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Communicable takes on hot topics in infectious diseases and clinical microbiology. Hosted by the editors of CMI Communications, the open-access journal of ESCMID, the European Society of Clinical Microbiology & Infectious Diseases.
[00:00:00]
Angela: hello and welcome back to Communicable, the podcast brought to you by CMI communications ESCMID's, open Access journal, covering infectious diseases and clinical microbiology. My name is Angela Huttner. I'm an infectious disease doctor at the Geneva University Hospital in Switzerland, and editor in chief of CMI comms.
I'm joined by my co-host Marc Bonten, who is now Vice Dean of Education at the University of Utrecht and director of the Education Center of the University Medical Center, Utrecht in the Netherlands, and associate editor at CMI Comms.
Marc is also a clinical microbiologist and an infectious disease specialist and is even a trained epidemiologist, which may be handy for today's discussion.
Marc: Hi. Happy to be here again.
Angela: Today we're talking about infectious diseases outbreaks. ESCMID recently created a new and essential subcommittee for [00:01:00] emerging infections.
It's one of those groups that you're surprise wasn't already there, because we know that as the new committee's mission states surveillance is crucial for safeguarding public health, ensuring global health security, and fostering international collaboration in the face of evolving health threats, but ESCMID's, timing couldn't be better given what we're seeing happen to governmental public health structures in the US Medical societies, other groups are having to step up and ESCMID is clearly doing so. And this emerging infections committee, which has an All-star team led by Xavier Lescure in Paris, is starting strong.
One new initiative that I've fallen for is the Epi alerts, which are issued every weeks by this committee in collaboration with the University of Amsterdam's Center for Tropical and Travel Medicine, if you don't receive these alerts, you should, they come in the ESCMID weekly newsletter or you can find them online. So just disclaimer here, the genesis of this episode is that I sent a fan letter. I started receiving [00:02:00] them and I was really excited about them.
They're very well done. They're concise. They give you just what you need to know, and they're fascinating. So I sent a fan letter to the ESCMID office, and then the ESCMID office was smart enough to say, well, you should get in touch with them. They're doing really good work and voila, communicable episode.
So we're very pleased to have the following two key members of the Emerging Infections subcommittee with us today. I'm thrilled to introduce Professor Martin Grobusch, a leading specialist in infectious diseases, tropical medicine and travel medicine. Martin earned his medical degree in Bonn Germany and completed specialist training in internal medicine, infectious diseases, and tropical medicine between the UK and the Charite University Hospital in Berlin.
After having worked three years in Gabon and Tübingen in as a clinical researcher, he was appointed as the first chair of infectious diseases at the University of Whitt Waters Rand in Johannesburg, South Africa. Five years later, in 2010, he returned to Europe and took up [00:03:00] his current position as professor and head of Tropical and Travel Medicine at the Academic Medical Center, university of Amsterdam.
Angela: Martin's research focus lies on the clinical development of interventions against infectious diseases, drugs and vaccines, and their implementation in low and middle income countries. He has conducted extensive field research, including in Gabon and Sierra Leone and has worked on malaria, HIV, tuberculosis co-infections, viral hemorrhagic fevers, arboviral diseases, and travel medicine related topics including vaccine immunology in immunocompromised patients.
And you should know he comes back to us from Brazil. Just arrived had to get past some snakes on the way we have the pictures. Martin, welcome to Communicable.
Martin: Hi everybody.
Yes, and I'm delighted to introduce our second guest, Dr. Pikka Jokelainen. Pikka is a veterinarian, a PhD, and has a Master in public governance, and she brings expertise in Zoonosis and [00:04:00] one Health to the Emerging Infections subcommittee.
Marc: Pikka serves as head of function for infectious diseases preparedness and one health at the Statin Serum Institute in Copenhagen, Denmark, as well as adjunct professor in zoonotic parasitology at the University of Helsinki in Finland. Her expertise, experience, and professional interests are in the preparedness for cross-border health threats.
In particular by using A One Health Approach, collaborating and improving national and international systems. Pikka is deeply engaged in International One Health collaborations with several leading rules, including coordinating the EU-WISH Joint Action on waste water-based surveillance, and One Health 4 Surveillance consortium that strengthens integrated one health surveillance approaches for zoonotic pathogens.
Pikka is also the president of the World Federation of Parasitologists. Pikka. Welcome to Communicable.
Pikka: Thank you. Great to be here.
Angela: We're so glad to have you both. [00:05:00] we start these episodes with a get to know you question The question this time is, you two have both done a great deal of travel in your lives. What's your favorite place in the world? Martin?
Martin: firstly, there is really no place like home I think that's most important.
And One of the most fascinating places would be Rapa Nui for its loneliness, the serendipity and also for keeping its mysteries still at least in parts unresolved. its About 3000 kilometers westward of the Chilean coast. was called Easter Island before, but the correct name is Rapa Nui . I think that would be my most favorite place, but there are obviously more on this beautiful planet. So the Nepali coast on Kawaii would be another one.
