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Transcript

Monkeypox Update · The SHEA Podcast

• 0:11
  SPEAKER_00: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare-associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:26
  SPEAKER_00: I'm Dr.
• 0:27
  SPEAKER_00: Chrissy Woods and I will serve as your moderator.
• 0:29
  SPEAKER_00: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:38
  SPEAKER_00: Shay is excited to launch this episode of the podcast that will provide an update on Monkey Pox.
• 0:44
  SPEAKER_00: Our speaker today is Dr.
• 0:45
  SPEAKER_00: Alison Arwoody, the commissioner of the Chicago Department of Public Health at CDPH, charged with leading the nation's third largest city's health department.
• 0:54
  SPEAKER_00: Dr.
• 0:54
  SPEAKER_00: Arwoody has been at CDPH since 2015, where she initially served as chief medical officer, overseeing the disease control, environmental health, emergency preparedness, and behavioral health divisions before being confirmed as commissioner in January 2020.
• 1:10
  SPEAKER_00: Prior to CDPH, she worked for the U.S.
• 1:13
  SPEAKER_00: Centers for Disease Control and Prevention, CDC, including as an epidemic intelligence service officer.
• 1:20
  SPEAKER_00: With CDC, she worked on HIV and tuberculosis in Botswana and international outbreak responses in Saudi Arabia for the Middle East respiratory syndrome and on Ebola in Liberia.
• 1:31
  SPEAKER_00: Thank you for joining us today.
• 1:32
  SPEAKER_01: Thanks for having me, and thanks to Shay for such a great podcast.
• 1:37
  SPEAKER_00: So we'll jump right into it.
• 1:38
  SPEAKER_00: Can you start by setting the stage for us?
• 1:40
  SPEAKER_00: What was monkeypox like as the outbreak really gathered momentum in the Chicago area?
• 1:45
  SPEAKER_01: Chicago, as one of the biggest cities in the US, was one of the early places to see monkeypox.
• 1:52
  SPEAKER_01: And we really see this quite consistently, given that the largest cities have the international airports, have the density of population, and frankly, a lot of the diagnostic capabilities that some other places may not have.
• 2:05
  SPEAKER_01: We were seeing cases by early June and really in full response mode by the middle of June.
• 2:11
  SPEAKER_01: I'd say right at the beginning, of course, there were a lot of questions.
• 2:15
  SPEAKER_01: We knew about monkeypox, but not the way that it was showing up.
• 2:19
  SPEAKER_01: We knew about it.
• 2:20
  SPEAKER_01: And in fact, it had an outbreak here in the Midwest, maybe a decade plus ago, that was more linked to MPV connection to some imported animals.
• 2:29
  SPEAKER_01: But knowing that this was traveling likely from Europe and then traveling in social and sexual networks meant that we needed to very quickly have a lot of focus.
• 2:39
  SPEAKER_01: So right at the beginning, we pulled a lot of partners together.
• 2:43
  SPEAKER_01: I will tell you the one thing we learned from COVID was that anything that was going to be successful in public health response was going to be through partners.
• 2:50
  SPEAKER_01: And I think especially for monkeypox or what we've come to more often call MPV in Chicago, that's especially true where you want to have trusted messengers, providers who regularly serve the LGBTQ community, lots of people part of this response.
• 3:05
  SPEAKER_01: And so, right from the, you know, I think by by June, we were having calls and webinars every day.
• 3:11
  SPEAKER_01: Some focused on healthcare providers, some focused on community-based organizations already starting to stand up some of the very targeted vaccine outreach.
• 3:21
  SPEAKER_01: We didn't have enough vaccine yet to be able to be hosting large clinics or say come one, come all, but this work of going through partners to try to get the highest risk people tested, to try to get the highest risk people vaccined, and to try to get good messaging out.
• 3:35
  SPEAKER_01: So it was really all hands on deck, but taking a lot of the lessons, the local lessons from COVID, very much to heart.
• 3:42
  SPEAKER_00: So in that spirit of partnership, obviously part of the equation is the general public, because those are going to be the individuals that we're going to need to help to understand how this spreads.
• 3:52
  SPEAKER_00: And I'm curious how you managed to target the key demographics impacted by monkeypox to try to help with some of that maybe behavioral change or even the understanding.
• 4:01
  SPEAKER_01: I'd say early on, this was particularly challenging because public health and healthcare was aware of monkeypox long before, in a lot of ways, the general public was.
• 4:13
  SPEAKER_01: And so early on, we were putting a lot out a fair bit of messaging that was saying the same thing we've been consistent with all along, that here is what MPV is, here is what we know at this point about how it is spreading, and very explicitly saying most but not all cases in Chicago across the US have been in gay bisexual and other men who have sex with men.
