(Re)emerging infectious diseases

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0:00:05.9 Speaker 1: There's no denying that the Covid-19 pandemic changed the way we collectively view infectious disease. Prior to the pandemic, many people wouldn't spend much time thinking about a news report about an emerging or re-emerging disease popping up in another part of the world, or even in our own country. But now, that news feels different, more consequential. As we collectively wrap our heads around what we need to do now to protect ourselves, we also have to consider diseases, and many of us probably thought were long gone. More and more, we're seeing viruses from our grandparent's generation.

0:00:36.1 Speaker 1: Ones, we may even have vaccines for popping back up. In this new era where global media attention has turned to epidemiology and infectious disease, how do we understand our situation and feel protected when it's seems like we're hearing about so many diseases all the time? Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level, from the microscopic to the macroeconomic, the social to the environmental, from cities to neighborhoods, states to countries and around the world.

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0:01:22.5 S1: We spoke with experts from a variety of areas of infectious disease to learn more about the re-emergence of old diseases, the emergence of new diseases, and how public health is keeping us prepared to combat all kinds of infectious disease. Mark Wilson is a professor emeritus of epidemiology and of Global Public Health at the University of Michigan School of Public Health. He's an ecologist and epidemiologist whose research focuses on infectious disease, transmission and dynamics. He spent a career studying the epidemiology and risk factors, including environmental and behavioral, the influence transmission of microbial infectious diseases. Dr. Wilson first addressed whether he believes we're actually seeing an increase in infectious diseases or whether we're simply paying more attention to that.

0:02:04.6 Mark Wilson: I think that both are occurring. We are now seeing more and more infectious diseases appear, and we are also better able to recognize and track them. Evolving pathogens are producing new diseases that are different than those that have ever been known before. Zoonotic or zoonosis are those which normally transmit from animal to animal and occasionally spill over to people. More and more infections are coming from animal sources and are spilling over into human populations, and then become recognized as new human diseases that were not known before. In addition, modern laboratory methods are better able to detect and specify these microbes that may have been previously infecting people, but perhaps had never been identified.

0:02:54.6 MW: We all know that the absence of evidence is not evidence of absence. So whenever researchers or public health officials test people who have historically been overlooked, new and unexpected infections often appear. Sometimes this is because the symptoms are not acute or dramatic enough to attract attention, but often it's because no one bothered to look. Finally, and I think this is good, there is greater awareness and interest in public health in general and infectious diseases in particular. Such that there is more information available through various media and other sources to inform people on one hand, but at the same time, perhaps to alert them to the challenges that these new diseases represent.

0:03:43.5 S1: So what's the difference between an emerging disease and what we would now consider a re-emerging disease? 

0:03:50.3 MW: Well, we think of emerging infectious diseases as those that have not been previously recognized as affecting humans, but they suddenly appear in a population. The pathogen associated with this new disease has really always been around, it's just been hiding in a sense, oftentimes in non-human animals. For example, the virus causing Covid-19 represents a good example of an emerging infectious disease where the virus was regularly transmitted among non-human vertebrates, perhaps for eons, and suddenly spilled over to people. That virus then was able to be maintained in a human-to-human-to-human transmission chain and the resulting pandemic that we all know well occurred.

0:04:36.3 MW: Some other examples would be Lyme disease caused by a bacterium found in small mammals and transmitted by the bite of a tick. Similarly, AIDS caused by HIV was unknown in humans before the 1980s. So emerging diseases have been around as infections, but not recognized as human diseases. Re-emerging diseases in humans, however, have been known for centuries and after a decline in incidents may have re-appeared in local epidemics sometimes in new places or affecting different populations, or they are more severe in symptomology or less easily treated due to drug resistance. So there are a lot of characteristics of re-emerging diseases that help us to define them as such. Dengue fever is now widespread throughout the tropics and sub-tropics much more so than before.