And not to mention all the urban wonders of Europe, but getting more and more so I keep it to that.
I'm [00:06:00] originally from Finland, so somehow that's resonates with me. And I think in this crazy times, something like with the old forest and the quietness and the nature that has the resilience and kindness somehow towards us, that would be the place to be.
I hear you. Yeah. This is the time for that indeed.
Marc: now to our topic, many of our listeners are clinicians, so we're going to dive right into that aspect. First with a question for you, Martin. What do clinicians underestimate most about working in outbreak zones?
Martin: Well, several aspects come to my mind, but I think the most important one is risk to underestimate the psychological toll it might take to, be placed in an outbreak situation.
And that is not only the psychological burden on, you as a caregiver it's, the psychological toll it might take from everybody involved, [00:07:00] particularly patients which might be in a life threatening situation, close to panic. I think that's a very, very important aspect one other aspect , when we are moving into an outbreak situation, we are focusing obviously on the disease in Quest.
That might be Ebola, that might be Marburg, that might be something else. But what we sometimes tend to forget it's not the immediate effect of this disease, which wreaks the largest havoc on the community. It's basically that these diseases kill indirectly by disrupting health services and the whole life economic aspects, everything very, very profoundly.
So it's that, once we. Placed in such a situation, we must not forget that the impact is much higher. Hospitals are closed down, health posts are abandoned. And I do believe very [00:08:00] importantly, if we try to organize resistance against, such an, disease evolving in an outbreak, we need to keep the bigger picture in mind and try to retain services also for those patients who are not immediately, struck by, the outbreak disease in Quest.
Angela: that's really interesting. So, would you advocate, Martin, that the first team that comes, to a new outbreak, should have a. A psychologist
with them?
Martin: Well, I do believe the, professional teams which are moving in, for example, by Médecins Sans Frontières and other groups, which are specialized on tackling those outbreaks, they do and very often, most team members might be very, experienced, but there might be less experience and it's always, probably comparable to move Into a war zone. So I do believe that is certainly an aspect not to be neglected. Yes.
Angela: So I've never been on the [00:09:00] ground in an outbreak, but being in Geneva, Our hospital has some agreements to take care of returning healthcare workers. So I do remember in the 2014 Ebola outbreak in West Africa, we had a healthcare worker who came back after having been bitten by a child with Ebola.
The man who had been bitten explained it to us. It wasn't the disease. It wasn't that he'd become mad with his Ebola infection. he was a little boy and he was being examined by a white man he'd never seen in his life.
And he was panicking, he was terrified. And he bit in self-defense and the healthcare worker, said that it was kind of his error, the way he just went and examined this little boy. he, he looked at it as his own misstep, , he could have been more careful and so it's, it's really interesting that aspect of psychological preparedness for ourselves, of course, but also for the patients
i'm also thinking understanding what is scary, what is worrying to different actors and people in these [00:10:00] situations.
Pikka: That is very important.
Angela: So another question for the sake of our clinicians, Martin, again, for you, what would you say are the most crucial actions, let's say in the first 72 hours when deploying into a rapidly evolving outbreak, in addition to, being more holistic, what needs to be done?
Martin: I would say that the first thing to do is to try. In whatever way possible to establish safe work conditions, establish stable communication structures within the group and outside establish clear task sharing structures. Who's doing what, who's reporting to whom, and with regard to establishing safe working conditions, I think infection control comes first and then we'll see.
These situations are semi chaotic, usually moving in with a group of caregivers is. Well structured or well-planned, but still every situation is different and enormous amount of flexibility is [00:11:00] important, but communication is paramount. Ideally, you work in a group which knows each other, where you do not have to establish personal relationships first, where you can rely upon each other right from the very beginning.
I think these things are essential.
Angela: Interesting. It's not just handing out medicine. it's much more about human beings and how they interact with one another.
Marc: Yeah.
It reminds me of one of the rules of the House of God. Are you familiar with that?
. In case of an emergency, check your own pulse first. So
Martin: that's true.
It also made it into the Oxford textbook of medicines. When you are seeing your first heart attack in an emergency unit and you opened your Oxford textbook, it also says that at the beginning, and it's a message well taken, I think. Yeah.
Marc: so Martin, as a follow up question, in your experience when you worked in Sub-Saharan Africa, what surveillance failures most commonly delay outbreak detection and, what [00:12:00] practical steps can clinicians take to compensate?
Martin: Yeah, this is difficult because every outbreak situation is different, but I think in general our problem as human beings is that we work, on the basis of our past experience, and we work often rightfully so on the assumption that what's, frequent is frequent and what's rare is rare.
the problem with those diseases, we are focusing in an outbreak. So let's say some viral hemorrhagic fevers. The problem is that they don't come with a distinct clinical picture. Unfortunately, you don't get the blue nose with yellow dots on it when you are infected with Ebola, no, you develop a flu like illness, which can be precisely that very often.