• 4:35
  SPEAKER_01: And I'll tell you right at the outset, there was pushback from people saying, if all the cases aren't in men who have sex with men, then why are you extra focusing on that group?
• 4:45
  SPEAKER_01: Isn't this stigmatizing?
• 4:46
  SPEAKER_01: And then on the other side, we had folks saying, you know, you're not being specific enough.
• 4:50
  SPEAKER_01: And so I think this is where every day really we were adjusting messaging and thinking about different populations and encouraging some fairly split messaging, just as one example, where we were thinking about targeting the key demographics.
• 5:03
  SPEAKER_01: We were using our own local data.
• 5:05
  SPEAKER_01: When we were doing our case investigations here, we're turning those around as quickly as we could.
• 5:09
  SPEAKER_01: We put a lot of folks on overtime to make sure every time somebody was diagnosed, we're getting those interviews done.
• 5:15
  SPEAKER_01: And we were seeing geographic locations, particular gathering sites, particular websites were feet, you know, and sort of dating apps that people were meeting on, and then using that information in real time to say, let's work on getting vaccine, you know, at this bathhouse, let's work on working with this network of people who are putting together particular parties, let's work with the kink club, let's work with all of these groups, not in a way that is saying your activities need to stop, but that we need folks who are part of your network to know that there is a risk right now and that there are certain things that folks should be doing to help limit that risk.
• 5:54
  SPEAKER_01: And we're never gonna say don't have sex, but you know, we did a whole campaign, for example, around before you turn the lights off, turn the lights on, take a look.
• 6:02
  SPEAKER_01: You know, does anybody have a sore?
• 6:04
  SPEAKER_01: Just sort of being a little bit playful.
• 6:06
  SPEAKER_01: Yeah, a little bit playful with it, but also really like you got to talk about sex.
• 6:10
  SPEAKER_01: You can't talk about MPV without being really quite willing to talk about what the risk factors are.
• 6:17
  SPEAKER_01: And pretty early, we knew that we needed to get some messaging together about highest risk, some risk, and lower or at this point minimal risk activities, because this hadn't really come out nationally yet.
• 6:30
  SPEAKER_01: And so we looked at our local data compared to what was known nationally and internationally, and created just a very basic graphic that said, you know, highest risk is intimate or sexual contact or direct contact with open lesions.
• 6:43
  SPEAKER_01: Some risk, kissing, perhaps being in the same bed of somebody who's infected, and then really minimal risk, the things that the general public was sort of unnecessarily worried about.
• 6:54
  SPEAKER_01: Things like, do I have to be worried going to the gym or crutching a doorknob or swimming in a swimming pool?
• 7:01
  SPEAKER_01: And trying to help both increase the awareness and potential behavioral change among the groups who are at highest risk, understanding what that risk is, and then decreasing in some ways the worry around people who were at this point anyway, really quite low risk, so that we could make sure, especially when our intervention resources were quite limited at the beginning, you really wanted to make sure that was getting where it was most needed.
• 7:28
  SPEAKER_00: That's a very tricky sort of walk to take, too, because you you want to make sure that you're reaching the groups that you really want to reach that you know, at least by your own statistics, are the ones that we really need to get the message out to.
• 7:39
  SPEAKER_00: But at the same time, you really, really risk stigmatizing those groups.
• 7:44
  SPEAKER_00: Again, the general public had their own opinions about sort of who is getting this and how they're getting this and you know what to do.
• 7:49
  SPEAKER_00: And it clearly was not always correct.
• 7:51
  SPEAKER_00: So I'm wondering what you did to try to balance that, how you tried to reduce the stigma around it while at the same time making sure that you're continuing to get the message out to the groups that at least demographically we know were most affected.
• 8:03
  SPEAKER_01: Yeah, it's so important.
• 8:04
  SPEAKER_01: I think we have learned a lot from the HIV AIDS epidemic and sort of how to talk about sex, frankly, but in a way that is not putting blame on individuals, but talking about are there ways that you can help limit risk?
• 8:22
  SPEAKER_01: How can you perhaps change behavior, especially in a temporary way, while this outbreak is while we're learning about it and while we're working on trying to get people protected?
• 8:31
  SPEAKER_01: I think the biggest thing, honestly, was for us to take our lead from trusted LGBTQ partners in Chicago.
• 8:40
  SPEAKER_01: Every Friday, for example, we were having these calls that were having 250 plus organizations on them, everything from federally qualified health centers that serve a lot of gay men in Chicago to the community-based organizations, some of the businesses that are particularly focused on this group.
• 9:01
  SPEAKER_01: And they were giving us very frank feedback and suggestions.
• 9:05
  SPEAKER_01: And our team was creating these message maps, which were the basics of here's what we know, here's how you can limit risk, here's what you should do, which obviously is changing as vaccine is available and treatment are more available, but then encouraging these partners to translate that for their audience.
