Episode 163: COVID-19 & H5N1: What's Going On?

Chris Dall: Hello and welcome to the Osterholm update, a podcast on COVID-19 and other infectious diseases with Doctor Michael Osterholm. Doctor 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 Dahl, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. Around this time three years ago, the Tokyo Summer Olympics were underway, held amid Japan's fifth COVID-19 wave in a city that was under a state of emergency. Billed as the Recovery Olympics, it was an Olympics unlike any other we've seen, with strict precautions and athletes performing in empty stadiums. And as many of you will recall, those games took place a year later than scheduled because of the COVID-19 pandemic. Fast forward three years to the Paris Olympics, and COVID is having a more limited impact despite rising COVID activity around the world.

Chris Dall: The arenas are packed with fans and you hardly see any masks, but the World Health Organization reported this week that at least 40 athletes have tested positive, though many are monitoring their symptoms and still performing in their events. COVID is still having an impact. "Adam's okay. He's not dying. He's all right, just a bit of a cold," British swimmer Matt Richards said of his teammate Adam Peaty, a day after he missed out on a gold medal in the 100 meter breaststroke. We'll be talking about COVID and the Olympics on this August 8th episode of the podcast. We'll also provide an update on the latest H5N1 avian influenza developments, discuss a study on masking policy at US cancer centers during the winter 20 2324 COVID surge. Answer an ID query about flu shots and tell you what you need to know about a nationwide listeria outbreak linked to sliced deli meat. And we'll bring you the latest installment of This Week in Public health history. But before we get started, we'll begin with Doctor Osterholm's opening comments and dedication.

Dr. Osterholm: Thanks, Chris, and welcome back to the podcast family. It's great to be with you again. Thank you for all of your feedback regarding the last podcast. In particular, it was noted that, uh, there are a lot of Joe Mauer fans out there that, uh, really appreciate him far beyond the borders of Minnesota. And so thank you for your comments on that. Uh, also, I just want to note that if you're a new listener, uh, I hope you find the information you're looking for here. We've listened very closely to what our podcast families requested by way of information, and I hope that fits with you and that you can join us. And in terms of the dedication today, it's going to follow a theme that I've used several times in recent podcasts. If you've been listening to the podcast recently, you've heard me use this dedication segment to share my enthusiasm for athletes who inspire me. As I noted in the last episode, I shared how impressed I was with Joe Mauer on his induction into the Hall of Fame and in Episode 155, I shared how impressed I was with the way Caitlin Clark was changing the story of women's basketball. I'm so inspired by athletes who are not only amazing competitors, but all around incredible people.

Dr. Osterholm: So it may come as little surprise that this week, I'm dedicating the episode to all 10,500 athletes who are competing at the Paris Summer Olympics. It has been a gift to be able to watch these Olympics on television. The camaraderie, the sportsmanship, the ability to get up after having just lost a race to someone and hug them and congratulate them for what they did, is a remarkable testament to the human soul. So from my perspective, we saw some of the very best in the world, not just in sports performance, but in the ability for one person to relate to another. The scenes from Paris have been a gift so far. Athletes scoring last minute goals, shattering records, soaring high in the air and leaving it all on the track or in the pool. But just as impressive as the physical feats have been the stories of perseverance and overcoming adversity. There's been Simone Biles making her triumphant comeback after taking a step back from competing because of how her mental health was affecting her gymnastics performance, or her teammate Suni Lee, a Saint Paul native who helped her team earn gold in Paris only 18 months after being diagnosed with multiple kidney diseases that left her unsure of her gymnastics future winning silver. Laura Kraut, a 58 year old showjumper, became the oldest medalist from the US at the Olympics in 72 years, proving that it's never too late to make your dreams come true.

Dr. Osterholm: Katie Ledecky, the dominant female swimmer who speed in the pool, seems untouchable, has been training while dealing with postural orthostatic tachycardia syndrome, or Pots. These stories of redemption also remind me that, in a way, the Olympics themselves have made a comeback. Tokyo's Olympic Games were a far cry from the packed stadiums we see in Paris in the 2021 games, rescheduled from 2020 because of the pandemic. Athletes were isolated, ceremonies were scaled back, and outbreaks of COVID-19 still plagued the events. As I watched the Olympics this year, I'm reminded of how far we've come as a global community since then. The loss, grief and polarization of the pandemic will endure, but so will our perseverance. And of course, we will ultimately learn how much COVID actually did occur among participants in the days ahead. As we'll talk about it in a moment, I'm sure that it's actually more than we realize. Congratulations to all the athletes who have inspired us through the Paris Olympics. Of course, I have to give a special shout out to Matt Wilkinson, a former student of mine at the University of Minnesota who ran in a qualifying heat of the 3000 meter steeplechase on August 5th.

Dr. Osterholm: He missed out on the finals, but just a handful of seconds. But it was a hell of a race. Matt, team USA Olympians from around the world. You are an inspiration and we applaud all of you for your hard work and but most of all, for your sportsmanship and your ability to respect the talents of your competitors. Well, moving on to another part of the podcast that you all know is coming. Yep. Today, sunrise this morning in Minneapolis was 6:07. Sunset at 8:29. 14 hours, 21 minutes and 47 seconds of sunlight. Still love that light, but we continue to lose light at an ever increasing rate. Today it was two minutes and 37 seconds in Auckland. Our dear, dear friends with the Occidental Belgian Beer House on Vulcan Lane. Your sunrise today is at 7:12. If your sunset is at 5:41, ten hours, 29 minutes and 67 seconds of sunlight. That's one minute and 51 seconds you gain today. You're catching us. But as I pointed out earlier, when we get to that point in September when we pass the same numbers of sunlight each day, I know you'll be very kind in sharing it with us.