Martin: And that was the big problem with the large West African outbreak, starting with this 12-year-old boy in Guéckédou in Guinea in [00:13:00] December, 2013 actually, was that by. All means only a tiny minority of patients developed full-blown disease with bleedings. Actually, people were dying from a febrile disease with watery diarrhea, which led to the mis assumption that one would be dealing with an outbreak of cholera later.
This assumption was changed and it was assumed that it was a large malaria outbreak. It took very long to realize that those diseases can come in different disguises. And to that end it's also very, very difficult to make safe predictions or to come up with a list of things which can be easily worked through to avoid these misunderstandings.
And at the Emerging Infections subcommittee, we try to look back at the outbreaks of the past. Couple of centuries actually.
And we tried to [00:14:00] identify whether there were common, underlying mechanisms which led the medical community into a wrong direction initially. And the point is that there is no easy lesson to be learned. we are as human beings prone to fall into bias traps. And in that paper published
in CMI, we come up with page wrong lists of possible biases, which might lead us into wrong directions. So I must confess, Marc, there is no easy answer and probably we haven't seen the last outbreak where we are galloping into the wrong direction. And that has basically to do with the fact that firstly, very often these disease outbreaks happen in very remote areas.
Communication might be difficult. There might be very few resources on the ground to. hit the nail spot on. And this is what leads to [00:15:00] misconceptions. it's human and it'll be very difficult to, change that for all times. But what we learn is that of course, early reaction is important, .
And lots of things have happened in the recent past. if you follow the list of outbreaks of viral hemorrhagic fevers. to name the most prominent example Then you can see that the reaction times become much shorter. We hardly now see any outbreak where it takes 10 to 14 days after a rumor had it that there is something going on before a team is moving in.
You might have noticed that usually the reporting time of a definitive infectious agent has been cut down to several days,
so I think that's the good news and the bad news is we are humans, which means we are and will always be prone to bias.
Angela: So I'm gonna throw in a a follow up to Mark's question about surveillance [00:16:00] failures. Can you give us a sense of what is going to change now that the US has disbanded?
U-S-A-I-D has deeply cut its financial and organizational support to global surveillance.
Pikka: I'm thinking surveillance of infectious diseases and finding those early signals and also sharing information, that's a global thing that's for everybody.
And then there are these changes, unfortunate changes that sometimes we really are cuts on those resources in different places or, structures are disturbed in a way that we don't get the same information from different places. So it can like shake the systems. And I think there one thing is of course, if we overall are good in sharing data and doing the work together, there is resilience in that.
Then there are other countries, other sectors, other funders, other structures that can, chip in with the information. But that is the challenge for surveillance. We need sustainable long-term funding and stability for that to build the systems that is needed.
Martin: I [00:17:00] might add to that.
we have seen, and COVID-19 probably was the most prominent example how difficult it is already, let's say, in a, a high income setting to connect all the dots, to bring all the information together and to be timely on the right track. Surveillance on a global level is even more tricky business because vast parts of our world are still remote by all standards And early surveillance on a global level means finding. One needle in a zillion of haystacks. And there will be challenges which will remain and maybe a classical surveillance or refinement of surveillance is most important in areas where we have zillions of dots to connect. There are still some areas in the world where there are few dots to connect.
Martin: And that's also why we see so many outbreaks in the vast [00:18:00] repositories of unknown life forms, which are to be found in the big rainforest belts around the world to my understanding, it'll be , very difficult come up with a global surveillance system, which really picks up every thinkable signal very early.
I think key is to react timely to signals wherever they are emerging and in whatever form they come.
Pikka: encouraging this community that we are doing it together and, sharing those signals and tools for analyzing them in other places, because then we can kind of complement the strengths there are and maybe overcome some of the challenges with that. So, working together is, the solution for this.
Angela: Yeah. And not having any one country or one group take on most of the burden such that we're all unprepared or less prepared to handle these surprises. Martin was alluding to all these creatures, these unknown creatures out there who can carry diseases
so Pikka, speaking of [00:19:00] many of our outbreaks are indeed zoonoses. So how would you advise clinicians to better recognize early signs of zoonotic outbreaks, especially for less sort of headline grabbing pathogens.
Pikka: Yeah, there are different levels in this. So I would mention at least the three levels.
So like awareness at the individual level human relations connections as a second level, and then also there are some structures and being aware of those and, and using those. So first of the awareness point is understanding indeed most of new emerging diseases that hit us humans are zoonotic.
And, thus it's like a too small picture if we only look at what's happening in the humans and how it's will go in the human population. So being aware of that and maybe having a little overview which animal populations are relevant and how is it going there in the region one is, the nearby regions or areas that are somehow connected.
being aware that it's not only disease burden, the thing is not only in the human population. And I [00:20:00] think that, human connections, human relations come really important here because to really know this and discuss this in a good way, we need to have connections to people across professions and sectors and countries, When there's a signal, you maybe read somewhere in animal population there's something happening. Do you then have a colleague from the animal health veterinary side to discuss, is this a concern? What, kind of signals are you following and seeing? Have we seen this before?
how big is change is this. And, that we have the common understanding of the, situation. that helps a lot. And third is that there are more and more these. One Health like structures built. at the global level, the Quadripartite has been really promoting the One health approach for this, field.