0:05:30.4 MW: Tuberculosis now affects diverse populations and is resistant to many of the drugs that previously were used to effectively treat it. Cholera is re-emerging during the past decade in the Americas due to socioeconomic and hygiene conditions that affect water quality and sanitation. So re-emerging diseases really are ones that have been recognized for a long time and are suddenly re-appearing either with greater severity or in a more widespread setting, and they're equally as important as those that we consider to be emerging. In places where infectious diseases have been locally eliminated, there's always a risk of re-introduction. But that depends on factors like the pathogen's normal mode of being transmitted, the usual reservoir or source for the pathogen, and even the effectiveness of surveillance.

0:06:28.6 MW: With the rapid global movement that we now know so well of huge numbers of products of animals and of people, this has dramatically increased the likelihood that pathogens can hitch a ride and be newly introduced or re-introduced to virtually anywhere in the world. Whether or not the environment in which they are re-introduced is suitable is a separate question. And whether that introduction takes hold really depends on many different environmental characteristics on whether capable vectors are present if the disease is vector-borne on the proximity and density of humans or of non-human reservoirs and a whole variety of social and behavioral features. All of this, again, points to the importance of continued public health surveillance to quickly detect introductions or re-introductions so that they can be contained and eliminated before expanding and becoming uncontrollable.

0:07:29.5 S1: But there's a difference between elimination and eradication. Elimination means that you've expelled the disease from a given region. Eradication means there is no known circulation of that pathogen in the world. The only example we have of a globally eradicated disease is smallpox. By 1980, the disease was considered eradicated. This timeline alone implies that eradication is no simple feat. Dr. Wilson explains the public health efforts it took and the natural characteristics of the disease that made it possible to eradicate smallpox.

0:08:03.5 MW: Well, smallpox is exceptional not only for it being the only disease that has been eradicated globally, but also for characteristics that allowed for that. Smallpox is a severe, often fatal disease, so it really deserved the attention that it received. It's obvious symptoms make it easier to identify. The pox lesions on the skin were easily recognized, and this meant that cases were identified and treated or isolated as needed. The third point I would make is that people with smallpox symptoms are highly infectious to other people. So you know when they are not only infected, but also infectious, and these are the people who you want to try to separate from others who have not yet been infected. Next, none of the people who were infected were sub-clinical or asymptomatic in their infection.

0:08:58.6 MW: In other words, you could easily recognize that those people were infected and you knew that they were likely to transmit if someone were in contact with them. In addition, only humans can be infected with the virus, and so this means that there are no non-human reservoirs, unlike many of the other diseases that we deal with, so this simplified the problem. The transmission is actually quite easy to occur through sneezing, coughing or talking and by contact with these pox lesions. So that meant that in some ways, you could also limit the exposure of others to people who are infectious. There's no insect vector to this virus, so you don't have to worry about treating vectors that might be transmitting or other modes of transmission. The seasonality of transmission also made it easier to intervene because vaccination could occur at times of the year when no transmission was occurring.

0:09:57.1 MW: Another really important characteristic of smallpox is that there's no recurrent infection. In other words, once you are infected or vaccinated, you have immunity that protects you for a long period of time, perhaps even for life. So you're no longer involved in a transmission cycle, either as someone who could become infected or who could again become infectious. There's only one viral type and no viral variants that appeared so that the vaccine was able to produce immunity against that single strain of smallpox virus. And that vaccine was highly stable. And this is extremely important in the context of reaching far away places where there was limited electricity or limited infrastructure to keep the vaccine from spoiling. So in other words, having no need for a cold chain meant that there was easy access to vaccination in very remote settings.

0:10:52.2 MW: So these are all characteristics that made smallpox relatively easy to eradicate and their characteristics that aren't shared by many of the other microbes or pathogens that we know of today. Microbes like all living things are constantly evolving, often at rates of change that are much faster than other organisms with less abundance or who have fewer offspring or who have longer life spans. Basically, genetic changes are occurring all the time in these microbes and some of these changes produce characteristics that lead to there being more likely transmission, the microbes perhaps becoming more pathogenic or better able to infect different hosts or even less susceptible to our treatment of them. We should expect change rather than stasis.

