Communicable E016 - climate change and infections
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[00:00:07] Nav: Hello and welcome back to Communicable, the podcast brought to you by CMI Communication, Eskimoid's open access journal covering infectious diseases and clinical microbiology. My name is Navneet Narayanan. I'm an infectious disease pharmacist and faculty at Rutgers University in the United States and an editor at CMI comms.

[00:00:23] Nav: Today's topic is climate change and its effects on infectious diseases. We're really delighted to have two expert guests with us. First is Shreya Doshi. She is a fellow in Pediatric Infectious Diseases at Children's National Hospital in Washington, D. C. Shreya runs a group called Sustainable ID that talks and publishes about medication waste, Carbon emissions from antimicrobial stewardship and carbon emissions from cultures.

[00:00:47] Nav: Shreya, it's really nice to have you here. Thank you.

[00:00:49] Shreya: so much for having me today.

[00:00:52] Nav: And our second guest is Laura Jung. She's an infectious disease trainee and clinical researcher at Leipzig University Medical Center in Germany. She has been a board member of the German Alliance on Climate Change and Health for the past five years and represents member organizations on the board of the Global Climate and Health Alliance.

[00:01:11] Nav: In addition, she co leads the Planetary Health Working Group of the Junior Doctors Network of the World Medical Association. Besides global health and health advocacy, she focuses on how to integrate planetary health into medical education. Laura, welcome to Communicable.

[00:01:26] Laura: Hello, thanks for having me.

[00:01:28] Nav: Climate change is an existential crisis. It really threatens the entire world and the global population on that note, To get to know each other a little bit better, what is your favorite global disaster movie, show, book

and I'll start just to break the ice, mine is Interstellar, the movie, it's, a little bit, Post global disaster where they now have to escape the earth, the part that appeals to me is, have 2 daughters and despite blatant global disaster and traveling out of the galaxy, the link between the father and the daughter was very compelling.

When we think about climate change and what we're leaving to our children or the next generation. I think about my daughters all the time throughout that. So Laura.

[00:02:09] Nav: what about you

[00:02:10] Laura: Interstellar is a good 1. I think I talked too much about climate change to really enjoy disaster movies. so I got to go with that. Child friendly option. and I'm going to say Wall-E, the little robot who has to clean up Earth after humanity had to leave, and it actually got some pretty good public health messaging included as well on active transport. There's these scooters now all over the U. S. and it makes me think about the part in WALL E where nobody walks around, they just glide around. Shreya, what about you?

[00:02:39] Shreya: That was a great, , movie selection, Laura. I really like Wally. when I got this question, I was thinking of, , a movie called Day After Tomorrow, which I probably saw two decades ago. But honestly, I don't think that, anything, that Laura and I do is inspired by these movies, because we're seeing this firsthand in real world.

[00:02:58] Nav: I agree. For experts such as yourself popular media probably doesn't inspire you in a way, but it's always really interesting to see how things like a compelling book or a compelling show can Convince people that this is something that we need to pay attention to, .

[00:03:12] Shreya: I just want to add. I really like this author. Her name is Ayana Elizabeth Johnson, and she writes about climate change. So definitely encourage the audience to check out her books.

[00:03:23] Nav: thank you for sharing that.

Now, snapping back to reality, we know climate change is a real thing, and our climate is changing quite rapidly right now. , we really have no choice but to deal with the day to day consequences.

[00:03:36] Nav: For many of us, those consequences. Are outside of our normal sphere of work. we're seeing more frequent infections that some of us might not be familiar with. And maybe we need to ask ourselves, as medical professionals, How are we contributing to this issue as well as how can we deal with these problems? The U. S. Centers for Disease Control and Prevention tells us that quote, many infectious diseases are intensifying and new threats are emerging because of longer summers, milder winters, and more extreme weather events.

[00:04:03] Nav: these changes are making it easier for mosquitoes, ticks, animals, And the infectious organisms they spread to expand it to new geographic areas and infect more people. there was even a systematic review published in nature climate change a couple of years ago found that over half. Of known human pathogenic diseases can be aggravated by climate change.

[00:04:23] Nav: What I really want to do, especially with both of you here is extend our conversation to the clinical perspective and so as 2 clinicians that specifically work in the space of climate change and environmental sustainability.

[00:04:34] Nav: What disease or type of climate impact concerns you the most in your particular practice as clinicians. Laura, do you want to start?

[00:04:41] Laura: Yes, absolutely. As you said globally, we see that climate change significantly influences the spread and also the severity of various infectious diseases, posing a growing threat to everyone.

[00:04:53] Laura: in different ways, it affects quite a few diseases. and I think among the most concerning ones are certainly, mosquito borne diseases, such as malaria, dengue, and zika. And we see that rising temperatures and altered rainfall patterns are expanding the geographic range of these diseases, particularly in regions like Southeast Asia.

[00:05:17] Laura: Sub Saharan Africa and South America. , we have pretty good data from the Lancet countdown that shows that for example, an extra, I think 20 percent of the global landmass became more suitable for the transmission of malaria compared to the 1950s and, quite similarly in the same timeframe, that temperature suitability for the transmission of West Nile virus has gone up by, I think, 5%.

