalization rates, aside from adults over age 65. And finally, we also know these vaccines have great safety profiles for kids.

Chris Dall: Let's turn now to the Ebola outbreak in the Democratic Republic of Congo, where it appears that there may be some glimmers of hope. Last week, a DRC official said on social media that transmission of the Bundibugyo Ebola strain is gradually slowing and may have peaked. Un officials were a bit more cautious but said they saw signs of progress. Mike, what is your read on the situation?

Dr. Michael Osterholm: Four months into the Ebola outbreak, there are signs that it may be slowing in some hotspots, but it isn't true in all areas. The virus has now been detected in seven DRC provinces, with declines in cases and deaths noted in the Interior province, the epicenter. But increases are being seen in some health zones, such as in North Kivu. And on Sunday, the virus was identified in a new health zone in Haut Uele. The health zone Dungu, borders South Sudan, necessitating stronger cross-border surveillance. As of Saturday, the DRC had documented 7672 infections, including 3699 deaths. Last week, an independent review by an African advisory group concluded that although the noted declines in some areas are encouraging, the data haven't confirmed that the overall outbreak has peaked. The African Centers for Disease Control and Prevention Emergency Consultative Group cautioned against interpreting a short term decline as sustained interruption of viral transmission. The group also recommended that the Public Health Emergency of Continental Security continue, and called for intensification of the response to address persistent community death gaps in contact tracing. Limited lab capacity and poor access to essential health services. Additionally, we still don't yet have a vaccine with known effectiveness against the Bundibugyo virus, which is causing the outbreak. And it will take at least 6 to 9 months to develop one. What is encouraging is that over the weekend, health workers and Bunia, the capital of Ituri, were the first to receive the vaccine as part of a trial.

Dr. Michael Osterholm: The trial is designed to evaluate the effectiveness of the vaccine against Bundibugyo. We already know the vaccine is effective against the more common Zaire Ebola strain. The United Nations has said that 20,000 doses of Ervebo have been allocated for the trial, with another 50,000 earmarked for immunizations outside the research program once its efficacy has been estimated. In another promising development on Monday, the European Center for Disease Prevention and Control announced that it was sending experts to the DRC to increase support to Ituri, the site of eight and ten infections. As we've noted before, the public health response to this outbreak has been especially challenging for several reasons, including ongoing armed conflict, massive population displacement, poor access to health care, decaying infrastructure, hunger, distrust of government and medicine, and unpaid health workers. These difficulties are especially apparent in rural areas and those ravaged by conflict, which is why Ebola has been able to spread into more provinces and health zones. All of these challenges have been intensified by difficulty marshaling international support and resources, including those from the United States. This is an example of the short sighted global failure to prioritize pathogens like Ebola, which typically are limited to low income countries without more international support and investment. We are likely to see more devastating outbreaks as our defenses against them crumble worldwide over time.

Chris Dall: Now for an update on COVID and other respiratory illnesses. What does the picture look like right now, Mike? And what's your advice for our listeners who are wondering how they should be thinking about COVID 19 and how they can protect themselves in the fall of 2026?

Dr. Michael Osterholm: Let me start with flu and RSV. We are still not seeing any signs of increase in RSV activity. There have been some slight increases in RSV hospitalizations in children under one year of age, but no other notable changes. Flu activity is continuing to rise very slightly, just as we would expect for this time of year. The percentage of outpatient visits for influenza like illness has increased slightly, from 1.4% to 1.5% since our last episode. As a reminder, this is the metric we use to determine the beginning and end of the flu season. Each year, there is a national baseline established based on the previous season's metrics and when the percentage of outpatient visits for influenza like illness rises above that baseline, which was 3.1% last season, we considered ourselves in the flu season. And the flu season lasts until the outpatient visits for influenza like illness dropped back below that threshold. We're still far below that threshold. And I also add that we are well below the percentages. As we have seen at this point in the previous five seasons. We have also seen very slight increases in the percentage of Ed visits related to flu in nearly every age group. But again, these are very minor changes. We're talking about an increase from 0.3% to 0.4% in children under one year, from 0.5% to 0.7% in the 1 to 4 year old age group, which has now the highest percentage of any age group.