0:11:43.0 MW: Pathogens are evolving. Rapid international transport of people and goods is happening at an ever-increasing pace. Environmental change, including urbanization, deforestation, global travel, civil strife, these are all more frequent and diverse in human-to-human contact impacts, which are also leading to greater risk of emergence or re-emergence of infectious diseases. Even though medical advances in treatment are important and prevention through vaccination, for example, is also important, ultimately, I believe that understanding and influencing how socio-economic and behavioral factors affect risk of exposure and transmission of pathogens to others, this will have the greatest and most long-lasting impacts.

0:12:31.8 S1: Another important tool in infectious disease work is surveillance. The ability to quickly identify diseases and effectively implement public health strategies is critical. But as our world gets more connected, diseases have more opportunities to spread and much more quickly. Dr. Wilson says collecting and analyzing a large volume of data needed to make global disease surveillance effective is something that we must find room for in modern life.

0:12:54.5 MW: I really don't think there is any necessary conflict between modern surveillance for infectious diseases and modern life that involves global travel, environmental change and increasing consumption by more and more people throughout the world. Surveillance for emerging and re-emerging microbes, however, should become a normal part of the public health responsibilities, both of the public health workforce and of the population at large. Covid-19 is again an extreme but useful example. People throughout the world had reduced travel and social exchanges, they experienced increased constraints on their behavior and many other interventions that were aimed at reducing infection.

0:13:41.4 MW: In addition, the need for surveillance was highlighted and in some cases produced some minimal disruption. However, if it weren't for that, the pandemic could have killed hundreds of thousands of people beyond the unfortunate large number of deaths that did occur. The pandemic would still perhaps be widespread throughout the world in ways that it is not now. So the role of surveillance is critical and at the same time, minor disruptions to our lives should be put in the context of the benefits from that surveillance. In general, I think that the public's health will be better protected if we accept scientific evidence that shows how surveillance and response has been able to thwart epidemics today and into the future.

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0:14:36.9 S1: If infectious disease surveillance is already a normal part of public health action, why are we seeing diseases like polio, which was long considered under control, re-emerging? Joseph Eisenberg is a professor of epidemiology at the University of Michigan School of Public Health. He studies infectious disease epidemiology and is especially interested in the environmental determinants of infectious diseases. Dr. Eisenberg explains more about why polio is one of the diseases we're seeing re-emerge.

0:15:05.8 Joseph Eisenberg: Polio is very hard to control and mobilization and movement of people globally continuously at a high volume of people moving around the world can easily spread a disease from one place to another. And I think that's another reason why we might be seeing something like polio, where we are on the brink of eradicating polio. Polio, the wild polio type is only circulating in a couple of countries in the world right now. The hope is that we do eradicated it, but this is an example of showing how difficult it is to eradicate a pathogen like polio. There's a couple of reasons why we're seeing it re-emerge. One of it's because we are looking at waste water more seriously from a public health perspective. And that is much more sensitive way in which to look for pathogens.

0:15:56.9 JE: So polio is a great example of a pathogen that mostly is either asymptomatic or if you do have symptoms when you're infected with polio, they're broad symptoms that could be anything. Rarely one in 1000 cases or so, you get a serious case of paralytic polio. Because of that, it's hard to really monitor how much transmission polio is happening in any given area or region, and so once we started to look at sewage more closely, and example of that is in Israel in 2014, when they identified polio in their wastewater. It was a wild polio type, it was quite a lot of polio, and they mobilized... Started a oral polio vaccine campaign. They administered the vaccine nationwide and the polio disappeared in the sewage. We call this a silent epidemic because we never actually saw a case of acute flaccid paralysis, which is actually what defines a case of polio by the WHO.

