Episode 161: What's Going On and Why Does it Matter?

Chris Dall: Hello and welcome to the Osterholm Update, a podcast on COVID-19 and other infectious diseases with 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 nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. I'm Chris Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. Given the patterns that have been established over the last four years, shouldn't be surprised to anyone that, just as we've seen in previous summers, COVID-19 cases appear to be rising again this summer. The centers for Disease Control and Prevention said late last week that some areas of the country are seeing consistent increases in COVID-19 activity, while Bno news reported that COVID cases have been rising slowly for five straight weeks and are likely much higher given that most people are testing at home and many states and hospitals are no longer reporting detailed COVID data. Are we on the cusp of another summer surge of COVID cases? That will be our lead topic on this July 11th episode of the podcast. We'll also discuss COVID wastewater levels, provide an update on the latest H5N1 developments, answer an ID query about the timing of updated COVID shots, and discuss the latest news on measles, mpox and dengue fever. We'll also bring you the latest installment of This Week in Public Health history. But before we get started, as always, we will begin with Doctor Osterholm's opening comments and dedication.

Dr. Osterholm: Thanks, Chris, and welcome back to all the podcast family members who are joining us again. Uh, thank you for staying in there with us. We appreciate that very much. And for anyone who might be new to the podcast, I hope today that the information we're able to share with you is what you're looking for and that you find useful. I will warn you, if you're new to the podcast, the podcast family members already know this. It's an eclectic kind of podcast, you might say, where we cover topics freely from A to Z, from the head to the heart, and. But nonetheless, I hope that it's helpful to you. I'd like to start today by talking about a topic that's been on my mind a lot lately. I'm sure it's also been on yours, at least for some of you, over the past few weeks. Willingly or not, our country seems to have been thrown into a debate about what it looks like to age and to age. Well, and I'm not even sure necessarily what that even means to age well. Recent conversations with many of my friends and colleagues have been reflective of this too. The topics of surgeries and fall prevention have now become common among the other regular life updates we share with each other. Whatever the motivation for thinking about aging, maybe you're nearing a milestone birthday or just love someone who is. I think it's a worthwhile topic to reflect upon. I personally have reflected a lot on this. Most of you know on the podcast, I'm 71 years old and I've lived a lot of life, and I look today at who I am and what I am, and I ask myself, is this the same Mike Osterholm that was doing this job 20 years ago? Am I able and capable of doing the job that's necessary for me to do to run this center in a way that's highly effective? I also think about my accumulated life history scenario and remind myself why, in all those early years of long distance swimming challenges, you know, swimming, the English Channel, uh, issues like that, where I literally did everything I could to induce skin related cancers and later life, I don't know why I didn't do a better job of protecting myself at that time, but I didn't.

Dr. Osterholm: I think about even the extent of which today I regret that I was the victim of unfortunately far too many punches to my eyes from a drunk father when I was a young boy. Today, I actually experienced the challenges of that very kind of trauma that I had many years ago. I think about the fact I'm one of the few people that should know better, but more importantly, having had the opportunity to know better once and then twice, I have fallen off a two story roof twice in my lifetime, both times asking myself, what was I doing up there to begin with? And number two, after the first one, you would have thought I would have given away all my ladders to the people out there that I don't like. I didn't, and I fell a second time, and I'm paying for that today in terms of some of those arthritic conditions that one has to suffer, having had various aspects of orthopedic injury.

Dr. Osterholm: I think about all those things. I think about how I spent my time in life. What did I really learn? What did I really share? What is it that I am today because of that life? And it's all about aging. So it unfortunately, it seems to me that we've only come to think about aging when it's in response to something scary or negative a diagnosis, a loss, or a public show of cognitive decline. What about all the other things that come with getting older? I like to think about the biggest sign of my own aging is the ever growing collection of memories and stories I have and share about my family, personal adventures, and professional accomplishments. I have to say, it's also a wonderful opportunity to take all these hard learned lessons that I've had, and to try to share them with the upcoming generations my kids, my grandkids, my colleagues, and say, you know what? Learn from this one. Don't do what I did. This is what you can realize now without having to experience what I did. Aging is both a very good and sometimes a very challenging combination. It's the new aches and pains, the mobility challenges, the loss of loved ones. It's the ability to adapt. It's reflecting on our priorities. It's the understanding of loneliness and finally, the wisdom that comes from having lived a full life. The conversations in aging is one that can't be put off any longer.

Dr. Osterholm: The number of Americans aged 65 and older is projected to increase from 58,000,000in 2022 to 82 million by 2050. That's a 47% increase in just the next 28 years. From a public health perspective, which I know you all care about as listeners of this podcast, how will we care for our aging population is a major challenge our field will have to grapple with. It says a lot about who we are as individuals, as members of our community, as family and friends, and even what are the values that we hold in this country. In addition to addressing the very real health concerns of the older population, how can we target interventions that help them not just survive, but thrive? Today's dedication is for all of those who are growing older and wiser. I consider myself lucky to be one of you, and I can't wait to see that what this stage of my life brings, knowing that it will be a combination of gifts and challenges. So I hope for all of you, as you are growing older, you to reflect on the lives that you've lived and how you can live those remaining years of your life to maximize your happiness, the happiness of others, and to know that you can feel satisfied in how you have lived your life. For all of you, I accept this dedication as not just a challenge, but an opportunity to reflect on how do we accommodate growing older with the quality of life that we all hope and want. Now moving on to that other topic that, uh, if you're again, you're a routine listener to the podcast, you know all about our sunlight.