Dr. Michael Osterholm: Flu related hospitalizations have also remained low and unchanged across every age group. I know that hearing that there had been increases may make you want to run out and get your flu shot immediately, but we're still not quite there yet. I'm personally holding off of getting my flu shot for a few more weeks at the very least. Now moving over to COVID, where the data paint a slightly murkier picture. Based on COVID related emergency room department visits and hospitalizations, the data suggests that COVID 19 activity may have peaked. COVID related ED visits have decreased in all age groups. Below 18 remained unchanged in the 18 to 49 year old age group, and very slightly increased in the 50 to 64 and 65. And older age groups and COVID related hospitalizations have decreased in every age group. When we factor in the wastewater data, however, this peak doesn't seem to be as clear cut and straightforward. Nationally, the wastewater concentration is considered low, up from very low in our last episode. This increase is being driven by increases in the Midwest and the northeast, which are both still considered very low but are increasing. The South and the West are considered low, but seem to have passed their peak and are now seeing decreasing concentrations.

Dr. Michael Osterholm: Texas is still the only state considered to have a very high wastewater concentrations, while California, Florida and Washington are the only three states with high concentrations. I again want to add a caveat that the levels we're talking about are so small that small fluctuations at one point in the pandemic would have just shown up as a straight line, are now looking like small increases because the activity is so low. This is a good problem to have, but it certainly makes interpreting data more difficult. One thing I am comfortable saying is that there has not been any new variants that are having significant impact on activity, and that is reassuring news. Ultimately, I think we're in a wait and see moment with COVID 19, where we're waiting to see if the activity will tick up with rising wastewater concentrations in the Midwest and the northeast, or if these minor increases are minor enough, that we will continue seeing activity decline along with the southern and Western decreases in wastewater concentration. All this being said, as with any respiratory virus, if you are in a high risk group, you should always take as many precautions as make you comfortable to avoid exposure. Do not feel any peer pressure as to what you should do. You need to do what's best for you. This goes for COVID, RSV or flu.

Dr. Michael Osterholm: I know there are people who continue to mask indoors. People who avoid large gatherings, people who have completely returned to their pre-pandemic lifestyles. And nobody here is wrong. I'm not here to tell you all the precautions you should or should not take. Only you can determine what is best for you and what will make you feel comfortable, particularly given whether or not you have any underlying health conditions. That could be a much greater challenge should you get infected. What I can tell you is that the vaccines, together with your N95 respirators, are the best tools we have, and I want to encourage everyone to be sure that they're receiving their vaccines when the time is right and using their N95 respirator to protect them when they may be in a higher risk for exposure. As a reminder, in our last episode, we covered the issue of how to best time COVID 19 and flu vaccines each season or wave. And I'd like to encourage you to go listen to that portion of that episode, number 217 Making Sense of Measles misinformation. If you have questions about timing, as I just mentioned, I still have not received my flu vaccine, but I will let you know as soon as I do. I'm looking forward to receiving the new mRNA flu shot when the time is right.

Chris Dall: That brings us to our ID query. And this week we actually have two questions. The first is from Ali, who wrote, I am disappointed and disheartened by the RSV recommendations. My understanding is that the vaccines showed good immune response for the 18 to 50 age group. The FDA approved both the Abrysvo and mResvia vaccine for individuals 18 to 59 who are at high risk for severe lower respiratory disease. But neither the CDC, ACIP nor the American Medical Association recommend it. I want to understand why.

Dr. Michael Osterholm: Thanks for sending in your question, Ali, because it allows me to highlight, again the incredible collaboration of the Vaccine Integrity Project, the American Medical Association, and the other medical subspecialties responsible for making recommendations for vaccine use. For listeners who didn't tune in to the previous episode, on September 2nd, the American Academy of Pediatrics, Infectious Disease Society of America, American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists had a coordinated release of vaccine recommendations for the upcoming respiratory season. These recommendations were developed based on the COVID-19 RSV and Influenza Evidence Review, conducted by the Vaccine Integrity Project, and represent months of high level scientific collaboration. Although this work is typically the role of the Advisory Committee on Immunization Practices, the Vaccine Integrity Project and the American Medical Association have filled this gap during this era when the committee is not functioning as intended. Ali's question is why the recommendations didn't include a recommendation for RSV vaccine for high risk adults. And the good news is they actually did include it. The Infectious Disease Society of America, or IDSA, was tasked with issuing recommendations for immunocompromised people for RSV. They recommend that any immunocompromised adult over 18 years of age receive a dose of the RSV vaccine. This is based on the evidence. As Ali pointed out, the RSV immunization for this age group is consistently associated with reduced risk of severe RSV and RSV related hospitalizations. For any of you other listeners who may still have questions or uncertainty about vaccine recommendations for certain vaccine types or subpopulations, I encourage you to go to our show notes, where you can then link to spread the facts.org, where the American Medical Association has compiled all the medical society's recommendations into a format that makes it easy to find just what you're looking for. We want this information to be accessible to both physicians and the general public, which is why so much work went into harmonizing the release and communication of these materials. Again, this resource is linked to you in our show notes.