And that is also a good call for everyone who listens in the Lancet countdown on health and climate change is a great resource with annual updates on a range of indicators and that includes climate suitability indicators for various infectious diseases. Something to look up.

[00:06:03] Laura: but it's, not only these warmer regions that are more affected. It's also in Europe and North America where we traditionally didn't see certain mosquito borne infections and Sometimes still called like tropical diseases, right? But, they are not that tropical anymore and we find more and more cases and actually transmission, for example, within Europe and the U. S. in Eastern Germany where I practice, we now have West Nile virus infections becoming a regular occurrence and we're pretty sure they are here to stay. , so that's one change that we have noticed. And then another vector borne disease entity of concern certainly are tick borne diseases.

[00:06:44] Laura: So this is here in Europe, something, Quite concerning we have tick borne encephalitis and we have Lyme disease and both of these. Diseases are increasing in Europe. We find new cases in regions previously unaffected. The ticks go more north and they go into higher altitudes. So for clinical practice, what that means is we need to be more aware that these diseases now exist in previously unknown regions and we need to consider them as differentials for meningitis and encephalitis, even in regions where we thought they might not be there. so this is something , to be always, aware of in clinical practice. same is also true for waterborne diseases. So now, for example, We feel only ficus infections that cause severe wound infection and sometimes even sepsis, especially in all the populations, which we also have more of, , and, these infections are rising as coastal waters warm.

[00:07:42] Laura: For example, in Germany, we see more and more cases at the Baltic Sea. I think these diseases, some of them are quite uncommon. Most practitioners haven't maybe seen them in their clinical practice and they are unaware , which just delays diagnostics and We have to as infectious disease doctors especially, be aware that these changes are occurring and keep ourselves up to date with the regional trends that are happening and just keep monitoring the changes. , I think we were playing by the old rules where we knew diseases were at different places, we knew what to expect, but now the rules are changing and that means we also need to adapt our practice.

[00:08:22] Laura: , I want to point out one more disease entity and these are fungal infections. , I think These are actually very interesting. due to the low thermal tolerance, fungi normally struggle to survive at a mammalian body temperature and are not So dangerous for humans. , but with the rising global temperatures, it's expected to also cause fungi to adapt to a higher heat tolerance.

[00:08:47] Laura: So potentially allowing them to survive and replicate better At human body temperatures. we also see a lot more extreme weather events due to climate change, for example, wildfires and dust storms, and they also increase fungal spread by promoting the growth and dispersal of spores. And they also promote traumatic injuries in humans.

[00:09:08] Laura: Opening up the body's barrier and allowing these spores to enter the human body. So here we have these situations where we see more and more fungal infections that are related to extreme weather events. There is not that many studies out on that, but it's definitely upcoming and something to, monitor in the future.

[00:09:27] Nav: Yeah, the really, , compelling points to think about the spread across space. Where the regions are changing as well as time where the seasonality is also changing. Shreya, what about you? What worries you about what's changing in terms of your clinical practice?

[00:09:41] Shreya: the CDC issued an alert this summer on the rise in dengue cases, , in the Americas. So I think the number of cases doubled from last year and they're up to a 11 million dinghy cases now just from this year alone, which was really concerning. And I [00:10:00] saw that in my patients who were travelers and returning to D. C. As well, we saw a lot of dinghy this summer. , malaria as well. . We've seen, , three or four cases of locally acquired transmission of malaria now in the U. S. in different parts of the country. CDC, again, they wrote about that as well. , I recently did a survey along with Preeti Jaggi who's at Emory. , it was a survey of pediatric infectious diseases providers. , mostly from the U. S. There were some international participants as well.

we asked for anecdotes from their practice, what they have seen. A lot of them spoke about expanding territory of Lyme disease. And, , our colleagues in Arizona, California, they spoke about how coccidioidomycosis is really getting more severe more difficult to treat and they're seeing it in so many more people now.

[00:10:55] Shreya: And then although we haven't seen much of it in pediatrics, I know that on the adult side, candida aureus and resistant candida aureus is a huge problem right now.

[00:11:08] Nav: Yeah, unfortunately At my institution, we've been dealing with candida auris, and it's quite a challenge. And we had a communicable episode recently about candida it's quite interesting to see the ecology changing and giving a niche for these types of organisms to emerge.

[00:11:24] Nav: , I want to go back to the root of the problem. When we think about climate change. There's a lot that goes into that, right?

[00:11:30] Nav: So what are really the phenomena within climate change, those actual pathways that are responsible for the increased infection? Is it the warming itself? Is it the precipitation changes? Is it the sea level changes? What is it about climate change that's being to facilitate that? The infectious diseases changes that you guys have described.

[00:11:50] Nav: Trey, do you want to start with that? The changing temperature affects how our ocean currents behave and lead to more severe disasters storms, flooding events, droughts. So that's like the short version of it.

[00:12:04] Shreya: I don't know if Laura wants to add to that. Thanks so much.