Dr. Osterholm: I must say that in the state of Minnesota right now, sunlight is actually a rare commodity in the sense of actually seeing the sun. We've had so much rain over the past month, but again, we needed rain. Just unfortunately for some parts of our state, we got far too much, resulting in major flooding. But as we have a clear day today here in Minneapolis-Saint Paul, the sun rose at 537 sets tonight at 859. That's 15 hours, 21 minutes and 12 seconds of sunlight. Unfortunately, we are now having turned the corner, beginning to lose that light. Uh, we lost one minute and 25 seconds of sunlight today, but I'm happy to report from our very dear friends and colleagues at the Occidental Belgian Beer House on Vulcan Lake in Auckland, New Zealand. Today. You saw the sun rise at 732, setting tonight at 521. That's nine hours and 48 minutes and 55 seconds of sunlight. Yeah, we've still got you beat by a while, but guess what? You're going the other way. You had 59 seconds of additional sunlight today. We will meet somewhere in September, and at that time, exchange that happy roll of I'm getting my sunlight back. Wish you were. Again. Thank you for joining us today. I hope that this podcast is helpful as we're taking on a number of complicated topics, ones that are front and center, and we're acknowledging the discussion that we're all having in this country today on what it means to be aging.

Chris Dall: Mike, we've been leading with H5N1 for the last several episodes of the podcast, but this week we are turning back to COVID with cases on the rise again. As I noted in the last episode, the anecdotal data certainly seemed to indicate an uptick here in the US. But how much is that being reflected in the official data? As sparse as it is and what's going on in other countries?

Dr. Osterholm: Let me begin this answer with one word repeated a few times for emphasis. Humility. Humility. Humility. This is where we have to be honest and say, what do we know and not know? What has experience taught us? What do the data that we are collecting tell us? What are the gaps in those data that therefore we have challenges understanding what's going on? What is it this virus is doing that might be new? And in that sense, Chris, I can say quite honestly, as I've been trying to piece together what's been happening with COVID, it almost brought me back to the early days of the pandemic, where we had to really emphasize that there were a lot we didn't know. Case data was scarce because tests were so difficult to find, and we relied pretty heavily on hospitalization data. Fast forward to today, and case data is scarce because most people are testing at home. And even if they're testing at all, and those numbers are not making their way to local and state health departments. However, on top of that, we're now also missing out on a sizable chunk of hospitalization data because hospitals are no longer required to report these cases either. As a result, wastewater data has become one of the go to metrics we have, at least for the US data. And as I mentioned last episode, even that can be confusing at times. And as I noted in the previous podcast, we will get into that confusion a little bit more and we will do that in just a second.

Dr. Osterholm: But let me first just provide a brief overview of where things stand with COVID as we see them. First, here in the US, the amount of virus that's being detected in wastewater surveillance has increased throughout the past couple of months, basically ever since May. Now, the good news, at least at this time, is that the overall levels remain relatively low compared to what we've seen in the past. As an example, according to data published by the CDC. There was a stretch from August 2023 to March of this year, a total of 33 straight weeks where the levels exceeded where they're at now. Still, our current trajectory has some parallels to the increase we saw last summer, which eventually led to some of the elevated activity I just mentioned from last fall into the spring. In this present situation, however, the increase seems to have started around a month and a half earlier than the one we saw last summer. Last summer increases began in July, whereas this summer it appeared to start sometime in mid-May. So how long will this last and where will things peak? At this point, I'm not sure it warrants a sounding of the alarms, but as always, the increased activity is something to keep in mind and pay attention to. This is especially true for those living in areas of the country with levels above the national average. On a regional basis, this includes the western US and southern parts of the country.

Dr. Osterholm: In addition, there are several states, including Hawaii and Florida, that have been seeing some fairly dramatic increases in wastewater levels. Otherwise, beyond the wastewater data, there also has been some additional signs of increases, including climbs and test positivity, the percentage of emergency room visits resulting in COVID diagnoses and hospitalizations. Now, again, as I just said with hospitalizations, the data aren't complete by any means. For example, Bno news is reporting that just 34% of the US hospitals provided COVID data this past week, which is down from 91% in early May. Again, this is a byproduct of US hospitals no longer being required to report COVID numbers to the center for Medicare and Medicaid Services. However, even with the decline in hospitals reporting this information, COVID hospitalization numbers have climbed, going from less than 1800 in mid June, when 35% of the hospitalizations reported to nearly 2600 as of last week. Again, these numbers really only account for what's happening one out of every three US hospitals, so it's not the entire picture. As a result of this, we once again expect the deaths will start to rise. Otherwise, right now, the weekly total stands at a record low of 283, which is the equivalent of 40 deaths a day. More specifically, that's about 14,600 deaths per year. And as I've said so many times on this podcast, but it bears repeating every time. These were not just numbers.

