Episode 210: Ebola: What the Past Tells Us about the Present

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, Doctor 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. During the large Ebola outbreak in West Africa in 2014, the US government helped build, coordinate and lead the worldwide response, deploying thousands of experts to help stop transmission of the deadly virus and keep it from spreading further. Here's what President Barack Obama said in October 2014: "We can beat this disease, but we have to stay vigilant. We have to work together at every level federal, state and local. And we have to keep leading the global response because the best way to stop this disease, the best way to keep Americans safe is to stop it at its source in West Africa."

Chris Dall: Jump forward 12 years to the current Ebola outbreak centered in the Democratic Republic of the Congo, and you'll see a more muted U.S. response. The Trump administration does have people on the ground in the affected countries and is helping fund international outbreak response efforts, but it does not appear to be playing a leading role in those efforts. The U.S. government at the moment appears to be less focused on stopping the outbreak at the source and more focused on keeping anyone from the infected areas out of the country and treating Ebola exposed Americans in other countries. The U.S. response to the Ebola outbreak will be among the topics we explore on this June 4th episode of the Osterholm Update episode number 210. We'll also discuss lingering questions about how Ebola is transmitted, bring you the latest on the hantavirus outbreak, review a long awaited report from the FDA on pediatric deaths linked to COVID vaccines, provide updates on measles and other respiratory viruses, and answer an ID query on travel to Africa. 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's opening comments and dedication.

Dr. Michael Osterholm: Thanks, Chris, and welcome back to the podcast family. It's always good to be with you, even though we may be many miles apart. We sure feel your presence here at our recording studio. I also want to welcome anyone who might be joining us for the first time, or for that matter, maybe a few times. And I hope we're able to provide you with the kind of information that you're looking for. And as we say with every podcast, we hope that you'll give us feedback about how we might improve this experience for you. It's all about really you, the podcast family, and how we can be helpful. Before I start out, I want to make it clear we have a lot of ground to cover today. So I'm going to try to do my best to not leave out any important information, but at the same time, not speed through it in such a way that it doesn't make a lot of sense. So just buckle up your seat belt and hold on. This week, I want to dedicate the episode to each and every caretaker and healthcare worker on the Ebola front lines. The situation unfolding in the Democratic Republic of Congo and now Uganda is nothing short of devastating. Healthcare workers, nurses, doctors are dying on the front lines while taking care of patients.

Dr. Michael Osterholm: Dr. Richard Lokudu, a hospital director in Bunia, told the Guardian: "We who are fighting Ebola are like soldiers. We are fighting for the same cause to save human lives from the Ebola epidemic." Lokudu explained how several of his staff have caught the virus, and a few of them have even died in just the last month. The New York Times reported that some hospitals are severely lacking in protective gear, including goggles, suits, masks, as well as medical supplies like tests or even clean drinking water. Meanwhile, only a few staff members have proper training on how to fight the disease, let alone proper equipment. We'll have links to both articles in our show notes for your further reading. These frontline healthcare workers, as well as family members of infected patients, are often at the most risk of infection because of the close proximity and possible contact with body fluids during caretaking. Yet they continue to put themselves on the front lines, much like the soldiers. We just heard about fighting this disease and fighting for their patients and loved ones. And just know that as stressful as the actual work itself is, it is incredibly tough with your full protective equipment on in these very warm temperatures. And how many cases of health care providers can do no more than 30 minutes of work before they have to take a mandatory rest because of just how tight this is.

Dr. Michael Osterholm: Some of the frontline workers are also being met with rising anger and distrust from some groups of locals who don't believe the disease is real, or may even be a money making plot between the government and foreign aid workers. Dr. Lokudu described these conspiracy theories as a terrible crisis. He told The Times: "We're here to save them. They think we want to kill them." There has been even attacks on Ebola treatment centers in the DRC, including the burning of isolation tents run by Doctors Without Borders, as well as Ebola patients fleeing treatment centers. Treating Ebola is already an incredibly challenging job, and these circumstances are only making matters worse. So we are thinking of each and every one of you on the frontlines of the Ebola outbreak. The grief and devastation of this situation is unimaginable, but your bravery and sacrifice is a shining beacon of light in the darkness. We stand beside you in this sorrow while also commending your incredible service. Thank you from the bottom of our hearts. Well, now let's move to what I always consider to be one of the most wonderful aspects of this podcast.

Dr. Michael Osterholm: For some of you, you may want to take a break right now, but I don't mean it's wonderful just because we're going to talk about sunlight today, but we're there. We are watching the longest days of the year here in Minneapolis, Saint Paul today, on Thursday, June 4th, sun will rise, will be at 5:28 a.m., sunset at 8:55 p.m. that is a full 15 hours, 26 minutes and 49 seconds of sunlight. We're close to the maximum amount of sunlight of 15 hours and 36 minutes. Just ten more minutes of sunlight will be showing up in the next couple of days. So all I can say is enjoy this. This is a wonderful, wonderful feeling for many of us. Now for our dear friends and colleagues in Auckland, New Zealand, particularly at the Occidental Belgian Beer House on Vulcan Lane, a little different for you. Your sunrise today is at 7:26 a.m.. Your sunset, 5:11 p.m. you have nine hours, 45 minutes and 25 seconds of sunlight, losing about 52 seconds of sunlight a day. Well, you're almost bottomed out. It won't be much longer, and you will be seen the turnaround in which your sunlight will get longer and longer each day. In the meantime, in the best of spirits, we share with you our sunlight.