[00:12:07] Laura: I think you came up with a really great list and the simple answer is it's all of it. And that's what makes it so complicated is that all these different root causes, they also interact with each other, right? And that's why having these models and predictions is so hard because infectious diseases in itself are already quite complicated.

[00:12:26] Laura: And the climate changes that we're seeing also quite complicated and sometimes unknown, right? And there is tipping points that might come up. And a lot of things that we don't know yet. So making these predictions is. Quite complicated and we're learning more and more every day. We also know it's not just climate.

[00:12:45] Laura: It's about other planetary boundaries as well, like biodiversity, for example and all of this interacts. it's all of it. And it all together.

[00:12:55] Nav: It feels like we're playing with fire, but it's fire that we don't even know exist yet.

Because there's changes that we don't even know the consequences of yet in terms of, ocean acidification, how that's changing that ecology and how that's going to affect things for us in the future. And so there's a lot that goes into it. And I think it's A good way of putting it that it's all of the above, which is the easy 1 in a multiple choice test.

we're having these new disease frequencies that we worry about. And even these new disease entities in places like, you gave brief overview of, but, what about the ways that these diseases are presenting now? And so there's the typical presentation, and I feel like now we talk about atypical presentations so much that it's become norm.

[00:13:35] Nav: Can we really still trust that certain infections, especially those that are arthropod born infections, will only occur in the summer months? Is there evidence that's accumulating that they're occurring in the winter as . 1 of the problems is that sometimes we still see climate change as. Global warming, warm, and we just pretend like everything is warming up a bit. But the really concerning part is that climate change leads to increasingly unstable weather and seasons. And this also obviously affects the seasonal patterns of infectious diseases, especially in vector borne infections.

[00:14:09] Laura: So traditionally, diseases in especially temperate regions, were primarily seen during warmer months, summer. Maybe from like late spring to early fall when the vectors are the most active. But we are now seeing that these patterns are shifting and I think everyone feels that the seasons are not the same anymore as what we are used to.

[00:14:33] Laura: So we have milder winters, we have shorter frost season in many regions that allows vectors to survive year round and reduces the traditional off season that we are used to. the warming trends, especially in like higher latitudes mean that diseases like, for example, tick borne encephalitis or Lyme's disease are appearing earlier in spring, sometimes in some years, it might even be during the winter months that we see the first cases and they persist until later into the year.

[00:15:03] Laura: in addition to these lengthening of transmission seasons, extreme weather events can disrupt usual patterns at any time. for instance, there might be unseasonal warm spells or flooding during winter months that can create favorable conditions for vector activity. At times where we're really not prepared for that.

[00:15:23] Laura: So while we are still relying on seasonal trends to predict outbreaks, think we're increasingly seeing these infections occur outside of their typical time windows and these shifts underscores the need for year round surveillance and adaptability of public health surveillance and response strategies.

[00:15:44] Laura: Kind of be always ready because with these, especially extreme weather events, they can happen at any time. And we need to use these to predict outbreaks as well. And some organizations do that, right? MSF is using extreme weather events to predict outbreaks because it actually works.

[00:16:03] Nav: We just presented some work at the ID Week conference about tick borne diseases, and it was actually very interesting to see that we had this, Upward trend of tick borne disease cases, as well as specifically Ixodes tick related infections in the off season months.

[00:16:19] Nav: it really hits on exactly the point we're seeing it here in New Jersey, and the study was basically a 20 year study. Of New Jersey tick borne disease cases, but it's also the same thing.

[00:16:28] Nav: It sounds like in some the European regions and other regions in the world. I know this is quite. A bit of doom and gloom, and it makes everybody a little sad as they're listening to this, but I really want to get to the action part as well.

[00:16:40] Nav: So what is it that we can do as infectious doctors, pharmacists, microbiologists, and any kind of infectious professional? What can we do to mitigate these changes? Shreya, we know that the root of this problem is climate change itself. It's a lot of complicated interactions of these changes and the phenomenon that sort of contribute to that.

[00:17:00] Nav: And we're all contributing to that, right? No matter what we think, we're all contributing to this issue. Is there information particularly when we think about I. D. we think clinical microbiology. So is there information that we have for microbiology labs as to what their carbon footprint might be?

That's a great question. And this is a little bit in my wheelhouse. I love talking about sustainability. I want to take a step and give a broad definition of what healthcare sustainability is. we want to be able to provide good clinical care. To the patients of today without taking away resources from the patients of tomorrow.

[00:17:36] Shreya: That's what sustainability is. if you look, the healthcare industry's carbon footprint, so not just specifically microbiology lab we contribute pretty significantly. if the healthcare industry were a country in itself we would probably be the fourth or fifth largest emitter of greenhouse gases.

[00:17:56] Shreya: So that's how huge our footprint is. to talk a little bit about the U. S. specifically, the U. S. healthcare industry contributes to about 8. 5 percent of the total greenhouse gas emissions. in the US. So again, that's quite significant. And this comes from a lot of different processes that happen within the hospital, but also from our supply chain, from our anesthetic gases, from the waste we produce, not just in the micro lab, but also in the patient's room and from many other sources.