Dr. Osterholm: These were our mothers and our fathers. These were our grandparents. These are our brothers and sisters. And unfortunately, even in some cases, there are children. Again, we'll see what the weeks and months ahead bring in terms of COVID activity. Hopefully we'll have a better understanding of what the role of the FLiRT variant the Cp2 and CP3 have had combined. They account for more than half of US cases and could certainly be playing a role in the increases. As you've heard me talk about this before, variants are a wild card. We do not understand what they really will do to us in the future. We've seen variants arrive that were suspicious and concerning, for which little happened. On the other hand, we've had variants sneak up on us and move quickly, rapidly increasing case incidence. I don't know what the FLiRT variant will do, but I don't like having it around. Supporting the possibility of an influence from the FLiRT variant. Recent upticks in places like Australia, New Zealand and the UK, where the frequency of FLiRT variants is also climbed is an important warning. Otherwise, growth of another variant, LBX.1, which is similar to the FLiRT variants but with an additional mutation in the US and beyond, is another trend we're keeping an eye on, since it could potentially prolong or worsen any sustained COVID increase. And of course, remember waning immunity. The combination of both new variants and a 4 to 6 month post-vaccination or illness history is what waning immunity is all about.

Dr. Osterholm: And so from this perspective, are we seeing an overlap now again, in both the new variant and waning immunity, which surely is there for many of us? And I'll talk about that more later. When we talk about the vaccine. So will the current situation play out like the increase of last summer, which shifted the baseline up heading into fall and winter? Will this be a more simple, subtle rise and fall? We don't know. I do know there still is no evidence of seasonality, a winter virus or a summer virus. It seems to be a virus that comes with new variants and waning immunity. We'll have to wait and see. But in the meantime, we're all asking ourselves, how do I live my life? What does this mean? And I again support all of you in any of you who are at increased risk for serious illness, older underlying health conditions, who have been at least 4 to 5 months out from your last vaccination or previous COVID infection. Take the steps that you feel most comfortable with to protect yourself. Masking when necessary. More testing. Testing of people coming to see you. At this point, that is such an important tool that you have. And then then hopefully we can get through to the point of where we'll be talking about vaccines in a moment, and you can get your next dose of what I think will be, again, another good vaccine matchup.

Chris Dall: So, Mike, let's dive a little deeper into that wastewater issue You just cited the wastewater data from the CDC, but that's not the only group that's monitoring COVID levels in US wastewater. And over the past few weeks, those sources have had different interpretations of what's going on. So is that still the case, and if so, why?

Dr. Osterholm: Well, Chris, it is and it isn't. And I'll do my best to explain why that's the case. Basically, at this point I'm aware of three major clearinghouses of SARS-COV-2 wastewater data in this country, which helped shed some light on regional and national trends. These include wastewater scan, the CDC's National Wastewater Surveillance System, abbreviated NWS, and then a third organization, the Biobot analytics. Let me talk about Biobot first because I'll kind of move that to the side. It really isn't a major source of information today, although we've looked at BioBots data quite a bit in the past to help develop information for this podcast, they actually announced this past May that they'd be rolling back their public data reporting efforts for COVID. So they really have played a limited role in the recent wastewater data story. So when it comes to your question, Chris, I'll only really be referring to the two other sources I mentioned, the wastewater scan and the CDC national wastewater surveillance system. These are the two sources that at times have provided some conflicting data in terms of wastewater trends. And that's what we're seeing right now, for example, which is perhaps the starkest difference between the two is their assessment of the overall national wastewater trend, according to the wastewater scan, which is work led by researchers from both Stanford, Emory and Verily, a private company. Us levels are now considered high. From looking at their website, the designation was made based on overall concentration levels of the virus in sampled wastewater and several weeks of ongoing upward trends.

Dr. Osterholm: Now, how does that compare to the CDC's wastewater surveillance system? Well, according to them, the overall national levels are low, at least as of this past Monday. So what is it? Is it high? Is it low? What's the difference and why? Well, first of all, it's a subjective term. Ultimately, it's up to each group to come up with the criteria they want to use to designate what's happening. So this certainly reflects some differences between the two in that regard. However, there are also other important differences that are worth pointing out too. One is the overall number of sampling sites and states that each source includes with water waste scan. There are a total of 120 sites with recently updated COVID data located across 38 states. Now for comparison, the CDC's National Wastewater Surveillance System had up to date data from 963 sites from across 49 states. So 120 sites versus 963 38 states versus 48 states. So in terms of the overall representativeness, I think it's safe to say that the CDC national wastewater system provides a more comprehensive picture of what's happening with wastewater activity. In fact, the National Wastewater Surveillance System data reportedly covers 126 million Americans, compared to wastewater scans 39 million. Moreover, while the wastewater scans data includes sampling sites across 38 states, a total of 48 of these states, or 37%, had data from just one individual site in that state. In other words, whatever is happening in one single wastewater site, a municipal wastewater treatment facility could also mistakenly be applied across an entire state.

Dr. Osterholm: And if you're not being careful, you could come away with some trends that don't necessarily reflect what's actually happening across the entire state or region. So that's where, again, I think the national wastewater surveillance state is a safer choice when it comes to looking at state level and regional trends. That being said, I also want to note that there are certainly still lots of value with the wastewater scan data. In general, it's more up to date compared to the national wastewater surveillance system. For example, as of Monday, wastewater scan featured data up to early July, whereas the national wastewater system data only goes up to June 22nd, and it has yet to be updated due to the 4th of July holiday. So it can provide a more real time update, particularly for those places where it has sampling sites. Beyond that, the wastewater scan group actually monitors for a dozen different pathogens, not just SARS-CoV-2. This makes it a very important resource. Otherwise, I think it's also important to highlight the fact that regardless of any discrepancies in activity level categories such as high, medium, and low, both sources are showing a rise in wastewater activity across the US. So there are now upward trends and that's important to keep in mind. That being said, it's also important to consider what sources you're using and what the strengths and limitations are.

