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Join Nicholas A. Daniels, an internal medicine physician and the author of Outbreaks and Pandemics: The Life of a Disease Detective. In this episode, we delve deep into the crucial role disease detectives play in solving and controlling infectious disease crises. Explore historical breakthroughs, the significance of vaccines, and the ever-evolving challenges faced by these dedicated professionals.

Nicholas A. Daniels is an internal medicine physician.

He discusses the book, Outbreaks and Pandemics: The Life of a Disease Detective.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Nicholas Daniels. He’s an internal medicine physician, and we’re going to talk about his book, Outbreaks and Pandemics: The Life of a Disease Detective. Nicholas, welcome to the show.

Nicholas A. Daniels: Thank you very much.

Kevin Pho: We’ll get into your book in a little bit. First off, briefly share your story and journey.

Nicholas A. Daniels: I grew up in Buffalo, New York, in a pretty resource-limited, racially segregated neighborhood. I received a scholarship to go to Cornell University, where I did premed studies in biochemistry. Afterward I went to Yale University and did an MS in public health and infectious disease epidemiology. I decided I wanted to live on the West Coast, so I moved to Seattle to attend medical school at the University of Washington, and afterward I went to UC San Francisco for my internship and residency in internal medicine. That was followed by a fellowship at the CDC in Atlanta, where I did the Epidemic Intelligence Service, the EIS, a two-year fellowship at the National Center for Infectious Diseases. Following that, I worked as a consultant for the World Health Organization, based in Southeast Asia, in the Philippines, Cambodia, Laos and Vietnam. Then I came back and joined the medical school faculty at UC San Francisco and then UC San Diego. Currently, I’m at Mayo Clinic in Scottsdale, Arizona.

Kevin Pho: All right, so you wrote the book Outbreaks and Pandemics: The Life of a Disease Detective. Tell us what led you to write this book.

Nicholas A. Daniels: Well, the book and the article are based on my memoirs. It’s about my life story, from growing up in Buffalo all the way to the present, following my career and the outbreaks and pandemics I’ve lived through and worked through as a doctor and as an infectious disease epidemiologist. So it’s really telling my life story. I think one of the key things I wanted to highlight was the lives of disease detectives. They do incredible things. They help characterize diseases and come up with control mechanisms and strategies to reduce disease and save lives. I think not a lot is known about them. They work in the background, but they really are the backbone of our public health system, and they are critical for dealing with outbreaks and pandemics. That’s really where the book came from.

I’ll tell you a little about what a disease detective does. They’re good at figuring out transmission routes, dose response, risk factors and environmental surveys. They do surveillance of diseases: how much, when, where and who. Then they conduct epidemiologic surveys, case-control studies and cohort studies, analyze the data and evaluate the efficacy of vaccines: Are prevention efforts working? Then they communicate their results and findings, on and on. Many disease detectives work 24/7; you never know when there’s going to be an outbreak or a pandemic. During my two years at the CDC, I basically lived out of my suitcase. I was on call, and at any moment I could be told, “You’re going to Africa or Asia. We have an outbreak; we need to respond.” So sometimes these disease detectives may actually put their own lives at risk going into an unknown situation.

Kevin Pho: Tell us the story of one of those calls, when they sent you either somewhere in the United States or overseas to track down a disease, and run us through that story.

Nicholas A. Daniels: I’ll give a few examples. One outbreak was a cholera epidemic in West Africa, in Guinea-Bissau. They were having a cholera outbreak, with thousands of people sick and thousands of people coming to the hospital. We went and set up a clinic, and we went to the emergency ward, where we saw people being carried into the emergency department near death by their loved ones. What we found was that the mortality rate in this clinic was 10, 15, 20 percent, when the case fatality rate should be more like 1 percent. Why were all these people dying, and what could we do to reduce that mortality rate?

So we developed an intervention. To figure out why people were not getting better on the cholera ward, we tested the oral rehydration solution being given, and we found that they were using open buckets, and people were allowed to dip their cups into the buckets to retrieve it. We analyzed it and found cholera, typhoid and other coliform bacteria. That was the reason folks were not getting better: They were becoming reinfected. So we used a closed vessel with a spigot, so that people could not dip their hands or cups inside; they could use the spigot to dispense ORS. We were also able to use some bleach, or chlorine, to purify the water going into making the ORS, so we were able to provide ORS that was not contaminated. We tested it, and it was completely clear of other microbes. As a result, people got better and were able to be discharged. When we left, in conjunction with Procter & Gamble, we gave out these vessels to cholera clinics across Guinea-Bissau, and the mortality rate went down. I thought that was a real-life intervention in the midst of an epidemic, not knowing what we would see until we got there, and I think we really made a difference.

Kevin Pho: Tell us about the role of disease detectives in our most recent pandemic, which of course is the COVID pandemic.