Chris Dall: Mike, it's no surprise that we're seeing some COVID infections at the Olympics, and there are probably many more than we know about, given that COVID activity has been picking up around the world. So what does the national and international situation look like at the moment?

Dr. Osterholm: Oh my. Chris. Uh, the upward trends we've talked about have only seemed to continue, and at this point, it's clearer that there's plenty of virus circulating around out there. Let's just start out with the national level. Here in the US, COVID wastewater levels have continued to climb and have now actually exceeded the height of last summer's uptick. This is something we've seen play out since early May, so several months of this rising wastewater activity and where it goes from here, we're not sure. Let me just say personally, as it relates to friends, family, colleagues, etc., I know of so many people that are currently infected with COVID, including members of the CIDRAP team. It's of note, however, most of these illnesses, while they may put you in bed for a few days, none of them have progressed on to what we'd call serious illness requiring hospitalization. So that part of the picture is really an improvement. But we have to acknowledge we're back in the throes again of individuals who are infected. Based on the latest data posted by CDC, 44 states have levels of wastewater activity considered high or very high, up from 36 states at this time last episode. So just two weeks ago, we were at 36 states, today at 44 states. So not many exceptions in terms of elevated wastewater activity. In fact, right here in Minnesota, things are considered very high with these wastewater trends. We've seen hospitalization and death data increase as well, which of course is not unexpected.

Dr. Osterholm: And clearing seeing these numbers increase is not where we want to be. I'll comment more in a moment about what I think is driving this activity and what we are, or we are not doing about it. Let me first, though, note what's happening with hospitalizations. They've been on the rise since mid-May, and according to Bno news, one of the most reliable sources today for information on what's happening in COVID With the lack of active surveillance in many locations, they now estimate that there are over 4500 Americans in the hospital, up from 3900 last week. And again, let me remind you that these numbers only account for about a third of all US hospitals, so it's not a complete picture. Regardless, it would still be helpful to provide some historic context. During the Omicron peak, we were seeing more than 150,000 new weekly hospital admissions, so our current 4500 is a 97% decrease in hospitalizations to the Omicron surge. So yes, we're getting hit, but fortunately, it's nothing like what we saw in 2020 to 2022. Unfortunately, deaths are also increasing, with 652 weekly deaths reported, up from 539 last week, a notable increase. This marks the first week since April that deaths have exceeded 600. Let me also add some context here and remind you that during the Delta surge and the early days of the Omicron surges, we were seeing around 2000 deaths every single day, not 652 weekly deaths. That added up to more than 14,000 deaths each week In January, just about seven months ago, we were nearly at 2600 weekly deaths.

Dr. Osterholm: All this is to say that we're certainly moving in the right direction overall, but we are still losing 600 Americans every week, and that's nothing to celebrate. That is still 600 loved ones every single week who are dying. This includes our grandma and grandpa's, our moms and our dads, our brothers and our sisters. And unfortunately, even in some cases, our children. Now, what is actually going on? What is happening? Well, it's really twofold. One is the variant changes and the other is waning immunity, something we've talked about many times. And this, to me, if anything, is almost like the seasonal concept of you can expect winter in December, you can expect summer in July. If you're here in Minnesota. What we have come to understand is you can expect that about every 4 to 6 months, you're going to see a new variant arise that will change the whole infection picture. That's what's happening here. On top of that, we know that waning immunity from either previous vaccination or infection starts to wane at about 4 to 6 months. And so when you merge these two together and we happen to see the most significant variant change overlapping with waning immunity, we've got some problems ahead. So what's happening with the variants right now. Remember the variants are viruses that evolve through mutation. And the most notable characteristic that we're concerned about is that they become able to evade the immune protection of the host.

Dr. Osterholm: Meaning if I've previously been vaccinated or I've previously had infection, do I still have protection If one of these new variants shows up, that's different than the one that I had been infected with or I had been vaccinated with before? Well, now we're seeing a shift. Originally, we were concerned about a descendant of the original JN.1 Variant that gave us what was called thought variants. You've heard me use that term multiple times. FLiRT, which is basically FLiRT in letters that represent the two different variants that have occurred with this JN.1. And then now another branch of JN.1 Offshoots known as CP.3 or CP.3.1.1. These two variants, which together account for roughly half of the country's cases, are technically not part of the third family since they now lack one of the characteristic mutations, the R346T Again, you don't really need to know that other than just know that these variants are changing. However, these new variants have their own mutations that, while not a FLiRT variant, confer additional advantages given their frequency. In particular, CP.3.1.1 has seemingly started separating itself from the variant pack, going from 1% prevalence in early June or two months ago to 28% as of now. According to genetic analyzes, CP.31.1 has had significant growth advantages over circulating variants, largely due to heightened immune evasion, and its rising prevalence is expected to continue. So in light of this, it's really important to understand that we're going to be faced over the next several months with this new variant that is going to be more immune evasive.