Chris Dall: Now to H5n1. The CDC reported on July 3rd that a fourth US farm worker had been infected with H5n1 avian influenza. Mike, can you discuss this case and any other items of note since the last podcast?

Dr. Osterholm: Well, Chris, let me first just, uh, give an update on where we're at with the case numbers in terms of the dairy cattle outbreak. We're now up to 143 farms. But in the same 12 states that we've been talking about now for over a month, there's no evidence at this point of additional transmission in these other states. Now, I hear from people often saying, well, you could be missing a lot of transmission out there in some of these states. And I think that's a possibility. But I am struck by the fact that now that there is so much more awareness of what's happening, if in fact, a farm, even in one of these other 38 states, were to have activity, it would probably likely be detected by local veterinarians, agriculture related employees, etc., even if the farmer themselves didn't necessarily bring it forward. So I don't think that we are seeing widespread transmission in many states. That also matches up with what we're seeing with human illness. The human illnesses continue to be associated with those areas already identified, and they're now four cases. You talked about the most recent one, which was a case of conjunctivitis, again, someone who got infected in their eye. I've talked about that before, that I expected more of those cases to occur. That is where the two three receptor is at the bird virus receptor for the cells in the eye. And that's why you're likely to get infected there. This person did not have classic influenza. Now why do I think that this is important in terms of the number of states impacted? Because I think it's helping to provide some definition as to what happened in the early days of the virus movement.

Dr. Osterholm: The fact is that we can now say with some real certainty that this is a single spillover event. If you look at the genetics of the virus, it's clear it's the same virus we've been seeing in all 12 states. And we continue to see even the infections of the four individuals. And if there had been more spillovers in other locations, we would have seen slightly different viruses genetically. The other thing that I think supports the fact that this was a single spillover is that we're not seeing any evidence right now in Canada or Europe, where they're doing market basket survey, sampling of milk products, looking for any evidence of H5n1, and they're not finding it. And so from that perspective, it also says they have not been impacted yet. And so I look at this now as understanding a little bit better, the fact that this virus likely did have a single spillover event and that that's what we're dealing with. So what do we know about the virus in this podcast that we didn't know a couple of weeks ago? And I don't think much. Uh, there was a paper that was published this past Monday in nature which suggested that the virus from the dairy outbreak did bind quite well to the two six receptor. This is the one that, of course, is the human receptor that's in our respiratory tract and the respiratory tract of pigs.

Dr. Osterholm: And of course, as we've now found out, is also in the udders of cows. But what I think was important to note here is that while this paper supported the idea that, oh my, this may be now binding to human cells. There have been other groups who have found opposite results. I think that was a miss by some of the media, and surely even some of my colleagues, when they really emphasized the findings about the receptors from this current paper versus what had been found elsewhere. So I still see this as a relatively low risk to humans in terms of the transmission of the virus, which would lead to human to human transmission, i.e. leading more to a pandemic kind of situation. Now, let me be very clear. We're going to have more influenza pandemics. H5n1 could possibly be the virus that eventually makes that happen. Uh, and reassortment could take place overnight, where a bird virus and a human virus get into the lungs of a human, a pig, or now in the udder of a cow and result in that new virus. But I don't see that happening right now. And so we need to be prepared. Now, I have been frustrated by, uh, some of my colleagues who continue to assert that, you know, we've got to be better prepared for this by getting vaccines right now. Well, first of all, uh, we don't know what the next pandemic virus is going to look like in terms of at least influenza and specifically, will H5N1 do it, even the 4 million doses of vaccine we have now, which, by the way, really equates to 2 million people getting vaccinated because each person will need two doses.

Dr. Osterholm: Um, we don't know that the vaccines we currently have will have any impact at all on protecting people from a new Reassortant virus or a mutated virus, should it occur with H5n1. Remember, I keep pointing out, and while it's not a perfect example, it gives you some sense. Remember, in 2009 we had an H1N1 seasonal virus vaccine, and then along comes the new H1n1 from the swine operations of central Mexico. And voila! We needed a whole new H1n1 vaccine because the seasonal provided no protection, even though they were both H1n1. So I think we have to be careful in the days ahead, I will have an article coming out in Foreign Affairs, which will actually dig in deep to the issue of what would it take for us to be better prepared for influenza with vaccines that work? When I say work, I'm not expecting them to be highly, highly effective. Remember, with seasonal vaccine, we get 20 to 55% protection against medically attended influenza. Now, what that means is it keeps you anywhere from 20 to 55% of the time, from having to go and be seen at a hospital or a doctor's office. That's still a very positive result, but it's not what we all like to see where it protects against most of all the illnesses.

