With the different modes of transmission and the variability in their incidence rates, infectious disease outbreaks can be difficult to manage once they appear. 

The introduction of COVID-19 reaffirmed how quickly an infectious disease can take hold and how dangerous a viral pathogen can be to a larger, global population.

Ebola, on the other hand, has had very bad regional outbreaks in various countries within Africa. And while its mode of transmission is different (through body fluids), the fear it could spread to other areas in the world remains intense due to the disease’s harmful effects and potential mortality. Ebola’s 

 according to the World Health Organization, but there is also great variability with rates ranging from 25% to 90% from past individual outbreaks. 

is a mysterious fungal infection and not much is fully known for why outbreaks appear. It remains highly contagious in health care settings and is often multidrug resistant. Similar to Ebola, the mortality rates for 

 vary greatly according to Jeffrey Rybak, PharmD, PhD, instructor, Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital.

Outside of a smattering of cases in Europe and the US, Ebola outbreaks have remained on the African continent. Conversely, 

 has had outbreaks in several continents occurring simultaneously, according to Rybak.

In the second installment of an interview with 

Rybak discusses outbreaks across different geographic locations including one where there was a high incidence rate of COVID-19, 

 mortality rates, and whether it has enough durability that will provide it with a sense of permanency and therefore remain a concern in public health for years to come.

Videos

The emergence of this fungal infection remains mysterious as the world experiences more outbreaks. 

Considering Candida Auris Outbreak Behavior

Welcome to our series, 1 Big Question, which asks 1 question to the medical community and we get their feedback on an important infectious disease topic.

In this episode, our 1 Big Question is: One of the more interesting treatment areas within C diff is fecal microbiota transplants. What is your take on this potentially being used as a therapy in patients with recurrent c diff?

We interviewed, Sahil Khanna, MBBS, MS, is a Professor of Medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic, Glenn Tillotson, PhD, FIDSA, FCCP, GST Micro LLC, and Anurag Malani, MD, infectious diseases specialist, St. Joseph Hospital, and a fellow of Infectious Diseases Society of America (IDSA).

Check out our video to hear their insights.

With fecal microbiota transplants (FMT) becoming a potential emerging therapy for these patients, here are some aspects to consider when treating.

Clinical Considerations for FMT for Recurrent Clostridioides Difficile 

In early July, control of COVID-19 seemed to be trending in the right direction including vaccinations increasing, caseloads going down and a sense the pandemic might become somewhat under control.

Pfizer began advocating for booster doses in early July

, officials from the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) told Pfizer officials that relevant data supporting a COVID-19 booster dose remained inconclusive.

By August, the Delta surge which had torn through the United Kingdom and India earlier in the year, was now in the United States and creating havoc as caseloads went up, including hospitalizations, increases in mortality, and the emergence of breakthrough infections. This very acute surge was perplexing to public health officials as well as the general public, especially to those who were vaccinated.

Addressing the Shifting Vaccination Policy

Just weeks before, the FDA and CDC did not see the utility of a booster dose. Then in August, the Biden Administration began publicly advocating for a booster dose months after the second dose of the vaccine. Initially, it was 8 months and then there were reports it has decreased to 6 months after the second dose.

And for those who are already vaccinated, booster doses will likely be available for some people this fall and winter including the immunosuppressed, people 65 years and older, and health care workers. Last week, the Vaccines and Related Biologic Products Advisory Committee (VRBPAC) decided 

 to vote on an Emergency Use Authorization (EUA) for a booster dose for people 65 years and older and those deemed high risk of COVID-19. That vote passed unanimously in favor of those two groups being eligible for the booster dose. In addition, they created a poll question during the meeting addressing health care workers (HCW) and that also passed unanimously in favor of HCWs being eligible for boosters. 

This shift in health care policy came largely from 

, which saw a COVID-19 surge of its own this year, leading to more hospitalizations and higher mortality rates. That country decided upon a booster strategy to bring down incidence rates. 

It is important to note, VRBPAC members at the September 17 meeting, discussed their reservations to recommending an approval for booster doses for the Pfizer-BioNTech COVID-19 vaccines for everyone 16 years and older, and a large part of their reasoning was due to the fact there was very limited data to demonstrate the need in the United States to give everyone a third dose.