0:16:57.4 JE: So if they weren't looking at the wastewater, we would potentially never known that there was actually spread. The case in the United States recently is unusual because we did actually identify a case of acute flaccid paralysis first. The person wasn't traveling to Israel, but it was in a Jewish community and there was likely a lot of travel to Israel. There was a small outbreak in Israel, and then that's likely how it spread to the United States. And then when we looked at the sewage, we saw a lot of polio. In this case, it was a vaccine variety of polio and not wild polio. So it turns out that when you take the oral polio vaccine, you shed an attenuated variety of polio that is usually not pathogenic, but it can mutate into a pathogen. And that happened here, and in this case, someone actually came down with an infection of polio and acute flaccid paralysis.

0:17:48.4 JE: What I take from the polio situation is how difficult it is to eradicate a pathogen. We eradicated smallpox and smallpox was chosen for eradication because we felt it was one of the easiest pathogens to eradicate. Once we eradicated smallpox, we started looking around to see, well, can we do this again? And polio came up as another pathogen that we thought, well, okay, we might be able to eradicate this one also. It wasn't picked because it had this huge burden of disease globally, if that was the case, we probably would have picked another pathogen. It was picked because we thought we could eradicate it, that was in 1988. We still haven't eradicated the pathogen and we're still spending billions of dollars a year to try and eradicate this pathogen.

0:18:34.4 JE: So the lesson there is, from a public health perspective, it may not be the right thing to focus on eradication. Those resources that we're taking to eradicate polio, and we're talking about billions of dollars a year, and they're estimating through 2040 at least to eradicate it, if things go well and as planned. But that money could be used to do a lot of good with respect to lowering disease burden in a lot of regions. And so it's not clear that eradication should be our goal as opposed to lowering disease burden and controlling diseases. Pathogens are not gonna disappear, we gotta learn to live with pathogens, we gotta learn how to manage pathogens and control them, but they're not gonna disappear.

0:19:22.0 JE: They adapt to well, and evolve too quickly for us to really consider that eradication is gonna be a solution, a public health solution. I think it's important to know that pathogens have been emerging and re-emerging throughout history. I think since the advent of agriculture, we've seen spillover of lots of different diseases. All of the childhood diseases that we think about, measles, chickenpox, whooping cough, those are all of zoonotic origin, and originally from livestock. So zoonosis is really just about the ability of a pathogen to sustain itself in non-human animals. And the reason why we have these diseases is because agriculture put us in this intimate contact with animals, livestock specifically, and the encroachment of wildlife has caused more emergence. But emergencies and re-emergence has occurred throughout history, it's nothing new.

0:20:22.0 S1: The One Health movement encourages us to rethink our role in the spill-over of diseases. Through industry, agriculture, urbanization, and more. And how the ebb and flow of disease emergence is closely tied to our relationship with the world around us.

0:20:36.4 JE: One Health is a perspective that you need to take really a more holistic ecological perspective on disease and public health and emerging pathogens. I think One Health is a re-emergence of a concept that goes way back to Hippocrates. This idea that the environment is important with respect to human health, is something that has been thought about and developed as the theory of human health. And it's really the advent of the germ theory, and vaccines, and antibiotics, we kinda lost our way with respect to thinking that the environment was important and we focused on, "Let's make sure people are vaccinated. Let's make sure we administer antibiotics when we see infections." And it moved into this more kind of, "Let's deal with the individual." And now, with this increased appreciation that emerging pathogens come from the environment, come from zoonotic diseases of non-human species, there's been a resurgence of this One Health concept.

0:21:35.3 JE: And so the idea is that by understanding diseases in the context of the environment, and that it's of both wildlife and livestock, that we can better understand how diseases emerge, when they emerge, and what the implications of those emerging pathogens are within the context of human health. So there's numerous examples of the emergence of pathogens coming out of the livestock and exposing people. There's a great example of a outbreak that occurred, started at the University of Michigan, and I think in a law school people were eating burritos and they got sick, and it was this E. Coli 157. I think five or six hospitalizations, one death. They started investigating, looking at the restaurant, seeing whether the restaurant was the cause. And then all of a sudden another outbreak, similar symptoms, they found out it was the same pathogen occurred in Ohio.