, When we've been talking about surveillance, more and more focus on the integrated one, health surveillance. there are different data sources. There can be testing of environmental samples, testing animal samples, also. for the same pathogen.
Pikka: And how these different dots then can, tell [00:21:00] the, story better. So, that would be a way to be aware early on, but at the same time have that critical balance of the information, how trustworthy it is and what it actually means.
Because that's a challenge when you have a signal from a different field, it can be really different structures. If we think humans how we behave and travel a lot and go around, usually the animal hosts are more local at the same time, for example domestic animals that are kept for human consumption, they are put in these groups.
So epidemiologically, it's very different data we are seeing and there needs to be some understanding of that to really read the signals.
Angela: Interesting. We hear this term all the time now. One health. It's really, quite trendy, definitely WHO uses the term all the time. Can you define One Health for us?
Pikka: Luckily, it's been defined recently, so 2022, it was published in PLoS pathogens, actually a definition by the one health high level expert panel that is a long text. And then there's an illustration. Basically it's an [00:22:00] approach and it's an understanding that the health of us humans, health of other animals, and health and the situation of our common environment, they are interconnected it's also described as a unifying approach. how to work together and there are some key, principles like coordination, collaboration communication and capacity building. it's, also a lot of learning, understanding that one person, one organization, one structure can contribute to that, but we need to work together.
so it's kind of a complimentary learning together approach. And just understanding, remembering the awareness of. Interconnected things.
Angela: So Pikka, just sticking to the topic of the zoonotic threats, what would you say are some underappreciated zoonotic threats here in Europe today?
Pikka: Hmm. The big ones like avian influenza.
People are aware that this is zoonotic. typically we have focus on viruses. So the bacterial fungal and parasitic ones would be my thing to like think wider in this. we [00:23:00] often talk about tropical areas globally, but we have the arctic areas and there are some changes to keep an eye on, also.
Martin: I agree. The Arctic regions will hold some surprises for us with thawing with temperature changes. It's not only release of pathogens by thawing, but it's increased accessibility of areas which haven't been easily accessible. It's interrupting of natural temperature circles by areas which.
Might have been deeply covered by snow and ice for months in the year, which become now permanently above zero So lots of things will be happening there I would say if we underestimate something in Europe, it might still be that we underestimate everything tickborne. That would be my guess.
There is one other interesting thing. There are a couple of diseases which occur ubiquitously around the globe. I'm thinking of leptospirosis in that case. [00:24:00] We identify it easily. In our returning travelers because it's always high up on our list of differentials. And in a country like the Netherlands, for example, where we see about 60 to 80 cases maybe per year, half of them are imported from all over the world.
But the other half is auto autonomous. And it might be difficult. Well the Netherlands might be an exception with, its a very dense network and structures in infectious diseases and microbiology. But in some other countries it might be more difficult that if half of the patients with a strange disease appear rather in general practice than in specialized units, that we might miss a boat early.
I'm not saying there is a potential for huge outbreaks, but in any case yeah, there is the risk here and there that we might miss the emergence of. Infection, at least local and temporarily. But in principle, I think we are [00:25:00] rather well prepared. I think one example is the spread of diseases, which we were thinking of in terms of tropical or imported conditions.
The establishment of local foci, of chikungunya dengue, west Nile, et cetera, they were anticipated and they are usually quickly recognized and tackled. It doesn't mean it enables us so far to stop them from spreading, but I wouldn't say we are in general ill prepared.
Marc: So staying with, the Arctic region and, coming back to you Pikka, can you speculate on what might come out of the permafrost or what may come out of the freezer that may be a, threat for humans?
Pikka: I mean, there is some suspects like, Anthrax would be one certainly can be staying long time in the soil and, in these conditions. Or we should think about the environmental component of One Health more because the environments there, there are many pathogens have some forms that can be highly [00:26:00] resistant to environmental conditions.
then exactly like Martin said, this, Arctic areas are changing, there is more access to those areas. So also the exposure then can be more relevant to more people.
Marc: Yes. And when we talk about climate change and let's say the effect on, infectious disease dynamics, we mostly talk about Arboviruses or hemorrhagic fevers.
You're , an expert in parasitology. Is there anything we can expect? From that area that will be affected by climate changes and that may change in the coming time.
Pikka: Oh, yes, certainly. I would mentioned again the environmental parts, so many parasites have an environmental form,
then when there are changes, climate change related things like extreme weather events heavy rains, flooding, these can kind of become closer to humans and animals. for example, uh, cryptosporidium species also Toxoplasma gondii has an environmental forms. So that would be one thing. Another thing is vector bone diseases.
there are several [00:27:00] parasitic vector bone diseases that are relevant in our region. One. Is aria species. So those have been finding new areas in Europe recently, in the last 15 years. For example, filarial weapons.
