Can Poop Cure an Infection?

Can Poop Cure an Infection?


Anna Rothschild: Ever wanted someone else’s
poo pumped through a tube in your nose? Me neither. But doctors are performing this procedure
on patients across the country. I’m Anna Rothschild, and this is Gross Science. Inside every person’s digestive tract there
are trillions of bacteria and other microbes, and these little guys are really important.
They do things like produce molecules your colon cells need to survive, or they extract
nutrients from your food. Scientists call these microbial communities your “gut microbiome.”
And in a healthy person’s gut, there’s a balance among the organisms present that
keeps the whole system in check. But, let’s say you wipe out a population
of bacteria, say because you had to take antibiotics for some reason. Other microbes can suddenly
proliferate out of control, in ways they never could before. This is exactly what happens
in many patients who have Clostridium difficile, or C. diff, infections. Certain microbes disappear,
allowing the bacterium C. diff to take over, causing diarrhea and even deadly inflammation
of the colon. So, how do doctors reset the microbial balance?
Well, recently they’ve been turning to something called a “fecal transplant,” which while
extremely effective, is also about as gross as it sounds. Essentially, doctors collect poop from a healthy
donor, mix it up with saline, and then filter out any undigested bits to create a brown
milkshake looking substance. They administer the poop slurry in one of
three ways. The first is backwards, through the anus. The second is through the nose,
using a tube that gets threaded down to the person’s stomach or small intestines. And
a newer experimental way is giving the treatment in pill form. The idea here is that the poop slurry contains
a complement of gut microbes from the healthy donor, which re-colonize the patient’s gut
and out-compete the disease-causing bacteria. This process sounds totally revolting, but
recent studies have shown that patients with C. diff who were given fecal transplants had
an average cure rate between 91 and 93%. Fecal transplants really challenge our ideas
of what we think of as “clean” and “dirty.” Current research is showing that they’re
simple life saving treatments, and yet, I wouldn’t blame anyone for being a little
squeamish. By the way, don’t try this at home. Ew. Joe Hanson: That was definitely gross. Wanna
know more about C. diff and other superbugs? Head on over and watch my video at It’s
Okay To Be Smart.

About termite damage to structural timbers

About termite damage to structural timbers


These are eastern subterranean swarmers. These are the caste of termites that people see when they have a termite problem. Termites live a cryptic life and the only caste you’ll see outside of the galleries are the swarmers or slates. Termites swarmers differ from carpenter ant swarmers, or any other ant for that matter, as they have wings of equal length

Termite Control : How Large Are Termites?

Termite Control : How Large Are Termites?


My name’s Tyler Royce. I’m with TNT Pest Control.
Today we’re talking about the size of termites. Termites range, depending on which stage they’re
in, they’ll vary from an eighth of an inch up to a quarter of an inch. Different stages
you have are the…the eggs. Then you have nymphs, then you also have workers, soldiers,
wing-productive termites. When they’re in the king and queen stage, what happens is
when the nest becomes very large, they’ll actually…the queen will lay kings and queens,
and they’ll actually come out with wings on. They’ll come out of the nest, fly off to start
off to start off new colonies. With their wings they can be up to a half inch long with
the wings. And then after they’re done flying to their new location, they will drop those
wings, burrow back into the ground, and start a new colony. The size of termites vary from
an eighth of an inch from the workers, up to a quarter of an inch for the kings and
queens and soldiers.

