Episode 209: Awareness vs. Alarm: Making Sense of the Headlines

[00:00:08] 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 update podcast. At the time of the recording of this podcast, there have been 11 reported cases of hantavirus and three deaths linked to the Dutch cruise ship MV Hondius. 122 guests and crew aboard the ship have been evacuated, including 16 Americans who are currently in the National Quarantine Unit at the University of Nebraska Medical Center. Follow up and contact tracing for all contacts of hantavirus cases linked to the ship is ongoing. The situation appears to be well contained, and both the World Health Organization and the centers for Disease Control and Prevention have characterized the public health risk posed by the hantavirus outbreak as low. But for some, even those who recognize that hantavirus is not the next COVID, the episode is nonetheless raising questions about the ability of health officials to respond to potentially larger and more serious outbreaks.
 

[00:01:52] Chris Dall
Here's what David Wallace-Wells of The New York Times wrote last week: "This does not appear to be the superbug of your nightmares, capable of spreading rapidly across the world and killing far more efficiently than that pandemic ever did. But hantavirus infection does have a terrifyingly high mortality rate. It is spreading from human to human, and health officials around the world have proved terribly inept at even properly describing the risk of transmission, let alone containing it." The response to the hantavirus outbreak, and the lingering questions that remain about how the virus spreads, will be among the topics we explore on this May 21st episode of the Osterholm Update episode number 209. We'll also bring you up to speed on a new Ebola outbreak in the Democratic Republic of Congo. Discuss the findings of the Vaccine Integrity Project's review of Tdap vaccination during pregnancy. Review the latest data on U.S. respiratory virus activity. Talk about the resignation firing of Food and Drug Administration Commissioner Marty Makary, and examine a significant new study on aluminum in vaccines. And of course, we'll have the latest installment of This Week in Public Health history. But before we get started, as always, we will begin with Dr. Osterholm opening comments and dedication.
 

[00:03:06] Dr. Michael Osterholm
Well, thank you, Chris, and welcome back to the Podcast family. We're very happy to be with you again. Thank you for your support, your feedback, your thoughts. We truly feel very special to have you in our lives. And to those of you who might be joining us for the first time, I hope we're able to provide you with the kind of information you're looking for. Please let us know if we're not and what we might do to better serve your needs. Also, I want to make sure everyone knows on the podcast today the up. I don't sound quite normal. Some would argue I never do, but in this case I have been suffering through an upper respiratory infection the last week. It's not influenza or COVID. Nonetheless, it has surely taken a little toll on my upper airway here and I'm recovering doing much better. But I may sound a little off today. So with that background, let me share with you a very special dedication, one that means a great deal to me, particularly given what I've done for the last 51 years. As this school year comes to a close, I want to take the time to dedicate this week's episode to all the graduates, whether it's a high school, college, trade school,
or grad school, graduating is a remarkable achievement. Making it to the finish line takes so much dedication, hard work, perseverance, and sometimes an unbelievable amount of coffee to push through all those late night studying. I hope that if you're a graduate, you take the time to reflect on all the hard work you've put in over the years. Please take a moment to feel proud of all that you've achieved.
 

[00:04:36] Dr. Michael Osterholm
I can't emphasize this enough. Graduating is a big deal. It's far too easy to brush it off, but really, with the amount of time, effort, and hard work you put into getting where you are today, this is really a very special moment. Of course, we are all products of our environment, whether it's family, friends, colleagues, peers, professors, or mentors, it's certain that graduation wouldn't be possible without a solid support system. Shout out to all the parents, grandparents, relatives, teachers, friends and supporters who helped graduates along the way. While one chapter may be coming to a close, another is beginning on the horizon. Dream big and more importantly, put those dreams into motion with action. And never, never underestimate the power of kindness. The world can certainly feel like a big, dark and scary place, but little kindness goes a very, very long way. And better yet, kindness tends to ripple out from person to person, much like a little pebble in a big pond. So congratulations to all the graduates. I hope you take the time to celebrate yourself, and we're all wishing you the very best luck in moving forward. Now, on a very personal note, one that is based on my 51 years of teaching at the university and having had the wonderful opportunity to advise many graduate students, including a whole incredible group of PhD students. There is one that I have to acknowledge today. This past week, Dr. Sydney Redepenning received her diploma, one that we are all so very, very proud of her achieving Sydney is an unusual one. First of all, you know her by name because she is cited each and every week as one of the key individuals helping to put this podcast together.
 

[00:06:19] Dr. Michael Osterholm
I've had the good fortune to work with Sydney since she was an undergraduate. I swear there was no one on a faster track to getting down to the PhD than Syd, and she did a marvelous job. So Syd, from all of us at CIDRAP, we're so proud of you. We're so glad you're staying with us to work at CIDRAP. And congratulations on a job well done. Now, let me move to that part of the podcast that some of you may want to take a 32nd break. Today in Minneapolis on May 21st, 2026, sunrises at 5:37 7 a.m., sunset at 8:42 p.m. That's 15 hours, four minutes, and 19 seconds of sunlight that we're gaining sunlight at about two minutes per day and will peak in one month on June 20th and the 21st, where both days, the longest days of the year will occur at 15 hours, 36 minutes and 50s. So we still have about 32 minutes of sunlight to gain. Wow, what a time of year. And for our dearest friends and colleagues in Auckland, particularly at the Occidental Belgian Beer House on Balkan Lane, we're sorry to tell you that your sun length is getting a bit shorter today sun rises at 7:16 a.m., sun sets at 5:18 p.m. that's ten hours, one minute and 29 seconds
of sunlight. Unfortunately, you're losing sunlight still at about a minute, 26 seconds a day, but soon that'll turn around and you'll start back up that hill of increasing sunlight. In the meantime, we're more than happy to share ours with you.
 

