Episode 172: A Tunnel of Uncertainty

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. On the last episode of the podcast, we discussed the nomination of Robert F. Kennedy Jr. to be secretary of the Department of Health and Human Services, and what that selection might mean for public health in this country in the coming four years. In the ensuing two weeks, the incoming Trump administration has announced its selections to lead the nation's other health agencies, and those selections suggest we could be looking at some major shakeups in those institutions with potentially profound impacts. Who are the nominees to run the centers for Disease Control and Prevention, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, and the National Institutes of Health? And how could their leadership, if they are indeed confirmed, change these agencies? That's where we'll be starting on this December 5th episode of the podcast. We'll also discuss COVID-19 and other respiratory virus data, provide an update on developments in the H5N1 avian flu outbreak, and we'll bring you the latest installment of this week in public health history. But before we get started, as always, we will begin with Doctor Osterholm's opening comments and dedication.

Dr. Osterholm: Thank you, Chris, and welcome back to all the podcast family members, it's wonderful to be with you again. I also want to welcome those who may have been listening to us from time to time, but not regular listeners. And surely, we want to welcome anyone who might be listening for the first time. We're hopeful that the information we provide is of real use to you, and that we will hear from you over the days ahead about things we could do to improve on that information sharing. I want to start today's episode with a special dedication, reflecting on something most of us here in the U.S. just celebrated Thanksgiving. It's a special moment when many of us look forward to spending time with family, food, and giving thanks. But as we all know; the holidays aren't always as perfect as the curated images we see on TV or social media. They can be complicated, messy and often carry a mix of emotions. For me, the Christmas holiday season was a challenge. As the oldest son growing up in a family where my father was a violent alcoholic, it seems somehow that the holidays brought out the worst of him at that time. Unfortunately, those memories still linger many years after the experience. For many of us, Thanksgiving means sitting around a table with loved ones, exchanging stories and indulging in delicious food. For some, the holiday table brought difficult conversations about politics, public health, or disagreements that have seemed to deepen over the past few years.

Dr. Osterholm: We may have found ourselves avoiding certain topics or bracing for hard debates. These aren't easy conversations, but they're real. They are very real, and many of us had to navigate them with family members we don't always agree with or struggle to understand. And let's not forget, the holiday season can stir up a deep sense of grief for those who have lost loved ones, are facing challenges with their own health, or simply are feeling overwhelmed by the weight of the world. This time of the year can bring sadness just as much as it brings joy. So, before we dive into the public health topics that we love to unpack here, I just want to acknowledge the complexity. Please know we understand that it's okay that you didn't have a perfect holiday, or if it was hard for you to show up in the way that you wanted. What we've learned, especially in the context of public health and the challenges we've faced over the past few years, is that we're all trying to find a balance between resilience and vulnerability. Today, we're going to continue to have those difficult conversations, the ones that matter. And if this Thanksgiving brought up anything tough for you, know that you're not alone. As always, we the podcast family, you and our team are here to support, to inform, and to have open conversations, even when those conversations are very hard.

Dr. Osterholm: Now, let me move on to that moment within the podcast that I love. And many of you would just as soon as I skipped it. This is the one gift I give myself. So, on December 5th, here in Minneapolis Saint Paul, Minnesota, we will have sunrise at 7:35 a.m. Sunset at 4:31 p.m. for eight hours, 55 minutes and 48 seconds of sunlight. Note: we're now on a string of days where the sun sets at 4:31 in the afternoon, and this will be the earliest that we'll see sunset, as the days will start getting longer in the afternoon in about eight days. But they'll continue to getting shorter in the morning, such that it will be December 21st, when we have the shortest day of the year where the two intersect. Now for our dear friends and colleagues in Auckland, New Zealand, and particularly those at the Occidental Belgian Beer House on Vulcan Lane today your sun rises at 5:54. Your sun sets at 8:28. You have a whopping 14 hours, 33 minutes and 42 seconds of sunlight, and you're still gaining sunlight at about 58 seconds a day. We know that you're enjoying that sunlight. We know that you're a very kindly sharing that with us. And as I've said time and time again, we promise when we get to our June time period here in Minnesota. We'll send you some of our sunlight back.

Chris Dall: So, Mike, here's where we are right now with president elect Trump's health team. In addition to Robert F. Kennedy Jr. at HHS, we have cardiologist and TV personality Mehmet Oz nominated to be the director of the Center for Medicare and Medicaid Services. Johns Hopkins surgeon and Professor Marty Makary named as the commissioner of the FDA. Former Congressman Dave Weldon, nominated to lead the CDC. and Stanford physician and health economist Jay Bhattacharya named as director of NIH. Trump also named family and emergency medicine doctor Janette Nesheiwat to be Surgeon General. Now, if you look at all these nominees together, along with RFK Jr, you see a couple of broad themes coming through. Their supporters say they're going to put a real focus on fighting chronic disease and reducing the power of the pharmaceutical industry. But some of these nominees, Kennedy in particular, have a history of questioning vaccines. Others have been very critical of COVID-19 mitigation efforts and have really raised their profile by being COVID contrarians. And none of them have infectious disease expertise or experience running government agencies. And a really big theme is that they have all been highly critical of, if not hostile to, the agencies they have been named to lead, and that's likely why they were chosen. So now that you've had some time to digest all of these nominations, Mike, what are your concerns?

