Episode 169: The Most Important Episode I'll Ever Record

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 Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. Last week, the CDC's Advisory Committee on Immunization Practices recommended a second 20 2425 COVID-19 vaccine dose, spaced six months apart for people aged 65 and older, and younger people with immunocompromising conditions. The recommendation replaces a vaguer additional doses language that was used in an earlier recommendation for the latest COVID-19 vaccines, and will likely be welcomed by those who are confused by the previous recommendation. The ACIP recommendation is among the topics we'll be discussing on this October 31st episode of the Osterholm update, after we bring you up to speed on COVID-19. We'll also provide an update on flu and other respiratory viral activity, discuss the latest news in the H5N1 outbreak in U.S. poultry and dairy cattle, and tell you what you need to know about foodborne, E.coli and Listeria outbreaks. 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: Thank you, Chris, and thank you to all the podcast family members that have joined us again today. And to those who might be listening for the first time, or maybe only a couple. Of times we welcome you to. I will have to say that the outset here, this particular podcast, has been one that has been more challenging for me than any I've done in my entire career, not just the Osterholm update. Hopefully it will become clear to you why I say that as I go through the podcast, particularly as I close, I have taken very seriously the relationship that we as a podcast family have had over the course of the past four years. It has been a remarkable gift to be able to join you every week and then every other week with this podcast, knowing that the responsibility for being credible, for being honest, for being fair, and oftentimes having to be humble is really something that I take very seriously. So today, as we end this podcast, I hope that the message that I have for you is one that you will appreciate that you will explore and most of all know that it was meant from very, very deep down inside my heart in terms of what I want to share with you. I'm sure that for many of you, our title this week, the most important episode I'll ever record, did catch your attention. We didn't choose this title lightly, but the whole team felt it was appropriate considering the topics I planned to discuss today.

Dr. Osterholm: As I'm sure everyone listening to this podcast knows, we're less than one week out from an Election Day here in the United States. I'm going to comment more on the election later in the episode, which will be the first time for me in my nearly 50 year career, that I've ever commented on a political aspect in such a way. But before I get into those comments and the rest of the content we're going to cover in today's episode, I want to first dedicate this episode to a very, very important group of individuals who are often overlooked during election seasons, the election officials and poll workers who make our elections possible. In the 2020 presidential election, there were nearly 800,000 poll workers who worked hard setting up and taking down the voting equipment, verifying voter information and registration, counting ballots and much more. Many of these individuals have had to take time off from their regular jobs in order to serve in this critical role. These jobs are often thankless and in some cases can even be dangerous. In 2022, three and four election workers reported that harassment and threats in their jobs have increased in recent years. And sadly, with tensions higher than ever going into the 2024 election, there is little reason to believe that won't be the case again this year. To all of those who will be working hard to make this upcoming election possible and fair, thank you for everything you do.

Dr. Osterholm: We will be thinking of you and wishing you a safe and successful Election Day. We need you. We count on you. Now, let me move into the lighter part of the moment here. And that, of course, is our sunlight. And some might say, well, this isn't even the lighter part of the podcast today, given where we're headed with sunlight in the Northern hemisphere and today in Minneapolis, on this Halloween date, we have sunrise at 7:50. Sunset at 6:01, ten hours, ten minutes and 47 seconds of sunlight. We're losing about two minutes and 47 seconds of sunlight a day. That number is slowing down as we get closer to the winter solstice. Of course, as you know, we'll turn the corner and start going back up. But for right now, yes, it's getting darker, I feel it. I can sure sense others that feel it. Now, on the other hand, our dear, dear friends in Auckland, New Zealand, at the Occidental Belgian Beer House, you are experiencing a wonderful gift today. Your sunlight begins at 6:16. Your sun set sunset at 7:52. You have 13 hours and 36 minutes and eight seconds of sunlight, and you're gaining each day now. So, uh, enjoy it, appreciate it. Share some of it with us. Uh, we are prepared to go into the darker days of the year and knowing, however, that this podcast family, regardless of which day of the year it is, keeps things bright and shiny once again.

Chris Dall: All of the CDC's COVID metrics, including wastewater viral activity, continue to trend downward. We obviously know that can change and quickly, but it seems we remain in that better place. You talked about in the last episode, how would you assess the current COVID situation?

Dr. Osterholm: Well, I think you really set the tone very well here. Chris. Um, we're in a good place. Not great. Great would be if we had little to no COVID at all. But we're in a good place compared to where we've been over the course of the past four years, things are moving in the direction we would like them to. Yes, we are in that better place. All the COVID indicators, wastewater, hospitalization, ED visits and deaths across the country continue to decrease. National wastewater concentrations are still considered low and are decreasing in every region. Some states have still moderate to high activity, but coming down rather quickly. All the severity indicators, including hospitalizations, emergency department visits and deaths, continue trending downward. Remember that this should be our last week with only partial hospitalization data. As healthcare organizations around the country will be required to report their respiratory virus hospitalizations come this Friday. But for now, what I can tell you is that there are about 900 Americans hospitalized with COVID-19, and the 16% of hospitals that reported their data last week, and around 13% of those hospitalized were in ICUs. Using this rather crude assumption that these 16% of hospitals are representative of all hospitals, we could approximate that between 5000 and 6250 Americans are currently hospitalized across the country for COVID-19.

