By Sarah Buss, manager of HIV, viral hepatitis, STD and TB, APHL
The first ever and long-awaited APHL ID Lab Con opened with an inspirational message from keynote speaker, Demetre Daskalakis, MD, MPH, director of the Division of HIV Prevention at the US Centers for Disease Control and Prevention (CDC). He is also currently serving as the White House National Mpox Response Deputy Coordinator. Dr. Daskalakis described public health laboratories as a ray of light that “illuminate the way for effective response to infectious disease threats, both acute and chronic,” and this imagery served as an underlying concept throughout his talk. Dr. Daskalakis drew on overlapping themes from his work to form an innovative and yet logical blueprint for realization of public health systems equally prepared to deal with emergency response and everyday needs.
Although his career has been primarily focused on HIV, Dr. Daskalakis explained that he has been frequently pulled to support public health emergency responses over the years. Most recently, he joined the federal mpox response as the White House National Mpox Response Deputy Coordinator in August 2022. Daskalakis used his experience with HIV and mpox to illustrate that “similar strategies work for chronic and acute outbreaks.” The first strategy Daskalakis outlined was meaningful community engagement with appropriate messaging to at-risk populations. Then he addressed political will. “People who have power need to understand how important the work is,” said Daskalakis. When community engagement and political will come together, Daskalakis explained, science is elevated leading to a three-part response to infectious diseases consisting of testing, treatment and prevention.
Using a 2018 Legionnaires’ disease outbreak in New York City as an example, Dr. Daskalakis stressed that public health programs and public health laboratories are tools for each other. During that Legionella response, public health epidemiologists, environmental scientists and laboratory teams worked together, mapping positive Legionella urinary antigen results, sampling cooling towers near Legionella clusters and sending samples from patients and towers for laboratory scientists to culture. Labs then worked to sequence any resulting isolates and sent the data back to epidemiologists who worked with the public health department to identify and treat the source tower. The response was successful because of the close interaction between the public health program teams and the lab teams. Given his frequent Madonna references throughout his talk, it is shocking that Daskalakis did not say, “epi holds the lock and labs hold the key,” but it was clear that was what he meant.
Transitioning back to HIV, Daskalakis outlined how testing used in the right place with clear, targeted messaging opens doors to a variety of interventions. Daskalakis explained that during an investigation of a multi-drug resistant (MDR) HIV case, sequencing data was used to link a New York City bathhouse to transmission of the MDR HIV. Daskalakis decided to bring testing services closer to where people needed them. This led to HIV testing in the bathhouse and ultimately to the development of the New York City HIV Status Neutral Prevention and Treatment Cycle, which Daskalakis described as “the notion that an HIV test opens the door” to treatment and prevention services.
Building on the concept, Daskalakis described the evolution of HIV testing in New York City. Citing statistics that show various sexually transmitted infections (STI) increase the risk of HIV infection, Daskalakis explained that, “STI testing is HIV prevention.” Consequently, clinics in New York City began to offer both HIV and STI testing, treatment and prevention services. Messaging and nomenclature was revised to flip the focus from disease intervention to prevention and wellness with the advent of NYC Sexual Health Clinics. Then, deriving inspiration from London’s Dean Street Clinic, Daskalakis and the New York City Department of Health and Mental Hygiene moved toward the creation of a Quickie Lab within one Sexual Health Clinic. Opened in 2019, the Quickie Lab focused on the rapid detection of chlamydia and gonorrhea in part as a tool for HIV prevention. The Quickie Lab revolutionized STI testing in the clinic by significantly reducing turnaround from specimen collection to result reporting and treatment.
While the Quickie Lab that opened in summer of 2019 was initially focused on STI testing, Daskalakis said that the instruments could be used for other testing. The plan was that the labs could be “flipped” for emergency response, which was put into action in 2020 as the Quickie Lab was flipped for use in the COVID-19 pandemic response. Daskalakis encouraged the audience to “never let an emergency go by without taking advantage of it for your foundation.” He explained how COVID funds were used to quickly open eight additional COVID-focused Quickie Labs in what had been NYC Sexual Health Clinics, and how these COVID labs are now being flipped back to Sexual Health Clinics. Continuing to reinforce this concept, Daskalakis shared that during the mpox response select agent laboratories were flipped to focus on sexual health.
To close his keynote, Daskalakis summarized the lessons he has learned from his career working on HIV and the other acute outbreaks that have demanded his attention. He encouraged us to build disease-flexible labs at sites that reach the public and always consider and communicate “the flip.” He stressed that “laboratory capacity is critical during war and peace time” and said laboratories can be “kept warm” for acute emergencies by testing for chronic challenges at an increased capacity.
Dr. Daskalakis brought an infectious energy to this first ID Lab Con. While he equated laboratories to a “ray of light illuminating the work that we do every day,” he was the ray of light at ID Lab Con.
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