Dr. Osterholm: And on top of that, I have to just remind people that when I hear, uh, the idea that we're going to use these vaccines to stop transmission, uh, we have little data at all to support that influenza vaccine, at least from a seasonal standpoint, does that. It doesn't stop transmission. People still can get infected. It's just the point that makes them good. Vaccine, from my perspective, is it does reduce serious illness, hospitalizations and deaths. So I think at this point, Chris, it's a stay tuned moment. Uh, nothing has happened in the last two weeks that would give me pause to think we are heading down a bad road here. I think at this point, what we have to remind ourselves is things could change in a heartbeat. But at the same time, we have to be honest. We have to nuance what we know. For those of us who've been dealing with this virus since 2003, you know we've been here a number of times to the edge of the cliff and only to suddenly be pulled back and then wonder why we got to the edge of the cliff, and also, why do we get pulled back? I don't know if that's what's going to happen here or not, but at this point I would say I don't see any real red flags, uh, that were, uh, about to experience something much more severe than we currently have.

Chris Dall: It's time now for our ID query. And this week our question is about the timing of COVID vaccine shots. Given the uptick in COVID activity, many listeners who are six months or more from their last COVID shot have been asking us if they should get one now, or wait until the updated COVID shot is ready in September. Mike, what are your thoughts?

Dr. Osterholm: Well, first of all, I want to ask myself that same question. I hope I give myself a good answer. Okay, because I'm with you. I'm completely with you. I'm now five months out from my last dose of vaccine. Uh, you know, I've already commented. I'm 71 years old. Uh, I've already had COVID once. Uh, I experienced four months of long COVID after that. I don't want to get it again. So I'm looking forward to getting that new vaccine. Let me preface my comments here by saying this is not an official recommendation or medical advice I'm going to address, because there is none that really answers that question. It's just my opinion, and it's what I'm personally going to do and why I'm going to do it. So right now I'm choosing to wait to get the new vaccine when it becomes available, hopefully sometime by late August. That's what we're hearing. COVID activity is currently relatively low, but yes, it's increasing and the variants are at the center of the action. But these new vaccines will target these FLiRT variants, meaning the mRNA vaccines from both Pfizer and Moderna. This will provide better protection against these circulating strains. Getting another dose of the current formulation would protect us again against Xbv 1.51 that has virtually disappeared.

Dr. Osterholm: It's an old one. Now, the Novavax vaccine, which is a protein vaccine, will continue to use Xbv 1.5 because they're not able to bring their manufacturing forward in a timely way to produce their vaccine with the FLiRT variant. So it's a gamble. I should get a vaccine again. Right now, I'm at that stage where I've been out far enough where I can do it, uh, but with probably less protection than I surely would hope to have for 4 or 5 six months. I can gamble and wait for another two months or a month and a half and get the FLiRT variant vaccine with Moderna or Pfizer. I've elected at this point to wait. Uh, and I hope that that's a good answer. Now, remember, for those who have been infected, you have to wait 3 to 4 months according to the W.H.O., or 90 days if it's in this country from CDC between the time of infection and get a new dose. So if we do get infected in the next couple of weeks, you wouldn't be able to get your vaccine for at least 90 days after your recovery. Now, if you've been vaccinated, you have to wait four months.

Dr. Osterholm: And that's the downside right now. If I get vaccinated now with an additional dose, which I'd like to have because I'm far enough out there, then in fact, I have to wait four months to get the actual variant vaccination. So I'm going to elect at this point to wait it out, hope that I don't get infected. And the fact being that right now we seem to have a relatively much lower level of infection transmission, and then we might very well have in a couple of months. So please do not take this as official advice. This is me. This is talking to all my colleagues and what they're going to do. And I would say right now, nine out of ten of my colleagues that I've talked to who are in the same boat, meaning that they are at least four months out from their last dose of vaccine, are going to wait and get the new mRNA vaccine that will include the FLiRT variant. Feel free to do what you think you should do. Talk to your physician. Uh, but now you have my least logic for what we're doing, and all I can hope. Knock on wood, that is the right logic to have.

Chris Dall: Now to some other infectious disease news. On June 25th, the CDC issued an alert to warn health providers and the public about an increased risk of dengue virus infections in the United States. Mike, what prompted the CDC to issue this alert?

Dr. Osterholm: Simply put, Chris, the shockingly high numbers of cases this year prompted that alert. It's impossible to ignore. In the Pan American Health Organization's America region, the number of confirmed dengue cases has now surpassed 10 million just this year, more than twice the number recorded in all of 2023. Of the 43 countries and territories that have reported dengue cases, Brazil has the highest number of cases with 7.8 million. Now, it's important to note they have a population of 218 million. Knowing that dengue is underreported, even the reported cases still have impacted 3.2% of the population just this year so far. So this gives you an idea how widespread this is. And it's important to note that Brazil is one of several countries being hit hardest that have all four serotypes of the dengue virus circulating along with Mexico, Guatemala, Honduras, Costa Rica, Panama and El Salvador. Now, let me take a step back to help everyone be more familiar with what is dengue is all about. This is a virus again transmitted by the 80s mosquito, Aedes albopictus and 80s aegypti. I'll come back to that in a moment. But what's important is, is that in historic terms, there were four different serotypes of the dengue virus that arose over the evolution of time. The and none of those overlapped each other. There were two in northern and southern Asia, one in Africa and one in the Americas.