• 9:24
  SPEAKER_01: So when we had some of the large festivals here, right, we have not just Pride, but there's a number of other large LGBTQ-focused festivals that bring a lot of travelers.
• 9:35
  SPEAKER_01: We saw businesses really step up to create their own posters, their own messaging for the TVs in the bar, their own handouts, their own, and sort of checking back with us, like making sure that this is correct.
• 9:49
  SPEAKER_01: But in those cases, being, for example, a lot more risque in the messaging sometimes than the health department might be.
• 9:56
  SPEAKER_01: And that messaging is well suited to that group.
• 9:59
  SPEAKER_01: Whereas when you're working with Latino focused organization that works through churches, for example, to support LGBTQ folks, that messaging is not going to be a good fit.
• 10:09
  SPEAKER_01: And so it's this let's make sure you're getting the basics in, we're being clear about what people should do, but then please adapt this.
• 10:16
  SPEAKER_01: We pointed everybody back toward our website.
• 10:19
  SPEAKER_01: We set up a website very quickly with our local data.
• 10:22
  SPEAKER_01: Here's what we know, here's lots of things to download in lots of languages, and it's just a ton on social.
• 10:27
  SPEAKER_01: Like that's something that we didn't have a lot of capacity to do, honestly, prior to COVID.
• 10:32
  SPEAKER_01: But we now have a graphic designer, we have someone who can make videos and TikTok, we have people who can really quickly develop materials that actually speak to people and are a little more interesting than the traditional very dry public health messaging, which is important, but often perhaps doesn't get the attention that we need it to, especially when you're in a hurry.
• 10:52
  SPEAKER_01: So it's all about partners.
• 10:53
  SPEAKER_01: And when people are talking to people that they already trust, they're more likely to hear the message and feel that people are speaking to them, that this is not about stigma, this is just about protecting the community.
• 11:07
  SPEAKER_01: And that, you know, the LGBTQ community, I think again, partly because of HIV AIDS, is very tuned into infectious diseases in some way and just protecting the community and really advocating for resources and messaging.
• 11:22
  SPEAKER_01: And I see that as a major strength.
• 11:24
  SPEAKER_01: We really appreciate the push on how we can work together to get more resources more quickly, turn things to be the way that it is.
• 11:32
  SPEAKER_01: And so I think it's about saying we don't want this to be stigma.
• 11:35
  SPEAKER_01: Here's the truth.
• 11:36
  SPEAKER_01: I was in a press conference with the mayor, I remember early on, and I don't do as many press conferences infectious disease focused with her as I was during the height of COVID.
• 11:47
  SPEAKER_01: And she was getting questions that had nothing to do with monkeypox, but then some of the reporters started asking these very specific about, you know, certain kinds of sexual activity and is this at risk?
• 11:57
  SPEAKER_01: And the mayor was just like, is this what your press conferences are like?
• 12:01
  SPEAKER_01: I was like, mayor, this is what people have questions about, you know, and and this sense that you just want to be very straightforward.
• 12:08
  SPEAKER_01: Like, here's what we know.
• 12:09
  SPEAKER_01: Let's be adults about this and make sure that we're being clear.
• 12:13
  SPEAKER_01: There is a group that is most affected, but not all cases are in that group.
• 12:18
  SPEAKER_01: And so anybody who's got a new sore, they don't know what it is, go to your doctor.
• 12:23
  SPEAKER_01: You can get a test, and then we can vaccinate people around you if it is MPV.
• 12:27
  SPEAKER_01: But I think it it was important from the beginning to highlight that it is not only that group who is affected, especially if there are people who aren't out or aren't as willing perhaps to talk about same-sex interactions.
• 12:40
  SPEAKER_01: We made a point of telling the stories of women who had been infected or, you know, people who had been at risk through sharing a household, et cetera, even though that wasn't the majority of the cases while doubling down on the majority.
• 12:52
  SPEAKER_01: But it was a lot of outreach right at the beginning and really a balancing act.
• 12:56
  SPEAKER_01: And we were looking every day at what was landing well, what was getting uptake on social, what was getting a lot of, you know, potentially negative feedback early on.
• 13:04
  SPEAKER_01: And we just kept going at it.
• 13:05
  SPEAKER_01: And I actually think it went reasonably well, all things considered.
• 13:09
  SPEAKER_00: I completely agree with you on the fact that our partners in the LGBTQ communities have really helped with getting on top of this, wanting to get the messaging out.
• 13:18
  SPEAKER_00: We had a lot of questions from a lot of groups, specifically asking then once the message was out, like, well, how do I get tested?
• 13:24
  SPEAKER_00: How do I get vaccinated?
