Episode 212: Major Roadblocks

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. In a press briefing last week, the head of the Africa Centers for Disease Control and Prevention warned that with contact tracing lagging far behind where it needs to be, the Ebola outbreak in the Democratic Republic of Congo is dangerously close to spinning out of control. If we don't stop this outbreak now, for sure it will be the largest Ebola outbreak ever, said doctor Jean Casey. Casey went on to say that health workers need to track and trace 80% of the contacts of confirmed Ebola patients to end the outbreak, but at the moment, that figure stands at only 30%.

Chris Dall: On a more positive note, The New York Times reported that an assessment by DRC's Ministry of Health suggests symptoms in this outbreak may be milder than previous Ebola outbreaks. Unfortunately, that could also mean controlling the spread of the disease may be harder. What will it take to end this outbreak? That will be among the topics we discuss on this July 2nd episode of the Osterholm Update episode number 212. We'll also talk about a growing flu outbreak on an Air Force base in San Antonio. Discuss what some newly released CDC emails reveal about the tenure of Health Secretary Robert F Kennedy, Jr. Fill you in on the Vaccine Integrity Project's latest efforts, and examine some recent studies on the effectiveness of last season's COVID vaccines. We'll also answer an ID query on New World screwworm  and bring you 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 to all the podcast family members. It's great to be back with you again. To those 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, and I hope you also get a sense and can experience what many of us have come to understand, to mean to be part of the podcast family. It's a very unique and wonderful experience and we've sure been through a lot together. And we can also anticipate there's more coming. So hold on, stay tight and stay with us and we will all get through this together. I'm sure by now all of you are well aware that this weekend is the 4th of July. And it's not just Independence Day. This year marks the 250th anniversary of when America officially declared its independence from the British. Of course, it's critical to acknowledge that the indigenous peoples from thousands of different tribes were on the land for thousands of years, long before we called it America. And people from Africa were forcibly taken, enslaved and brought to this country well over a century before the Declaration of Independence was signed, the same document that declared that all men were created equal, excluded many people that had historically made up and currently make up our country. Today's America can also certainly feel exclusionary, and I know that many are not feeling particularly patriotic after the events of the past year.

Dr. Michael Osterholm : But today I want to dedicate this episode to the America I've witnessed, the America I admire, the America I hope for, the America that I love. Just as our landscape is full of a variety, from rolling hills to red deserts to breathtaking mountains to sprawling prairies, the American people are just the same. A nation of many immigrants made up of so many different people from so many beautiful, different places. We may not all speak the same language, cook the same foods at home, or listen to the same music. But that's the beauty, isn't it? To share it all with one another, to be neighborly. We are united in our love for our families, our communities, and taking care of our beautiful home. America was the first country to send people to the moon. Jazz, Sesame Street and Beyonce came from America in that order. Our country is full of dedicated and hard working people, farmers who grow and deliver our food. Teachers who shape our children's future. Scientists who research our world to find solutions to our most severe problems. Health care professionals who care for those who most need it. I dedicate this episode to all of you, my fellow Americans, my fellow neighbors. And before we get to the ever controversial minutes of sunlight, I want to take a moment to share how grateful I am, as well as the entire CIDRAP team, for the ongoing support that we've received from so many of you.

Dr. Michael Osterholm : Whether you're a first time listener or you've never missed an episode, we can't thank you enough for being here. If you like our show and want to help CIDRAP continue our mission to lead with science, truth and kindness will always include a link to different ways that you can support us in our show notes. As routine listeners of this podcast know, we are committed to never, ever putting our content behind a paywall. To me, that is the worst I can imagine in terms of our obligation to help all of us move forward. And as you know, we also don't receive support from private companies or government programs to keep this podcast running. We rely entirely on you, our podcast family. And it's not just donations. Consider sharing the podcast with a friend or family member who you think might enjoy it, might get something from it. If you're listening on a platform like Apple Podcasts or Spotify or YouTube, please subscribe, rate and review. Consider subscribing to our CIDRAP daily newsletter. Again, it's free, not behind a paywall. Engage with us on social media and tell us what you think about what we're doing, what we can do better.

Dr. Michael Osterholm : All of these things help us continue to do what we love. Sharing information with you on behalf of the entire podcast team and all of us at CIDRAP. I truly cannot thank you enough for your support. Now, as I just noted a moment ago, welcome to the next segment. For those who want to tune out here for 30s, I understand. Today in Minneapolis and Saint Paul, besides the fact that it's very, very hot. On July 2nd, the sunrise will be at 5:31 am, the sunset at 9:02 pm. That's a whopping 15 hours, 32 minutes, and three seconds of sunlight. We are now losing sunlight at about 47 seconds a day. And in fact, just since June 21st last week, we've already lost over four minutes of sunlight as we now march towards the winter solstice. And for those of our very dear friends at the Occidental Belgian Beer House on Vulcan Lane in Auckland today, your sun rises at 7:34 am, your sun set at 5:15 pm. That's a nine hour and 40 minutes and 45 seconds of sunlight. But you're gaining today. You've gained 30s of sunlight and it'll get better and better. So we'll pass soon as you're going up and we're going down. But remember one thing. We're always here to share the light.

Chris Dall: Mike, the DRC Ebola outbreak currently stands at 1307 cases and 377 deaths, with an additional 20 cases and two deaths in Uganda. We've talked in previous episodes about the challenges with this particular outbreak. What's your assessment of how DRC officials and the WHO are handling this outbreak, and what they're going to need to do to get it under control?