[00:18:27] Shreya: So what should we do about it? What are the solutions? , how can we mitigate these emissions? I really like a mnemonic that was coined by the Providence Healthcare. It's called WE ACT. The W is for waste, and that means you want to eliminate all waste. Low value tests and treatments because that caused waste decreasing pharmaceutical waste all the solid waste we produced from patient care.

[00:18:52] Shreya: all that PPE so on Additionally, single use plastics. I know that some of it cannot be eliminated, but there's so many low hanging fruits out there when it comes to single use plastic use that we really need to work on it. So that's W. The E stands for energy and water.

using our renewable sources and procurement of renewable energy whenever possible by the hospitals. same water conservation. The A stands for anesthetic gases. We know that some anesthetic gases have a higher, larger carbon footprint than others. And agriculture.

[00:19:29] Shreya: So offering more plant based options to patients if it is a possibility. I'm not saying eliminate completely, but you can even decrease the amount of meat you serve. Additionally, you could try to have a system so that less food is being wasted and then compost whatever you can.

[00:19:49] Shreya: So that's agriculture anesthesia. And the C is for chemicals and pharmaceuticals. So a lot of the healthcare industry emission comes from the supply [00:20:00] chain. And especially for our medication, their whole life cycle, especially for our IV medications. is much larger than oral medication. the T is for transport. So all the transport happening from both patients coming to the hospital and employees commuting to the hospital. So telemedicine is something that you can use whenever you have an option, wherever it seems suitable, it should be promoted. that in short is the WE ACT that's a starting point. If you're thinking, what can I do at my hospital? This is where you can start because we don't want to sit on this problem. We all have to get together and do something. now to answer your specific question about the microbiology lab. that was a 2022 study done from the Netherlands.

[00:20:51] Shreya: they said that for the production and transport of agar plates, for example, they needed to culture samples in this 1320 bed hospital that resulted in about 16, 000 kilogram of carbon dioxide emissions. my mentors, Preeti Jaggi, she also recently did a where they basically weighed all the supplies that you need for a blood culture and respiratory culture then calculated emissions from that.

[00:21:20] Shreya: for 1 blood culture. It was equivalent to driving about 0. 6 miles and one positive endotracheal tube It was equivalent to driving about 0. 4 miles. So when you think of a large hospital, think about how all those cultures add up and result in emissions.

Diagnostic stewardship and antimicrobial stewardship, or lab stewardship, even radiology stewardship, like deciding when your patient needs imaging All those are such important pieces of how we can mitigate this effect.

WE ACT, I think, is a helpful way to structure things . And my other takeaway is that there's probably another point to advocate for keeping labs on site instead of shipping them off to some central, faraway avoiding that carbon contribution from having to travel on a daily basis to ship culture somewhere far, that segues nicely, Treya, to a group that you run.

[00:22:16] Nav: So there's a U. S. based group Called sustainable I. D. and you recently published a call to action in June in the journal of , pediatric infectious disease society. From your perspective, what are the strategies that I. D. societies? Should be taking as well as even just ID professionals in terms of addressing climate change.

you talked about very practical day to day things, but from a society standpoint, or a larger professional organization standpoint, what are the things that you think that they should be doing?

We are we are pretty inclusive and we're always happy to have presenters from other countries because this is truly a global issue.

[00:22:50] Shreya: And what we need to do is learn from each other, like maybe Laura can teach me what she does at her hospital. What, she has done around stewardship that has brought her emissions down and we need to share that knowledge and teach each other. And that's eventually will help mitigate these emissions.

But to answer your specific question, I think that the first step is acknowledgement of this problem, which, I. D. Physicians, pharmacists providers. already acknowledge it, but we need to translate it into action. Some of the things that we propose in that article was education. So we want to expand ID training to include more modules on healthcare sustainability on climate change.

[00:23:34] Shreya: The second thing is create more funding and publication opportunities within ID societies and journals. So this is one of the first articles and it's actually like a series of articles. On microbiology based on antimicrobial pharmaceutical based in pediatric hospitals on research lab based on infection prevention and control related strategy. So similarly, we want more journals to.

[00:24:02] Shreya: Support health care, sustainability related projects. The third thing was encouraged students. sustainability can be incorporated into most quality improvement projects. The UK has Something called Sauce Q.

[00:24:17] Shreya: I where they have courses for quality improvement. Basically what they're saying is being sustainable can also help hospitals save a lot of money. So when you're doing your Q. I projects, why don't you include healthcare sustainability as a primary or secondary research let's say I'm doing. A project on follow up blood I'm looking at, where we need a follow up blood culture and Gram negative rod bacteria, that's great. But maybe one of my secondary objectives can also be , how many emissions am I saving?