The Loneliness Epidemic

The Loneliness Epidemic


How has the most connected society in history also become the loneliest? It’s easy to forget how far we’ve come. In just a matter of years, we’ve gone from phone calls to text messages to video chat. In an instant we can ring up a family member across the world and feel more connected with them given the distance then we could have at any other point in history. This was science fiction in the 20th century. It’s during that same period of innovation that brought us one-click shopping: anything we could need delivered to our door the same day. And so we bought, and stored, and used, and replaced a generation living better than Louis the fourteenth, yet finding ourselves more secluded than ever. Why do people, even after they have their basic needs met with all the tools we have available, why are we not only unhappy, but largely depressed? Author and journalist Johann Hari set out across the world to speak with leading experts on depression, anxiety, and loneliness to discover both how we’ve gotten to this place and more importantly how do we as individuals in a society start to turn the tide? This is my 20-minute interview with Johann about what he learned from that research. All right, so why don’t we start out with a little bit of a intro about yourself and about your work. I really- I write my book “Lost Connections” because there were the- these two mysteries that were really hanging over me for years Look, I was quite afraid to look into them in some ways The first mystery is I’m 40 years old and every year that I’ve been alive Depression and anxiety have increased here in the United States, in Britain, and across the Western world Right and I kept asking myself Why? Why is this happening? Why are so many more of us each year that passes finding it hard to get through the day right and I guess I wanted to understand that from because I’m a more personal mystery When I was a teenager Remember going to my doctor and explaining that I had this feeling like a pain was leaking out of me out So I put it at the time and I felt Very ashamed of it I felt Confused by it I didn’t understand why it was happening And my doctor told me a story that, and now realized were speaking to the leading scientists in the world on this was oversimplified Right. My doctor said we know why people feel like this. It’s just cuz of a problem in your brain There’s a chemical called serotonin that makes people feel good Some people are naturally lacking it. You’re clearly one of them. All we need to do is give you some drugs You’re gonna feel better so I started taking a chemical anti-depressant called Paxil and I felt significantly better for a few months and Then this feeling of pain came back. So I’m back doctor said wanna get high enough dose. I was gonna hide dose again I felt better again. The feeling of pain came back and I was really in this cycle of taking higher and higher doses until for thirteen years I was taking the maximum dose you’re allowed to take at the end of which I was still really depressed And I was surrounded by people who are becoming more and more depressed So I just forced myself really to start looking into this. So I ended up going on this big journey for the book I travelled over 40,000 miles I wanted to meet the leading experts in the world about what causes depression and anxiety And what solves them most importantly so I’m at you know Not just leading experts, but just a crazy mixture of people with different perspectives from an Amish village in Indiana Cuz the Amish have very low levels of depression to a city in Brazil that banned Advertising to see if that would make people feel better to a lab in Baltimore than where they were giving people Psychedelics to see if that would help and I learned a huge number of things but the core of what I learned Is that there’s scientific evidence for nine different causes of depression and anxiety Two of them are in fact biological. My doctor wasn’t wrong and Your genes can make you more vulnerable to these problems just like some people find it easier to put on weight than others and There are real changes in your brain that begin when you become depressed that can make it harder to get out but most of the factors that cause depression or anxiety are not in our biology. Most of the factors for which there’s scientific evidence are Factors in the way we’re living and what I learned in the process of writing the book and speaking to so many Scientists is once you understand the causes of depression or anxiety in this more complex way Opens up a much broader range of possible solutions that I saw being pinned Just all over the world And these are solutions that we need to be explaining to people and offering to them alongside not instead of but as an option alongside Chemical antidepressants why is society at large? Reacting in this way. What do you think are some of the influences on people’s well-being? That’s leading to the higher and higher rates and depression and anxiety I’ll give you an example of one of the nine causes that arrived at in lost connections. We are below Lea’s society There’s ever been there’s a study that asks Americans how many close friends do you have you could turn to in a crisis and When they started doing this years ago The most common answer was five today the most common answer not the average but the most common answer is none half of all Americans Asked how many people know you well say Nobody right? I spent a lot of time talking to an amazing man called professor John Cacioppo is that it was the leading expert in the world on loneliness. He was at the University of Chicago And he explained to me Why are we alive you and me and everyone watching this? Why do we exist? One key reason is that our ancestors on the savannah’s of Africa were really good at one thing They weren’t bigger than the animals they took down. They weren’t faster than the animals they took down But they were much better at banding together into groups and cooperating just like bees evolved to live in a hive Humans evolved to live in a tribe and if you think about the circumstances where we evolved if you were cut off from the tribe You were depressed and anxious for really good reasons. You weren’t terrible danger you were about to die Those are still the impulses we have we are the first humans ever In the long 2 million year history of our species to try to disband our tribes and is making us feel awful So a key thing for me was not just to understand these problems. But ok. How do we solve those problems? Right and one of the heroes of my book Lost Connections is an amazing man called. Dr Sam ever Hampton who pioneered a whole different approach based on this understanding so Sam was a general practitioner in East London poor part of East London where I live for a long time and Sam was really uncomfortable because he had loads of patients coming to him with terrible depression and anxiety And like me he thinks there’s some role for chemical antidepressants But he could also see most of the people he was giving them to did become depressed again And he could see that they were depressed and anxious for perfectly understandable reasons Right like to give one of the examples I took about in the book loneliness So he decided to pioneer a different approach one day a woman came to see him called Lisa Cunningham He’d been shut away in our home with dreadful depression and anxiety for seven years and Sam said to Lisa. Don’t worry I’ll carry on giving you these drugs. I’m also gonna suggest something else. There was an area behind the doctors the suite of doctors offices There was no known as dog share alley which gives you sense of what it was like just kind of scrubland Sam said to Lisa what I’d like you to come and do is turn out a few times a week I’m gonna come to you cuz I’ve been pretty anxious We’re gonna meet with a group of other depressed and anxious people. And we’re gonna find something to do together as a group, right the first time the group met Lisa was literally physically sick with anxiety But the group starts talking they’re like, what can we do? These are inner-city East London people They don’t know anything about gardening they decided they’re going to teach themselves gardening right gonna turn dogshit alley into a beautiful garden So they started watching YouTube. They start to read books They start to get their fingers in the soil. They start to learn the rhythms of the seasons There’s a lot of evidence that exposure to the natural world is a really powerful Antidepressant start to do something even more important. They started to form a tribe they started to form a group they started to care about each other and you know, if If one person didn’t turn up, they’d go and look for them. They’d see if they were okay They did what human beings do when they’re part of tribes. They started to solve each other’s problems The way Lisa put it to me as the garden began to bloom. We began to bloom There was a study in Norway of a very similar program found. It was more than twice as effective as chemical antidepressants. I Think for an obvious reason, right? It was dealing with some of the reasons why they felt so bad in the first place and this is something I saw all over The world from Sydney to São Paulo
to San Francisco the most effective strategies for dealing with depression and anxiety Are the ones that deal with the reasons why we’re in such distress in the first place? You said that we’re living in the loneliest society. There’s ever been how Can that possibly be with all of these tools at our fingertips, right we have social media We have the ability to connect and interact with anybody in an instant I can FaceTime my mom in a second. And if she picks up then we can I can see her face to face has social media Played some part in the fact that we are lonely This is a complex question and with a complex answer So the glib answer is to go, yeah social media did this to us. Is this too simplistic? To understand this I went to the first-ever internet rehab center in the world. It’s in just outside Spokane in Washington State It’s called restart, Washington. I remember I’ve arrived there. It’s a clearing in the woods I get out. I got out the car and absolutely instinctively I looked at my phone to check my email and felt really pissed off. I couldn’t see it go. There was no reception I was like, oh wait you came to the right place? Right and I spent a fair bit of time there and it’s totally fascinating They get a whole range of people at restart Washington, but they disproportionately get Young men who become obsessed with these multiplayer role-playing games like World of Warcraft or not at the time that I was there but now fortnight right and I’m about Dr. Hillary cash the amazing woman who runs this Center Sent me that you’ve got to ask yourself What are these young men getting out of these games? Because they’re getting something right? I think what they’re getting is a Kind of hollow version of the things they used to get from the society But they no longer get they get a sense of a tribe they get a sense of status and they can gain in status They get a sense. They’re good at something they get a sense. They’re moving around Young people barely leave their homes. Now. It’s incredible the figures for how rarely children play outdoors but what they’re getting is, I started to think that the relationship between say these these games or For media and social life is like the relationship between porn and sex, right? I’m not against porn don’t meet a certain basic edge But if your entire sex life consisted of looking at porn you’d be going around pissed off and irritated the whole time Because we didn’t evolve to masturbate over screens We evolved to have sex right that wouldn’t meet your deeper needs in the same way I’m not obviously not against the internet would be ridiculous, right? But we didn’t evolve to talk through screens, right We didn’t evolve to look at each other and interact through with our friends through screens If you and I was speaking even via Skype now I wouldn’t feel you were seeing me and you wouldn’t feel you was the other way around In the way that we feel that we are seeing and hearing each other now, right? human beings have a need to be seen and The leading expert on loneliness in the world professor John Cacioppo said gave me good little rule of thumb. He said If social media is a way station for meeting people offline or staying in touch with them that you’ll see offline It’s a good thing if it’s the last stop on the line generally something’s gone wrong But he’s I think we have to think about as well the moment in human history when social media arrives Right a lot of the causes of depression and anxiety that I write about in my book loss connections Were already supercharged by then by the late 90s the early 2000s loneliness have gone up Values have gone up a whole range of things And what happens is the internet arrives and it looks a lot like the things we’ve lost You’ve lost friends. Here’s a load of Facebook friends. You’ve lost status Make some status updates, right but it’s not the thing. We’ve lost. It’s a kind of Parody of the thing we’ve lost and what we need to do in very practical ways is restore The thing we’ve lost it seems like today. We have a lot of distractions That could potentially pull us away from that connection It seems like a lot of people are driven through consumerism and materialism and Many of us are safer and have more than ever have before the size of homes has increased steadily since the 1930s and 40s is there any correlation between material wealth and Happiness, one of the things I found most challenging in the research for the book because I could see how much it played out in my own life Was some research by an amazing man called Professor Tim Casa So everyone knows junk food has taken over our diets and made us physically sick right as I can tell from my chins I’m not immune to this myself But it’s equally strong evidence that a kind of junk of values have taken over our minds and made us mentally sick Professor Kass showed. So for thousands of years Philosophers have said, you know if you think a life is about money and status and shoving off. You’re gonna feel like shit, right? It’s not an exact quote from Confucius. But that is the gist of what he said, right? But no one scientifically investigated this until professor Kassar And he showed a few I think really important things Firstly he showed the more you think life is about money and status and shoving off The more likely you are to become depressed and anxious by a really quite significant amount I think this is because we’re going a little bit beyond professor kasih here, but I think this is because Everyone knows they have natural physical needs right? You need food. You need water. You need shelter. You need clean air If I took those things away from you. You’ll been real trouble real fast, and there is equally strong evidence that all human beings have natural psychological means You need to feel you belong you need to feel your life has meaning and purpose. You need to feel that people See you and value you beautifully. You’ve got a future that makes sense and our culture is good at lots of things I’m glad to be alive today but we’ve been getting less and less good and meeting these deep underlying psychological needs if you think partly because there’s many factors going on but partly because if you think life is about money and and Displaying that money that’s gonna divert you from the things you actually do need to have a a meaningful and satisfying life But professor Cass also said something else. So you showed the more you follow these junk values The more likely while to become depressed and anxious He also showed as a society as a culture. We have become much more driven by these junk bodies It’s a cliche to say to your viewers You won’t lie on your deathbed and think about what the likes you’ve got on Instagram and all the shoes you bought right? You’ll think about moments of love and meaning and connection in your lives. But as Professor Casa puts it we live in a machine That’s designed to get us to neglect What is important about life right more eighteen-month-old children know what the McDonald’s M means the know their own last name? we’re immersed in a machinery that tells us how to do this professor Gossard had really interesting research about how we How we undo some of that and some of it was really simple he got a group of people to me once every couple of weeks for four months and just talk about firstly consumer objects, they thought they had to have things like Nike sneakers Once they talked out loud how do you think your life will be different when you’ve got them didn’t take long for people to start seeing maybe this is Bullshit that’s been implanted in my head by advertising but then there were important bit was they’ve got people to talk about well What are moments That’s not a moment that’s gonna make you feel satisfied What are moment’s you have actually felt your life was meaningful satisfying, but we’ll talk about different things to some people It was playing music some people it was swimming some people it was writing whatever it was and and they started saying well How could you build more of that into your life seeking more of that and doing more of that and less of? seeking this kind of junk value stuff and Just that process of meeting every couple of weeks and checking in with each other and explaining how they try to do it Led to a measurable. They did a good scientific study at this Immeasurable shift in people’s values to become less materialistic, which we know relates to less depression and anxiety. Now of course is the case that And a guy professor richard Laird has done research on this if you don’t have a baseline of material goods right If you are in poverty that makes you then you are going to be unhappy But once you’ve actually reached a fairly low level of income that you’re not actually wanting the basic things additional money makes, you know happier and actually Constantly seeking it leads to a corruption of values that makes significantly more unhappy We talked a little bit before we sat down here about Marie Kondo and minimalism and this movement of people rejecting consumerism and materialism to live with less stuff to purchase less things to Focus less on status in their lives Do you think I’m curious Just what your your thoughts on this this movement towards less is and if you think in some way it will help people Figure out their values again and reset these junk values that we’ve created for ourselves I haven’t looked into any huge amount of detail, but We live in a hurricane of messages Telling us The answer to our pain and distress lies in shopping, right? This is a really interesting study that was done in 1978 really simple You get a bunch of five year olds you Divide them into two groups first group is shown two advertisements For whatever the equivalent to like Dora the Explorer or the Teletubbies was in 1978. I forget what it was Second group is shown no advertisements then all the kids are told Hey kids got a choice now You can either play with a nice boy who doesn’t have the toy in the embarrassment or you can play with a nasty boy Who’s got the toy? The kids had seen just two advertisements overwhelmingly chose the nasty boy who had the toy and The kids who haven’t seen their advertisements overwhelmingly chose the nice boy who didn’t have the toy right? So just two ads just two We’re enough to prime those kids to choose an inanimate lump of plastic over the possibility of fun and connection, right? Every single person watching your video has seen more than two ads today right more than two advertising messages. So we’re living in this hurricane of messages Bombarding us with a very particular before Advertising sells any specific product. It sells the idea that the solution lies in Purchasing things right? I mean imagine Advertising is the ultimate frenemy right? It’s saying babe I love you. I think you’re great. But if you didn’t stink I mean, I’m just saying if you weren’t so hairy, I’m just saying, right. It’s the ultimate yeah, it’s It worked. The premise of is it has to make you dissatisfied right? I mean in the advertised you look at what advertising people say internally to each other they’re very candid about this they call it invented once right because actually The things that we need are relatively limited The whole machinery has to be built around making us feel inadequate and then making us by the solution right? So I think Movements that say, you know, I’m just gonna purge this shit right back That is not the answer right? Of course. There are nice things. We all like to have nice things I have some nice things but the idea that this ceaseless Treadmill are buying and displaying useless bullshit The idea that we might want to step off that treadmill and go Maybe I’ve got a limited amount of time in which to be alive. Maybe I’ll spend my time on things that are more meaningful seems to me to be a really positive step Thanks for watching this video If you want to get the full 40 minute interview with Johan you can get it at patreon.com slash Matt de Bella Thanks for watching and we’ll see you next time