Dr. Michael Osterholm : Well, Chris, I continue to be very concerned about the Ebola outbreak. And as you noted, the number of cases and deaths continues to climb, particularly in the Democratic Republic of Congo. And these numbers are growing day by day. And additionally, there have been at least 20 cases and two confirmed deaths in neighboring Uganda. And we're hearing today of the possibility of cases occurring on the border with South Sudan. Cases in the DRC have remained isolated to the northeastern part of the country. Mass gatherings have been banned in all of the provinces for several weeks. And on Monday, leaders in the DRC announced that mass gatherings are now also banned in three additional provinces in the northeast, as well as the nation's capital, Kinshasa. Although Kinshasa is located on the opposite side of the country, health officials are still concerned about Ebola transmission due to the very dense population of 18 million people there. And because Kinshasa serves as a major hub for most of the travel that occurs throughout all of the DRC, making it vulnerable to a potential outbreak if the Ebola cases were to reach the city. This outbreak is growing faster than healthcare workers have been able to control it. Only 30% of patients have had additional contact tracing and monitoring, falling well below the target of 80%. Additionally, the outbreak is occurring in a region that is already struggling with significant instability due to the unethical labor practices, including child labor, as well as control by the M23 rebel group.

Dr. Michael Osterholm : The ongoing violence in the region has impeded response efforts from the DRC health officials, as well as all the international groups, including the WHO. There is no question that there will be a lot of challenges ahead with this outbreak. I think it's fair to say at this time, all the international organizations that are involved with this response, including WHO, are surely trying their very best to deal with this. This is a significant challenge trying to provide health care for those with Ebola, as well as for those who have other serious illnesses due to infectious diseases. So I think it's very important to note that the system for response was already well behind in the earliest days of the recognition of the epidemic. In addition to this, we've already heard publicly from Tedros, the Director general of the WHO, of the immense challenges of trying to get the contact tracing done, increasing the number of professionals available to provide the health care facilities that are so desperately needed, and the ability to do community education that will help people understand why body contact at this time is a significant risk factor for Ebola. And therefore, if you had contact with someone with Ebola, you need to understand what you need to do to isolate yourselves. So should you become infected, you don't transmit the virus on. I think at this point, one of the challenges we also have is just getting good information out of this area of Africa.

Dr. Michael Osterholm : It's been very difficult, and we actually have a sense of what's going on. But I think it's far from what we need to know to be able to strategically deliver on services. Now, when it comes to the United States, I have to say we're late to the table. The fact that we actually destroyed USAID presence in this area of Africa before the outbreak began meant that clinics that had been open, supported by USAID, no longer existed. We have reports of physicians who have had to go and work in the mines, because they could not otherwise find employment after our U.S. support failed. And so from the perspective of will we have adequate staffing there? I don't know at this point, it appears that we're far short. In addition, it's notable that when we look at who might come volunteer from the United States to come to this area of the world, the kind of health care worker, public health worker response that we saw in the 2014 to 2016 epidemic. I don't know if we're going to have that, because now we have a unique challenge of who's going to provide health care, who's going to do the follow up for those who go and volunteer and end up getting exposed, or even for that matter, developing Ebola as a result of an occupational exposure. We learned earlier this week that the Kenyan government was not going to allow the United States to build a medical facility in Kenya that would be reserved for American physicians, nurses, other health care workers should they become infected.

Dr. Michael Osterholm : Of the $1.4 billion that had been slated by the US government to assist in this outbreak response, $800 million was slated for this new hospital to be built. At this point, it surely is a question as to if I were a doctor or a nurse or any other healthcare worker in DRC, I became exposed. Would I ever see my country shores again? And I think that's a real possible challenge. To sum it up, Chris, this is a mess. It's a mess. We need a much larger and well-trained workforce to be able to go into these communities, these very densely populated communities, populations that were 80% do not have safe water populations where malaria is widespread, populations, where other infectious diseases have been the number one priority for this country. Chris, this may be the biggest public health challenge that I have seen in my career, and that includes COVID in the sense that we know what to do. We know how to do it. But the conditions on the ground are such that it made a major roadblock to doing what we need to do. I don't know if we're going to end up having the necessary expertise on the ground to be able to really bring this home. And that by itself is why so many people are so very, very concerned about the future of this outbreak.

Chris Dall: And Mike, what do you make of this New York Times report that the symptoms in this outbreak may be milder?

Dr. Michael Osterholm : Well, Chris, this is surely a possibility. And let me explain why. As you noted, the article in The New York Times published last week compared the severity of symptoms in the current Bundibugyo virus outbreak to previous Ebola outbreaks. However, I need to be very clear about one thing, Chris. Nothing about an Ebola outbreak that rather than being 50% of cases dying now at 25% of cases dying means that this isn't yet a very serious and very significant public health challenge. The article notes that fewer Ebola patients in the current Bundibugyo virus outbreak demonstrate internal or external bleeding symptoms, the hallmark sign of late stage Ebola. Data from the Ministry of Health and DRC suggests that only 10% of patients are developing these really severe symptoms. This finding comes with both good and bad news. The good news is the reduction of morbidity and mortality. And as I'll share with you in a moment, I think even the potential for transmission with a lower case fatality rate, there will be fewer people suffering from the disease's most horrific end stages and fewer people dying. This is obviously good news. But let me take a step back and talk about transmission. The course of illness was someone who has. Ebola is actually quite complicated. The virus goes through a series of, you might say, relationship challenges with the human body. I'm going to describe for you the various stages of clinical illness associated with Ebola infection. And there's a method to my madness here, because ultimately, it will have a lot to do with the potential for transmission of the virus.