Dr. Osterholm: Chris, let me begin by saying that we're all on a journey. We're on a journey with regard to how to deal with the next four years of US government leadership, what it means for public health. We're all trying to understand what our own emotional feelings are, about what we're about to experience when we don't know for sure what this all means. This podcast is on a journey. We're trying to understand how we best can be helpful to you, how we can understand the issues of the day in Washington, D.C., and what that means for you and what we can do to impact on those. So please know that this is a journey and we will get better at it. I promise you. We will listen. We will learn, we will get better. But right now, let me just start off by saying yes, I'm very concerned about these nominations. I think this is clearly a challenge, trying to find the balance between explaining why these appointees could be problematic for public health without creating unnecessary fear about the things that these individuals might be able to do. That said, there is value in raising awareness about those appointees and who they are and the power that they might have. We will continue to update you as the new administration takes office and potential changes do occur. But now, let me be really clear before I talk about any one of these individuals, none of them yet have been confirmed.

Dr. Osterholm: And while I do expect most of them will, as you have already seen, there can be interesting things happen in Washington, DC. Today, we're living in a world that's very transactional. Somebody gets something for something and somebody else gets something for that. So where are these positions will finally all come together? I don't know, but the second point of it is, as I've stated before, it's not necessarily the lead person in an organization or agency that really is critical in dictating what happens on a day-to-day basis. Imagine trying to run almost a $2 trillion agency. Do you think that the Secretary is able to actually micromanage down at levels that would be of real concern if they could make the decisions about yes or no? So, at this point, it's going to be who's gets the number 3 or 4 spot. Where do they sit in the administrative chart in such a way that they can make decisions on their own and actually have big influence. And so, I'm still waiting to see who all the new additional appointments may be. So let me just briefly touch on each of these nominees. You've already heard a lot about them. I'm not going to go into great detail on them beyond what you probably already know. Well, first and foremost, let's start with RFK Jr. We've already talked a bit about him in previous podcasts, and his appointments received a lot of media coverage.

Dr. Osterholm: I'll just briefly reemphasize a few of the most concerning aspects of this appointment. Kennedy is clearly an anti-vaccine advocate, despite his occasional remarks that he is merely a skeptic asking questions. That's simply not the case. He has said outright that there is no safe and effective vaccine. We have that in his own words. Prior to his presidential campaign, he was the chairman of the Children's Health Defense, an anti-vaccine advocacy group. A 2021 study found that Kennedy's Twitter account was the top spreader of vaccine misinformation on the platform, with his content retweeted three times as much as the second largest spreader of vaccine misinformation. Although Kennedy has stated in recent interviews that he has not anti-vaccine. His words and actions over the past several years have consistently proven otherwise. In addition, I want to add one other piece. We all recognize that as a population, we have some major challenges with chronic diseases. If you look at the diseases of aging, heart disease, cancer, strokes, you look at obesity, you look at a number of different challenges that we have. They are real and we do need to address these, and we're not doing a good job of addressing them today in any meaningful way. But to keep talking about Making America Healthy Again and this idea in the next 2 to 4 years, what we can do, that's simply not going to happen today, to actually turn around the health behaviors of many of those in our society, as well as bringing about the kind of interventions from a medical standpoint that can make a difference, is a process that's going to take years.

Dr. Osterholm: Generational issues not going to happen in 2 to 4 years. Don't promise that. And I fear that right now we're so focused on the idea. And as Mr. Kennedy said, we need to basically drop out of the infectious disease world for the next eight years and invest all of our resources into chronic diseases. You can do that, but you're still just going to only begin to make changes in society that will then ultimately affect the issue of these chronic diseases. So do not be fooled by the fact that Make America Healthy Again is going to suddenly change the risk of cancers, of heart disease, all these other chronic conditions that we surely do understand and that we're very concerned about. Now, let me move on to just briefly talk about the other potential nominees that we need to be concerned about. For example, Doctor Mehmet Oz, best known for his TV show The Doctor Oz Show, was selected to run the Centers for Medicare and Medicaid Services. Doctor Oz has had a long history of promoting misinformation on his TV show, despite the fact he is a cardiothoracic surgeon.

Dr. Osterholm: A 2014 study found that more than half of the recommendations he made in his show were either unsupported by substantial scientific evidence or entirely contradicted by scientific evidence. During the pandemic, Doctor Oz supported the use of hydroxychloroquine, a drug that was found to be ineffective at treating COVID, but was nonetheless promoted by many prominent individuals, including then President Trump. It's worth noting that Oz has financial ties to a hydroxychloroquine supplier, which likely influenced his decision to promote the drug. Oz will now be responsible for the division of HHS that runs Medicare, which insures 66 million people. Medicaid, which partners with states to ensure 72 million people. And the Children's Health Insurance Program, which insures 7 million people in total. These programs provide insurance coverage for over 40% of the US population. Oz has said he's looking forward to Making America Healthy Again, a slogan you just heard me reference. He also is looking forward to working under the leadership of RFK Jr. It is unclear exactly what Oz will prioritize in his role, but his record indicates he does not value science, making this a very concerning appointment. Moving on. Doctor Marty Makary, the surgeon who was appointed to be the commissioner of the FDA, has historically been a harsh critic of the organization. That does not necessarily mean that it should disqualify him at all. I myself have had my challenges with FDA, particularly around the issue of foodborne disease outbreak response.