[00:07:47] Chris Dall
Mike, let's start with the hantavirus outbreak. And this will serve as our ID query for this episode. Since we received so many questions about it on our last episode, you said, quote, I find this outbreak to be a great epidemiologic mystery story, but not one of great public health significance, end quote. Two weeks later, do you still feel that way? And what for? You are among the questions that still need to be answered. One question I have, for example, is about the idea that people need to have close, prolonged contact with infected patients to catch the Andes strain of hantavirus. Is that still the case?
 

[00:08:24] Dr. Michael Osterholm
Well, Chris, first of all, let me begin by saying that there are yet many unanswered questions with the disease that we've had such limited experience with, and what I mean by limited experience, we're talking about specifically the Andes strain of the hantavirus, the one that we know can be transmitted person to person. But at the same time, there's a lot of information here that we could glean from what happened on the ship based on our previous experience, and I think we actually knew a heck of a lot more than we gave ourselves credit for. That's an important point, because what happened was so many decisions were being made assuming an absence of information. Let me start out by just saying that this ship outbreak was not new, in a sense, with regard to what we've seen with the Andes strain of hantavirus. Actually, there were four previous outbreaks in Argentina in 1996 in Patagonia, the first ever recorded event of person to person hantavirus transmission was documented involving 16 cases. Three of these cases were health care workers. In 2002, in Buenos Aires province, scientists identified four clusters comprising 13
linked cases. This confirmed that person to person spread was not unique to the southern Patagonia lineage. Then, in 2014, in the Rio Negro province, a small cluster of three cases were confirmed, including two brothers and a nurse who cared for them. And then, of course, the one that we've all been hearing about is the 20 1819 outbreak in the Chubut province. This was the largest human to human hantavirus outbreak recorded to date and resulted in 34 confirmed infections and 11 deaths.
 

[00:10:00] Dr. Michael Osterholm
It was driven by three symptomatic superspreaders at crowded social events. Now, why is this important to talk about the context? Because what we can see from the transmission perspective is there is not a specific pattern that we can expect in terms of transmission from individuals. Rather, this is the classic super spreader type disease. And what I mean by classic, think of what we had with SARS in 2002 and three, what we had with MERS, Middle Eastern respiratory syndrome in 2012, and then again in Seoul, Korea in 2015. In these outbreaks, as much as we saw with the previous outbreaks in Argentina, was the fact that some people transmitted to an increased number of people, others transmitted zero. And it's not just this gradient where somebody might be a little bit more infectious than somebody else and somebody else. Super spreaders were key to what was going to happen here with this outbreak. This is why I was so confident that we'd be able to stop this. We stopped SARS, we stopped MERS. We didn't have vaccines. All we had was good shoe leather, epidemiology and contact tracing follow up, particularly of those who are
super spreaders. By isolating them from the population, we were able to, in fact, greatly slow down transmission to the point of bringing the transmission to a level which was not sustainable. I found many different people making claims about what we call basically the R0.
 

[00:11:29] Dr. Michael Osterholm
This value of how many people, on average just one patient transmit to. And people came up with these numbers that were somehow as if everybody had a certain amount of transmission. And without taking into account that many people transmitted very little and some people transmitted a lot. And that's exactly what happened on this ship. If you look at the 11 cases and I'm adding the new one in that came from Canada this week and dropping the one that turned out not to be test positive. Last week, a week ago last Sunday, I was on the George Stephanopoulos This Week show on ABC on Sunday morning. And I made this statement at that time that I thought this outbreak would be over with in several weeks at most, and that in fact, we would not continue to see cases. Well, I can tell you, I got a lot of feedback, much of it from my colleagues who thought that I was somehow underplaying this whole situation, which for many people, that's ironic because most people think I overplay everything. And the bottom line was, is that I predicted would happen is actually happening. If you look at what information we have, I keep hearing people
refer to the incubation period of this idea of 42 or 44 days, and everyone's focused on that. Well, that's important, but those are the exceptional cases. What's really important is what's happening in those first 18 days, which is what we call the median incubation period, where by that time half the cases should occur.
 

[00:12:51] Dr. Michael Osterholm
If you only have 1 or 2 cases in the median incubation period, you're not going to have 15 or 20 in the last half of that curve. Then no longer, that's not the median. And we've seen nothing to change that. So all along I kept saying that we were not going to see this kind of sustained transmission unless we had another super spreader. And I don't believe at this point anyone has demonstrated that. So I think it is important to, number one, acknowledge that there are questions about how we address this disease. But let me add that I think one of the major challenges we had besides public health, inability to come up with a common message was the news media. The news media drove a lot of the hype around this. I can tell you at least two different reporters. I feel like I had to walk them off the edge of the cliff because they were certain that this was now the new pandemic. There was a boat involved. There was this new virus involved. There are people who are now out into the public who might be transmitting the virus. There is no similarity between what happened with COVID and this particular outbreak. And so from that perspective, I felt like
we needed to have a better understanding that we can have situations where we don't have all the information, and yet we can still come up with a lot. So to summarize this, let me just say that unless we see a super spreader show up in the long incubation period of more than 18 days, this outbreak is done.
 