Chris Dall: Mike, we're going to start today with the Ebola outbreak in the Democratic Republic of Congo, which now stands at more than 300 confirmed cases in more than 40 deaths. So first off, what is your assessment of where this outbreak stands at the moment?

Dr. Michael Osterholm: Chris, I remain extremely concerned about this outbreak as it has every potential to be as big as the one we saw in 2014 and 2016. The number of cases you just listed is clearly a major underestimate of what's happening. As we are realizing now, how many people have not been tested for the Bundibugyo virus, which is actually one that is not picked up routinely on the screening tests that we would use for the other Ebola strains of virus. So to say that there are hundreds of cases could very well mean that there are thousands of cases, and this is going to be something that only with additional work are we going to really know the true extent. But the bottom line message is, is that this really is a very serious situation. I want to put the current situation into context by taking a look back at the 2014 to 2016 Ebola outbreak in West Africa, the world's largest Ebola outbreak to date. Prior to that outbreak, the greatest number of cases observed in any Ebola outbreak was 425 back in 2000 to 2001 in Sudan. Most of the outbreaks had fewer than 100 cases. It was something that was largely only observed in more isolated rural communities. The virus would burn through those communities, leaving behind a great deal of death and tragedy. And the outbreak then would fizzle out. There was always a present fear of what would happen if we saw Ebola spread to a more densely populated area, which is exactly what happened in the 2014 outbreak, which resulted in over 28,000 cases and over 11,000 deaths. It was like nothing had ever seen before.

Dr. Michael Osterholm: And this is a tragic chapter of our global health history record. The only silver lining in that terrible outbreak is that we learned a great deal about this disease, gaining a much stronger understanding of how to contain it in the event of future outbreaks. African countries are more prepared than they were in 2014, largely due to improved laboratory systems, surveillance capabilities and outbreak response training, much of which was supported by the US during the Obama, Biden and even first Trump administration. We saw these systems work effectively in the Ebola outbreaks that have occurred since 2016. The largest of these outbreaks occurred in 2018 to 2020 in the DRC, in which 3470 people were infected and 2280 people died. Most of the other outbreaks were much smaller. In large part due to these improved public health systems and because of two other critical developments effective vaccines and treatments. As a result of the work done during and after the 2014 outbreak, we now have Ariba and Zabdeno two safe and effective Ebola vaccines that target the Zaire strain, which was responsible for the 2014 outbreak and most of the outbreaks that have occurred since then, and two monoclonal antibody treatments to improve outcomes for those who are infected. Vaccination was highly successful in containing outbreaks of Zaire Ebola that occurred after 2016, largely through a strategy called ring vaccination, in which contacts, as well as contacts of contacts and high risk frontline workers were vaccinated for the disease in order to reach the most vulnerable individuals during times of limited supply and or capacity to administer vaccines.

Dr. Michael Osterholm: Though it is impossible to say exactly how large these outbreaks would have grown in the absence of these vaccines, we can say for certain that they have been life saving and greatly increased our ability to contain Ebola when cases inevitably emerge. It is also worth noting that we have had two outbreaks since 2016, which were not caused by the Zaire strain. In 2022 and 2025, we saw small Ebola outbreaks in Uganda caused by the Sudan Ebola virus, a strain for which we still do not have a vaccine or a treatment. These outbreaks were still contained effectively. The 2022 outbreak resulted in 164 cases and 77 deaths, and the 2025 outbreak resulted in 14 cases and four deaths. And all of the containment efforts relied on other critical public health system improvements. The ones I mentioned earlier, including improved laboratory capacity and surveillance networks, appropriate PPE for health care providers, and isolation of infected patients. This should be good news. We've learned a lot about Ebola, and even without a vaccine or treatment, we should be more prepared today than we were in 2014, even for a strain that does not yet have vaccines or treatments. But based on what we've observed in the past, several outbreaks. Sadly, I worry this is not the case anymore, largely because of the dismantling of USAID and PEPFAR, which were critical in the public health infrastructure of many African countries. For example, as of today, less than 20% of the known contacts of cases have been contact followed up, meaning that in fact, we want to identify these people to make sure that they are quickly isolated if they become clinically ill.

Dr. Michael Osterholm: The lack of ability to contact these people who are known contacts in of itself is a very significant issue. I also want to take this opportunity to acknowledge that the USAID and PEPFAR efforts were critical in the 2014 response, and now international partners will have to navigate this outbreak without the resources these groups provided. Additionally, the Office of Pandemic Preparedness and Response Policy in our White House has been gutted, and many key global health positions of federal agencies remain vacant. The outbreak is growing faster than the 2014 outbreak was at this point, and despite all that we have learned, we may be in a weaker position to combat it. As I stated in a recent op-ed in the Washington Post, which we will link to the show notes, quote, "Outbreaks do not wait for governments to organize themselves. Pathogens exploit delays, complacency and political fatigue," unquote. Not all the damage that has been done by cutting critical international aid programs can be reversed, but it's not too late for the U.S. to do something and something important. Even the current administration's own strategy states, quote, when necessary, the United States will also surge diagnostics, vaccines, therapeutics, personal protective equipment and other commodities to aid in the response of an outbreak like this. I hope that we, as well as our international partners, can step up to help. Or we could be facing cases and death counts like those we saw in 2014. Or even worse, we know that we can effectively support an Ebola response. The question, sadly, is whether we will.