• 13:26
  SPEAKER_00: And we had a lot of issues with testing delays, with the availability of tests, with limited supplies of vaccine.
• 13:32
  SPEAKER_00: I know in New York City, you know, there'd be a text that would come out to book appointments and our website would crash because everyone was really trying to access it.
• 13:40
  SPEAKER_00: And it sort of felt, in some ways, like the early days of COVID where the testing was so restricted.
• 13:44
  SPEAKER_00: And I mean, with that, we were dealing with an unknown disease, or so it was a little bit different.
• 13:48
  SPEAKER_00: But those some of those parallels have been made.
• 13:50
  SPEAKER_00: And I think to some extent they're fair.
• 13:52
  SPEAKER_00: So I'm curious how you were able to manage those testing delays and the delays of supplies or limited supply availability.
• 13:59
  SPEAKER_01: Yeah, absolutely.
• 14:00
  SPEAKER_01: So one thing I think it's just important for everybody to recognize that the only reason we actually had a test that could work for this, that we have an antiviral that can work for this, that we have a vaccine that can work for this, is because as a country, we've invested in preparedness around smallpox.
• 14:19
  SPEAKER_01: Because of that, in case there were to be a bioterrorist event, we have orthopox testing available at all of the public health state labs.
• 14:30
  SPEAKER_01: And so, unlike COVID, where there really was no test available and everything had to go to CDC, and it was very it was really not meeting anything like the demand.
• 14:40
  SPEAKER_01: Here, right at the beginning, you could at least get that orthopox test.
• 14:44
  SPEAKER_01: And if an orthopox test is positive, you basically know it's either monkeypox or smallpox.
• 14:48
  SPEAKER_01: And in this context, it's monkeypox.
• 14:50
  SPEAKER_01: But every single case had to be approved through the local health department to get tested at the state laboratory.
• 14:56
  SPEAKER_01: And so that meant my medical staff that are on call 24-7 are having to triage and we're we get overwhelmed very quickly.
• 15:04
  SPEAKER_01: It's very frustrating for providers because if there is somebody who's really pretty low risk, we can't always take that test forward because there are people who really need the testing capacity more.
• 15:16
  SPEAKER_01: And so we really in public health had to stand up, run the labs over the weekends, run that support sort of to providers and work on getting testing out.
• 15:26
  SPEAKER_01: So when the expansion came, which was really pretty quick, I mean, it could always be faster here, but that expansion to really get that testing available in the clinical labs so that your quests and your lab cores of the world could do the test, that was revolutionary for us because then all of our providers can use their regular approaches.
• 15:46
  SPEAKER_01: And we can literally say, go to any doctor in the city, they should be able to do it.
• 15:51
  SPEAKER_01: And our first, you know, hundred or so cases, I think they were diagnosed by about 50 providers across the city, which let us know.
• 15:58
  SPEAKER_01: We were watching that too to see is messaging getting out to providers, are enough people aware and testing?
• 16:03
  SPEAKER_01: So we were very pleased, and most of them were primary care providers.
• 16:06
  SPEAKER_01: It wasn't, I mean, yes, there were people being diagnosed, of course, in STI clinics or more LGBTQ focused, but there were lots of initial positives early on from these other settings.
• 16:16
  SPEAKER_01: And so as a health department, when the testing is very limited, you're having to compare and you know that we you always want more testing capacity than is available.
• 16:25
  SPEAKER_01: So once that opened up, and I think you know, messages for the future is just the sooner we can move to quickly expand that testing capacity, the better.
• 16:34
  SPEAKER_01: And if this had not been an orthopox, it probably would have been much worse if we had a real emerging disease that we didn't have that in place for.
• 16:42
  SPEAKER_01: And I think on the vaccine front, just quickly, we took a different approach from what New York did because we were frankly seeing what was happening with the crashing websites and the severe, very understandable frustration.
• 16:56
  SPEAKER_01: We did not initially advertise like we're gonna have a clinic, here is where you can go to get vaccinated.
• 17:03
  SPEAKER_01: We used the COVID analogy and we said at the beginning of COVID, there was not enough vaccine.
• 17:07
  SPEAKER_01: It had to go to the very highest risk, the healthcare workers and the those over 65, the neighborhoods that are hardest hit.
• 17:14
  SPEAKER_01: And we took that same approach in explaining it.
• 17:16
  SPEAKER_01: But really, we were embedding vaccine efforts in these highest risk settings, related to the bars, related to some of the gathering spaces, related to some of the events, and then really putting them in again, the providers that we knew from our data were seeing the most impacted patients.
• 17:35
  SPEAKER_01: We were doing some campaigns, certainly where you do hundreds, but we weren't like come and sign up just yet.
• 17:42
  SPEAKER_01: Because I think when you do that, ideally you want to have all men who have sex with men be getting this vaccine.