[00:14:18] Dr. Michael Osterholm
It's over with. And that is something that we could have concluded several weeks ago. This is exactly why I concluded what I did on that ABC This Week Sunday talk show. And this outbreak is unfolding pretty much as I expected it to do. So at this point, we do need to answer more questions about this particular strain of hantavirus. I can't predict for you when the next outbreak might occur, but it's going to. And the questions we had about what it means to bring an outbreak like this under control is the first and foremost thought should be containment, containment, containment. But that also means we can stop it without a vaccine, without the kind of tools that we would think of for so many other infectious diseases. And Chris, let me follow up on your comment about the prolonged exposure. I've been frustrated by this very discussion of what it means to be exposed to someone who actually might be shedding the virus in the respiratory tract. And what I mean by that is, is that, as I pointed out earlier, there will be those who are super spreaders and there will be those that are not among the superspreaders and the people you have contact there. That contact can actually not even be person to person. It's all about swapping air. And we've said that time and time again, we go back to COVID the same thing.
 

[00:15:34] Dr. Michael Osterholm
Remember the example I gave? If you're smelling cigarette smoke and you look up and see somebody 50ft upwind of you smoking. That's an aerosol. That's what you're breathing in. You can be in a room and be five feet from someone. And depending on how the air movement is, you have very little exposure to their virus. You can be in a room with someone who's 25ft away from you. And in fact, if the air currents are right, they're the ones that are getting hit with the virus, not you being five feet away. And this is a very important point to make. This is why contact and close personal contact is should never be measured by the number of feet. You are away from someone for a period of time. It's helpful. It's more likely if you're close, you might have been exposed to their air and the virus in it. So it's really important to understand. Also, this was a very unique environment in this ship. And I say unique environment because most cruise ships are not all about trying to keep warm air inside the ship. And just to note, when you're on a cruise ship in warm, tropical regions. You're drinking your martinis out on the outdoor patio. You're not concerned
about being cold if you're in the Antarctic, as this ship was. You are very concerned about temperature. You button that ship up really tight. And the potential from an Hvac system standpoint, to actually have air recirculated such that someone could be in a very different part of the ship and be exposed to you, and no one would know it.
 

[00:17:02] Dr. Michael Osterholm
And so this also adds to the question about what it meant to be a close contact. And there's no way you could define that based only on the amount of minutes you spent so many feet away from someone. And that's true for the previous outbreaks. If you go look at the other outbreaks we've had of the Andes strain, in each and every case, there appeared to be potential exposures that just didn't make complete sense, meaning the people who were further away from the source case got infected when others closer didn't. That makes perfect sense that Since that could happen again, it's about swapping air. And so I hope that when people hear about this issue, why we talk about the importance of an N95 is because that's what stops that. If I'm a case and I have an N95 on, I don't shed the virus into the environment. If I have an N95 respirator on and I'm exposed to the virus, I don't breathe it in. And that's why something that simple can make a very big difference in risk of exposure. I hope that the term a close, prolonged contact is no longer used in our world in terms of measuring potential exposure, because you don't know unless you can define where the air movements are and how it's moving, you have no real clue what is a real exposure.
 

[00:18:19] Chris Dall
Mike, I want to go back now to that. David Wallace-Wells op ed that I quoted in the introduction. He's not the only person to suggest that this episode has been a test or a dry run for an outbreak of a pathogen with pandemic potential, and that the response hasn't been encouraging. Is that fair? And how would you assess the response so far?
 

[00:18:42] Dr. Michael Osterholm
Well, first of all, let me start out by saying I am a very big fan of David Wallace-Wells. I read his every column and have, over the years, appreciated his very thoughtful analysis of what's going on, particularly during the pandemic. I'm afraid I have to disagree a bit here with him on this situation. I hope everyone is becoming fully comfortable with the idea that there's no evidence that the Andes hantavirus will ever cause a pandemic. This virus does not spread person to person efficiently unless you're a super spreader. And when it does, the super spreader will determine exactly what's going on. I do acknowledge that hantavirus is frightening if there's no vaccine against it, and it kills roughly 35 to 40% of the people infected, it's therefore really only human that people are worried about this in the wake of a COVID pandemic. But this is a very, very different pathogen, and the threat to the general public is very low. I do think that David raises some important points in his piece. He does criticize officials from the WHO and HHS for issuing delayed guidance in what he calls an erratic and confusing series of messages that have downplayed the
risk of the disease and undermined the effort to aggressively limit its spread. But let me spend a couple of minutes going through the five major points that David raised in his article, and then share with you why I think he's missed the mark on this.
 

[00:20:07] Dr. Michael Osterholm
First of all, he notes in the second paragraph of his article, and I quote, and health officials around the world have proved terribly inept at even accurately describing the risk of transmission, let alone containing it. Well, first, I just have to say at this point, who is he talking about? Is public health officials. We've had many talking heads from government agencies from academic centers. I'll consider myself one of those. Any number of places where people have become self-appointed experts and who are making comments about what is the risk and what do we know about it. And I think that's by itself a challenge is we don't have a public health voice. We have an entire choir, and some of them aren't necessarily singing on key. And they don't, for example, bring to bear the kind of information they could that would help deal with understanding what the risk is and what can be done about it. I also believe that just as we saw in previous outbreaks in Argentina with this particular virus strain, they can be brought under control fairly easily once you recognize the kind of transmission pattern. But let me go through these points that David
raises. He said, and I quote, over the past week, as the world began worrying over hantavirus, officials from the WHO, the U.S. Department of Health and Human Services and other organizations spoke almost in unison to caution against public panic. In a certain sense, the message was appropriate.
 