Chris Dall: So, Mike, what's your opinion of the US response so far? And to be clear, I believe the US is the leading government funder of the response efforts, and there are US personnel on the ground in the affected areas. But it is different from the 2014 response. And among the more controversial moves has been the plan to establish a quarantine unit in Kenya for Americans who have been exposed during the outbreak. Does this make sense to you?

Dr. Michael Osterholm: Chris, this is one of the worst moves I've seen in responding to a public health crisis in my 50 year career. On one hand, I'm not surprised, given this administration, that this is what is happening. At the same time, it's really going to be a challenge. Just to be clear, this administration has decided to require US citizens who are exposed to the Ebola virus or who have actually become cases of which, of course, most of these would likely be health care workers must quarantine and receive medical care in Kenya. This is all about projecting control of the virus, which is not scientifically supported, and puts these workers at risk of not receiving the life saving treatment that is available here in the U.S. We must remember from our track record, particularly in 2014 through 2016, we had healthcare workers from Africa who became infected, who were brought to the United States for care. That was done safely. It was done in such a way that we could actually also provide the state of art care for them. And now to deny that to me is just absolutely stunning. We also have to remember that with Ebola virus infection, you do not likely become infectious for some days after the onset of your symptoms. The example I can give you is what happened in 2014, when a private citizen came from Africa who had been exposed to the virus. He actually lived in a small apartment building with a family over the course of several days, and only after he became clinically ill did they take him into the hospital. Well guess what? He didn't transmit to anybody in that household and only transmitted to health care workers when he was on his last dying days, when they had inadequate use of their personal protective equipment.

Dr. Michael Osterholm: The Ebola virus is one that will not be transmitted before someone has had a relatively long history of clinical illness. We can identify these people and bring them to quarantine locations and into hospital settings where they can be cared for. There is no need to keep them offshore. We have the resources in the U.S. right now, which is absolutely not possible to obtain in Kenya. We have invested significant amounts in the U.S. to provide state of the art medical care facilities for patients, just like what we're seeing with Ebola. These facilities were designed exactly for this type of outbreak. And in fact, as you know, these are the same facilities that have been brought to bear dealing with hantavirus. You cannot replicate what we have already established here in Kenya in any short period of time. So no administrative official can convince me that it's because of flight time issues, etc. we can take care of patients on these planes with the flight times from Africa to the United States. And I just keep thinking over and over again as a public health professional, how do we treat our soldiers? We never leave a soldier on the battlefield. We'll risk sending multiple individuals to that battlefield to retrieve that soldier, even if it puts them in harm's way here. How are we leaving our soldiers on the battlefield? I think this is just absolutely wrong.

Chris Dall: So, Mike, let's talk a little bit more about transmission. We know that Ebola spreads through contact with the bodily fluids of someone who is very sick. And in a recent piece by CIDRAP news reporter Liz Sabo, you said that we have no evidence that Ebola is airborne, but has airborne transmission been completely ruled out?

Dr. Michael Osterholm: Well, Chris, this is a topic that I absolutely hate to talk about, okay? Because it's emotional. I will have colleagues who will be very upset with me for just raising this topic, because they believe that it automatically translates to the public than being in a panic state, thinking that somehow Ebola is going to be an airborne transmitted virus, much as we see with COVID. For that reason alone, I want to be clear to this audience of what we know and do not know. And why are we even talking about this? Most people say, just drop it. I don't think we can. We've had a number of questions come in to us here at CIDRAP in the last week and a half about this very issue. Can this virus be transmitted via the air? Well, let me be very clear. We in fact, have documented multiple experiences in laboratories where the virus has very likely been transmitted between animals that was not related to close contact, but rather it had some aspect of an airborne transmission. Do we have the same evidence for humans? No, we do not. And I want to be very clear. So today I'm not saying that there is airborne transmission occurring among humans. From a human to a human. But we have to be mindful and alert to that possibility. Our group, along with 17 of the leading Ebola experts in the world, in 2015, published a paper entitled Transmission of Ebola Viruses What We Know and What We Do Not Know. We have actually provided you with a copy of this paper in the show notes. The full PDF is there so you can read it yourself. And we actually lay out the case for the fact that there have been clear evidence of transmission of the virus by likely an airborne route for animals.

Dr. Michael Osterholm: Let me just take a step back and remind everyone that the very reason Ebola became such a interesting topic to so many back in 1994 was because of the publication, the nonfiction book The Hot Zone, which documented the 1989 discovery of Reston Ebola virus and the outbreak in monkeys at a non-human primate quarantine facility near Washington, D.C. In that particular outbreak, there was clear evidence that, in fact, transmission did occur via an airborne route. And while it surely could not rule out that there could have been also close contact, the fact that there could have been feces that were thrown across a lab floor, etc. But if you begin to look at the other outbreaks that we've seen involving animals, there is actual reason to believe that we could see a possible situation with Ebola virus being transmitted via the respiratory route. Let me be very clear. We do not have evidence today that this is at all a measurable way of transmitting this virus from human to human. Now, it surely could be in the sense that you can create aerosols from vomit. You can create aerosols from diarrhea, meaning you have to talk about the actual regular respiratory transmission area and that in fact, you could have virus transmitted that way. Now, some of my colleagues who I have great respect for are absolutely adamant this will not happen, and that it's a unnecessary, frightening action to talk about this for the public. On the other hand, I believe one of the things that we will always be faulted for is we don't lay out what the potentials could be for the future, and to actually look at that carefully and say, we are looking for this, we are considering this.