Dr. Osterholm: While he's not as prominent in the anti-vaccine movement, he made numerous statements throughout the pandemic that were not based on scientific evidence and in fact, in many cases were quite contrary to what the scientific evidence of the day actually provided. So, I think we all hope that the person who is going to take over the FDA is going to be wise and use the kind of scientific information that's available at this point that's still to be seen with him. The CDC director appointee, Doctor Dave Weldon, is both a physician and a former GOP congressman. During his time in Congress, he introduced a bill that sought to transfer vaccine safety oversight from the CDC to an independent organization. The fact that he will now be leading the organization that houses the ACIP, the group responsible for making vaccine recommendations in the US, is incredibly alarming. If the ACIP does not recommend a vaccine, that, in fact is a vaccine that likely will not be covered by insurance and surely by federal programs. Doctor Janette Nesheiwat was nominated to be Surgeon General, a role responsible for communicating health information to the US public. Doctor Nesheiwat is a medical director at CityMD, a chain of urgent care clinics in New York and New Jersey. She has many ties to the Trump administration, however. To me, that does not necessarily suggest that she will, in fact, not be a clear and compelling voice in public health.

Dr. Osterholm: I know for a fact that she's consulted frequently with several of my colleagues on issues around vaccines, and so I hold out some hope that she might actually be a very productive and helpful appointee. Time will tell. I just remind people that during the days of the Reagan administration, when HIV was roaring its ugly head, our federal government refused to talk about HIV publicly. It was only with a surgeon general who had been brought in to really promote a pro-life agenda, who took the bull by the horns and changed that whole discussion around HIV in this country. I'm talking about Doctor C. Everett Koop, a former pediatric surgeon in Philadelphia who came in as surgeon general and one day was in when inquiring about what we should do about HIV, he was told the president would like him to write a report that could be shared. What they didn't understand was Doctor Koop took that in a literal way that allowed him to become a national hero. He, in fact, not only wrote that report, which was very, very clear about the absolute critical importance of responding to HIV infection, but he then authorized to have a copy sent to every household in this country, unbeknownst to the White House. Needless to say, he was someone who when he first came in, we all were concerned about what his politics might be.

Dr. Osterholm: He turned out to be a hero. So, I leave the current discussion about Doctor Nesheiwat in a similar spot. Maybe we actually can have a very productive and positive working relationship. Finally, Doctor Jay Bhattacharya, the appointee to lead the NIH, also has a concerning history. He is highly critical of the NIH, and during the pandemic, he coauthored the Great Barrington Declaration. As you know, this document criticized the government's response to the pandemic and suggested that by October 2020, most individuals in the country would return to their lives as normal as we all know, the darkest days of the pandemic were actually still far ahead of us at that point, making his advice not just misguided, but simply dangerous. We will have to wait and see how he will respond. In terms of the support for the NIH, a crown jewel organization not just in our country but around the world. Yes. Can we do better at the NIH? I believe so, but are we talking about wholesale dismissal? No, we're not. The bottom line is that these appointees surely do have the potential to cause great disruption, and could be dangerous for our society. The final piece that I remain very concerned about, and I've been following with bated breath, trying to learn as much as I can is what it's going to happen with Title 42. Remember, I explained to you in previous podcasts that the senior leadership, both scientific and policy in the US government, are actually hired under the rubric of Title 42.

Dr. Osterholm: It is a designation that allows them to have salaries above and beyond what otherwise would be available. It also puts them at great risk for immediate dismissal. Now, it can't be just capricious dismissal, but there's ways to get around that. And as we've already heard, RFK Jr. has said that in fact, he wants to immediately dismiss at least 600 Title 42 people in the first day that he is secretary. Now, as I've shared before with you, the senior leadership of CDC, NIH, FDA are all really very important to our everyday health. These are some of the best experts in the world on the various diseases they deal with. They are some of the policy experts. Do they always get things right? No, they don't. Do I have concerns sometimes about what I see happening in federal agencies? Of course, I do. But do I think that this group is a key, core group that keeps us basically functional in times of crisis? Yes, I do. And if you, in fact go ahead and fire these people from what would almost be a revenge type move, I can honestly say our preparedness, for example, for such a thing as an influenza pandemic would be the equivalent of cutting the head off of a body and then telling the body to go run a marathon, it will be an incredible challenge.