• 17:49
  SPEAKER_01: But right at the beginning, in the same way you have to target testing, we really targeted.
• 17:52
  SPEAKER_01: And this is where the partners were critical, telling us where do we most need to put this first.
• 17:57
  SPEAKER_01: And then, of course, we worked to make sure that we did have appointments available in the city's sexually transmitted infection clinics.
• 18:05
  SPEAKER_01: And as that supply opened up a little bit more, we then stood up larger clinics and you know, we sort of grew that.
• 18:11
  SPEAKER_01: But at the very beginning, people are very used to public health during COVID saying, come on, come all, get a vaccine.
• 18:16
  SPEAKER_01: And it was this real tension between wanting to make sure we were using vaccine up as fast as it was getting here, but also that it was getting to those spaces that were most driving our outbreak.
• 18:27
  SPEAKER_01: So folks who were provide, you know, prescribing PrEP, we were like, this is who we want to get vaccinated.
• 18:32
  SPEAKER_01: And then thinking about equity.
• 18:33
  SPEAKER_01: This has been a major focus always, but especially during COVID in Chicago.
• 18:38
  SPEAKER_01: So looking geographically and by race, ethnicity, where are we seeing cases?
• 18:43
  SPEAKER_01: What is the breakdown there?
• 18:44
  SPEAKER_01: Who are we seeing vaccine uptake lagging in?
• 18:47
  SPEAKER_01: Who is getting teapots, the treatment, and who is not, how do we really kind of watch that as well?
• 18:53
  SPEAKER_01: And so we were reporting that out from the first probably two or three weeks and then adjusting our efforts every week to try to fill gaps where we saw, for example, vaccination lagging in Black and Latinx Chicagoans.
• 19:05
  SPEAKER_00: In terms of vaccination, there's been a shift in certain situations, certainly not all of them, to the subcutaneous to intradermal injection.
• 19:12
  SPEAKER_00: And I was wondering if there are any decisions or policy implications related to that change to address the limited supply.
• 19:20
  SPEAKER_01: Frankly, in Chicago, we were very pleased by this switch to intradermal injection because it let us have about four times the amount of vaccine right at the time when we were at the peak in July there, I think, if I remember correctly, of the most cases that we were seeing and so much demand.
• 19:36
  SPEAKER_01: And it was really with that we were able to start having more of these larger clinics open up eligibility.
• 19:43
  SPEAKER_01: I think with the shift from subcutaneous intradermal, we saw, I mean, there's training that's required on that.
• 19:50
  SPEAKER_01: There's supplies.
• 19:51
  SPEAKER_01: We didn't really have funding to help people buy as many of the tuberculin syringes that you'd like for the intradermal.
• 19:59
  SPEAKER_01: And we saw larger clinical settings be able to make that shift a lot more quickly than our smaller community-based providers.
• 20:07
  SPEAKER_01: And again, where you're thinking equity, et cetera, that really was a concern.
• 20:11
  SPEAKER_01: But we tracked, you know, within the probably a week or two, we had probably half of our providers switched over to intradermal.
• 20:18
  SPEAKER_01: And then within another couple of weeks, just about everybody's.
• 20:21
  SPEAKER_01: Obviously, there have been some concerns.
• 20:24
  SPEAKER_01: There's a lot of education needed around that.
• 20:26
  SPEAKER_01: So people understand why their first dose perhaps was subcutaneous and their second is intradermal.
• 20:31
  SPEAKER_01: If there are people with concerns about not wanting it on their arm, making sure we had the direction for where else you can do it, certainly some conversations, and you want to be really upfront about if anybody has a history of keloids, what can we do there?
• 20:44
  SPEAKER_01: But really, I think this was welcomed, even though it was operationally a struggle.
• 20:48
  SPEAKER_01: We were so anxious to have more vaccine that it worked well.
• 20:52
  SPEAKER_01: And we're part of a vaccine efficacy study here, really looking at breakthrough infections.
• 20:57
  SPEAKER_01: Are we seeing people get MPV after a first dose, even after a second dose?
• 21:02
  SPEAKER_01: Does there seem to be any difference in terms of motive administration?
• 21:05
  SPEAKER_01: Those are the kinds of questions that are really important to answer long term.
• 21:09
  SPEAKER_01: But we were really very much embracing of this because we just needed vaccine, was like the main thing.
• 21:16
  SPEAKER_01: We've got all the operations in place from COVID to be able to ramp up as quickly as we want, but if you don't have the materials to do that, so we we really did welcome it, but it required, again, a reshift and more education.
• 21:28
  SPEAKER_00: All of this takes a large amount of funding to accomplish.
• 21:32
  SPEAKER_00: And I'm curious if you can talk about the impact of COVID funding on the monkeypox response and how the response to monkeypox has been or not been funded.