Dr. Osterholm: When you were infected with one of those viruses, you had the case of dengue. Some call it breakbone fever. And through history, the case fatality rate for dengue was actually very low. People felt like they were going to die. That's why they called it breakbone fever. Because you felt that bad, but you fully recovered. Well, what's happened since World War two? We have now moved mosquitoes all around the world, and now all four serotypes are located geographically. Wherever prior, there had been one serotype. And with that post-World War two picture, we now have a new manifestation of dengue infection that is so critical. It's called dengue hemorrhagic fever. This is a very serious illness. And this occurs when you've been previously infected with one dengue strain and you have just enough antibody not to protect you, but to cause a condition called immune enhancement when you're infected with a second dengue strain. This is where the hemorrhagic fever piece comes in. This is where it becomes a very serious challenge, in the sense that anywhere from 10 to 20% of people may die, particularly young kids, from this infection. Now the challenge we have is if you have no antibody, you get dengue again, remember, but you don't get dengue hemorrhagic fever. You have lots of antibody from previous infection. Then you actually are protected against dengue or dengue hemorrhagic fever.

Dr. Osterholm: It's that waning immunity amount in the middle. And it also varies somewhat by the actual strain of the virus you got infected with first and that which you get infected second. So why is this all happening now? What's changing? Well, largely it has to do with urbanization. Some people say it's climate change, but really at this point, that's only of limited impact. 80s mosquitoes love to live close to people. They love to live around junk. They love to live around anything they can actually hold. Just a little bit of water. A good example of post-World War Two was all the military equipment that was left behind in these tropical areas, particularly in the South Pacific. You know, an old jeep might sit there and rust away, but it also held a lot of hidden water spots from rainfall. Ideal locations for Aids to breed. Aids are what we call the household mosquito. They won't fly across the city street. They won't fly across an open park. They live right there. And when you have the kind of plastic, garbage and junk that people have in these urbanized areas, many, many breeding spots for these 80s. So, in fact, what we're seeing right now is really a result of this modernized world of moving things around the world and then providing the habitats like we just talked about.

Dr. Osterholm: So this is now become a huge challenge. Now the picture in the US is not nearly as severe as those we just discussed, but because we're living in an ever globalized world, the alarm bells are really still ringing. As of mid June, there have been 1597 cases of locally acquired dengue in the US, with 1580 of those from Puerto Rico and 17 others detected in the Virgin Islands. In Florida, dengue continues to be a threat to public health in Puerto Rico after the country declared a state of emergency regarding the virus in March. I believe the combination of severely heightened dengue cases of all serotypes in Central and South America, plus the season of summer travel, results in a greater risk of dengue exposure and ultimately prompted the CDC to issue the health alert. The centers alert included specific recommendations targeting health care providers, health departments and the public, which I think was a good move. Awareness and response needs to increase among all these groups in order to effectively manage dengue. That includes this diagnosis and treatment. We will post the CDC's health alert in this episode's notes for our podcast family to review. It's especially important to be aware of dengue and other vector borne diseases. If you reside in or traveling to one of these areas with frequent circulation.

Chris Dall: Finally, Mike, we've been wanting to discuss measles and the Mpox virus on recent podcasts, but just haven't had the time. So let's start with measles. What's going on there?

Dr. Osterholm: Well, Chris, one area in particular that really concerns me when it comes to measles is the Who's European region, which includes 53 countries from 2009 to 2017. Reported measles cases did not exceed 40,000 cases across these countries. But something changed in 2018, though, when the recorded case numbers reached almost 90,000, followed by 106,000in 2019. From there, the pandemic hindered measles data collection, which led to a less clear picture of the disease and a major setback of progress. Fast forward to 2023. The W.H.O. recorded 61,000 cases, which was still somewhat obscured by the pandemic conditions. Now, as of April 2024, the European region has already reached 70,000 cases in just four months, though deaths remain relatively low thanks to medical advances. More than half of the infected individuals are typically hospitalized and can experience severe symptoms and complications, including pneumonia and encephalitis. You may be wondering what happened here. From a bird's eye view, measles vaccine coverage appears high during this period. It was about 95% of children received at least one dose, and 91 to 92% got both jabs. What is obscured by this regional data, though? There are entire communities within and between countries that remain susceptible. There are also countries with relatively smaller populations that account for a disproportionate number of measles cases, most of them which are located in the eastern part of the region. These countries now account for almost 98% of the reported cases in the region.

Dr. Osterholm: But let me put this into context. The W.H.O. estimates that about 136,000 deaths occurred from measles in 2022. 95% of the deaths occur in countries with low per capita income and weak health care systems. And when you look at it a global level, only 83% of the 134 million children born in 2022 were vaccinated by their first birthday. That means 23 million kids in this world were not vaccinated by their first birthday against measles. These are the children that will develop measles one day and will unfortunately help spread it around the world where we don't have 100% protection. So this is really an important issue right now. We have a very safe and a very effective vaccine. This should not be on the public health agenda of 2024. We should be close to keeping measles to just a few thousand cases a year across the world. And yet we're not. The W.H.O. has issued a warning about these trends in the countries around the world, urging them to vaccinate the vulnerable, concentrating on those newborn children. But there continues to be such hesitancy. I fear that the combination of hesitancy and lack of resources in low income countries is going to mean that we're all going to be facing a kind of measles world that just 10 to 15 years ago, we never could imagine would ever be back with us.

