Senior Epidemiologist Haylea Hannah, PhD, MPH

(upbeat music) - Don't be afraid to push yourself or apply for the thing. Like if it's something you're really passionate about, it totally might not work out. And I have many, many things I applied for that did not work out. But I also, because I like didn't necessarily have this fear of applying, I was kind of, I got it some advice from a mentor early on of like, if you're really interested in passionate about it, like let someone else tell you, no, don't tell yourself, no. Welcome to Epidemiology, a podcast, where we learn about the different specialties within the field of EPI, through conversations with epidemiologists. We'll talk about how they got into your fields, turning points that shaped their careers, and any advice that they has for new epidemiologists entering the field. I'm Dr. Casey Ingalls, I'm a disaster epidemiologist, and I work in governmental public health. This show is for anyone wanting to learn more about the field of epidemiology, or to just kind of learn about what it is that Epis do day to day. In today's episode, we talk to Dr. Hayley Humman. Dr. Hammett is a senior epidemiologist with the California Mental Health Services Authority, and her conversations range from her studies at Emory to her work as an applied epidemiology fellow at a local health department in Marin County, California. We also talk about her doctoral work at the University of Washington, focusing on substance use disorders, and how important it is to integrate the voices of people affected by the policies of programs we enact into our work. - I was a biology major, and I think like some people who come to public health, I saw it. I wanted to go into medical school, so I was premed, and then through my different biology coursework, I ended up doing some things like volunteering at the hospital. At one point, I also was an emergency department scribe, it's one of my jobs during undergrad, which was an amazing experience. I learned a lot about emergency department documentation and medical billing that actually was really helpful as an epidemiologist later, looking on kind of the opposite end at administrative data. But through those experiences, I realized I liked being around people and like things that were people facing, but that maybe the kind of medical field was not quite a right fit for me. I took a global health class, which I would say was my kind of first formal introduction to maybe even learning what epidemiology was. And in that global health course, I got very interested in this concept of structural violence and how there can be policies and things that really shape how people experience the world. And I learned what epidemiology was in that course and it made me think that maybe something interesting that here's my desire to work with people and kind of love of the scientific process. And a little bit on a whim, I remember me and one of my good friends decided to just, we were like, next month, we're gonna take the GRE. And then studied like heck for a month. But we just said like, we're just gonna do it and we're gonna apply to grad school and it might not work out. And I was definitely assuming it wouldn't. But we took the GRE, I ended up applying to I think only four programs and had kind of decided if I don't, to masters of public health programs and epidemiology and I decided if I don't get in, that's totally fine. I'll like take a more thoughtful swing at it. But I did end up getting into Emory and got kind of really excited. The more I talked to current students, the more I talked to Sockoldy and kind of learned more about epidemiology. I was really excited about Emory. I think because after taking a global health course in some of the medical anthropology coursework I took, I got really fascinated with the CDC. I had always liked movies. Now that I think about it, I'm like, this makes sense. I had always liked movies when we were growing up like outbreak or contagion. (laughing) And then I started reading a bunch of books, I'm forgetting his name now, that we're like about the CDC labs and if people are on it. Hot zone? Yes, exactly. I was like reading those books in early college anyways. And so I was super excited about the thought of going to Emory and working with the CDC. So that was kind of my like dream application. When you were at Emory, did you have like a lot of opportunities to work with Epi as the CDC or kind of like what was that experience like? I did. Emory has a great work study program where there's a lot of opportunities for students to get paid to work at the CDC. And so I was able to work in the division of tuberculosis elimination part time while I was at Emory and like absolutely loved it. It was, I remember taking a picture of my badge and being so excited. (laughing) Yeah, all of them. Yeah, it was like a dream. Yeah. I had a meeting at the CDC after my first public health job and I went there for, it was just like a training and I'm sure since you've been there, there's only like one spot where I allowed to take a photo and I'm in front of this like very non-descript background that says CDC. I was like, oh my God, I'm here. Yeah, I feel it's so exciting. It's like sending it to people and they're like, that can be literally anywhere. (laughing) It was great. Yeah. Although I will say it's the funny side of that is it was not at the main building. I was like in a random administrative office. (laughing) Am I here? Yeah. So it's kind of funny because you have like a vision in your mind and then in reality I was like at a cubicle. Working with me. Really brilliant people, but like an cubicle. So you're at Emory and you're working in TV, was that kind of like the focus of your study? So I actually came to Emory wanting to work in tuberculosis. So that's that position with the CDC really felt like a dream job because it was like, oh, I'm super interested in this. Now I get to see what tuberculosis surveillance looks like at a national level and be able to work with data from the CDC, which was really exciting. They also had the opportunity to be part of a student-led group, the student outbreak and response