Nicholas A. Daniels: Yes. There were disease detectives working in the background, but I would say that, unfortunately, during the COVID pandemic many of them were sidelined, at least at the CDC specifically. I had lots of colleagues who couldn’t speak to the public; they were told what to say. So I think we really didn’t make tremendous use of them, because of the political situation they were in. Their hands were tied, so we didn’t have the leadership we needed during COVID, and I think that’s one of the reasons we had so many deaths and so much misinformation. That’s a problem. There were some disease detectives who spoke out early and talked about masking and social distancing, but they were quickly sidelined. That was not the message the government wanted to get out to the public, so it was not a very good situation during COVID.

It was very similar during the HIV/AIDS epidemic as well: There were political factors that kept messages from getting out. So I think one of the key lessons is that we need to try to get politics out of public health. Public health is so important. It affects everyone, regardless of political affiliation, and we need our disease detectives out front, not sidelined, during these pandemics.

Kevin Pho: Now, in your ideal world, let’s say we did remove the politics. What would have been your ideal scenario for the role of disease detectives during COVID?

Nicholas A. Daniels: In the ideal world, well, we had a CDC official, someone I know, who was embedded in China before the pandemic, but she was recalled to the CDC three months before we heard about COVID. If she had been there, we probably would have heard about it earlier. By the time we heard about it three months later, it was too late. It had already spread around the globe, so containing it would have been very difficult. What we need is for countries, when they notice there’s an outbreak of global proportions, to notify the WHO and let us know, so that we can be prepared.

In general, for the next pandemic, we need to be prepared. We need to have masks and PPE, gloves, protection for our health care workers. We need to have reagents; we can’t run out of reagents for running tests. We need rapid tests available, and we need a sufficient number of ventilators, so we don’t have to decide who lives and who dies by rationing care.

Kevin Pho: Now, how has the politicization of the COVID response affected the effectiveness of disease detectives going forward?

Nicholas A. Daniels: Well, I’m hoping that under new leadership the CDC will be able to take its position as a leader in public health. Not only is it the leader for the United States; it’s the leading health agency in the world. Everyone looks to the CDC for guidance on public health issues. A lot of the officials in other countries have trained at the CDC. They come to the CDC, and the CDC goes to them. We have a very strong global network of public health people who all know each other and coordinate, but they really do look to the CDC for leadership. So we need that leadership to tell us what we need to do, to work with the WHO, to work with member countries and advise them on how to get a global pandemic under control. We need that coordination, and the CDC really needs to be the key player coordinating the response.

Kevin Pho: Now, I think the political climate, as you mentioned, really led to a lot of mistrust of our public health officials. How can the CDC, and more broadly our public health officials, regain that trust in our polarized environment here in the United States?

Nicholas A. Daniels: I think it’s possible. I think the CDC can regain that trust. They have to speak honestly with people and explain to people what’s going on. In general, doctors and public health officials need to do a better job of explaining complex medical and public health issues to patients so that they understand them: that it’s not all about you as an individual; it’s more about the group. People need to learn more about risks and benefits. What are the benefits of a vaccine? What does it do? There’s a lot of education that needs to be done, and you need to be honest with the public. I think there were some things where some officials were less honest, or were giving some misinformation, and when that happens you lose the public’s confidence. So you have to be honest and straightforward. But I think the trust can be rebuilt and regained, and the public will respond, but your messaging has to be correct, honest and straightforward, so that people can understand it.

Kevin Pho: What was one example where public health officials said something that you didn’t think was quite as honest as you would have liked?

Nicholas A. Daniels: Two things come to mind. One would be when they were telling people to go out and make cloth masks. I knew that cloth masks really hadn’t been tested to see whether they would provide protection. We needed N95 masks; we needed surgical masks, which are much better at stopping respiratory droplets. When I heard that, I thought, “Oh my God.” They said it because there was a shortage, but it was misleading to suggest that these things people were making at home were going to protect them against COVID. I knew they had not been tested and were not going to be effective.

The other thing is that after vaccines had been made available, and after Paxlovid had come out, they made statements that these things were going to be distributed equitably. I have been in medicine for 30 years now, and I have very seldom seen things in medicine distributed equitably. It was clear that pharmacies did not have vaccines in certain neighborhoods, and people would have to travel long distances to get the vaccines. You could get Paxlovid in certain pharmacies; if you had access and money, it was easy for you to get it. That disparity persists in most things, and it persisted throughout COVID. Even though the official line was that they were going to try to make things equitable, in reality I didn’t see that at all.

Kevin Pho: What kind of training does one need in order to become a disease detective?