Dr. Michael Osterholm: And so I urge you to take a look at our paper that's in the show notes. You can read it for yourself. You can look at the titles of the people who are involved. Anytime you have a paper where you have 17 of the leading Ebola experts in the world on that paper, I think you got to take this kind of seriously. So I can only say I'm hopeful that we never see clear and compelling respiratory transmission of the virus, particularly that the sustained transmission. But at the same time, we have to be cognizant of that. And our paper really goes into the kind of detail that also tells you why that could be a possibility. And to those who are going to be upset with me and say, oh, you're scaring the hell out of people needlessly, you know, that's what gets us in trouble is when the public feels like we're not looking at these issues, we're not taking them seriously. And I think this is really important, and I don't for a moment minimize the fact that this is already a horrible situation. Hopefully, my description of what I have seen so far in this outbreak should surely make it clear this is a horrible situation. This discussion is not meant to make it worse. It's only meant to be certain that we're constantly on guard for this, and should it ever happen, we will be in a position to be prepared for how to respond.

Chris Dall: That brings us to our ID query. This week we received an email from Annette who asked, would you advise those with plans to visit Rwanda in July to change their plans? How likely is a tourist to be at risk for Ebola? And just a note for our listeners who don't have a map in front of them. Rwanda sits on the eastern border of the Democratic Republic of Congo, just south of Uganda, and the outbreak's epicenter is in the northeast corner of DRC.

Dr. Michael Osterholm: Well, Chris, I'd first like to thank Annette for sending in this question. You are not the only person to send a question in like this. And we recognize that this is the time of year when people are thinking about many of their expeditions to Central Africa, an area of immense beauty, but now also one of struggle. I'll start by just being very honest and saying I don't have a straightforward answer, but I do have some real concerns about travel generally in Central Africa right now. The virus spread undetected for weeks in DRC and the situation is still rapidly evolving. This, in combination with some of the protests and attacks on healthcare facilities, heightens the possibility that there are still a number of undetected cases in the community, and that number could increase substantially in the days ahead. Last week, Who Director General Tedros stated, and I quote, we cannot build community trust or isolate the sick while bombs are falling, unquote. Public health workers can't do their jobs in these settings, and that never results in good outcomes. If we look geographically, where Ebola is known to be spreading in DRC, it does include provinces that share borders with Uganda, Rwanda and Burundi. There is also evidence of ongoing cross-border transmission to Uganda, and I wouldn't be surprised to see that expanded to other neighboring countries as well.

Dr. Michael Osterholm: The U.S. Department of State has Rwanda's border with DRC characterized as level four, the highest advisory level possible. The rest of the country is characterized as level three, with a note stating that the U.S. government has limited ability to provide emergency consular services to U.S. citizens in Rwanda due to the health situation. We must remember that Ebola itself transmits through that close contact we've talked about with infected body fluids of a symptomatic individual. While the individual risk to a general tourist in Rwanda is likely not particularly high, assuming they aren't actively providing health care or caregiving in affected regions. Travel may still result in real complications. Our listeners should also consider that it's not just a matter of getting to Rwanda, it's getting home afterwards. The U.S. has already put enhanced public health measures in place to screen travelers arriving from DRC, Uganda and South Sudan. The list of countries will likely expand over the days ahead, as I do believe the outbreak will continue to expand to. So, Annette, from that perspective, I can only say this is probably not the year you want to pick to go there. I think it's going to be a real challenge. Even if you're not near the epicenter, but you're in other parts of the country.

Chris Dall: So let's turn now to the hantavirus outbreak that occurred on the Dutch cruise ship MV Hondius. Mike, what's the latest?

Dr. Michael Osterholm: Well, Chris, I'm actually happy to report that the short answer is that the outbreak continues to move in a direction that I find reassuring. And by the way, it's playing out exactly as we talked about in the last podcast and our previous comments to the media, in the time since we recorded our last episode, there have been two more cases identified, bringing the total number to 13. Both of the individuals from the latest cases have traveled aboard the cruise ship and, according to WHO, were identified through routine weekly testing of high risk contacts during follow up while quarantining in their respective countries. One was located in the Netherlands and reportedly developed symptoms on May 19th. This case was first announced publicly on May 22nd. The other was in Spain. It did not have noticeable symptoms when they tested positive on May 25th. So we now have seen a total of 13 cases and three deaths in this outbreak. And all of them traveled aboard the ship either as a passenger or crew. Notably, you have not seen any evidence of ongoing transmission beyond this group. And that's a really key point. Even with these latest cases, there aren't any signs that the outbreak has taken off or growing in some unusual way. Rather, it's what we'd expect to see with public health officials actively monitoring and testing those high risk contacts. With that being said, there are some important questions that need to be answered. One is whether these latest detections can ultimately be traced back to the index case, who appears to have been a superspreader.