Dr. Michael Osterholm : And it's at the end stage of disease. You have the transmission occur, which has a lot to do with who might be exposed in the community to the virus as opposed to who would be exposed in the hospital setting. The Ebola virus begins its attack on the human by targeting and hijacking crucial immune cells, specifically ones that act as the body's early warning system. They blind the defenses of the body to the virus, as it disables the internal alarms of these immune cells. Unchecked replication means that without any immediate immune response, the virus begins rapidly replicating and spreading to major organs like the liver, the spleen, and the lymph nodes. And then what follows next is quite remarkable. We call it a cytokine storm. Once the body finally realizes a massive infection is underway, the immune system launches a desperate brute force counterattack known as the cytokine storm. Now we have collateral damage where the immune cells release an uncontrolled flood of inflammatory proteins we call cytokines. This now leads to things such as the destruction of the blood vessels. And then with that, we see clotting chaos occur. Simultaneously, the virus triggers a condition called disseminated intravascular coagulation, where tiny blood clots form throughout the bloodstream, blocking blood flow to vital organs. This rapidly exhausts the body's supply of clotting factors, now making it impossible to stop any subsequent bleeding. And now you see towards these end stage illnesses, the bleeding occur from body orifices.

Dr. Michael Osterholm : And then we hit a period of very severe fluid loss and shock as the virus ravages the gastrointestinal tract victims experience severe nonstop vomiting and diarrhea. Patients can lose up to 2.5 gallons of fluids every day now because blood vessels are leaking and fluids are being emptied throughout the GI tract. The total volume of blood in the body begins to drop dramatically. Then we move to the final stages of the illness. This is where we have multiple organ failure and ultimately death. I know this was probably more detailed than some of you wanted to know, but it's important to understand that these stages of illness actually do relate to the infectiousness or the ability of someone to transmit the virus. Let me give you an example of something that happened right here in the United States in 2014 with the large Western African Ebola virus. In late September of 2014, an individual flew from Liberia to Dallas. At that time, he was asymptomatic. When he landed on the ground, came through the airport and went and stayed with family. A number of people living in the same apartment building. Over the course of his stay there, he began to become ill with fever, sore throat, etc. They took him into the emergency room, which even though he acknowledged he had had foreign travel, nothing was considered in terms of possible Ebola and they sent him home. Three days later, he returned back to the hospital and soon crashed.

Dr. Michael Osterholm : He was admitted to intensive care and at that point was in the final stages of Ebola. Why is that notable? It was notable about the potential for transmission, in that he stayed in his fiancee's apartment with multiple other people. Why? He had his earliest symptoms of Ebola. None of those individuals became infected. In addition, dozens of other people interacted with him at that same time before he was finally admitted to the hospital. Also, no one became infected with Ebola. The two people that did become infected were both nurses, and it was noted at the time that their use of personal protective equipment was deficient, and that's why they were infected by him. But notice he did not transmit to anyone until he was in his end stage of disease, where he was actually bleeding out. That's when you're most infectious. So to bring this full circle, if in fact people are not as severely ill, we don't see as many cases moving towards that final stage of multi-organ failure and uncontrolled bleeding. Very possible. We'll see less transmission of the virus from those infected people who then recover without having to have had that very severe case. So I think at this point, we would expect that that would dampen down the number of new cases if in fact, we're seeing fewer severely ill individuals. But time will tell. In the meantime, there still are a lot of people who are experiencing end stage Ebola virus infection, and that is a real challenge.

Chris Dall: Now to another outbreak. The number of flu cases linked to an outbreak at Lackland Air Force Base in San Antonio is now close to 300, according to the most recent update. The outbreak is noteworthy not because it's a new strain of flu or more severe, but because it comes two months after Defense Secretary Pete Hegseth ended the military's flu vaccine mandate. Mike, is this outbreak a reminder of why this mandate was there in the first place?

Dr. Michael Osterholm : Well, Chris, this is a really tough question. And I say tough because it's not a clear cut answer I'm about to give you. And it's an answer I think many of you will find unsatisfactory. First of all, let me just note that we're now talking about the Joint Base, San Antonio, Lackland Air Force Base. That's exactly what it's called. It was as a result of a combining three different air bases in 2010. So if you hear Joint Base Where you here, San Antonio or here? Lackland. Basically, it's all the same location. Well, we don't typically hear about flu outbreaks in the US in late June. I can say that I'm not surprised that we would see one. We have had a history over the years of having outbreaks associated with influenza, usually in very close settings with limited number of cases. For example, I was actually involved with working up outbreaks of influenza on cruise ships off of Alaska during the summertime. Ironically, many of the people who were on the ships that got infected were actually from the southern hemisphere, notably Australia. And so we do have these kind of outbreaks, but we don't see ongoing transmission. Typically, once it's out of that closed group kind of setting. Now, what happened at Lackland Air Force Base is one that I've seen a lot of my colleagues basically making charges that by relaxing the mandatory vaccination for influenza for new recruits led to this outbreak. I don't agree. And what do I mean by that is that I, first of all, strongly support influenza vaccination.

Dr. Michael Osterholm : I continue to do so. I spoke out against Secretary Hegseth's comments. I spoke out against Secretary Higgs actions in which he no longer made it mandatory for vaccination, particularly in part due to the issue of military readiness. Why did I say that? Maybe the vaccine didn't have nearly as much to do, whether or not the outbreak actually occurred? Well, we have good, compelling data that influenza vaccines, the inactivated vaccines that we routinely receive, are very effective at reducing serious illness, hospitalizations, and deaths. And they do do that. And to me, that is a reason right there why everyone should be vaccinated for influenza, but because of the fact that these vaccines do not really increase mucosal kinds of immunity, meaning the upper respiratory tract. People can still get infected and can still shed the virus. And so that even with vaccination, you can still see these kind of outbreaks. But the big difference is it's a major reduction in serious illness, hospitalizations and deaths. And there were some very sick individuals, even as young, healthy recruits that were part of this outbreak. And so from that perspective, when my colleagues are sitting here saying that they are not, or the number of cases that would be expected to occur from contact with someone who was infected, that just doesn't hold water. Now, could there be a very limited amount of protection that we see in terms of infection or transmission? The studies that we have looked at over the years that have tried to measure this show very, very limited evidence of that.

