IPs Are "True Blessing"

When IDWeek 2021 kicked off, Joshua Nosanchuk, MD, programs chairperson of the conference, extended a warm welcome to all health care professionals dealing with infectious diseases, including IPs. He specializes in treatment of fungal infections. In a wide-ranging interview with Infection Control Today^® (ICT^®), in addition to discussing the important role IPs play in infection prevention and control, Nosanchuk talks about how to handle medical misinformation, the structural determinants of health, the importance of fostering a worldwide community of medical professionals dedicated to fighting infections, and the challenges involved in running a virtual conference—and, of course, what the health care system has learned from the COVID-19 pandemic. “The care of a patient with COVID-19 today in my hospital—compared [with] early March 2020 when we first had 1, then 2, then 20, then 2000 at a time in our hospital—is night and day,” Nosanchuk tells ICT^®. “It’s just incredible.” The interview took place right before the start of IDWeek 2021.

Infection Control Today^®: Let’s start with what you specialize in. Just how much of a challenge do fungal pathogens present to the health care system?

Joshua Nosanchuk, MD: Over the past several decades, we’ve seen more fungal pathogens. With the explosion of HIV in the 1980s, with more extensive regimens for treating different cancers, with all the newer biologics that we’re seeing, we’re seeing tremendous numbers of these cases in our patients. Many of these organisms are all around us. We breathe them in almost every breath we take. If you have a compromised immune system, it can be overwhelmed. Similarly, there are some [that healthy] individuals are susceptible to. [For example,] coccidioides, which is a fungal pathogen found mostly in the southwestern United States as well as in Latin America. If there’s a dust storm out in the San Joaquin Valley and you breathe in some of those spores, anybody can come down with a very significant illness. There’s such a remarkable range in these organisms. Fungi are very similar to humans in terms of their structure and machinery, and so many of the drugs that we would really like to develop would also be toxic to us. The drugs that we give many of them like amphotericin, and the azoles like fluconazole, can have toxicities in ourselves as well because of similarities with cholesterol, for example.

ICT^®: That seems a serious problem in terms of treatment. How do you approach that?

Nosanchuk: First, we need to make sure we consider these in our differentials when we’re looking at a patient. We must aggressively pursue appropriate diagnostics. Diagnostics for fungi have continued to lag. Once we know a patient has these diseases, some are easy to treat in terms of duration of therapy. For Candida albicans, line infection—most of the time that’s a 2-week treatment. But for certain infections—there’s one called paracoccidioides, which is mostly found in Latin America—we treat those individuals for at least a year and sometimes for life. They’re really complicated. We must think about vaccines for certain groups of individuals, particularly [those] who live in certain areas and may be at high risk. We must continue to develop newer medications. There are some now in the pipeline. But we haven’t had many new things for armamentarium against fungi.

ICT^®: Regarding IDWeek, you’re the chairperson of programs. My core audience comprises IPs, most of whom have a nursing background. What’s on the agenda that you think will be of particular interest to IPs?

Nosanchuk: There’s a lot that’s happening and some of it has already begun. There are some premeeting workshops on antimicrobial stewardship and on infection control that are very important. Some of these are focused more on trainees and others are for experienced individuals. One of the important things about our meeting is that over the past several years, we’ve increasingly focused on structural determinants of health—not just dealing with the immediate problem but how and why do [individuals] end up with these diseases? How can we prevent that from happening? How can we prevent it as [individuals] move forward from whatever acute crisis they’re having? COVID-19 has also shown very marked structural determinants that have influenced certain communities. For example, where I am in the South Bronx, [consider] individuals who developed COVID-19 back in April or May 2020. If they went home to isolate there was no place for them to isolate. They were living in multigenerational houses with only 1 bathroom; very different than somebody who’s more affluent and may have many different rooms in their house where they can go. [We need to be] thinking about not just the incidents where you’re engaging with that patient in a nursing home or hospital, but what’s going on in society and communities more broadly. The other thing that I’m very happy about with our IDWeek is that we’ve tried to have robust presence of diverse individuals for speaking. Over the past many sessions, we’ve had at least a 50/50 split of men and women as speakers. For this year, we have at least that as well. That’s important to share. We have incredible talent across our field [that includes] PharmDs who are now a major force in our societies, as well as physicians, as well as our nurse colleagues. It takes an interdisciplinary approach to be successful at addressing some of these weighty issues. One of the things we’re all focusing on is misinformation. There’s a nice session on misinformation and public health, and what we can do better. There’s one that’s entitled “A Psychological Vaccine Against Misinformation” by [Sander van der Linden, PhD], who’s coming from Cambridge in the United Kingdom. This is important: How do we make sure in a time of infinite information access that we as a community of health care practitioners are giving the right information? Unfortunately, there are some in our fields who are not delivering true data. We must figure out how to make it more robust. There are also talks on how to authentically engage and communicate with different communities. What may work in my community may be very different than what you may need in Colorado, California, or Texas. And so, [it’s about] figuring out the needs of the community and not just going in and trying to hypereducate, because that’s not what some [individuals] want. [Individuals] want to be heard. They want their concerns and their fears to be able to be aired; coming in and just telling them that they’re wrong is not always a very effective way of convincing [individuals] to change.

