Episode 176: Responding to Shock, Awe, and Censorship

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. It's been less than three weeks since Donald Trump officially began his second term in office. And yet, the moves his administration has made in that short time could have profound and lasting impacts on public health and our ability to fight infectious disease. A freeze on foreign aid that funds HIV treatment programs, upon which the lives of more than 20 million people on antiretroviral drugs depend. Pauses on National Institutes of Health grants that fund much of the nation's infectious disease research. Removal of pages from the CDC website.

Chris Dall: And most recently, the dismantling of the US Agency for International Development. The list goes on and changes by the minute. Some of these moves may be temporary at this point, we just don't know. But they are, at the very least, a signal that the US government's long-standing efforts to fight infectious disease and promote public health, both here at home and around the world, could be in jeopardy as the Trump administration looks for ways to cut spending. We're going to start this February 6th episode of the podcast with a look at these moves, who has been affected, and what it all means. We'll also discuss the confirmation hearings of Robert F. Kennedy to be secretary of the Department of Health and Human Services, review the latest respiratory virus data, update you on latest developments in the continuing H5N1 avian flu outbreak in poultry and dairy cattle, and answer an ID query about the tuberculosis outbreak in Kansas. And we'll bring you the latest installment of this week in public health history. But before we get started, we'll begin with Doctor Osterholm's opening comments and dedication.

Dr. Osterholm: Thanks, Chris, and welcome back to all the podcast family members. Feeling very fortunate to be able to spend this time with you. Also, I want to welcome back people who may not listen to us routinely, but have started to pick up on the podcast since the inauguration and the changes that are occurring in Washington. And then finally, for those of you who may be coming here for the first time, I hope we're able to provide you with the kind of information you're looking for. I can say with all certainty that it's going to be information that will be challenging. It'll be information that will be changing. And most of all, I think it's information that means a lot to us in our everyday lives. I want to start today before we get into all that's going on with some perspective. And what I mean by that is I'm a voice. This whole podcast is clearly the efforts of a number of people here at CIDRAP. But I'm the voice. And in that regard, people may attribute what I say to certain beliefs that they believe I hold or certain actions that I have taken in my past, and leaving one to sometimes question, well, what is he talking about? Or why would he say that? I can only give you the perspective from my 50-year career vantage point. I have made an effort throughout that entire time to be nonpartisan. Public health is all about taking action. It's all about policy development. It's also all about bringing people around the table to try to solve the problems of health in our society.

Dr. Osterholm: I have served in every presidential administration since Ronald Reagan, there working closely in the AIDS Commission. I was also in the first Trump administration. I served as a science envoy for the State Department and spent two years touring the world, helping countries better prepare for a pandemic and promote the policies of the Trump administration with regard to activities and our foreign support. During my time as a state epidemiologist in Minnesota, which was almost 25 years, I served two Democratic, two Republican and one Independent wrestler governor. And I can say with certainty, I was close to every one of those governors, and never did I once feel a partisan divide, or that I was made to say something or do something that somehow might not be in keeping with the very best in public health. And although CIDRAP is the Center for Infectious Disease Research and Policy, this doesn't mean we're a partisan group. We are not. In fact, it means just the opposite. Our goal is to use science to inform the best policy possible without regard to which party is in office. Our center cares about every life. We care about every location. We care about every reason why we can improve health. The fact is that public health victories and public health failures can come from both sides of the aisle. Later in this episode, we'll discuss PEPFAR, an incredibly successful and impactful public health effort that was started by the George W. Bush administration and continued to receive critical support from the Obama administration, the first Trump administration and the Biden administration.

Dr. Osterholm: I mentioned this because I don't want listeners to think that we are blindly disagreeing with or criticizing the current administration just because Mr. Trump is the Republican president. We have not and will not blindly agree with decisions by any president, Democrat or Republican, if they are not in keeping with the best public health practices and purposes of what we do. We are here to call balls and strikes regardless of who's in office. Our priorities and our response will always be based on what is the best thing that we can do to make the world a safer place. And this is a safer place for our grandparents, our parents, our colleagues, our loved ones, our children, our grandchildren, all of them. As I have said many times in doing introductions here on this podcast, I don't need to get up every morning to find a reason to go to work. I have one built in that is, I think, about what kind of world are my grandchildren inheriting from my generation. And so, for me, it's very simple. Public health is all about doing the most for the most people to help them live healthier and happier lives. Now, with that in mind, I have to say that of all the things happening in Washington, D.C. right now, it is nothing short of painful.

Dr. Osterholm: We are only in the third week of this administration, and thus far, it is proving to be a significant threat to many public health programs or activities, both in the US and globally. I will comment on that more in a moment, but I want to start today by dedicating this episode to all of those who already have been, or soon will be affected by the actions of this administration. There are those who carry out the government policies, carry out the government programs. They have lost jobs in recent weeks, unsure of how they will put food on the table and roof over their heads. There are those who are still employed, but now fear for the security of their jobs, living every day with anxiety and uncertainty. To the researchers impacted by frozen funds, to those who, even if they keep their jobs, know that they won't be able to do their work effectively to make the difference in the world because of the restrictions they now face. To those both in the US and internationally who rely on the many programs that are at stake to keep themselves and their families safe and healthy, this episode is dedicated to all of you. We are in for a challenging four years, but we promised to be here day after day, week after week, podcast after podcast, continuing to provide the information here in an honest and unbiased way. It's with that I know that we as a podcast family will get through the next four years.

Dr. Osterholm: It will be a challenge. We can only hope that we see more victories and defeats, but at the same time, we're prepared to do it together. And that is what is going to save us. Well, now, after that introduction, let me move to something with a bit more light. Yes, all of you who find this somewhat troublesome to have to sit through this tune out for a minute here. But for those of us who are celebrating what's happening in our communities around the Northern Hemisphere, we do delight in this today, February 6th, here in Minneapolis, Saint Paul. Sunrise was at 7:26AM. Sunset tonight at 5:28PM. That's ten hours, two minutes and 39 seconds of sunlight. Boy, are we starting to increase. Today we had two minutes and 44 seconds of more sunlight than yesterday. And of course, for all of our very dear friends and colleagues and visitors from the United States or other countries to the Occidental Belgian Beer House in Vulcan Lane in Auckland today, your sun rises at 6:41AM. Your sun sets at 8:29 p.m. You still beat us. You've got 13 hours, 45 minutes and 31 seconds of sunlight, but you're losing that at about two minutes and three seconds a day. And in a couple of weeks, we will, in fact, pass you in the amount of sunlight as your numbers continue to get a little darker and ours will continue to get a lot lighter. And for all of you who are anticipating that spring sunlight is coming.