Chris Dall: And now for our second question. And this one is from Ron, who wrote what if a person got the seasonal flu vaccine now, and he notes that he got his. On September 10th of this year and later realized that they should have waited until late September or early October. Could they get a second shot at a later time in order to ensure protection? And Mike, I'm sure Ron is not the only listener who has this question.

Dr. Michael Osterholm: Well, I can actually say with complete honesty, this is the question I get asked more than any other question. I think of my job from friends, neighbors, colleagues, etc. all the same thing because they all hear me say, don't get vaccinated too early because you'll have waning immunity. So their logic, which is actually right on the mark, is, well, if I have a waning immunity for a couple of months, can I just boost it and get it back up to where it was before? So I'm covered early should the flu emerge quickly? But I'm also covered late if in fact I need to have that protection some weeks or months later than from the time I got the shot. Well, I wish I could say that you can get two doses, but the current recommendation is a single dose. And at this time, I suspect you could probably get another dose of vaccine. You'd probably have to pay for it yourself, but I surely would not make that recommendation and would just say, again, I think the most important thing you can do is literally just as flu season is beginning to take off, get your shot and you'll have the best protection. And that's all you're going to get for that season.

Chris Dall: Mike, I don't think we've ever discussed rabies on this podcast, or at least not that I can remember. But there's always a first for everything. Last week, the CDC issued a health alert network advisory about a nationwide increase in human exposure to rabid or possibly rabid animals. What's going on with rabies?

Dr. Michael Osterholm: Well, Chris, I, like you, believe this is the first time that we've ever covered rabies in almost the five years of doing these podcasts. And it's surely a timely topic, I believe. Let me start out. Rabies is one of those infectious diseases you cannot be wrong with, because if you're wrong, it often means the death of the individual. And so this is a very important disease that continues to plague us throughout all of North America, and one that for which there's unfortunately still quite a bit of misunderstanding about what the risk of transmission is. How do you become infected and what do you need to do when in fact you might have been exposed to the virus? Let me start with a little bit of background information for you to better understand this. Rabies is what we call a viral zoonotic disease, meaning it's the one that can go between animals and humans. And it's nearly 100% fatal. Rare rare cases have survived, but it's entirely preventable with post-exposure prophylaxis, or PEP, as we call it. This prophylaxis includes multiple doses of rabies vaccine, and for those who have not previously been vaccinated, such as a veterinarian or others who might have been for occupational reasons, you also receive human immune globulin injected into the area where the bite or exposure might have occurred, as well as in the rest of it in the body. It's very important that both the vaccine shot, as well as the immune globulin, be administered as soon as possible after exposure.

Dr. Michael Osterholm: Remember, you're already fighting what might be an emerging infection in your body. Rabies is spread to humans through infected animal bites, scratches, or oral secretions. In the United States, bats, raccoons, skunks, and foxes are the primary reservoirs for rabies. But other animals, including pets and livestock, can become infected if exposed to one of those reservoir species. Here in the Midwest, when a skunk becomes rabid, it may actually live for quite some time with rabies, but their behavior begins to change substantially. Fearing almost nothing. And it's not unusual to hear of a dairy operator who has 15 or 20 cows out in a large pen area, and a rabid skunk gets into them and bites them all on the legs. This can be a really challenging situation following a potential rabies exposure. It's important for health officials familiar with rabies epidemiology to assess exposure risk and determine whether the exposed individuals needs the post-exposure prophylaxis. In the United States, an estimated 1.4 million people seek medical care after animal contact. An estimated 1.4 million people seek medical care after animal exposure and undergo evaluation each year, and approximately 100,000 people receive rabies post-exposure prophylaxis following that exposure. It's also worth noting that exposure isn't always an obvious or painful bite. In some cases, bites from animals like bats can be so small that people don't even feel them. When in doubt, always talk to your health care provider or contact your state health department.