• 21:41
  SPEAKER_01: My number one frustration leading a local health department is that I have millions of dollars still of COVID funding that is not spent, that I am unable to redirect to Monkey Pox response.
• 21:56
  SPEAKER_01: And this is because of the way we fund public health.
• 22:00
  SPEAKER_01: This country.
• 22:00
  SPEAKER_01: The funding came tied to a disease.
• 22:04
  SPEAKER_01: Congress passed not just here's funding for COVID, but here is X million dollars to support COVID testing in schools.
• 22:12
  SPEAKER_01: And here is X million to support, you know, COVID therapeutics, whatever.
• 22:17
  SPEAKER_01: And we're not even allowed to move money between those lines.
• 22:22
  SPEAKER_01: So if I have unspent money for COVID testing in schools, I can't use that and move it to be able to do the COVID outreach to encourage people to get their updated booster.
• 22:32
  SPEAKER_01: And even more than that, we did not receive a single dollar for monkeypox response.
• 22:38
  SPEAKER_01: What does that mean in practice on the ground?
• 22:41
  SPEAKER_01: We can't not respond.
• 22:43
  SPEAKER_01: And so we have been using a lot of the things we've built during COVID and just assuming that we'll be able, frankly, to have it fit COVID in some way.
• 22:54
  SPEAKER_01: So when we're out doing monkeypox vaccines, we have to make sure there's like a COVID vaccine there too, to be able to use the people who are COVID funding toward vaccinations.
• 23:04
  SPEAKER_01: And I just give it as one example because my biggest frustration in this role is that we don't fund for just general infectious disease preparedness, especially in large cities where these things tend to emerge.
• 23:18
  SPEAKER_01: I've been doing this for quite a while, and this is our pattern.
• 23:21
  SPEAKER_01: You underfund about 2% of our budget, and this is mostly comes from the federal government.
• 23:26
  SPEAKER_01: That's where most of our funding comes from at the local level.
• 23:29
  SPEAKER_01: About 2% was on infectious disease prior to COVID.
• 23:33
  SPEAKER_01: And then you fund a large amount for, oh, there's an Ebola outbreak, like months after you need it.
• 23:39
  SPEAKER_01: Here's funding for Ebola.
• 23:41
  SPEAKER_01: There's Zika, there's H1N1, whatever it is.
• 23:44
  SPEAKER_01: We only fund after the emergency starts.
• 23:47
  SPEAKER_01: And in this case, I think Congress is like, we've already given a lot to public health.
• 23:51
  SPEAKER_01: I understand that with COVID, but the way that it's been done, we officially cannot use that funding.
• 23:56
  SPEAKER_01: And that has been behind the scenes.
• 23:59
  SPEAKER_01: My administrative team has just been back and forth.
• 24:01
  SPEAKER_01: And it's been frustrating, frankly, I think for all involved.
• 24:04
  SPEAKER_01: And recently there was a decision made, you know, even after the state of emergency was declared, we weren't allowed to use COVID funds.
• 24:11
  SPEAKER_01: And there was a decision made that we can use now unspent HIV or STI funds.
• 24:17
  SPEAKER_01: But the problem is we don't have unspent HIV or STI funds.
• 24:20
  SPEAKER_01: We have unspent COVID funds.
• 24:22
  SPEAKER_01: And if people hear nothing else, I would hope folks interested in infection control, epidemiology, all of the work of Shea, a strong public health integrated with a healthcare system.
• 24:34
  SPEAKER_01: It is about stopping funding in a disease-specific way for emerging infectious diseases.
• 24:41
  SPEAKER_01: It has been extremely frustrating because people are used to us being able to do what we did during COVID, stand up all kinds of community engagement and sites and do lots of billboards and pay for all kinds of things.
• 24:55
  SPEAKER_01: And mostly to help support these community-based organizations.
• 24:59
  SPEAKER_01: During COVID, we regularly funded our federally qualified health centers who were standing up extra vaccine clinics or were doing extra outreach or extra case investigation.
• 25:10
  SPEAKER_01: We funded community-based organizations that were going door to door and making sure people knew about vaccine.
• 25:16
  SPEAKER_01: None of that has been possible with MPV.
• 25:18
  SPEAKER_01: And so it's just frustrating because we know what works.
• 25:21
  SPEAKER_01: And it's not only in Chicago.
• 25:22
  SPEAKER_01: Like we've spent the last few years figuring out what work.
• 25:26
  SPEAKER_01: And yet the way things have been funded, our amazing partners who are doing a thousand MPV vaccines a day, we don't have any federal funding to be able to support that work.
• 25:38
  SPEAKER_01: And so it's been my biggest frustration and something that I just think nationally we need to be lifting our voice about.