Dr. Osterholm: There are actually several other issues that I'd like to raise around this, and I've thought out the voice of others who have been very thoughtful about what we need to do to move forward. The first one is someone familiar to many of you, because if you've listened to this podcast, you've heard me talk about him before. Doctor Peter Sandman. Peter is, in my mind, one of the greatest experts on assessment of risk and how to respond to it, and how do we communicate effectively within the context of crisis. Well, Peter actually reminded me in a series of emails that he went and I went back and forth on, as well as a recent discussion that, yes, HHS does need some reform. And I would agree that there are things we can do better, but we have to be very conscious of what we mean by that. We're not talking about destroying the place and starting over. And as Peter has pointed out, there are two theories on how to reform an organization that needs to be reformed. The first thing is to bring in a reformer. This is someone who respects the organization and has its respect. It's someone who will take care to preserve the aspects of the organization worth preserving, who will institute incremental changes with all due care.

Dr. Osterholm: Or you can bring in a disrupter, someone who doesn't respect the organization much or care much about its respect. Who will take a sledgehammer to it? And then when that's all done, get rid of the hated disruptor and bring in a reformer who can put the pieces back together again. As Peter said, I'm not sure which theory is soundest. Well, I do believe that even with reform today, you can do that with a reformer. Bringing in a disruptor is dangerous at this point, because we don't have time for this organization to be down. We're building this plane at 30,000ft. We're painting the outside of this train at 60 miles an hour. We don't have the luxury of just benching them for months at a time to fix them. And again, I don't believe that any of these organizations are in dire, desperate need of reform, but they surely can do better. So, Peter, thank you, I hear you. I have fallen down more on the reform side than the disruptor side, but time will tell. The second voice I wanted to share with you comes from someone who I've met through the podcast, who I have great respect for. Bill Clark is the Harvey Brooks Research Professor of International Science, Public Policy and Human Development at the John F. Kennedy School of Government at Harvard. Bill was very kindly, has shared his feedback with us as he is a routine podcast listener.

Dr. Osterholm: And he actually made it very clear, and I agree with him. We need as a podcast family to hear about what can we do. What is it we're going to be asked to do in the days ahead? And while we surely can talk about our job as calling balls and strikes and pointing out what's needed in terms of federal reform, but how does that involve you? How does that get you involved in what has to be very important? And as Bill said, he had one request based on his 50 years of studying and teaching public policy, he said, and I quote, “throwing science grounded light on the public health implications of whatever chaos is created by the incoming national administration is necessary, but it is not sufficient. Also essential is encouraging agency and engagement by all of us, the listeners in this podcast community.” Specifically, he pointed out, as I said in episode 170, a great deal of what is or isn't done to secure public health happens at the state and local level. So, for each of the specific acts of federal ignorance, error or lunacy that we identify, it will be also very important that we help us target our voices and energies on specific state and local officials who can make a difference. We promise you; we will do everything we can to understand how you can be involved. For example, if we do see challenge to vaccine availability, distribution or how it might be even recommended, we can deal with that.

Dr. Osterholm: At the state and local level. We can get organized, we can do things to help override the potential negative side of what may come out of the federal government, and what we promise you in the days ahead, we will continue to look at and explore. How can we internalize what's happening around the country, but specifically in our own backyard, and what can we do about it? So, give us some time. We're trying to get our sea legs on this issue. We don't want to talk just to talk. We want to be able to share with you words that we've learned through our own experiences may be helpful to you to hear, and helpful to guide you about what you can do. We're all in this together. We all have family. We have grandkids. We have kids. We have grandparents. We have neighbors. We have friends. We have colleagues. We have acquaintances. We all have people who matter. And we're going to try to do our best over the course of the next four years to give you ideas about what you can do. And we need you. This is no time for sitting on the sidelines. We need you to respond to whatever comes out of Washington, D.C., and how it matters at our local and state levels.

Chris Dall: Now to COVID-19. For the last four years, we've been concerned about potential surges in COVID cases resulting from large holiday gatherings. Now, it's too soon to know if this Thanksgiving holiday resulted in a COVID spike. But the Pre-holiday metrics seem to indicate that we're still in a pretty good place with COVID. Mike, is this a lack of reporting or are we just learning to live with this virus?

Dr. Osterholm: Well, Chris, let me just be very clear. There's a little of both going on and let me try to break that apart a bit. At the moment, we're in a pretty stable place. But like you mentioned, the coming weeks will tell us a lot about how much COVID-19 was around our Thanksgiving tables for the weeks leading up to Thanksgiving ending November 23rd. 82.8% of the hospitals in the United States reported their hospitalization data, and I still expect the number to increase in the near future to close to 100%. Less than 1% of inpatient beds were occupied by COVID patients, which is about 5369 patients. This is lower than the 6184 occupied beds were reported in our last episode, which surely is a good sign. Wastewater levels are still considered low and decreasing in every region, but looking at the state level data, the levels in Idaho, New Mexico and South Dakota are considered very high and six states are considered high. Like I mentioned, the coming weeks are going to be very telling about how COVID-19 impacts the remainder of the holiday season and for that matter, throughout our winter. So, we'll be keeping a close eye on those trends. Let me just also add that as much as I talk about high, low and medium levels of wastewater activity, I'm not always sure I know what it means.