Chris Dall: Mike, there's a lot to get to. I mentioned some of it in my introduction, but as I think our listeners know, things are moving very rapidly. Can you take us through what has happened in the past week, your reaction to it and the impact it all could possibly have on public health and our ability to fight infectious disease?

Dr. Osterholm: Chris, as I said in the introduction, you know, I am approaching this as someone whose primary concern is about the well-being of all of us who live on this planet. This is not a political statement. This is not a financial statement. Surely there is no ideology here. It's about the common sense of helping all of us live better lives. And I mean all of us. So, when I comment on the events of the past two weeks, please know that is exactly the line of sight that I'm looking at. But I have to admit that in my 50 years in this business, I have never experienced a two-week period like these last two. It has been a nightmare in terms of the implications for public health and what it means for not only those of us here in this country, but from around the world. Let me just start out with some kind of highlights that lead into additional issues, and know that we're going to be talking about this every two weeks for many, many months to come. And so, we've got to pace ourselves. We've got to understand that right now, what's happening in Washington, D.C. is a shock and awe approach. Basically, as has been described by Steve Bannon, one of the president's advisors. Basically, you want muzzle speed right now. What they want is to just overrun and overwhelm us. And in that regard, this is going to be something we're going to digest a bit at a time.

Dr. Osterholm: I could literally spend the next five hours on this podcast just going through the events of the last two weeks and what they mean. So, you're going to get an abbreviated view of this from me, but I promise you, you will get this view all the time. Every time. Our entire team will work hard to bring you the truth. The facts. And what can we do about it? Let's start out what happened this past week. The Senate Finance Committee voted by a margin of one vote, 14 to 13, to pass Robert F. Kennedy, Jr. on to the full floor for consideration as Secretary of Health and Human Services. Next week, we have every reason to believe he will receive an affirmative vote in a party line basis in the Senate and will become the next secretary. It was telling to me of some of the challenges that were confronted with when you had a potential secretary nomination at risk, and yet you continued to peddle what was clearly mis and disinformation. I don't know how many of you are aware of this, but Mr. Kennedy actually shared a paper that had just been published in science, Public Health Policy and Law, which is actually not a scientific journal. It's a web press blog that basically claimed, in this case, that the vaccinated children in Florida's Medicaid program had significantly higher rates of neurodevelopmental disorders, including autism.

Dr. Osterholm: He shared this right during the hearing, handed it out. And in fact, this study had so many major flaws. And fortunately, Doctor Jester and Doctor Bertha Hidalgo actually had written a wonderful review of the challenges with this paper and why it was from a methodological standpoint, it is a disaster. And yet, right at the very minute when he was still trying to sell his wares as a reasonable, thoughtful individual on vaccines, he decided to put this forward. This paper by Mawson and Jacob was funded by the National Vaccine Information Center, which is an anti-vaccine advocacy organization. And it really has become an embodiment of how flawed methodology and biased analysis can be can be used to promote vaccine hesitancy. In fact, despite being a repeat of a previously retracted work and contradicting decades of rigorous research showing no links between vaccines and autism, this paper is circulating widely now in parent groups and has gone totally viral on social media. Thank you, Doctor Sheeran, Doctor Hidalgo, for doing such a wonderful analysis of this paper and sharing what I just shared with you now. I point this out because obviously this is one of many such papers, but the idea that you would actually present this in front of those who are challenging you for this very reason, that you are not a scientist, you have a bias against vaccines and that you'll continue to operate in your normal mode. Not at all.

Dr. Osterholm: In keeping with what the mission of HHS is all about. So, expect him not only to get confirmed, but to see major, major changes occur at HHS. Now, it's been it's been interesting because other than some of the website issues, which I'll come to in a moment, HHS has really not been in the news with many of the changes that we've seen, for example, in Homeland Security or the Department of Justice or USAID, etc... And the question is why? Well, I think many of us believe they wanted to hold off on these, what are going to be quite remarkable changes until after Mr. Kennedy was confirmed and then moved forward. So, expect literally in the next 2 to 3 weeks, major acceleration of literally organizational gutting activities at HHS. And one thing we're following very closely is what will happen to the CDC's Advisory Committee on Immunization Practices. As you know, this is the organizational structure at CDC that brings in the outside experts to make decisions about vaccines, how they're used when they're used. And once the ACIP has reviewed this information. It is then sent to the director of the CDC with recommendations and almost universally are accepted. Well, now, we have seen over the course of the past several weeks what this administration will do to outside advisory committees. Look no further than the Department of Homeland Security, where such committees have all but basically been disbanded by firing all of its members.

Dr. Osterholm: We have every reason to expect the same thing is likely to happen at ACIP, and should that occur, some of us are already working on how can we develop a shadow organization that can carry out similar functions to what ACIP did? Because this is such an important organization, and the last thing we want is to have the recommendations from a US advisory committee to reflect junk science, which is exactly what we've seen so far. So, at this point, the Kennedy hearings and the Kennedy vote, I think, will mark the beginning of what will be a very rapid-fire impact on the Department of Health and Human Services. Let me give you some further examples of what I'm talking about. At this point, even with only two weeks of activities undertaken, I have watched the rapid destruction of the public health world, both domestically and internationally. I'm sure almost all of you have heard about the fact that this administration has now decided to pull out of the World Health Organization. There is some question about when that can happen, given that they need a year's lead time from notifying the W.H.O. that they're leaving. But there are some claims that because of a previous announcement of this in Trump, one, that in fact, it does not need a whole year. But why is this important? Because W.H.O., which we have worked closely with over the years, does have some real need for reorganization or reconsideration of Iteration of structure and how it is overall managed.