Pikka: That's a nematode, it's a mosquito transmitted nematode. And it usually likes to go under the skin and makes more, noodles, not really dangerous, just you can remove it. But of course very important differential diagnosis for some other things. and kind of a horror story perhaps.
So, that has been seen, in the last 15 years in the baltic countries. you would see how it's emerged and first typically in each country. It was first found in dogs. And describes and after a few years, the first human case was found. And of course, the awareness then increases when you'll find it first in one population.
But yeah, certainly parasites are on the list when we think about pathogens that are climate sensitive.
Martin: Yeah, if I might add, and if we look beyond Europe and at other influences other [00:28:00] than only climate change, I think the fascinating thing about parasites is that they are incredibly resilient against our attempts to get at them because most of them have very complex life cycles and they may change, tune and pace as soon as we try to intervene.
Look at malaria.
In many areas of the world, we are coming close to elimination, if not eradication. But if you had been with me in the remote Ecuadorian, Colombian, Amazonian jungle last week, we still find in remote villages along the big rivers. In Amazonia actually, one or other case, most of them asymptomatic. The diseases are incredibly resilient and even if we get close to elimination it will be very difficult in many areas to go the final step and really get rid of them.
And as soon as we [00:29:00] loosen our grip, they will come back. And this is particularly something we see with parasites. Another example would be an outbreak of Naegleria fowleri.
One of the free living amoebae. Usually we see. Occasionally a case here, a case there in certain areas where their living conditions are ideal, hot springs, et cetera. All of a sudden there is an outbreak with at least a hundred, if not many more cases in Kerala, in South India. And whilst all these diseases have no potential to eliminate us as a species, they are always good for surprising rises in certain areas, at least for certain times.
Martin: So I think that's very unique for parasitic pathogens.
Pikka: Yeah, I'm thinking one more thing to this. That's especially for parasites. a good parasite would not cause too much trouble to the host because it really needs the host and it actually needs also often a biodiversity of some [00:30:00] kind because there can be this complex life cycle with different hosts.
Of course, they can adapt and find nuances very often, but, the host is important for the parasites. And one thing that we also kind of like, now outside the climate change and all these changes, but the human population, how large a proportion are in one way or another, immune compromised. This can also affect the patterns we will see with parasites.
I mean the, classical story of the AIDS epidemic and then how toxoplasmosis became a, major cause of death even because it's, challenging. suddenly has an opportunity to take over and not be controlled by the host enough. So I think also the host side, environmental side and how the pathogens themselves are developing all things are important in this.
Angela: They're all converging. No, indeed. You talk of immunosuppression, but maybe it's not even the really deeply severely immunosuppressed, because now we have like hundreds of these monoclonal antibodies on the market that regular people take for all kinds of [00:31:00] things, including even like high cholesterol.
And I do think that some of these mAbs know that some of them might take out a little bit of mucosal immunity in a very targeted way. And who knows if that's like, the one cytokine that you might need to release when you're upfront against one of these parasites, , in terms of mucosal immunity, so it's, an immunosuppressed population that is actually very heterogeneous and that is absolutely growing
So I have hopefully a positive question for both of you. What is, in your opinion, the biggest success story in the history of recent,, let's say the last 30, 50 years, recent outbreaks and what has been actually the biggest failure?
So, a happy and a sad question.
I hope we will become better in learning from past experiences, like really taking the learning into new, situations. This is actually something, there's a concept in the disaster risk reduction and management field.
They say build back better. And somehow [00:32:00] I always think are we really doing this? And how would we do it better? I do think, we are learning,
we have a demonstrated history of being able to manage quite challenging infectious disease outbreaks and, epidemics and pandemics somehow. On the positive side, I do want to mention One Health here because it has indeed become a part of these discussions. And I think that is a success that is needed because otherwise we are kind of late and don't have the full picture.
Pikka: If you would only look at the human population. so that it's at different levels come into the discussions both at the really high level. So the Quadripartite is highlighting this. And then there are discussions across different organizations for example, in Europe there is across agency task force for One Health across the EU agencies where they discuss topics.
So there are these like structural things also. And I think at least I also feel very welcomed and really like the discussions in our emerging infections subcommittee, very often there is something, one health, like there is something about the, zoonotic [00:33:00] aspects I think that's a success.
Of course, we need to continue on that, but I, think that's great to observe.
Angela: Wonderful. Martin.
Martin: Yeah, well, one example for both terrible failure and devastating failure, and also for huge successes. I think the West African Ebola outbreak is good for that. It took many, many, many months before the full scale of the outbreak was recognized.
And before the pendulum swung back, before there was concerted action to bring that outbreak under control. In the same breath, it's also a formidable example for our capacity to push back on infectious diseases. Actually if you look at the, development of vaccines and drugs within the short time window where the outbreak was recognized, where we reacted towards it and the, termination of the outbreak.