Dr. Osterholm: It does not necessarily correspond 1-to-1 to numbers of cases in a community. So, we're still trying to learn that. Do I think it's a good indicator? Yes, it is. Do I think it's a perfect indicator? I don't. Weekly deaths continue to decrease, with 560 deaths in the most recent week with complete death data. This marks the 21st straight week above 500, but the provisional data for the month of November shows that more than 75% of the deaths occurred in people 75 years of age and older. We need to do much more on focusing on vaccinating this age group and preventing more of these deaths, which I think is surely doable. Just about 19% of the US adults are vaccinated, which is ahead of what we saw last year at this point, but is still quite low. Vaccinations for adults are up from 14% a month ago, but this is still much lower than we'd hoped. Looking at the variant picture right now, there isn't anything that stands out to me as particularly concerning. XEC continues to increase in prevalence, now accounting for 38% of the US cases, but has yet to take over from the predominant variant, KP 3.1.1, which still represents 44% of US cases, but I'd expect this to switch in the coming weeks.

Dr. Osterholm: We are also keeping an eye on MC .1, which is a descendant of KP 3.1.1. That accounts for only 6% of cases, but it's increasing. Ultimately, though, I don't think there is a game changing variant in any of this mix that is going to cause a major surge in cases. Since XEC started gaining traction in October, we haven't seen any concerning increases in human activity and I can't see that changing significantly. So, is this a better place for finding ourselves due to a lack of reporting, or are we learning to live with this virus? As I said earlier, I think it's a little of both. Good quality COVID-19 data are still tough to come by. The new hospitalization reporting is now helpful, especially in knowing how much severe disease is out there. But that's not perfect. At the same time, we are quickly approaching five years since COVID first came into our lives. We're starting to learn to live with this virus that is clearly not going anywhere anytime soon. Even if the majority of the public sees COVID as a thing of the past.

Chris Dall: And what are we seeing with us? Flu and respiratory syncytial virus numbers?

Dr. Osterholm: Well, we continue to see flu activity gradually increase across the country. Wastewater data shows concentrations are moderate and are increasing over the last few weeks. Two weeks ago, with the exception of California and Rhode Island, every state was considered either low or minimal. This week, two states, Arizona and Virginia, have high viral activity in their wastewater, and eight, including California and Rhode Island, are considered moderate. These increases in wastewater concentrations are consistent with the hospitalization data, which shows that about 2000 inpatient beds are occupied for influenza patients, up from 1402 weeks ago. As I noted just a moment ago, there are over 5300 individuals hospitalized in this country for COVID, so there's 2000 inpatient beds occupied for influenza patients is surely at a lower level than we're seeing for COVID. Unfortunately, there was a pediatric death associated with seasonal influenza reported this week ending November 16th. RSV activity is also picking up a bit, but wastewater concentrations are still considered minimal. Across the country, 12 states and the District of Columbia are considered moderate, high, or very high. Hospitalization data also shows about 2000 inpatient beds occupied by RSV patients, up from 1402 weeks ago. Of note, that 2000 number combined with the 2000 inpatient beds for flu. Still at 4000, is lower than the COVID number of 5369. So, in that regard, COVID still is the leading cause of major serious illness with respiratory viruses Coronaviruses in our country. But at the same time, I think those numbers are going to be changed over the weeks ahead.

Chris Dall: Mike, as you know, long COVID remains a topic of great interest to our listeners. So, is there any new long COVID research that you'd like to highlight for our listeners?

Dr. Osterholm: Well, Chris, there actually is. There are a few recent studies that I want to briefly mention. We'll be sure to link these studies in the show notes for anyone that wants to look through them in more detail. The first is a meta-analysis of 14 million people from 25 states to assess the impact of the COVID vaccine on long COVID outcomes. This study found that two doses of COVID vaccine reduced the risk of developing long COVID by 24%, and one dose of vaccine reduced the risk by 15%. Another study, which was conducted among over 900 essential workers between June 2021 and September 2022, found that getting a third dose of a monovalent RNA COVID vaccine reduced the odds of gastrointestinal, neurologic, and other long COVID symptoms by 63%, 44%, and 52%, respectively, compared to those with no doses of vaccine. While the results of these studies may not provide much comfort to those already suffering from long COVID, and we know you're out there, particularly those who are vaccinated, they should serve as yet another reminder of the importance of getting your updated doses of COVID vaccine, even if you're not at high risk for severe acute infection. Getting vaccinated to prevent you from experiencing long COVID is by far a great investment. Finally, I just want to say I have no idea what the thoughts are among the new administration leaders, including Mr. Kennedy, with regard to dealing with long COVID research going forward. As I noted earlier, remember, Kennedy has already stated he wants us to take an eight-year hiatus from doing infectious disease research. What does that mean? And also includes that with long COVID, we don't know.

Chris Dall: Now let's turn to H5N1 avian flu, which continues to spread in dairy cattle and California poultry flocks in several states and in farm workers. Mike, this outbreak appears to have no end in sight, and there are many who remain concerned that we are sitting on a powder keg. So, what has stood out to you over the past few weeks? And do you see any light at the end of the tunnel?