Dr. Osterholm: But at this time, it is a critical element of dealing with public health issues around the world and helping to coordinate not only the funding, but also the response and the follow up. Well, we have feared that this might happen, and I think it's just beginning. Yesterday, Argentina announced it too was going to pull out of the World Health Organization, the first time in its history since right after World War two that any countries have ever pulled out. And we have it on good authority that there are several other countries right now that are considering a pullout at the same time. Why? Well, they may have their own legitimate issues with W.H.O., but we believe in part it's to follow the American lead that, in fact, this is what we've seen happen with so many business people, politicians, etc., who are bending to this administration as to what they want and what they demand you to support. So will other countries follow if they do. I could literally see kind of what I'd call a W.H.O. flu occur, where it will spread quickly through other countries who they themselves may have reasons to stay in W.H.O., but they're looking at the big picture. Is it important to be a friend of the United States? Well, if this happens, all I can say is the demise of the W.H.O.

Dr. Osterholm: is something I could not have imagined in my lifetime. Boy, have I, like others, had ideas on how we could make it a better organization. But never, never have we ever, ever thought about destroying it. If you look at what's happened domestically right now, what's happening to USAID breaks my heart, literally breaks my heart. This is an organization started by President Kennedy in 1961 and expanded upon and supported by every president since that time up until this administration. And when I talk about what's happening with USAID, all I can say is it was summed up by Elon Musk this past weekend when he said, yep, we threw that thing in the woodchipper. That's incredible. They called it a criminal organization. They have dismissed all of the wonderful benefits that this organization has imparted upon the world. Now, on January 20th, they put in place a 90 day pause on any funding or activities. Several days later, that was updated. The Secretary of State, Rubio, announced that even though that USAID is an independent agency within the federal government, it was now operating under the support and leadership of the State Department, and that in some cases, humanitarian aid could continue to flow. Remember, this is an organization that provides food distribution for the starving world. It helps provide water supplies, safe water supplies for countries. A major project in Kenya has brought safe water to many individuals there for the first time in modern history.

Dr. Osterholm: It has done much to respond to and control malaria and TB. It now accounts for almost 47% of all global humanitarian aid. And yet, remember, it is less than 1% of our federal budget. It's not like somehow, we're giving lots and lots of money away. We're making the world a better place with USAID. And the leadership there has been remarkable over the years. But the one that, to me is heartbreaking beyond all others is PEPFAR, the President's Emergency Response Program for HIV AIDS. This particular effort, which was started by George W. Bush, involves 55 countries, 20.6 million people who are infected with HIV, including 166,000 children. And literally since 2003, we have been providing antiretroviral drugs to individuals in these 55 countries. We have worked hard to establish local supply chain systems so that some of the most amazing creative supply chain opportunities occur, such as the women who ride their motorcycles every day to rural areas of Africa to make sure everyone takes their retroviral drugs that day. They have been amazing what they've done. We have saved likely well over 20 million lives in the early days of my career. I spent many, many, many hard hours working on the earliest days of HIV/AIDS. There were times in Minneapolis here where I would go to 3 to 4 funerals a week. I saw AIDS in the most ugly of ways, and like many others in public health and medicine, what a gift the antiretroviral drugs have been, how they have revolutionized what in fact HIV/AIDS could be all about.

Dr. Osterholm: Well, in much of the world. Yet we are the reason why that can happen. Survive AIDS. It's because of USAID providing these drugs. It also provides the stability in these countries to be economically sound. This is something is all about our soft diplomacy. What some of us call public health diplomacy. It is what has brought us the most important goodwill. And I saw this firsthand when I was a science envoy for the State Department in the first Trump administration. I traveled to many of these countries on behalf of the US government. And you know what? We were heroes. We are still heroes. However, now this program is being systematically dismantled. Today, as I address you, virtually all of the of the USAID workers have been furloughed. Home. Their computers shut off. They no longer have access. I watch many of the talking heads in the white House right now, who are really proud of the fact that they are basically destroying PEPFAR. Now, remember, this was not a partisan effort. I mean, it was President Bush that did this. And so today, all I can say is, is that this is a challenge. But why is PEPFAR a challenge? Well, the PEPFAR philosophy has been based on five pillars, and these pillars have been in place since the first days.

Dr. Osterholm: The five pillars are health equity, sustainability. Public health systems and security. Partnership and science. Now, how could you be against those? Well, they happen to be against health equity. It's a word we're not even supposed to be able to use. But yet when you look at HIV infection, it is all about equity. And you can't say it any other way. So, from this perspective, all I can say is, is that the destruction of these kinds of agencies and what they do are incredible. And on an international level, one of the most productive centers of research in all of public health is the International Center for Diarrheal Disease Research in Bangladesh. This week, more than a thousand employees, many of them local, many of them making limited wages, received termination letters based on their contract work with USAID and the stop in funding. Can you imagine that this is a center that because of their research and their vaccine work and development, they have saved many, many, many, many thousands of lives, if not millions? And now we're no longer going to fund them, even though if you look at their budget, it was literally minimal. We learned on Tuesday that the National Science Foundation, one of the most critical government agencies, funding really important research that benefits our country every day. We are going to see 25 to 50% of those workers dismissed within two months. They announced that it's going to happen 25 to 50%.

Dr. Osterholm: And this is not an organization that people have sat there and said, oh, they're bloated. They don't need this. It's just everything about anti-science. Go at it. And then on top of that, we have information that as soon as Mr. Kennedy is actually confirmed and as soon as he takes over, we will see 25 to 50% of workers in agencies like CDC and NIH possibly at risk for losing their jobs. I can't fathom that. I can't fathom that it would be almost like saying, we've got ten people here to respond to Hurricane Helena, okay? And we'll spread those ten out as far as we can. What are we doing? What are we doing in terms of communication here at home, I have to say yes, we were all disappointed and frankly quite upset when the federal agencies started scrubbing their websites with diversity information and the websites went down last weekend. Well, a number of them are back with the information having been scrubbed, but in fact, that is censorship at its best. That's exactly what it is. And the kind of data that we often collect as it relates to diversity is so important for many of our programs. I'll comment on that in a moment. But I also want to point out that we're now beginning to see the impact on our medical journals, the vehicle upon which we base scientific integrity research conducted in peer reviewed by colleagues.