[00:24:50] Shreya: How many miles am I saving? that's how we can integrate it into research. For the fourth point was having formalized committees. Formal committee is related to sustainability and all our major societies can be done and we should definitely encourage that. Lastly, job creation. So we can advocate hospital systems to include funding for I. D. Physicians to be leaders and sustainability. there's one medical director of sustainability. That's an I. D. Physician. Dr Shira Abeles. She's at U. C. S. D. I think that given our prior work in stewardship and infection prevention control we make a pretty good group because we know how to collaborate within the hospital if we wanted to pursue more leadership rules and sustainability.

[00:25:37] Shreya: So I think all of those things and then just start counting a lot of the work we're already doing is sustainable, but we're not counting it as sustainability, we're not calculating emissions on it. So moving from a stewardship mindset to sustainability mindset is what we can do.

if I can, I would like to add on the education bit of it because I think it's so important and actually it's not just about. Offering more of climate education within infectious disease teaching and actually all of medical teaching. This is something that the students nowadays demand from us, right?

[00:26:14] Laura: So they come to us and they want that, but it's also about how we teach that because I think with this, ongoing climate crisis. It's not just about creating the knowledge. It's part of it. But what we try to do, and I had the pleasure of working with amazing medical educators here in Germany, is to use a form of education that's more leans into transformative education.

[00:26:39] Laura: And that inspires people to become change agents on their own. So having the knowledge, but then also walk the next steps actually take the action, and we could even publish, in the Lancet Planetary Health, a paper on how you can even do that with an online lecture. So it doesn't always need to be very specific.

[00:27:01] Laura: small group, very intensive. But even through online education, if you do it right, you can inspire people to become active in their fields. And I think that's very important. the second bit I want to add is medical education. We very often think about med students and that's great. But until we have nowadays med students in a position where they take decisions.

[00:27:26] Laura: It's going to be too late. So we actually also have to address the doctors that are already practicing the people in their fifties that are in decision making positions right now. And they also need to know, and they also need to be inspired to take these actions because we don't have the time to wait until the next generation is ready to take the changes.

[00:27:48] Shreya: completely agree with Laura. I think that education needs to be at all levels,

[00:27:53] Nav: yeah, and I think the, interdisciplinary aspect to it of how we practice now is also quite important. We've done interdisciplinary work across, Health professions with medical students and farm students and nursing students, and we've done that for stewardship and other important sort of disease states.

[00:28:10] Nav: And I think, , environmental sustainability, addressing the climate crisis is no different point about. I. D. Professionals already being tuned into that cross disciplinary work, just being stewards in general and now also translating that to environmental stewards, I think, is a really important point, We think about antibiotic stewardship and diagnostic stewardship. All that feeds into sustainability. And I. D. Professionals as a whole, I think, are poised To really take, the bull by the horns and walk into those leadership positions. And I think that's quite inspiring because it's hard to think about the patient tomorrow, or generations from now.

[00:28:49] Nav: And so we think about that with antimicrobial resistance. How do we not just do a disservice to the patient in front of us, but make sure we're doing the right thing for patients in the future. And it's the same thing with climate change. We're thinking generations ahead. And so I think that's hard for people to grasp, but I think ID professionals are tuned into that because of the fight against antimicrobial resistance

[00:29:08] Laura: but we are not only right, we're not only thinking ahead, like both AMR and climate change are also affecting us now. I think that's why we sometimes overlook a bit with both actually, but we feel the health threat of climate change right now. some people in some regions of the world feel it far more than others, but it affects all of us already.

[00:29:30] Laura: Now, I think that's. something to keep repeating because people try to push it away in the future, but it's not. It's now.

[00:29:37] Shreya: I completely agree with Laura on this. sometimes in certain regions, people have that impression that, oh, this, problem of climate change is a problem happening to some other people on another continent far away, but truly it is affecting all of us wherever we are.

[00:29:55] Nav: that's probably a better way of pitching it right to the general public. We've just had [00:30:00] multiple hurricanes in the U.

[00:30:01] Nav: S. just devastate various regions. These extreme weather events are getting worse by the years. In a way that we don't think about it affecting us. Share we dealt with the major fluid shortage because of a hurricane wiping out a facility that produced fluids and peritoneal dialysis fluids for 60 percent of the country.

[00:30:20] Nav: that's another layer, right? We dealt with this before when there was a large hurricane that hit Puerto Rico and knocked out a different manufacturing facility IV fluids. The scary thing is that it only get worse if we don't try to mitigate these things now.

[00:30:33] Shreya: Yeah, I'm so glad you brought up the IV fluid shortage because at many hospitals, we set up IVs. plans like, okay, this is what we're going to do. We're going to do selective surgeries. We're going not do maintenance IV fluids for people who can drink water.

[00:30:48] Shreya: There's so many steps we put in place. We had data dashboards, , we are doing everything possible to make sure we save those IV fluids and use them judiciously. What if we use them judiciously to begin with? And we were sustainable to begin with, and that way when events like these happen which of course I'm hoping that they don't happen but the reality of climate change, says on the vice, we should really be prepared in the event that these events happen Train our minds to be sustainable beforehand,

[00:31:25] Nav: it's quite convincing. I'm sure to administrators that are thinking about costs and lost revenue from cancelling elective surgeries because of the fact that we had fluid shortages. And if there's no other way of appealing to people that are decision makers, loss and revenue is a pretty good way of getting people's ears.