Dr. Michael Osterholm : And so I want to be careful not to have people walk away saying, I don't need to get vaccinated. That's not the case. But I think it's also important to understand, I believe this outbreak could very well have happened even if there had been a vaccine mandate in place. But I do believe that the severity of the illness would have been potentially very different. And so we're all on the same page about supporting flu vaccine. We're all on the same page is we don't want our military recruits becoming ill and potentially seriously ill. And we at the same time, have to be honest and understand that we need new and better flu vaccines. We do. Our center has been at the forefront of the influenza vaccine roadmap work now for a better part of eight years, trying to help us achieve better flu vaccines. And it's time that we understand that this kind of outbreak should just illustrate for us why we need to have these new and better flu vaccines. And that means investment. That means people willing to continue to support the kind of research that would give us new and better flu vaccines. Remember, the technology that we're using today with these inactivated flu vaccines is almost the same technology we used in the 1940s and 50s. That should be a sobering note to people saying, boy, we can do better.

Chris Dall: Speaking of flu, the FDA's Vaccine and Related Biological Products Advisory Committee, or VRBPAC two weeks ago recommended approval of Moderna's mRNA flu vaccine for older adults. As you might recall, this is the vaccine that the FDA said it wasn't going to review back in January, then quickly changed its mind again a week later. It still needs to be approved by the agency. But, Mike, do you think this vaccine could be an important addition to our flu prevention toolbox?

Dr. Michael Osterholm : Let me just cut to the chase and say yes, yes, yes and yes. I think this is a very important new vaccine. And I think it does provide for us a model of how flu vaccines can even incrementally be improved. And let me emphasize that having an mRNA influenza vaccine in our toolbox not a vaccine requiring chicken egg production, but rather the kind of laboratory based vaccine development that we see with mRNA technology can truly be a game changer. Chris, as you know, and many of the people on this podcast may know, for more than almost 20 years, I've been pushing for new and better improved flu vaccines. And this is an example of what that kind of work is all about. We now have a new, much better tool in our hands. Not only does this mRNA vaccine provide superior protection compared to the standard dose vaccines, it also offers several other benefits. While the vaccines would still require seasonal updates, the mRNA vaccines can be manufactured much more quickly than the traditional egg based vaccines. Shorter manufacturing time means strain selection could occur closer to flu season, which would minimize the risk of mismatched vaccines. Similarly, in the case of the pandemic influenza strain, the mRNA vaccines could be manufactured and rolled out much, much more quickly than traditional vaccines. I've talked about this before on this podcast, and I covered this extensively in my book, The Big One that was published last year.

Dr. Michael Osterholm : We now have the ability to actually improve our flu vaccine portfolio unlike anything we've had literally dating back to the past 60 years. Let me wade in to the next steps about this vaccine. First of all, I applaud VRBPAC and what happened at the FDA. It was a normal meeting. It's a meeting that we would have expected to have had over the past 5 to 10 years. And from that standpoint, that was great news. I think that the discussion was outstanding. The members of the committee took their vote. It was a unanimous decision to support this vaccine, and I give them all great credit. But now the question comes, who can use this vaccine? And I keep hearing from colleagues that the ACIP, the Advisory Committee on Practices, still needs to make a decision about who should get this vaccine. That's a bit unclear. We don't know that ACIP has to make a recommendation for this vaccine to still be used. Once it's licensed and approved, the manufacturer can bring it to market, and then the clinical community can decide if they're going to use it or not. In the past, of course, we tied that to ACIP recommendations. Also, the payers were often tied to a recommendation from ACIP. Now, could this vaccine be on the market this winter? We need to ask Moderna.

Dr. Michael Osterholm : We've not heard from them yet. Are they prepared to bring it forward with vaccine licensure? And I want to be careful here, because I hear over and over again that this vaccine may not be available or it couldn't be recommended if ACIP does not recommend it. And I think we're all basically wondering what ACIP is going to do or look like in the weeks to months ahead. So I still am of the mind that with payers likely to cover this, we in fact may be able to use the vaccine without a specific ACIP recommendation given license survivor pick. Now, none of us really know. I have had discussions with many people, both inside and outside of government, inside the vaccine manufacturing industry, and experts who have served in many years on the ACIP committees. No one really knows. So stay tuned. Hold tight. I can just only hope that this vaccine ultimately does become available. I surely will be a recipient of it, even though I know that the number of slight reactions following the vaccine may be increased. Fever, feeling a bit ill for a day or so because this vaccine will be by far the most effective tool that we currently have against influenza. And only time will tell how that's all going to play out.

Chris Dall: We'll talk a little bit more about ACIP in a moment. But first, Mike, the back and forth on the Moderna flu vaccine was one of the many indications of how the Trump administration, under the leadership of Health Secretary Robert F Kennedy Jr, has handled vaccine policy. As you might recall, FDA initially said it wasn't going to review that vaccine, and that really seemed to be tied in to its feelings about mRNA vaccines in general. Just last week, new internal CDC emails released by Senator Bernie Sanders reveal even more about what Secretary Kennedy has been doing to influence vaccine policy from the very moment he was confirmed. Mike, what did you make of those emails?