[00:34:00] It was a very, very small time window. And yet. Vaccines which were already lying on the shelves ready to be tested into the field, were put to test in chaotic situations. Actually, these outbreaks didn't happen in and around European or American University cities where research infrastructure would exist.
No, these outbreaks happen in very, very remote areas and also many more ethical issues applied than we are usually faced with when it comes to clinical trials. Imagine you have an Ebola vaccine at hand. You want to put it to the test, but still rules for clinical trials apply. You have a control group which is deprived of the intervention, actually.
How do you circumvent that? And within a , very short period of time vaccines were brought to the field, very sophisticated. Clinical trial designs were. Developed how you can do [00:35:00] that without grossly violating basic ethic rules. And at the end of the outbreak in 2016, imagine we had two functioning vaccines and or three, basically two combined into a combination.
And then the other vaccine, which can be administered without a heterologous booster actually amazing. We also figured out what works in terms of antivirals. there is very little, but we also develop the concept of the monoclonal antibodies. And for the first time at the end of this outbreak where we failed so badly in the beginning to recognize it and to throw our full weight against it, we had vaccines and even concept for drugs, which helped to curb some of the.
Downstream outbreaks, at least those which were caused also by Ebola outbreak. And then I would say the big elephant in the room is, of course, [00:36:00] COVID-19, where we all think that we abysmally failed in the beginning to recognize the full scale of the problem. And I do believe the good thing is that we do have this enormous wealth of initiatives to do better to enhance surveillance, to think about one health to try to connect all those dots.
So whatever is good as an example for failure is also good as an example for huge successes.
Marc: Yeah. So you both mentioned successes and in the settings where these successes were achieved. So it was a prominent role for a global funder that has now mostly withdrawn its activities in those areas. How do you see, or what do you think that is needed to maintain, let's say, the level of alertness and responsiveness that we would need to respond to [00:37:00] new outbreaks in an area that is now suffering from withdrawing financial support?
Martin: Yeah, mark, thank you. Very good question. I think if I may. The biggest problem with the withdrawal of a major funder from health activities is not necessarily the response to outbreaks there. In my view, we have seen a lot of initiatives. If you look for example, at the Marburg outbreak in Rwanda.
New initiatives arise. Firstly, surveillance in Africa has been drastically improved over the past couple of years. And not only because it was supported maybe by one single funder local initiatives are built. if there is a vacuum rising from the withdrawal of a major funder or player, then others will move in and to recognize their responsibility in the world of outbreak [00:38:00] response.
I think the problem is not as big as in the world of sustainable effort into implementing established tools. If you see and realize that there are now. All of a sudden, millions of people who are deprived from their safe supplies of, for example, antiretrovirals, which they could capitalize on for decades now I think that causes a , much bigger problem.
I see a big problem in clinical trials. I think hundreds of them being brought to an end from one day to another. Study subjects who have volunteered to partake in drug trials for all possible infectious diseases and non-communicable diseases who call into their study center for the next blood draw or drug supply, only to find it having been shut down from one day to another.
Martin: I think these two areas research and. Continuous [00:39:00] supplies of medication. These are far bigger than in the world of outbreak control. I think there we have exhibited a enormous flexibility and the latest outbreaks of viral hemorrhagic fevers, for example, across Africa, show that even with the retreat of a major funder the answers are strong and they are timely.
Marc: Thank you. That's, Somewhat reassuring. and Pikka, what is your take on this?
Pikka: , Very similar thoughts. Certainly. I think one thing is this, long term funding that we can trust and that is needed to build structures at the same time we need to build those so that they are more resistant to changes. So think about the risk and dependencies. In a way, I think the capacities that are built and the knowledge and the networks, those are not.
So effective. So I also kind of see optimistically, but it is a hard hit when major funding is suddenly not there. And then also to think what [00:40:00] are the key things when we have less resources what to do more, what to do less. There is always these challenges.
And I think generally for example, for data sharing, making sure that we get these communications out from these areas and, understand what is really needed. It's there comes more discussions of priorities I think in these situations.
These epi alerts, which I love getting, it's just a little piece of such a bigger world, and it's obviously precious information. How do you get this information? what's this network?
Angela: Where does this all come from?
Martin: Yeah, maybe I should answer that question or make a first attempt. If you look back how that all started, it was about 15, 16 years ago when I started working in the Center of Tropical and Travel Medicine, which I'm heading. And the quest was looking how to filter out of the wealth of the surveillance information, which was already provided at that time.
Huh. Endless [00:41:00] streams of information coming in, for example, via ProMED and other sources. And my question was how can we, in a meaningful way. On a continuous base filter out the one signal out of rapidly produced signals which might be relevant for the patient care within our department.