[00:31:42] Nav: But I agree with you. We've thought about that when we've had antibiotic shortages. How can we be better stewards when we run out of blood cultures, which we dealt with recently? How can we be better about blood culture stewardship and doing it for the appropriate patients? Every crisis is an opportunity in disguise.

[00:31:57] Nav: And so it's probably an opportunity for us to learn to be better stewards in many different ways. along that line, when we think about even just basic stewardship interventions, IV to PO. Something simple for patients, safer for patients, more convenient, helps reduce length of stay and things like that.

[00:32:14] Nav: The other thing that I think is lost is that IV medications require a lot more energy to produce, right? So their carbon footprint is substantially higher than the production of oral medications. And so switching to oral medications is a better stewardship and environmental stewardship giving antibiotics that are once a day instead of multiple times a day can be also another intervention to help reduce carbon emissions from a clinician's perspective. How do you manage these sort of competing interests,

[00:32:42] Nav: maybe we can start with you for example, set tracks on once a day.

[00:32:47] Nav: Great. But, that affects maybe the microbiome much more substantially than. six times a day penicillin for a strep infection. How do you reconcile that as a practicing clinician? That's also an environmental steward at the same time.

[00:33:02] Shreya: That's a great question. As a physician, of course, the first Aim should always be providing the best patient care by no means , am I suggesting that we do something that's better for the environment but is harmful for the patient?

[00:33:18] Shreya: That's a no. But what I want to emphasize is that there's so many low hanging fruits out there that we could start with all of those and still have plenty of work to do for the next 10 years, and it not be a competing interest. So I give an example about pharmaceutical waste in pediatric hospitals.

[00:33:37] Shreya: So as We make doses in advance. It's called batch processing. So maybe four to five hours in advance depending on what your pharmacy does. Now, when you're making a dose specifically for a three kilo child in the nicu or a 18 kilo child in the picu, and you're making, let's say IV vancomycin for them five hours in advance.

[00:34:02] Shreya: But then you have your morning rounds, and you cancel that vancomycin and you switch them to something else, you're escalating, de escalating, whatever you're doing. a lot of providers do not know that dose of vancomycin that's already prepared, Is going to waste and it's generating emissions because it's being incinerated or autoclave, depending on where you are, and that results in a lot of unnecessary waste of antibiotics in this era of shortage and leads to emissions.

[00:34:32] Shreya: and there's a cost to the hospital. So that's a low hanging fruit right there. How do we change this system into maybe a circular economy, or maybe there's some other interventions that, we can all put our brains together and think about it. But I know that at least three pediatric hospitals have published data about this and they have anywhere between 20, 000 to 50, 000 doses.

[00:34:58] Shreya: antimicrobial wastage for a year. So that's a lot of waste. we can do something to change the system and not be a competing interest with patient care.

[00:35:10] Nav: for folks that are not Typically involved in, environmental stewardship or antimicrobial stewardship, whatever there's a false perception that you're compromising care to have a greater benefit, but that's not true.

[00:35:22] Nav: The point is to be win win for both. You're taking care of your patient and giving them the best care, but also providing sustainability and the possibility of great care for future patients by not compromising a public good, which are antibiotics. that same thing goes for environmental stewardship and the climate crisis and avoiding future issues.

[00:35:40] Nav: But maintaining optimal care for the patient in front of you.

[00:35:43] Nav: When we think about pharmaceutical waste, just for listeners, there are a few groups that we've mentioned, which we'll put links to, medicine for a changing planet dot org is a great resource but another resource or a group is R. X. for climate dot org. And we'll put a link to that as well. They're. Groups purpose or vision is promoting the role of pharmacists in mitigating climate change impacts. And so there's a lot of great resources there . And that really dovetails off of the things that you mentioned about pharmaceutical stewardship from an environmental perspective.

[00:36:12] Nav: And with that in mind, piggybacking off of what you've already talked about What do you think is the role for pharmacies within the health care system in addressing environmental sustainability? We've talked about diagnostic stewardship in the micro lab, but what is your view from pharmacies, especially touching on the things that you've already mentioned?

[00:36:30] Shreya: So we know that the P. O. Antibiotic or pure medication has smaller footprint than the I. V. One just because we know that by means of manufacturing and processing and transporting.

[00:36:45] Shreya: The IV medications have a larger So pushing IV to PO conversion whenever appropriate. If your patient's able to take PO, then why not? The second thing we're already doing this is by keeping up with the literature on when shorter courses are appropriate.

[00:37:02] Shreya: So for uncomplicated community acquired pneumonia in pediatrics, we know we can do five days. You can keep your patient in the hospital for a shorter time because each hospital day also contributes to a lot more emissions.

[00:37:16] Shreya: And then I mentioned the pediatric pharmaceutical waste, which is like thousands of doses and thousands of dollars. We should definitely work on this. I also think that not so much for pharmacy. I feel like we need to partner with some engineers who can do a life cycle analysis, because I think that the only life cycle analysis we have is for vancomycin, we don't have it as much for other antibiotics.