Dr. Michael Osterholm : Well, Chris, first of all, it's very important to have what I call situational awareness, meaning that you have to be mindful of what is all around you and happening for you to make an important decision about what you must do. And nothing surprises me at this point. Nothing surprises me. We have seen a whole series of events that, in a sense, kind of flood the field with confusion, with lack of clarity, and in some cases, unfortunately, untruthful statements. So it's fair to say that these emails are very telling. And I'm grateful to The New York Times and other media outlets for covering this issue. For context, the emails came from internal CDC and HHS communications that were obtained by the Senate Health, education, Labor and Pensions Committee. They spanned the first few months of Kennedy's tenure as HHS secretary in 2025, over a year ago. But it feels like a lifetime, as many of us in the public health field remembers all too well. This time period was a whirlwind of new leadership, layoffs and rapid changes to communication and policy. And Senator Sanders' press release the emails released to the show, quote, Secretary Robert F Kennedy Jr's politicization of HHS willingness to ignore vaccine science and undermine the basic health and safety of Americans, unquote. The emails cover a range of high profile decisions, including efforts to stop the CDC flu vaccine communication campaign during the flu season, abrupt changes to COVID 19 vaccine recommendations and implementation of White House executive orders, changing and removing certain web pages.

Dr. Michael Osterholm : They document the day to day interactions between career public health staff who are trying to navigate an administration asserting greater and greater control over vaccine policy and public health communications. After reading these emails, what stands out the most to me is not what decisions were made, but how they were being made. One thing that is quite consistent has seen career CDC scientists and staff seeking to understand, document and sometimes push back on directives coming from HHS political leadership when they go against scientific evidence or standard operations on vaccines. Specifically, the emails reinforce a pattern we've been discussing for the last year. Decisions that traditionally would have flowed through CDC's established scientific review process are instead being driven by political leadership without the input of any science expertise, whether it's a messaging, changes to the recommendation or the advisory committee's makeup, political officials were taking a far more hands on directive role than has historically been the case. None of this is particularly surprising following the decisions that have been made over the past year, but it's still jarring to see how little evidence based decision making actually occurred. The theme for me after reading these messages one word Tension. Tension between career public health experts doing their best to keep the ship afloat and protect the health of our population and political leadership with very clear ideological agendas.

Dr. Michael Osterholm : As the tension builds, you stop wondering whether something will snap. But what will break first? And to add context to this, in the past week, an article was published in Bloomberg by Jessica Nix, one of the reporters at Bloomberg, in which she highlighted the current situation at CDC, where now the new CDC leaders claim that they're going to try to boost the skeleton staff left after the DOGE cuts. She noted that at least 11 centers and offices at the CDC are filled with an acting director, according to his website. The US Public Health Agency has been without a permanent director for nearly a year. Over the last 18 months, about a quarter of its staff left or were cut by Elon Musk's Department of Government efficiency. When you look at the CDC, they are in free fall. And this is a challenge then for all of us in public health, because we count on that agency so much to provide us with the scientifically sound lacking, political overtone kind of information that we need to make decisions about protecting our health. The problems continue with this administration's leadership of Health and Human Services, and specifically to the issues of the day regarding vaccines.

Chris Dall: Returning back now to the ACIP, the CDC last week posted the new charter for the group, which has been in limbo since a March court ruling. Reporting suggests that this new charter downplays ACIP's role in recommending use of new vaccines, and adds some new duties regarding alternatives for disease prevention. Mike, is this simply another avenue that Kennedy is using to shape our vaccine policy?

Dr. Michael Osterholm : You know, Chris, I have no idea what goes on inside his mind. But in seriousness, yes, I think updating the charter is another way in which actors in this administration are rewriting the rules for their own benefit. I want to start by explaining what the Advisory Committee on Immunization Practices, or ACIP's charter is, and why it's so important. Listeners have heard us talk many times about ACIP and how its originally intended function as a group to make federal vaccine recommendations has been thwarted by Kennedy and others with clear anti-vaccine ideologies. The ACIP charter is the governing document that shapes how the group can operate. Because the ACIP recommendations form CDC's guidance, along with insurance coverage and vaccine access programs, these changes to the charter. Minor to major, can have considerable downstream effects on public health. There are several aspects of the new charter that raised red flags to me in terms of their motivation and implications. The first is the shifting ACIP objectives and scope of activities. In prior iterations, the committee's role was clearly centered on evaluating evidence and making recommendations to optimize vaccine use and prevent disease. The new language now appears to broaden, even dilute, the mission with gold that could be interpreted in a number of different ways. Ambiguity matters here.

Dr. Michael Osterholm : It creates opportunities to cherry pick priorities or pieces of evidence. Another alarming change in the new charter is an updated definition of committee members qualifications. The new language moves away from requiring members to have expertise in vaccine use, research or safety and efficacy, and instead states that members should, quote, collectively represent a balanced range of scientific, clinical and public health expertise, unquote, and include people who are knowledgeable about consumer perspectives and or social community aspects of immunization programs. Dr. Jake Scott, a well-known author and physician at Stanford, spoke with CIDRAP News about the changes and rightly pointed out that the new definition opens the door for anyone with a health adjacent working title who may have an anti-vaccine agenda to join the committee. This will further allow the ACIP to become a mechanism for building a case against the use of vaccines, instead of establishing an approach for how to best use them. Shifting the ACIP charter is undoubtedly a way to legitimize the destruction of U.S. vaccine policy ongoing and likely future. So while this may sound like bureaucratic fine print, it's really about whether ACIP remains a body grounded in vigorous science and public health. And that's something all of us should be paying close attention to.

Chris Dall: Mike, there's been a lot of reporting in the political press, shall we say, the D.C. press, that the administration wants Kennedy to keep quiet on vaccines until the midterms are over? But it really appears like there's a lot going on behind the scenes that he is doing that maybe the average person doesn't know about.

