Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. This is the CMAJ Podcast. So today we're doing a "Five things to know" article about the dreaded H5N1.
Dr. Blair Bigham:
That's right, Jola. Today's article is “Highly pathogenic avian influenza A virus,” which is the H5N1 virus. It isn't new but is newly in the news after some dairy cattle transmissions in the United States.
Dr. Mojola Omole:
And then also in cattle to human transmission.
Dr. Blair Bigham:
Cattle to human. That's the one that I care about.
Dr. Mojola Omole:
So I guess reading through the article, my first question is, are we better prepared than we were for COVID? Is the reaction that you get when you read the news and online, is that the reality that microbiologists and public health are looking at? So those are the kind of questions that I have for our speakers today.
Dr. Blair Bigham:
Yeah, and I would sort of balance that with, are we just overly sensitive coming out of this very disruptive pandemic? There’s only been 900 cases since 25 years ago, so I'm just wondering, is this as big a deal as TikTok is making it seem to be?
Dr. Mojola Omole:
I think between SARS and H1N1, which I had.
Dr. Blair Bigham:
Yeah, I had that too. It was awful.
Dr. Mojola Omole:
It was not great. And then COVID, we definitely are probably in a little bit of PTSD regarding mass pandemics.
Dr. Blair Bigham:
Well, fortunately, we have some experts to chat with us. We're going to speak with one of the authors of the "Five things to know about" article, and then we'll speak to a public health expert about whether or not we're ready for another pandemic.
Dr. Mojola Omole:
That's coming up.
Dr. Blair Bigham:
...on the CMAJ podcast.
The practice article is titled "Five things to know about highly pathogenic avian influenza, A H5N1 Virus." Dr. Robert Kozak is one of the co-authors. He's a microbiologist at the Department of Laboratory Medicine and Pathobiology at Sunnybrook Health Sciences Center. Thank you so much for joining us today, Rob.
Dr. Robert Kozak:
My pleasure. Thanks so much for having me.
Dr. Mojola Omole:
Okay, so when I'm on Twitter, I'm extremely concerned about H5N1, but how concerned are you about the rise of H5N1?
Dr. Robert Kozak:
I'm not overly concerned. It's something I think that we should all be watching. There are a number of reports that come out from the CDC, and from FAC that said the risk to the general population is low. But because we've seen transmission from animals to humans, it's definitely one that we want to keep on our radar and prevent it from being something much more serious than it is.
Dr. Mojola Omole:
How many human cases have there been so far?
Dr. Robert Kozak:
So with this particular clade, the clades like 2.3.4.4b, they really need to come up with a better naming system.
Dr. Mojola Omole:
Oh yeah, yes, I know. I remember that one.
Dr. Blair Bigham:
Yeah, that was on my Royal Society exams.
Dr. Robert Kozak:
Perfect, perfect. So, there have been three documented cases in humans among agricultural workers. Whether or not there are other ones that haven't been reported or symptomatic, we don't know. We need more surveillance studies to figure that out, but we've had three reported cases so far.
Dr. Mojola Omole:
And how sick did it make them?
Dr. Robert Kozak:
Fortunately, not too bad. None of them were reported to require hospitalization. Two of them had only conjunctivitis, and the third one had conjunctivitis and mild upper respiratory symptoms. So the cases were relatively mild. It wasn't the severe influenza-like illness that we sometimes see in hospitalized patients, but again, it's still disconcerting because they are sick. They were showing some symptoms, and we always worry about the potential for transmission at that point.
Dr. Mojola Omole:
Do we know how it went from cows to humans?
Dr. Robert Kozak:
That's a very good question. There are lots of different theories. I mean, depending on the different hypotheses, clearly it was being shed by the cattle. We don't know if it was potentially that they were sprayed or they touched their eye with milk where the virus was detected. But also, the cattle have been reported to have both respiratory symptoms and diarrhea. So all those are potential ways that it could transmit as well. We really don't know.
Dr. Mojola Omole:
It's like being around toddlers.
Dr. Robert Kozak:
That's true. I'm not sure which has more diarrhea. But yeah, so it's something that we need to understand better. What is the mechanism of transmission?
Dr. Mojola Omole:
And have there been any human-to-human transmissions?