And so the idea was born to. Put one of my staff members on this and try to develop a system to filter out this most relevant information, really with the question of us being able to anticipate better if somebody with an odd condition from an area where we wouldn't expect such a disease would surface in our department.
So, a young physician, the next one who got an appointment was Abraham Goorhuis, and really for many, many years, he took this on as an extra task, developed a [00:42:00] system which information sources most efficiently to screen, and to put that together in a very concise. Summary for our weekly departmental meeting actually.
Martin: And so the quest was not to display all the hundreds of signals arriving, but really filtering out some which might be of relevance to us. And it worked several times. For example, we were ready for receiving Zika cases when the Zika outbreak swept through the Americas. We were prepared for that.
It helped us in some other aspects. And the key was really to come up with some objective criteria for selection size of an outbreak, geographical area, but also to recognize signals which might. Evolve into something in the future. And when we founded the emerging infection subgroup yeah, I was in doubt.
We were trying to pull our ideas [00:43:00] how we could most meaningfully start feeding back information into the ESCMID community and beyond. And I had my doubts initially because we really designed it to clinicians' needs in Europe, in a country in Europe, anticipating what would be coming along.
But to my surprise there was a broad consensus that might be of use for the bigger community. So we tried it and it worked, and by now we have changed and fine tuned the system. It is not. Hinging on one single person any longer, but we have created a system where the same philosophy is now applied by a team of five or six of us across Europe.
we are also backing our efforts up with a ai approach, which we have developed over the past couple of months. Under the lead of a, colleague from Portugal a microbiologist professor from Lisbon Thomas Hanscheid, [00:44:00] where we do two things. Once we pull the subjective. Opinions and results of the screening of the five individuals in a teleconference every Monday before we submit to ESCMID to be published on Tuesday.
Martin: But we also have an parallel, an AI system running, and to our surprise, actually, we have an 80% congruence of what might be relevant or not. Yeah. That's it in a nutshell.
Angela: That is really interesting. I hope you're studying of course, and, and we'll publish the results of the AI versus human appraisals of what's useful, what's not.
I have to be honest, and this is nothing against ProMED because I was a big fan of ProMED, but I had the same problem with the ProMED emails. I would receive so many, there was so much I wanna say noise almost, because that's just it. it was very hard to get a sense of, okay, which outbreaks are relevant, for [00:45:00] clinicians, for my region, I ended up having to, not get those emails anymore because it was just overwhelming information that to me, it was not, directed. And that's why I have to say I really love the epi alerts because to me it's really just the right level of, sensitive and specific for our human worries,
Martin: Thank you. Yeah. The interesting thing here is that every week there are doubts, shall we include this signal or not?
And if in doubt, we usually don't do it. And we say, if it's really of relevance, it will be there next week as well. And that way I think we still filter out the most important signals. Maybe two things to add. I mentioned ProMED because that was the first system really where. On a large scale, lots of information was produced, but there are of course, also other sources, which are also very proliferative and others fade away like ProMED is now hidden behind the pay wall and has been replaced by many others.
If you want to single out some, then I think the Beacon Initiative [00:46:00] is really worth mentioning going up to a massive scale and a very valuable and laudable source of important information. I also should mention that I do believe we are not the only ones which had such a idea as, for example, an initiative from the Swiss Institute of Tropical Medicine, which produce something similar.
Martin: Our approach was mainly directed to our own needs, but apparently we share them across the community. We want to keep the information palatable for the busy clinician, the busy microbiologist, and so. We decided for the time being, it should not be more than two pages in a worldwide summary.
And we have started then a couple of months ago, even to make it more palatable for the busy reader and come up with five highlights, which can be read in about one and a half minutes And to my understanding, that is what most users also do and [00:47:00] use,
Pikka: I can add to that. That's from our subcommittee.
We also have other communication quite often that then compliments this very pre communication. And there you can find more One health already now.
Angela: Hmm. it's really fantastic, I have to say.
Okay. And so finally probably your least favorite question, but it must be asked, what in your opinion is the next pathogen X?
Angela: Can you hedge a bet, Martin?
Martin: Well, if I, have to go first. for sure it'll be a virus and for sure it'll be a respiratory virus. Which one is difficult to predict? The various influenzas are high on the list, but it can be something else, but it will be a respiratory virus and will be a zoonosis obviously.
Pikka, what do you think?
Pikka: Yeah, certainly. , I would also say similar lines. I would maybe keep my short list even wider, so just say zoonotic maybe add very likely something climate sensitive because those are the changes we see and we are maybe not so ready for then it can have a chance to actually become a, bigger problem.
And I would also add that better [00:48:00] chance we think we know how they are changing their skill sets. Like if you take avian influen dairy cattle in the us I mean that was a major change in how we thought that virus group is behaving. So, so there are these things to keep eyes open.
It isn't pathogen X because we don't know.
Marc: to add to that as a host from the Netherlands, actually yesterday, it was on the front page of one of the big newspapers, serious newspapers here, the, rampant spread of H5N1 among poultry in the Netherlands. And we are the most densely populated country, not only for humans, but also for animals and agricultural industry with millions and millions of poultry that are now increasingly infected with H5N1.