Dr. Michael Osterholm : One of the things we have to understand is that while Mr. Kennedy has a incredible bully pulpit and the ability to have an impact on vaccines that any secretary could. Even more importantly is the fact that he's assembled an incredible team of his colleagues, the many people who are also anti-vaccine in many ways, that are every bit as dangerous as his own ideas that are now placed throughout all of HHS and the CDC, the NIH, the FDA. And because of that, even if Mr. Kennedy was to leave tomorrow. His fingerprints will mean that the policy issues regarding things like vaccines will not change overnight. They already established infrastructure that he's put in place is remarkable. It's been done quietly. It's been done in a way that surely plays to a long term strategy, and one that I don't think we fully appreciate yet just how much damage this whole team of individuals can and will do with regard to vaccines in the months ahead.

Chris Dall: Well, that brings us to the latest Vaccine Integrity Project effort, which aims to improve the process through which ACIP and the CDC assess and recommend vaccines. What can you tell our listeners about it?

Dr. Michael Osterholm : Well, I always start out any discussion of the VIP project with a sense of great gratitude for what is happening with that effort and the people who have contributed so much to doing whatever we can to assure that vaccines are here for us when we need them, where we need them, and how we need them. And I can't say enough incredibly good things about the people who are part of this project. All the changes to the ACIP charter that I was just describing are only the latest in what's been a whirlwind of changes and iterations of ACIP in the past year and a half. Major changes to federal vaccine policy have included the dismissal and replacement of ACIP members, and changes to the well established childhood immunization schedule that were later invalidated by a federal court. As of right now, the committee itself doesn't exist, and there are many signs that the role of ACIP may be reduced going forward. As I noted in a previous discussion today, the ACIP charter is undergoing changes and new membership is likely to be added. And with that, we can only imagine what else is going to happen with AC IP. But let me just speak to the current time. This is the backdrop for the new effort from the Vaccine Integrity Project. The goal here isn't to simply recreate what existed before, but to ask what would a resilient, modern vaccine policy and recommendation system look like in the US going forward? Our initiative is focused on the process, how vaccines are evaluated and how recommendations are established at the federal level. It will involve taking a close look at the role that ACIP and the CDC have historically played, and exploring ways that the process could be strengthened.

Dr. Michael Osterholm : This may include things like reinforcing scientific independence, increasing transparency, improving conflict of interest policies, and making certain that the system can remain stable and reliable across different administrations. Of course, to get these answers, we need to listen to the people who engage with this process most closely. We're setting up a number of focus groups to hear from former ACIP members, public health officials, clinicians, insurers, manufacturers, medical societies, and more. We also will be gathering public input through a survey so that the recommendations reflect the widest range of perspectives and expertise. Ultimately, we'll generate a set of policy and process options for reconstituting and strengthening of future advisory body grounded in science and transparency. These options could be adopted by future leaders at HHS, CDC, and other agencies. We'll share these findings in a public report by the end of this year. This work is done in tandem with The Evidence Collective, an organization of science and medical experts and communicators. The Vaccine Integrity Project's priority will be looking at the role that ACIP has historically played in the vaccine recommendation process, but the Evidence Collective will zoom out to consider how vaccine guidance is communicated, how trust is built and how policies are implemented. Together, the findings from both groups will outline a comprehensive vaccine policy making system. Chris, the key takeaway here is that this is a forward looking effort. We recognize that vaccine policy today sits at the complicated intersection of science, politics and public trust. So the question is, how do we build a new evolution of this system that both meets today's challenges and is set up for success for decades to come?

Chris Dall: Now for our ID query on our last episode, you answered a question about the level of risk posed to people by New World screwworm , the parasitic fly whose larvae feed on the tissue of warm blooded animals. We also discussed the threat to cattle and other livestock, but we've also been hearing from listeners who are asking about the threat posed to wildlife. What can you tell them?

Dr. Michael Osterholm : Well, thanks, Chris, and thanks to the listeners who sent in their questions about this. It surely has piqued the curiosity of many about what just is going on with this screwworm . I must admit, based on the number of questions we received, it's clear the whole situation with screwworm  has unique ability to capture people's attention. This is a fly that can theoretically affect all warm blooded animals. A lot of attention gets placed on livestock and other farm animals because of the economic implications with trade and food production. But wildlife in areas where this fly circulates are also surely at risk. So it's really any warm blooded animal with a wound or a break in the skin, something even as small as a tick bite where these female flies can come in, lay their eggs and the hatching larvae feed on the living tissue. And when these infestations are left untreated, they often lead to serious injury and death. But to help think about through the implications of wildlife. We're fortunate enough here to connect with a couple of people who have expertise on this topic. One is Dr. Aaron Burton at the University of Minnesota's College of Veterinary Medicine, whose work and research spans parasitology, clinical pathology and animal health diagnostics. And the other is Dr. Jamie Humber, who's a veterinarian by training here at CIDRAP and who has really kept up with a lot of what's been happening with screwworm  to date. Together, they really provide us a thoughtful perspective on this. So a huge thank you to them.