Epidemic “One Life” (Produced By Esco) Music Video

Epidemic “One Life” (Produced By Esco) Music Video


Epidemic “One Life”
Somethin’ For Tha Listeners Produced by Esco
Cuts by Dixie Chorus (Tek-nition)
Yo it’s one life to live, so if you focusing on funds ice and cribs
It’s a gamble so it’s one price to bid nigga (yo so why lie)
And those who run trife get bids, through these rough nights the sunlight gets hid nigga
(so why try) Im Tryna get up off these streets, cause if
I make it son we all can eat (see that’s why I try)
Cause dwelling in this hell gets tough, tryna excel before I self destruct Verse 1 (Tek-nition)
Its like I’m pulling off a gem, the recognition I put in off the gym
Define me as your dynasty when you’re pulling off your brim, salute
I never lay-up cause I’m good from off the rim
Once I get on your nerves, I’ma have you pulling off your skin
My roots is royalty, which can signify my loyalty and being dishonorable can boil me
You feel the need to address me then look up and speak
I ain’t the type for diss records over hooks and a beat
And I would never let my stress loose to cook up the streets
Plus I got nieces and my nephews that look up to me
To all my niggas in a trap tryna push to a key
Incarcerated, now them crackers tryna push you to plea, now that’s a trap for ya
It may not look as it seems I got ya back brotha
Turn your nightmare to a dream then I’ll be back for ya
My shorty look as a queen, how can I pass on her
All that back she put in them jeans with all that ass on her
Frenchy, my goal is to resuscitate the game No standard rookie can ever play the same,
my art’s infinite Your mark or blemish couldn’t fluctuate the
stain If you borrowed my thoughts for a minute I’d
suffocate your brain But then again that’s a love and hatred thing
Too over analytical won’t sell my soul over grands that’s pitiful
It’s business and I overstand residual I know your plan so I don’t need no one to
hold my hand like I’m in middle school So I won’t swear under your oath or your allegation
So I won’t stand to that smoke when you stand to satan
That’s my perplexion as an educated learner nigga
Now watch me kill the game premeditated murder nigga Chorus (Tek-nition)
So if you focusing on funds ice and cribs It’s a gamble so it’s one price to bid nigga (yo so why lie)
And those who run trife get bids, through these rough nights the sunlight gets hid nigga
(so why try) Im Tryna get up off these streets, cause if
I make it son we all can eat (see that’s why I try)
Cause dwelling in this hell gets tough, tryna excel before I self destruct Verse 2 (Hex One)
I spit what foes be tryna outdo But these little pricks below me got a mouthful
They’ll tell you switch the flow then try to doubt you, to get this doe
I think of all the pits and falls that I done bounced through
So what the fuck could make you think you know what I’ll amount to punks
I seek my own fate, and taking L’s is what propels my feet to home plate
I never fell, through severed trails I keep my road straight
And just in case if heaven fails my thesis holds weight in hell
Until my cold state prevails, but before I’m laying deep in a hole
Son I’ll be racing through this treasonous globe looking for reasons like
I wonder what a jealous nigga sees in his soul
If he wasn’t hating now, he’d probably be achieving his goals
A focused mind, see I’m careful who I hang out with
Cause most the time them niggas ain’t ’bout shit, I’m close with mine
If we’re broke its fine, but if there’s rope then you’re supposed to climb
What I wrote’s divine, I’m like coke but with doper lines
So if blood is thicker than water, then liquor is hope
Cause sometimes mud is thicker than both, you throwing dirt on me
You turn ya back on ya team, and that shit hurts homie
So what does loyalty mean and what’s it worth for me?
Everything nigga, word up, now tell me that wasn’t some real shit Bridge
“I make these, I sell ’em for twenty dollars a piece. I thank god, you know
That I do have a place that I can do my artwork, you know. Um, I guess that’s all.” (for real) Verse 3 (Tek-nition)
Life decisions can be so contradicting I remember wanting my watch to glisten
Cop a whip and stunt while my biological clock is ticking
But time is different I struggle to keep a pot to piss in
Kissing my boss’ ass to keep my tabs on this heartless system
Niggas from school is on the same ol’ shit Still sticking their dirty dick up in the
same ol’ bitch It’s a shame but who’s to blame I’m on my
same ol’ tip Dreams of touring but I remain home sick while
mind traveling like Running in place but never caught up with
life Too light to be black and always been too
dark to be white But I’m different so fuck a pigment what you
thought to be right Is a figment we all fought for these stripes
Blaming the whites for your ignorant asses When section 8 is your primitive action, living
for fashion Many kicks but have minimal assets (nigga)
There’s more to life than living in a scheme When most you nigga’s rims is bigger than
your dreams I’m swimming on to bigger better things cause
these Sierra Leone’s Ain’t coming with me when they bury these
bones, God knows I don’t give a fuck about being the heir to
the throne Long as he spares me in his likeness when
he carries me home Chorus (Tek-nition)
Yo it’s one life to live, so if you focusing on funds ice and cribs
It’s a gamble so it’s one price to bid nigga (yo so why lie)
And those who run trife get bids, through these rough nights the sunlight gets hid nigga
(so why try) Im Tryna get up off these streets, cause if
I make it son we all can eat (see that’s why I try)
Cause dwelling in this hell gets tough, tryna excel before I self destruct (I’m tryna fly
high)

Bugs

Bugs


*Intro Music plays* I grew up with two sisters And it was usually my job to take care of bug invasions [lol me to][R.I.P] And cleanse the immediate area of apparent danger, Whenever spiders, centipiedes, or… Whatever appears I’d be in my room and suddenly hear a scream (Background) EHHHHH And a cry for my help, I’d get there and I’ll be like: “WHAT?! What is it?! I’m fighting Sephiroth right now and Donald keeps dying! “This better be important!” Dom’s Sister: Kill it! Oh my god kill it! *Slight pause* :But…… It’s not hurting anyone…… Sister: Kill it!!!!!!!!! But it’s on the ceiling.. SIster: KILL IT!!!!!!!!!!!!!!!!!! Dom: But- Sister: I don’t care just kill i-i-i-i-i-i-i-i-it Now, I neither like nor dislike bugs, I don’t have a phobia of them. But I don’t welcome them with open arms when they enter the same room that I’m occupying. I actually used to be pretty brutal with bugs. One time a spider crawled up my wall, And I caught it with my peripheral vision. So I grabbed the nearest book, and my arms reached and, launched it at the wall Obliterating the spider, (complete distuction)and whatever hopes and dreams it had, (sick animation)There was carnage on the wall, there was carnage on my book! I wiped it off my book, but whatever was left on the wall I didn’t clean it off, and kept it there as a message, I guess? For any future trespassing bugs who were like: Cockroach Dave: Bro! I need to get to the ceiling! (fast) Cockroach Tom: Are you crazy man? While he’s around?(you serious?) Cockaroach Tom: Did you see what he did to Will? (R.I.P Wii the Spoder 1969-9000) death by obliteration Cockaroach Dave: Yeah, you’re right (peace out) It’s probably like been 8 years since I killed Will, but his bloodstains are still on that wall.(i aint going back!) When I used to live in Virginia, my family and I lived at the first floor of this townhouse complex (Nice) One day, I noticed an ant colony found its into my room, and I realized that they had found a piece of cookie that fell on the gap of my table on the wall. I tell my Dad and hes like: Here’s some bug spray, Good luck..(aka. kick their ASS) And the can of bug spray was like pretty much full when I got it, but when the time that I was done it was probably more than half empty. I sprayed those ants as much as I put cheese on my pasta, okay? If I even see a square milimeter of pasta, (pasta is done)I don’t got enough cheese. Gimme the cheese bowse!(Thats alot of cheese O.O) If I saw an ant, that ant gotta be drowned in bug spray. So after the massacre took place in my room, I stood on the battlefield among all the carcasses, and indulged in my victory.(demonitized) Went to bed, And found myself very ill due to the lingering toxins of the excessive bug spray that I used. I inhaled that (domics bro ur going to get me in trouble) all night! Truly ironic. Good game ants, goo-Good game I-I played myself.(congratulations ya played yourself) 16-year old Dom? you-you-you played yourself. But I mellowed out a bit now with bugs, I think. I actually have this unwritten policy with them, If they ever enter in my line of sight. Basically: If I catch you on the premises, you get a warning. I’ll let you proceed with whatever business led you to getting caught by a lethal human who occupies this space. But if I see you again, You’re dead.(you here you die) I mean it might be a bit unfair since I don’t exactly communicate this agreement to them, but I-I-I’m sorry if you’re just passing by, then that’s cool. But if know that you’re lingering around, then, you gotta die I can’t have you crawling in my mouth while i’m sleeping, (gag) Can’t let that happen sorry, Imma have to end you I don’t go all Starship Troopers on them anymore I keep it a little more civil now, And give them the Sharben treatment followed by the trash can treatment. But if it’s lucky enough to be caught on the 1st floor by a door or a window, then i’ll probably set it free(you are free small one) I do have some exceptions for first sightings though If you’re coming for my food, you’re dead.(not the pizza!!!) If you’re crawling on me, somewhere on my body, you’re dead If you’re on my bed, you deeeeaaad. If you’re 5 cubic meters or larger in volume. Then my bad, Take the house I-I don’t want it no more, I’m setting it on fire. I say all this, but honestly the bugs I encounter don’t even come CLOSE to the kind of demons people in other countries have to deal with. Australia for example Like… DDDDDDDAAAAAMMMMMNNNN Whaa? What even? HOW Even!? SssSSSssSSHhhhHHHHIiiIIIItTTTT W-Why!? A-Are you guys okay over there? And it’s not even just bugs, I wouldn’t be surprised if you’re from Australia and you’re halfway into a snake right now while you’re watching this Then if you are… Well, shiiiiiit… You loyal! I appreciate that Ohhhhhh Boy! Guess what’s back again? School tiiiiimmmmeeee! aka barf well… …for you guys anyway. I’ve been done with that for years now. (Maniac laughter) Oh man I’m old 🙁 Anyway, you guys know I love anime And more so affordable merch of Anime This month, LootAnime’s theme is Demi-Human ooooo Including items from: ONE-PUUUNCH Man, Bleach, Tokyo Ghoul, And Twin Star Exorcists Just a quick run through of how LootCrate works for the newcomers Its a monthly subscription service for all sorts of merch. For LootAnime you pay less than $25 a month you’ll get a selection of items ranging from T-shirts, Manga, Posters, Figures worth more than double what you pay Cut off for months themed Crate is the 19th at 9 PM PST *Bad British Accent* And all future crates, Hence both can be automatic as long as you stay Subscribed (It was really hard to copy that.. Why Domics???) If you sign up on LootCrate.com/Domics or click on the link in the description, And enter the code: DOMICS That’s: D-O-M-I-C-S You can get 10% off on New Subscriptions Last Month the theme was: “Back To School” it had a few cool stuff from Danganronpa, Ass-Class, And Persona 3 But hey! No worries if you missed that one, There’s plenty of cool new upcoming stuff in future Crates! One more time that’s: LootCrate.com/Domics with a Code in: DOMICS to save 10% on New Subscriptions Link in the Subscription below. Enjoy! 😀 (The Captioners: Rex Legason DICK and KayleeN Thats it we only made all of this Subtitles I’m so lonely ;(. ) (Not really, though) (Also this took 1 Week to make because of school N’ Stuff>_