Dr. Osterholm: So that protection that you had a month ago may not be as nearly helpful in the months ahead. Then, as I just pointed out, ultimately with waning immunity, and we now have good data to support that, we do find important protection against serious illness in those first 3 to 4 months after being vaccinated or previously infected. However, by the time you get 4 to 6 months out, that waning immunity becomes a problem. And because of that, if that coincides at the same time that we're seeing a new variant emerge, boy, that's a bad combination. But again, as I just pointed out a moment ago, our numbers, while they may seem somewhat overwhelming, they are surely nothing close to what we saw in the 2020 to 2022 time period. So long story short, these different viral variants keep spinning out and ultimately leave us playing catch up in terms of what it all means. Add that to our waning immunity. And as they say in the movies, Houston, we got a problem. In a moment, we will discuss what you might want to consider doing to protect your health at this moment. But let me first share with you a sense of what's happening on the international level. I think it has some important lessons for what could very well happen here.

Dr. Osterholm: Now, turning to that international side of things, there are signs of COVID activity growing throughout parts of the Americas, Asia, Europe and possibly even Western Africa. In terms of specific countries dealing with this trend, one of the clearest examples is South Korea, where the number of people being hospitalized with COVID on a weekly basis grew from less than 100 in early July to over 500 by month's end. That being said, the overlying mantra continues to be that we're in this post-pandemic stage of the disease. Now, what is this post-pandemic stage and what does it mean? Well, honestly, I'm not 100% sure. Clearly, as I just pointed out, in terms of severe disease and death, we're not seeing numbers anything like we did at previous points in the pandemic, and that's obviously important. But at the same time, I think some of us are interpreting this concept of post-pandemic to basically mean COVID isn't a problem anymore, and that's not reflective of reality. I found it interesting. In the past several days I've been traveling. I went to a meeting in Washington, DC, and in the entirety of my trip, both on the plane to Washington in the airport, at the hotel, then in the meeting, and then coming back. I probably saw no more than 10 to 15 people out of hundreds to thousands who had any kind of respiratory protection on. I'm sure that there are many of these people who are in a position of having waning immunity, be an important part of their risk profile, and have not recently been vaccinated, So they weren't concerned.

Dr. Osterholm: And they many of them looked at me like, what am I doing with that thing on my face? Just take the Olympics happening right now in Paris as an example. Unlike the past two Olympic Games in Tokyo and Beijing, there are no COVID related protocols or restrictions in place. This includes no requirements in place for testing, which of course makes it difficult to determine what's really happening in the terms of transmission. Nevertheless, there are an increasing number of reports, and in fact, over 40 Olympic athletes now confirmed from a number of different countries that have tested positive for COVID. And while to some that may not necessarily sound like a lot, I am convinced there are many, many more reports of athletes dealing with COVID like symptoms but not testing. Which makes sense because there's no universal rules for isolation even if an athlete tests positive for COVID and living in the dorm like locations that the various participants are living in. In some instances, athletes have withdrawn from their events after receiving a positive result and not feeling well enough to compete, mirroring what happened last month during the tour de France, where several top cyclists tested positive and withdrew from the competition because of illness. Unfortunately, this is another example of the new normal we're living in, and it's not necessarily surprising given what happened during the tour de France.

Chris Dall: Over the last few episodes, we've talked a lot about when people should get their next COVID shot. And Mike, I understand you have an update that you want to share.

Dr. Osterholm: Well, let me first of all say that I've been on a journey with regard to how to best protect myself. As I just noted in my previous answer, I actually have been wearing an N95 respirator in public places, uh, flying on airplanes in meetings, despite the fact that you could probably count the number of people in large numbers of people near me who are wearing them on 1 or 2 hands. So what am I doing now? Well, realizing that this surge is beginning to increase in terms of its intensity. Realizing that I don't want to get COVID. I think my best opportunity right now to avoid infection is to get a dose of the old vaccine XBB mRNA vaccine, realizing that it is substantially out of date with regard to the current variant. But there is evidence that I still get a boost in my immune system that, even if it won't protect me from getting infected, may very well reduce the likelihood of serious illness. So originally, I told you I was going to wait for the new doses of vaccine. The mRNA with the new CP2 variant included the Moderna and Pfizer vaccines out hopefully sometime early next month will contain these two more updated variants. Notice they're already still behind KP.3.1.1 The Novavax vaccine. Uh, the JN.1 Variant included. It was supposed to be out originally in July, as they noted that. And now it looks like that vaccine may not be out until the mRNA vaccines are out.

Dr. Osterholm: Or even if they're out, then. So what have I done? Well, because of my number of public appearances and a need to fly, I need to be in meetings despite wearing in a respirator. I've gone out and gotten another booster of XBB.1.5. This is the old mRNA vaccine that we got five and six months ago. And so while it's not closely matched to the current Cp2 or CP3 1.1 variants, I do feel I'm going to get a good boost out of it that will help me avoid serious illness. I can't give medical advice. I'm not suggesting to you what you do other than to say, this is what I did, and I will then wait four months, which I got my booster dose a week ago. I will now wait four months after that and get them the new, uh, mRNA vaccine with the Cp2 variant when I'm now eligible. Again, if you find yourself at increased risk for being infected and you're already at increased risk for serious illness, older, etc., I would surely consider getting a booster dose now. Not waiting another 4 to 6 weeks, uh, because in fact, that may be the time that you will ultimately get infected. Uh, if you do wait, uh, that makes sense for you, then do it. But, uh, at least for me and for the people close to me. Uh, this is what we're doing. We're getting our dose now and waiting for months for the new one.

