My Experience in the Online Texas Epidemic Public Health Institute (15 mins)

Infectious disease fascinates me. When the State of Texas offers a free certification program in pandemic preparedness, including courses in epidemiology and infectious disease, I'm eager to sign up. Tune in to hear some of what I loved, what I didn't love, and why access to this type of knowledge is a great opportunity overall.

Key Points:
-Public Health History in Texas
-Research Hesitancy
-Neglected Tropical Diseases

References:
-Texas Epidemic Public Health Institute (2024). Certificate Program. https://www.tephi.texas.gov/training/index.htm.
-Kuhn, T (1996). The Structure of Scientific Revolutions, 3rd ed. U of Chicago P.

Transcript

Free Public Health Infectious Disease Training

I have exciting news if you are a Texas healthcare nerd whose heart skips a beat at the words “infectious disease.” I love studying things like how to measure the virulence of an infectious disease outbreak, so I was thrilled when I discovered a wonderful opportunity for Texas residents in the science of disease surveillance and public health data analytics: the Texas Epidemic Public Health Institute’s (TEPHI) free Pandemic Preparedness certification offered through the University of Texas-Houston School of Public Health.

And even better, the certification is free for Texas residents.

So far, I am loving the material.

As I wrap up the second course, I’ve especially enjoyed the examples that relate to Texas history. Dr. Reader shared stories about the exotic peyote and opium treatments for cholera, folk remedies like wrapping a porous stone in dried deer stomach and boiling it in water to absorb rabies, and other fascinating facts about Texas public health history.

One of my favorite stories focused on the town of Sanitorium, Texas, where Tuberculosis patients used to come from out-of-state to take advantage of the dry air and West Texas weather. The town was eventually closed when TB treatment improved with antibiotic regimens, but for many years it was a major residential medical complex the size of a small city. I rather love the idea that recovering from “consumption” in a small town in West Texas was somewhat like going to Bath on the English seaside in a British novel.

And I’m sure many of us relate. Raise your hand if you planned a camping or hiking trip during COVID to strengthen your lungs, lift depression, and pretend that trees are good company?

The courses also use a lot of supporting resources like video interviews with a physician who helped treat the last known case of smallpox. The stories were fascinating, and coming off the recent experience of a pandemic, it seemed even more relevant to hear how historical figures managed the socio-political as well as clinical aspects of different diseases. I felt a wave of déjà vu hearing Dr. Fauci’s name mentioned in the context of AIDS demonstrations and resulting policy.

There are four classes plus a virtual capstone in the Certification program:

·      Foundations of Epidemiology

·      Foundation of Infectious Disease

·      Surveillance of Infectious Disease

·      Public Health Emergency Preparedness and Response

I’m just starting the third class, so I’m sure I’ll have updates after I’ve completed the whole certificate, but so far I can say that the instruction is top-notch. I think it’s really innovative of the state to offer this kind of training for Texans. It benefits the state because they are building a workforce that can help with the collection and management of data for surveillance. Each person is trained on a response system, which I haven’t gotten to yet, so that students are prepared to assist in the case of a future public health incident.

For students, it includes free Certified Nursing Education (CNE) credits, as well as access to current electronic textbooks for no additional charge. All the courses are asynchronous, so it works around any schedule.[1] It is very forward-thinking to offer coursework that meets clinical license requirements. It’s free,  it’s different, it’s interesting, but it also helps us contribute to a civic need.

What’s not to love?

While you only need to be a Texas resident with a high school diploma to take these courses for free, the material is offered at an undergraduate level of instruction and is open to everyone for a fee. My fellow students, who check in on the discussion boards, are from a variety of backgrounds. Some are in jobs that have a population or healthcare quality assurance aspect to their work, some are healthcare clinicians, some are students in a healthcare field, and others are international public health officials from other countries.

These are all things that I love about the course. But it isn’t all smallpox and tuberculosis though; there are things that aren’t great too. Back in college, I read a book called The Structure of Scientific Revolutions by Thomas Kuhn.[2] Kuhn talked about how science has notoriously struggled with paradigm shifts. Galileo was persecuted for suggesting that the sun was the center of the universe, Semmelweiss was attacked for suggesting that physicians could carry germs on their hands – clearly just their credentials would scare away any of those filthy microbes! – and the list goes on. The refusal to accept a counter argument or even to assess the value of a treatment leads me to perceive vaccination as a scientific paradigm, and the paradigm of vaccines for everything is quite heavy in both the textbooks and lectures.

Before anyone stops listening, let me explain. This isn’t an anti-vaccine rant by any means. 

Treatments, whether they are individual or population focused, are always weighed on a cost-benefit scale. We no longer give smallpox vaccinations to the entire population, because we no longer have cases of smallpox. It would be ludicrous to initiate a nationwide smallpox vaccination program when it is costly in both lives and the economy, and the benefit is null and void.

So there are some vaccines that go through the cost-benefit ratio and fail. That ratio is very much dependent on the environment, the population, incident rates, and the risk of an adverse response.

Another example would be the Bovine Tuberculosis (BCG) vaccine that was determined to not be worth giving in the United States, because TB cases are so rare and the vaccine carries a lot of risk. However, in Mexico it is still given to school children because the risk of infection is considered to be greater than the risk of adverse events. As migration increases across our borders, our decision on the BCG vaccine may change, depending on the incidence of TB cases.