team. It's a partnership between Emory and the CDC and other local health departments in Atlanta to provide students with opportunities in applied public health. And a lot of what it practically looked like is if there was a big outbreak response, we would have the opportunity to support local or CDC response efforts. Through that, I would say I recognize like I really like local public health. So with that in mind, I ended up applying for the CST-Applied Epidemiology Fellowship with the thought of going into a local health department. And for people that may not be aware, could you describe like what CST is? It's the Council of State and Territorial Epidemiologist and it's a national organization for applied epidemiologists at the local and state level. And also national, they have partnerships with the CDC and other national groups. They have a lot of subcommittees that allow local and state health jurisdictions across the US to work with one another and come up with guidelines for their work, share best practices, and even like foster partnerships that can maybe result in like, frost state or cross jurisdiction research. Where did you spend your fellowship? I matched in Marin County, California. It's a county health department. It was around 250,000 residents. So because of that, a lot of the epidemiologists they're end up being generalist epis. So even though it was maybe a like, cold and infectious disease fellowship, I really had the opportunity to work on everything from like aging to overdose surveillance, to some tuberculosis, some outbreak response. It's kind of all hands on deck. My main project was to do a community-wide vaccine hesitancy survey. So Marin County being in California and being in the San Francisco Bay area has a lot of vaccine hesitancy, especially for vaccines required for kindergarten entry. And so I had the opportunity to lead a community-wide vaccine hesitancy survey of kindergarten parents specifically. I should mention to it was a follow-up survey that the prior CST fellow had done two years before. At the time, there was a policy that was about to go into affecting California that was going to remove personal belief exemptions for the vaccines required for school entry. And we were really interested in seeing one, adding some questions about this policy, what were parents going to do? Parents who were previously hesitant, what were they planning to do now that personal belief exemptions were no longer available. There was some concerns that some parents who had previously opted for personal belief exemptions might seek medical exemptions and then medical exemptions for vaccines would increase. So that was some of what we were interested in with the survey. And then when the survey was first conducted as well, a lot of it was online. So we wanted to offer a paper option to kind of expand the opportunities of parents of kindergartners to respond. And then we also wanted to expand it to conduct the survey in Spanish. For my surveillance evaluation, I evaluated our fatal overdose surveillance system. So at that time, like many other communities in the US, although it hit the West Coast a little bit later than it hit the East Coast, there was kind of a rapid rise in fatal overdose deaths. So there was really an interesting understanding kind of what is our system capturing, how exactly does it work? How do we think about timeliness so that we can have more timely data to inform overdose response efforts? And so I had the opportunity to move through the standard kind of CDC evaluation framework and evaluate fatal overdose surveillance. And I really enjoyed that. That got me interested in kind of the science of surveillance, I think, because I truly believe there's a lot of scientific decisions that we make when we design surveillance systems. And I think a lot of the concepts we think about in FU bias, completeness, validity, all of that is so intertwined into what seems like, might seem like a simple ask of just how do you count something, that there's so many, so many decisions. I know as you know. Yeah. I'm curious, so when you talk about fatal overdose surveillance, how do you find that information? Is that coming from death certificates or what is the data source? Traditionally, it comes from death certificates. Those death certificates are, however, completed by usually in the case of an overdose. They're completed by a medical examiner or a coroner. So I mentioned that because we ended up like through the surveillance system evaluation, we ended up identifying like we're waiting for death certificate data, which go through a really advanced process until you have kind of a final certified cause of death. So the coroner or medical examiner will investigate the death in the case of an overdose. They will assign the cause of death, do toxicology. They need to wait for the toxicology to come back. All of that will then be sent to the state level and then the national level. And then it's kind of formally assigned what's called an ICD-10 code. And those ICD-10 codes are then what we can use in standard public health surveillance so that we can compare statistics across jurisdictions. And then they're also assigned, generally assigned a jurisdiction at that stage. Like let's say somebody had an overdose in a jurisdiction in which they don't live. The coroner might still investigate that death, but then those data are both shared with the place where the overdose occurred, as well as the place where that person lived, so that we can kind of count the number of overdoses by where they occurred and also among our residents. And that whole process can take up to a year, a year and a half before you have completed ICD-10 coded overdose surveillance data. And so with that surveillance valuation recognizing that timeliness, we started to recognize both of the coroners investigating this. That also means there's toxicology reports that we could have a lot sooner within like, you know, two weeks to a month of someone experiencing an overdose. And then we also could get coroner's reports that would have autopsy information and other things that they might have investigated on scene. In