[00:37:41] Shreya: If we had that, we could, apply that data to some of our projects. And then, you could say, Navneet, that I did a project on saving Maripanem and let's say, I saved hundred doses of myrapenem in one month. So what does that translate to? How many emissions does that mean? I think if we had a little more of that, that would also be helpful.

[00:38:02] Nav: Yeah, we had a nice episode recently about wastewater surveillance, where we had a professor of engineering and the other guest was a clinician and the synergy from just that conversation was quite incredible. And I think that really applies not just to wastewater surveillance, but even to environmental sustainability and understanding these aspects.

[00:38:21] Nav: There's so much we can learn from colleagues in completely different professions, meaning like engineering and supply chain management and things of that sort. I agree with the show, it's not even just pediatric pharmaceutical waste, but even on the adult side and the adult hospital, it's exactly the same thing we're dealing with.

I know there's a little difference in the process of a batching and a syringe batching and things like that for our small patients, but we deal with the same thing. There's so much wasted. Pharmaceuticals and especially antibiotics, it pains me inside to see antibiotics dumped down, into places that are appropriate in terms of disposal and the impact that has from an environmental standpoint.

[00:38:57] Nav: So those points are really well taken. We've already talked about this a little bit already, but the parallels between how we view. And microbial resistance as a global health threat. And so when we've addressed that we always talk about the strategies that include and coordination.

[00:39:13] Nav: Laura, really want to hear from you where you particularly think that national governments fit in into this, action against climate change and how that links to health in particular.

[00:39:23] Laura: Yeah, I think to understand the role that natural governance play in addressing the challenges of climate and health, we have to understand that most of the essential changes that we need to see are happening actually outside of the health sector.

[00:39:37] Laura: Shreya did a great job telling us a bit about what can we do within, but. give or take, I think it's 5 percent of the emissions nationally that come out of the health sector. Even if we do perfectly fine, there is 95 percent of emissions left. We really have to look at the energy sector, transport, building, agriculture, that's where the big wins are.

[00:39:59] Laura: a lot of [00:40:00] these changes, if we manage to do them, come with health co benefits. But it's not the health care professionals themselves within the health sector that are doing these changes. we need governments to recognize climate change as a health crisis and embedding health considerations into their climate policies.

[00:40:19] Laura: That's essential. But then the governments need to prioritize cross sector collaboration, basically the same thing we just said for within the hospital. We need that on the bigger scale, on a national level, linking public health, environmental and economic policies. that's something we have learned, right?

[00:40:37] Laura: We cannot ignore the economic side of things. But for instance, promoting renewable energy sources and sustainable urban planning, and that can reduce air pollution. So it benefits health. But it's doing so much more for the climate as well. And that's what we talk about when we say health co benefits.

[00:40:56] Laura: Improving health outcomes while simultaneously address the climate crisis. And then I think the governments need to come together internationally. To engage in coordinated efforts through frameworks for example, the Paris agreement aligning their national policies with the global climate goals.

[00:41:14] Laura: And this can mean reducing greenhouse gas emissions, phasing out fossil fuels and also ensuring equitable financing for climate adaptation in low resource settings. I think it's for sure trying to always. Adapt to climate change is going to cost much more than trying to mitigate the climate crisis from the beginning.

[00:41:37] Laura: I think we've missed the beginning, but. Still, there is so much more we can do now. We are just a few weeks after cop. 29 has closed. So that's the annual global climate conference. I think it's fair to say we didn't see that. see necessarily the commitment that we would like to see especially when it comes to the phase out of fossil fuels.

[00:41:58] Laura: But what we see and that's a really positive development is a growing house community that is present at these climate negotiations and that's advocating for the recognition of health considerations in climate policy. I think governments need to support vulnerable populations and that's in their national context, but also in an international context because those are the populations who endure most of the climate sensitive health impacts and that have the least resources to adapt.

[00:42:26] Laura: So I think these are the most important points and a lot of them are very similar in a way what we need to do frame.

[00:42:33] Nav: just actually piggybacking off the very last thing that you said, that the political declaration that came out of the recent U. N. General Assembly high level meeting on antimicrobial resistance.

[00:42:43] Nav: Had a lot of mentions of climate change. That was so profound to see how inextricably linked those two were what are your general impressions of seeing that and what policy actions do you think you want to see from governments at a global level to better incorporate, this lens of health and in the climate crisis?

Yes, I think the integration of climate change in the AMR declaration is quite critical and forward thinking acknowledgment of their interconnected nature.

[00:43:14] Laura: And I actually went back into the text to dig out the mention of climate change, because I think most of the listeners might not be so familiar with the declaration. So what it calls for is to acknowledge the need to strengthen the capacity of health systems for monitoring and minimizing the health impacts of, and the adverse effects of climate change on antimicrobial resistance.

[00:43:35] Laura: Through preventive measures, preparedness, timely response and effective management of natural disasters. what that hints at is. Mostly having climate resilient health care systems, because what we know is wherever health care infrastructure is weakened or collapses, and that can be through extreme weather events that can be through conflicts or other reasons AMR is on the rise.