MY PET SNAIL!! New Morning Routine catching bugs with Adley in Hawaii


– Adley, it’s a big slug! Do you see it? – Yeah, I see, shall we go and catch it? – Let’s go find it. – I see it! – Let’s go get it and
take it to the house. – Yeah. – OK, let’s get the slug. – Wow, it’s a slug. (cheeky brass music) – Sh, Mommy’s sleeping. – Sh. – We’re gonna catch bugs. – Bugs. – Hey Hophop! – You guys have matching pajamas! – Uh huh. – Cute! – And she has a skirt on. (groovy guitar music) – OK, shall we bring Hophop? – Yeah, let’s bring Hop (boinging noises) hop, hop, wait, ready! – Oh I found these things. – Check, where should we look first? – This way. (makes squeaking noises) – Do you see anything? – I see a head! – Where? – In the plant. – Ooh, shall we look under this rock? – Yeah. Mosquitoes on it. – Oh! – Whoa! – Did you see that? – Yeah, I did! – That was a big one! – Yeah, that was so big. – Shall we keep looking? Hmm. – Keep looking. (gasps) – I hear a bird. (birds chirping) Ooh, maybe there’s slugs,
let’s go look, come on. – Ooh, slugs. Watch out for lizards! – Lizards? – Yeah! Follow me, Dad. – OK, I’ll follow you. (birds chirping) – She should find a shell. – Yeah, we will. – I found one! (dramatic chords) – Where? – Right here. – (gasps) – Shall we tap it? (boing noise) – Whoa! – Look at its eyeballs. (boing noise) – Cool. (lively jazz music) – Well, it’s going back inside. – Do you wanna put it on my hand? Whoa, I’m holding a slug. Ooh, he’s making bubbles! – Yeah. – He’s inside. – (laughs) – Hello! – Hello! – Shall we go put him in the shade? – Let’s go put him in the shade. – We’ll put him right here. Here, do you wanna put him down? – Let’s make him a bed! – OK, what’s his bed? What do you think? – Maybe we need a leaf. (gasps) – Here’s a leaf, could this be his bed? – Yeah! – OK, put him in the bed and then – We need more rocks in front of that. – and then this could be a slide for him. Shall we go find more? – Yeah, but I know what he needs. – What? – Some chairs! – [Dad] Chairs? – Yeah, in case he – [Dad] Grab ’em right there! Maybe these could be chairs,
for when friends come over. – And a baby chair and a sword and another sword. Maybe this is his Christmas tree. – What’s that? – A Christmas tree. – A Christmas tree? OK, that’s your Christmas tree! – [Adley] Let’s go find more friends. – OK. (gasps) – What? – Is this one? Adley look, there’s the shell. Right there. See if there’s one inside. – Just a plain shell. – [Dad] Argh! OK, let’s keep looking. – Keep looking. – Adley, it’s a big slug! Do you see it? – Yeah, I see. Shall we go and catch it? – Let’s go find it. – I see it! – OK, let’s go get it
and take it to the house. – Yeah, take it to our house first. – Yeah, OK let’s get the slug. Right, do you wanna grab him? – No, I don’t want! – No? – Wow, it’s a slug – Come here, little guy. (gasps) – (squeals) – Come to our new home! – Come on! – Come on Dad! (squeals excitedly) – We’ve got a slide and a Christmas tree. – And a bed! – And a bed. – We have a friend for you and swords. – He needs lots of friends in that bed. – OK friends, here’s your bed. – [Adley] Now we need more, now we need get another bed for more. – [Dad] OK, get another bed. – I got one. Let’s put it by the bedroom! I did it. We need a kitchen right here, a kitchen and then this is where you’ll eat. – This could be the kitchen and that’s the hallway
that goes to the kitchen. They go through here and
then that’s the kitchen. – And they walk right here to chairs. We will be right back,
we’re getting lots of more. – Yeah! Careful. – We got another one. That’s another bedroom
and that’s a kitchen. – (gasps) He’s going to the chairs. – He’s gonna go sit on the chairs to eat! Shall we get some food? – I think they eat leafs,
but not like leafs like this, just little baby leafs. – OK, let’s go get some baby leafs. – OK. – This is their food. – Maybe some of these, like that? – No, we need a lot. – A lot? Let’s go! – Let’s go feed them. – OK. – Shall we put these in the kitchen? – Yeah. – ♪ Broccoli and greens ♪ This is their refrigerator. – [Dad] Oh, right there? – [Adley] Yeah. – [Dad] Shall we put some in the kitchen? – [Adley] Yeah. – (gasps) He’s going in the kitchen right now. There you go, there’s your kitchen food. Oh look, he’s still sleeping in his bed. – [Adley] Heh, that’s funny. – [Dad] Shall we go look for other bugs? – Yeah, let’s go look. There’s one, there’s one. – [Dad] Oh no. – [Adley] It’s right there! – Oh, they’re so hard to catch. – One time, my dad got
one by the swimming pool. – Yeah, it was by the swimming pool and it jumped on my shirt, remember? – Yeah! – [Spongebob Squarepants
Narrator] Flashback. (musical twinkly noise) – [Dad] Look! – [Adley] Look! (boing noise) – [Mom] Oh my gosh! – Adley, I finally got a lizard! – Yay! – Yay! – Look Adley, we’ve finally go one! – (squeals excitedly) Wow! – I wanna pet it. – I don’t wanna pet one. – [Mom] Touch him, Adley! – Here, pet him! We’ve been trying to catch
a lizard the whole trip and we finally got one! – Whoa! – [Mom] Oh my gosh! – (squeals) I never pet a lizard before. – Is that the first time? – Ooh, don’t squish him. – We’ve been trying the
whole trip to catch a lizard and we finally got one. – Dad, shall we take him in? (boing noise) – [All] (scream) – He’s on my arm! He’s crawling on my arm! What do I do? – [Mom] Oh my God. – [Dad And Girls] (scream) (musical twinkly noise) – [Spongebob Squarepants
Narrator] End of flashback. (relaxed lounge music) – There’s lizards all over in this bush. I just saw like five of ’em. Where did they all go? Maybe let’s see if there’s
any in these bushes. – [Adley] Dad! – What? – [Adley] Shall we go look for some bugs at the swimming pool? – [Dad] OK, let’s go. – We gotta be up here. – Go through the jungle. (whooshing noise) – Pretty flowers. – Way pretty flowers. – Look for bugs, look for bugs. Let’s put our feet in the water. – OK. Oop, don’t get your jammies wet, ooh. That was some good bug
catching Adley, good job! Oh yeah! – Thanks for watching! – [Both] Bye! (jazzy keyboard music)

Most DANGEROUS Bugs Around The World!

Most DANGEROUS Bugs Around The World!