some cases might even give us more detailed information than the arcoxic kind of death certificate data, which is really, really structured and has demographics and primary, secondary, and tertiary causes of death, but might not have other factors. It might not even list all of the drugs that were potentially found in the person's body at the time that they experienced their overdose. So we then started working with the coroner's office to actually pull in toxicology data and receive those data and started analyzing them to see like, how could this be useful in a prospective way? Part of what you had mentioned earlier was being able to rapidly identify overdose death. So utilizing these toxicology reports, when we think of Epi, you know, there's a confirmed case of something in getting a death certificate is then it considered a confirmed case. So is this like a presumptive like overdose case or how I guess like, how does it, how does it work? So that's it. Yeah. That's a really really good question. And I would say it depends on that jurisdiction. So yes, I would say in the case of like a classic, what is a fatal overdose death? You can would compare across places. It's the kind of that I CD 10 code of of what is assigned and that would be a confirmed overdose. A lot of jurisdictions have done some really cool work to look at like earlier death certificate information, even before those I CD 10 codes might be included, including, including incorporating things like toxicology where they might develop like an overdose risk score or they'll even count presumptive overdose deaths via toxicology and then use that information more rapidly to mount a response. In marine county, we were doing that actually where we had a partnership with the coroner where whenever there was a presumptive positives and he suspected an overdose, you would give us a list of that information, some of the kind of extenuating circumstances associated with it, the geography so that we could see if there might be clusters. And in a couple of cases, we identified clusters early. Because one in one case, for example, I think we had five fatal overdose events within one week. I think our average was something like one to two per week, so we knew that was high. From an implied epi standpoint, what do you do with that information? What's the public health action that comes from getting alerted that there are now increased in fatal overdose deaths? One, we notify the public health officer and then they decide kind of what particular action they they might take. In a lot of cases when I was working or in the public health officer would issue a health alert, a public health alert that might let the community know about the increased risk. And then with that, we pair a lot of harm reduction messaging like never use a loan. We give some even a hotline that people can call if they are using drugs and they don't physically have someone with them, they can also call a line and actually talk to someone while they're using drugs who would respond or based on the person's wishes, may or may not call somebody to help them if they don't hear them respond after they use. Also, we would share information about where people can find the lock zone. We would encourage friends and family members to tell people about increased risk and also gain access to the lock zone, which reverses an opioid overdose. Yeah, that was mainly the, I would say the route. We also have a Marin had a community collaborative overdose-free Marin that would develop and share that messaging as well, often on social media, through community channels, through partnerships that they worked with. Are there specific reasons for an uptick, like a higher strain of a substance that's then in the community? There's a lot of different factors. It could be, I think one thing that's happening currently, as an example, there's maybe people have been using methamphetamine, their whole life, they know the dose that they're supposed to take. They're used to using the dose that they get. And one time they go to use that same dose and it has something mixed in it that they're not expecting. And that could be fentanyl or it could be xylazine or kind of a mixture of other things that are being added to the illegal drug supply. So with that, in mind, what that then looks like is somebody who's never used that drug before, then has a sudden influx of a new opioid or some other drug that kind of increases their overdose risk and they're unknowingly taking that so they don't know that their risk is increased. There is, as you were just mentioning too, there's some studies that have come out of Canada as well that have shown that even in one gram of fentanyl, for example, if somebody is using one gram of fentanyl today and one gram of fentanyl tomorrow, they might think it's just one gram, but the potency of that fentanyl in the illegal drug supply is actually changing over time. So it makes it difficult for someone using drugs to anticipate exactly how much they might be using. And then the third thing I would say is there is, like, there's some drugs where if you mix them together, it increases your overdose risk. So there could be some underlying curiosity or people use drugs for a lot of different reasons and people might be taking some combination of drugs that just has an influx in their body. I suspect from the work that we did, then most of it is kind of the potency and the contamination that's increasing risk. Could you talk a little bit more about harm reduction in general? What is harm reduction and how do you approach that from an at-beast standpoint? So harm reduction grew from the community of people who use drugs. And it has principles kind of underlying it that I would say things like respect to human autonomy. I think practically as an applied epidemiologist the way I think about it because I want to say that because I feel like I can't speak to that part as well as true harm reductionists who work in the community and have lived experience. So I encourage anybody listening to look up something like harm reduction coalition and read about it because it's pretty incredible and it's such an