• 25:45
  SPEAKER_00: I have a feeling I know what you're going to say to the next question, but do you have any specific thoughts on how you would make changes should we have another big outbreak of an infectious disease, whether novel or not so novel?
• 25:58
  SPEAKER_01: Yeah, and you're right.
• 25:59
  SPEAKER_01: I already sort of pre-sage that a little bit.
• 26:02
  SPEAKER_01: I think there's nothing else that we fund like this.
• 26:05
  SPEAKER_01: If you think about how we fund federally qualified health centers, how we fund NIH, how we fund the work outside of healthcare, there's sort of this expectation that based on your population, in some way, depending what your risk is, there's a certain amount of funding that comes to make sure you can do the supports that are needed for the community.
• 26:26
  SPEAKER_01: But that is not the way public health is funded.
• 26:28
  SPEAKER_01: It's all line item.
• 26:30
  SPEAKER_01: And that creates just administratively challenges, but more than that, it leaves us not prepared.
• 26:35
  SPEAKER_01: And so I really strongly feel that funding around preparedness in the way we fund preparedness for terrorism, right?
• 26:44
  SPEAKER_01: And cities receive funding to make sure we've done exercises, we've built up capacity, we should be doing that same thing around infectious diseases because they serve, you know, as much, if not more, potential risk.
• 26:57
  SPEAKER_01: And if there is not sustained funding, the boom and bust approach is no good.
• 27:02
  SPEAKER_01: I can't hire people who I tell them the grant will run out in a year.
• 27:05
  SPEAKER_01: Won't you please come work for the health department?
• 27:07
  SPEAKER_01: And I can't sustain the on-the-ground capacity.
• 27:10
  SPEAKER_01: We've built so much here during COVID, you know, we built wastewater surveillance, as many places have around the country as a result of COVID.
• 27:18
  SPEAKER_01: We started doing monkeypox surveillance with wastewater, right?
• 27:21
  SPEAKER_01: That wasn't something we could do prior to COVID.
• 27:24
  SPEAKER_01: We want to be able to build not for a disease, but for the kind of surveillance work that we need to do long term.
• 27:32
  SPEAKER_01: So that's probably my biggest thing.
• 27:34
  SPEAKER_01: And then just to be able to always administrative preparedness is kind of my big thing.
• 27:38
  SPEAKER_01: It's not what people think about, it's not the sexy stuff.
• 27:41
  SPEAKER_01: It's working with all of the regulatory agencies about how we can speed this up, whether that's moving existing tests into the more private or the traditional lab sector, whether it's using the infrastructure that is actually very good for immunization distribution across the country.
• 27:59
  SPEAKER_01: And how do we track, you know, hundreds of thousands of immunizations?
• 28:02
  SPEAKER_01: Let's use that same system.
• 28:04
  SPEAKER_01: Let's build on that, as opposed to trying to set something up differently when it's a new outbreak.
• 28:09
  SPEAKER_01: And then just build on, you know, everybody's got a lot of lessons from COVID, good and bad, and really being serious about how we are as nimble as possible, and that that is true right at the beginning of an outbreak, because the longer it is to be able to really put the interventions in place, of course, the worse it'll get and the farther it'll spread.
• 28:30
  SPEAKER_00: Is there any specific success in managing the monkey fox response that you're particularly proud of?
• 28:36
  SPEAKER_01: First of all, just on an internal level, my team here at CDPH has really been amazing on this.
• 28:43
  SPEAKER_01: These are folks who have been very busy with COVID and all other things for the last couple of years.
• 28:48
  SPEAKER_01: But we saw this in some ways as an opportunity to trial some of the new procedures, new people that have come on, and we practiced a lot of our both structures and who needs to handle which part.
• 29:02
  SPEAKER_01: And then the work with the partners has been amazing.
• 29:05
  SPEAKER_01: Like the way the folks in Chicago stepped up.
• 29:09
  SPEAKER_01: And I don't just mean the public health folks, I mean at all level.
• 29:12
  SPEAKER_01: We saw this during COVID, and I was thrilled to see it again during MPV.
• 29:18
  SPEAKER_01: I wish I could fund it more, but even in the absence of funding, this real sense of we have strong opinions about how to do this well, and we want to work with the health department around being as on top of this as we possibly can as a city.
• 29:30
  SPEAKER_01: And so it has been really wonderful both to see folks on my own team have so much more capacity.
• 29:38
  SPEAKER_01: You know, we stood up, like I said, a local dashboard within days.
• 29:41
  SPEAKER_01: That was not something we could have done prior to COVID.
• 29:44
  SPEAKER_01: We've developed really good social media and outreach.
• 29:47
  SPEAKER_01: That was not something we could have done with that kind of speed.
• 29:50
  SPEAKER_01: And so it was a little bit of a test for us.