ICT^®:You use the term “structural determinants of health.” I’ve heard of social determinants of health. Is there any difference?

Nosanchuk: It’s similar. It has just been changing to that newer term over the past 3 years or so. It’s because there are so many facets to it. It’s not just social. There are other aspects in terms of race and gender. It’s become a broader term to try and catch more of the influences that come in and affect someone’s wellness.

ICT^®: You talked about the problem of misinformation. Was that a problem in terms of how you went about organizing the IDWeek conference? Did you have to sift through a lot of data that just didn’t make the grade?

Nosanchuk: We have an abundance of riches in terms of the [individuals] who can speak toward these very complicated processes. We’ve also expanded to get individuals outside of the common groups that we frequently used [in the past]. We now include social researchers. We include many more PharmDs. We include many more nurse practitioners. When I started going to IDWeek it was only infectious disease faculty. Occasionally for some of the basic science work, we would have professors in microbiology or immunology talking. We’ve become much more inclusive in who we are inviting to speak. We also have grown into an international meeting. We’re including a lot of international folks. Last year because of COVID-19 and switching to virtual and trying to figure out the best way to deliver important information…we started something called Chasing the Sun, which started with US investigators and clinicians, and then we included our colleagues from around the world. We’re doing that again this year. That hopefully will be interesting. We’ll finish with [Rochelle Walensky, MD, director of the CDC] giving a nice presentation on the status of where we are. The status is continuously moving. You may have noticed that there’s been a lot of controversy over a third shot for the mRNA vaccines, and there have been [individuals] weighing in on both sides. Rochelle Walensky just made the statement that that third booster will include [individuals] whose jobs put them at enhanced risk for acquiring SARS-CoV-2.¹ [Individuals] talk to me all the time: “Where are we?” I keep saying it’s a roller coaster and we’re learning more all the time. What we have learned over the course of this pandemic has been incredible: the numbers of papers, the numbers of drugs that have been assessed, and some of them have moved in and made an incredible difference. The care of a patient with COVID-19 today in my hospital—compared with early March 2020 when we first had 1, then 2, then 20, then 2000 at a time in our hospital—is night and day. It’s just incredible. There are new data about things like remdesivir as an outpatient drug, reducing hospitalizations, and improving outcomes.

ICT^®: To go back to your statement about misinformation: Do you use preprint studies sometimes? How do you decide which are worth keeping and which are not?