amazing community, amazing brilliant community of people who have do incredible advocacy. But the way I think about it as an applied epidemiologist is it's recognizing that people will use drugs or do other things and then kind of respecting their autonomy to be able to do whatever they want to do with their body. And given that reality we then just want to provide things that can make that safer for them. You can also think about harm reduction. I think in a lot of sectors of public health it kind of grew out of the drug use space. But I think you could think of harm reduction in like the sexual wellness space as well where people might be engaging in what public health would have traditionally labeled like risky sexual behaviors. But people are going to have sex and so it's just what condoms or prep or other things can we give them to make sure that whatever sex they're having that they're kind of empowered to be able to do it safely. And I would say the same thing is true of harm reduction in the drug space where it's it's thinking about things like clean needle kits so that people who are injecting drugs are able to safely inject drugs. It's providing things like meloxone so that if somebody experiences an overdose or has a friend who is experiencing an overdose that they can respond to that. I think forms of treatment are also harm reduction. So something like somebody with an opioid use disorder taking methadone or buprenorphine is also reducing their harm of potentially having an overdose from using drugs from the illegal drug supply that might have an unknown potency. So after you're applied at the fellowship what kind of was your next step for you intending or hopefully hoping that you would then get a position at Marin County or what were you thinking after the fellowship ended? - In the back of my mind, I was always thinking I might wanna get a PhD and part of me recognized that if I had continued working, it might be harder to go back to school. So in some ways, I was treating like the end of the two year fellowship as kind of like the R8, you should apply and just see what, and I similarly took it kind of like the masters where I was like, I'm just gonna apply to a few programs. I had so good long time of preparing and stuff, but I decided I was gonna select a few programs, talk to some professors and some current students, and then kind of take my shot at the PhD and if I didn't get it, I would just apply in another year 'cause I was really happy working. I think it was just for me felt like a timing thing where I felt like the end of the fellowship was like a natural time to try for what felt like it was gonna be maybe a first year of many tries. And I would say through all of that kind of overdose work I was mentioning, I started getting really interested in substance use like as a topic, I was still kind of bouncing around this policy infectious disease, maybe even tuberculosis, but I was just finding that like the projects I enjoyed the most were the substance related projects. So I ended up being lucky enough to get into University of Washington for my PhD, then I left it kind of the end of my applied at the genealogy fellowship and moved to Seattle. What was it about the University of Washington you were interested in? I can share I was choosing between in the end University of California, Berkeley so kind of staying in the Bay Area University of Washington and Columbia University. I visited all three because I learned like a big part of the PhD is fit. So I wanted to make sure that whichever one I chose I was kind of at the place that met all of my goals. One of my big goals 'cause I had a lot of student loans from undergrad and also from my masters was, I wanted to do a funded PhD. I did not want to go to a place where I was going to worry about funding or not have kind of a clear path to make sure the whole thing was funded. So that was a big motivation in weighing programs. The second one I would say was kind of fit and how I felt around like discussing with current students and discussing with faculty almost like a gut feeling. Third, I would say is the science like would there be a good fit for me there? I was kind of a, which I'm not sure if this happened to you too, like I think some academic institutions didn't know what to do with me because I really like applied public health and some academic institutions like Emory are really used to that. But some are very academic and maybe are kind of like, I'm not really sure who we put you with, which happened to me a little bit in some of the places that I was interviewing or looking. And I think University of Washington, one, what was biggest for me was the people. Like I loved the faculty I spoke with. I really loved the students I spoke with. When I visited I just felt like home in a way that I spent time at a couple of Berkeley events, which Berkeley I also really enjoyed, but the funding was not there in the same way that it was for University of Washington. So I was feeling concerned that I maybe reach a point in my PhD right wouldn't be funded. And then Columbia University, I think when I visited it just didn't feel like the right fit for me. It might be that I felt too clinical and then I also felt concerned. I think I had like a three year training fellowship, but after that there was kind of the funding was also up in the air. And so if I felt concerned about funding and living in New York City without funding. - What year was this that you started? 