0:22:32.4 JE: This was in rats, and it turned out that it was the lettuce that was the cause. And then they tracked the lettuce down to this big food distributor of lettuce, and they tracked that down to a farm in Arizona. And that Arizona farm was getting contaminated water from a RV park up the road from the lettuce farm. And so we don't even know where, you know, the people that were infected from that RV park. So you go from... You started at this luncheon in the law school and University of Michigan, and the trail goes all the way to a number of people sick in an RV park in Arizona. This is occurring, I guess both because of this high density farming of animals, as well as centralized food systems such as lettuce, where you get a lettuce purveyor who is selling and sending lettuce all over the country.

0:23:23.8 JE: The extent in which we are seeing more and more emerging pathogens is both probably because we're in a smaller world now, based on the fact that we can move globally so much easier. And because we are increasing in populations and we're changing the environment in so many different ways, like in climate change and such, has also been a big force in potentially increasing the number of pathogens that are now emerging and re-emerging and spreading to new areas. So just to put it in the context that it's not something new, and it's probably happening at a greater rate than it was in the past, but also we're looking at it much more closely and we've got tools to identify them much more readily than we did before.

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0:24:16.9 S1: Understanding how known and novel infectious diseases live and evolve is only half the battle. A diligent offensive strategy is key to curbing future epidemics. Disease surveillance and preparedness plans are the techniques epidemiologists and public health workers use to monitor and control outbreak incidents. From nationwide agencies, to local hospitals, there is a vast network of public health professionals at all levels who work to stifle the impact of these emerging and re-emerging diseases. We spoke to two Michigan Public Health alumni about their respective roles in infectious disease control.

0:24:50.3 S1: Sharon Greene is the Director of the Data Analysis Unit for the Bureau of Communicable Disease at the New York City Department of Health and Mental Hygiene, and she's a graduate of the University of Michigan School of Public Health. Greene overseas disease cluster detection, data quality assessment, and other analyses for more than 70 reportable diseases. The tools we use to look more closely and identify those outbreaks, that's where Greene comes in. Her job is to analyze the essential data that tells us how disease is making its way through a population.

0:25:20.1 Sharon Greene: Working in New York City is such an incredibly large and diverse population, it's a fascinating setting to have the privilege of working in public health. With diverse populations traveling and immigrating from all over the world, working with the New York City Health Department is a great place to be doing that kind of work as we have a institutional focus on dismantling structural racism and improving health equity. The very large population, we have about 8.8 million residents, makes it easier to find patterns because we have a lot of data to work with. Sometimes working in this area has been described accurately as drinking from a fire hose. It's never boring, there's constant streams of data and interesting activities happening at all times. 

0:26:16.8 SG: My work primarily affects public health response and action for infectious diseases through cluster detection. So, searching for unusual clusters of diseases in space and time, and the way that actually leads to public health action, is by identifying patients who should be interviewed to determine what they have in common and possibly intervene to prevent ongoing exposure. Or to conduct community outreach and health education to reduce ongoing exposure of that disease. Also, when we identify unusual disease clusters, it sometimes means that's an area where we want to quickly re-allocate public health resources such as increasing testing access and community outreach in areas that have rapidly increasing Covid test positivity.

0:27:17.1 SG: I also work on nowcasting, and real-time trend estimation, so that we can quickly notice, despite data lags, when cases or hospitalizations and deaths are increasing or if they've already peaked following an epidemic wave. And I also work on quickly noticing when inequities are emerging early in a public health response, like access to testing for Zika virus and for Covid. So when we notice that there were inequities in who was getting tested, we can help re-allocate those testing resources and improve linkage to care for those patients. I also work on data quality assurance. One example is searching for laboratory reporting drop-offs. So, the way that we get our data is primarily through electronic laboratory reporting. So a patient goes to their healthcare provider, they submit a specimen that gets tested for a pathogen, it gets sent to a laboratory, and that lab is required by law to report the positive results to the health department.