Chris Dall: There is a study published last week in the journal Jama Network Open that looked at masking policies at National Cancer Institute designated cancer centers during the COVID surge in the winter of 2023-2024. Mike, what struck you about this study?

Dr. Osterholm: Well, Chris, before I get into my thoughts on this issue, I just want to provide a brief overview of the results of the study. The study was conducted by researchers at Tulane University, who reviewed the masking requirements of all 67 National Cancer Institute designated cancer centers during the winter of 2023-2024. They found that during the 2023 and 2024 winter surge, only 42% of cancer centers had universal masking requirements. These requirements meant that masking was necessary for patients, staff, and visitors at the clinic. Among clinics that had these universal masking requirements, less than half required universal masking in all areas of the clinic. In addition, researchers found a discrepancy in the information for a given clinic based on where you got your information. For example, 12% of clinics had inconsistent information about their masking requirements. When comparing the information from the clinic website with the information shared by the clinic with the patient via phone clinics in the northeast region of the country, clinics with more funding and clinics with higher care rankings all had higher rates of universal masking requirements compared to the other two clinics. Also, I want to note, however, that even this information can be a bit misleading in that there was no evaluation done to determine what it meant to be masked. Were they only using surgical masks? Were they using something other than an N95 respirator? Because if they were, they may have found only very limited protection from that surgical mask, even though they had in place a universal masking policy.

Dr. Osterholm: There are two major takeaways I want to address here. First, this information is really concerning. How is it that we don't have a greater percentage of clinics with policies in place to protect vulnerable patients from all respiratory pathogens, just not COVID-19? Cancer patients are often immunocompromised, and it's very disheartening that we aren't doing more to protect them. However, that brings me to my second takeaway, which is that the results of the study do not really clarify whether these policies have had done much to protect patients anyway, because researchers, as I just noted, don't specify what types of masks are required in these clinics and when they must be worn. A universal N95 requirement would go a long way in protecting vulnerable patients. But if the masking policies of these clinics allowed for the use of cloth or surgical masks, it's highly unlikely that these policies made a real difference in protecting patients respiratory protection guidelines that allow for the use of these ineffective cloth and surgical masks are nothing more than hygiene theater that provides a false sense of security to patients and providers. Though I'm glad that this study shed some light on just how few cancer centers required universal masking last winter, I hope that we can see further research in this area to get a better sense of how many clinics had well-informed and effective respiratory protection requirements, with some kind of follow up to assure that masking was occurring.

Dr. Osterholm: Considering studies that only looked at presence or absence of masking policies does not really give us a good picture of how much compliance actually occurred. So what's the bottom line message here is we just still haven't learned much about protection and respiratory protection after having gone through these last four years of COVID. This is really unfortunate and to think that it's in our health care facility. So yeah, you know what? You're a patient with cancer. You have real challenges ahead of you. The last one you need is to have what we call a hospital acquired infection. Because your health care provider or whoever else was seeing you was not masked up in an effective way, meaning that they were using respiratory protection that could actually make a difference. So from this perspective, this is an important study. I congratulate the authors for doing it. I would love to see more information on what masking actually meant. And most of all, when are we going to learn that we can do so much, particularly protecting vulnerable patients by improving all of our respiratory protections?

Chris Dall: Let's turn now to H5N1 avian influenza. We continue to see more cases in dairy herds, and a preprint study last week suggested there might be more human infections among dairy workers than we know. Mike, has your assessment of the outbreak changed at all from where it's been?

Dr. Osterholm: You know, I can't say that it's changed, but I can say that it's reaffirmed my worst fears. And what I mean by that is this is a damn mess. This is a mess. And I feel like the, uh, federal agency is really overseeing this activity. Have not really squared with the public what's actually going on. And what I mean by that is, is that as much as this is a concern in the dairy industry, and I understand that it's not that big of a concern because it's not at this point one that they are really taking seriously. And what do I mean by that? And I realize these are hard words, but I truly mean them. We are realizing that this infection is much more widespread than the 189 herds that have been found in 13 states, and the state of Colorado is really helping us to understand that. My hat's off to the public health and ag officials in Colorado. They now have mandatory bulk tank testing that has to be done every week. Just today, we've added nine new farms with positive results because they had virus found in the bulk tank. Testing for that farm. In other words, they would not have been reported otherwise. That's just Colorado. Colorado today accounts for 62 of the 189 herds in this country that are positive. Do I believe that this is only in 189 herds? Absolutely not.