2017. - So you're doing your PhD work, I guess. How was it? - Hey, there were parts of it. I loved one thing I always tell people, like it's just such a personal experience. And it brings up a lot of like the closest thing. I'm not like an artist. I mean, I draw for fun, but I don't. I'm not like an artist or anything with the closest thing. I feel like I can describe about the vulnerability might be like an artist. Is the thing I feel like I would compare it to where you just, like I guess even, like it's like I work to my own projects at work, but at the end of the day I always had a mentor or somebody I was talking to that you were kind of bouncing ideas off of and doing that. And you still do in a PhD, you have your dissertation chair, but it's like at the end of the day, all of the work is yours and you're doing it and you're designing it and you have to defend it. So I feel like there's a piece in there of like, at least for me, I was like proving to myself what I could do. And then I also enjoyed the parts of it where like I did have an opportunity to kind of build my own thing, which doesn't always happen in a PhD. But in that process, I think I like proved myself that like I could put all of my values in my work and there were ways to make that work and that if I had an idea, like I want to work with someone who is actively using drugs or who's using medications for opioid use disorder, which was the topic of my dissertation. Like I could do that, I could talk to people, I could recruit someone to work with because it is your project, so you can kind of design that how you want. But yeah, I do think it's a lot of work and it's very busy in like a way where you never feel like you can put the thing down. Like it's like nights and weekends, which you probably know too. Like you just, you could put it down and a lot of people do and you just have to set, I don't know, I guess it's also an exercise in boundaries of like setting boundaries for yourself because you could get engulfed in the work. Like I won't work after six or seven and I won't start working before nine and I will save at least one weekend day where I'm not working even if I have to study or work the other day. And I think you definitely have to set those kinds of boundaries 'cause otherwise I could just take goals to you. And there's always something you could do more. And I think it's an exercise and at least for me like recovering from perfectionism as well because a done dissertation is better than the perfect dissertation. I feel like that's really good advice. I remember I had like a little like whiteboard that I think I just wrote on it. What did I write? It was like you're just doing the best that you can, that you can right now. Because I was pregnant when I was going through part of my PhD and then I had two small children and so like, and there were twins, so they were early 'cause twins always aren't. So it was like, I am my daughters in the NICU and I'm like trying to submit like one of my midterms and I forget. I like do the whole thing. And I don't click submit and then I'm like, just fair. Well, I guess I get a bad grade on it. I mean, but that's the other thing is I feel like I had like really understanding professors so like that got fixed. But you know that I'm like writing my dissertation and it's just like, I like two hours. I can't say. I like the time to like really is just doing the best that you can I think. But no, I like that like a done dissertation is better than a perfect one. This is things I think I told myself. - So you're working on your dissertation. It's completed, I guess. - Yes. - Did you, I guess like, some programs have like different, I guess like, degree requirements to complete your PhD at the University of Washington. Did you have to like publish a certain number of papers or was publishing and like involved at all? - You didn't have to publish to graduate. So it was, you did have to write the dissertation and they kind of encourage you, which is how I wrote it. They encourage you to write it as if they're manuscripts. They're ready to be published after you complete it. And then the big thing is the oral defense and then the, yeah, completing like the written dissertation requirements, some of which is also set by your chair, kind of what your chair and committee decides. They would like you to focus on. - Yeah, and did you do your oral defense so for Zoom? - Yeah. - Which then at the end I was kind of like, what happened? Like it was just me and my room, which is where I had done most of my dissertation. And then at the end I just like, turned it off and was like, "Oh, okay." - I guess I'm done. - I guess I'm a doctor now. - Oh. - It's okay. - Yeah. - It's sad though. - COVID, COVID was a weird time. - And so after you completed your degree at UW, did you have a position lined up? Like what, I guess what were your next steps? - My intention was to leave Marin County work remotely for a little bit of time. And then like it established in my PhD and kind of, then I should say to the way that University of Washington's funding works for a lot of students, is that if you at least were 20 hours a week for the university, they'll wave your tuition and you also get an annual salary. And then I was working from Marin still the whole time as well, which was meant to be like a short term, like, "Oh, just work for six more months." And then I just like enjoyed the work so much. I loved working at a local health department. I was finding like all kinds of ways to integrate what I was learning in my classes, to kind of solve things we were curious about in Marin. So, and then the COVID-19 pandemic hit and it felt like how could I possibly leave now? And so I continued working remotely during kind of all that time from Marin. And I think because I got a grant for my dissertation as well, that made that more possible. 'Cause it was, it was always kind of, I mean, I was like pretty much working full time between 20 hours a week in Marin, 20 hours a week for UW, and then was also taking PhD classes and doing a lot of stuff. Mind I ended up going back to Marin in kind of a new position. So I had been in a, I think, department analyst position initially or during that whole time, I was at university, Washington, remotely. And then I came back as a senior department analyst and had an opportunity to really work more topically on substance use surveillance. And then I ended up doing a lot of wastewater surveillance. as well. I'm not interested in my PhD. Can you, I have a couple questions. So first, when you're talking about the pandemic, did your role change at all during the pandemic, or did you continue doing substance use surveillance? Yeah, I mean, it totally changed. Yeah, because it was-- It was deflation, right? Yeah. It was kind of a, like, what is the need of the