[00:21:34] Dr. Michael Osterholm
I don't think there was as much a chance. The outbreak is the beginning of something epochal, given its slow rate of growth and the limited spread of previous outbreaks. But there remains much we don't know how this outbreak will unfold. Even armed with knowledge of previous outbreaks and the estimated mortality rate for this strain of 30 to 40% of known cases offers a grimly worrying anchor, unquote. Well, first of all, he's made several assumptions here that we couldn't predict what the future might be on this outbreak. And once we were following up on contacts and isolating those contacts, we did understand what could happen. And I think the fact that here we sit today with the 11 cases, only one new case in the last few weeks, and the period of time that someone might even become a case is rapidly coming to an end for most of the exposed individuals. Says to me, this outbreak unfolded and played out just exactly as I thought it might have. And I think others in public health thought the same way. So we weren't at a loss for explaining this. What happened was the media was at a loss, and I think this has been a real challenge as the
media themselves brought a lot of this on. I urge you to watch a linked episode of Jon Stewart that we have on the podcast notes, where he actually takes on the media for piling on this concept of panic and fear.
 

[00:22:56] Dr. Michael Osterholm
And that by itself is an issue. I have heard of no one other than Jon Stewart and one other reporter call into question. What role did the media play in this? Not once in any of these articles include David's article has anyone talked about the role of the media played in creating this confusion? He went on and said in the first of five comments, we have a few weeks or so until we even get a sense of the second generation of cases. Previous outbreaks suggest that that may be at least several more waves to follow. Well, that's just simply not the case. Remember, a median incubation period of 18 days means about half the cases should be expected to occur in that time. I've seen nothing that changes that overall incubation period for this virus from previous outbreaks. So when you get to day 18 out from when exposure likely occurred and you only have a couple of cases in that group, you're not going to suddenly see a whole slug of new cases occurring in the second 18 days. That's just not going to happen. We could have predicted a lot of what was going to happen by just looking at what happened in the first 18 days of this outbreak, and that would have given us a good sense of which, of course, I particularly used the second thing he said that we need to know with this strain of the disease, human to human transmission is not just possible but also documented.
 

[00:24:14] Dr. Michael Osterholm
But again, remember what we're talking about here with a super spreader in a ship. If I had to develop a mechanism for enhancing transmission of virus like this. I would put them on a cruise ship made for cold water areas like this one, where air recirculation was common and the Hvac systems were unique and say this probably will enhance the whatever super spreader is going to do. Well, remember, there were ten cases now out of over 160 people on that ship, and we have no evidence that there's any additional ones beyond the one we had this past week. That's an attack rate of 6.5%, meaning only 6.5% of the people on the ship under these very close environment became infected. So it wasn't a situation. We didn't know what would happen. The second series of cases had there been additional superspreaders. That's the possibility. But that's the very thing that we were working on to try to avoid from happening. The third thing he says is that we need to know that asymptomatic infection is possible in sick. Individuals can transmit the disease without showing obvious symptoms. Now, I think this point is one that's fair. We don't know exactly how often transmission occurs before one is clinically ill, but I think the vast majority of the data that we have, and having talked to a number of the hantavirus experts, is really upon onset of symptoms.
 

[00:25:40] Dr. Michael Osterholm
That's when there is maximum viremia, and that's when most likely we're going to see transmission in a day or two before. Could that happen? Surely it could. We'll obviously learn more about that over time. But it's not somehow that these missed opportunities to detect someone in the very earliest stages of their illness has in fact, made it impossible to control this disease. The fourth thing he said we need to know is that transmission does not appear to happen as easily as other respiratory viruses, but that it also doesn't seem to require an enormous amount of close contact. Well, again, this all goes back to the super spreader model. You can't characterize all individuals Infected as the same. Why someone becomes a super shedder is unclear, but they do. And they're very, very different than all the majority of people who never transmit in super spreader fashion. For example, in the past year, there have been over a hundred cases of hantavirus caused by the Andes strain in Argentina, and which at this time, the health departments have not documented one instance of person to person transmission beyond the initial transmission
from the infected rodent to the person. So at this point, again, we can't say what does transmission mean when you have a super spreader situation? And finally, his fifth point is to emphasize that on each of the first four points, public messaging has been at least confused, often misleading, and in many ways counterproductive in this initial window.
 

[00:27:09] Dr. Michael Osterholm
I would agree with that completely. But the challenge is, I think the media again played a key role in that, enforcing
the kind of discussions. You know, when you have major media sources breaking in live TV to tell you that the virus is
now in three additional countries only because of the fact they airlifted sick people off the ship to those countries for
hospitalization. If you didn't know better, you would think from that headline that in fact, it had now spread in person
to person manner. And so we all have a lot of lessons to learn here and to go back and check on this. I stick with my
prediction in the next 2 to 3 weeks. This hantavirus epidemic will be over, and we'll hopefully be able to go back and
learn from the mistakes made. And I just can tell you, one of the ones that I hope we really address is that revolving
around the role the media played in creating the confusion that surely public health and government contributed to.
Absolutely did. But until we deal with the media, I'm afraid we're not going to be able to get the public health
messaging down any better. So in closing, let me just say, David, thank you for your very thoughtful comments. I
hope my comments, in turn, help further develop what you were trying to get at, and I look forward to having these
discussions with you over the days ahead.
 

[00:28:29] Chris Dall
Mike, this discussion about outbreak response is timely because just as it appeared the hantavirus situation was being contained, we received word late last week of a new Ebola outbreak in the Democratic Republic of the Congo. Now, the DRC is no stranger to Ebola. There have now been 17 outbreaks in the country since 1976, but this one appears to be a little different. So, Mike, what do we know so far and what concerns you?
 