Chris Dall: And then earlier this year, we discussed the emergence of a new strain of the Mpox virus in the Democratic Republic of Congo. That's different from the strains circulating globally. Do we know anything more about this strain, Mike.

Dr. Osterholm: First, Chris, let me just lay out a little background for you related to Mpox. This virus is related to smallpox. It's part of what we call the Orthopoxvirus family. And throughout history, smallpox was the very dominant infection that occurred throughout the world. And people would get smallpox and either die from it, or they would survive and now have immunity against smallpox, which actually provided cross protective immunity against mpox. However, as you know, in the late 1970s, when we brought about to the world the greatest public health achievement of all times, the elimination of smallpox from the world is eradicated. There was no longer a need to vaccinate. So therefore, in all of Africa, smallpox vaccination stopped. Well, it took about 20 years. Then we started seeing a population from an age cohort standpoint, 20 years or less, who actually started to develop impacts infections from contact with rodents, monkeys or other mammals that also carried the virus. And then that started some limited transmission within the countries between person to person. Well, since that time, things have even gotten much more complicated, where now the vast majority of the African population has no immunity impacts. And in fact, there now appears to be much more contact as the population grows between those who live there and these animal species I've just talked about. So as I talk about this, I want you to just understand the background of how we went from a disease of virtually no public health importance to one now of great importance. The strain that you just mentioned, Chris, is a cause for a significant amount of morbidity and mortality in the Democratic Republic of the Congo. As a reminder to our listeners, this strain is from clade one lineage, which causes more severe disease and death compared to clade two lineage, which was responsible for the global mpox outbreak that occurred in 2022, in the DRC.

Dr. Osterholm: There have now been over 7800 Mpox cases and 384 Mpox deaths reported so far in 2024, yielding a case fatality rate of almost 5%. And sadly, many of these cases and deaths have occurred in children with children under the age of five accounting for 39% of the cases and 63% of the deaths. Clade two the less deadly lineage of the Mpox virus is continuing to spread in other parts of the world. South Africa saw its first case of mpox the clade two strain, now back in early May, and has now reported 19 additional cases since then, including three deaths here in the US. An uptick in clade two mpox cases have been reported in Los Angeles, with LA County Public Health reporting approximately ten cases in a two week period in June. This was up from two or fewer cases per two week period during the past several months. Again, these are largely associated with sexual contact. As always, we'll keep you updated in this situation as it progresses, both in the US and internationally. I think it's very important that we understand that the clade One virus does pose a potentially major threat to health in countries, particularly in Africa. At the current time, there is a vaccine that's available. There are efforts underway to provide that vaccine. In Africa. Supplies are limited. The US government is doing its part to get as much of the vaccine to Africa to now deal with this local animal, human contact model, and to also make certain that anyone who is infected with the virus doesn't spread it to others, particularly those who might be traveling outside of country.

Chris Dall: Now for this week in public health history. Mike, how are we celebrating this week?

Dr. Osterholm: Thanks, Chris. In fact, today we're featuring Doctor Joseph Goldberger. He has an extensive career in public health that we will just scratch the surface of today. We'll include some additional resources in the show notes in case you want to learn more. Joseph was born in Slovakia on July 16th, 1874, and immigrated with his family to New York City at age nine. He later capitalized on that experience after finishing medical school and joining the US Public Health Service, where he conducted health inspections for newly arrived immigrants. He continued serving within the US Public Health Service in a variety of posts working across the spectrum of infectious diseases including yellow fever, dengue, typhoid, diphtheria and measles. His proximities to these conditions and their hosts resulted in him being infected by a number of these pathogens. This was notable when facing his next public health challenge in early 1900s, a poorly understood condition causing the four D's dermatitis, diarrhea, dementia and death was running rampant in the American South in 1914, Congress called upon the U.S. Surgeon General to conduct an investigation. He then chose Doctor Goldberger to lead the effort after visiting hospitals, orphanages, and cotton mill towns across the South. Doctor Goldberger noticed something unique. Most professionals at this time were convinced that this was an infectious disease. However, Doctor Goldberger noted that the condition was most prominent in poor communities, and it did not seem to pass between patients to providers or staff.

Dr. Osterholm: Instead, he hypothesized that people suffering from this condition, identified as pellagra, were experiencing nutritional deficiency. Doctor Goldberger began numerous studies in these populations, providing a more varied, nutrient rich diet. Results were clear. A diet with more varied sources of protein was protective against pellagra. It wasn't until Doctor Goldberg's death that researchers discovered that a deficiency of niacin, also known as vitamin B3, was the culprit. Despite all the evidence to the contrary, many of the medical community were dead set on believing pellagra had an infectious etiology, doctor Goldberger conducted some experiments which would never pass an ethics committee today to try to prove that those who consider themselves expert on this condition, in fact their science, did not support this view. Many in the South saw Doctor Goldberger as an arrogant Yankee from up north, coming down to rehash the Civil War and criticize their current way of life. Indeed, cotton was still king in the South, and in large part due to the continued labor and exploitation of African American sharecroppers, these families surviving off a rations of cornbread and molasses. Were also disproportionately affected by pellagra. Doctor Goldberger did receive some recognition for his groundbreaking work. He was nominated four times for a Nobel Prize. His portrait currently hangs in the National Institutes of Health director's building, as a reminder that public health is not solely about infectious agents, but the social and political conditions in which we live.