Dr. Osterholm: We are nearing the lowest hospitalization rates we've seen since the start of the pandemic. Lastly, deaths are also down and finally below 1000 per week. Remember, the deaths are a lagging indicator and they take time to confirm. So when we talk about weekly death numbers, it is for several weeks ago, the week of September 28th, which is the most recent week with complete data. We lost 950 Americans to COVID-19. I want to make it clear that just because we're back below 1000 weekly deaths does not mean that it's time to celebrate. I still visualize what it means to lose nearly a thousand grandparents, mothers and fathers, brothers and sisters, sons and daughters in one week. That is nothing to celebrate. And let me remind you that this marks 16 straight weeks with more than 500 deaths. All that being said, please go get your vaccines if you already have it. They are the best defense we have against this virus right now. I'll have more to say about that in a moment.

Chris Dall: One of the things that could change the COVID trajectory, of course, is a new variant. And last week there was a preprint analysis of the XEC variant, which appears to be steadily gaining ground here in the United States and elsewhere. What did we learn from this analysis, Mike?

Dr. Osterholm: Well, Chris, remember that we have two constants in our world of COVID today. Much like we can say gravity is a constant. One is waning immunity in humans, meaning that once you obtain a certain level of immunity from either a vaccination or from previous infection at some point within months. After those events, you will start to see less and less protection from those previous events and the immunity that resulted from them. So that's a given. And we know that we went through substantial COVID activity in July, August and September of this year here in the United States. And as a result, we know that we probably have 4 or 5 good months, relatively speaking, of protection against COVID infections. But that will wane as we get into the early months of next year. The second given like that gravity issue, is the fact that we will see new variants. This COVID virus continues to throw us curveball after curveball after curveball, virtually nothing else like it in my world of infectious diseases and respiratory transmitted viruses. So what does this mean with this new variant? This preprint, which came from the Saito lab in the University of Tokyo, predicts that the XK variant will likely become the world's predominant variant in the near future.

Dr. Osterholm: And I must tell you that the Saito lab in Tokyo has, in fact, provided us with really very reliable information in the past, and I would take this message very seriously. Researchers in the lab compared the XEC variant to the currently dominant CP3 1.1 variant, and found that it outperformed in three primary ways. First, researchers found two spike mutations in the EXC variant compared to the CP3, which increased the infectivity of the XEC. Remember, CP3 is the dominant variant that we're seeing now in across the country. Second, neutralization experiments to assess breakthrough infections found that neutralization against XEC was lower than CP31.1. This means the XEC is more immune. Evasive. Lastly, based on modeling and surveillance from five countries, researchers found that the reproductive number of XEC is greater than the CP31.1. This means that on average, there are more additional cases generated by each case of XEC in a susceptible population compared to the current dominant variant. CP31.1 or more simply put, it means that XEC is likely to take over as the dominant variant. The analysis ultimately confirmed that what we've been seeing and expect is the growth of the XEC, which now makes up nearly 20% of cases. So how does this jive with what I just said in terms of we are really in a great place right now with COVID compared to what we've experienced in the past four years.

Dr. Osterholm: I think this is going to be the constant tug of war that we are going to constantly be having with this COVID virus. It's going to be one where we will develop immunity as a result of either vaccination or infection. New variants will emerge, challenging that immunity. Waning immunity will occur, new variants will occur. I fully expect that sometime by mid winter we could see an increase again in COVID of real concern. Are we ever going to go back to those days of the actual full fledged pandemic? No we're not. But as I just pointed out a moment ago, a thousand deaths a week is still way too many. Way too many. And so, yes, we're in a good place. We are in a place where we will continue to see changes in risk in the community based on what variant is there and where our overall immunity is. But for now, I do think that this XEC variant is one of concern and one that we'll be tracking very carefully and letting you know what it means in terms of risk in your community.

Chris Dall: I want to talk now about the latest ACIp recommendations on the COVID vaccine, which were quickly endorsed by the CDC. Mike, was this the right decision?

Dr. Osterholm: That's right, Chris. The CDC did endorse the ACIP recommendation. The seniors and those with moderate or severe immunocompromising conditions receive a second dose of the 2024-2025 COVID vaccine six months from their first dose. In short, this is meaning really two doses a year. They also recommended an extra dose, three doses or more for those with immunocompromising conditions based on discussions with their doctor. This recommendation was based on a few factors, including the waning immunity issue. I just discussed the lack of seasonality and variant changes, each of which we discussed in this podcast are critically important. Now, to answer your question of whether this was the right decision, I'm sure it won't come as a surprise to our regular listeners, but I absolutely think it was the right decision. In fact, it's a recommendation I've been pushing for a very, very long time knowing that, in fact, we do begin to see waning immunity really become an important issue at 4 to 5 months after vaccination or previous infection. So yes, if I could get a dose of vaccine every two months, that in fact would give me maximum protection. Now remember, we know this virus is seasonal only in the sense that it occurs in all four seasons. It's not one like influenza, which is truly seasonal, meaning that we can expect primary and major activity in the winter months of each respective hemisphere, and not during the spring, summer and fall months, so that we know that our vaccines are not perfect. Yeah, wish we had better durable immunity, but boy, they can do a lot to really reduce the likelihood of serious illness.