From bullet ants to mosquitos, here are 9
of the deadliest insects in the world! Those deeply afraid of creepy crawlies beware! 9. Bullet Ant Known as the World’s Most Painful Insect,
getting bitten by a bullet ant is something you never want to experience. Native to the rainforests of Central and South
America, the small but powerful bullet ant is also known as the hormiga veinticuatro
meaning the “24-hour ant” which refers to the full day of pain that follows after
being stung. Only a little over an inch in length, it is
hard to believe that their sting can feel like getting shot with a bullet. Dr. Justin Schmidt, an entomologist and research
director of the Southwest Biological Institute in Tucson Arizona, invented the Schmidt Sting
Pain Index (SSPI) which categorizes the level of pain felt when stung by wasps, bees, and
ants. He let himself get stung by all kinds of insects
in order to rank their sting. He said that it really felt like getting hit
by a bullet with waves of burning pain that were absolutely excruciating and went on for
hours. The good thing is that it is a localized effect
and this sting does not directly affect your heart or lungs, so you won’t die from it
but it will hurt like a bi-atch. These ants are greatly feared across the rainforest
by people and animals alike. However there are several indigenous tribes
that use these ants in their initiation rituals. Young boys wishing to be seen as men by the
tribes must endure placing their hand in a woven glove filled with these ants. They must endure getting stung repeatedly
for at least ten minutes. If that wasn’t enough, the boy must sometimes
go through over a dozen of these rituals! None of them suffer long term effects although
the trauma may last forever. 8. Japanese Giant Hornets The highly aggressive and territorial Japanese
giant hornets are infamous for their painful sting and fearsome nature. A subspecies of the Asian giant hornet, these
monsters are much larger than normal hornets and are known to hunt and consume up to 50
unfortunate honey bees a day. As if honey bees didn’t already have enough
problems… The creatures which are rapidly becoming a
pest have now made nests in France and England and due to poor shipping practices, are spreading
across the globe. Their venom is known to destroy red blood
cells and those with allergic reactions are especially at risk of death. The Japanese giant hornets kill 30-40 people
in Japan alone every year, and send hundreds to hospital. Its venom attacks the nervous system and damages
the tissue of its victims. The stings can also cause renal failure. The giant hornets are attracted to human sweat,
alcohol, and sweet flavors and smells. They are especially sensitive when animals
or people run and they will start to swarm and attack. Some victims have required hundreds of stitches
and numerous dialysis treatments to survive and are still are left with deep scars. These hornets have lead to government initiatives
to destroy the nests in Japan and China, and maybe they have the right idea? These aggressive insects are pretty scary. 7. Fleas The hidden villain of the famous black death
that ravaged Europe during the Middle Ages, the flea feeds on blood and can spread diseases
to animals and humans. Capable of leaping 150 times their own height
they can move from animal to animal to consume 15 times their own body weight every single
day. The bubonic plague was spread by fleas carrying
the disease on-board infected rats and some estimates say it wiped out close to 2/3rds
of the population of Europe at the time. Though some might say that is was not the
fleas but the infectious bacteria they carried which made it difficult for the creatures
to feed. Therefore they would regurgitate infectious
materials on the host. In fact, the disease still survives in many
flea infested parts of the world, though it is much more easily treated today. Though the black plague changed the entire
face of Medieval history, modern fleas can still infect humans with diseases such as
typhus and are still common among the quickly breeding rat populations. Flea bites can cause disastrous allergic reactions
on both pets and humans alike due to the saliva that they leave behind after the attack itself. In most cases the only real stress is avoiding
the very itchy swollen bite marks and dealing with the infestation quickly as fleas can
lay over 50 eggs in a single day! 6. Tarantula Hawk Wasp This insect is the only other bug to reach
a 4 on the SSPI scale along with the bullet ant. The tarantula hawk is a solitary wasp that
wanders around looking for tarantulas. The goal of the tarantula hawk’s sting is
to get a predator such as a bird or a lizard to let it go. The pain from a tarantula hawk is like getting
shocked with a high-voltage electric line in a wind storm. The super intense blast is meant to surprise
and the pain only lasts for about 3 minutes. It might seem like longer if you are screaming
in agony but after a few minutes, it is suddenly gone. However if you are a tarantula, this sting
will not only shock but paralyze. The wasp will then lay a single egg inside
the tarantula’s body. When the larvae hatches it will began feeding
on the tarantula, avoiding vital organs for as long as possible so the tarantula stays
alive. For the rest of us, tarantula hawk wasps rarely
sting without provocation but geez, nature you scary! 5. Botfly The botfly though rarely fatal, makes this
list for the parasitic horror show it unleashes on it’s mammal victims. Last chance to preserve the innocence of your
dreams as the human hunting botfly allows its eggs to grow in human skin which burrow
deep and eventually develop into larvae which can be felt under the skin. They do this by catching a mosquito as host
and then implanting it with the bot fly’s eggs, which when they go to feed on a mammal
(and in many cases human), the eggs fall into the open wound. This insect horror show can cause the victim
to feel the larvae within the skin, squirming when their airway is blocked. Thankfully this species have the decency to
not have too large populations and live in many parts of Central and South America. They are usually treated with petroleum jelly
over the wound, which suffocates the invaders so that they can be removed with tweezers. Only one type of botflie routinely targets
humans but others can as well, though they usually target the intestines such as the
ones that specialize in horses. Some other animals can become easily infected
by the bacteria or other conditions and die soon after. 4. Killer Bees Widely known and feared, the Africanized honey
bee or killer bee has certainly earned its fearsome reputation. Though their sting is just as deadly as an
average honeybee, they are supremely aggressive, sending many from the colony to repeatedly
sting any perceived threats. In fact, they are so relentless they will
sometimes completely abandon the hive as the entire colony pursues an enemy, leaving the
nest completely unprotected. Deaths from bee swarms are disturbingly more
common in this species of bee. They were created in the 1950´s when Brazilian
scientists cross-bred the southern African honey bee with the European honeybee in an
attempt to create a bee that was more suited to the South American climate. Some bees were accidently released into the
wild in 1957 and had no problem breeding and multiplying throughout the Americas. They have since bred with many other colonies
of bees and are beginning to spread across North America as their African honeybee DNA
allows them to quickly build hives and grow their population. Unfortunately they have also inherited the
aggressive personality as well. These killer bees have been know to respond
viciously to simple things such as noises and even vibrations from vehicles, equipment,
and pedestrians. The good thing is that as bee species continue
to decline, more bees are good news for the flowers of the area. 3. Kissing Bugs Not nearly as innocent as they sound, the
kissing bug is incredibly deadly because of its tendency to spread the terrible Chagas
disease to human populations. Infected with a parasite that causes the disease,
they feed on blood during the night and at the same time transfer the parasites to humans. They get their name from their tendency to
bite humans near the blood vessel-rich areas of the eyes or lips, though this typically
isn’t the kind of makeout people are looking for. A little larger than the size of a penny,
they are mostly found in warm climates, such as the Southern US. I used to live in Florida and saw these all
the time but I didn’t know they carried diseases! The chagas disease that they spread has two
distinct stages, the first in which common symptoms such as muscle aches, rash, vomiting
and other such symptoms may or may not manifest. The second is the chronic stage, which affects
30% of the infected and can cause enlarged heart, and heart rate conditions. Good news is that this stage can take years
to develop, sometimes close to twenty, so if you can make it you’re laughing as you´ve
outlived your attacker by at least twenty times as they tend to have a one year lifecycle. If you suspect you´ve been effected there
are support centres to which you can send the bug if you can find it to ensure proper
treatment. 2. Locusts The name locust summons images of swarms of
flying insects that raze everything in site until only nothing is left. This plague however is all too real. They are very similar in many ways to grasshoppers
though their tendency to gather in large groups is what truly makes them a menace. The main damage isn´t directly to humans
ourselves, but a huge swarm can descend on a farm and devour everything in sight. Crops, grass and even clothes can disappear
forever within the giant cloud and lead to mass starvation for the communities affected.These
clouds can stretch hundreds of miles across and consume millions of pounds of plants every
day, in a vicious feeding frenzy made up of billions of locusts. Their telltale buzzing sound is the fear of
farmers the world over, yet many quickly scramble to construct large fires as the smoke can
debilitate a swarm. Interestingly, the locusts are a delicacy
in some parts of the world and their bodies can help make up for the lost food they consumed. Considered a natural plague by some the desert
variety is especially known for destroying the little crops that can be grown and are
known to move large distances in search for food. In fact one particular swarm was noted for
traveling all the way from Northern Africa to the island of Great Britain! 1. Mosquito The bane of fishing and camping trips alike
this seemly minor annoyance is in fact not only the most deadly insect but one of the
most deadly creatures on the entire planet. They accomplish this by spreading diseases
such as Zika, West Nile and Malaria where they can cripple a human population, especially
in areas where medical treatment is unavailable. Interestingly mosquitos feed mostly on plant
nectars but the females use blood to help their eggs grow and can consume up to three
times her own weight in blood to nourish them. Though this blood is easily replenished in
most working bodies, the diseases that the mosquito can spread are numerous and deadly. They are attracted to and lay their eggs where
there is still water, such as flooded sinks or buckets and can locate human targets by
sensing the Carbon Dioxide we exhale. They can even sense our body heat to know
exactly where to draw blood! At around 210 million years old as a species,
they have been feeding on Dino-DNA long before humans ever entered the scene. In fact, Alexander the Great was believed
to have died of malaria which is famously spread by mosquitoes and kills more than a
million people a year. As it turns out dragonflies may be our best
friends as they hunt hundreds of the mosquitos per hunt and some places even release them
into the wild as natural mosquito control. Thanks for watching. What insect are you the most afraid of? Be sure to subscribe and see you next time!