Nicholas A. Daniels: Since the 1950s, the CDC has had a program, the EIS program, that trains elite-level disease detectives. They’re usually medical doctors, veterinarians or PhD bioscientists, and they take in about 60 to 90 per year, so there are about 180 elite disease detectives at the CDC every year, and there are a ton of alumni who are still connected as well. That group is well trained and ready to respond to anything and everything, an incredibly talented group of people who are passionate about public health and want to do this work, get out in the field, get their hands dirty and come up with solutions. They also bring in people from other countries, so a lot of international doctors come and train and take that information back home to help globally. We need to be strong here, but the world is so interconnected now that we need everyone on the planet to work together, because within 24 hours a virus here could be anywhere else in the world.

Kevin Pho: Now tell us some of the other main messages you want to share from your book.

Nicholas A. Daniels: One of my areas of interest and expertise is foodborne diseases, and I would say I feel most passionate about Vibrio infections. In Africa I worked on Vibrio cholerae, and in the U.S. I’ve worked on Vibrio parahaemolyticus and Vibrio vulnificus. Vibrio vulnificus is a severe infection associated with eating raw or undercooked oysters. It can cause gastrointestinal infections, it can cause sepsis, and it can cause horrible wound infections, often described as flesh-eating bacteria, sort of similar to group A strep. These are horrible infections, and you acquire them by eating raw or undercooked oysters, or through contact between an open wound and seawater. Sometimes this infection can lead to a limb amputation, of a leg or an arm. It can be horrible.

This past summer, we saw an increase in the number of cases in New York, Connecticut, Florida and all over the country, in part because water temperatures had increased. It was an El Niño year. I had written a paper in the late ’90s on a year when there was an abundance of infections, and I attributed it to high water temperatures, which let the bacteria proliferate. They’re naturally occurring bacteria, not related to sewage, but they proliferate and can reach a high enough dose to cause very serious infections. There are technologies to get rid of these microbes in oysters and shellfish, but they have not been readily used, and there’s been some resistance on the part of the oyster industry and their congressional leadership to additional regulations that would make oysters safer. But they can be made safer.

Kevin Pho: Now, for those who enjoy an occasional raw oyster, what kind of advice do you have? Is it simply a risk they have to accept? What should they do?

Nicholas A. Daniels: Eating oysters is definitely a risk. They’ve done personality studies and found that oyster eaters are on the edge; people who eat raw oysters are risk-takers. The people at greatest risk for complications from Vibrio infections are those with compromised immune systems or chronic liver disease. Otherwise healthy people should probably avoid oysters between May and October, because that’s when the bacteria are at high levels. Outside of May through October, in the fall and winter, the cooler months, the bacterial count is relatively low, and it’s unlikely to cause many infections.

Kevin Pho: And there’s nothing a diner can do to smell, see or taste the Vibrio infection. Is that correct?

Nicholas A. Daniels: Not at all. The oysters taste fine. People tell me all the time that the oysters were great, but then I’m hearing about their cases: They got sick 24 or 48 hours after eating the oysters, and it can be quite severe. There are often warnings on menus telling people this could be a risk, but I’m not sure how many people read them. Early on, they were only in English, but then they eventually added Spanish so that more people could read them.

Kevin Pho: We’re talking to Nicholas Daniels. He’s an internal medicine physician. His book is Outbreaks and Pandemics: The Life of a Disease Detective. Nicholas, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Nicholas A. Daniels: I would say a few things. I want the audience to know that it’s important to advocate for sufficient PPE in their hospitals and clinics. In this day and age, we should not be running out of PPE or masks. Health care workers shouldn’t have to don garbage bags to protect themselves, so let’s make sure our hospitals have sufficient PPE.

The other thing is that I want to advocate for safer food. Some consumers think that the food they buy at the market has been tested and found to be safe for consumption, which is far from the truth. The meat, fish, chicken, pork, fruits and vegetables in our supermarkets are often covered with bacteria. During the wintertime, a lot of our fruits and vegetables come from other countries, like Mexico, that don’t have food safety standards similar to ours, and only 1 percent of those food imports are actually being tested at all. So there are a lot of things in our grocery stores that could be potentially unsafe, and we need to tell the public to make sure they wash their food thoroughly, prevent cross-contamination, consider their food contaminated and wash their hands. You have to be very careful with every food you bring into your home to try to reduce that risk. Again, there are technologies available, pasteurization, irradiation, UV light, high pressure, that can eradicate these microbes from our food, but a lot of that technology is not being used. So we have to be safe.

The other thing I would say is that the next pandemic is coming. It’ll probably be another respiratory virus, from a bat or some other animal. Because we’re in closer contact with animals now than ever, we’re going to see zoonoses, animal-to-human transmission of viruses, and we may find another virus that we have no immunity to. That’s going to happen, and I think we need to be prepared for it.

Kevin Pho: Nicholas, thank you so much for sharing your time and insight, and thanks again for coming on the show.

Nicholas A. Daniels: You’re welcome.