Dr. Osterholm: Utilizing them more frequently is absolutely the right decision until we have improved vaccines. So Chris, I do agree, but I do have to add one caveat. During the week of October 12th, the most recent data available, coverage of the 2024-2025 COVID booster was very disappointing. For example, we know that the highest risk of serious illness, hospitalizations and deaths are in those 75 and older. Yet, only 30.6% of adults in this age group have received the booster shot for those 65 to 74. 25%. And for those 50 to 64, only 12%. So those vaccines are not going to do any good unless they're in someone's arm. I recognize the fact that many will say, well, I've had COVID twice or three times. You know, it's no big deal. Let me just remind you, even if we're not talking about serious illness, hospitalizations and deaths, the data are becoming increasingly clear that long COVID can occur after having several bouts of COVID infection. And the most recent 1st May be the one that tips you over into that long COVID category. The data does support the vaccines, reduce the likelihood of developing long COVID, and therefore it by itself would be enough motivation for me to get my two doses a year. So yes, I very much support the ACIP recommendations. We'll be talking more about that in the next podcast. I'm going to dive into the issue around children and the use of vaccine there. So congratulations to ACIP. Congratulations to CDC.

Chris Dall: Okay, Mike, so just to be clear here, if you are a healthy person aged 65 or older, you can get two shots spaced six months apart. If you are a person of any age with severe or moderate immunocompromising conditions, it's three doses spaced two months apart. Is that correct?

Dr. Osterholm: Yes, you can get up to three doses. So the fact of the matter is you may space them somewhat differently, but that's now allowable. And I think that's the thing we were really looking for is for ACIP and CDC to be permissive. You know, for those that want to get these doses of vaccine, we encourage that taking place. If you're particularly at risk of having serious illness because of an underlying health condition.

Chris Dall: Okay, so while we're discussing respiratory viral activity, what are we seeing right now with flu and respiratory syncytial virus or RSV?

Dr. Osterholm: Well, Chris, this is one of the real good news issues. As I said in the last podcast, I want to repeat again, we are really at the lowest level of serious respiratory viral activity that I've seen in the last 4 to 5 years, clearly before the emergence of the pandemic in late 2019. If you consider kind of the triple crown of respiratory viral infections, we're talking about influenza, COVID and RSV. And right now for all three of these viral agents, we're seeing very, very limited activity. So right now, if you look at laboratory confirmed illness, outpatient visits for influenza like illness and influenza mortality, they have all remained steady for the past week and at very low levels. Five states in the US are currently reporting low levels of influenza activity, and 45 states are still reporting minimal levels of activity. That said, this is the time of the year when we can expect transmission to pick up. So now is the time to get your flu shot if you haven't already. Also, RSV activity has yet to take off this season, but we can expect it any day now. If you are in the 70% of eligible pregnant women, or 63% of adults over 75 who have not received your RSV vaccine, please don't delay your vaccination any further. As always, we will continue to keep you updated on as this year's respiratory virus season and unfolds.

Chris Dall: Let's turn now to the H5N1 avian influenza outbreak. Last week, the CDC announced the results of serologic testing on five Missouri health care workers who had symptoms of H5N1 avian flu infection around the time they were exposed to an infected patient. Mike, what did those results show and what is the significance of those findings?

Dr. Osterholm: Well, Chris, I think we could probably spend a couple of hours peeling back this onion, and all I can say is that there would be a lot of tears shed. I think if you really understood how confusing and difficult this situation is. First of all, let me just comment on what happened in Missouri. As you may recall, earlier this summer, we had an individual who was hospitalized for a condition not related to influenza, but on routine screening as part of ongoing influenza surveillance, they were found to have H5N1 infection. It was actually a virus that was growing up from the individual sample. Now, at that point, this individual had no reported contact with wild or domesticated animals that would support a relatively explainable exposure. There was a major investigation conducted for this individual, and nothing was really clear and evident as to how they might have become infected. At the same time, their spouse also had an illness, a diarrheal illness, and by the time that they recognized that the first patient had H5N1 infection, it was too late to test him or those health care workers you talked about who had actually taken care of this original patient, and who then also developed respiratory illnesses afterwards. Now, there were a number of people in this country that jumped immediately to the conclusion that, in fact, this was a cluster of H5N1 cases and that likely person to person transmission occurred.

Dr. Osterholm: If you've been listening to this podcast, you've heard me talk about it. I doubted that I didn't believe that was the case. And in fact, the results came back. Now with the serology. Remember, serology is the blood sample testing to look for antibody. If you're not able to do a throat swab on someone early in their infection, and it's only several weeks later, you learn that they may have been a case at least exposed to a case. The only opportunity you have then is to look for do we have an antibody response from having been infected? And that takes 3 to 4 weeks after your likely period of being infected. Before you'll see that antibody rise. No one should really have much antibody at all to H5N1 because we something we just don't see, unless you're in that occupational setting where you'd expect to see it. So all the five health care workers had no evidence of seroconversion or antibody positivity. Activity. That's not surprising to me on any one given day, particularly this past summer when we did see more respiratory virus activity, you'd expect to see a several percent of health care workers or anyone in the community showing signs and symptoms of respiratory illness that had nothing to do with influenza. Now, where it got more complicated was the index case was household contact did show some evidence of H5N1 seroconversion, meaning that there was on different testing methods.