0:28:14.3 SG: And so we are responsible, in the Bureau of Communicable Disease in New York City, to surveil for more than 70 reportable diseases, and we get reports from hundreds of different laboratories locally, but also around the country, and so it can be difficult to notice when one lab stops reporting one disease. Which can happen with changes in the laboratory information system, some problems in data file transmission. So we've set up cluster analysis to look for drop-offs in disease reporting. So that's another way that affects public health action, is when we notice a drop off, we can then contact the laboratory and get that file restored so that we have uninterrupted data stream, so that we can actually monitor for unusual diseases and do our public health surveillance and outbreak detection and response work.

0:29:00.1 S1: Greene describes the kind of efforts Health Department professionals like herself were actively contributing to through the emergence of the novel Coronavirus and its variants.

0:29:07.9 SG: I was primarily working on special studies to address priority questions from health department leadership, and those questions changed over time. So very early in the pandemic, we needed to establish that Covid had actually arrived in New York City, and produced early estimates of how common Covid illness was despite very limited testing access. So there were a lot of questions about, "Is Covid here? How prevalent is it? How severe it is." So once we clearly established that Covid was present in New York City, we then moved to characterize disease severity. We also very quickly started characterizing inequities in Covid test positivity and who was getting hospitalized, and who was dying from the illness. Throughout the pandemic, I've been focusing on real-time situational awareness.

0:29:55.3 SG: Now casting for near real-time trend estimation, so we know the trajectory of the epidemic curve, despite data lags, and also focusing on cluster detection. Thinking about the types of data that help optimize the effectiveness of public health responses, I like to think about it in the context of Covid-variant surveillance, because it really exemplifies investments in public health data and informatics. We recently conducted a large population-based study that relied on the New York City Health Department's capacity to link confidential identifiable patient data in the Covid 19 disease registry with laboratory data for sequencing results. Also with the Immunization Registry for vaccination status, also with past cases for diagnosis history, also with supplemental data sources for hospitalizations, and with the vital statistics registry for deaths.

0:30:47.3 SG: So, so much data linkage was required to properly compare the risk of variants that were previously dominant versus newly emerging, while accounting for prior immune exposures, prior vaccination, prior diagnosis. Even with all that data linkage, it would still be helpful to invest in linking further with healthcare systems, because ordinarily the public health system doesn't have good access to data on comorbidities. Other illnesses that patients might have that make their risk for illness more severe. We don't really have access to therapeutics that a patient may have received, which we don't necessarily know if they were admitted to an ICU without individual patient investigations. There are ways that we can further improve those data linkages to get even better public health data. I think the Covid 19 pandemic has changed the way that the public expects health departments to communicate about our data.

0:31:38.9 SG: So, the status quo before Covid for many infectious diseases is that we would report once a year at a long lag, so maybe reporting annually at a nine-month lag or so, giving us time to clean and finalize and interpret the data. And that's so different from the expectation since we started putting Covid data online everyday, so that the public had direct access to many different aspects and not just city-wide case counts, but stratified by different demographic variables and looking at tests and cases of hostilities and deaths. A real wealth of data. In nice, interpretable figures, and also allowing the raw data available on the back end, so users of different data literacy levels can easily interact with the data. So that might be the new normal for how health departments have to get out data, especially during emergencies. But it also encourages us to be more rapid in making the data that we collect available publicly.

0:32:33.6 SG: And to do that, we really have to continue investing in informatics, infrastructure, and data modernization initiatives. As an epidemiologist, I was conducting studies that were used to support local public messaging about the effectiveness of Covid 19 vaccination. I did a study that supplied real-world evidence of the effectiveness of New York City's vaccination program in reducing hospitalizations. And we did another study that demonstrated that Covid-19 vaccination is beneficial even for people who are previously infected, in that it reduces their odds of re-infection and hospitalization. And more recently, we've been focused on variant surveillance, so detecting newly emerging variants like Delta, like Omicron, and assessing their relative disease severity to support healthcare system preparedness.