Dr. Osterholm: And now we're watching organizations such as the American Society for Microbiology, which has a large number of journals, also receives from federal funds and basically an organization that had been supportive of black, female and LGBTQ populations, not at the expense of passing over other qualified individuals, not at the expense of somehow changing the science and minimizing it, but to how to help people move forward together. They literally pulled their journals off to sanitize them, in a sense, to this kind of wording. I don't know what they were thinking. On the other hand, the American Public Health Association, which is the publisher of the Journal of American Public Health Association, basically says, no, this is a First Amendment science issue. We're going to keep it. You know, this is what we need to do to stand up. I understand that they will say to me, well, you don't have to worry about that. This is not your organization. Well, I do worry. You have known, as I said in the opening, I have always tried to lead CIDRAP with one intent in mind. Call balls and strikes. That's it. Call balls and strikes. Even handed. Apply the same standards to all. And yet I here at CIDRAP, we've had to ask ourselves how might all of this activity impact on our organization? And to date, I'm happy to report that the University of Minnesota leadership has been supportive, said tell the truth.

Dr. Osterholm: You know, we're not out to pick out any fights, but we're also here to do a job, and our job is to tell the truth. Call balls and strikes. I'm watching a lot of organizations not do that. I just mentioned the ACIP. Where are all the professional organizations? There are many of them who are affiliated one way or another with the ACIP, from the pediatrics groups to the adult medicine groups to just. I can go down the list. Where are they right now? If you want to do something, get your organizations to stand up and speak now. Now when I look at the issue of funding, I mentioned already the fact that organizations like the NSF, CDC and NIH are likely to have big cuts. Well, what does that mean? Those cuts mean that they won't have the staff to fund the kind of research efforts that we've had in the past. We now know that the study sections, the groups that review the proposals for research from researchers all around the world are now back operating. But if the staff gets cut 25 to 50%, how are they going to function? They're not. We're going to see an overnight major, major drop in funding. Critical, timely and consequential research. What does that mean? Now is the time to talk to your congressional delegation. Remember, if this happens, it's not an issue of a blue state. This is all states. How many red state academic health centers are going to sit around and say, if we get a few hundred million less this year, so what? That won't happen.

Dr. Osterholm: Now is the time to begin engaging. Our institutions of higher learning have to be at the forefront. And I know it's not going to be easy. And people are going to say, they'll come at us, but you somebody's got to start to stand up and say, this is wrong. Now I am encouraged by the fact, as we look at the issue of the courts right now, we are surely seeing some response to this situation and I can only hope that we see more. Not because I have any expertise in legal issues, but we need to understand what is in fact legally appropriate, what is in fact the right thing to do. So, let me just conclude this by saying, for many of you out there, you're asking yourself, what can I do? What can I do? Tell me what I can do. I don't know yet. We're working on that. We really are. You know, we're sitting in the shock and awe world that you are, too. At least we're trying to catch everything so we know what is happening, and then we can start to make wise decisions. We will not sit on the sidelines, I promise you that we will not, I will not. I would let my career go down in flames before I'll stand aside.

Dr. Osterholm: But at the same time, I want to be smart. We all want to do what makes a difference. Not just to do something because it makes us feel good. So, hang with us. We're thinking about this, but let me give you one area you can start on. Make sure that your school boards make sure that your local city councils make sure that your county commissioner meetings are supported by reasonable, honest, thoughtful people who care about others and who will not market in junk science. That's where you can start. And it may start with your own doctors and your own dentists and your own public health professionals. It may start with business leaders. But now is the time that we have to come together and just know we're going to have to hunker down for the next four years. We will, but we're committed to doing that. And we need you. We need you. And just know that I have not for one moment hyped any of the things I've just said to you. I've said them from my heart, but I haven't hyped them. This is real. This is unlike anything in modern public health history in terms of what we're seeing and of course, all the other implications with all the other areas of life, whether it be financial, legal, you know, all military, all these issues. But we're here and just know that we do have an important mission on our hands. And this podcast family, we need you.

Chris Dall: Mike, let's just drill down a little bit more on the diversity, equity and inclusion issue because as you noted, many of the executive orders issued by the Trump administration are attacking this issue and they are likely to use a broad brush. So that could, for example, include the funding of clinical trials that seek to include racial and ethnic minorities groups that have traditionally been underrepresented in clinical trials. This will likely also apply to transgender people and non-binary people. So why is clinical trial diversity important for public health research?

Dr. Osterholm: Well, Chris, let me just start out by saying I've never seen any of us more superior to someone else. I don't care what their skin color is. I don't care what their gender is. I don't care how much education they have. I don't care about any of those things other than I want them to be able to live their lives as fullest as possible with whoever and whatever they are. Well, if you look at what's happening with the federal government's actions to target any and all diversity, equity and inclusion efforts, it is incredibly concerning for public health. This is because the principles of diversity, equity and inclusion are not simply one part of public health. They are integrated into all aspects of what we do. Following the executive order, the CDC removed and modified many pages on their website, including those of HIV, gender affirming care, contraception use, and data on how racism impacts health outcomes. These issues are nearly impossible to talk about without mentioning issues related to diversity, equity, and inclusion in some way. It's really important. But why do we need information like this? Well, despite the claims from DEI critics, who often argue that the most equitable way to address the concepts of race, gender, poverty, etc. is to ignore them all together, we know this doesn't work in a world where inequities currently exist.

Dr. Osterholm: For example, how can public health attempt to address the higher COVID mortality rates experienced by black Americans if we ignore that inequality entirely? How can we create effective HIV prevention messaging for at risk groups, if we do not address the fact that men who have had sex with men, for example, are one of the groups at higher risk. And as you noted, Chris, one area where this is really important is in clinical research settings. We need to continue prioritizing having diverse populations for our clinical research in order for us to make conclusions that are generalizable to the entire population. The fact is that if we don't prioritize diversity and inclusion in public health, then we are contributing to the health inequities we're fighting. It's unclear exactly what the recent executive orders will mean for the funding of grants to support clinical research that incorporates DEI into the design of the studies. It's also unclear to the extent to which government agencies like the CDC will be censored. But as things stand now, we are now likely to see a lack of transparency about health and equity from government groups, as well as projects that receive government funding, and this means we can only expect these issues to worsen. Until these changes are reversed.

Chris Dall: Well, Mike, now back to our regularly scheduled programing. So what trends are you seeing in respiratory viral activity here in the US and around the world?