Dr. Osterholm: I've taken it upon myself to contact and follow up with a number of my dear friends and colleagues in veterinary medicine in four different states people who are in large animal practices, often concentrated largely in the dairy area and in confidence. These veterinarians have shared with me that they believe that there is substantially more infection going on in farms, and that farmers are not willing to have the veterinary community confirm it. And in fact, one of them said to me that if I push this even one inch further, I'm likely to lose my contract with that particular farm. They'll find another large animal veterinarian to do the work. And so I'm certain that we're seeing much, much more in the way of infection. In talking to local and state public health officials who are on the front line. The same thing. So while we talk this idea of one health, that's just conversation right now. That's it. The dairy industry doesn't you really get it yet what it means? Yes. I understand you don't want your farm hit targeted. You don't want the potential loss. At this point, there's some debate about how much illness is actually occurring in the animals, and how does it actually impact and whether they produce or not produce milk, all those issues. I realize this is an economic concern, but as this virus continues to circulate, it obviously is a challenge for us in the sense of not only stopping in the cattle, but are there implications for it to spread to humans and in a way that could lend itself to be a pandemic virus? Now, I've said time and time again, I think that there are some very unique barriers for H5 to get over before it becomes a influenza like transmitted virus in humans.

Dr. Osterholm: I think we need to stop talking about H5N1 infections, as if the conjunctivitis and the influenza like illness are the same. They're not. The conjunctivitis is caused by infecting the eye of a human which has two, three receptors. That type of receptor, that's a bird virus receptor that I can expect to see more eye infections. All the cases we've seen to date in this country, including the 13 cases that are documented, uh, in terms of both poultry and dairy, all of these were basically conjunctivitis like illnesses. That's very different than getting infected with a virus at the two six receptor in the human lungs, which is where you get influenza, where you get human to human transmission. That's a concern. So I don't know if that's ever going to happen. But right now, we are not doing what it takes to adequately address this issue in dairy herds throughout the country.

Dr. Osterholm: I think it would be very important to actually make it mandatory for all the states, not just for Colorado to to actually do a bulk tank testing. And I think that this is one that would allow us to very quickly to get a handle on what's happening. I also urge the USDA and the FDA combined to go and do spot checks of milk samples throughout the entire country. Don't just do them in the states that have already seen cases. I'm sure there are many more states out there with infection transmission occurring in dairy operations beyond the 13 we note here wouldn't surprise me if 30 or more states have activity going on right now. We need that bulk tank testing and again, none of us want to hurt the dairy industry. I understand the challenges, but also we don't want to find ourselves one day down the line where because we didn't do more, this continued to be a major problem in the dairy industry and ultimately did result one day in a new virus emerging that ended up calling us in a pandemic. Now, I have to say this, and I know it will be controversial. And some will say I'm, you know, playing politics. I surely don't mean to, but I look at this situation right now, and if I were in China, I would look at what's happening in the United States right now and saying, how can you criticize us? What we did in Wuhan with after four months, look what you've done to deal with this issue in your backyard.

Dr. Osterholm: And I think they'd have a heck of a good case. So we got to do a better job here. We've got to get tougher on this issue. We've got to find out where the infection is. We have to determine what are the methods or the means for preventing it. I remain challenged by the fact about vaccine use for either the humans or for the animals in this case, and that may sound contradictory. Remember influenza vaccine, seasonal flu vaccine specifically is a good vaccine. It can reduce serious illness, hospitalizations and deaths, but it does not block transmission or infection. That's a key piece if we're talking about trying to stop transmission infection, vaccinating won't do that. That's going to have to be a physical barrier keeping the infected animals from having contact with infected animals, i.e. milking parlor. The second thing is, is that we have to understand that the seasonal flu vaccine loses its ability to protect you over time after you receive a dose. We know today that anywhere from 2 to 12% of those individuals who are vaccinated each month after vaccination will lose that protection that they already had.

Dr. Osterholm: So, in other words, after five months, you could see 40 to 60% of the protection of that vaccine you had when you got vaccinated is no longer there. That, to me is really an important point, so that if we're going to vaccinate people to even prevent severe illness, vaccinating them now is not going to be all that helpful. If the seasonal flu virus starts circulating in January and we're trying to keep workers from getting infected then so that they don't end up possibly bringing that virus into the dairy area and then having the H5N1 virus meet up in the udder of a cow with a seasonal flu virus, because they have the two six receptors in that udder as well as two, three. And then you get that new virus from Reassortment. So the bottom line message here is we need to step this game up a lot a whole lot. And we're not. And I've at this point, these are my friends and colleagues who are working on this. Uh I have voiced this opinion to them personally. Uh, so this is not a blindside hit, but, uh, but I don't see anything right now that's going to really dampen much of what's happening with this virus in the dairy herds of this country, given the approach that we're taking.

Chris Dall: So, Mike, you just mentioned the seasonal flu vaccine, and that is actually the topic of our ID query this episode. This week we heard from Russ, who wrote, when will the 2024-25 flu vaccine become available in past years? Vaccines started in August. None so far.

Dr. Osterholm: Well, thank you very much, Russ. That's a great question. And as I just noted in the previous answer, I'm frustrated about how we promote seasonal flu vaccine in this country. As I've already covered this topic in multiple previous podcasts over the last 4 to 5 years, but let me just revisit it again. The earliest shipments of the 2024 2025 influenza vaccine went out in mid-July, and we're approaching that time of year when you begin seeing lots of advertisements for flu vaccination. Walgreens, for instance, received their 2024-2025 influenza vaccine doses and is heavily advertising vaccination. Additionally, it's almost a guarantee that if you get a COVID booster in the coming weeks, you'll be offered a flu vaccine at the same appointment. Though it may seem intuitive to get the vaccine now to get ahead of this year's school year and cold and flu seasons. I want to remind everyone that because of the protection from influenza, vaccine substantially wanes with even 4 to 5 months. It is much, much better to wait until we're closer to the peak of the influenza season to get your shot. The best time to get your flu shot is shortly after influenza activity begins to pick up for the season, usually sometime around late October to early to mid November. We will keep you posted on when the best time to get your vaccine is this year, but for now, please continue to hold off on getting your flu shot and do not interpret this as being a challenge to getting flu vaccination. I very strongly recommend it.