Dr. Osterholm: Well, first of all, let me be very clear and very honest with you. I did know a lot more about influenza ten years ago than I know today. The more I've learned, the more I realize how little we do know about so many aspects of what this influenza virus can and will do. Frankly, Chris, I kind of feel like I'm stuck in the middle of a tunnel during rush hour. I have no idea how long we'll be stuck here or how many curves there are on the road ahead. There is so much going on in this topic, and the outlook seems to change on a daily basis. For now, I'd like to update our listeners on a few key topics as we navigate through this tunnel of uncertainty, and then give you my perspective on where I think we're at or where we're going. First of all, starting with detections in wild birds, backyard flocks and commercial poultry, we continue to see backyard flocks test positive for H5N1 across the western US, including Alaska and Hawaii, accompanied by more detections in commercial poultry facilities. That includes 57 total facilities, 22 in backyards, and 35 commercial. These outbreaks can be tied to migratory birds flying south for the winter in the Pacific Flyway, transmitting virus to, quote unquote, sitting ducks along the way. The spread has led to massive depopulation in the industry, and I believe there are more to come. Anybody who has a question about this, go look at the price of eggs today in your grocery store and try to understand why that increase has occurred.

Dr. Osterholm: Look no further than H5N1. Now we have more and more detections in dairy cattle, plus raw milk samples since November 27th. The USDA APHIS has reported 20 additional H5N1 outbreaks in dairy herds, all of which are in California. These updates bring the state's total affected herds to 481. The national total of dairy herds affected stands at 695 across 15 states. This incessant wave of new detection is really concerning, as more than a third of commercial dairy herds in California have now tested positive. Why is this? We need much more information from the USDA as soon as possible. As to what is the epidemiology of this infection? How is it going from farm to farm? What is it going to take to stop it? We do not want to have influenza viruses circulating in the animal populations, with we as humans also have close contact. That could potentially be a recipe for disaster. Last week, the California Department of Public Health also announced that their food safety laboratory detected live H5N1 virus in a sample of raw milk. There have been two batches from a single producer that have been implicated via retail sampling so far. This producer has since announced that their dairy herd has been infected with H5N1 and initiated a voluntary recall of their products. While I realize this is actually certified raw milk sales that are associated with this operation, I have, as a result of my career investigating raw milk associated outbreaks of illness, wondered how anyone could talk about certified raw milk. I think that's almost a contradiction. So, at this point, we have a natural experiment going on in California, where certified raw milk is commonly consumed with so many farms with H5N1 that may not be detected before this milk is to the consumer.

Dr. Osterholm: What will be interesting to see what this all means. Now on to human cases of H5N1. The total number of cases detected in humans has reached 57. As our listeners may recall, the vast majority of these individuals were infected while working directly with infected animals, either cattle or poultry, and their illnesses presented with conjunctivitis and cold like symptoms. A teenage Canadian patient is still in critical condition fighting this virus, but is stable with breathing assistance and has reportedly shown progress over the past few days. They have been sick since November 2nd and hospitalized since November 8th. A child in California with no known exposure to infected animals tested positive for H5N1 on November 19th after experiencing mild symptoms. They are recovering at home after treatment. Again, there is no evidence that close contacts of any of the detected cases also became sick. Well, what does this all mean? What's happening? Well, I think we're watching two very separate situations in the influenza world play out before our eyes. First of all, remember, from a genetic standpoint, this new H5N1, and I call it new in the sense that it's the one from the past several years that has infected so many mammals and avian species. This is part of what we call clade 2.3.4.4 B. That's kind of a more general term then. In fact, you can get more specific about what we call the genotype really, really fingerprinting this virus out.

Dr. Osterholm: And if you look at the outbreaks that have occurred in dairy cattle, this one, it was caused by clade 2.3.4.4 B and additional B 3.13. The bird virus activity, which has been largely in poultry and related to the transmission from migratory birds, is the same clade but a D 1.1 or D 1.2. Now, I think these are two totally different situations. And what do I say that if you look at the cattle one, the one in the dairy industry, this has been a very stable virus for the last 7 or 8 months. Nothing really has changed about it. But if you look at that bird virus, the one that's most likely affecting, uh, poultry operations, that D 1.1 or D 1.2 has now a new neuraminidase mutation. And this mutation is actually a real challenge because it's also facilitating or forcing mutations in the hemagglutinin. It may be that this specific virus is the one that we need to be most worried about, and we're trying to follow that. So, I don't want to dismiss the cattle situation as being unimportant, but for me, I'm keeping my eye on this. D 1.1 and do I know whether this is going to result in a pandemic? No. Nobody does. And if anyone tells you they know, be careful because they probably have a bridge to sell you to. So, we're really at the mercy of trying to understand this virus as it does what it does. Now in terms of the human cases, let me also just say that there have been 57 of them, 34 have been associated with cattle and again, they've all been the B 3.13 genotype.

Dr. Osterholm: There have been 21 associated with poultry, where in fact it was primarily the D 1.1 of genotype that we see. And if you look at the cases in humans, this is where we are, I think really need to be focused on is what's happening with this group. So where are we going to go from here? I don't know, do I believe that it's possible that this could cause a pandemic? Yes. Do I think it's likely? I don't know, and I think it's less likely that the dairy cattle situation is going to be the reason for that to happen. I think it still is potentially in wild birds. But you know what? I've been following this since 2003. I've watched it scare us multiple times in the past with what appears to be new activity, highly suggestive of 1 or 2 mutations away from causing a human Pandemic. And guess what? It didn't happen. So that does not mean we should dismiss it now. There will be additional influenza pandemics in the future, but will it be H5? I don't know, could it be H5? Yes. And I come back to the question I raised earlier. If in fact it occurs in the next several months, will we have people in place in all of the important offices in our federal, state and local governments that will be on the front line dealing with this and have the expertise to do so.