Dr. Osterholm: One test where they had some evidence of H5N1 previous infection. Now the challenge was, is that this particular test by itself did not meet the criteria for the W.H.O. of actually having antibody. So CDC actually really muddied up the water. And, you know, I'm disappointed. They had a press briefing where they basically presented this information and said that the contact did not meet the criteria for being called a case, and therefore they don't count that in their numbers. You'll look and see it's not there, but at the same time, they then gave explanations for how both the husband and wife could have become infected together, implying that the spouse who wasn't originally known to be infected actually was. So they really muddied up the waters. The media then covered it in the similar manner, some saying there was now two cases of H5N1 infection in Missouri in the husband wife combination. Others say no, no, it didn't meet the criteria. And so we're left with this confusion. What do I think it means? First of all, it's very possible that that spouse did have H5N1 infection, but clearly not evident that they had an illness that was classic influenza. That's a possibility. The second thing, though, it's possible that they didn't.

Dr. Osterholm: And and the test result that they did get was insufficient to declare them to have had the infection. Now, assuming that both of them did have infection, it doesn't mean that one gave it to the other. Where one got it, the other could have got it at the same time. So we can't say that there was evidence of person to person transmission. So at this point I just come back to the default position. We don't know. And we just have to say that. But what we do know is there was no evidence of widespread infection that might have occurred as a result of a human case of H5N1. Now, what might be the explanations for this, I don't know. You know, we've had this type of issue come up before with other avian strains of virus where some human gets infected with H7. We don't know where they got it. They don't have obvious contacts with birds, with other animals. What happens here, I don't know. You know, you can speculate all you want. Bottom line is the message is, is that it? In fact, there was no evidence of widespread transmission. Now, moving on from that, we are in a very, I think, complicated, difficult and frankly confusing position with what's going on right now with H5N1 and dairy cattle. Just on the first two days of this week, we've added 49 additional herds as being infected, such that now there are 388 herds with infection status confirmed, including 186 in California.

Dr. Osterholm: That number just seems to grow and grow and grow. It's not burning itself out in the dairy cattle situation. What does this mean? We don't know. And I think we have to acknowledge at this point that the original USDA supposition that this would just burn itself out in dairy cattle is surely not holding up. So where it goes with, we don't know. To date, there have been 36 total human cases. Of the 36, all are in cattle or poultry exposed individuals. The one unknown, of course, is the one I just talked about with Missouri. So that means 20 cattle related cases, 15 poultry. But when I say cases, we need to be very careful here. Again, I see people talking about H5N1 bird flu in contact with the viruses in the cattle and the poultry. And we're not seeing classic influenza. We're continuing to see largely conjunctivitis, which actually is associated with a certain type of receptor site binding to three binding, which is the avian bird virus binding characteristics. We're not seeing classic influenza with the two six binding, i.e. that of human influenza viruses. So we need to get much more information on this. The studies in Colorado and California, elsewhere, and infected individuals to learn what it really means to be infected with this virus.

Dr. Osterholm: Is there still a big, big, big jump it has to make to get over the bar to cause influenza like illness in individuals, where they then can transmit the virus person to person with respiratory illness. In short, communication has to improve from our federal government. Number two, the USDA has to acknowledge that the way they are now trying to control this is not working. It is not. And we need much more information about how is this virus, for example, spreading so readily in California. And number three, we have to tone down, I think our messaging that we're on the cusp of a major H5N1 pandemic, which I hear too many people say, let me remind you, there will be more influenza pandemics. And they could be horrible, and it could be that H5N1 is the cause of that. But after all these years, particularly since 2003, we have not seen evidence that this virus is readily infecting humans and humans infecting other humans. I don't know why. Nobody knows. But the bottom line message is, at this point, we do have a problem in our dairy cattle. We've got surely illnesses occurring in humans, but not the classic influenza. And we have to acknowledge with humility. We're just not sure where this is going.

Chris Dall: Mike, as many of our listeners probably know, there's been a lot of news about foodborne disease outbreaks lately, one involving a very well-known fast food chain. Last week, the CDC reported that 49 people have been sickened in a multi-state E coli outbreak linked to McDonald's Quarter Pounder hamburgers. That number has recently been updated to 75 people, with 22 people hospitalized and one death also. Treehouse foods issued a voluntary recall of frozen waffles that may be contaminated with listeria. And that's just the latest food item that's been linked to listeria. So, Mike, what do our listeners need to know about these outbreaks?

Dr. Osterholm: Well, first of all, let me just say that this kind of brings me back to my roots. You might say, in all the years I was at the Minnesota Department of Health, one of the areas that we really excelled in was the area of foodborne disease epidemiology. The team there was responsible for breaking many of the largest and most important foodborne outbreaks in the country, and really contributed a lot to the science of prevention of foodborne illness. So for me, it's an area that is near and dear to my heart in terms of public health and epidemiology. So let me just say that what we're seeing here is one that should not be unexpected. At the same time, we never want it to happen. The new illnesses associated with the McDonald's E coli outbreak continue to be reported. And as you just noted, as of today, 75 cases of infection have been reported with the outbreak strain of E coli O157 H7 and have been now reported from 13 states. 22 of these people have been hospitalized. Two developed hemolytic uremic syndrome, a very serious, potentially life threatening condition where the toxins produced by the E coli bacteria actually cause severe damage to the kidneys of individuals, and in many cases this can be fatal. In this outbreak, one person has already died. Early on, the evidence was clear that the Quarter Pounder hamburger was responsible for infection. But for those of us who worked in foodborne disease, a Quarter Pounder hardly describes what might be the actual cause of the outbreak because they contain not only the hamburger and cheese and garnishes or things like onions.