Dr. Osterholm: Well, Chris, before I dive in, I just want to restate that I feel very fortunate this week that we have access to data that is important to answering the question you just asked. It's something we weren't sure that we would actually have in terms of availability of information from the CDC. So based on what's happened over the past two weeks there, I want to salute the CDC staff who have made it possible for us to comment on this question today. Unfortunately, we're seeing something we haven't seen since 2019-2020 flu season, which we can call a double peak. During our last episode, we discussed that it looked like flu activity was beginning to decline, suggesting that we may have seen the activity peak, but we're coming to realize that this was just a false peak. Activity is rebounding dramatically and is now higher than it was when we reported the season's potential peak. Let me put this into context with numbers. Two episodes ago, at the beginning of January, 6.7% of the outpatient visits were because of influenza like illness or what we call ILI. Last episode, we thought we may have seen the peak because the percent came down to 5.4%, so from 6.7 to 5.4. We are currently, however, at 6.9%, which is actually among the highest we've seen in the past 24 flu seasons. Outpatient respiratory illness activity is highest in the South, but it is increasing across the entire country, with almost all states generating high or very high levels of outpatient influenza like illness activity.

Dr. Osterholm: 27 states and the District of Columbia are experiencing very high levels. 14 are high. Three are moderate to low. And three minimal activity is increasing across every age group, but remains highest in the youngest age group, 0 to 4 years of age, and lowest in the 65 years of age and older group, which has remained consistent throughout the entire flu season. Interestingly, though, the 5- to 17-year-old age group had a higher percentage of emergency room department visits for influenza than the 0- to 4-year-old age group, meaning school age children are having more severe illnesses. Now looking at severity indicators according to the CDC's flu surveillance report, there were 38,255 patients admitted to hospitals with influenza last week 38,255. This was a 22% increase compared to our last episode. There have been an estimated 250,000 hospitalizations for flu this season, with the highest hospitalization rates being in those 65 years of age and older. Unfortunately, since our last episode, there has been an additional 20 pediatric deaths, bringing the total for this season to 47 pediatric deaths, which has contributed to the estimated 11,000 deaths so far this flu season. All of this activity continues to be largely influenza A of the 2693 viruses reported by public health labs last week, 2642 were influenza A and only 51 were influenza B. Approximately 2000 influenza A viruses were then subtyped and was about 50/50 split between H1N1 and H3N2.

Dr. Osterholm: This has remained quite consistent throughout the entire flu season. So, based on this, what does it mean? Well, I'll tell you, given this new second peak and what likely will be continued activity for at least a few weeks, if not a few months, I would urge anyone who anyone who has not yet been vaccinated for influenza to get vaccinated tomorrow. Do it. It may be very likely that you still can get protection against what may be an infection coming 3 or 4 weeks from now. So, this is really, I think, the important message of the flu season. It's bad. It's killing people, particularly older people, and it's killing our kids. Definitely get vaccinated. It won't stop you from getting infected necessarily. It won't stop you in some cases from even getting ill. But it does a lot to keep you from developing serious illness, being hospitalized or dying. Now let's shift to COVID. The national wastewater level is considered high after the last several weeks of decreasing concentrations. Activity is increasing in every region but the northeast, the northeast and West are considered moderate, while the Midwest and South are considered high. Looking at the severity indicators, hospitalizations are Decreasing, but deaths continue to increase. Remember, deaths with COVID, as are reported often are delayed 3 to 4 weeks from the time at which the death occurred or that the illnesses were peaking.

Dr. Osterholm: For the most recent week of hospitalization data, which is the week ending January 25th, 1.5% of inpatient beds and 1.5% of ICU beds were occupied by COVID patients. That is, more than 10,000 inpatient beds and more than 1500 ICU beds, which is a 14% decrease from our last episode. Unfortunately, as I just noted, deaths continue to increase and the week with the most complete data, which is the week of January 4th, 773 American lives were lost to COVID-19. This is the highest number of weekly deaths we've seen since October. Since January 1st, there has been 1540 deaths, with COVID listed as the underlying cause of death and 760 that lists COVID-19 as the contributing cause of death. When we look at these same deaths since January 1st, it's important to note that most of them have occurred in individuals over age 50. In fact, if you look at the number of deaths by age, 6% of the deaths occurred in those 50 to 65. In those 65 to 75, it's 17% of the deaths. And for those 75 years of age and older, that 77% of the deaths. All I can say is, again, from a vaccination standpoint, particularly for those of our residents who are 65 years of age and older, it's our grandma and grandpa's. Please do everything you can to get them vaccinated in the next day or two. This vaccine may still very well protect them over the upcoming month from having severe illness, being hospitalized and as you just noted, dying.

Dr. Osterholm: Let me just add that the variant tracking data has not been updated since our last episode. There's not much to say besides the fact. As far as we know, XEC most likely accounts for a majority of US cases at the moment. Let me just add my own personal note here. You know, I've been following these variants very closely since 2020, and I must say that through a large part of the pandemic, it mattered a lot. Which variant was present in terms of transmission potential, the ability to cause serious illness and even cause death. But really, over the past year, whether it's the XEC or the LP.8.1, all these different variants, I've yet to see much in the way of meaningful impact from any one variant versus another. So as much as I may share variant data with you, just know from my own internal use I don't think that much about it right now. Now, if something should change where we suddenly see a new variant appear that impacts on transmission or disease severity, the ability to evade a main protection from previous vaccinations or previous illnesses. We'll note that. But for right now, I think it's fair to say we're in kind of a steady state status with COVID, and fortunately, it is substantially lower than we're seeing for that with influenza.

Dr. Osterholm: I also want to add one last piece to the COVID picture that I think is a really important consideration. CDC published this past Monday a paper. Thank you, CDC, for doing that. That addresses the issue of long COVID in children. It's based on some very, very good survey data that they've collected over the years, the kind of data that we've got to keep flowing into the public domain. They estimated that in 2023, there was over 1 million kids who actually were experiencing long COVID. Think of that. Over 1 million kids. Often it meant that there was severe lethargy, inability to carry out everyday activities, even brain fog kinds of issues. That number improved for 2024, from 1 million the year before to 293,000 kids having long COVID. Now, that surely suggests that you can recover over time. You do recover over time for many of the cases, but I think it's an important point. We talk about the fatal cases, those serious illnesses mostly being in those who are older, but we still see the real challenges that COVID presents to our children. And again, this is why I would do whatever I could to keep my children vaccinated as scheduled. Given the fact that you don't want your child to go through several years of long COVID. Last but not least, it's RSV season also, and right now, RSV activity in the US is considered moderate by the national RSV wastewater concentration.