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0:33:27.8 S1: For an even more localized perspective, we spoke with Jen Shearer, she's the Director of Emergency Preparedness at Massachusetts General Hospital, and a graduate of the University of Michigan School of Public Health. She shares how hospitals and healthcare systems collaborate with epidemiologists, public health departments, and networks of multi-disciplinary experts, to remain ahead of the next infectious disease event.

0:33:48.9 Jen Shearer: Day-to-day, our team really supports and manages the hospital's preparedness program. And so what that means is that we know within healthcare, there's a wide variety of things that can pose the potential to disrupt operations, whether that's technology downtime related, whether that's a mass casualty type of incident, or infectious disease type surge. And so we work incredibly closely with stakeholders from across the hospital to think about, how can we plan for those, as well as support response, if, and, or when, things do happen. So when we think about how do hospitals and the hospital systems get in front of re-emerging or emerging infectious diseases, there's a few different things that we can leverage to help support that initial preparations. The way that I initially would approach that is, what plans and policies do we have in place, let's not recreate the wheel.

0:34:43.5 JS: So let's look at what resources do we have in place. What are our recent lived examples? We know that whether it's a bad flu season or other types of things, there are often events within our own lived experience that we can draw examples from, that sort of backbone to then build from. And then from there, I think it's identifying our gaps. To be able to say, "Alright, if this continues as the status quo, do we have the resources, the staff supplies, to meet our needs?" But then we have to push ourselves, and I think that this is where, within the emergency preparedness realm, my boss will say that we are the chronic cynics in the room that have to poke holes in things. But we kinda do, and that's okay, 'cause then we need to really push ourselves to say, "What happens if it gets worse?" It's taking our plans and then continuing to push them farther.

0:35:32.1 JS: But the important point with this, and I'll probably say this several times, is that multidisciplinary voices at the table with us to be able to talk through that. So that we can rely on our materials management and supply chain experts to say, what is the forecast for things. Are there things on the radar that we recognize we may run into challenges? Because one hospital is not a silo, we also know that as we're working on building plans and making sure that we're ready for potential re-emerging events if we start seeing that, that everyone else is too. So how do we continue to partner and collaborate together? So, the planning piece I think is a big aspect. I think another thing is looking at the data. There's so many diverse areas and avenues and resources that exist for us to be able to say, whether it's through the Centers for Disease Control and Prevention, whether it's state and local public health and reportable type diseases.

0:36:23.7 JS: What are those trends that may help us indicate, are we seeing increases in influenza-type illness? Are we seeing increases within the healthcare setting for folks coming in for respiratory type testing? As just examples. So, thinking forward to say, "What are those trends that we can sort of rely on as early indicators to help us raise the flag to say there may be something that we need to think about." Part of this we do naturally, I feel like seasonally as we see ebbs and flows and things. But it really allows the framework that we can leverage for new things as well. I think that this is where really re-assessing our current plans and building from them, I think are important, and then sharing best practices. Because if we don't have the answer to something, it doesn't mean our colleagues across the street don't.

0:37:08.8 JS: This is where leveraging those relationships with other hospitals, with public health professionals, to be able to draw and learn from one another, I think is also a huge piece of that initial planning. We've been thinking about these types of infectious disease events really for years. When we look at diseases, it's often easy to look for things that we know exist. Whether that's seasonal, or respiratory-type viruses, or beyond. But what we really find is that it can be hard to be the first to catch something new. I will say that when we think about plans and preparedness, we've developed some great plans that help us to marry those epidemiological risks, whether that's travel history or other types of things, with symptoms. So that allows us to sort of say, if we see something and we're able to match those symptoms, that will help us sort of early identify and get ahead on things.

0:38:03.8 JS: And while that is effective for some things, I think one thing that we acknowledge is that does unfortunately also perpetuate the stereotype that bad things come from other places. So really, how do we continue to work to identify the things that don't perfectly fit there? And so, part of the way that we can work to prepare this is not only reviewing our existing plans. So, how do we identify? What are the actions that our staff need to take when we are seeing an increase in infectious disease, whether again, it's a seasonal-type respiratory illness that we're very well-versed with, or something that's more novel or re-emerging that we haven't seen in a while? And what I'll say is that, with any of these plans, that multidisciplinary stakeholder engagement is incredibly important.