Dr. Osterholm: Any one of them could have been the source. But for me it was obvious that this was not likely due to the hamburger. Even though in the past we have seen a number of outbreaks of E coli O157 H7 associated with ground beef. And why do I say it wasn't a likely source here? Because McDonald's and having experienced major E coli outbreaks back in the 1980s, really did a great deal of work to assure that their grilling temperatures are met before a burger leaves the grilling line and then put into a bun, and the temperatures far exceed anything that would kill E coli. Now, the outbreak also occurred suddenly in a region. When that happened, you couldn't have an outbreak of grills all going bad at once, which would just make no sense whatsoever. So I never did think that it had to do with the beef. On the other hand, what goes on the Quarter Pounder is important. And in this case, there's actually a slivered onion that is included that actually is not used on the other hamburgers that are sold at McDonald's. So you could have had a very clear relationship with Quarter Pounder consumption and not the other hamburgers, which maybe think the onions are likely it. Well, today where we sit, uh, the following one is there's been an announcement. Now that is not the ground beef because of some testing. I worry about that message because, frankly, unless you tested a whole lot of product, you couldn't be certain that there wasn't E. Coli in it.

Dr. Osterholm: And again, if there was E coli in it, which there could be, it would be adequately handled in terms of the cooking temperature, but also in terms of the onions. That is a product that, again, is raised in a field despite anyone's best efforts to prevent any kind of contamination of that product in the field, whether it be irrigation water, wild birds, other animals, defecating. However, you can't guarantee that that's going to be pathogen free short of, in this case, doing a process like what we call food irradiation. So there's work going on right now to look at this. I do know that the supplier of these onions, Taylor's Farms, is a very well respected organization that has put great emphasis on food safety, but it also just points out the vulnerability today of food products that will be consumed that, in fact, do not go through a kill step or a way to eliminate the actual infectious agent that might be associated with it. This is where good agricultural practices are so important and how we get into that. So stay tuned. I'm convinced that by the end of the week, we'll probably have an isolate from onions of E coli o157 H7, and then the effort will be on to make sure. However that happened, it doesn't happen again. Um, as you mentioned, Chris, there has also been a recall in a number of frozen waffle and pancake products. This recall is due to potential listeria contamination. As I've shared in previous podcasts. Listeria can cause serious illness, particularly in pregnant individuals, the elderly and those with weakened immune systems.

Dr. Osterholm: Unlike the McDonald's outbreak, there have not yet been any reports of illness so far. The issue was discovered during routine testing at the manufacturing facility and as such, to prevent potential illnesses from occurring. This recall went into place, but let me just put all of this into some perspective. What is the risk of foodborne illness? Well, think about the fact that there are over 345 million people in this country. Imagine we each eat three meals a day, which of course, we know there's no such thing as just a three meal a day kind of approach for most people today. They eat at any number of times throughout the day. Um, there's an estimated 48 million people that get sick among the 345 million people that eat three meals a day, or a billion total meals in a year. And so foodborne illness is still a very rare phenomenon, but anywhere up to about 4.8% of meals may result in a foodborne illness. And I think we just have to be mindful of that. What is it that causes that is raw product that is not subsequently cooked? Is food handlers who may handle product that was cooked but cooled and contaminated. And these are all part of a very complex and ever ongoing system of food safety checks and balances. Ask McDonald's. Ask any company that has suffered a major outbreak and they will tell you it's devastating. They don't want that to happen. Now, there are some cases where, as we've learned with the boarshead outbreak of listeria that we've already talked about on this podcast there, it's going to be a challenge.

Dr. Osterholm: There were conditions in those plants that should never existed. So I'm not going to sit here and tell you that all food preparation of food processing is in fact at the level that it needs to be. But the bottom line is that we eat a lot of meals in this country where we are not exposed to a foodborne pathogen. And let me just conclude with the issue of a frequent cause of diarrheal illness that may or may not be foodborne related, and that is norovirus. We know that norovirus is a highly infectious virus. Humans are the only source for this virus who is infected and ill with norovirus to contaminate the food. What, however, is often missed, and this is something that our group at the time at the Minnesota Department of Health back in the 80s and 90s showed convincingly, is that you can also have a respiratory transmitted norovirus situation. We worked up many outbreaks and continue to do so where respiratory transmission, not food, plays a role. And so today when you get that illness, that diarrheal illness, you feel like you're going to die even though you're not, but for a day or two, it feels like it. That often can be norovirus, which is not food caused in each case, but could just be from contact with individuals who have it. The bottom line is we just need to continually work to maintain the safety of our food supply. And it's not a one and done kind of situation.