Chris Dall: It's time now for our ID query. And Mike, you touched on this a little bit earlier, but in the last few weeks, we've received emails from several listeners who are concerned about some of the people that president-elect Trump has nominated to lead the nation's health agencies, and they want to know what they can do. What can you tell them?

Dr. Osterholm: Well, Chris, as I alluded to earlier in my answer with regard to what was happening with the post-election appointments. We all must be involved. Now, if you're wondering what that means, I can't tell you yet, but I am convinced that the changes that we see in our public health approach and our public health leadership are going to result in critical state and local issues. And that is where we need you to get involved. For example, I could see me one day on this podcast encouraging you, begging you to run for school boards, or to run for city councils to help affect how vaccines might be used in that school district or that community, because that by itself in your leadership could make all the difference. So, hold on. We're learning how to respond to this issue in a way that's meaningful to you. As I said before, we welcome your feedback. Bill Clark shared with us his thoughts about that. I agree 100% with him, that it is going to be important that we as a family can talk about what can we do? How do we roll up our sleeves? Just sitting along the sideline complaining, worried is not going to be helpful. And I can tell you right now, throughout my entire career, when you are not on the sideline, when you are in the middle of the game, you don't have time to worry. You think about what I'm going to do to make this world better for my kids and my grandkids, and that is everything that's important. So, Chris, I just want to be clear, I don't have answers yet. We have to see more of the cards that get laid on the table with regard to this administration. But we have no doubt we're going to need you. And so, hang on, get ready. You will find in the days ahead the kinds of requests for you to get involved, to help us deal with the public health issues that are going to confront us.

Chris Dall: And just a reminder to our listeners, whether you have science related questions or policy related questions? You can send them to us at Osterholm.Update@umn.edu and Mike. Now it's time for what is, I think, both of our favorite segments. It's this week in public health history. And Mike who are we celebrating this week?

Dr. Osterholm: First of all, I have to acknowledge I have a deep bias in this one. Okay. And you'll become clear in a moment why that's the case. But let me just say we've spent some time over the past few episodes covering RFK Jr.’s prominence in the anti-vaccine movement. One avenue he has used to spread this misinformation about vaccines is through an organization known as the Children's Health Defense. While the title sounds like a worthwhile cause, it is arguably the largest, most coordinated anti-vaccine movement in the US and has even expanded to chapters in Canada, Europe and Australia. But I want to contrast this incredibly dangerous organization that Children's Health Defense with a truly admirable one that started almost 40 years ago. Marian Wright Edelman was born on June 6th, 1939, in Bennettsville, South Carolina, to a Baptist minister. Despite the hardships her family faced after her father's death, Marian was an exceptionally gifted student. She attended Spelman College, graduating as valedictorian. While attending college, she became active in the Civil Rights Movement, participating in sit in protests in Atlanta. Marian graduated from Yale Law School and became the first African American woman admitted to the Mississippi bar in 1964. There, she continued her civil rights activism as director of the NAACP Legal Defense and Education Fund. Marian became increasingly interested in issues related to children's rights, health, and development as an extension of the broader civil rights movement. She was critical in the establishment of the Head Start Program, a free childhood education program for the children's most disadvantaged families. Notably, project 2025 explicitly called out the Head Starts program as something to abolish entirely. Marion next move to Washington, D.C. to work alongside Martin Luther King and advise his policy work, known as the Poor People's Campaign.

Dr. Osterholm: Even after Doctor King's assassination, Marion continued her advocacy to extend opportunities for children and families by establishing her own organization, the Children's Defense Fund. Let me just add, it was in 1984 that I led an effort on a national level to hold the first meeting on infectious diseases and child daycare and what we must do about them. It was a remarkable three-day meeting, and I contacted Marion and sought out her participation in this meeting, which was held in Minneapolis. She did agree to give one of the keynote addresses, and it was one of the most memorable addresses I've ever heard in my life. Now, counter to RFK Jr.’s infamous Children's Health Defense Organization, Marian Wright Edelman’s Children's Defense Fund has an impressive record of accomplishment for children's health and well-being that continues today. Under Marian's leadership, the Children's Defense Fund worked alongside with other organizations and bipartisan initiatives to establish the Children's Health Insurance Program, also known as CHIP, and to pass the Disabilities Education Act, also known as IDEA, which required schools to provide education for children with disabilities through special education and countless other initiatives that make sure all children in America are given the opportunity to succeed. Marian Wright Edelman is still living today and demonstrates what leadership and life of public service ought to look like. I'll end up with a quote of hers which I think sums up her passion for this work. “If we don't stand up for children, we don't stand up for much.” Today I get to talk about someone in public health history who I so deeply admire and has touched me in my lifetime.