So, the epicenter might be very nearby. Angela, as you're sitting in the Netherlands right now you may well be now in the epicenter of the next [00:49:00] pandemic. But luckily we have Martin as well here, so we have reasons to be optimistic.
Angela: The Dutch triangle.
Marc: Yeah,
Angela: as Mark says,
Pikka: I mean the cold group hearing in, Denmark.
And but I would like to add at the same time, I mean, Europe is like Martin said earlier, well prepared for this. And if I take it to the higher level, like the agencies ECDC and FSA both have just in a recent week come up with communications about this. so both from the animal health side and the human side and really this discussion.
But, but indeed, even though we often say things happen somewhere remotely, , it could be closer to us. We have some conditions for that, certainly in Europe.
Angela: You have here in the Netherlands one of the big experts for Avian flu for flu in general. And we did an episode with him last year Ron Chee.
Marc: Yeah.
Angela: Yeah. So I think we might have to call him up again and get another update. this was a year ago when we did this episode. He was not super positive about the outlook. he was certainly not a [00:50:00] doomsayer either, but he was given enough time, given enough human animal interaction, it's just a matter of time kinda.
I remember that episode. I listened to it. And also, if I remember correctly, he was mentioning also these different patterns like this with the dairy cattle, and suddenly it's in the milk. I mean also the occupational health aspect. We didn't think about the milk as somehow with people in that sense.
Pikka: So keeping eyes open for new patterns that might appear is important.
Angela: Yeah, yeah. And like you were saying, there are all these things happening at once, right? the pathogens are doing what they do, but then the hosts, you know, and now it's just very fashionable in certain circles to be drinking raw milk that is not pasteurized.
And it's like a perfect storm again, you know? I remember being shocked when he said, yeah, it's in the milk and no one's cleaning it out. It was, it was pretty sad, sad state of affairs.
Pikka: But actually that brings to the other way, like how to control, how to respond generally.
So many of our systems are. Protecting us from pathogens across different pathogen [00:51:00] types, like the pasteurization of milk. , So there are these things also that if we build systems that work across different pathogens, then we are also better prepared for the pathogen X or one of the pathogens We think we know evolving somehow.
Marc: Yes. But it's really changing to stay with the H5N1 and the avian flu in the Netherlands, for example, where we have many, many farms with 10 thousands of, chickens running around in close proximity. The approach always has been to cull. Even infection was demonstrated, but it is now realized that culling no longer is an option because it's spread by wild birds.
So it's not the sporadic transmission between farms, it's the continuous exposure of farms to another source, which means that if we stop calling, which I think. We will, we are moving towards that, that the transmission will only progress faster. we do have a lot of cows as well, so we produce a lot of milk.
So if that would become a way of, let's say [00:52:00] exposure to this virus, to other animals and to human beings this might be a perfect storm for our country. Having said all that, we're coming to the end of our podcast. And the final question always is if we wrap up the discussion, is there any last message you want to give our audience?
Something you didn't get a chance to say before? starting with you, Pikka.
Pikka: I would say we covered all the key things. talking, with each other and across professions, across sectors, across countries. That's very important. So, I would say to go out and learn something new about the infectious diseases and pathogens that we thought we knew and maybe of some new ones.
Martin: I can only reciprocate what Pikka said. I would like to draw our esteemed listeners attention to the fact that if you are really interested in emerging infectious diseases preparedness we do have our EIS, our emerging infectious subcommittee, which is [00:53:00] limited in sight.
In order to make things workable. But we also do have a interest group, a group of experts, which is growing which resource for reaching out, addressing certain questions. So if you are interested in the work of ESCMID EIS with our webpage, there are possibilities to engage and even more so in the future.
And with that, I would like to thank you also for the possibility to share thoughts this morning with you.
Angela: Thank you so much. It's really nice to know that this committee is open to others joining and helping out and learning from it. Of course. . Thank you so much to our guests today, Pikka Jokelainen in Copenhagen, Denmark, and Martin Grobusch in Amsterdam, the Netherlands. thank you for listening to communicable the CMI Comms podcast.
This episode was hosted by Mark Bonten in Utrecht, the Netherlands, and me Angela Huttner in Leiden, the Netherlands. It was edited by Dr. [00:54:00] Katie Hostetler, oy and peer reviewed by Dr. Ummu Afeera Zainulabid of the International Islamic University Malaysia in Kuantan, Malaysia.
Theme music was composed and conducted by Joseph McDade. This episode will be citable with a written summary referenced by A DOI in the next eight weeks. And any literature we've discussed today can be found in the show notes. You can subscribe to Communicable wherever you get your podcasts, or you can find it on ESCMID's website for the CMI COMMS Journal.
Angela: Thanks for listening and helping CMI, comms and ESCMID move the conversation in ID and clinical microbiology further along.