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

Dr. Osterholm: Chris, this week is one that's near and dear to my heart, because it's featuring a more modern figure in public health who has left a legacy that will last for generations. And as someone who was a dear friend. I'm talking about Doctor Paul Farmer. He was someone I had the pleasure to know and develop a deep respect for. Paul was born on October 26th, 1959, and raised on the Gulf Coast of Florida. His family of eight lived in a school bus turned mobile home while his parents worked in agriculture and commercial fishing. His family often worked alongside Haitian migrant workers, which shaped his future career plan. Paul was a strong student and attended Duke University to study medical anthropology. During his studies, he became inspired by different physician scientists, theologians, and union leaders who all shaped his world view on the importance of walking alongside and serving those who are more marginalized and under sourced. Paul began working with local advocates to improve the living conditions of Haitian migrant workers, harvesting tobacco in the region while listening to their life stories. Paul became fluent in Creole and immersed himself in studying Haitian history. He traveled to Haiti to begin working on capacity building projects for the local health care system. During this time, he authored more than 100 papers and published several books. Paul continued his education at Harvard University, earning an MD and a PhD in Medical Anthropology and became board certified in internal medicine and infectious diseases, all while continuing to serve in Haiti.

Dr. Osterholm: Alongside several of his Harvard colleagues, Doctor Farmer founded the organization Partners in Health. The organization began in the central plateau of Haiti, but now operates in more than 16 sites and employs more than 7000 people. The organization not only offers health clinics, but supports a range of public health programs, from housing to education to water, sanitation and hygiene. Doctor, farmer and his colleagues at Partners in Health have received countless awards and recognition for their global work fighting multidrug resistant tuberculosis, Ebola, Zika, and numerous other public health threats. Anyone who had the pleasure to meet Paul recognized the deep care and respect he had for each and every person, and his passion to make health and human rights throughout the world. Paul tragically passed from an acute cardiac event in his sleep in February of 2022 at the age of 62. It is very difficult to summarize the immense impact he had on the world and the continued ripple effect of his service and teaching. I would highly recommend the book Mountains Beyond Mountains The Quest of Doctor Paul Farmer, A man Who Would Cure the World, by Tracy Kidder to anyone who wants to learn more about him and inspired by his life and legacy. We miss you, dear friend. We miss you very much.

Chris Dall: Mike. Throughout the four plus years we've been doing this podcast, you have steadfastly tried to maintain political neutrality and stick to the science. But you talked about election workers and your dedication. And I understand now that you have some things you'd like to say about this upcoming election.

Dr. Osterholm: Well, Chris, let me just start out by a quote from Franklin Roosevelt to provide you some context of what I'm about to share with you. He said science is not truth, but rather a search for truth. And I hold those words. To be so important is the search for truth. Well, I have been searching my heart and soul for the past months on what this election means to public health. Now, let me set the tone here, because I'm sure some of you already may have the hair standing up in the back of your neck, because you're going to hear something from me that you thought that I would never do. I have, for the 50 year career that I've had in public health, served every elected official that somehow was in the chain of command that for which I worked, whether at the state health department, the federal government, and have done so in a totally nonpolitical way. I'm just a private in the public health army. I've had roles in every presidential administration since Ronald Reagan, where I first served in the HIV Aids Commission work, and I served in recent years in the Obama administration, National Science Advisory Board, and biosecurity and two other advisory groups in the Trump administration. I was a science envoy for the State Department, traveling around the world trying to improve our preparedness for a pandemic. And many of you know that I also served on the Biden-Harris COVID transition team and have continued to advise our government. I've served five different governors in Minnesota, two Republicans, two Democrats, and one I say affectionately as an independent wrestler, Jesse Ventura all around the issues of public health.

Dr. Osterholm: And it's one where, again, it was not important to me what their political label was. It was important to me is how did they hold to supporting public health and what it means. I still believe that's very important. That type of objective overviews of a subject matter expert should be there regardless of who you are politically. So what I'm about to share with you really is one that is very difficult for me. But I wake up every morning and I ask myself, why do I go to work? What do I do this for? I'm an old man. I could retire because of one simple thing my kids and grandkids. I could never, never not try to do what I can to make this world a better place for them. I see their faces every day. So for me, what I'm about to share with you is really a matter of both my head and my heart. I have never in my 50 years found myself in such a position where I fear for the future of public health. This election is unlike any that I've ever known. I'm not here today to tell you who to vote for. I won't do that. I will lay out facts. The truth. You will have to decide. All I ask you to do is your research and vote. Please vote without regard to whoever you're voting for.

Dr. Osterholm: Please vote. This is so important. So where are we at? What's going on here? Well, you know, I direct the center for Infectious Disease Research and Policy. Let's be honest, policy always somehow involves politics. But as I've said before, I have always ascribed to the politics of public health in a way that is not Partizan. It's about how do we do what we need to do to protect the lives of those who live in our communities. What we see now is a very, very different scenario than I've ever seen. We see the Trump team surrounding themselves with individuals who have developed plans for what the next Trump administration might look like. That, frankly, would be so highly destructive to public health. I don't know how it would exist. This is also highlighted by the fact that it's been announced even within the last week, that Robert F Kennedy Jr will have a senior role in all the areas of public health and activity. And let me clarify, when I talk about this election, I'm talking about every office from your county commissioner and your mayors all the way to the presidency. This is an election that's about all of them. So it's not aimed at just one individual. It's not just aimed at one office. For example, though, if you look at what's happened with COVID states, with Republican governors and more Republican state legislatures had a significant higher excess of COVID deaths. Once vaccine became available, stark differences were observed.