Dr. Osterholm: If you look at emergency room visits, they're also considered moderate. But decreasing hospitalization for RSV has decreased since our last episode, with approximately 6200 RSV patients occupying inpatient beds in approximately 1200 occupying ICU beds. The CDC estimates the burden of disease and has projected that since October, there have been anywhere between 5200 and 13,500 RSV deaths in the US, still a significant disease, for which again, we have a vaccine. Let me wrap this all up into what I think is a very important figure. If you add up the number of people hospitalized this past week for influenza in this country, 38,255 or COVID hospitalized this past week at 10,364, or RSV at approximately 6200. That's almost 55,000 people in this country were hospitalized this past week with a respiratory illness. That's pretty significant. Talk about a health care system's ability to respond to that and not actually be overrun. It's a challenge. For example, even here in the Twin Cities metropolitan area, we've seen because of the reduction in the number of pediatric beds and now this big increase in cases, children literally being hospitalized in beds, in closets and hallways because of a lack of space and number of employees. So, this is a real challenge. And, you know, I think sometimes we take respiratory illnesses for granted if they're not part of a big pandemic. But when you add flu, COVID and RSV right now, this is a constant source of critical illness in our communities.

Chris Dall: Mike, as our audience knows, we've been very focused on the H5N1 avian flu outbreak in U.S. poultry and dairy cattle, and we continue to get reports of infected poultry and dairy cattle on a daily basis. But last week, H5N1 was detected on a duck farm in California. Then just yesterday, a different genotype of H5N1 was detected in the milk of dairy cows in Nevada. Mike, what does this all mean?

Dr. Osterholm: Well, Chris, H5N1 continues to march on, and we know that this is a very important issue, not necessarily just because of what's happening now, but of course, because of that potential for it to be the source for the next pandemic influenza virus. Let me just update you a bit on the H5N1 numbers. It's increasingly difficult to quantify the burden of H5N1, primarily in migratory waterfowl, as the virus is now running rampant. But we are hearing of plenty of anecdotal reports about dead waterfowl across the country. This is something taking place in a number of states. As of this past Monday, the USDA APHIS added six more herds of dairy cattle confirmed to be affected by H5N1. Two from California and four more in Nevada, putting the national total at 956 and the state's total in California at 736. More detections in captive birds have been identified, as well as including backyard flocks. Commercial egg layers and poultry, including chicken, turkey and of course, ducks. There was a marked increase in commercial flocks affected since our last episode, rising from 49 to 82 in the past 30 days. This includes the nation's second largest egg producer located in Indiana, and the complete meltdown happened in Ohio, where a loss of over 6 million poultry animals in the last month has occurred. There continues to be detection in mammals. This includes domestic cats, foxes, squirrels, and even a dolphin. Let me just reiterate a point that I made in the podcast two weeks ago. I am convinced with this widespread infection in migratory waterfowl that are not really migrating right now.

Dr. Osterholm: They're literally in many states throughout this country. As long as there's open water, whether it's man-made heated water from an electrical generation plant or whether it is the large ponds for holding the sewage treatment, water from municipalities around the country, or even large agricultural areas where they have large ponds to hold the waste coming off of the various farm areas. Anywhere there's open water, you'll find migratory waterfowl. Right here in Minnesota, it's been up to 20 degrees below zero. And yet we see a number of migratory waterfowl here. Why? Because we've got open water. And that's true throughout the country. That's an important point because we can't control that. Those 40 million aquatic waterfowl that are residing in North America are here, and they are getting infected. Some die, some recover, and more chicks are hatched. And that cycle is just continuing unlike anything we've ever seen before with influenza. We have never seen this kind of continental season after season after season presence of this virus. So, expect that the pressure from this virus is going to continue. And notably, as I stated last time too, I am convinced we're not going to see improvements in egg availability and egg prices anytime soon until the industry does two things. One is recognizing that the major source of this infection is wind driven virus blowing into these barns as a result of virus that's on the fields from where the birds defecated and dried and then got blown in. And this is a classic environmental inhalation issue.

Dr. Osterholm: Those birds that do become infected in production are often extremely sensitive to this virus, so that they don't need much at all to get infected. And then once it starts in a barn, it goes. If you've ever been to a poultry production facility, you know these barns are not airtight and air can come in through any number of locations until we start building airtight poultry production facilities with HEPA filter air intake. We're going to continue to see this happening. Well, let me comment now on those other two issues. You asked about H5N1 and the new isolation of a different flu virus from cattle. Today in Nevada, let me start with the H5N1. That's kind of an easy one. Remember that influenza A virus that contain proteins on their cell surface. Now there are two very critical proteins that have a lot to do with how infection occurs and whether or not the virus can spread. One is called the hemagglutinin and the other is the neuraminidase. That's where the H and the N come from. There are 18 different hemagglutinin types. There are 11 different neuraminidases. The three hemagglutinin types that have been associated with previous influenza pandemics include H1, H2, and H3. We surely are concerned about H5 one day potentially becoming like H1 2 or 3, and being able to be readily transmitted to people by people and causing a pandemic. But when you look at H5, we've actually had a number of them H5, H6, H7, H9, H10 all have actually infected humans.

Dr. Osterholm: When we look here to see what's happened with H5N9, this is not at all unexpected. I'm surprised we haven't seen more of these atypical flu viruses showing up. So, I'm not really all that concerned about H5N9 suddenly being the significant virus that might cause the next pandemic. Historically, when we look at these, they most often in a sense die out. We've had some large outbreaks. There was an H7 outbreak in 2003, in the Netherlands, and a poultry flock that spread to some humans. It ended right there. Didn't see any more transmission from a human. And most of their illnesses were conjunctivitis, so I don't think I'd worry about this one as such. It's still, to me, is H5N1. If it's going to do it, that's the one that's going to do it. But now what is troubling is the finding that was reported out yesterday by APHIS. This is the Animal and Plant Health Inspection Service of the USDA. They confirmed by whole genome sequencing the actual first detection of the highly pathogenic H5N1 clade, 2.3.4.4B genotype D1.1. Now, let me break this apart for you. Okay. Remember, we all the H5N1 viruses we're dealing with right now are the clade 2.3.4.4B. Think of that like the family name. Remember that all the isolates to date in dairy cattle have been the genotype B3.13. And that's important because this one is different. And if for this one to be different as a D1.1, which is the one we've seen primarily in poultry and wild birds, says that this was a new spillover.