Dr. Robert Kozak:
Fortunately not. They've done some really good epidemiology and close monitoring of all the close contacts of the three cases. So far, we haven't seen any human-to-human transmission, and that's good. But it's again, something we really want to keep watching for if we have additional cases.
Dr. Mojola Omole:
So we don't quite know how it went from cow to human, but we know that it's been transmitted around other mammals such as sea lions and dairy cattle. Do we know what the mechanism of transmission within the species has been?
Dr. Robert Kozak:
I don't think that's fully understood just yet. There have been reports of infection in mice and in cats as well that have likely had contact with milk from the dairy farm. The cat running around on the farm, cats and milk. It gets sick. For some of these other ones, like the sea lion example, my suspicion is they probably had some contact with the feces from birds. But again, we really don't know. We're not sure exactly how the virus is jumping from one species to another. There are people looking into it, but we don't know yet.
Dr. Blair Bigham:
So three cases of dairy cow transmission have been pretty mild in how the patients have presented, but in the past, H5N1 has been pretty scary. What's the thought on why the dairy cow patients have been so mild?
Dr. Robert Kozak:
Yeah, it's a really good question. I mean, when people start analyzing some of the genome of the virus, they are seeing that the cases in humans are seeing a bit of mammalian adaptation. So that's disconcerting. But your bigger question is why H5N1 in the past has had a high case fatality rate and been pretty serious.
Dr. Blair Bigham:
I heard it was 50% when it was bird to human.
Dr. Robert Kozak:
Yeah, some of the initial reports, I think the first outbreak in Hong Kong, and I believe it was 1997, I think it was, had above a 50% case fatality rate. So truthfully, I am not sure we fully understand why this particular strain doesn't seem to cause as severe disease. I mean, I think also with H5N1 in general, we do see the very serious cases. If there are other cases that are more mild or even asymptomatic, they may have been missed. Often it tends to occur in places that may not have a really effective or functional public health system, more remote areas it might get missed. So again, it's something we don't fully understand, or there are scientists who may be able to explain better, but there's no sort of smoking gun where we can say, well, because of this, this is why it's not particularly lethal.
Dr. Mojola Omole:
So is it inevitable that it's going to adapt to humans?
Dr. Blair Bigham:
Yeah, it's hit white ferrets and cats and cows and seals, and it seems to be making its way around.
Dr. Robert Kozak:
I don't think it's necessarily inevitable. I mean, some of that is based on the measures we take. The more that we do to prevent it from jumping into new species, including us, I think that reduces the chance of it adapting. There's nothing to say necessarily that it will adapt to better get into humans. And obviously, we're fortunate we have not yet really seen it adapt to be able to transmit from person to person, which would be the thing we would be really worried about. So it's not a guarantee, but it's like spinning a roulette wheel. I don't think we want to just keep doing it and doing it in the hopes that it eventually comes up that way.
Dr. Blair Bigham:
How intense should our surveillance be? Should we be testing everyone for H5N1 when they have a runny nose or conjunctivitis?
Dr. Robert Kozak:
No, I mean, this was kind of why we were hoping to put the information out there. We were hoping that our clinicians that see patients in family practice or in the ED or anyone that might encounter these individuals would just ask the right questions. There are other respiratory
viruses circulating right now that can cause those types of symptoms. But asking those questions like, wait, are you a dairy worker? Have you had contact with a sick animal recently? Those might be the people that we would encourage for the frontline provider to inquire about additional testing, like sending it to a reference lab potentially. Most of the testing that we have will detect H5N1. It just won't identify, it will just say this patient has influenza and won't be able to type it specifically.
Dr. Mojola Omole:
And what are the symptoms in humans again?
Dr. Robert Kozak:
For H5N1?
Dr. Mojola Omole:
Yes,
Dr. Robert Kozak:
So currently, we have an N of three cases right now, but they just seem to be conjunctivitis and, in the case of the one person, mild upper respiratory tract symptoms. But historically, in other H5N1 cases, you can see much more severe what we call the stereotypical influenza-like illness. So we only have a small sample size, so I hesitate to say, oh, they're all going to be like this. I think just in general, if you see anyone with an influenza-like illness with the right exposure history to animals, H5N1 might be something you think about or at least ask somebody. You've got your friendly neighborhood ID physician or microbiologist, always happy to chat your ear off on it.
Dr. Mojola Omole:
I don't think I've ever seen a microbiologist at the hospital.