day? Yeah, so it would shift in a lot throughout the pandemic. I did end up doing a lot of, like, again, thinking about, like, how my school work ended up integrating into our work. There would be a lot of questions of, like, did Thanksgiving-- did the Thanksgiving holiday increase the incidence of COVID locally? And I would be able to, like, quickly do a time series quasi-experimental study to kind of answer that and exactly how much it might have changed the trend. And then I also ended up designing some, like, kind of fun cohort studies to see, like, what was vaccine effectiveness looking like by subgroups? And also did a lot of, like, mapping to help community organizations, like, prioritize week by week, which zip codes should they go into and kind of do additional outreach for the COVID-19 vaccine. So there were a lot of ways I could, like, really integrate the things I was learning in the PhD into our work, even during COVID. And then there was a lot of stuff, of course, like counting numbers and creating spreadsheets to collect something we had never collected before. And then eventually we ended up designing a new data system. And yeah, I'm sure as you know, too, from that time-- yeah, it was kind of like the need of-- whatever the need of the day was, which changed daily. Yeah, yeah, absolutely. Did you see an increase in fatal overdose data during the pandemic? Or was there any-- I guess, can you talk about that? Yeah. Yeah, there was definitely a lot of evidence, but substance use increased during the pandemic. And that wasn't just like what might be seen as illegal drugs. It was also things like alcohol increase. So we did have some-- several measures, I would say, like, there's alcohol disease-related index that we saw significantly increased in 2021, which incorporates generally fatal deaths that are associated with alcohol. And then we also did see at different points like some increases in overdose, particularly, I would say at 2021. It was probably like that year in between 2020 and 2022, where we saw more of a market increase. So then you also mentioned wastewater surveillance. Can you talk a little bit about what wastewater surveillance is? There's a system of types that basically go from your toilet to local wastewater management agencies that then treat that wastewater so that we're able to kind of safely dispose of it. And through those wastewater management agencies, there's a lot of partnerships now with public health, where public health will collect samples from wastewater from these local kind of localized areas. And then they can get a sense of-- they can then take that wastewater and measure things, like infectious diseases, like COVID-19. But we can also measure things like how much-- what is the concentration of cocaine? And how does that change over time or the concentration of methamphetamine? And that's what we were doing in Marin. We started with infectious diseases with COVID mainly and then expanded to other infectious diseases, including things like influenza, A and B, and RSV, also in our virus, a lot of different targets. And then eventually did a pilot too for substances in wastewater as well. What public health action do you-- I guess do you take when you see an increase in a substance in wastewater? Is it similar to what you kind of discussed earlier? Or is it just kind of factored in as another additional surveillance data point? Yeah, that's a great question. I would say it's something that is probably merging. So we initially thought about it thinking about some work from Canada as if there's more fentanyl in wastewater than there was before. Does that maybe suggest increased potency? Or a minimum does it suggest increased overdose risk? So we actually did a lot of-- in partnership with the CDC, we did correlation analyses to see if our overdose surveillance data were correlated with fentanyl and nor fentanyl, which is a metabolite of fentanyl that suggests someone might have used fentanyl. So we looked at both levels of fentanyl and nor fentanyl in wastewater and how that was associated with some of our overdose-related deaths or non-satyl-overdoses as well. And I would say through a lot of that work, like I think wastewater surveillance data for substances is probably more useful as situational awareness than it is as kind of an immediate overdose response tool. For one, if there is an increase in fentanyl in wastewater, it could also be more people using at that time and may or may not signify increased risk. The caveat I would put to that is there's some new drugs that are entering the illegal drug supply where any presence of that drug is in a lot. And that's where we did see that in Marin, where we started testing wastewater for xylazine, which is something that's being mixed in to drug more commonly on the East Coast and has now been happening on the West Coast as well. And it is significantly associated very bad wound infections for people who inject drugs as well as increased overdose risk. And we did see xylazine and wastewater in our public health officer just from that alone was kind of comfortable releasing a public health alert because then it would mean like, hey, xylazine might be in the drug supply. Here's what you can do if you see it. And also just alerting clinicians if you see something presenting as an overdose, it may need things other than just naloxone to treat it because it could be something other than only opioids that are being used. Interesting. OK. Yeah, because I was kind of at my question as you were talking about if the concentration is higher, because it could be a stronger dose of a specific drug. You can't tell this came from 12 people in the wastewater. Like, right, it could be like a really strong dose versus multiple smaller doses, right? Yeah, totally. Yeah. And you still-- I mean, at least right now, they can't really disentangle that. So Europe and Canada have been using wastewater for substances for many years. And they generally do use it as kind of a-- these are the substances people are using. It's increasing or decreasing over time to kind of give you a sense of what treatment you might want to target. In some