Dr. Michael Osterholm: Rabies information line. This was one of the reasons why I am so very cautious about handling baths. Should you find one in your home? You do not want to be exposed. The most recent rabies death I'm aware of was of a young boy who actually woke up with a bat on his face, does not recall any bites. They captured the bat, threw it outside and nothing was thought of it until the young man came down with rabies. So this is what you have to be constantly mindful of. On September 10th, the CDC issued a Health Alert network advisory in response to recent reports of increases in human exposures to potentially rabid animals and rabies post-exposure prophylaxis administration errors. In July and August of this year, the CDC received 17% more rabies related inquiries compared to the same time period in 2025. There have also been a number of mass exposure events to rabies recently. Worth noting In North Carolina, nearly 300 people were exposed to rabid baby goats at a mobile petting zoo that visited assisted living facilities and back to school events In this case, it appears that these goats were actually exposed to a rabid skunk and had bitten them in such a way that they all became infected. And remember, a goat doesn't have to bite you. If you have an open wound and you get saliva on it from that goat, that's sufficient to cause transmission to occur. In Minnesota just a few weeks ago, nine people were recommended to receive post-exposure prophylaxis after contact with a rabid dairy cow.

Dr. Michael Osterholm: They had no idea that the cow was rabid and handled it with extensive contact to the body fluids. Despite these one off events, bats are still the most common source of potential rabies exposure in humans. Several states and local health departments have released alerts about an increase in human encounters with rabid bats this summer. This begs the question why are we seeing increases now? I have a hypothesis that goes back to a phenomenon we discussed previously on this podcast, El Nino. We've talked about it previously in the context of hantavirus as well as mosquito borne viruses. But the severe weather associated with El Nino can cause food shortages for bats, forcing them to move closer to urban and agricultural areas for food. This increases the likelihood of bats encountering both human and domestic animals and therefore potential rabies exposure. We are currently experiencing a Super El Nino, which is expected to peak in late 2026 and persist into 2027, and to support the potential relationship with El Nino. There's actually been studies done looking at this. El Nino cycles often bring periods of intense heat. Long term epidemiologic data, such as prominent multi-decade study on cattle rabies in Costa Rica, shows that rabies outbreaks and mortality spiked during periods of higher temperatures. This is just one more reminder of why we need to be thinking about rabies when we have potential animal exposures.

Chris Dall: So my quick follow up question here. If you are in a situation where you find a bat in your home, what are you supposed to do? Should you call animal control?

Dr. Michael Osterholm: Well, in fact, it depends upon the ability that you have to capture that bat safely and let it escape into the environment. Or in fact, if there was a potential exposure to make sure it gets submitted to the state or local health departments so that they can test it. One of the most important things is to create a barrier between you and that bat. So heavy leather gloves is very important in. Some people will also then have their traditional Minnesota fishing net that they will use to catch it as the bat flies through the room. You want to make sure that you shut all doors into that room so that the bat doesn't get out and get into other parts of the house. In some cases, you're actually dealing with a bat roost where one or more baths actually take up residence during the day and then fly out at night. And when you have that, you really do want to call animal control. You want the professionals who deal with this, who understand the potential serious risk, but it's one that do not take lightly. Most of all, again, avoid any possible skin to bat contact that could result in them biting those little teeth that they have. You have no idea in most cases that you've ever been bitten, and yet that's more than sufficient to transmit rabies virus to you.

Chris Dall: And Mike, just a note here. If our listeners are looking to get more information on infectious diseases like rabies and other topics at the intersection of wild animals, humans, and the environments we share, they can subscribe to CIDRAP newest newsletter, Wildlife Interface. It's a curated monthly list of resources, including the most recently published literature, policy updates and CIDRAP news stories on the wildlife disease topics you care most about. You can find a link to the subscription page in the podcast show notes. Finally, there was an announcement last week from CIDRAP Vaccine Integrity Project on its next undertaking. Mike, what can you tell us?