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

Dr. Osterholm: Well, Chris, my concluding comments really focus on COVID. Number one, it is still here and at the rate it's occurring, it is still taking over 14,600 lives a year. While we are far below the levels of COVID activity we saw during the heart of the pandemic, it is still a concern, particularly for those of us who are at increased risk for infection, notably those who are older, those who have underlying immune conditions and so do not hesitate to feel empowered to protect yourself. What do I mean? If you're in public settings, do not feel uncomfortable wearing an N95 respirator, even though it may make others uncomfortable. Take control of your protection. If, in fact, you're having private events where you're getting together with family, friends, whatever, consider testing everyone just before they come, just as we used to do. Second, COVID vaccine is coming. Uh, I'm not sure exactly when it'll be here, but hopefully by the end of August. And the new mRNA vaccines, both by Moderna and Pfizer will contain the new variant as an antigen. So, the question is, should I get vaccinated before then if it's been at least 4 to 5 months and I keep coming back to the answer of no, for me, I'm going to wait and get that FLiRT variant for the antigen in my vaccine.

Dr. Osterholm: Finally, if we look at H5N1, where we're at and given all the publicity of the last three months, what can I say? It's about the same place it was two months ago. Not much has changed in my estimation. We surely could see this virus lead to much more serious human illness, even potentially a pandemic. But I think that that's actually a long shot. I don't think that's going to happen. So again, we need to be prepared for a future influenza pandemic. Don't get me wrong, I'm not trying to let influenza viruses off the hook. I just again, for all the reasons I've articulated for the past two months, it still believed that H5N1 has a bar that is just too high for it to cross right now to actually cause infections in humans, in which they then transmit to other humans. So the good news is, while H5N1 is still a challenge in the dairy industry, I think that as the CDC and W.H.O. have concluded, it still represents low risk for human infection.

Chris Dall: And if I had to guess, I would say that your closing song today is going to have something to do with aging, am I correct?

Dr. Osterholm: In my dedication today. I tried to really emphasize an issue that I believe is front and center for many of us today, not just because of the political reality of what's happening, but because for all of us, we recognize that aging is inevitable. Aging happens. Aging will continue to occur. And what does that mean for us? Well, as I pointed out in that dedication, as a 71 year old male, I surely think about things very differently today than I did 20 years ago, but I refuse to relinquish at this time my ability to continue to do things that I hope I can do for many more years to come. Today I've picked a song from someone who I have long admired as one of America's greatest singer songwriters of the country folk music world. This is someone who has been one of the most influential songwriters of his generation. I'm talking about John Prine, the late John Prine, who died on April 7th of 2020 from COVID. Prine was known for his signature blend of humorous lyrics about love, life and current events, often with elements of social commentary and satire, as well as sweet songs and melancholy ballads. He was an active composer, recording artist, live performer, and even occasional actor right up to the time of his death. One particular song from Prine has stayed with me for many, many years Hello in There, written in released in July of 1971.

Dr. Osterholm: Prine wrote the song about when he was 22 and a newspaper carrier, stating, I delivered to a Baptist old people's home where we'd have to go room to room, and some of the patients would kind of pretend that you were a grandchild or a nephew that had come to visit, instead of the guy delivering papers. That is always stuck in my head today. I hope that we can all understand and embrace the intent of this song, and how it might play into the conversation we're having. Here it is. Hello in There by John Prine. We had an apartment in the city. Me and Loretta liked living there. Well, it had been years since the kids had grown a life of their own. Left us alone. And John and Linda live in Omaha, and Joe is somewhere on the road. We lost Davy in the Korean War and I still don't know what for. Don't matter anymore. You know that old trees just grow stronger. In old rivers grow wilder every day. Old people just grow lonesome. Waiting for someone to say hello in there. Hello? Me and Loretta, we don't talk much more. She sits and stares through the back door screen and all the news just repeat itself like some forgotten dream that we've both seen. Someday I'll go and call up Rudy. We worked together at the factory, but what could I say if he asked? What's new? Nothing.

Dr. Osterholm: What's with you? Nothing much to do. You know, the old trees grow stronger and old rivers grow wilder every day. Old people just grow lonesome waiting for someone to say hello in there. Hello. So if you're walking down the street sometime and spot some hollow, ancient eyes, please don't just pass them by and stare as if you didn't care. Say hello in there. Hello. John Prine. I hope that this song gives you all a sense of what we can do to assist each other as we age, and for those who are very younger, enjoy life, do enjoy it. But know that as we grow older, life will change. But it doesn't mean that it has to be sad or bad, it just means it will change. Aging is really like gravity. It just happens to all of us today. Let me remind all of you. Saying hello to someone, particularly if they have those ancient eyes, is a priceless gift. Not just for that person, but also for you. So thank you again for joining us. I hope that the information was helpful to you today. I hope you think about the issue of saying hello and all that it means for all of us. I hope that you have a good two weeks. Be kind, be kind. Right now, this world needs that so badly. And stay safe. Protect yourself. Thank you again for joining. Be kind.

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.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning, Elise Holmes, Cory Anderson, Angela Ulrich, Meredith Arpey, Claire Stoddart, and Leah Moat.