Dr. Michael Osterholm: Given the long incubation periods we've seen with past outbreaks of the Andes virus, which can be upwards of 40 days, it's not outside the realm of possibility that these latest cases were in fact, actually traceable back to that original case. However, there is also that possibility that these two recent cases were infected by some of the initial secondary cases, meaning people who had been infected by the original case and then transmitted on to what we consider another generation of transmission. I would urge you for more information on this to look at a report published on May 20th and Public Health Alerts, which is the collaboration between Nejm evidence and CIDRAP. We do know that there were a number of individuals that did become symptomatic as a result of exposure to the original index case, and there's surely potentially could be spread of the virus on the ship during that time. This includes a period of time before any containment protocols were implemented on the ship, which was about May 3rd. So there is a possibility that some transmission may have occurred beyond the index case. But having said that, I think in fact, all of the transmission that we saw from a infected individual to others was with that index case. And in fact, this outbreak is now done. As I've said before, not all people infected with the Andes virus pose the same risk of transmission. This index case was the super spreader. Many others are not. They do not transmit to anyone.

Dr. Michael Osterholm: One classic example of this happened during a previous outbreak in 2018, where an individual became infected with the Andes virus while in Argentina, traveled back to the U.S. and after they had started developing symptoms, traveled on two commercial flights. In total, there were over 50 contacts identified, and none of them ended up becoming infected. On the other hand, there are people who for some reason transmit the virus very effectively. My point is, only a limited number of people are super spreaders, and we saw that in this outbreak. But I believe there was a single one and can be accountable for all the cases. Now, what I find encouraging is that each passing day without new cases makes secondary transmission much less likely, or in the event that it did occur, less impactful. Again, remember the median incubation period for Andes is about 18 days, which means that we could expect roughly half of all the cases that are going to occur following an exposure to happen within that time period. Well, we're now beyond that mark for most of the passengers and crew who left the ship. Most left on May 10th or 11th, and we've seen only a handful of additional cases emerge, which surely can be traced back to the index case. Of course, public health officials will continue to monitor contacts through the end of the 42 day observation period starting on May 11th, with June 21st being the endpoint. Right now, I think we're just watching and waiting for this outbreak to officially come to an end.

Chris Dall: We're going to move on now to a few questions about vaccines on the Friday after Thanksgiving last year. Vinaya Prasad, who at the time was the director of the FDA's center for Biologics Evaluation and Research, sent a memo to staff that said at least ten pediatric deaths reported to the federal Vaccine Adverse Event Reporting System from 2021 to 2024 were caused by COVID vaccination. He added that the number, in his opinion, was conservative. But a long awaited report by career FDA scientists released two weeks ago paints a different picture. Mike, what can you tell us about the report?

Dr. Michael Osterholm: Chris, to put it simply, there was a report does not support Prasad's broad claim that COVID vaccination caused ten pediatric deaths. Remember, this was a major claim from the FDA leadership at the time. There were no details provided about these cases, but that surely didn't prevent the claim from garnering widespread attention and repetition across headlines, interviews, and on social media. Now, six months later, we have a report conducted by career scientists at the FDA's Office of Biostatistics and Pharmacovigilance, the group responsible for vaccine safety monitoring. This group reviewed all 96 pediatric deaths reported to the federal Vaccine Adverse Event Reporting System, and their conclusions were considered more cautious using the World Health Organization's standard pharmacovigilance framework. The reviewers classified zero deaths as certainly caused by vaccination. Two deaths as probable cases five as possible, 62 is unlikely and 27 is unassessable because of insufficient information. And importantly, the report states that none of these classifications prove causation. Even the two deaths ruled probable for being caused by vaccination have alternative causes that cannot be ruled out. In other words, the report did not conclude that even two children were definitely killed by COVID vaccines, let alone ten. The report does identify a real safety issue myocarditis associated with mRNA COVID vaccines. But that's not new. We've known about it. The risk has been recognized and included in vaccine labeling since 2021. Also, we must add that the incidence of myocarditis following an mRNA COVID vaccine has dropped dramatically among children who are vaccinated from the early years of the pandemic, when there were actually biologic reasons why we believe that we saw these increased number of serious illnesses.

Dr. Michael Osterholm: What FDA scientists found is that rare fatal cases may occur and should be more clearly reflected in product labeling. They recommended stronger safety warnings, including a boxed warning and updates to prescribing information. But notably, the report did not recommend changing who should receive the vaccines. It specifically stated it was not conducting a benefit risk analysis and was not revisiting the broader question of pediatric vaccination policy. The broader disagreement isn't about whether vaccine associated myocarditis exists. Both Prasad and the FDA scientists acknowledge that it does. The disagreement is about what the evidence allows us to conclude. Prasad took the liberty of translating pharmacovigilance categories like possible and probable into definite claims that the vaccines cause specific deaths. The career scientist who wrote the report repeatedly emphasized that the available evidence does not support that level of certainty. But let's be honest, many people who heard the original claim are unlikely to read or even encounter a lengthy technical, 73 page follow up report. This highlights a common problem in science communication. Sensationalized initial claims tend to spread much more widely than later corrections, clarifications, or contextualization. As a result, many people may still believe that the FDA found proof that ten children were killed by COVID vaccines, even though the agency's own review did not reach that conclusion.