Nosanchuk: That is an incredibly important question. It’s hard. There are preprints that have come out of leading institutions that have then gone under fire afterward. You really must look at the data very carefully. You must look at whether they’ve defined what some of their shortcomings are. If they don’t describe what their shortcomings are, that raises red flags that they really were missing some things. The preprints have been very useful for investigators because they allow them to put a placeholder in their research. When somebody else comes through and has something published, they can show that they had this information. This has been a challenge for a long time. I had, at one point, published a paper on a novel gene knockout method for the fungus Candida parapsilosis. We had shared that technique with a colleague and ours was published in The Journal of Clinical Investigation, which has a long lag time from acceptance to publication. My colleague published her work in a journal that had a very rapid [time from] acceptance to online presence. When my paper came out, there were [individuals] saying, “This isn’t new. So-and-so already published it.” Being able to put things into one of these preprint servers has been helpful for the scientific community in general. But it also doesn’t mean everything in that realm is going to get published [in a peer-reviewed journal]. It hasn’t undergone the scrutiny, which is so important. Some journals have a very low threshold for publishing and there are a lot of predatory processes out there requesting you publish in their journals for a fee. Almost all journals now require a fee. One called Cellular Microbiology that used to be free has now moved onto a new platform and will no longer be free. The folks like myself, we get at least 2 to 5 emails a day from different journals saying, “Respected sir, please submit a paper to our journal. We’ll give you a very fast turnaround time.” There’s been literature where people have put things like “rubber ducks” or various random words into their manuscripts and they’ve gotten published. You must look at where things are being published to validate that it’s real. Some of these journals are also on PubMed and on other respected networks. How do you really determine whether something is valid? That gets to carefully reading the information. If there is an editorial that goes with it and analyzes some of its positives and negatives, and this individual who’s written that editorial is somebody well known in the field, that can help as well. More respectable journals will often do that with their impactful findings. The other thing I will say is that time from submission to publication, especially for things about COVID-19, was significantly accelerated. Many more things were published online before [they were published] in print through these journals to get that information out and to show that it was peer reviewed and validated in their eyes as being worthwhile for sharing with the community.

ICT^®: How much of a challenge is it to run a virtual conference? Are things being done at this virtual conference that you think will remain in place even after we’re able to meet face-to-face?

Nosanchuk: An important question. When we had to switch a year ago to virtual, we had a very short turnaround time and the platform did not work as well as we would have liked. We looked at different platforms and picked Juno, which is the one we’re using now. So far, we’ve been very pleased and impressed with how that’s been functioning. I think we will maintain some of these simu-live activities. I will also say that [during] the last in-person IDWeek that we had, we did stream several of our higher-impact programs, especially some of the named lectures. We were testing it. I was in an office watching instead of in the room, just to see how it would look and how well the fidelity was. We were impressed with it. We were planning on doing more of that last year. But we didn’t because we were fully virtual. We’ve been talking about what to do in the future. We are very hopeful that IDWeek 2022 will be in person and discussing what types of things should still be broadcast live and how we would be able to do that in a way that we’ll still have [individuals] coming. Because it is something that is incredibly easy to stay home and watch. I watched probably 3 times the number of sessions last year virtually then I would have if I’d been there. If I’d been there I would have been meeting with colleagues and sometimes not even making it into the room, because you’re in an interesting conversation. Whereas at home, I was able to watch and, in the breaks, instead of going to the poster hall and again meeting with colleagues, I watched another of the seminars. I thought it was incredible how much information I was able to get. We also kept the portfolio open all year. We were able to share that forward with the attendees. Certain sessions were impactful. One was on some of the real ravages of COVID-19 on societies. One of those we were able to get released so that, for example, the medical students at my school were able to watch because it was so impactful. So how are we going to do this? It’s unclear what platform we will be using in the future. We really want to get through this year’s meeting and [look at] some of the new interventions—especially having [individuals] come back live after the prerecorded presentation to do a Q&A, which we couldn’t do last year—and see how that goes. We really do want to get international folks to the meeting, especially from some of the developing countries. One of the things I often see is manuscripts or poster abstracts from individuals from lower-resource countries that are missing some key things that you really would want to see in the work to make it more robust, and having those individuals come in and meeting and talking with them. Introducing them to collaborators can expand their capacity to do research and discovery in the future. It’s important to try and have international folks coming in person. Many of them also will go and visit an institution or two while they’re here in the United States because if you’re going to spend the money and come, meeting with other colleagues is often very valuable. I do the same thing. If I go to a meeting in Brazil, for example in San Paolo, I’ll go and visit colleagues I’ve been collaborating with in Rio de Janeiro. It is important to foster those cross-talks and develop new collaborations because they have resources we don’t, and we have resources they don’t.² Together, we can always be stronger.

ICT^®: Walensky is going to give a presentation?