• 29:53
  SPEAKER_01: But it also, I think, just highlights that anything successful has to be done with the people who are the most affected.
• 29:59
  SPEAKER_01: There is nothing that's ever going to work well if you're coming from above and saying, here's the approach.
• 30:04
  SPEAKER_01: You've got to develop it always with folks who are most effective.
• 30:07
  SPEAKER_01: And I'm also proud of the fact that right from the beginning, we had some real internal metrics around things like our teapots and our vaccination.
• 30:16
  SPEAKER_01: So it wasn't just, oh, we vaccinated 35,000 people.
• 30:19
  SPEAKER_01: It was what percentage of these are in this neighborhood or are this background, and then trying to really week after week make adjustments.
• 30:27
  SPEAKER_01: So we're really using this local data to change our operations.
• 30:31
  SPEAKER_01: And that's what you want to see as a public health department.
• 30:34
  SPEAKER_01: And so I think also just our use of data and internal kind of quality metrics and being really serious about the fact that we have a long way to go, especially in terms of getting Black and Latinx Chicagoans vaccinated and not trying to hide that, having that front and center in our approaches and asking people to suggest and to help, and where we can eventually hopefully direct some funding, really do that in a very data-driven, targeted way in Chicago.
• 31:01
  SPEAKER_00: You alluded to this already in terms of kind of the changes that have been made and some of the things that have been put in place that have allowed you to be a bit more nimble and respond.
• 31:09
  SPEAKER_00: I'm curious what your thoughts are on how we can encourage and build resiliency in public health, not just with the public health sphere itself, but also within some of the personnel that have clearly been overtaxed from COVID and monkeypox and feeling like it's one wave after another of something.
• 31:27
  SPEAKER_01: Yeah, it really does feel like that.
• 31:29
  SPEAKER_01: And I think we've learned better.
• 31:32
  SPEAKER_01: We're still not perfect at it, but in public health and healthcare broadly, this need to make sure you have a good bench.
• 31:41
  SPEAKER_01: So there's not just one or two people that decisions are waiting on all the time.
• 31:46
  SPEAKER_01: We really move into this incident command that I know a lot of folks are probably familiar with at this point.
• 31:51
  SPEAKER_01: And you can move different individuals into that incident command role, into the leadership role in the different areas.
• 31:58
  SPEAKER_01: And it's good, I think, because it lets people build skills, but it also ensures that from the very beginning here, we had people.
• 32:06
  SPEAKER_01: I'm going on vacation for a week, I'm taking some time off.
• 32:09
  SPEAKER_01: Like this sense that yes, we are very much all hands on deck and using a lot of overtime and being really serious about this, but also that we're in this for the long haul and that it's on top of everything else that is going on.
• 32:22
  SPEAKER_01: And so I just we've gotten a little better at that, I think, because if you burn people out, they're just gone.
• 32:28
  SPEAKER_01: And balancing the needs and the prioritization.
• 32:31
  SPEAKER_01: But I really think rotating some of those leadership roles is very healthy.
• 32:36
  SPEAKER_01: And there's a number of us here who can step into any of those roles on this response and trust that it will continue in a way that is good.
• 32:46
  SPEAKER_01: And that to me is a sign always of a strong, prepared organization.
• 32:51
  SPEAKER_01: And I think something we all aim for, and we never get it all right, but it is about that this can't take over anybody's life 24-7 all the time for months on end.
• 33:00
  SPEAKER_01: That's a lesson we've learned really clearly from COVID.
• 33:03
  unknown: Dr.
• 33:03
  SPEAKER_00: Rowadi, I think we can definitely have this conversation for a very, very long time, but we're going to close it here.
• 33:10
  SPEAKER_00: I want to thank you so much for taking the time to talk to us.
• 33:12
  SPEAKER_00: It's really been a great conversation, and I appreciate all the insights that you've shared with us.
• 33:17
  SPEAKER_01: Absolutely.
• 33:18
  SPEAKER_01: Thanks for having me.
• 33:19
  SPEAKER_01: There's always so much more that we could say, but thanks to all the providers who are listening to folks who work in healthcare epidemiology, infection control play such a critical role every single day.
• 33:32
  SPEAKER_01: And we really appreciate the partnership between public health and healthcare.
• 33:36
  SPEAKER_01: And we're ready for whatever comes next, and I know you are too.
• 33:40
  SPEAKER_01: So thanks very much for the conversation.
• 33:42
  SPEAKER_00: Thank you again to Dr.
• 33:43
  SPEAKER_00: Arwady for sharing your perspective on this topic.
• 33:46
  SPEAKER_00: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program, where you will also find resources such as the Shea Town Halls.
• 33:57
  SPEAKER_00: This concludes today's episode of the Rapid Response Podcast.
• 34:01
  SPEAKER_00: Thank you for tuning in.