5 Most Beautiful Insects You Won’t Believe Are Real

5 Most Beautiful Insects You Won’t Believe Are Real


5 Beautiful Insects You Won’t Believe Are
Real. Number 5. Dactylotum bicolor looks like it’s one of
those “paint-by-numbers” projects with all those amazing colors! In reality though, it’s called a Rainbow Grasshopper
or Painted Grasshopper. Native to the United States, Canada and northern
Mexico, this grasshopper grows to an average length of about 20 mm (0.8 in) for males and
35 mm (1.4 in) for females. It is mainly black with distinctive reddish
and yellowish markings, a pale green prothorax and pale green wingpads. The tibia of the hind leg bears six to eight
spines, and this species does not develop wings and is unable to fly. Number 4. The spiny Flower Mantis, or Pseudocreobotra
wahlbergii, is a beautiful and colorful flower mantis with natural range in sub-Saharan Africa. They are white with orange and green stripes,
and as adults they have a beautiful patch of color on their wings that looks like an
eye. An easy way to tell males from females is
to look at the length of their wings: A female’s wings will reach to the end of her abdomen,
while a male’s wings will extend past it. Number 3. There are a number of Ruby-tailed wasp species
that look very similar and are difficult to tell apart. They’re all beautifully coloured, with red,
blue, green and bronze metallic colours. These wasps are solitary, meaning they don’t
live in large social nests. Being barely 10mm in length, they can be difficult
to spot. You can often see them running restlessly
over walls and tree trunks, constantly using their downward-curving antennae to pick up
the scent of their host insect. As a parasite they require another species
for part of their life cycle, Chrysis ignita mainly parasitizes mason bees and other solitary
bees. Number 2. Maratus speciosus, sometimes called the coastal
peacock spider, is an Australian species of jumping spider. They are only known to inhabit the vegetation
of the coastal sand dunes of southwestern Western Australia. Like other Maratus spiders, the males of the
species engage in a courtship display during which they raise their third pair of legs
and their abdomen, presenting their colorful opisthosomal plate
to potential female partners. Unlike other Maratus, however, the males of
this species have a set of bright orange hairs (setae) along both edges of the opisthosoma
which only become visible during this display. Number 1. Greta oto may sound like the name of a silent
movie star from Eastern Europe but is in fact the scientific name for one of the most exquisite,
and little known, species of butterfly on the planet. This butterfly’s claim to fame is that its
wings, spanning up to six centimeters, are almost completely transparent. That’s right, you can see just about right
through them. The common English name for this remarkable
butterfly is glasswing, which in itself speaks volumes about the appearance of this small
but unusual insect. However, it takes the romance languages to
step in and give the butterfly the name which, for many, suits it best. The Spanish name for the glasswing is “espejitos”. Literally translated, this means little mirrors. Just a glance at the insect in question and
one can imagine the thrill of pleasure when the moment of inspiration that came to its
Hispanic name giver.