Dr. Osterholm: Florida is an example. Florida's Surgeon General, Joseph Ladapo, had repeatedly made policy decisions that contradicted widely accepted scientific evidence, including the causes of measles and vaccination for measles. COVID vaccination. Looking at various associated drugs. Hydroxychloroquine, etc.. All of these issues were an indication of the unwillingness to accept science to run public health. So if I look at public health issues across the board, I am an infectious disease epidemiologist. Surely I understand what that means relative to pandemic preparedness, sexual health, sexually transmitted infections, vaccinations, the ability to look at any number of issues. But in fact, public health issues are much wider. It's not just that of infectious diseases. It's all about the issues of chronic diseases. How do you deal with them? Reproductive health. So this is a time when we have to come together. So where am I going with this? Well, if you look at what has become the standard bearer for the Trump proposal moving forward, it is project 2025. Now, I know that the Trump team has indicated that they do not support this and they are arms length away. But let me just share some data with you about this. It was created by the Heritage Foundation, who has staffed Republican presidential administrations dating back to the Reagan administration. The Heritage Foundation describes project 2025 as a historic movement to take down the deep state and return the government to the people. The Deep State is a key part of many political conspiracy theories, which suggest that a network of federal government members are working with financial and industry elites against the best interests of the American people.

Dr. Osterholm: This extensive document has 30 chapters, each detailing plans to overhaul a specific government department or agency. Most concerning to public health includes the Department of Health and Human Services. As I shared, Mr. Trump has repeatedly disavowed project 25, stating that the last presidential debate that he does not know who wrote it and does not intend to read it. However, there are many undeniable connections between the former president and Project 2025. 31 of the 40 authors of that were involved in the first Trump administration, either serving in the administration itself or working on the transition team or working in the campaign. This includes Roger Severino, who wrote the Health and Human Services chapter of project 2025. In the Trump's first administration, Severino served as the director of the Office of Civil Rights in HHS. Of the 267 additional contributors, 144 had a role in the Trump administration campaign and or transition teams. What are some of the agenda items and project 2025 that would harm public health? One would be eliminating the Affordable Care Act, cutting Medicaid benefits, increasing Medicare Part D prescription drug prices, fundamentally restructuring organizations like the NIH and CDC, which are critical to public health as we know it. They could have major budget slashes that would occur, and then they propose over a 50% cut. They also propose that the agencies be greatly reduced in their ability to actually work in a number of different areas of great public health importance.

Dr. Osterholm: They also, and I quote, unaccountable bureaucrats like Anthony Fauci, should never again have such broad, unchecked power to issue health guidelines. That will certainly be a basis for federal and state mandates. We all agree that we need to do a better job of communicating, but can you now imagine that, in fact, leaders in public health are silenced because they, in fact, are now part of government, which is where public health power resides. In addition, the report goes on and says COVID-19 exposed CDC as perhaps the most incompetent, arrogant agency in the federal government. There were challenges. You've heard me. I've never spared the rod in my comments about CDC, but I'm also the first to tell the truth about the good things. If we, in fact, lost the CDC as an important voice, that would be an irreparable harm to public health activity. The report calls for the removal of the CDC vaccination schedules and their use in school vaccination mandates. For example, they say never again should CDC officials be allowed to say in their official capacity the school children should be masked or vaccinated. Calling for the establishment of a national abortion registration, which could endanger women seeking reproductive care for elective abortion and miscarriages. One area that I find actually quite remarkable that in terms of it's not being spoken about more, is when we talk about mass deportation and regressive immigration reform. This would, in fact crash our food supply chain, which would have tremendous impacts on health.

Dr. Osterholm: Approximately 1.7 million undocumented workers are employed across the American food chain. The American Farm Bureau has stated enforcement only immigration reform would cripple agricultural production in America. Let me give you an example in the state of Wisconsin and what this would mean in food supply integrity. Today, there are 13,000 individuals, 10,000 who are undocumented workers. Literally 70% of the total. Who are the ones every day getting up early in the morning, working through the night to milk cows twice a day in the state of Wisconsin. Remember, this is the dairy land. If, in fact, suddenly those 10,000 undocumented workers were gone, the dairy industry in Wisconsin would cease as we know it would have to euthanize many of the animals. They would not be able to be milked twice a day. There wouldn't be the resources. If you talk to the owner operators of these dairies, they will tell you that these workers have been incredibly important to their everyday livelihood and that in fact, they are incredible workers with dedication to their jobs. We're not talking about what would happen there. And so I again, as a public health person, I can tell you food security would be really an important challenge. We are now seeing programs like PEPFAR, the president's program, to basically get antiretroviral drugs to many in Africa who now, as a result of having access to these drugs, have been spared HIV infection at birth and have had controlled HIV infections as adults. The Heritage Foundation issued a report alleging that the program is being used to fund abortions, for which there is absolutely no evidence that that's the case at all.