Chris Dall: And speaking of COVID vaccines, the FDA's Vaccines and Related Biological Products Advisory Committee last week voted to recommend a new target strain, the Xfg variant, for next season's COVID vaccines. Your thoughts?

Dr. Michael Osterholm: Well, I'm actually happy with the outcome here. We've got an evidence based recommendation, which is exactly what we should expect from this meeting. If you remember back to last episode, I mentioned that the WHO again recommended the same target as last year, the monovalent LP 8.1. The group also acknowledged that manufacturers may include other circulating variants such as FCG or RnB 1.81, all of which are descendants of the Omicron J n point one variant. The Vrbpac recommendation to target FCG rather than the LP 8.1, is a slight departure from the WHO recommendation, but one that, like WHO's, was based on evidence, which is how public health decisions should be made. Currently in the US, Xfg strains account for more than half of the cases, while LP 8.1 was the predominant strain last summer. It has since been overtaken by Xfg and has not been detected in wastewater variant testing in the U.S. since late last year. Preclinical data presented by Moderna and Sanofi found that the vaccines targeting FCG triggers higher antibody concentrations against strains currently circulating in the US compared to the current LP 8.1 Targeting vaccines. I do want to quickly add that none of this is to say that the WHO recommendation was a poor one. Data presented at the WHO meeting showed that vaccination against LP 8.1 also still does provide protection against J&J point one and its descendant variants, which includes NB 1.81 and FCG. The recommendation is now in the hands of the FDA, who will give the final okay to manufacturers to begin vaccine production to prepare for doses to be ready in the fall.

Chris Dall: One last late breaking vaccine item here. Late last week, the Trump administration issued an executive order directing the CDC and the Advisory Committee on Immunization Practices to review an assessment of the US childhood vaccine schedule that was conducted by the Health and Human Services Department last year, and to align the schedule with the findings of that assessment. Mike, there is a lot to unpack here, but does this executive order really change anything?

Dr. Michael Osterholm: In short, no, it changes nothing. First of all, remember, there is not a functioning asset. It's still under a court order, has not been reconstituted with a new charter. So in that fact, who are they going to give the new executive order to to actually carry out this review. The second thing is this is more of the same. This is what we heard from the administration months ago about this idea that our children are over vaccinated. And of course, we've debunked that. And I'll talk more about that in a moment. But on Friday, the president did sign this executive order directing the CDC and ACIP or again, remember, not a functioning ACIP to review an assessment from the Department of Health and Human Services that aim to align our vaccine schedule with other developed countries. The executive order states that the review should consider ways to provide maximum flexibility to parents and doctors, through recommendations for timing and sequencing of the administration of routine immunizations. I'm really concerned about this for a number of reasons. First, I want to unpack what it means for our schedule to be aligned with other developed countries. In short, it doesn't make sense for us to adopt a vaccine policy of other nations when our overall population, health, and the rest of our health care policies are not aligned. For example, other developed nations have universal health care. This not only means a greater chance of quality, routine medical care for children infected with vaccine preventable diseases, but also a greater likelihood of prenatal screening for vaccine preventable diseases that can be transmitted during pregnancy and childbirth.

Dr. Michael Osterholm: We also have much weaker sick leave benefits for parents to be able to take time off to stay home with sick children. Finally, just because other countries aren't recommending vaccines doesn't mean there aren't evidence based reasons to do so. Oftentimes, the United States is the leader globally in moving certain vaccines to the routine part of the table. I think many of us were asked by our parents at some point growing up, if your friends were all to jump off a cliff, would you jump too? That same sentiment applies here. Just because another country isn't recommending a safe and effective vaccine that protects against a harmful disease. Please understand, it doesn't mean we shouldn't either. One of the arguments for changing our vaccine schedule that was mentioned in the executive order was a shift in the number of vaccine doses and antigens received in the last 20 years. In 1980, American children were recommended to receive 23 doses of vaccine, but in seven shots, which protected against seven total diseases. In comparison, in 2023, Americans were recommended to receive 84 vaccine doses, compared to 23 and now in 57 shots to protect against 17 diseases in 2023. Now that 57 shots sounds like, wow, this is a pincushion situation. Please don't forget that these 57 shots are also based on a recommendation for a COVID and flu shot each year.

Dr. Michael Osterholm: Meaning in the first 18 years of life, 36 of these 57 shots are COVID and flu each season. So it's not as if somehow, as a young child, we're hitting these children up with all of these vaccines at one time. So if you take out the influenza and COVID number of shots, you're now talking about 21 shots to protect against 17 diseases. That's very comparable to what we see in the rest of the world. And it's important to note that children receive more vaccines now because we have vaccines to protect against more serious diseases. This is medical and public health progress. We've seen it in nearly every field of medicine during this time frame. For instance, the overall five year cancer survival rate has increased from 50% to 1980 to about 70% today. This is largely because we have greatly expanded the types of diagnostics and And therapeutics available to treat cancer during this time. Yet we see far less pushback, suggesting that these improvements in care are part of the medical conspiracy. They are celebrated as a means of reducing morbidity and mortality. There is no reason that we shouldn't think of vaccines in the same way. The language encouraged additional flexibility around vaccine timing is also of concern. Delayed vaccination schedules are becoming more and more common, and while they may seem like a harmless way to get hesitant parents on board while vaccinating, they only prolong the amount of time that children are vulnerable to infectious diseases and increase their likelihood of missed doses.