In the background behind the Delta surge and the discussion on boosters, is the impending flu season. Last year it did not develop into a large concern due to all the restrictions related to COVID-19. The influenza season was the lowest it had been in years.

However, in 2021, with many restrictions lifted, people vaccinated, and life getting back to normal, there will be more person-to-person interactions and the possibility of more people getting influenza. With this possibility comes one of the concerns public health officials have had: “the twindemic.” This is a phenomenon where providers and the public are battling COVD-19 and influenza simultaneously.

As the southern hemisphere goes through their influenza season now, indications thus far show it has been a mild season there. 

 remains very low at < 10% positivity of tested specimens.

Still, with the unpredictability of this seasonal virus and the pandemic virus and taking into consideration the risk of these viruses individually or combined, getting vaccinated should be part of everyone's care plan.

Although decisions and guidance by public health agencies are evolving depending on the latest data released from studies, in the meantime, there are vaccination health care recommendations that can be followed now.

 spoke with William Schaffner, MD, medical director for the National Foundation for Infectious Diseases (NFID), professor of Preventive Medicine in the Department of Health Policy, and professor of Medicine in the Division of Infectious Diseases at the Vanderbilt University School of Medicine, who offered some guidance in terms of vaccinations, the potential of the twindemic, and the timing of booster and influenza vaccines.

With the Delta cases surging in recent weeks, and the upcoming flu season almost upon us, here is a glimpse of what providers and the public can expect when both viruses are circulating.

When Delta and Influenza Intersect 

The University of Miami’s green and orange colors add some contrast to the otherwise all-black truck, which is sitting in a parking lot in a Miami neighborhood. A visitor to the truck has come in to get information on sexually transmitted infections (STIs), and stays to get some counseling on 

 from one of the education navigators working the clinic.

This truck is a mobile clinic created by the University of Miami, and it goes out into various areas within Miami-Dade County to deliver care related to STIs, HIV care, and HIV prevention to people who might be at-risk and who might not be seeking medical care.

“It provides us the opportunity to go to neighborhoods that may not have PrEP services in place,” Susanne Doblecki-Lewis, MD, MSPH, FIDSA, professor of Clinical Medicine, and director of HIV Prevention, Division of Infectious Diseases, University of Miami Miller School of Medicine. Doblecki-Lewis heads UM’s PrEP outreach.

As many urban areas across the US, Miami has been challenged with HIV incidence rates. As of 2018, Miami had the second highest rate of HIV infection in US cities behind only Baton Rouge according to the Centers for Disease Control and Prevention (CDC). In 2019, there were 25,671 people living with HIV in Miami-Dade, and 1170 people were newly diagnosed with HIV that year.

“We are hoping that based on the barriers that we have seen to PrEP—and we have studied here in Miami—our goal is to leap over some of those barriers in one step by rethinking the clinical environment entirely,” Doblecki-Lewis stated.

The mobile clinic is equipped with an exam room, phlebotomy station, a place to collect specimens, and an area for counseling. The clinic often has hours in the afternoons and evenings to accommodate people who want to come in after work.

“We try to make it welcoming and make it fast,” Doblecki-Lewis said. “Rapid is one of our main tenets. We don’t want people to spend a lot of time to get these services.”

The clinic also tries to remove the stigma associated with some department-of-health clinics, and the service is free, explained Doblecki-Lewis.

The PrEP clinic has some corporate sponsorship, and Doblecki-Lewis credits the navigators’ passion for keeping the clinic going. “They are the heart of program; they are what makes this work,” Doblecki-Lewis said.

spoke with Doblecki-Lewis recently about the genesis for the clinic, how they decide on the different mobile sites, who they are reaching in the community, and how they carry out a continuum of care for their patients they serve.

The University of Miami (UM) has a community-based mobile clinic that offers PrEP counseling along with other medical services to those who might not otherwise have access to or seek clinical care. 

A Vehicle for Care, Counseling Out in the Community

A new study reported there were more than 1000 maternal deaths in Mexico from February 2020 to February 2021. This trend contrasted with a decrease in both the previous years (2018 and 2019). 

According to the Centers for Disease Control and Prevention (CDC), maternal mortality is defined as a death of a woman during pregnancy, at delivery, or within 1 year after delivery. The CDC notes that about 700 women in the US die annually as a result of pregnancy or delivery complications.