cases, I think they've done it in schools as well, which I have mixed feelings about depending on if it's used like punitively or with public health. But in schools, they found things like increased cocaine that they weren't expecting. So then they could do harm reduction messaging about that and say, you know, to help raise awareness about kind of overdose signs, things to look for, things that might be in someone's cocaine that they're unexpected, that kind of thing. And is that your current role now? Are you working in the same kind of position that you weren't? No, I'm a senior epidemiologist now. And the California Mental Services Authority helps-- so each county in California, the County Behavioral Health Department is responsible for delivering what are called specialty mental health services to and substance use disorder services to people who have medical or who are uninsured. So now I'm a senior epidemiologist, and I really focus on kind of that medical or uninsured population and supporting county behavioral health departments in delivering those specialty mental health and substance use disorder services. And how did you move into that from your prior position? I guess how did you become aware of this kind of work? Or did you have a contact there, or just happen to see an opening? Or-- I feel like this is a great example of some advice I would give people is always be willing to kind of network in the different places that you are, because I did make a lot of contacts in Marin when I was working there. One of which was I was providing data to somebody who at the time was managing treatment programs in the behavioral health department. And that is now my current boss. So she eventually left Marin, went to a couple other places, and then she herself ended up at CalMesa, which is where I currently work. And she had kind of been pinging me a couple of times, saying, hey, I'm trying to build this new-- this team in CalMesa and build in more epidemiology. And I really enjoyed working with you on Marin, and I'm just wondering if it's something you'd be interested in. And it took me a little while to scale ready to leave Marin, but I continued to stand touch with her. And then at some point in Marin, I absolutely loved the work I was doing, but I started wanting to be more of a leadership position, which at a medium-sized health department is sometimes those opportunities won't come up for five or 10 years. And I felt like I was kind of ready to move up, or maybe use more of my PhD training. I had a lot of opportunities to use it in Marin, so it's not necessarily that. I had been there nine years and was thinking, like, personally, I maybe needed a new challenge, because I was feeling very comfortable. And I was super happy. But I'm also super happy. And I knew a job. It was just-- I was kind of like, yeah, I need to move on and challenge myself and maybe move to the next step. Can you talk a little bit about what your day-to-day work is like in your current role? One thing we do is we provide electronic health record to 27 counties in California. And the goal is eventually to have every county in California on the electronic health record. And through that, we then have access to a lot of data. And we might use those data to conduct analyses, to kind of understand how exactly counties are delivering services, maybe to advocate for a policy with the Department of Health Care, services who sets a lot of the Medicaid policies that kind of dictate how counties deliver care. We also use those data to develop a suite of dashboards that we provide directly to counties that kind of offer or buy into that service. And those dashboards are on topics like what is the population of people experiencing homelessness that you're serving in your specialty behavioral health system? What are those demographic? What kinds of services in which programs within your county are providing services to that population? And the goal is for those types of data to help county behavioral health plans make strategic decisions that can kind of maximize their service benefits and also outcomes for their clients. Are there additional data analysis skills that you kind of worked on that help you be successful in this role? We do a lot of SQL coding which was completely new to me when I joined this role I had used like R and SAS and STATA a lot but never SQL. So I still am learning SQL I would say. For sure. I still use R a lot so I've had the opportunity to do some things like try to use publicly available data to develop simulation models that can maybe help counties understand like how many people might have a clinical need for different behavioral health programs that will be required. So there's some like policy analysis work that I get really excited about again with the goal either being kind of arming county with data that can help them plan or the state so we can kind of advocate for policy policies on behalf of counties. And then the other thing is I do I recently had the opportunity to have build a team so I have a few people that I'm working with so I'm kind of also now learning my own management style. I've kind of informally managed people on other project with Marin but I've never or served as maybe like a mentor for like a summer internship but I've never had the opportunity to be like an ongoing manager so I would say that's a skill I'm kind of actively building. I feel like there's not I'm just thinking back to to like my MPH and my PhD I didn't feel like there was a lot of training for like how to supervise. Well totally or like how to be like a lead I mean the CST has the like the lead program oh cool which I guess that's one option but like also just professional training programs for Epis to be in leadership positions. I feel is a little bit lacking so totally. Yeah what kinds of things are you are you kind of like doing to help be like a leader. I'm assuming you have Epis under you maybe not but like being an Epi and a leader in your department. I mean I think one thing I because I've had the opportunity to have mentors like this like I always want I feel like everybody has a unique skill and perspective