Dr. Michael Osterholm: The executive order states, and I quote, executive departments and agencies are directed to ensure all actions, regulations, funding and coverage related to child and adolescent immunization fully aligned with the updated vaccine schedule recommended by ACIP, which. Ensuring the Americans retain all the access they currently have to vaccines. This is an inherently contradictory statement. First of all, the only recommendations still in force are those made from the ACIP that was in place when this new administration arrived. So those are the ones that the courts have recognized is still there. So nothing's changed. So let me just conclude by saying, without a functioning ACIP to act on this order, there's really no way for this to be implemented and enforced. But that doesn't change the fact that it's contributing to harmful rhetoric that continues to undermine the public's trust in vaccines, medicine, and public health. And there is no telling what it will mean if and when ACIP is functional again. We will keep you updated as this situation continues to unfold. In the meantime, please be sure that your children are up to date on their vaccines, especially if they're relying on Medicaid or VFC for coverage. As of this moment, these vaccines are still being fully covered.

Chris Dall: Mike. The CDC reported last week that the U.S. has nearly 2000 confirmed measles cases this year. Not that far off from the 2288 reported for all of last year. So where do you think we are in the trajectory of this measles surge that we've been seeing over the last 18 months?

Dr. Michael Osterholm: I'd say the trajectory is concerning and getting worse. As you mentioned, it's only June, and we're already approaching the total number of measles cases reported in all of last year, a year that by itself was historic for the United States. And it's not surprising. Measles is one of the most contagious viruses we have, far more so than COVID, influenza, or even chickenpox. Why would we expect it to change course when the conditions that fueled its resurgence remained largely unchanged? Vaccination rates have continued to decline in pockets of undervaccination have grown both across the nation as well as the globe. Roughly 90% of the cases in the US right now are our outbreak associated. That tells us we're not dealing with the typical pattern from the last few decades of isolated travel associated infections that are quickly identified. Instead, we have an outbreak that sparks, burns and takes months to contain. Much of the public conversation has focused on toddlers and school aged children who, under the recommended immunization schedule, should have received at least one dose of the MMR vaccine. One group that deserves particular attention right now are infants under one year of age. The first routine dose of MMR vaccine is recommended at 12 months, leaving younger infants dependent on the immunity of the people around them. These babies rely on protection from their community, their families, their daycares, their friends, places of worship, doctor's offices, and all those settings where they may interact with others. The same is true for people who are immunocompromised, both children and adults who are at increased risk of infection and severe outcome from measles. Measles is an important reminder that vaccination isn't purely an individual decision, but its effects can have a long lasting impact on others.

Dr. Michael Osterholm: Utah offers a striking case study for this phenomenon. It is currently experiencing the nation's largest outbreak, with more than 670 cases since it began in the summer of 2025. State officials report more than 60 infants under age one have been confirmed to be infected with measles. This is particularly concerning because infants under one are more vulnerable to complications from measles. One of the most devastating is subacute sclerosing panencephalitis, a big word but known as SSPE, a progressive and universally fatal neurological condition that can occur 7 to 10 years after an initial measles infection. The idea that a child could survive measles as an infant, only to develop a fatal brain disease as a second or third grade child, underscores how serious the stakes are here. While newborns do receive some temporary protection from measles from maternal antibodies, this, of course, is only the case when they are born to vaccinated or previously infected mothers. Utah has documented at least 12 pregnant women who have been infected with measles, raising concerns about how much passive protection some infants may be receiving, not to mention the risk measles poses during pregnancy. Pregnant women are actually ten times more likely to die or experience severe complications from measles than non-pregnant adults, and there's also a risk of congenital measles in infants. Chris, all I can say is that measles is a wildfire in North America. We can't expect it to put itself out on its own, especially for the sake of our community's most vulnerable members. We must increase vaccination rates and put significant investment into our public health systems to be able to identify and control these outbreaks.

Chris Dall: Anything worth noting on COVID, flu and respiratory syncytial virus?

Dr. Michael Osterholm: Well, let me just start out by saying I'm really happy to report there isn't a whole lot worth reporting on for these three viruses. But just let me give you a brief update. Since our last episode, every metric has either decreased or remained unchanged at very low levels of activity. Wastewater concentrations for all three viruses remain very low nationally and in every region. I've been hearing some questions about a summer COVID wave, but I want to emphasize that COVID, again, is not a seasonal virus like flu. And the crystal COVID ball might be the murkiest crystal ball in my murky crystal ball collection. What I do know is that as soon as we see signs that we might be coming up on an increase in COVID 19 activity, we'll be sure to let you know. But for now, there are no signs that are pointing towards a COVID flurry or wave in the near future.