Dr. Robert Kozak:
We do tend to hide in the lab quite a bit.
Dr. Blair Bigham:
So if you have symptoms and you have sort of those exposure questions in the affirmative, how do you test for H5N1 beyond just sending off a flu swab that comes back positive, but just for flu?
Dr. Robert Kozak:
Yeah, so the cases in the US, they actually did conjunctival swabs as well. So that's something that people are investigating to see if that might be a type of specimen we have to collect as well. But generally, when you do your standard nasal pharyngeal swab and it comes back flu A positive, that's when you'd contact either your microbiologist, your infectious disease expert, or your local public health, and they'd refer it on to a public health or the national microbiology lab, which have the specialized tests that could identify it as H5N1.
Dr. Mojola Omole:
Are there any treatments available currently to treat it?
Dr. Robert Kozak:
Yeah, the recommendations, and we provide a link to that in our article so people can look at them. Oseltamivir is the recommended treatment and prophylaxis. And I know in the US too, they also recommend, I believe there's a couple, like baloxavir is one of the ones as well. But here in Canada, there are good guidelines for oseltamivir for avian influenza.
Dr. Blair Bigham:
But if my routine flu swab at any community hospital comes back negative, then I can be pretty confident it's not H5N1.
Dr. Robert Kozak:
Yes. So that's the nice thing about our PCRs, the common target that they have should detect all types of influenza. So it just can't tell you whether it's the circulating influenza or H5N1. But the good news is, too, our numbers in terms of seasonal influenza are quite low right down, so we really shouldn't be seeing too much of that right now in the summer.
Dr. Mojola Omole:
Are there any vaccines that work to prevent infection?
Dr. Robert Kozak:
There are a couple that have been designed around viruses that are very similar and they have good, some of the serological studies say that the matching is pretty good. And I know in the US they've got a bit of a stockpile of vaccines that seem to match well with the H5N1 that's currently circulating. But the caveat is we don't know, there are ongoing clinical trials looking into this, but we don't know how well it works, how well it protects. We'll have to wait for the data on that. Actually, hopefully we'll never have to know because we won't have enough cases to actually need it.
Dr. Mojola Omole:
So if a patient presents with flu-like symptoms, they have conjunctivitis, we should make sure to ask about exposure to animals, correct?
Dr. Robert Kozak:
A hundred percent.
Dr. Blair Bigham:
Then if they are exposed to animals, that flu swab you sent, if positive, should probably go to some fancy place. And I guess I call an ID doc to make that happen, or I call my lab to make that happen.
Dr. Mojola Omole:
Or is it reflexively sent?
Dr. Robert Kozak:
No, it's something that you have to request and you have to ask. And if you don't have them, if your hospital doesn't have a microbiologist or an infectious disease team, you can call Public Health Ontario or the public health office in whichever province you're based. The microbiologist there can help you out. They can help you approve the testing, guide you through what needs to be sent, and have that discussion to say, if you said, well, I got flu and I was around a dead fish, that's probably a little less likely than if you're, say, a poultry worker or somebody who works with cattle.
Dr. Mojola Omole:
Cool. Alright.
Dr. Blair Bigham:
That was great. It's so interesting.
Dr. Mojola Omole:
Thank you for being with us today.
Dr. Robert Kozak:
My pleasure.
Dr. Mojola Omole:
Dr. Robert Kozak is a microbiologist at the Department of Laboratory Medicine and Pathobiology at Sunnybrook Health Sciences Center.
Dr. Blair Bigham:
If H5N1 does begin to spread human to human and we have another pandemic on our hands, are we better prepared than we were pre-COVID? Dr. Thomas Piggott is the Medical Officer of Health and CEO of the city and county of Peterborough, Hiawatha, and Curve Lake First Nation Public Health, and an assistant professor at McMaster University. Thomas, thank you so much for joining us today.
Dr. Thomas Piggott:
Yeah, it's a pleasure. Thank you so much both for having me.
Dr. Blair Bigham:
Dr. Kozak said there is a vaccine that works well on H5N1. Should we be stockpiling vaccines the way the US is?
Dr. Thomas Piggott:
Well, I mean, I think scientific preparedness, being ready to mobilize, is one thing. I think spending a lot of money is another complex, I would say, political decision and needs to weigh the large costs that would be associated with that, with the potential benefits. I think regardless of that decision, we need to be prepared for H5N1 or the next pandemic threat.