The study’s investigators found COVID-19 was the leading cause of maternal death, with 22.93% being from confirmed cases, and 4.5% being unconfirmed cases. And they noted there was also an increase in deaths related to hemorrhage and hypertension during the study period.

The investigators used public health data from Mexico’s General Office of Health Information to estimate changes in the maternal mortality ratio due to COVID-19 infections and changes in care resulting from efforts to control the pandemic. During the study period, 1056 maternal deaths took place, with 835 reported between weeks 10 and 53, and 221 reported in the first 10 weeks of 2021.

“The results highlight the need for timely, organized, and efficient maternal and obstetric healthcare at all times, but particularly during a pandemic,” the investigators wrote. “Providing pregnant women access to the necessary healthcare resources in the community and clinical settings must be considered a priority.”

It is important to note the study period took place before the availability of COVID-19 vaccines in Mexico. Vaccinations did not begin to ramp up in that country until later in 2021.

With at least a quarter of the deaths in the study related to COVID-19, the COVID-19 vaccine will likely play a much bigger public health role going forward in preventing maternal mortality.

And although the COVID-19 vaccinations remain paramount in public health, providers should be counseling their patients on the value of the influenza vaccine as well. And pregnant women need to be thinking about the value behind the vaccines not only for their health, but the health of their babies.

 spoke with William Schaffner, MD, medical director for the National Foundation for Infectious Diseases (NFID), professor of Preventive Medicine in the Department of Health Policy, and professor of Medicine in the Division of Infectious Diseases at the Vanderbilt University School of Medicine, about the importance of pregnant women getting vaccinated for both COVID-19 and influenza.

A study from Mexico shows that maternal mortality increased nearly 60 percent during the COVID-19 pandemic, and reaffirms the importance of both COVID-19 and influenza vaccinations for pregnant women.

Maternity Mortality Increase During COVID-19 Affirms Value of Vaccination During Pregnancy

) was first identified in a single case in Japan where a man had it appear in his ear. According to the Centers for Disease Control and Prevention (CDC), a retrospective review of 

strain collections found that the earliest known strain of the fungus dated back further to 1996 in South Korea.

In the ensuing years, the fungal pathogen has been mysterious in appearing very quickly in places and then disappearing almost as quickly. Earlier this year, two outbreaks were made public with one happening at a nursing home in Washington, DC, and the other at 2 hospitals in the Dallas area.

During this outbreak, a cluster of 101 cases was detected in the Washington, DC, nursing home and a cluster of 22 cases was detected in 2 Dallas areas hospitals from January to April.

According to reports, some of these patients infected with 

did not show any clinical improvement after being treated with all 3 major classes of the antifungals. In fact, in 5 patients who were fully resistant to treatment, 3 of them died.

 does not appear to have a high incidence rate, the infection presents some serious challenges to clinicians. It is especially troublesome as the CDC has outlined 3 main concerns about it, including:

It being a newer, emerging fungus, it can be challenging for labs to diagnose with standard laboratory methods, which can lead to misidentification and in turn lead to the incorrect treatment and management;

And lastly, it can quickly lead to outbreaks in health care facilities.

 fungal infection is still relatively rare, when it occurs in the 

, it can quickly take hold and become an outbreak if infection prevention measures are not taken.

 clinical isolates are resistant to one of the 3 classes of antifungals that we have to treat invasive infections,” Jeffrey Rybak, PharmD, PhD, instructor, Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, said. Rybak has been conducting research on 

 in trying to identify novel targets for therapy, apply next-generation sequencing technologies, and develop molecular tools to advance the study of the fungus.

Rybak also points out that isolates might become resistant while someone is on therapy. “Even while it might be susceptible upfront, after a week or two of therapy, we may find that the patient has an infection now caused by an isolate of the same 

 that has become resistant to the echinocandins and we are really left with nothing else.”

Rybak says these investigational agents show promise against the infection, but that they need to see more clinical trials to see their full treatment utility.

 spoke to Rybak about the challenges of multidrug resistance with 

uris, how diagnosing it is evolving, the merits of monotherapy over combination therapy, what to consider in seeing resolution of symptoms, and some of the big picture public health concerns associated with this infection.

With the unpredictability of when it will appear, and its propensity to be multidrug-resistant, this particular pathogen is challenging to diagnose and treat.  