[00:28:56] Dr. Michael Osterholm
Well, Chris, I have to say that this is one of those deja vu moments for me. It was actually back in August of 2014. I wrote an op ed in the Washington Post entitled What We Need to Fight Ebola. And this was very early in the days of the Ebola outbreak that finally hit three countries very hard over the course of the next two years. And at the time I wrote this, it was a world wake up. You know, things have changed in Africa, making it much more conducive for this Ebola outbreak to occur. And we're not going to just see these 20 and 30 person outbreaks anymore. They were going to be much larger and every reason to be. And I wrote in the op ed, I said, what's different about this outbreak? The Ebola virus hasn't changed. Africa has changed. First, residents of the affected countries Guinea, Liberia and Sierra Leone, travel much further and have many more contacts than they did in previous decades. Following up on all the contacts we'll have a few miles from a case is much easier than tracking down people who may live far away. With modern transportation, family members may travel hundreds of miles to be with sick loved ones and more of
this outbreak in West Africa's urbanized than when many of the previous outbreaks occurred in Central Africa. So the virus spreads faster. I could go through and read that whole entire editorial, and you could think I had just written it for this one. We've not gone a long ways in getting better at controlling Ebola, with one exception. And that, of course, is the vaccines we have for Zaire Ebola, the strain of the outbreak in 2014 and 15, but unfortunately not the strain now for which we therefore have no longer have a vaccine.
 

[00:30:36] Dr. Michael Osterholm
I want to also say at the outset that things are changing so rapidly with this Ebola outbreak that this information will largely be outdated within a day or two of this episode being released. I would highly encourage our listeners to keep up with the latest Ebola news on our website, as we will have additional Ebola news stories covering what's happening there between now and the release of our next episode in two weeks. To give you some context on this, when our team met just a week ago to discuss what we might cover in today's episode. This outbreak wasn't even on anybody's radar. The next day, news of the outbreak broke, and since then, things have been changing by the hour as of May 19th. There are now 516 suspected cases and 13 confirmed cases associated with the outbreak in the DRC.
Tragically, there have also been 131 confirmed deaths. The US CDC is reporting that an American healthcare worker caring for patients in the area tested positive Sunday and is clinically ill. This individual and their family, who are all considered close contacts, were evacuated to Germany for treatment and monitoring. Health officials in Uganda have confirmed that the outbreak is caused by the Bundibugyo strain of the virus. The good news about this is that it's less fatal than Zaire strain, the one causing the 2014 2016 outbreak. Bundibugyo Ebola virus has a fatality rate of about 25 to 40% compared to Zaire Ebola, which is 60 to 90%.
 

[00:32:04] Dr. Michael Osterholm
The bad news is that about 20 to 40% is still incredibly high fatality rate, and that two licensed vaccines for Ebola virus. Both target the Zaire strain, but not the Bundibugyo strain. So the bottom line is that although the strain is somewhat milder, we have fewer tools to protect against it. Now, let me remind everyone that while the Zaire vaccine is now available, it was not available through the vast majority of the 2014 2016 outbreak. It only came into use at the very end of the outbreak after much of the work of contact tracing, isolation, improving health care related transmission issues, meaning better protective equipment for health care workers all took place. Right now, we're going to have to count on that same thing. And it's unclear given the current situation at WHO countries like the United States and their contributions. What this is going to mean the outbreak is occurring. And the DRC is a province in the northeastern part of the country bordering both South Sudan and Uganda. Health officials are greatly concerned about disease transmission in this region for several reasons. First, Bunia, the capital of the Ituri province, and Kampala, a nearby district of Uganda, have dense urban populations where disease can spread very efficiently. Second, there is a significant amount of population movement occurring in the area where the outbreak is occurring. There is a significant mining activity in the province as well as refugee movement in the area. Third, the DRC has faced significant political instability and unrest in recent years, including dangerous labor conditions and child mines where cases have been reported.
 

[00:33:49] Dr. Michael Osterholm
These challenges can complicate international aid during an outbreak like this and may hinder disease control efforts. And fourth. During the previous Ebola outbreaks, a significant amount of support was provided by USAID. Sadly, as listeners of this podcast know, USAID no longer exists, having been cut by this administration. Fighting an Ebola outbreak in an urban area with lots of population morbidity is challenging enough, but it will be even more challenging without these resources available. Finally, I want to acknowledge something that will echo my stances on previous Ebola outbreaks. This is not a virus with wings. While it may have a devastating impact in the affected regions, it is not going to cause the next pandemic. Ebola spread through close contact with blood and other body fluids, not through the air we breathe. Our group has considered that possibility, and while we can't say someday it couldn't happen right now, there is zero evidence that this is any other transmission than body fluid contact transmission. The people most likely to get Ebola are those directly caring for an infected person, typically family members or healthcare workers. We all should be concerned about what's happening right now with Ebola, but the concern should be for the people living in the DRC and surrounding countries, not for the possibility that this will cause widespread disease and death in the United States. It won't. So let me just be really clear. This is a very significant challenge for Western and Central Africa. This is not a significant challenge for all the countries outside of that region.
 

[00:35:22] Chris Dall
We're going to turn now to the latest vaccine review from CIDRAP Vaccine Integrity Project. This review looked at evidence on tetanus, diphtheria, acellular pertussis or Tdap vaccination during pregnancy. Mike, what did they find?
 

[00:35:38] Dr. Michael Osterholm
Thanks, Chris. This was another amazing and important piece of work from the Vaccine Integrity Project at CIDRAP. Listeners will remember that last episode. We announced the HPV report and now we're rolling out Tdap. The project takes great care in selecting these topics, and this one was no exception. Last year, discussions and appointments from the spurious ACip group led us to believe that they were going to potentially focus on vaccines recommended during pregnancy, there are only four immunizations that are routinely recommended in pregnancy. In the US, COVID 19, influenza, RSV, and Tdap. Tdap, as you mentioned, includes coverage for tetanus, diphtheria and pertussis in pregnancy. In the United States, the most important piece is pertussis, which has been on the rise in recent years. Newborns are especially vulnerable as they cannot receive their first vaccination until they're two months old, and four additional doses up through kindergarten. Pertussis infection before six months of age also tends to be more severe than other pediatric age groups, with 41% requiring hospitalization. Therefore, Tdap administered during
pregnancy is a powerful tool that provides passive immune coverage in infants and bridges the gaps between birth and the first vaccine dose. I'll add a quick note that although it wasn't the focus of this review, maternal and neonatal tetanus is also a significant issue in low and middle income countries around the world, while maternal and neonatal tetanus was eliminated in the US in 2017, its presence globally provides us an even broader perspective on the full importance of Tdap vaccines in pregnancy for both maternal and infant protection. As with all other systematic reviews, this one focused on the safety, effectiveness, and immunogenicity to build a well-rounded picture of the impact of a vaccine on a given population.
 