Dr. Michael Osterholm : To start out, it's important to remember that the New World screwworm  was first eliminated from the US back in 1966. So it's basically 60 years where we really haven't had much in terms of data on its effect on wildlife populations here in this country. With that being said, we did see an outbreak emerge in 2016 in the Florida Keys. And in fact, Key deer, which are an endangered subspecies of white tailed deer, are unique to some of the islands in the area were primarily affected in the early parts of the outbreak, which ultimately spanned a total of seven months. They actually noticed unusually high mortality rates among adult males, almost double the number they typically see. Of course, when screwworm  was confirmed there, it prompted a sizable response, which helped reduce the spread. Intel was eventually eliminated there in 2017, but in total, there were 135 key deer that died from screwworm  infestation, which represented 10 to 20% of their entire population. And many of those deaths occurred in the span of just over a month. Left unchecked, it surely would have been much worse. So it goes to show what screwworm  was capable of in certain wildlife populations. However, Dr. Burton pointed out the key deer situation likely represents more of a worst case scenario in terms of the impact screwworm  can have on wildlife, given the fact they live on relatively small, isolated island, with larger populations spread across wide geographic areas, such as white tailed deer in the continental U.S. We likely wouldn't see that level of concentrated mortality.

Dr. Michael Osterholm : Still, it can lead to challenges. Dr. Umber pointed out to us that some of the data out of Texas from the 1950s pre-elimination showing that screwworm infestations in deer fawns were documented in each of the nine years that comprised the study period. In two of those years, 1955 and 1957, screwworm  infestation was a leading cause of fawn mortality and actually suppressed population growth. Interestingly, the researchers leading the study noted that each of those years followed warmer winters, which would likely lead to higher overwinter survival of the fly population. So from that perspective, the reemergence of this in parts of the United States is surely another thing that will need to be considered when it comes to maintaining healthy wildlife population in terms of where things stand now. We have not yet seen any official detections of screwworm  in wildlife at this time. A house reported a total of 27 cases, all in domestic animals. From what we've heard. There is work being done to look for it in wildlife located in areas with detections, but it can be difficult to verify in wildlife given the logistics. For instance, infested animals often die quickly and out of sight. Carcasses are decomposed and scavenged before samples can be collected, and the larvae leave the animal when it's dead. Still, I personally think it's safe to assume that at this point, some wildlife in areas with the fly are going to be affected, and it's just a matter of time until the official confirmation happens.

Chris Dall: In the last two weeks, there have been several studies published on the effectiveness of the 2025-26 COVID vaccines. Mike, what do these studies tell us about the value of getting an annual COVID shot?

Dr. Michael Osterholm : Yes, Chris, these three studies reaffirm the importance of getting vaccinated against COVID 19 each year. Two of the studies suggest that the updated COVID booster vaccines still provide meaningful protection against major adverse COVID related outcomes, cardiovascular complications, hospitalization, and all cause death. This is true even as the virus and population immunity have evolved, and the protection from the booster has become even more modest. In the first study published in Jama Internal Medicine, CDC researchers found that vaccination reduced the likelihood of COVID related emergency department or urgent care visits by 26%, hospitalizations by 35%, and COVID related critical illness by 41%. Even though the protection is relatively modest and wanes over time, the benefits still outweigh any risks, particularly in light of the potential major risks of Routes of infection and long COVID. The second study, published in the same journal, found that in more than 1 million veterans who received a COVID vaccine at the same time as a flu vaccine or COVID vaccine only resulted in COVID vaccine reducing cardiovascular deaths, heart attack, stroke, and hospitalization for heart failure by 51% in those older than 75. So again, just to reemphasize, the study design was individuals who got both COVID and flu vaccine at the same time and those who only got COVID. And that's how they could compare the influence that COVID had versus flu.

Dr. Michael Osterholm : A third study, this one published in JAMA Network Open, showed that the most recent COVID vaccine formulation slashed the risk of hospitalization and emergency department and urgent care visits. Of the more than 111,000 US adults, the vaccine halved. Emergency and urgent care visits cut hospitalizations by 55%. Notably, this study's findings were suppressed from publication earlier this year by interim CDC Director Jay Bhattacharya. If you remember, he had questioned the test negative design used in the study to calculate vaccine effectiveness. Despite the design having been used for decades as part of a routine flu vaccine monitoring program and the CDC's own effectiveness estimates, it's notable that the test negative studies are truly a practical alternative to more costly, complex and lengthy randomized trials and are essential for broader routine vaccine monitoring and timely public health decision making. This approach, despite what Dr. Bhattacharya has noted, are a standard tool that we use in public health with great success and effectiveness. And let me just conclude this by adding one last comment. The bottom line message for what I just discussed with you is that getting your COVID vaccines this fall is as important as ever. I will certainly be getting mine and maybe even be able to get a COVID and a flu vaccine in the same dose.

Chris Dall: Finally, Mike, is there anything worth noting on COVID-19 flu and respiratory syncytial virus?

Dr. Michael Osterholm : Well, despite the attention that's been paid to flu the last week because of the outbreak at Lackland, I have to say that flu activity is actually really at a very, very low. And the same is true at this point with COVID-19. There may be a slight indication of some potential increase in COVID in 1 or 2 of the southern states, but in general, it's low. And notably, for the past few years, there has been a sense of a summer COVID wave, as many people suggested we would have. And anyone who's listening to this podcast knows that I have not jumped on board with that conclusion. I think it's more of been a function of every six months or so, we would see an increase as waning immunity allowed people to be more vulnerable to infection. We'll see here. But right now there does not appear to be a summer COVID wave coming. So again, I can just emphasize to everyone from a COVID, flu and RSV standpoint, we're in pretty darn good shape right now.