Dr. Michael Osterholm: Well, Chris, as I said in previous episodes of this podcast, this is one of the wonderful parts of this podcast to talk about what's happening with VIP, the Vaccine Integrity Project. I'm so proud of the team at CIDRAP and VIP for the work that they're doing and how it is contributing to a national system of vaccine recommendations that are so critically needed at this time. As listeners and readers of CIDRAP news know well, the Vaccine Integrity Project has no intention of slowing down. Our central goal with that work is to provide public health, medical, specialty societies and the public with data driven evidence to form vaccine guidelines and make decisions for their health. In the pursuit of this goal, the research team recently published evidence reviews for the big three respiratory viruses COVID, influenza and RSV. And now we are turning our attention to evidence reviews of pneumococcal and meningococcal vaccines for children and young adult. These reviews will provide a current assessment of the safety and effectiveness of US licensed vaccines, while also taking a look at the latest evidence on the burden and epidemiology of pneumococcal and meningococcal disease among the pediatric population. The research teams will assess evidence related to these outcomes in immunocompromised children and those with chronic medical conditions at increased risk for severe disease. In addition to data relating to co-administration with other routine childhood vaccines, we expect the reviews to be completed in early 2027. In the meantime, stay up to date with the latest announcements from the Vaccine Integrity Project by visiting our website and following the program on social media. And of course, you can always find the links in our show notes. At a time when trusted scientific institutions are being challenged and vaccine preventable diseases like measles are once again reminding us of what's at stake. It's more important now than ever. We rely on rigorous evidence. Speak with a unified voice, and have the grit to stay focused on protecting the public's health.

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

Speaker 4: This week we're talking.

Dr. Michael Osterholm: About a more recent event in history, the Flint water Crisis. For those of you who may not have heard about Flint or simply need a refresher, I've got you covered. Flint, Michigan is a small city home to about 80,000 people, the majority of whom are black residents. In April of 2014, the city decided to switch its water source from the Detroit system to the Flint River. By May, residents started complaining about the color and smell of the new water. By August, E coli and total coliform bacteria were found in the drinking water, prompting a boil water advisory. As the months progressed, things only got worse. In October 2014, General Motors stopped using water from the Flint River, fearing corrosion in their machines. By January 2015, Flint was found to be violating the Safe Drinking Water Act and started. In February of that year. There were ongoing reports of extremely high levels of lead found in different homes. This brings us to the day 11 years ago, September 24th, 2015, when Mona Hanna-Attisha, an associate professor at Michigan State, published groundbreaking research. Her study showed that children under five years of age who were tested had lead levels in their blood that were nearly double after the 2014 water source change. The research went on to prompt a city led emergency, followed by state emergency.

Dr. Michael Osterholm: Months later, President Obama declared Flint a state of emergency at the beginning of 2016. Federal congressional testimony followed, as well as some increasing regulations and testing. However, many Flint residents today are still wary of drinking from the tap. An estimated 140,000 Flint residents were exposed to lead in the water supply. Official reports state that 12 people died from the crisis due to an outbreak of Legionnaires disease. Although there are likely dozens more who are impacted, scientists also estimate that Flint's water caused permanent brain damage in thousands of children exposed. The CDC actually conducted a formal investigation and verified that the spike in children's blood lead levels directly correlated with the time frame of the water switch. Once Flint switched back to the Detroit water system in late 2015, the percentage of children with elevated lead levels began returning to a pre-crisis baseline. I commend the Flint residents, who were persistent in speaking up about what was happening in their community, as well as scientists like Mona Hanna-Attisha and countless journalists who helped bring these injustices to light. We're still thinking of all of you in Flint. Safe. Clean water is a human right, deserved by all.

Chris Dall: Mike, we once again have covered a lot of territory today. What are your take home messages?

Dr. Michael Osterholm: Well, my three messages really boil down to what has largely been the thrust of my messages over the recent podcast. Number one, in holding true to the fear that I had, measles continues to challenge us in this country. We are going to, I think, see an ever increasing number of cases occur over the upcoming months. Remember, measles, like influenza, does have some seasonality to it. At least it did 30 and 40 years ago when it was more widespread. And that seasonality favored mid to late winter transmission. So I think we have to anticipate that we could really still see some big challenges with measles coming down the pike. The second thing is expect the very unhelpful language on vaccines to be put forward by this administration. They're going to continue to put out myths and disinformation that is going to confuse young parents who are wondering about, should I vaccinate my child? These are, again, not people that are anti-vaccine. They're concerned when they hear the leader of the public health activities in this country, as Secretary Kennedy is, make the kind of statements he does, they have every reason to begin to wonder, should I just defer my child from being vaccinated? We've got a lot of work to do. And finally, still a little bit too early to get your flu shot. We're getting close. We're getting close. And I'll keep in touch with you. Maybe I'll have a better answer for you at the next podcast, but for right now, I feel confident and comfortable holding off on that flu shot and trying to preserve as much of that impact from the vaccine for later in the winter, when I think flu is going to be really a major challenge.