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

Dr. Michael Osterholm: I think this one will surprise a lot of our listeners. And it's, I think, a really important comment on community. This week, we want to highlight America's first EMT service, the Freedom House Ambulance Service of Pittsburgh, Pennsylvania. The ambulance service was founded back in 1967 by the civil rights organization Freedom House, which provided job assistance and training to the Black community in Pittsburgh, particularly in the Hill District neighborhood. The service was staffed entirely by Black paramedics. At the time, most ambulance services in Pittsburgh, as well as the rest of America, were provided by the police, who had rushed people to the hospital in the back of their police van. As both then and now, Black citizens faced disproportionate discrimination and abuse by the police. Given these racial tensions, the Hills district's Black citizens were justifiably reluctant to call in an emergency because there are police force was predominantly white. If they did call, response times were usually slow or unreliable. This is where Freedom House stepped in and launched their own ambulance service for the community and by the community. The program recruited people from all walks of life, including folks who had faced extended unemployment, had criminal records, were Vietnam War veterans, and on and on. Freedom House teamed up with Dr. Peter Safar, AKA the father of CPR, to develop a 32 week training program that covered advanced first-aid and CPR, nursing, anatomy, physiology and defensive driving training.

Dr. Michael Osterholm: At the end of their 300 hours of training, these recruits were transformed into a full fledged first responders. This was groundbreaking because freedom House paramedics could offer emergency care to patients while en route to the hospital. A newfound concept at the time. Response times were quick and the care was exceptional, especially because the paramedics were from the community they were helping. During his first year of operation, the Freedom House Ambulance Service responded to nearly 5800 calls, transported over 4600 patients and saved at least 200 lives. The Freedom House became a leader for ambulance services both in the U.S. and internationally, making EMS history by helping to develop the first national training model for paramedics and EMS services across the country. Despite this prestige and the overwhelming support from the Hill District community, the Freedom House Ambulance Service was forced to close operations in 1975 after Pittsburgh instituted a citywide ambulance service. It should be noted that most of Freedom House's Black paramedics were excluded from comparable work within the new system, despite paving the way for these services to exist in the first place. Today, we honor the incredible work of the Freedom House Ambulance Service and recognize how their legacy shaped our EMS system of today.

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

Dr. Michael Osterholm: Well, the obvious headline is Ebola in Africa is a slow moving infectious disease tsunami. And when even when I say slow moving, I'm not sure that's a fair evaluation. I think we're going to see ever increasing rapid transmission in the days ahead as more and more people become infected and then transmit to others. The second point is that the vaccine world will only continue to become more and more challenging. And the information that comes from our federal government today is unfortunately not scientifically based, but sounds to so many of the general population as the thoughtful and rightful answer to vaccines. This is a huge tragedy. Finally, as I just pointed out, seasonal virus activity is looking pretty darn good right now. Keep our fingers crossed and hopefully we can get through an entire summer with very limited activity.

Chris Dall: And finally, what is your closing song for this episode?

Dr. Michael Osterholm: Chris trying to find a song that matches up with the dedication, or at least have some tied to it was a challenge until, of course, the obvious song came front and center. We've chosen "Good Job", which is a song by American singer and songwriter Alicia Keys, is written by Keys The Dream, Swizz Beatz and Avery Chambliss and produced by Keys. The song was released through RCA Records on April 23rd, 2020, as the fourth single from keys seventh studio album, a piano ballad, the song is dedicated to frontline workers fighting against the COVID 19 pandemic. Sounds familiar with Ebola? The song received a very positive critical reception, with many complimenting the song's message and keys vocals. Keys actually was quoted about the song as saying. Crazy enough, this song is like it was written for the moment, and there are so many people or heroes among us right now. And I can say with certainty, that's actually happening day after day right now in Africa. So here we are: "Good Job," song by Alicia Keys.

You're the engine that makes all things go. And you're always in disguise. My hero. I see your light in the dark. Smile on my face. When we all know it's hard. There's no way to ever pay you back. Bless your heart. Know I love you for that honest and selfless. I don't know if this helps, but good job. You're doing a good job, a good job. You're doing a good job. Don't get too down. The world needs you now. Know that. You matter, matter, matter. Six in the morning, as soon as you walk through that door, everyone needs you again. The world's out of order. And it's not a sound. And it's not as sound. When you're not around all day on your feet. Hard to keep the energy. I know when it feels like the end of the road. You don't let go. You just press forward. Your engine. That makes all things go. Always in disguise. My hero. I see a light in the dark. A smile in my face. When we all know it's hard. There is no way to ever pay you back. Bless your heart. Know I love you for that honest and selfless. I don't know if this helps it, but good job. You're doing a good job, a good job. You're doing a good job. Don't get too down. The world needs you now. Know that you matter, matter, matter. The mothers, the fathers, and the teachers that reach us. Strangers to friends that show up in the end. From the bottom to the top. The listeners that hear us, this is for you. You make me fearless. You're doing a good job, a good job. You're doing a good job. Don't get too down. The world needs you now. Know that. You matter, matter, matter. Yeah. Alicia Keys. 

Well, thank you very much for joining us again. I hope we were able to provide you with the kind of information you're looking for. A lot of very tough issues before us right now. The need for good public health is obvious and apparent every day. We have CIDRAP always welcome your feedback. As I've shared with you, I want to thank the podcast team for their help in putting this all together. And just to say that we got to hang together. As Ben Franklin once said, we must hang together. We surely shall hang separately. And right now, more than ever, we need that. So just remember, be kind, be thoughtful. As tough as it is out there, sometimes just that one act can make a big difference. So thank you. Have a good next two weeks and I look forward to talking to you then. Be good, 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.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.