Changes in Clinical Diagnostics and Tracking Infectious Diseases

Changes in Clinical Diagnostics and Tracking Infectious Diseases


>>Thank you for joining us. I’m Dr. Phoebe Thorpe and it’s
my pleasure to welcome you to CDC, Public Health Grand
Rounds for October 2016, “Changes in clinical diagnostics and tracking infectious
diseases”. We have a very exciting session. So let’s get started. But first, a few
housekeeping slides. Public Health Grand Rounds has
continuing education credits available for many disciplines,
physicians, nurses, pharmacists, veterinarians, health
educators, and others. Please see the Public
Health Grand Rounds website for more details. In addition to our website,
we’re also available on social media and we
are live tweeting today. So please use
#CDCGrandRounds for all your tweeting needs. We also have a featured video
segment on YouTube called “Beyond the Data” which is
posted after the session. And we are partnered with
the CDC Public Health Library and Information Center to feature scientific articles
relevant to this session. The full listing is available
at CDC.gov/scienceclips. Here is a preview of our upcoming Public
Health Grand Rounds session. Please plan to join
us live or on the web. In addition to today’s
outstanding speakers, I’d also like to take a moment
to thank the many contributions of the individuals listed here. Thank you. And now for a few words from
CDCs Director Dr. Tom Frieden.>>Technology continues
to advance, change and improve our lives. One example is a new
generation of Culture, Independent Diagnostic
Tests or CIDTs. These CIDTs make it possible
for healthcare providers to determine which pathogen
is causing a patient disease, often while the patient is
still at the doctor’s office. When a specific cause is known
quickly, patients benefit from faster diagnosis
and targeted treatment. CIDTs are available
for many infections, including tuberculosis
and chlamydia. They can confirm infections
that weren’t easy to test or culture before such as
legionella and C. difficile. But as with other
technological advances, there are unintended
consequences. Although, CIDTs provide
rapid diagnosis, there is no organism
available for further testing, including by traditional
culture. If clinical care ends
with the CIDT results, we may not get answers
to important questions. We can’t determine whether
one person’s illness is part of a larger outbreak. Whether a bacteria is
resistant to antibiotics and how likely it is to
cause severe illness. Information that’s
key to understanding where infections come from and how they spread is
especially important in the case of infections spread
through our food. Additional laboratory testing is
still needed for positive CIDTs, without it the food
supply will be less safe. Every year, 48 million
Americans get sick from food borne illness; 128,000
are hospitalized and 3000 die. Twenty years ago, along with
our partners CDC established PulseNet and FoodNet
to track the spread of food borne diseases
and work with partners to trace illness back
to contaminated food. Over that time many
outbreaks have been stopped, but not before infecting too
many people across the US and in other countries. In 2015, there were 35
multistate outbreaks of foodborne disease. And each year, the number
of outbreaks increases. Only by connecting these
individual infections can public health investigators trace
illness back to the source and stop further spread. Without cultures and
detailed genetic information, connecting affected individuals in multiple states is more
difficult, takes longer and leaves contaminated
food on the shelf. As you’ll hear today, our scientists are using
many approaches including collaborating to
develop new technologies to help address these issues. But these advances take time
to implement and until they’re in place, public health will
have to continue to rely on cultures to detect, trace
and stop foodborne outbreaks, and keep our food supply safe.>>And now for our
first speaker, Dr. Chris Braden.>>Good afternoon. Today I will be giving you an
introduction to the advances in Culture, Independent
Diagnostic Tests. Culture-based diagnostic
tests have been used for over 150 years, having
been invented by Louie Pasteur. More recently, culture
independent tests have been developed with antigen-based
tests coming into wide use in the 1980s and 1990s. These tests detect
antigens which are specific to a certain pathogen type. In the 2000’s, molecular
detection test based upon polymerase chain reaction
methods were developed. These tests detected short
genetic sequences specific to a single pathogen type. Since 2010, we have seen a major
expansion in the production of multiplex PCR
panels which detect one or multiple pathogens
simultaneously. These panels are often designed
around disease syndromes such as gastroenteritis,
respiratory diseases, meningitis, or bloodstream
infections. Though we will be focusing
mainly on diagnostics for enteric bacterial
pathogens today, culture independent
tests based upon antigen or nucleic acid detection
have been applied to many different
types of pathogens and are often the only practical
way to detect viral pathogens. For enteric pathogens
the number and type of culture independent
diagnostic tests have increased rapidly. In the last 5 years there
has been an increase from 5 antigen-based
tests for Campylobacter and Shiga-toxin-producing
E. coli or STEC to 8 antigen-based tests, several laboratory
developed PCR test used in large commercial
laboratories, and to date 5 multiplex PCR
panels have been FDA cleared. Still others see CIDTs including
multiplex PCR panels have been FDA cleared for respiratory,
meningitis and bloodstream pathogens. FoodNet, a network
covering about 15% of the US population
monitors CIDT use as part of its surveillance activities. For the bacterial
infections tracked by FoodNet, on average 7% were diagnosed
by CIDT in 2012 through 2014. As depicted by the blue
bars in this graph. This more than doubled
to 16% in 2015. Uptake of CIDTs in clinical
laboratories varied by pathogen and the use of multiplex
PCR panels is growing. The use of CIDTs may
impact surveillance trends. Compared with the average
incidents in 2012 to 2014. In 2015, the incidence
of Cryptosporidium and non-0157 sugar
toxin producing E. coli almost doubled. This increase might,
in part be caused of increased use of CIDTs. As you can see from this
graphic, the workflow and CIDTs including multiplex
PCR panels is relatively simple and fast. The clinical specimen
is prepared for testing in a sample tube containing
reagents, which is inserted into the automated
diagnostic instrument. Detection of specific PCR
products yields a positive result for one or more
pathogens included on the panel. Automated analysis
can produce a result in as few as 1 to 2 hours. Reflex cultures should be
done to provide an isolate of the pathogen for
additional testing such as conventional
identification, antimicrobial susceptibility,
and pathogen characterization. More on why this is
important in a moment. However, conducting
reflex culture of CIDT positive specimens
may not always be clinically necessary and entails
additional costs. If reflex culture is done
for public health reasons, it is not clear whether
the clinical or public health laboratories
should conduct the culture testing and bear these costs. Also, in some instances,
it may not be possible to conduct reflex cultures. For example, if the original
specimens obtained with a swab, the entire specimen may be used
and inactivated when transferred to the sample tube
with reagents. Test procedures should include
the option for reflex culture from the original specimen. The benefits of culture
independent diagnostic tests are impressive, especially
for clinical care. They can provide
much faster results for targeted early treatment of
infections, including whether or not antibiotics are needed. The panel test can detect or
rule out multiple pathogens in a single test and are likely
more sensitive than culture. These tests may provide
faster information for local public health action. However, CIDTs alone do not
provide cultured isolates. Isolates are needed to
characterize the pathogen. In addition to the
clinical utility of antimicrobial susceptibility
results to tailor treatment, hospitals and public health
programs need this information to track resistance trends in their facilities
and jurisdictions. Determination of virulence
factors can inform clinicians and public health officials of
the likely severity of illness. Serotype and genotype
information is used to identify specific strains, whether a strain is
causing an outbreak and possible routes
of transmission. Genotype information has been
used extensively in programs such as PulseNet to connect
cases, identify outbreaks and prevent over 270,000
illnesses each year. PulseNet is in the
midst of transformation to more detailed DNA
fingerprint analysis to facilitate outbreak detection and investigation using
next generation whole genome sequencing technology. But this technology also
requires cultured isolates. Each year, 48 million people get
sick, 128,000 are hospitalized and 3000 die from
foodborne disease. Public health programs
need to enhance efforts to make our foods
safer and we need to conduct DNA fingerprint
surveillance of foodborne pathogens to do so. Other possible drawbacks of culture independent
diagnostic tests are related to the difficulty interpreting
test results in some situations. Because DNA from dead microbes
can produce a positive test result, clinicians may not know
a patient is still contagious and public health officials
won’t know if it is safe for a patient to return
to work or to daycare. Also, a single test may
detect multiple pathogens, some of which may not
be causing illness. A study of one brand of a
multiplex PCR GI panel found that over 30% of positive
tests detected more than 1 enteric pathogen. This may lead to
diagnostic confusion and unnecessary treatment,
and to confusion for public health
surveillance systems. CDC has strategies to meet the
surveillance challenges posed by culture independent
diagnostic testing. First, we need to support
the use of reflex cultures for positive CIDT samples
by encouraging states to update referral and
reporting guidelines and loss. We also need to decide who performs the reflex
culture and who pays for it. We can develop expedited
isolate recovery methods to make culture simpler and
cheaper, and we need to work with the diagnostic
device industry to make sure specimens can be
cultured using our procedures. Second, in the short term, we need to implement a whole
genome sequencing technologies for surveillance. Though this will also
require continued use of isolates from
reflex cultures. Developing large whole genome
sequence databases will allow the type of research
and development required to achieve the third tier of
our strategy for the long term, the development of
metagenomic diagnostic tests. Meta-genomic technology
has the potential to provide both the
essential clinical and public health information
direct from specimens without the use of cultures. Dr. Besser, will be
providing some insight on different methods
for metagenomics, including amplicon sequencing,
and shotgun metagenomics. As technology advances,
we must pursue a path that benefits both patient care
and public health surveillance. The solution includes
building a broad understanding of the issue among many
partners, including experts from public health,
clinical medicine, diagnostic device makers,
Congress, regulators, and insurance officials. In 2012, CDC convened a
multi-stakeholder forum to raise awareness of
the impact of CIDTs on public health programs. In 2013, the infectious
disease Society of America published
specific recommendations to improve diagnostics for
infectious diseases in a way that also benefits public
health surveillance. FoodNet partners are tracking
the growing use of CIDTs in evaluating changes over time. And The Council for State and Territorial Epidemiologists
is discussing how best to count infections
identified by CIDT and public health surveillance in updating surveillance
case definitions. And now I’d like
to turn the program over to Alicia Cronquist. [ Applause ]>>Good afternoon. CIDT is having a major impact
on surveillance in Colorado. Our most recent data show that 15 labs are using
multiplex PCR testing. To put this in perspective 40% of enteric bacterial pathogen
cases reported in Colorado so far during 2016 have
been tested using PCR, 89% of the salmonella Shigella and Shiga-toxin-producing E.
coli are xTAG tested using PCR have also had a reflex
culture tested performed either at the clinical lab, or the
state public health lab. In Colorado laboratories of
various sizes and from urban and rural settings are adopting
multiplex PCR since 2013. And we’ve been busy
responding to this switch. Our activity falls
loosely into 3 categories, ensuring accurate
case reporting, facilitating isolate recovery and adapting our day-to-day
public health practice in light of the new types of
cases being reported. Until recently surveillance for enteric bacterial
pathogens captured only culture confirmed cases. The classification scheme
we use in all 50 states, or the case definitions
have been modified to incorporate CIDT positive
results as probable cases and we need to adjust
accordingly. We monitor the local
uptake of CIDT by regularly serving
clinical laboratories. It’s important to know the
types of tests each lab is using so we can understand the
surveillance information we receive from them and
ensure we’re receiving that information correctly. We started this in late 2009 when a few Colorado laboratories
began using antigen-based tests to detect Campylobacter. Currently, we survey
laboratories within our FoodNet
catchment area which is the 7 county Denver
metropolitan area, twice a year. We do a similar survey once
a year with laboratories in the rest of the state where
resources are not as robust. While this activity
is very important, it is also labor-intensive. Knowing which labs are using see
CIDTs is only the first step. Next, we needed to modify our
disease surveillance database to capture the new tests, and ensure data are properly
exported when queried. For us, this required working
with our IT department. We have discovered there are
many ways in which errors in reporting culture
independent results occur. And we continue to work
with disease reporters to improve the quality of the
CIDT case reports we receive. For example, some labs using
electronic lab reporting needed to change their electronic
settings so that CIDT positives
flowed to us correctly. Other laboratories had trouble
modifying printed reports they sent to us. They would report culture
positive for salmonella, for example, when we knew
they were no longer performing culture for salmonella. And finally the thorniest
issue is one of incorrect test
interpretation and reporting. Some multiplex panels
include pathogens that are not reportable, but sound like conditions
that are reportable. We continue to have cases
incorrectly reported to us. Shigella, Shiga-toxin-producing
E. Coli or STEC, and Plesiomonas shigelloides
sound similar, but only two are
reportable in Colorado, and each is a different
pathogen. We’ve created guidance documents
and held several meetings and webinars with infection
preventionists, laboratories and local public
health partners. We reach out individually when
we identify a particular issue and we continue with
frequent stakeholder outreach. We feel we cannot
over communicate with our partners
about these issues. Of course case reporting is
only one part of surveillance, we need isolates for
subtyping for cluster detection and monitoring trends. The big question for us is
where the culture happens. We’ve taken a hybrid approach
to isolate recovery in Colorado. Historically, we have had