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

Dr. Osterholm: Well, Chris, there are a number of them that I could use, but let me try to focus on three. First of all, everyone stay the course. Stay with us. We're in a period right now where it is surely getting darker by the day. Not just outside, but inside. And we will have more clarity in the days ahead of what this all means. And we will be prepared together as a podcast family, as a community to respond accordingly in a way that can make a difference. But right now, as we're finding out what our challenges are and what our opportunities could be, we need to stay the course. Second of all, we're actually in pretty good shape right now with COVID, RSV and Influenza. But I am quite convinced that in the next 4 or 5 weeks, we're likely to see major spikes in one or more of these viruses, and that could cause some real challenges. So, if you haven't been vaccinated yet, please go out and get vaccinated. If you're older, please consider this a very high priority. As I shared with you today, 75% of the deaths from COVID are in those 75 years of age and older, for which we know the vaccine can surely reduce your likelihood of serious illness, hospitalizations and death. And finally, it's not what I know about influenza. It's what I don't know that really concerns me at this point. We still don't understand what's happening with H5N1. Oh, my. None of us want to go through another pandemic, do we? None of us. But, you know, we're sitting on that possibility. And so, we will continue to keep this topic front and center of what do we know? What don't we know? What can we do about it? And should anything change, we will immediately let you. Our podcast family audience? No.

Chris Dall: And what closing song have you selected for us today?

Speaker3: Well, Chris, this is also a song.

Dr. Osterholm: That is very, very personal to me and I'll explain why in a moment, but it's one that we've used before on the podcast. On May 19th, 2020, in episode 104 ‘Tougher Than Rocket Science’, it was actually recommended to us at the time by Sue, a routine listener of the podcast, which shared the following with us in an email back in May of 2022. She said there's a song that's been going through my head for a few weeks that I want to share with you all, because it's about gratitude for the special people in our lives. This song is from the musical Wicked, and it's a duet sung by the characters Glinda and Elphaba. And during this melancholy time in human history, I find the words of the song to be particularly comforting. I would think that others might feel the same. So, you guessed it, we've picked ‘For Good’. And as Sue noted, it is a musical number from the musical Wicked. It was sung as a duet between Elphaba, the Wicked Witch of the West, and Glinda the Good Witch of the North as well. Farewell. The song score and lyrics were written by composer Stephen Schwartz. The song is performed near the end of the musical, as the two were bidding each other farewell. The song's lyrics concern about how both Elphaba and Glinda had been changed by their friendship with each other. Schwartz commented after the show premiered that for the opening of the song, he asked his daughter what she would say if she would never see her best friend again, and her answer became the first verse ‘For Good’. So, I'm about to share this with you, but I have to add one other piece that is about the bias. It's a long, long story, but back in 2008, August 22nd, specifically, I had the most unique opportunity to participate in the Broadway show Wicked. I was in all three acts of the play, and needless to say, it wasn't because of my artistic skills. It was because of some friends of friends. But we have posted pictures of me as one of the countrymen on the website here for you to see of what it was like back in 2008 to be on Wicked. And of course, because of that, I obviously hold a very dear and special spot in my heart. So yeah, I'm biased in this one. So here it is. At a time when we need to think like this ‘For Good’. 

Dr. Osterholm: I've heard it said that people come into our lives for a reason. Bring something we must learn, and we are led to those who help us most to grow. If we let them and we help them in return. Well, I don't know if I believe that's true, but I know I am who I am today because I knew you like a comet pulled from orbit as it passes the sun. Like a stream that meets a boulder halfway through the wood. Who can say, if I had been changed for the better? But because I knew you, I've been changed for good. It well may be that we will never meet again in this lifetime. So let me say before we part, so much of me is made of what I learned from you. You'll be with me like a handprint on my heart. And now, whatever way our stories end I know you have rewritten mine by being my friend. Like a ship blown from its moorings. By a wind off the sea. Like a seed dropped by a skybird in a distant wood. Who can say I've been changed for the better? But because I knew you. Because I knew you, I have been changed for good. And just to clear the air I ask forgiveness for the things I've done you blame me for.

Dr. Osterholm: But then I guess we know there's blame to share. And none of it seems to matter anymore. Like a comet pulled from orbit. Like a ship blown from its moorings. As it passes the sun. By the wind off the sea. Like a stream that meets a boulder. Like a seed dropped by a bird. Halfway through the wood. Who can say if I've been changed for the better, I do believe I've been changed for the better? And because I knew you, I have changed for good. ‘For Good’ and Wicked. Well, thank you very, very much for being with us today. We covered a lot of material. I hope not too much. I just want to thank you so much for all that you have done to provide us feedback about how we can and must improve our messaging, our understanding of what's happening. We continue to welcome that. I thank Peter and Bill for allowing me to use their very thoughtful input today on the podcast. And just remember that if there was ever a time to be kind, it's now. We need kindness. And I know sometimes that's really hard days when I get really frustrated and I'm overworked and I have too many deadlines, I just have to take a step back and remember how fortunate I am to be, where I'm at with who I'm with. And that includes you. So have a good, safe two weeks. We look forward to talking to you then. Uh, thank you so much for being with us. Be kind, if anything, today. 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 Corey Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddard, and Leah Moat.