Chris Dall: And do you have a closing song for us this week.

Dr. Michael Osterholm: I do have a closing song and one that ties back to the opening dedication. The issue of mental health and suicide in particular, is really one that today we want to honor those who have spent their entire careers trying to respond in the most effective way they can to help others who are in great pain. For those of you listening to those podcasts that have lost family members, loved ones, colleagues to suicide, my heart goes out to you and I hope this song gives you some sense of a more positive view of what is really a difficult situation. Today we have a song from Noah Kahan. Noah is an American singer songwriter. He had a breakthrough single, "Hurt Somebody", achieved gold status in the United States and charted in multiple international markets. And one of the songs that I think is among his very best is call your mom. It marks one of the seven new tracks on the deluxe version of Stick Season, a deeply emotive song recalling life's darkest moments. "Call Your Mom" is a heartfelt ballad of unconditional support for those living with mental health issues, particularly depression. It's not an easy song to perform live, as Noah has mentioned on Twitter a number of times. "Call Your Mom" speaks deeply to the struggle with mental health as con appeals for someone he cares about to choose life over self-harm. His raw lyrics suggest he's familiar with depression, both through personal battles and through supporting loved ones facing similar struggles. Kahan's word Choice expresses empathy by sharing that he's been exactly where you are, conveying resiliency and solidarity.

Dr. Michael Osterholm: Con touches on the devastating impact of suicidal thoughts on friends and family, recalling waiting in the hospital, fearing for someone he loved with lines like if you could see yourself like this, you'd never tried it. He highlights the lasting effects of those left behind, urging listeners to choose life. The lyrics could have been seen as a plea to find any lifeline as reflected in the bridge medicate, meditate and Save Your Soul for Jesus, which suggests a mix of seeking help, finding peace or connecting with something greater to keep going. For me today, it's both an honor, but it's also a very difficult moment for me to share this incredible song. Call Your Mom. Oh, you're spiraling again. The moment right before it ends you're most afraid of. But don't you cancel any plans. Because I won't let you get the chance to never make them stayed on the line with you the entire night. Till you let it out. And you let it in. Don't let this darkness fool you. All lights turned off can be turned on. I'll drive, I'll drive all night. I'll call your mom. Oh, dear. Don't be discouraged. I've been exactly where you are. I'll drive. I'll drive all night. I'll call your mom. I'll call your mom. Waiting room. No place to stand. Just greatest fears and wringing hands and loudest silence. If you could see yourself like this. If you could see yourself like this. You would never tried it. Don't let this darkness fool you. All lights turned off can be turned on.

Dr. Michael Osterholm: I'll drive. I'll drive all night. I'll call your mom. Oh, dear. Don't be discouraged. I've been exactly where you are. I'll drive. I'll drive all night. I'll call your mom. Medicaid. Meditate. Swear your soul to Jesus. Throw a punch full of love. Give yourself a reason. Don't want to drive another mile. Wondering if you're breathing. So won't you stay. Won't you stay? Won't you stay with me? Medicate, meditate and save your soul for Jesus. Throw a punch. Fall in love. Give yourself a reason. Don't want to drive another mile without knowing you're breathing. So won't you stay. Won't you stay? Won't you stay with me. Don't let this darkness fool you. All lights turned off can be turned on. I'll drive, I'll drive all night. I'll call your mom. Oh, dear. Don't be discouraged. It's been exactly what you are. I've been exactly where you are. I'll drive. I'll drive all night. I'll call your mom. I'll call your mom. Noah Kahn.

Dr. Michael Osterholm: Thank you very much for joining us again this week. I hope we're able to provide you with the kind of information you're looking for. I just want to thank all of you out there for your support of our work. What we're doing, your feedback. It means more than I can put into words in this time of great turmoil. Every day, every hour, practically something new of a crisis. Nature happens. We just have to keep on course. And just remember, one of the ways to keep on course is to be kind, be thoughtful, be kind. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm update. If you enjoyed the podcast, please subscribe, rate, and review wherever you get your podcasts. And be sure to keep up with the latest infectious disease news by visiting our website, CIDRAP.umd.edu. This podcast is supported in part by you, our listeners. The Osterholm Update is produced by Sydney Redepenning, Elise Holmes and Ruby Guthrie. Our researchers are Cory Anderson, Meredith Arpey, Leah Moat, Emily Smith, Clare Stoddart, Angela Ulrich and Mary VanBeusekom.