Dr. Osterholm: It's a good vaccine, but it's not a great vaccine. It does provide that protection for three to 4 or 5 months against serious illness, hospitalizations and deaths. And if, in fact, given close to the time when the flu season actually begins, you still have that protection on board someone today getting a dose of vaccine in early August. Think about where their immune system will be if it's mid to late January that they encounter the virus with seasonal flu. They'll have lost anywhere from 2 to 12% of the protection per month. That's a cumulative okay, so after five months you could lose 50 to 60% of the protection. And we are not sharing that information with the public. And I think we need to do a much better job. So don't confuse my statement with saying that there's some problem with flu vaccine or don't get it. It's all about the timing and that's what's really important. So I'm going to get my flu shot in October or November whenever flu season starts to show up. And I'll let you know on this podcast. Bingo. Now's the time. Go get it. Okay. And I think that's the important message. So if you go into a clinic today, you go into a pharmacy and they want to vaccinate, you say, no, no, a thousand times no, but I'll be back. And that's when you will have the best protection from your flu vaccine. And let me just also put into context my statements just now about flu vaccine with COVID vaccines.

Dr. Osterholm: COVID is not a seasonal disease. We continue to see it occur in all seasons. We happen to be in a peak right now in the late summer, early fall. We have seen this through the entirety of the pandemic, at least ten different surges, and they've been distributed through all four seasons. So unlike the flu shot, where I can count on the season to occur November, December, January and therefore plan my seasonal flu vaccine approach around those key months, I can't do that with COVID because I don't know when the next variant is going to emerge. Or I can predict the waning immunity 4 to 6 months after previous vaccination or illness that comes and goes. But so I want to also then therefore make it clear that I wish we could do COVID like seasonal flu, but we can't. So I don't have people tell you how important it is to get both shots together. It's not It's not. You want to time your COVID vaccine to when you have waning immunity 4 to 6 months after previous vaccination or illness and when new variants emerge. And so, you know, I could see getting a flu vaccine once a year around the season. And I could see getting a COVID vaccine 3 or 4 times a year around the emergence of a variant and my waning immunity. And until we get that kind of message across, I think there will continue to be confusion of trying to merge flu vaccine and COVID vaccine together. That is a mistake.

Chris Dall: Now to some other infectious disease news. And today we're going to focus on foodborne illness. The CDC is currently investigating an outbreak of listeria that's infected 34 people in 13 states and caused two deaths to date. The outbreak has been linked to meat sliced at deli counters, with one brand, Boar's Head, directly implicated so far. Mike, what else does our audience need to know about Listeria and about this particular outbreak?

Dr. Osterholm: Well, people may wonder, why are we including this in this podcast? You know, this bug called listeria and talking about deli meat. It's a very important one because this is a really, truly serious infection that occurs very much put in one at risk for dying and also causing spontaneous abortions in women who are infected while pregnant. And the reason I want to emphasize this, because this is one of those confusing ones where you may have no idea that you're at risk. This is a type of infectious disease. From a foodborne disease standpoint that's unlike virtually everything else we deal with. First of all, let me just repeat listeriosis. The what we call the disease is the foodborne illness caused by the bacteria Listeria monocytogenes, which is unique in that it actually thrives in cooler temperatures, typically temperatures in your refrigerator. Those below 40°F, slow the metabolism of potentially harmful pathogens for a period of time, which is why we store perishable food in refrigerator. Many times, spoilage bacteria, which can grow in some refrigerated events, actually overtake even the pathogens that are there and cause them to even be fewer in number because of their competition with these cold enriched, as they call them a harmless spoilage bacteria. So in this case, Listeria, however, is different in that it continues to grow in these temperatures.

Dr. Osterholm: And you may actually, uh, have this product stored in your refrigerator for up to weeks where it hasn't spoiled yet. And now the listeria has grown from a point of presence to actually being a high enough infectious dose that it may actually cause you to develop this severe illness called listeriosis. It's particularly dangerous, as I pointed out, to those over 65 years of age and who have weakened immune system. It is particularly threatened to pregnant women who are at higher risk for pregnancy loss, premature birth and life threatening infection in their newborn. I have worked up far too many outbreaks of listeriosis in my days at the Minnesota Department of Health, where these tragic outcomes were a reality in terms of the current situation. The CDC first informed the public of the outbreak on July 19th, announcing that deli meat sliced at various locations appears to be the food source linked to infections. I might add that a number of state health departments have been very actively involved and providing some of the real, important leadership in this investigation. On July 26th, the CDC announced that the epidemiologic data suggested the outbreak was tied to slice liverwurst and from the Boar's Head brand. This news triggered an immediate involuntary recall of liverwurst products, which Boar's Head then expanded several days later to include all 70 plus products produced at their facility in Virginia.