Dr. Blair Bigham:
You serve a region that has quite a few rural areas and farming and agriculture. To what extent are you on the lookout for the spread of H5N1 from dairy cattle to humans?
Dr. Thomas Piggott:
Well, yeah, I mean, I've been part of provincial and national conversations around preparedness, and we have preparedness plans for avian influenza. We've dealt with outbreaks of avian influenza, H5N1, in poultry populations before, as recently as the last few years. And we do see them intermittently. In fact, they appear to have been increasing over the last few years in chickens. So poultry populations, often backyard chickens that are contaminated or infected by wild birds. We have not seen any cases of H5N1 in cows or humans yet in this region, and that is obviously a really good thing. But preparedness and monitoring so that if we do see the emergence, we're able to detect it is really important. Most of the leadership on that is being taken by the provincial and federal governments. So we're screening cattle coming into the country. There's large-scale milk testing happening so that if there are fragments of H5N1 virus found in milk, we would be aware of that very quickly. But at this stage, we're still in a preparedness mode. We haven't obviously had to respond to things yet.
Dr. Blair Bigham:
How prepared do you think we are?
Dr. Thomas Piggott:
Well, I mean, I think one of the biggest challenges in pandemic preparedness is similar to other unknown threats. We could invest effort 24/7, all of the resources that we have in Canada towards preparedness, and would we be a hundred percent prepared? Maybe not. So the question is, what level of preparedness are we willing to tolerate? And at this stage, I think we've learned a lot from COVID, but some of the most critical lessons learned, I don't think have been enshrined and retained. I also think that we're already seeing the disabling of the infrastructure that was created in public health through the COVID-19 pandemic. This is a perpetual experience of public health. In my career in public health so far, I've seen investments and resources come and go for H1N1, for the MERS-CoV threat, for Zika, for Ebola, and obviously most recently for COVID-19. When we see the waxing and waning or the large investments in a reactionary standpoint to a pandemic threat, and then nearly immediately after it finishes, the retraction of those investments such that we're not as prepared as we should have been. That's a real challenge. And I think for COVID-19, we saw tremendous scientific advancement. We saw large investments in public health to vaccinate all Canadians, that we were able to in a very short period of time to have case and contact tracing, to have wastewater surveillance, like these incredible surveillance and scientific achievements that have come and investments across all of those areas are being canceled by governments, including here in Ontario. We're seeing a retraction in investments that are tremendously important. In public health we've had very little budget increases in the last 10 to 20 years, despite all of the findings of the Naylor Commission for SARS-1 in 2003, despite all the findings of those other pandemics in the intervening time. And so I don't think we're as well prepared as we should be. A little bit of investment from a prevention preparedness standpoint goes a long way. When we think about H5N1. Getting out and seeing human-to-human transmission in a sustained way would be an unmitigated disaster. It would be awful, and it would be most concerning because there's a lot that we could do to prevent it from getting there. So in order to do that, we need to be enhancing surveillance so that we can detect this in milk or cows. We need to be educating farmers, people working with cattle. We need to be supporting those populations in an equitable way so that they can get access to care if they need it. And if we do all of those things, we might never be talking about having to have a vaccine for all Canadians and that kind of approach. It's the old adage, an ounce of prevention is worth a pound of cure. But for some reason, every time we learn through a pandemic that we need more pounds of cure, we tend to forget the ounce of prevention months to years later.
Dr. Blair Bigham:
One of the surveillance tools that came up during the COVID-19 was wastewater testing. That's also, I think, on the chopping block in a lot of jurisdictions. How could wastewater testing and surveillance help us pick up H5N1 in Ontario or anywhere in Canada?
Dr. Thomas Piggott:
Well, in the United States, they've pivoted and are investing way more in wastewater infrastructure instead of where in Canada, we're already cutting small-scale investment. I think that's shortsighted, and I think this will come back. We know that wastewater surveillance is a needed scientific support here to stay. In the United States, they were able to detect H5N1 circulating in jurisdictions where we had no idea there were cattle outbreaks or human cases, for example, California in the last couple of weeks.
Dr. Blair Bigham:
So the wastewater surveillance actually picked up. It wasn't just really for monitoring. It was like, Hey, guess what? We have a problem here.