[00:37:30] Dr. Michael Osterholm
We found that administration of Tdap during pregnancy did not increase the risk of adverse events such as stillbirth, preterm birth, hypertensive disorders of pregnancy, gestational diabetes, congenital anomalies, and other serious complications in either pregnant women or their infants. Despite limitations that are commonly known in vaccine studies, the body of evidence for vaccine safety is very strong and reassuring. Our review also reinforced that maternal vaccination provides protection for infants before the age they can be vaccinated with probable reduction in pertussis infection, severe disease and death. Immunogenicity findings support the mechanism that leads to this observed clinical protection. We developed this report so that national medical societies could use the updated evidence base as a tool to look at their own recommendations and determine if any changes need to be made. Based on the results of this review and conversations with these shareholders. I don't anticipate any changes to the recommendations for Tdap vaccination during pregnancy any time soon, but one thing we can always count on from this current HHS is a curve ball. So if there happens to be one around Tdap or similar focus on safety and effectiveness of vaccination and pregnancy. We will be ready. And I just want to close this topic out by saying how much we appreciate the VIP team at CIDRAP and what they're doing here, and specifically the leadership provided by Sherri Berger and the group that she works with. They have done a remarkable job, and we're very fortunate to be able to be part of this entire effort.
 

[00:39:11] Chris Dall
Mike, early last week, Food and Drug Administration Commissioner Doctor Marty Makary resigned amid widespread rumors that he was going to be removed by President Trump. Later in the week, his colleague Tracy Beth Hoeg, who was the head of the FDA's center for Drug Evaluation and Research, was fired. Now, there are numerous reasons why Doctor Makary is no longer in charge at FDA, but we're not going to get into those. What I want to ask you is whether this episode reinforces the notion that critical agencies like FDA need to be led by people, whatever side of the political aisle they're on, who have some experience working in a large bureaucracy.
 

[00:39:51] Dr. Michael Osterholm
Well, Chris, I think there are really two separate issues here. The first is the experience and expertise of the people leading these agencies. The second is the instability caused by frequent and unexpected turnover of leadership and staff. Starting with the experience issue, it's important to remember that agencies like the FDA and the CDC have historically been staffed by people who have spent years, often decades, dedicating their lives and careers to this work. Even here in the University of Minnesota campus, I see students studying biology, epidemiology, and community health every day because they want to develop treatments for rare diseases, reduce maternal mortality, or respond to outbreaks. They go on to build careers in public service and develop deep expertise over time. Now imagine being one of those career professionals and suddenly reporting to a political appointee who may have little to absolutely no experience running a large agency, let alone in your field of work. Perhaps they were even a vocal public opponent to your agency and its goals. Now this person decides your priority, your budget, even what and how you're allowed to communicate. It's got to be truly infuriating and demoralizing for many. We have to understand at this point, leadership is more than just a word. Then there are the second issues a revolving door of leadership. As a reminder, the last CDC director only lasted four weeks. These frequent leadership changes often come with reorganizations, staffing and resource disruptions, and overall uncertainty about priorities and long term goals.
 

[00:41:19] Dr. Michael Osterholm
This instability creates a perfect storm for really talented, dedicated individuals to burn out, or especially even leave public service altogether. Remember that in fact, we've not had a surgeon general. We've not had a functioning ACIP. I could go through the laundry list of all the different leadership positions that have been absent. This creates chaos. We've seen with the recent hantavirus outbreak, lots of misstatements by leaders who, frankly, are way out of their league and have no idea what they're doing to respond to some of these issues. So let me just say that I recognize there is much to criticize about how different agencies have handled public health issues, both past and present. There are certainly opportunities for improvement, but the success of these institutions require expertise in continually, especially for issues such as outbreak, drug safety, predictability and stability. They really matter. So I hope people see Doctor Macari's departure as more than just another personnel change. It's part of a larger issue about the long term strength and reliability of the public health institutions rely on. We have to understand this experience we've just gone through and continue to be confronted with, teaches us that everyone, in particular those who accuse the public health leaders during the COVID pandemic, that it's a lot easier to criticize the system from the outside than to change it from the inside. And at this point, this group has failed completely to change things on the
inside in a more positive public health manner.
 

[00:42:52] Chris Dall
Let's turn now to U.S. respiratory activity. Last episode you said we're done with cold and flu season. I'm assuming your personal experience aside that that outlook hasn't changed. But for those who are starting to think about the next cold and flu season, do we have any information on updated vaccines for flu and COVID 19?
 