Dr. Osterholm: This was over 7.5 million pounds now. In the meantime, however, you've gone to the deli. You've bought this type of product, a boar's head. Specifically, you brought it home, put it in refrigerator, and you may never have heard about listeriosis. We know that many times the public is not aware of what's happening here. Well, that liverwurst that's in your refrigerator right now is a potential ticking time bomb. On top of that, think of what happens in a deli. I go in, I look at the case of all the different products available, and I pick this one out or that one out, and I have the deli worker slice it for me. Well, slicers notoriously become contaminated with things like listeria from first cutting a Boar's head product and then turning around and cutting something else, a totally different product. So virtually, you have to think of everything that went through a deli for up to the past several months as potentially a source for this bacteria. And we know how popular delis are in this country, and Boar's Head has such a large reach in delis across the country.

Dr. Osterholm: Not only is their product a problem, but they may have made a lot of other products a problem. So even though I have turkey in my refrigerator and it didn't come from Boar's Head, that could be contaminated now too. So we just wanted to make sure you were aware of this situation. And if you have any deli meat products that you bought prior to a week and a half ago, I'd tell you right now, ditch them, throw them. Okay. Even though they look okay because it's cold, enrichment really hides the growth of this listeria in this product in a way that you can't tell. So if there's anything you can take away from this segment is that you got to check your refrigerator right now. You've got to look for any deli sliced products you've had, uh, whether it's Boar's Head or not. And if it was purchased before the July 26th, uh, announcement, when delis across the country were informed that they had to clean out everything, start over again, terminally clean their equipment. You have to basically realize you may be getting a very unhealthy dose of listeria with your product that you're eating, so I hope this is helpful information. If we can save even just one life, that'll be helpful.

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

Dr. Osterholm: You know, I have to say thank you, by the way, for the people who provide us feedback on this segment. You know, we put this segment into the podcast because a number of us have CIDRAP celebrate the history of what we've done over the years and try to never forget the pioneers who made public health what it is today. And in addition, you know, what are the lessons learned from 40 years ago that are, well, retaught again today? So your feedback on this segment has actually been wonderful. Thank you. Well, today we're celebrating a public health hero who had a trait I deeply admire, relying on the best scientific evidence and providing straight talk even if it's not well received or for that matter, even believed. Francis Kelsey, affectionately known as Franny, was born in British Columbia in 1914. She had an early interest in the sciences and received advanced degrees in both pharmacology and medicine while in graduate school, Franky worked on a contracted research project for the FDA to investigate the deaths of 71 adults and 34 children. The affected individuals had taken an antibacterial product with an ingredient, diethylene glycol, commonly known as antifreeze. Rightfully, legislative changes were made, and the 1938 food, drug, and Cosmetic Act then required the disclosure of a product's ingredients, as well as tests of safety and approval for the FDA to protect consumers. Doctor Kelsey's next notable project was working on quinine, a common antimalarial that was needed by soldiers in the tropics during World War Two. In the process of testing different compounds, Kelsey found that multiple drugs harm the fetus of pregnant animals. This led her to pursue additional education and research in embryology and teratology.

Dr. Osterholm: Doctor Kelsey also served as an editorial assistant at the Journal of the American Medical Association, or Jama, which developed her skills to rigorous review study design by 1960. Doctor Kelsey had worked her way to the FDA as the head of the New Drug Application Division. The second drug that Kelsey received on her desk was called Cavedoni. The brand name for thalidomide. The current law gave the FDA 60 days to review the product's proposal. It was not processed in that time, the company was able to begin marketing. Companies could also distribute products to doctors and label them experimentally even before approval. As many of you may be aware, thalidomide was a sedative and anti-nausea medication marketed especially for pregnant women. Doctor Kelsey rejected the company's initial proposal due to insufficient data on methodology and limited results from clinical trials. Doctor Kelsey also noted that the study's authors had produced multiple disreputable studies in the past. The company continuously submitted proposals to the FDA, visiting the office more than 50 times in 18 months. They became more and more frustrated. Their applications were not getting through Doctor Kelsey and attempted to escalate the proposal above her head. Luckily, FDA officials stood by her and trusted her judgment. Meanwhile, across Europe, Australia and Asia, where the drug was already approved and widely available, doctors were delivering significantly increased numbers of babies with congenital malformations, especially leading to the drug being pulled from the market. It is likely that Doctor Francis Kelsey's persistence prevented thousands of these birth defects here in the United States. Thank you, Doctor Kelsey, for your service. You are a real hero.

Chris Dall: Just a reminder now for our listeners about the podcast schedule and a change we announced a few months ago, but not everyone may have heard. I think over the past four years, most people have been used to getting the podcast in the morning on Thursday mornings, but we now release episodes of the podcast every other Thursday at noon central time. So if you are on the East Coast, that would be 1 p.m. your time. West coast, 10 a.m. Mountain Time 11 a.m. and that will be our schedule going forward. We apologize for any confusion. Mike, what are your take home messages for today?