Dr. Thomas Piggott:
Yeah, California, this is in the last month. And that's tremendously important information because we would heighten other ways of looking for cases, including maybe enhancing the frequency of testing of cows or milk, really ramping up the surveillance so that we could detect agricultural worker cases. In the United States, in some of the early outbreaks, especially in southern states like Texas, we saw likely a total underreporting of human cases of H5N1 because a lot of the cases were happening in migrant worker populations that don't have equitable access to care. And so we might see similar things in the Canadian context, which is really concerning. We know Mennonite populations have a large role in the production of milk in Ontario. That's a key population, but there are other migrant populations that work in the agricultural industry that may be at higher risk, and those populations don't necessarily have the information that they need to take precautions and keep themselves safe. And I would be concerned about case finding and access to care if we do see them. So where wastewater surveillance could really be useful is in ensuring that we have the best information that we can. So if we did see a transmission in a jurisdiction that we didn't think we should be, that really flags a question that we need to delve in deeper to understand better. And I think that beyond that, it could potentially play a role if there is a need to understand the burden of disease. If this did get out into human populations and have sustained human-to-human transmission, that's where it's been really useful in COVID to see, oh, wastewater is trending up. We need to prepare the healthcare system. We need to start taking better precautionary prevention measures. And regardless of the pathogen, I think wastewater could be helpful. We've seen that useful for Mpox. We saw it useful for now in our jurisdiction, we're doing RSV and influenza testing. That's a much more real-time way of knowing, make sure you get out and get your flu shot than what we used to do, which is, oh, the emerg and hospitals are getting overburdened with flu cases, really ramp up now.
Dr. Mojola Omole:
Is it expensive to test the wastewater? I don't understand. It seems like it's probably cheap compared to emerg.
Dr. Thomas Piggott:
It’s so cheap compared to individual patient testing. I would say if you compare one person getting tested in the emergency department with a PCR nasal pharyngeal swab compared to one sample of wastewater, which could in this community test a hundred thousand people at once, the cost is actually lower for wastewater surveillance. So overall, as a population strategy, it is very cost-effective and very helpful information.
Dr. Mojola Omole:
So you've kind of outlined some of the gaps that are in public health. It seems mainly political and financial. What can we do? Because it seems that most of us who have worked through the pandemic don't really want to have another pandemic. It's just so much stress on the healthcare system and led to so much burden and people leaving healthcare that it almost feels like, okay, public health is advocating constantly, but what can the rest of us do to help support this because eventually it affects all of us?
Dr. Thomas Piggott:
Well, it's no coincidence that I have seen four or five pandemic threats in my very short career in public health so far, whereas that might have been a generation ago how many people would see in a several career span. We are seeing increased frequency and severity of pandemics. That is as a result, in part, because of globalization and the connection between people around the world, but in an important way, it is also because of climate change. We are seeing species extinction and species pushed into smaller areas and in closer quarters with humans. And we're seeing transmission between animals and humans in ways that we haven't seen before. And that is the story of climate change. So I think addressing and advocating for addressing climate change is going to be very important to pandemics as well. I think that we also need to advocate, obviously, for a little bit more in terms of the capacity and resources for prevention-oriented activities, access to primary care. If our line of defense against pandemics is the emergency department, which I know you work in, and I do a little bit of work still clinically in, that is not a good strategy. And I think lastly, I think we, as clinicians, can be really important case finders and collaborators with public health. We know across the country that there are mandatory reportable diseases. You'd know about them. But I think taking a collaborative approach with public health, calling up your medical officer of health if you have something that seems bizarre and that you're concerned about, is really important. Any new outbreaks and emerging things that I've had through my career to date have been identified because an astute clinician was on the lookout and helped public health to identify and then eventually respond and hopefully stop the outbreak in its tracks.
Dr. Blair Bigham:
Are there two or three top-line lessons learned from COVID that you just really hope we as a society don't forget about?