Candida Auris: An Enigmatic and Difficult-to-Treat Fungal Pathogen

In the spring of 2020, the COVID-19 pandemic engulfed New York City. Hospitals began filling up with the virus that at that point no one knew how to treat successfully. And the 

 of the Montefiore Health System became one of the first designated COVID centers, and the first to achieve in-house COVID-19 testing in New York City using the polymerase chain reaction.

As with health care in general, Montefiore experienced more HAIs. In the early days of the pandemic, before the realization of treatment protocols for COVID-19, Montefiore struggled to find therapy regimens and had a lack of medical devices and equipment so these things had to be shared.

Priya Nori, MD, director, Antimicrobial Stewardship, Montefiore Health System and associate professor, Medicine & Orthopedic Surgery, Albert Einstein College of Medicine, program director of the infectious diseases fellowship program, talked about the data from studies showing increased incidence rate of HAIs. “We know now that this is a pandemic surge-driven phenomenon,” Nori said. “And this is because healthcare workers were overwhelmed; our capacity to take care of people was overwhelmed.”

In the second installment of an interview with Nori, she spoke about how COVID-19 care has changed since the beginning of the pandemic, offered some insights into the bacterial infections they saw, and how they combatted them with infection prevention measures. To see the first interview, go 

New York City-based Montefiore Health System has adapted its inpatient treatment over the course of the last year to help enable better patient care and reduce healthcare-acquired infections (HAI). 

The Evolution of COVID-19 Care

The emergence of zoonotic spillover events that develop into human infectious disease is a significant health issue. More than two-thirds of human viruses are zoonotic.

There have been a number of zoonotic diseases such as Ebola virus, rabies, Zika virus, African swine fever, and 

severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

 that have emerged into people through an intricate and complex biological process known as spillover.

And although not proven definitively, the ongoing 

 emerged was due to a zoonotic spillover event.

Zoonotic spillover is determined by interactions among several factors, including disease dynamics in the reservoir host, pathogen exposure, and the human factors that affect susceptibility to infections.

In response to the COVID-19 pandemic as well as the potential of other spillover events, the United States Agency for International Development (USAID) announced the launch of the Strategies to Prevent Spillover (STOP Spillover) project in September 2020. It is designed to be a five-year, $100 million project to anticipate and address threats posed by viral zoonotic diseases.

Tufts University is leading the STOP Spillover project, along with a consortium of wildlife and human-disease experts including: AFROHUN, SEAOHUN, Bangladesh (ICDDR,B),  Right Track Africa, JSI Research & Training Institute, Tetra Tech, University of Washington Institute for Risk Analysis and Risk Communication, University of Glasgow Institute of Biodiversity, Animal Health and Comparative Medicine, University of California, Los Angeles, the Broad Institute of MIT and Harvard, University of Nebraska Medical Center, Humanitarian OpenStreetMap Team, and Internews.

The consortium is trying to reduce future outbreaks from known zoonotic viruses by having partners on the ground in various parts of the world to monitor, analyze, and characterize the risk of priority zoonotic viruses spilling over from animals to people.

STOP Spillover is in 5 countries including Uganda, Liberia, Cambodia, Bangladesh, and Vietnam with the long-term goal to be in 10 countries across Asia and Africa, explains STOP Spillover Project Director 

An important distinction in this project is that it is not only monitoring for outbreaks, but will create actionable interventions in those vulnerable areas that can prevent or reduce potential outbreaks.

“A really important starting point is to speak to the stakeholders who live in the highest risk areas, places where interfaces between animals and humans are most likely to yield spillover,” Kochevar, said. “Our project focuses on empowering stakeholders, asking them where they think the interventions would be most effective, and then assisting in bringing expertise and working together to put in place interventions and assess them.”

 recently about the consortium’s aims, the specific families of viruses they will be observing, and the importance of understanding and mitigating risks in potential spillovers.

1. Woolhouse M, Scott F, Hudson Z, Howey R, Chase-Topping M. Human viruses: discovery and emergence. 

Virus spillover and emerging pathogens pick up speed

3. Plowright, R., Parrish, C., McCallum, H. 

 15, 502–510 (2017). https://doi.org/10.1038/nrmicro.2017.45

The STOP Spillover project is aiming to prevent remerging infectious disease outbreaks.