The Dengue vaccine is relatively new, and it may even increase the risk of severe illness from future dengue infections. This is the nature of the disease, not the vaccine. Dengue is just one of those diseases that increases in severity with repeated infections, so even though someone may have immunity to the strain of dengue they had as a child, they can get even more violently ill from if infected from a different strain as an adult. It’s not necessarily the vaccine’s fault, but the risk is there and cannot be discounted. It’s just the nature of the illness and it would be folly to ignore that and vaccinate an entire nation only to find that the ICUs are full of severely ill people experiencing a severe secondary response to dengue even though they’re infected for the first time.

So when we talk about experimental vaccines – like the dengue vaccine, for example – we don’t really know yet if it passes the cost-benefit analysis, or whether it fails. I can’t say that it would be terrible, but no one can say for sure that it will be great either. We only know that it is possible to make, but we don’t know if it’s worth administering yet.

So when we discuss heralded, rather novel vaccines like the ones for HPV and COVID, my brow furrows. How long have we had it? How long have we collected data? How many cases of illness are there? Is it a good idea for certain population groups, or for everyone? 

My complaint is that, rather than discuss the details of an individual vaccine’s value for a given population, the term “vaccine hesitancy” was used repeatedly to describe religious fanatics whose superstition is limiting science. Healthcare scientists are not going to win a lot of friends with that attitude, especially when there are good scientific reasons to be hesitant rolling out vaccines for everything under sun. 

In quality improvement, the assessment stage is critical to properly identifying the true problem and developing a solution. If we arbitrarily label everyone who is hesitant to use an experimental vaccine as a religious fanatic, then we can be sure that the assessment and problem-identification stages have just not happened, and a real solution is frankly impossible without a better understanding. Perhaps we’ve entered an era of “research hesitancy”? We need to ask why the providers and purveyors of novel vaccines are unwilling to study and discuss the potential drawbacks of the interventions.

To be fair, one of the video resources did include a discussion about the harm that was done to international vaccination programs after it came to light that the CIA had been involved in vaccination programs to gather intelligence and carry out operations. That particular video did at least acknowledge a cause for suspicion internationally and related such suspicion to politicization of healthcare rather than just religious fanaticism and superstition.

And equally frustrating, there was no discussion on how a healthcare professional could work with a public that was having vaccine hesitancy. Calling patients fanatics and waving away their fears probably isn’t going to do it. 

On a completely different note, I was horrified to hear the list of the populations that are most at-risk for sexually transmitted diseases: They listed high school students, university students, and prostitutes. Folks, if our students can be grouped with prostitutes as having an equal or higher risk for STDs, we may need to rethink our culture’s emphasis on sexual freedom and consider whether these kids have any idea what they are doing or how risky it is for their reproductive health and future relationships. I will leave it at that because it is not my favorite topic.

Overall though, I think these couple of controversial issues aren’t enough to deter anyone form taking the course, just things to consider.

As a sub-tropic Texan though, my favorite part was the overview of Neglected Tropical Diseases (NTDs), because that material is just not widely available to average clinicians. It used to be a specialization only available in neglected tropical regions and perhaps Oxford University, but it’s not exactly easy to gain an awareness of these illnesses. And since more than a billion people suffer from them globally, and our world has become a place of global travel and cultural exchange, it seems wise to gain an awareness of what they are and how they work.

For example, who could have predicted that something like the Zika virus would show up in our home state?

Given that world is indeed a small place these days, it helps a lot to be able to recognize when something is out of the ordinary. Some of these diseases do not even have an identified source. It’s the 21st century and there are still infectious diseases without a known cause. Who knows? Perhaps by sharing what we do know, someone will figure it out.

While I was learning about foodborne illnesses, I even wondered if one of the Guillain-Barre cases I saw in the past was actually a case of botulism, because the symptoms are similar, it can cause paralysis, and yet it’s not the first thing that one thinks about when they are caring for a patient in an industrialized part of the world. We ask about allergies, immune disorders, previous vaccination history, and we might even consider polio, but I didn’t even think to ask about canned food consumption, and such. If I recall, the physician did test for it, but it just wasn’t on the radar in my mind. Now, I have a new category to consider clinically, and when it comes to reporting, it’s really important to raise those questions and ask whether something is unusual and ought to be considered for reporting.

Likewise, mosquitoes are found all over the world, and if a freak case of some new illness appeared, I’d be really glad if I had some knowledge of similar vector-borne diseases found in other parts of the world. It would give me a framework to consider vector exposures in the clinical history, for example.

I have much more to learn in the next two courses and I’m looking forward to getting a stronger grasp of our reporting system and how public health data is managed. It seems like an ideal marriage between healthcare and data analytics – which are two things that I love.

So, if studying unusual parasites is right up your alley, then these courses are an amazing way to obtain free continuing education credits and acquire some fascinating new knowledge. Just visit the Texas Epidemic Public Health Institute’s page at tephi.texas.gov/training to sign up for the certification. And feel free to reach out and let me know that you’re taking it!

[1] Texas Epidemic Public Health Institute (2024). Certificate Program. https://www.tephi.texas.gov/training/index.htm.
[2] Kuhn, T (1996). The Structure of Scientific Revolutions, 3rd ed. U of Chicago P.