Dr. Osterholm: Well, first of all, Chris, I just want to thank the listeners for hanging in there with us and I hope the information was helpful to you. Uh, number one, uh, clearly is COVID is up. It's here. Protect yourself. Fortunately, it is not like it was during the really peak of the pandemic from 2020 to 2022, but it's still a very significant cause of deaths in this country over 600 a week right now. Uh, and there's much you can do to protect yourself one again, I'm not giving you a medical advice. I'm telling you what I did. But if it's going to be four or 6 or 8 weeks before we get the new doses of vaccine out, I would go and get one of the older doses, the XV dose. I did that last week, as did a number of my colleagues. That means you won't get the new doses for four more months, but you buy some protection now when we know we're going into a surge time period. Number two, do not be afraid to use respiratory protection anywhere in the public or private settings. Yeah. Did I feel out of place in the last couple of days flying to my meeting in Washington, DC, sitting in a large room with a lot of infectious disease experts and being one of only 4 or 5 people that had on an N95.

Dr. Osterholm: Yeah, I did, but you know what? My health is more important to me, and I hope all of you can feel empowered that if you do have to be in a public place, you have to be with other people. Wearing an N95 respirator can go a long, long ways in reducing your risk of getting infected. And don't feel as if somehow you're the odd person out. Third is if you're going to be in a setting where there may be other individuals who you're going to be close to, make sure that they are not ill, that they test if they are ill, and not come to be part of that group. Don't feel at all as if somehow you're asking them to take on an extra burden. What you're doing is forcing them to basically use the kind of public health etiquette that we all should be using. So I think that may be a challenge for some, particularly if it's in, you know, birthday parties and other kinds of parties that you go to. But again, if you're at increased risk for serious illness, you're older, you have underlying immune deficiency issues, etc.

Dr. Osterholm: do not do not hesitate to protect yourself. If you don't, no one else will. Uh, my second and last point is that flu vaccine is here. Don't get it. Now, if you take that quote out of context, I'm sure I will be hung in effigy, uh, in the public health world. But add my caveat. Wait until it's time and then get it and absolutely get it. And that's for all ages. Uh, at this point, I would urge you to wait until we sound the alarm that, in fact, we're beginning to see the flu season start and then get your shot. Then you'll have the maximum protection for the next several months in which the flu season is here. Now, some will say we can't do this. It's just too difficult. Scheduling. Now we got to get them in before we can get it checked off. We got your vaccine dose. What good is that if the vaccine dose is going to be, you know, minimally effective for five months from now during the flu season? So again, don't be afraid to opt up for the flu vaccine. Get it? But wait until the maximum time for your most protection.

Chris Dall: And what is your closing song for today?

Dr. Osterholm: Well, I'm following up on the theme that I started with in terms of the dedication about the unique gift that we are able to witness in our athletes of the world who perform at such a level and spend years and years of training to get to the point of where they have that one chance, that one chance to win that particular race or finish first in a sporting event. And one of the things I was struck by as much as the world is in such chaos and it is, uh, challenged the number of individuals who demonstrated the best in sportsmanship, watching people who finished one place out of a medal after a long and very difficult run. Go and hug the person who beat him. And you obviously whisper something positive in their ear because of the smiles. You know that takes the best of the human condition to do that. And I think that that's that's exactly the the spirit that I hope we can leave it in. And while the song I picked today is not about the Olympics, it's about a similar kind of experience of of the unique ability to be on the stage of the world and to put all that you have up against the very best of the rest of the world and what that means. And so what I've picked, actually, is a song from a songwriter singer that we all have loved, have used his song several times on Father's Day.

Dr. Osterholm: Leader of the band is from Dan Fogelberg, uh, who unfortunately recording this in 1980. Uh, this particular song. And while he's still not with us, he died of prostate cancer in 2007. His music still really is so meaningful to so many of us. This song, run for the roses was actually about the Kentucky Derby, but it was also one that there are lines in here that will help you understand what it means to even be a potential candidate for that great event. And so, yes, it's about a horse, but it's actually transcends that. So here it is today. Run for the Roses by Dan Fogelberg. Born in the Valley and raised in the trees of western Kentucky. On wobbly knees with mama beside you to help you along. You soon be growing up strong. All the long lazy mornings. In the pastures of green. The sun on your withers. The wind in your mane. Could never prepare you for what lies ahead. The run for the roses so red. And its run for the roses. As fast as you can. Your fate is delivered. Your moments at hand. It's the chance of a lifetime. In a lifetime of chance. And it's high time you joined in the dance. It's high time you joined in the dance. From sire to sire. It's born in the blood. The fire of a mare. And the strength of a stud.

Dr. Osterholm: It's breeding and it's training. And it's something unknown. That drives you and carries you home. It's run for the roses as fast as you can. Your fate is delivered. Your moment at hand. It's the chance of a lifetime. In a lifetime of chance. And it's high time you joined in the dance. Dan Fogelberg. I must say, when I think one of the most amazing lines in a song that I've ever listened to is the one here where he says it's breeding and it's training, and it's something unknown that drives you and carries you home. And so many of us only can hope for that unknown in all of our lives that carries us home. So thank you very much for spending your time with us today. I hope, uh, these, uh, comments were helpful and I want to thank the podcast team. As always, I want to remind everyone that, uh. Yep, 600 deaths are still 600 deaths every week. COVID is not done with us yet, thank God. It's not like it was a few years ago, but it's still here. And these are our moms and our dads, our grandpa and our grandmas that we know are potentially at risk today for serious illness, hospitalizations and deaths. Let's protect them. And most of all, right now in a world of turmoil, be kind. Be kind. Right now, it, uh. It's such an important thing to do. Be kind. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm update. If you enjoy 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 and Elise Holmes. Our researchers are Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.