Preventing Viral Zoonotic Spillover Events

It is vital to get the global society to adopt 

 to help prevent the spread of HIV, and WHO has certainly taken on this 

Back in 2015, the WHO recommended offering once-daily oral PrEP to people at substantial risk of HIV acquisition, and in the following year, the United Nations General Assembly set a global target of 3 million oral PrEP users by 2020. 

 in 77 countries in 2019, after two-thirds of countries (120) had adopted WHO recommendations into national guidelines. This resulted in a 69% increase from 370,000 PrEP users across 66 countries in 2018, when 30 countries had adopted the recommendations, but fell short of its goal of 3 million oral PrEP users by last year.

Sub Saharan Africa is one region that is scaling up its PrEP usage, but the continent as a whole remains challenged by HIV. 

, for example, has the largest HIV/AIDS population in the world with 7.5 million people, according to the CIA World Fact Book’s latest estimate done in 2019. In addition, it has the fourth largest prevalence with 17.3% and the highest mortality with 72,000 deaths estimated that same year. 

 in the world. There are over 3 million people on ART according to one 2015 statistic. One can imagine if South Africa has the public health structures in place to deliver ART that the addition of PrEP should be made easier.  

Renee Heffron, PhD, MPH, associate professor, Global Health, associate professor, Epidemiology, Department of Global Health, University of Washington has been working in African countries to help with understanding local cultures and developing strategies to create greater PrEP utilization.

For example, in order for PrEP to be getting out into the African communities of need, it is important to have conversations and engage people where they are locally and not just in clinics or health care settings and understand the structural barriers that prevent people from taking it.

Heffron participated on a panel at the 11th International AIDS Society Conference on HIV Science in July and made a presentation titled, Preparing for Delivery of Proven Efficacious interventions, during it. She spoke about the various therapeutics in PrEP, lessons learned about daily oral PrEP, and tied it together by talking about the importance of community health.

spoke to Heffron who provided insights into her presentation, PrEP usage in Africa, and structural barriers to greater initiation.

It is important to go out into the local communities to educate people about PrEP as countries try to scale up with the World Health Organization’s (WHO) PrEP recommendations. 

Africa is Significant Piece in Global Aims for PrEP Utilization 

New York City has traditionally served as a destination for both immigrants and international travelers. The bright lights, the attractions, and opportunities for a new life all help to bring millions of people to its doorstep every year.

With that, it can also bring pathogens, and the city’s hospitals need to be prepared for any known or unidentified viruses or illnesses that appear.

From its beginnings, New York City-based Montefiore Health System has had a legacy of treating infectious disease. The first hospital opened in 1884, and cared for patients with tuberculosis and other chronic illnesses. And in 2020, the 

 became one of the first designated COVID centers, and the first to achieve in-house COVID-19 testing in New York City using the polymerase chain reaction.

Today, the health system consists of 15 hospitals and a primary and specialty care network of more than 180 locations across Westchester County, the lower Hudson Valley, and the Bronx. The health system includes the Montefiore Medical Center (Moses Division), which is an academic medical center and the primary teaching hospital of the Albert Einstein College of Medicine in the Bronx borough of New York City.

It was the rise of Ebola in 2013  that really helped Montefiore focus their attention to the possibility of treating infectious disease outbreaks, according to Priya Nori, MD, director, Antimicrobial Stewardship, Montefiore Health System and associate professor, Medicine & Orthopedic Surgery, Albert Einstein College of Medicine, program director of the infectious diseases fellowship program.

“Our hospital was one of the designated treatment locations within New York State," Nori said in speaking about their experience with Ebola. “We had to quickly stand-up a special unit…and train a cadre of nurses, providers, physicians, and people willing to take care of a patient with a highly transmissible illness.”

The Montefiore staff who were involved in the Ebola planning were able to pivot and transition to treating patients with COVID-19 when the pandemic hit New York City in the spring of 2020.

Although COVID-19 remains of paramount importance, Montefiore remains diligent to the possibility of other pathogens, including 

 spoke with Nori recently about infection prevention protocols at Montefiore, the challenges of treating and eradicating 

, and what other precautions they take to avoid potential outbreaks.

Montefiore Health System has a long history of treating infectious disease, and with the current pandemic and other emerging pathogens, they remain vigilant to potential outbreaks. 