[00:44:01] Laura: And the climate crisis is definitely straining health care systems. And we had mentioned that before there is more extreme events. There is a lot of health care infrastructure that is struggling under the climate crisis and this is only going to By now, linking these the declaration recognizes that effective AMR.

[00:44:22] Laura: Prevention and management must account for these environmental and systemic disruptions caused by a warming planet. then also the inclusion of health adaptation measures within broader climate resilient plan is also quite noteworthy and that kind of goes a bit the other way around. What we do at COP trying to get health into the climate policy, underscores the need for a proactive approach where health systems are not only reactive to AMRs threats, but also actually equipped to prevent and manage these threats.

[00:44:55] Laura: From the beginning what are the actions that we need to see from governments to make that a reality? This is a wish list. We are quite far from that. But I think what we need is health systems with the capacity to monitor AMR trends in the context of climate change and that includes early warning systems for climate sensitive outbreaks linked to Resistant pathogens.

[00:45:17] Laura: And that means to train healthcare professionals on the intersection of AMR and climate risks. We need surely strength and surveillance, and we have mentioned that quite a few times but track how the climate variables influence. Infections and patterns is going to be essential in the future to inform targeted public health response.

[00:45:40] Laura: We need sustainable healthcare practice. That's what we have talked about before. And then we need an equity focused implementation because we have low resource settings that are struggling from the climate crisis and from AMR the most and they are again, the ones that don't have the measures to adapt and The ones that don't have the measures to pay a lot for preventive measures right now.

[00:46:05] Laura: On an international level, we need to see how can we make a means end for these settings and provide technical expertise, funding resources to build resilient health systems everywhere all around the world.

[00:46:19] Nav: . It's, hard to grasp the fact that the communities that contribute the least in terms of the climate crisis is suffering the most and has the least resources to deal with that in a resilient way. So I think that's extremely well said. As we come to a close, Laura and Shreya, what are the key messages that you want to leave our listeners with?

[00:46:39] Nav: Maybe Shreya, we can start with you and Laura, we can give you the last word.

[00:46:43] Shreya: By the way, Laura, that was so wonderfully put. We need to have good healthcare policy action all our minds need to be put together. We need to do collaboration. We need to do research together. We need to advocate together to make this happen.

my end message would be for healthcare sustainability. I just want to remind everyone Anything that you do related to sustainability is going to be good for the environment, and it's going to bring some savings to your hospital. So that's definitely reason to include a sustainability objective into your research objectives, and there's so much room for innovation, even on the outpatient side, you know, I've read studies about people doing QR codes for discharge information about diseases instead of providing papers.

[00:47:35] Shreya: There's just room for innovation at every single step. So we can just go through our day and think of all the activities we're doing at a clinic, in a lab, or in a hospital. And think, how can I modify this to reduce emissions and produce savings from this?

[00:47:53] Laura: Thank you, Shreya. That was very well said. I'm just gonna add that our instinctive response to the health impact of the climate crisis as clinicians is to focus on adaptation. We wonder how can we protect ourselves in a changing climate? What can we do? And this is clearly important, but we need to recognize that this approach to adaptation has its limitations because humans can only adapt so far.

[00:48:19] Laura: the most crucial factor to protect health is going to be mitigation, trying to slow down The pace of global warming and undo some of the harm to the planet. And this requires a clear and decisive commitment to phase out fossil fuels. And this is not just me saying that saying that the Lancet saying that a whole range of experts saying that and as healthcare professionals and as clinicians, I think we have to come forward and make clear that mitigation is our focus.

I think what is. Probably a hopeful note at the end. Sometimes when we talk about the impact, it can be very disheartening and very scary, but the best remedy for that actually is to become active yourself and engage in your community and really try to mitigate the climate crisis in a way that, for example, Shreya is doing it, and I think she can tell us that it does a lot also for your own mental health to be active yourself.

[00:49:27] Laura: So I'm just inviting everyone after listening to this episode to start doing something in their own way. Workplaces and communities.

[00:49:37] Nav: Thank you both for those excellent closing messages. So I just want to say thank you to our guests, Laura Young from Leipzig, Germany, and Shreya Doshi from Washington, DC in the United States.

[00:49:47] Nav: Thank you for listening to communicable the CMI comms podcast. This episode was hosted by Navneet Narayanan, . Editor at CMI comms estimates open access journal. It was edited and produced by [00:50:00] Dr. Katie Hostetler Oy and peer reviewed by Dr. Laura Grunwald of the University of Tartu in Estonia. Theme music was composed and conducted by Joseph McDade.

[00:50:10] Nav: This episode will be citable with the written summary referenced by a DOI in the next eight weeks, and any literature that we've discussed today will be found in the show notes. You can subscribe to Communicable on Apple, Spotify, wherever you get your podcasts, or you can find it on EskMed's website for the CMI comms journal.

[00:50:29] Nav: Thank you for listening and helping CMI comms and ESCMID move the conversation in ID and clinical microbiology further along.