Dr. Osterholm: Meaning now we don't have just a spillover starting in Texas that spread through the cattle industry because of the contact between cattle. This is likely another bird event that spread into these cattle in Nevada. And it's not clear what the cattle picture looks like in Nevada, because this was actually picked up through the silo testing under the USDA's National Milk Testing Strategy, where they're testing milk in big bulk tanks. And they found it. So, we knew it came from that area. So, the point being here is, is that we no longer can count on the spillover as just being a very remote, won't ever happen again kind of situation. And if we can in fact control the H5N1 in cattle, it will go away and we're done. Now it shows. You know what? As long as long as there's this kind of pressure on the migratory waterfowl throughout North America, the cattle will always be potential hits for a spillover. That's an important point. And that's why just this one little finding of a D1.1 in dairy cattle in Nevada really is kind of a game changer. It doesn't mean that, you know, it's going to ultimately result in a human transmitted H5N1 virus. It doesn't mean that at all. But it now says you can't count on the one spillover event in Texas of a year ago to be the only spillover that we might see. And that surely has to have people thinking, what else do we do?

Chris Dall: Now it's time for our ID query. And this week we received several questions about a tuberculosis outbreak in Kansas, which officials with the Kansas Department of Health and Environment say is the largest outbreak the state has seen. And at the very least, it appears to be the largest outbreak going on in the country at the moment. Mike, what can you tell our listeners about this TB outbreak and where does it fit into the global TB picture?

Dr. Osterholm: Well, Chris, before I get into the details of this particular outbreak, I want to first provide some background on tuberculosis for listeners who may not know much about it. This is a disease that many people think is in our rear-view mirror, and do not realize the global impact at this time of what TB is all about. Tuberculosis, often called TB, is an infection caused by the bacterium Mycobacterium tuberculosis. TB primarily infects the lungs but can spread to other areas of the body. Most people are asymptomatic during the earliest stages of TB, called primary TB infection. Then, the disease typically progresses to latent TB, in which patients are not yet symptomatic or infectious. Finally, the infection takes the form of active TB, which is when patients are symptomatic and infectious. Active TB causes very serious illness and can be fatal, particularly when left untreated. TB is spread through the air as an airborne infection, but unlike pathogens like SARS-CoV-2 or influenza, prolonged airborne exposure is necessary for TB transmission to occur. TB is treatable, though antibiotic resistance has been an ever-increasing challenge and complicating the recovery of many TB patients. The current outbreak of TB in Kansas, as you mentioned, Chris, is one of the largest outbreaks in recent years here in this country. There have been 67 active and 79 latent cases of tuberculosis reported in the outbreak, which has spanned two counties in the greater Kansas City area. Sadly, there have been two deaths associated with the outbreak. This outbreak is still ongoing, meaning we could still see more cases occur. But due to the nature of how TB spreads, it's hopeful that the overall risk to the public remains low. In light of this outbreak, many of our listeners, and had questions about vaccination and tuberculosis. There is a vaccine for TB called BCG vaccine that is given to infants and young children in countries where TB is more prevalent.

Dr. Osterholm: The BCG vaccine is not, however, routinely administered in the United States because the risk of TB infection here is quite low, and because the vaccine's effectiveness is highly variable, particularly in adults. It can also cause false positive TB skin tests, complicating any kind of investigation follow up. There are rare circumstances in which BCG is used in the US for children who will be continuously exposed to an adult with untreated or treatment resistant active TB, and for health care workers treating patients with treatment resistant TB. Since these criteria are fairly narrow, I doubt we'll see any type of large-scale vaccination efforts in Kansas in response to this outbreak. Testing and monitoring of exposed individuals for latent tuberculosis, and recommending appropriate treatment accordingly is generally a much more effective approach, particularly in a well-resourced setting like the U.S. So, I suspect that the public health officials in Kansas will continue to combat the outbreak this way. Lots of good contact tracing and follow up and active treatment programs. Finally, I want to acknowledge that while an outbreak of 146 cases of TB is certainly alarming in the US, this is actually just a drop in the bucket when put into the context of the global burden of tuberculosis. It is estimated that in 2023, 10.8 million cases of TB occurred worldwide, resulting in 1,000,250 deaths. Global health efforts to fight TB remain very important. This is another example of an essential part of our public health world that will struggle without the U.S. as a member of the W.H.O., as well as providing substantial support for tuberculosis control through the USAID. This is going to be a huge challenge.

Chris Dall: Finally, it's time for this week in public health history. And this week we're celebrating the birth of a program that is very timely given the news of the last few weeks. What can you tell us, Mike?

Dr. Osterholm: Yes, Chris, this week we're featuring a program that I think of as one of the most impactful global health initiatives this country has ever undertaken. And unfortunately, it's on the ropes right now and likely to go down soon. I don't understand why the 1980s in public health was most notably marked by the devastating crisis of HIV/AIDS, while there was great optimism regarding the development of a vaccine. It became clear as the disease ravaged its way around the world that preliminary measures would need to be taken to prevent transmission and treat infections. In the mid to late 1990s, antiretroviral medications became available to help control the replication of the virus and to keep the infection from progressing from HIV to AIDS. Along with improving the health of the individual, studies begin to show that antiretrovirals were also effective at preventing transmission of HIV from pregnant women and during the delivery process. However, the cost of these drugs and the ability to distribute them made it difficult to access for those in greatest need, primarily in sub-Saharan Africa. While considering his run for president in 1998, George W Bush spoke with his colleagues and future Secretary of State Condoleezza Rice on their ideas to improve the provisions of foreign aid in Africa. At the time, the United States spent less than $500 million on global HIV assistance spread across six agencies. After multiple initiatives from the Global Fund to the Millennium Challenge account and under the advisement of leaders from Bono to Tony Fauci, The President's Emergency Plan for AIDS Relief, also known as PEPFAR, was born. This program officially launched in 2003 and provides global funding for prevention, treatment, and research on HIV/AIDS. Since its inception, the U.S. has allocated over $110 billion to PEPFAR, more than any country has dedicated towards a single disease. Before COVID-19, the global AIDS coordinator sits in the State Department to oversee the work across more than 50 countries.