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

Dr. Michael Osterholm : Well, since this weekend marks both the 4th of July and the 250th anniversary of the signing of the Declaration of Independence, I wanted to highlight a story about our first president, George Washington. I'm sure you've heard many stories about Washington over the years, but did you know he implemented the first mass immunization policy in the US before he officially became president? Washington served as a military general, leading thousands of soldiers in the Continental Army. On February 6th, 1777, George Washington ordered for his entire Continental Army to be inoculated with smallpox. This was because, in fact, the Brits that they were fighting against came from a country where smallpox was common, and many individuals as children would develop smallpox died or survived, of course, and then would go on and be immune from further smallpox infections. Then, therefore, if they were in the United States, they were not vulnerable to the virus. Meanwhile, because those who lived in America had been shielded from most of smallpox and with very limited transmission, we had a very high level of vulnerability to smallpox in this country. And Washington knew that if he was going to prevail against the Brits, he could not have most of his soldiers out with smallpox or, for that matter, even dying with that decision to order his Continental Army to be inoculated, he wrote.

Dr. Michael Osterholm : "Necessity not only authorizes, but seems to require the measure for, should the disorder infect the army, we should have more to dread from it than from the sword of the enemy." Even back then, Washington recognized how infectious diseases could pose more of a threat than war itself. So it was that all the Continental Army in Philadelphia and Morristown, new Jersey. Those taking on the British soldiers were in fact exposed to what is called variolation. In this case, what happened is that someone would take a thread and rub it over a smallpox lesion from a case, and then break the skin of another individual and take that thread that had the pus from the infected patient and inoculate that individual with that. A very crude but yet turned out to be highly effective way to provide protection. It is true that there was some increased serious illness and mortality. But what is subsequently represented now was the ability to have your troops become immune to what the British Army was already immune to. In summary, Washington's decision to inoculate the entire Continental Army was controversial at the time, but it proved extremely important for the success in the long run in protecting the Continental Army against a virus for which the British military were already largely protected.

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

Dr. Michael Osterholm : Well, there's a trend here with these messages. The first one, something I've repeated through several recent podcasts, and that is the respiratory illness in this country are down. They're down. And that's even considering the Lackland Air Force Base outbreak. That's good news. We'll keep you informed at this point. We all will be anticipating our fall vaccines And if we can stay in a similar mode in terms of transmission, as we're seeing now, we will be in the best place we've been in in over seven years with these respiratory viruses. The second thing, Ebola is not looking good. It's just not. I worry very much that we're losing control of what's happening there. And the more that that happens, it means that the greater the likelihood that it'll take us that much more to bring it under control. Think of yourself as a forest firefighter and what that means when you approach a blaze of 100 acres versus a blaze of 100,000 acres, a very, very different approach to what you must do. And right now, I worry that we're losing the opportunity to fight Ebola at the 100 acre level, and we're soon going to be seeing ourselves at 100 000 acre level. The third one is the screwworm  has surely captured a lot of people's imagination, and understandably so. I think this is going to be a big challenge. I think we're going to see a number of additional states impacted this screwworm  can survive where it doesn't freeze over the winter. And there was another a number of southern states where, in fact, I think you're going to see, unfortunately, frequent infections with this fly not only what it means for livestock, but as we've just discussed today, for wildlife and even for domestic pets.

Chris Dall: So, Mike, there has been a theme for this episode of the podcast revolving around 4th of July. And I think your closing song fits nicely into that.

Dr. Michael Osterholm : Well, thank you Chris. I did want to hit home something about the 250th anniversary of the signing of the Declaration of Independence, but in a way that also can bring a smile to everyone's face. And so I've chosen today a song that most of you probably could sing from memory. This land is your land. It's one of the most famous American folk songs written by Woody Guthrie. On February 23rd of 1940, the track was conceived as a critical response to Irving Berlin's God Bless America, which Guthrie felt was unrealistic, complacent and overplayed on the radio. The original title was God Blessed America for Me, before changing the signature reframe to this Land Was Made for You and Me. Notably, Guthrie lifted the melody note for note from a Baptist gospel hymn called When the World Is on Fire, famously recorded by the Carter Family. This is a song that I remember so well listening to Pete Seeger sang, as well as many other folk artists. Today I share with you the spirit of the moment of the 250th anniversary. And this land is your land. 

This land is your land. This land is my land. From California to the New York island. From the redwood forest to the Gulf Stream waters. This land was made for you and me. As I was walking that ribbon of highway. I saw above me that endless skyway. I saw below me that golden valley. This land was made for you and me. I've roamed and rambled. And I followed my footsteps. To the sparkling sands of her diamond deserts. And all around me a voice was sounding. This land was made for you and me. When the sun came shining. And I was strolling. And the wheat fields waving. And the dust clouds rolling. As the fog was lifting. A voice was chanting. This land was made for you and me. As I went walking, I saw a sign there. And on that sign it said no trespassing. But on the other side it didn't say nothing. That side was made for you and me. In the shadow of the steeple. I saw my people. By the relief office. I seen my people. And as they stood there hungry, I stood there asking, is this land made for you and me? Nobody living can ever stop me. As I go walking that freedom highway. Nobody living can ever make me turn back. This land was made for you and me. Woody Guthrie. 

Well, thank you again for spending your time with us. We covered a lot of complicated, difficult topics. I hope some of it made sense. And I want to again thank you for your support of our efforts. We so appreciate and welcome the feedback. It means a lot to us. And if you have ideas for what else we can do on the podcast, or particularly questions about topic areas you'd like us to address, please share those with us. So thank you. Have a great 4th of July. Be safe. Enjoy the weather, wherever you're at. If you're in Minnesota, you may not just enjoy it unless you're in a lake somewhere. All I can say is I'm happy we're not sitting in 40 below zero. Thank you for your kindness and be kind right now. Boy, do we need that. 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.edu. This podcast is supported in part by you, our listeners. The Osterholm update is produced by Sydney Redepenning, Elise Holmes and Ruby Guthrie. Our researchers are Cory Anderson, Meredith Arpey, Leah Moat, Emily Smith, Clare Stoddart, Angela Ulrich and Mary VanBeusekom.