Dr. Thomas Piggott:
Yes, I think we've learned a lot from COVID. I think there's still learning to be done. And one of my concerns is that we haven't actually consolidated our learnings collaboratively. We haven't seen an inquiry, we haven't seen a significant report emerge, like what came from SARS1. And I think that would be useful, to not just it being my opinion on what we learned, because we've seen lots of fracturing and polarization looking back at COVID. But I think we need, as Canadians, to come to some consensus on the key lessons learned. For me, I think a few of the key lessons learned, one is that we can take a more equitable approach to responding to pandemics. In the 10 years from H1N1 in 2009 to COVID-19, we had a dramatic pivot in the approach, and I think some of that was political leadership, but some of it was also what we've learned over the years. In 2009, I remember working in public health and the headlines that body bags had been sent to a First Nation as support for pandemic preparedness. In 2020, when we saw at the end of the year and into early 2021 the rollout of COVID-19 vaccines, we saw First Nation communities, we saw other priority populations prioritized in the rollout. We saw large investments into more equitable access to vaccines in key priority populations. And that, I think, has been a tremendous success. We know that communities were not equally affected by COVID-19, and it had significant impacts by indigenous status, by race and ethnicity. And if we do not enshrine and remember that for the next pandemic, I think that will be a real disappointment because we've seen that that is really important. I think that the other key piece that COVID has taught us is that there are other interventions needed to help to support people, to have the means to stay home. And some of the big financial investments into businesses and individuals, in my mind, were public health responses because that helped to make sure that people had the income supports they needed to protect themselves and their families. And I think that is tremendously important as well. We haven't seen that in other pandemic threats. Often public health has this approach where we're going to have to isolate you, keep you away from friends, family, and work for a period of time. One of the key public health ethics principles is reciprocity. If you do do that to somebody, you owe it to them to mitigate the negative impact that has on their life. I think that we did a good job of that in COVID-19. And finally, I think the last lesson learned I'd want to share is that, again, prevention is tremendously important. An ounce of prevention is worth a pound of cure. If you look at how much we spent on procuring vaccines internationally, had we had a little bit of domestic capacity that could have been ramped up, we would have probably saved a lot of money. Had we maintained our PPE stockpiles, we wouldn't have had to overspend in tremendous ways to buy PPE at the last minute. Had we had a little bit better scientific awareness and capacity, we wouldn't have had to put tremendous resources in that we necessarily did. And so I think trying to get to a healthier balance between a responsive approach to pandemics and a more calm, slow, and steady preventative prepared approach is really important.
Dr. Blair Bigham:
Thomas, thank you so much for joining us today.
Dr. Thomas Piggott:
Thank you for having me.
Dr. Blair Bigham:
Dr. Thomas Piggott joins us from Peterborough, where he is the Medical Officer of Health and assistant professor at McMaster University.
Dr. Blair Bigham:
So much rage, Jola .
Dr. Mojola Omole:
I feel frustrated for our public health colleagues because it must be maddening to work in a system where you are just trying to prevent and no one else seems to really give a,
Dr. Blair Bigham:
And it's all in a shoestring budget of all the places to put just a little bit of extra money. The return on investment is so obvious, and yet they're getting cut or cutting wastewater.
Dr. Mojola Omole:
Surveillance, which I don't even understand. If the US is increasing wastewater surveillance and it seems to have shown good evidence in what it can predict, why would you get rid of something that is probably not expensive?
Dr. Blair Bigham:
Because COVID’s over Jola , there's nothing to worry about, it's all taken care of.
Dr. Mojola Omole:
I think for us as physicians, we need to look at who we vote for from a political standpoint, not just for who is going to protect our corporations, which I do think is important, but also on things like this. Because personally, I don't want to contract H5N1. I don't want to catch it from a patient, and I don't really want to go through another pandemic. So I do think that we need to become more politically active in terms of understanding where we should be spending our time and advocacy, because this is very important.
Dr. Blair Bigham:
It's frustrating, and that's just you and me after a 30-minute podcast. I can only imagine these public health heroes who are just doing the impossible on a shoestring budget and just constantly getting slapped in the face by governments and probably other people in healthcare as well, who are just like, meh, that's not important.
Dr. Mojola Omole:
So I guess all I can end with is say thank you, just to thank them for all the work and whichever way we can support them as clinicians better, let’s find that way.
Dr. Blair Bigham:
Absolutely.
That's it for this week on the CMAJ Podcast. Thanks so much for listening. Help us help the public health folks and spread the message. Please like or share wherever you download your podcast. Leave a comment, retweet it or re-X it, how do we say it now? Throw it on Facebook. Post it on Instagram. Do a TikTok about this episode or tell your friend. The CMAJ Podcast is produced for CMAJ by PodCraft Productions. I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well. Support public health.
Dr. Blair Bigham:
Test your wastewater.