Dr. Osterholm: The program was established by President Bush's idea of partnership, not paternalism, which grants countries flexibility in the means by which they implement the work in their own communities. This includes really unique efforts, including hub and spoke models of community health workers delivering medications on motorbikes. It's estimated that the program has saved more than 25 million lives and prevented more than 5.5 million cases of HIV being transmitted from a mother to the child during the birthing process. And this has occurred primarily throughout sub-Saharan Africa, but also is present in 26 total countries. PEPFAR has been reauthorized consistently and regardless of which political party was in office, most recently in 2024. However, the current administration has thrown a wrench into that mix. As we've mentioned earlier in the episode, the impacts of the pause on this funding and the chaos that has caused will have a devastating impact for years and possibly generations to come. It's critical now more than ever, that we share the success and the necessity of programs like PEPFAR and ensure their stability for the health of the entire world. When I look at the potential consequences of withdrawing this antiretroviral therapy for up to 22 million people worldwide, and I think about the fact that's just slightly less than the total number of people who have died of HIV since the beginning of the epidemic in the late 1970s. And imagine now we may rerun those same days again, over and over again, where many of us in this country often went to multiple funerals every week. That is going to happen in many countries of the world, if in fact, antiretroviral therapy is withdrawn. I do not understand how anyone could find that acceptable.

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

Dr. Osterholm: Chris, let me just say that these take-home messages today are challenging. At least one of them in particular. And that is the fact that we have to acknowledge that we are on a collision course with history and public health for that matter. We are on a collision course with history and global governance, but public health is going to take some huge hits. I think about the fact that as I watched all these people die of HIV infection back in the 80s, people who I cared a great deal about, and then I watched the wonderful success of the antiretroviral drugs, and I watched the success of a U.S. program that was based on not only good will, but humanitarianism at its best. Well, I'm thinking about these 22 million people that are infected with HIV that have benefited from the PEPFAR program. And I think to myself, what happens when they don't get drugs anymore? And many of them very well may not. Are we going to go back to days like we saw in the 80s and early 90s where people talked about, you know, what were the five funerals you attended this week? That's beyond tragedy. That's just inhumane. And so, we really need as a take home message to say we have to stand up stand up and say, this is not acceptable. This is not, you know, yes, we're all going to die. There will always be a top ten causes of death, but these deaths from HIV are absolutely unnecessary. They are not written into stone. We have done so much to lift that burden, and to me to watch what's happening right now with overall public health governance. But specifically, this event is tough. Please, as listeners of this podcast, don't forget what's happening right now.

Dr. Osterholm: You can't just throw your arms up and say, I'm done. I can understand why you would want to do that. You can't walk away from it. This is going to impact all of us. One way or another. You're going to know an immediate impact public health wise, because of something that's happening right now. Trust me. So, from one take home message is let's hunker down. We're going to do this together. We're in it. We're going to try to identify actions that you can take personally, professionally, as neighbors, as good citizens. We're going to try to find these and share these with you. Second of all, this new spillover of H5N1 into dairy cattle is a concern. Does it mean that “Oh, my. The things have changed dramatically.” No, but it says, you know, it's not going to be quite as simple as getting, uh, H5N1 out of dairy cattle, as we once thought. With the period of the last almost year where there was a single spillover event likely. Stay tuned on this one. And then finally, as I shared with you, in terms of the current respiratory illness picture, it's bad. This double peak in influenza means that if you haven't been vaccinated yet, go out and get vaccinated today. Now, because you may still benefit for the next 3 or 4 weeks, maybe five weeks of activity. And it could be the difference between getting really sick, potentially being hospitalized or dying and getting infected, but doing okay. All the vaccines get up to date your flu, your COVID, and your RSV. It may save your life and more importantly, it may save the lives of your loved ones, particularly if they're older.

Chris Dall: So, Mike, we have covered a lot on this podcast. Do you have a closing song or poem that could somehow sum up your feelings about what's going on right now?

Dr. Osterholm: Well, Chris, I do, and it's one that is a very favorite of mine. It will be familiar to some of you. I actually use this particular poem on the last live episode we did in October 15th of 2020, and it was one that at that time was really meant to try to provide that kind of moment of, we can do this. This is a poem by John Greenleaf Whittier. He lived from 1807 to 1892. He was an American Quaker poet and advocate of the abolition of slavery. He was often referred to as the Fireside poet. He was influenced by the Scottish poet Robert Burns. Today I share with you his wonderfully beautiful poem, don't quit when things go wrong, as they sometimes will. When the road you're trudging seems all uphill. When the funds are low and the debts are high. And you want to smile. But you have to sigh. When care is pressing you down a bit. Rest if you must. But don't you quit. Life is queer and its twists and its turns. As every one of us sometimes learns. And many a failure turns about when he might have won had he stuck it out. Don't give up, though the pace seems slow. You may succeed with another blow. Success is failure turned inside out. The silver tint of the clouds of doubt. And you can never tell how close you are. It may be near when it seems so far. So, stick to the fight when you're the hardest hit. It's when things seem worse that you must not quit. John Greenleaf Whittier. Thank you so much for joining us today. I hope that we're able to provide you that kind of information you are looking for. When I promised you in our last podcast of November, I'm here for the next four years.

Dr. Osterholm: I've signed back up. CIDRAP is looking carefully at what we can do to help respond to the current situation of protecting public health, and what we must do to save lives. I realize that at this time, you're all looking for what to do, in many instances feeling somewhat lost, feeling the shock and awe of what has happened. Well, all I can say is, is that we'll continue to work on this issue. We will continue to try to identify what are those things that we as citizens can do to respond. We're still watching things shake out. For example, while we don't know that Mr. Kennedy is going to be confirmed next week as the new secretary of HHS, it's highly likely, as he made it through the Senate Finance Committee vote on Tuesday. That means that we may expect to see major changes at CDC, that we are going to need to be able to respond to quickly. We will keep you informed of those changes and what they mean. But in the meantime, as we talked about in this poem today, don't quit. Please don't give up. And most of all, please never stop being kind. This is going to be tough these days. This is hard. There are days that I just feel lost. But then all I have to do is think about my grandkids. And I have purpose all over again. We all need to find that place. We need to find why it is that we find what's happening right now is unacceptable. And how we're going to respond. So, thank you very, very much. Again, please be kind. Be safe right now. Be kind. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoy the podcast, please subscribe, rate and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease news by visiting our website cidrap.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to cidrap.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddart, and Leah Moat.