to bring to any team like no matter where you are in your career so I feel like one thing I feel strongly about is maybe breaking down those classic like bureaucratic barriers and trying where where I can to allow people to kind of ask questions or be excited about a project and kind of volunteer for something or come up with a project on their own and we can see if we have time to do it based on the goals of the organization. So I think and now that I'm I like very recently had the opportunity to build a team so I've been working with one person who's actually currently an epidemiology and PhD student and then I just hired two epidemiologists and now that work a new team I would say like one thing I'm doing is trying to involve them in the planning like what do we want our work to look like like what are things you're excited to learn how can I help you learn that and I again I think that comes from like I feel like I had phenomenal mentors and like my CSD fellowship and my PhD who maybe even like put opportunities in front of me that I would have been nervous to do but they were like hey you've got this and if you don't like I'm here to support you and I feel like I want to do that for for like my my now team too. Is there any other things you that we didn't touch on and like your current role that you wanted to talk about? Any other like specific I mean yeah maybe I didn't get a chance to talk about some of like probably because I could talk about it all day of like within the substance use realm and a lot of it came up for me during my PhD of just like wanting to involve people who are involved in the policies that we are enacting like in the whole process including like integrating their perspectives and to how we design policy but also like thinking about people who use drugs for example in different leadership positions or the ones that are who are delivering harm reduction services and I think I'm in my current role like there is I don't necessarily get to work with it as much although I always love when I get the opportunity to their calme say actually does run a peer certification program where people with lived experience with mental health or substance use disorders can become certified providers and start providing services to people with substance use disorder and yeah I just feel really strongly about that and I think another exciting thing about my PhD is because I had the grant and I could kind of design it myself I had the opportunity to pair like a quantitative study with qualitative focus groups in the community people who use drugs are living with substance use disorder or who had been formerly incarcerated to kind of learn their experiences with treatment during incarceration and make sure that that was kind of paired or integrated with our quantitative findings so yeah I really love like qualitative or mixed method studies and then also things that kind of allow community voices to be integrated into all this process. Yeah and that's so important to write to not just study at a community and be like I'm going to study you but like involve them in the the process and make sure that yeah they have a scene at the table I just feel like being able to also do a qualitative analysis is like a really strong benefit and just skill and I think for applied epi and just like focus in public health in general. One question that I'm asking everybody is if somebody were to come to you and be like I want to be an epidemiologist like and you kind of touched on it already a little bit but what would you tell people are like what additional advice would you have for someone who's interested in epi? Yeah I'm thinking about the things that have led me to like the parts of my career that worked best for me. I guess one like stay true to yourself and trust your gut and then like don't be afraid to push yourself or apply for the thing like if it's something you're really passionate about it totally might not work out and I have many many things I applied for that did not work out but I also because I like didn't necessarily have this fear of applying I was kind of I got it some advice from mentor early on of like if like if you're really interested and passionate about it like let someone else tell you know don't tell yourself no so maybe I would say that and then like I would say stick to it like if you don't I really wanted to be a TA at different points and the first few things I applied for I wasn't getting but eventually I got to TA and it was a really great experience so yeah I would just say make sure or I don't know don't give up like trust your gut where possible like totally advocate for yourself and try to espouse the values that you have into what you're doing I guess the other advice I would give even for myself is like very very early in my career especially I was so worried probably because I was around like other or like such brilliant people and many other epidemiologists who are like further along in their career who were really accomplished and I at first found that really intimidating and I wouldn't ask questions and I'd be too scared to ask the wrong question or or even share how it's feeling about something because I think they don't want to know that or they already know that and I think yeah to that as well I would say like don't be afraid to speak up or ask the question and no question is stupid and all of us have been like at a different learning point at different times in our career and and like worst case you'll ask a question and maybe if that person turns you down for asking a question like that's the wrong person to ask that question too don't be afraid to not be perfect maybe what do I would say thank you for listening to this episode of Epidemiology be sure to click the follow button on your podcast app so you don't miss a new episode of the show and if you have any questions about epidemiology or suggestion for future guests or if you're interested in being on the podcast yourself please drop a comment on this episode or send me a note on Epidemiology's substack which will be linked in the show notes again I'm Dr. Kessi Ingles and you've been listening to Epidemiology