0:38:50.2 JS: This isn't one or two people sitting in a room saying, "This is what we think should happen." But rather, we need those subject matter experts, we need the infectious disease physicians, we need infection prevention, we need our clinical staff that care for the patients. And then beyond that, what are the supplies, the laboratory type equipment that we need, how do we test? It's all of those diverse voices that we need to bring that perspective to say, "How do we really meet the needs of our patients and also safely care for them?" While my personal perspective from this is coming from health care, we don't work in a silo. So all of this also means that we are partnering closely with our local and state public health and our other partners to ensure that not only are we sharing best practices, but that preparedness is really a full team sport.

0:39:37.0 JS: From the emergency preparedness side of things, there are best practices and policies and plans and frameworks, that we can leverage to support any things that our teams may face. And whether that's a re-emergence of something like polio when we see some of these outbreaks that are taking place in communities and populations that we may not have seen before. But I'd really rely on our clinical experts to really talk about how we begin to really work through what we know are those... Whether it's vaccine hesitancy, whether it's access. How do we continue to keep our communities informed with the best information to protect themselves, to protect their family, while at the same time recognizing that there are definitely gaps in access and other types of things? So it really requires that engagement across the board and spectrum within public health, for us to really be successful.

0:40:37.5 S1: So, has the increased attention on how we prepare for disease outbreaks from the media and the public, been a change for the better? 

0:40:44.6 JS: I joke with my family members that I feel like three or four years ago, as I explain my day to day job, I don't think they fully wrapped their head around what it means to really prepare and think ahead to emergencies that we may face, especially for infectious disease types events. And I think what our experience from the Covid pandemic and whether we look at the ongoing RSV surgeon illness, or other sort of bad respiratory seasons is, it's brought that information to the public in a way that we haven't seen necessarily in recent years, or really within my lifetime. And that's good and bad.

0:41:22.2 JS: I think with that, we've been able to provide voices to public health professionals, to healthcare experts, to talk about the basics for not only how do we as individuals within a community contribute to preventing spread, what measures can we take to protect ourselves, our family and our friends, but also to the broader, how do we as a broader community support one another within that. And it's been really interesting as someone who is very new to my institution within the Covid pandemic, to see how rapidly that information has changed. And so I think it's been both a positive, in that when we've been able to bring things to the light. But I think we've also seen the reality of things like disinformation and misinformation, and I think to me, it continues to codify that importance of the roles that our public health professionals play within healthcare, within local and state, and beyond, to continue to be a voice, to provide those insights.

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0:42:28.6 S1: On the next edition of Population Healthy.

0:42:31.8 S6: In my personal experience, when I've received gender affirming care, it has had to do with receiving mental health care, receiving hormone replacement therapy, working with doctors to schedule gender affirming surgery, and other forms of care. I think the first time I felt like I was receiving gender affirming care was when my doctor asked about my personal identity and asked what I preferred to be addressed as. Although this wasn't anything specific to my gender identity, it felt as though I was being seen in the healthcare setting for the first time.

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0:43:09.6 S1: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us, and hope you learned something that'll help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Be sure to follow us @UMICHSPH on Twitter, Instagram, and Facebook, so you can share your perspectives on the issues we discussed, learn more from Michigan public health experts, and share episodes of the podcast with your friends on social media.

0:43:38.6 S1: You're invited to subscribe to our weekly newsletter to get the latest research news and analysis from the University of Michigan School of Public Health. Visit publichealth.UMICH.edu/news/newsletter, to sign up. You can also check out the show notes on our website, population-healthy.com for more resources on the topics discussed in this episode. We hope you can join us for our next edition, where we'll dig in further to public health topics that affect all of us at a population level.