Dr. Osterholm: At this point, it's really a challenge to keep PEPFAR going, and it's likely after all these years. Remember, this was a Bush program that he started, that this program likely will not be reauthorized. If you look at the issue of sexually transmitted infections, they're now at an all time high. And the current Trump approach would be to promote abstinence only Ed and dismantle prevention and harm reduction strategies, setting us back even further for against these high rates of STIs. One additional piece is the Trump administration literally threw out the pandemic playbook that was created by the Bush and Obama administrations. That still is the case today. So all I can say is, is that I don't agree with everything that the current Biden administration has done. It was not perfect and it hasn't been perfect, but it's done a great deal. And let me just bring this to some conclusion here by saying one of the other things is we need the healthcare providers of this country to vote. There was a very important paper published in the January 2021 issue of the Journal of General Internal medicine entitled Voting Behavior of Physicians and Health Care Professionals. This paper looked at of all of us in the community by profession, who votes and who doesn't. And it turns out that if you look at the issue of health care professionals, whether they be physicians, dentists, pharmacists, registered nurses, we are way below the voting records of many other professions, including teachers, business executives, civil engineers, social workers, lawyers, etc..

Dr. Osterholm: Why is that? Because we're very busy and that was given as the reason for not voting. Please vote. I'm not telling you who to vote for. I gave you information that I think is relevant, but vote. But also please do your homework. This is without a doubt the most consequential election of my lifetime. And this is someone who has worked, as I said, with all these different administrations at the federal, state and local level, and I will continue to do so. I will continue to do so, but I also recognize how public health will in fact look so different in just a few months depending on the outcome of this election. And that difference will mean lives. And it's a world where my kids and grandkids will be put in additional risk situations that would not need to happen. So I'm sorry if I've offended anyone on this podcast for speaking my mind. I just can't, not because of my kids and grandkids. And as I said to you now, I'm not telling you who to vote for. I'm just asking you to do your homework. And if anyone has questions about what information I've shared and I can share much more, I'm more than willing to do that. But at this point I will not. I will not just step aside and watch what could happen to public health without speaking my voice.

Chris Dall: And Mike, do you have a closing song selection for us today?

Dr. Osterholm: Well, Chris, after that heavier message just now. I'm not sure anybody wants to listen to one, but actually I do have one that I think is very relevant and very timely. Uh. A Beautiful Noise is a song recorded by a female American recording artist, Alicia Keys, Brandi Carlile, and written in addition to Keys and Carlile by Brandi Clark, Hillary Lindsey, Lori McKenna, Hailey Whitters, Linda Perry, and Ruby Amanfu. It was released as a single on October 29th, 2024 years ago through RCA records. The song was performed live on Every Vote Counts A Celebration of Democracy, and they released the single immediately following the song's premiere on CBS. A Beautiful Noise was recorded to inspire American voters to vote in the 2020 presidential election, and it's a song that I think today is, in a sense, a potential anthem for what all of us want. We want a beautiful noise. We want people to appreciate the gift of voting, to experience that gift and to be part of how we map the future for all of us. So here it is a Beautiful Noise by Alicia Keys and Brandi Carlile. I have a voice. Started out as a whisper. Turned into a scream. Made a beautiful noise. Shoulder to shoulder. Marching in the street. When you're all alone. It's a quiet breeze. But when you band together. It's a choir of thunder and rain. Now we have a choice.

Dr. Osterholm: Because I have a choice I'm not living to die. Don't stand in a wasteland. Look at me in the eye. Stop living a lie and stand up next to me. You got to put one foot in front of the other with a hand in the hand, holding on to each other. Go on and rejoice, because you have a voice. It is loud. It is clear. It is stronger than your fear. It's believing you belong. It's for calling out the wrong. From the silence of my sisters to the violence of my brother. We can. We can rage against the river. Feel the pain of another. I have a voice, I have a voice, and I let it speak for the ones who aren't yet really free. It's killing me. No one is saying what we need to hear. I will not let silence win when I see all the pain our people are in. There's no other choice. Because I have a voice. It is loud. It is clear. It is stronger than your fear. It is believing you belong. For it's calling out the wrong. From the mouth of our mothers to the lips of our daughters. We can. We can dream like our brothers. Speaking out loud. Like our fathers. We can. We can heal. Can we hear us? Can you hear us now? I have a voice. Started out as a whisper.

Dr. Osterholm: Turned into a scream. Made a beautiful noise. Shoulder to shoulder. Marching in the street. When you're all alone. It's a quiet breeze. But when we stand together. It's a choir of thunder and rain. Now we have a choice. Because I have a voice. Well, thank you all very much for listening today. I appreciate this. And, um, again, my apologies if I've offended anyone with my closing comments about where we're at at the same time. That's a small price I'll pay for hopefully encouraging all of you to do your research and to vote. Uh, please. It's a such an important time and as I have already voted, but when I did my mail in ballot, I didn't just see words on that piece of paper. I saw the faces of my kids and my grandkids. I'll never forget that. Thank you for being with us. I'd like to say I hope you have an uneventful week, but I have a feeling that by the time we get together again, it will be somewhat eventful again in all of this madness that is happening. Just remember what we have talked about so many times now. If there was ever a time to be kind, it's now. If there's ever a time to reach out to others now, do it. It's priceless. So thank you. Stay safe, stay well. And most of all, please go vote. 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.