[00:43:13] Dr. Michael Osterholm
Your assumption is correct, Chris. Respiratory activity is very low across the board, and we're seeing all metrics and wastewater concentrations for COVID, flu and RSV decreasing or remaining low and unchanged. I don't know what I have, however, it's not one of those. We'll continue to keep you updated with any relevant information going forward into this off season. But at the moment, there are no notable changes or new variants that are ringing alarm bells. This is great news. Now, to answer your question about vaccines for the next respiratory season, I have some good news and some uncertain news, starting with the good news. Back in March, the FDA made their strain recommendations for the 2627 flu vaccine, and their recommendation is consistent with the WHO recommendation as well. The updated vaccine will target H3n2 subclade K that was circulating this past flu season, as well as updates to the H1n1 strain and the influenza B strain. We anticipate these updated flu vaccines to be available as expected, consistent with previous season. WHO also announced its recommendations for the 2026 2027 COVID 19 vaccine formulation. On May 16th, the Technical Advisory Group meets twice a year to review global SARS-CoV-2 surveillance data and determine which viral strains should be targeted in upcoming vaccines for the 2026 2027. The group again recommended a monovalent LP .8.1 formulation. The same target as last year.
 

[00:44:45] Dr. Michael Osterholm
WHO also acknowledged that manufacturers may include other circulating variants such as XFG, which is the currently dominant strain being reported in the US. Like LP 8.1, XfFG is part of the broader JN.1 lineage, which has been the main focus of genomic surveillance over the past few years. Now, turning to a more uncertain side of the COVID 19 backstory, an FDA VRBPAC meeting scheduled for May 28th. Currently, the only agenda item listed for the meeting is to discuss and make recommendations on the selection of the 2026 2027 formula for a COVID 19 vaccines for use in the United States. Given the results of the March Influenza Strain selection meeting, I am cautiously optimistic that we will have a recommendation in line with WHO following this meeting. If all goes as planned, there should be the most up to date COVID 19 vaccines available by fall. What remains less clear is who will ultimately be eligible to receive these vaccines. That decision isn't made by FDA and VRBPAC. Made largely by ACIP, which of course, we don't have right now. Still, getting a formulation recommendation in place will allow vaccines to be manufactured, which would be a step in the right direction. Ultimately, it will all know a lot more after this meeting, and we'll be sure to keep you in the know in the upcoming episodes.
 

[00:46:10] Chris Dall
Finally, I'd like to discuss a recent study covered by CIDRAP news colleague Liz Szabo on aluminum and vaccines. I'll provide a quick summary of the findings, but then I'd like to get your thoughts on the significance of this study, Mike. So just to remind our listeners, aluminum salts are the most widely used vaccine adjuvants worldwide. Aluminum salts are used in the Dtap vaccine that we just discussed, along with vaccines for pneumococcus, meningococcus, human papillomavirus and hepatitis A and B, they play a critical role in enhancing the immune response to vaccination, and that, in turn, has allowed for a lower antigen dose in childhood vaccines and a reduced number of vaccine doses. They've also become a target for anti-vaccine groups, who have claimed that use of aluminum salts in vaccines is linked to autism, asthma, allergies and autoimmune disorders. The study, published on May 7th in the British Medical Journal, or the BMJ, is an important addition to the literature on the potential health effects of aluminum adjuvanted vaccines, because it's not one single study. Rather, it's a review and meta analysis of 59 studies conducted between 1971 and 2025 on the subject. The review included 37 case series, 11 randomized controlled trials, nine cohort studies, and two ecological studies. So this was really looking at the totality of evidence, assessing the quality of that evidence, and then synthesizing the results. And what the reviewers found when they analyzed all the data from these studies, is that there was no association between aluminum adjuvants and vaccines and systemic conditions, including autism spectrum disorder. Type one diabetes. Asthma. Headache and other chronic conditions. No. Association. The researchers found only one benign medical condition potentially related to certain aluminum containing vaccines, and that was small skin nodules that go away on their own. Fewer than 1% of people, given the Tdap vaccine developed these nodules. The evidence shows that vaccines containing aluminum are safe. Joseline Zafack, senior author of the study and an epidemiologist at the Public Health Agency of Canada, told my CIDRAP news colleague Liz Szabo. So, Mike, your thoughts on this study?
 

[00:48:26] Dr. Michael Osterholm
Chris, this is a very powerful science. 59 studies included in this review. And all information supports the safety of aluminum in vaccines. And we know, of course, the aluminum plays an important role in making that vaccine more effective. So I hope that this would put to rest any question about aluminum and its safety and the vaccines. Unfortunately, I know it won't. People will still continue to pursue it. But for the average mom and dad who has their young child, they're taken in for vaccines, whether it be in a physician's office or with public health agency. I hope that, in fact, they will know this information and be able to share it in such a way as it will provide comfort to the parent about the safety of what they're doing and, more importantly, the benefits that that child will now receive.
 

[00:49:15] Chris Dall
Now it's time for this week in public health history. Mike, what are we celebrating this week?
 

[00:49:21] Dr. Michael Osterholm
Oh, this is a special one for me in that I have had such a long term involvement with this group. This week, I want to highlight a program that I don't think many people necessarily heard of. Did you know that the CDC actually has a disease detective program? It's called the Epidemic Intelligence Service or EIS. It's been around for 75 years. I had the good fortune in the 25 years I was at the state health department to supervise 16 different EIS officers during that time period as they sought training here at Minnesota. The EIS was founded back in 1951 by Doctor Alexander D. Langmuir, who was the CDC's chief epidemiologist at the time. Langmuir started the program because of concerns with biological warfare during the Korean War. EIS officers soon became known as the disease detectives. These epidemiologists investigate the origins of diseases, how they spread and who they affect in ways to prevent future outbreaks. To become a disease detective, the EIS requires a two year training program in epidemiology. Officers in training work alongside relevant experts at the CDC, as well as at state and local health departments to lead
investigations of diseases and outbreaks.
 