Nosanchuk: Dr Walensky was one of the chairs of IDWeek in the past, so she is very well connected with the Infectious Diseases Society of America and IDWeek. She has been a wonderful colleague and asset to all of us. We often do have very well-known keynote speakers, [individuals] from [the National Institutes of Health (NIH)], the CDC, and the [World Health Organization]. [Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases] launched our Chasing the Sun [global broadcast] last year, and that was incredible to have him start out with that. This year, [Barney S. Graham, MD, PhD] who is from the NIH, will be launching Chasing the Sun. We have been very fortunate to have significant individuals in public health, epidemiology, stewardship, and infection prevention give these major talks at IDWeek. We’ve had [individuals] from the [Bill & Melinda] Gates Foundation and other impactful foundations come and participate as well. We try to bring individuals who will inspire and who have made major changes in the way we address the challenges in our field.

ICT^®: Speaking specifically of IPs: What do you think they’d find compelling on your agenda?

Nosanchuk: I think it’s remarkable when you go through the agenda [concerning] what addresses infection prevention. Because how do you look at infection prevention? Is it through having improved diagnostics, so you can have a quicker knowledge of somebody being ill or not ill and therefore put in faster infection controls to isolate or otherwise restrict access to that patient’s room? Is it about having better medications to more rapidly clear an infection so that [individual] can then come back into the community? I look at infection prevention as an incredibly broad net; basically, how do we prevent [individuals] from getting sick? But once they are sick, how do we most rapidly and efficiently make them better and keep them from spreading this disease to other [individuals]? It also is structural in terms of gowns and gloves. What are the right kinds of gowns and gloves? COVID-19 is another example of the fact that we weren’t sure what to do very early on in terms of wearing masks in large gatherings: wearing an N95, wearing a face shield. There’s going to be information on this. There is a session on appropriate gowning and gloving in long-term care and nursing homes. There’s also a session about how we are going to emerge from this pandemic. It’s called “Emerging IP Issues Outside of Acute Care: There’s No Place Like Home.” Focusing on personalized infection control within various settings. There’s one [called] “Infection Prevention in Long-Term Care: Finding the Silver Lining After COVID-19.” Infection prevention when the home becomes the health care setting. There are interesting presentations that will energize the community, leading to more questions and hopefully new studies that will give us better answers in terms of how to prevent certain diseases. If you have something like Clostridioides difficile and you have these spores that are so resilient, how do you treat a home of a patient who has this, when they develop it at home, come into the hospital, and go back to home again? Should we have some type of process to clean the home or to clean everybody’s shoes in and out of that home? There are a lot of unanswered questions. Having communities come together and ask these is the best way to start addressing them in the future.

ICT^®: Dr Nosanchuk, is there something I neglected to ask that you think is pertinent to this topic and that you’d like IPs and other health care professionals to know about either fungal pathogens or IDWeek?

Nosanchuk: We must always be on our toes; frontline individuals like IPs sometimes are the first to start seeing and figuring things out. Over the past several years, we have [had] Candida auris, but we’ve also had Zika, we’ve had Chikungunya, we’ve had Ebola. We’re going to probably see more diseases coming as the world continues to get smaller, and we have climate change that is disrupting so many areas of our lives. I just would advocate for [individuals’] ongoing vigilance. The other thing I would say is that what our community is doing is so incredibly important. When I teach the medical students, one of the things I want them to always remember is that washing their hands is one of the most important things they can do for the wellness of their patients. Simple things like that, always stopping to think, “Let me wash my hands. Let me wash my hands after.” Constantly putting infection prevention ideas and processes in place is what will keep our community the safest. What the IPs are doing is a true blessing for our community and not always as well recognized as it should be. Even though you think “maybe I’m just doing the same thing over and over,” it’s an incredibly impactful activity that changes lives and saves lives. I just want to say thank you to all the [individuals] who are doing this work. Over my career, I’ve seen it improve and continue to improve and it’s so impressive.

This interview has been edited for clarity and length.

References:

1. Diamond F. CDC chief vetoes advisors: health care workers can get booster shots. Infection Control Today®. September 24, 2021. Accessed September 29, 2021. https://www.infectioncontroltoday.com/view/cdc-chief-vetoes-advisors-health-care-workers-can-get-booster-shots
2. Diamond F. $2.1 billion to be invested for infection prevention and control efforts. Infection Control Today®. September 20, 2021. Accessed September 28, 2021. https://www.infectioncontroltoday.com/view/-2-1b-to-be-invested-in-infection-prevention-and-control