[00:50:31] Dr. Michael Osterholm
In fact, the EIS logo is actually a worn shoe leather, which represents its boots on the ground. Training and philosophy the EIS officers have been involved with major health investigations, including helping to eradicate smallpox, responding to Ebola outbreaks and understanding how COVID 19 was spread. They've also investigated
other public health concerns, like childhood lead poisoning, the dangers of e-cigarettes and vapes, as well as gun violence. The EIS doesn't just respond to huge historical outbreaks, they often investigate diseases that affect our communities and everyday lives. For example, back in 2019, EIS officers discovered that a mumps outbreak across numerous states could be traced back to a single local wedding in Nebraska. Now there's a wedding you'd never forget. After identifying the source, the EIS officers, together with state and local health officials, worked to contain the outbreak with focused vaccination on this particular group of individuals. All in all, what a fascinating program. Thank you to all the disease detectives past, present and future for your critical investigations. Public health would not be what it is without your hard work. Cheers to 75 years and hopefully many, many more years to come.
 

[00:51:45] Chris Dall
So Mike, what are your take home messages for today?
 

[00:51:50] Dr. Michael Osterholm
Well, Chris, first let me say public health messaging, when done by a disorganized orchestra can sound pretty poorly. And I think that's what we're seeing right now when it comes to issues around the risk of transmission of hantavirus. I'm sure we're going to see much of the same situation with Ebola virus, and we need to make it a national priority to work together to come up with the best information we can and how we can communicate with the public. Today, when I say somethin  safe and somebody else says something is safe. Is there any relationship between those two terms? Do we actually have any consistency of message? What does that mean? And I think we really have a lot of work to do here to really better understand public health messaging. The second thing is be aware Ebola is going to get us. And what I mean by that is it's going to be a real challenge, I think, in the parts of Africa that we're currently seeing it happen, it's going to get to be a much larger outbreak than it is now. I'm very happy to report. However, the rest of the world will be largely unaffected from it, and we have to be careful not to overreact in these other countries
to what's happening with Ebola in the African arena. And then finally, the respiratory season is over, except for some of us who are picking up non-flu non-COVID-related illnesses. And all I can say is, I'm glad to see that none of these, at least my illness wasn't serious. It was just merely aggravating.
 

[00:53:17] Chris Dall
And so, Mike, for our closing, since it is graduation season and the time for graduation speeches, I think it's fitting that you you've picked an excerpt from a graduation speech. What can you tell us about it?
 

[00:53:30] Dr. Michael Osterholm
Well, this is a very special one for me. I'm going to actually use the words of the late Paul Farmer. Some of you will recognize his name right away. Paul was an American medical anthropologist and physician. He held an MD and PhD from Harvard, where he was a university professor and chair of the Department of Global Health and Social Medicine at Harvard. He was a co-founder and chief strategist of Partners in Health, an international nonprofit organization that since 1987 has provided direct health care services and undertaken research and advocacy activities on behalf of those who are sick and living in poverty to improve equitable access to health care. Paul is someone who is well known in our in the public health world, and as well in many others. He was known as the man who would cure the world, as described in the book Mountains Beyond Mountains by Tracy Kidder. Paul and Partners in Health received the peace Abbey Foundation Courage of Conscience Award in 2007 for saving lives by promoting free health care to people in the world's poorest communities and working to improve health care systems globally. I could go on and on and talk about Paul. Unfortunately, on February 21st, 2022, he died while working in the field, as he did so often. Paul was a philosopher and a friend. I can tell you that having participated in several events where he and I shared the same stage and podium, it was always an inspiration to be with him, and he never was afraid to take on tough issues, but he always took them on with purpose, dedication, and humility.
 

[00:55:03] Dr. Michael Osterholm
And one of the ones I thought that was most interesting was this graduation speech he gave at the University of Delaware in 2013, where he talked about a disease he called empathy deficit disorder or EDD, I think it holds up pretty well to understand. EDD is defined as a colloquial, non-clinical term used to describe a person's inability to understand and relate to or share the emotions and perspectives of others. So this is what Paul told the students at the University of Delaware in 2013. You can be the cure for EDD and its chronic and acute forms. You can be the folks who address local outbreaks, EDD, and also the global pandemic, which has affected people in every single nation on this fragile and crowded planet. Indeed, ours is a world that requires nothing less than linking empathy and compassion to reason, plans that harness it to meaningful action. I don't think anyone sitting out there or up here believes for a minute that humanity doesn't have a future. The UD students I met with last night and this morning remind me of the talent and smart and goodwill of the next generation. But even our short term survival calls for deliberation and calculation and expertise. These will not be marshaled in adequate quantities, nor for public good, unless we address the global pandemic of empathy deficit disorder.
 

[00:56:25] Dr. Michael Osterholm
Paul Farmer. What an inspiration. Well, thank you again for spending time with us on this podcast. We covered a lot of information. I hope it made sense. I'm certain we'll be back to you on hantavirus. Hopefully wrapping it up in the next podcast will also surely keep you posted on Ebola and what's going to be happening with it. In the meantime, all I can say is that we all right now are thinking about summer. We can't wait for those summer months. We'll give you an update in a future episode on what's happening in the tech world. And should we be concerned about mosquitoes this year? This is going to be an interesting year. I predict we're going to see a major uptick in hantavirus activity in the Four Corners area, as the El Nino likely predicts increased rainfall in that area, which will be a proliferation of the mice that will then carry that virus. So we'll keep you posted on all these things. In the meantime. Thank you so much for being with us. It means a great deal to all of us. We appreciate you. We surely welcome your feedback, your thoughts, and just the fact that your energy is out there and we feel it. So thank you. Enjoy the early days of summer and just now, more important than anything. Be kind. Just be kind. And I can't say that enough times. Thank you.
Thank you. Be kind.

[00:57:51] 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.um.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, Claire Stoddart, Angela Ulrich and Mary VanBeusekom.