excellent relationships with our clinical labs. We received approximately
95% of the isolates needed without having any regulations
for isolate submission in place. We’re building on these
established relationships to find a path forward. We prefer when isolation
is performed at the clinical laboratory. Culture results are available
faster, it decreases concerns about transit of raw
specimens, and the chance that pathogens will
die in transit. It also means that susceptibility testing
can still be performed at the clinical level where
it could impact patient care. We encourage each
lab that adopts CIDT to perform reflex
cultures at a minimum for salmonella, Shigella
and Vibrio. We review our isolate submission
protocols with them to ensure that any isolates that
are generated are sent to the public health lab. When reflex cultures
are not done, clinical laboratories are asked
to forward clinical material which is generally
stool, that tests positive to the state public
health laboratory, where we can then attempt
to isolate the organism. A lot has gone into
creating a workable plan. First we had to prioritize
pathogens. We chose STEC, salmonella,
Shigella, and Vibrio. These organisms have
the highest likelihood of public health action based on confirmation or
subtyping results. Next, we sought and continue
to seek additional funding to perform culture which adds
considerably to our costs. To ensure we would receive
specimens we ask the Board of Health to modify our
disease reporting regulations to require submission
of isolates or clinical material
for select pathogens. This is the first time specimen
submission has been required rather than voluntary
in Colorado. We’ve also worked to
facilitate rapid delivery of viable specimens to the
state public health lab. We reviewed the courier
service we provide to ensure couriers are regularly
going to all labs that need it, and we provide transport media
and written guidance about how to ship clinical material to us. This is an area that’s evolving
as APHO is performing studies to determine the best
methods for isolate recovery. However, none of
this is perfect. Despite all this effort are
specimen submission rate has dropped to 90% and we continue
to see a range of issues. For example, stereotyping during
an outbreak investigation was substantially delayed when
one rural lab mailed clinical material instead of sending
it to us via the courier. The final area is the one where we still need
to do the most work. With CIDT, the data we’re acting
on has changed and we need to figure out how to use
the information we receive. We see an increase
in case reports with less certainty
about each one. Reporting is faster
with respect to the time between specimen collection
and public health notification. However, we now have
a longer period between the time public
health first learns of a case and we have subtyping
information to pair it with. First off, we need to implement
the new CSC case definitions to classify and transmit
surveillance data correctly. To do this, we routinely
collect more detailed test data. In Colorado, we attempt to
collect negative results when they’re pertinent. For example, if a
PCR is positive and culture was negative,
we try to capture that in our surveillance data. We’ve worked to train internal
and local public health staff to appropriately
assign case status based on the new criteria. This includes creating new cheat
sheets and guidance documents for information that’s
ever more complex. We’re working to establish
and evaluate guidance for which cases should
be investigated based on their case status. While it would be great
to interview all suspected and probable cases, we need
to consider local resources and prioritize across
the spectrum of diseases they are
asked to investigate. For example, a suspected, highly infectious respiratory
case would be a higher priority than a probable PCR
positive Campylobacter case. The timing of case
investigation is also critical. For the case categories
we decide to investigate we launch
an investigation based on PCR results and
don’t wait for culture. Other jurisdictions might make
different choices about that. When should we initiate
worker and childcare exclusion or restriction for
PCR positive results? We have chosen to treat a PCR
positive the same as culture in terms of excluding
or restricting workers. Yet, is that’s the right choice? For follow-up testing we accept
a PCR or a culture result. Although culture is
often the test used, since much of the follow-up
testing is performed at the SPHL at no charge to the patient. And how do we handle patients
who are CIDT positive for 2 or more reportable conditions. From a public health
perspective, we need to decide what type of
exclusion might be necessary and which questionnaire to use. Our guidance is currently to choose the disease control
measures for the pathogen with the greatest
risk of transmission, and to interview the patient
using the pathogen specific questionnaire that is
most comprehensive, or merge the 2, when applicable. For example, when a patient is
supported with a PCR positive for Shigella and Campylobacter,
we instruct local public health to follow Shigella exclusion
policies, and interview with a questionnaire that’s
a blend of the Campylobacter and Shigella questionnaires. But clearly much more
research is needed. We have focused our response to
CIDT on accurate case reporting, isolate recovery and
adapting public-health actions to the new types of
cases being reported. These areas have
several factors in common which are a critical assessment
of resources, prioritizing based on public health
goals of detecting and mitigating disease risk and
frequent ongoing communication with partners using a variety of modalities including
guidance documents, phone calls, and training sessions. Thanks. [ Applause ] And now I’d like to introduce
Brad Spring.>>Thank you Alicia and
good afternoon everybody. I’m going to be representing
industry, although I work for BD. I do represent an organization
called AdvaMedDx which I’ll provide
a little bit more detail later. But I’m going to give you
the industry perspective on how we develop tests,
but also how we can partner with public health and other
stakeholders to solve some of the challenges we’re seeing. So, as described earlier,
we do have advantages and challenges of CIDTs. Multiplex PCR test can be
more sensitive than culture and provide results
in a few hours. They may also save costs and significantly
improve healthcare. But because PCR tests require
the organism to be lysed, or the cells be broken apart
to extract the DNA or RNA, we don’t have viable
organisms available for surveillance purposes. Companies do recognize
the need to partner with public health agencies and
FDA to collaborate on solutions. And AdvaMedDx which is an
association represented by over 50 diagnostic companies, can leverage our
strong relationship with lab communities,
government agencies and public health laboratories
to work towards a common goal of providing rapid diagnostic
solutions while meeting the public health needs. So I just want to give you an
overview of how we develop tests in the industry by covering our
product development process. And we typically use what’s
called a phase gate approach. And as you can see here we
start in the concept phase, go through definition,
development, qualification of the validation stages, and
then we’ll launch the product. But the first step in concept
and then through definition is to conduct what we call voice
the customer activities. And this is where we build
upon what are the requirements for the new test. And this is really where we
come up with the ideas and some of the challenges our customers,
or future customers may have and how to address them. So as we do these voice
the customer activities, we gather requirements. And the requirements
may not be specific. A customer may say I want
a test that’s easy to use. May provide fast results. Or it’s small in size. Now these aren’t measurable. So we translate those
requirements into specifications. So for example, a fast result
may be translated into a result within 2 hours including
specimen processing. And we go back to the
customer to verify that essentially
meets their requirements. But certain needs may only be
met by existing technologies that could create what we
call conflicting requirements. So for example, to
achieve a fast result, PCR may be the technology
of choice. And in the cases we’re
discussing here today, you’re not able to get a viable
organism when you use PCR. But just because we have
a conflicting requirement, meaning using PCR doesn’t allow
us to culture the organism, at least from the PCR specimen, we don’t abandon
these requirements and we try to find workarounds. So while requirements
may conflict, that doesn’t mean we just
give up as an industry. We try and find other
ways to address them. So I think, you know going
forward, and even looking back on previous product
development activities, we need to encourage engaging
public health laboratories, CDC, state labs, and others in these
voice of customer activities. So as another example, we
may go to a clinical lab, gather the data, but
rarely are we getting data that says we need to be
able to culture the organism for submission of public health. And then we go to public health,
we’ll hear, well we’ve got to make sure that the
organism’s cultured. So, I’m going to cover too, a couple of potential
opportunities to solve this problem and I think the other speakers
will be addressing these as well. So one example is our
instructions for use need to remind laboratories that
they have to follow state and federal requirements for
collection and preservation of organisms needed
for epidemiological or the public health purposes. So in those instructions for
use, and a customer needs to follow those instructions
for use, we will hopefully achieve a
little bit better compliance to state requirements. There are opportunities in product development
for new technologies. As you’ll hear more about later. There are some on the horizon that will help reduce
compatibility issues between CIDTs and public health. Metagenomics holds the
most promise, today, as it may be possible to
both detect the organism in a metagenomic specimen
and differentiate strains for epidemiological purposes. However, there is much
work still required to develop this technology and you’ll hear more
about this later. One thing to consider, though, is when an industry actually
may decide not to create a test for manufactured test
for clinical lab, a clinical lab may create
that test on their own. So there are a number of lab
developed tests out there today that are basically put in
place to meet an unmet need. So, if there is an
enteric pathogen that isn’t currently
detected using one of these multiplex PCR
tests, a lab may create that test on their own. So as we look at
culturing organisms, it’s not just the industry
instructions for example, they might have to
change, we have to do more to educate the labs on what
their requirements are, especially for LDTs or
lab developed tests. So, just to kind of cover in
more detail the instructions for use opportunity here. Some manufacturers, not all, do put specific precautions
in their labeling. And under the clinical
laboratory improvement amendments, which
are regulations that govern laboratories,
CLIA does require that labs follow
manufacturer’s instructions. So if our instructions
state, for example, the APHL recommended language around laboratories must
follow state and/or local rules pertaining to reportable
pathogens, the lab must do that. Otherwise they during
inspection may get observation regarding that. So going forward, you know we
as an industry do agree we need to put such labeling and
standardize it, these statements in our labelling going
forward and that will help. It doesn’t do everything,
but it will help with the public health
labs and ensuring that these pathogens
are also cultured. So we believe this type
of information is one step in the right direction. We do believe there are
continuing opportunities on these collaborations. So we will, as an
industry, work with CDC, other public health laboratory
agencies, as well as FDA to discuss efforts to
explore additional measures to aid in the surveillance. So, you know, we’ve
talked about the labeling. There may be other
opportunities that we can, as we come together
collectively, figure out how best to
meet this challenge. We have conducted
and will continue to conduct educational outreach
meeting with key stakeholders. So like I said, the
public health labs, other microbiology groups
such as maybe the IDSA, ASM and through other
industry meetings. And as a manufacturer, you
know we have a salesforce, a pretty large salesforce
out there. And we currently use those
salesforces obviously to, not just sell our products
but to also educate customers in a variety of issues. One example being the get smart about antibiotics week
coming up here in November. We’ll distribute material to our
customers to help educate them on antimicrobial resistance. So this is another opportunity
to at least increase awareness and educate customers. And then finally, one thing
we are looking at is just to provide better informational
resources and we’re talking, collectively talking to FDA
about posting a list of approved or cleared molecular
diagnostics on the FDA website. It will serve essentially as
a one-stop shop to finding out what CIDTs are out there
and what are the procedures used to conduct those CIDTs. So, and thank you very much. And now I’d like to
introduce Dr. John Besser. [ Applause ]>>Thank you Brad
and good afternoon. I’m going to be speaking today
on efforts to develop tests for characterization of
our public health pathogens that can be done
directly from specimens. I’m going to be focusing on the
bacterial enteric pathogens, our PulseNet pathogens. And I will be attempting
to squeeze a graduate level in molecular biology
into 8 minutes. So let’s see how that goes. But first why are
we developing tests. Well, most importantly we want
to ensure continue compatibility between our public health tests,
and the commercial systems even if the specimens are
biologically inactivated. And the second compelling
reason is that these tests have the
potential of being quick, which is of course one
of the same reasons that makes CIDTs desirable
for clinical diagnosis. The process of detecting
outbreaks through pathogen
based surveillance, can be a lengthy process,
as illustrated here. Cases must be identified
and linked to other cases, food vehicles identified,
and depending on how a direct specimen tests
are implemented they can have the potential for significantly
reducing the amount of time to an actionable result,
which in turn means that more outbreaks would
be solved more quickly. More illnesses prevented. Developing direct tests for public health is
not a trivial task. Stool is an immensely
complex environment, containing a wide variety of
different DNA and RNA species. There could be significant
human DNA from white blood
cells, epithelial cells. All the food that
you eat, the plants, the animals they all have DNA. There’s bacteria,
parasites, viruses, fungi. Every one of us has an average
of 1000 species of microbes in our gut at any one time. And every gram of stool can have up to 100,000 organisms
per gram. And of particular
concern to us is that many of our PulseNet pathogens are
virtually identical to some of the commensal flora. Every line in this figure
represents the genome of a bacterium that
might be in our gut. The commercial developers
need to find a marker which is conserved within
the species of interest. And specific to it. Meaning, that that marker
doesn’t appear in any of the commensal flora. For public health tests, we must
also specifically detect the pathogen, but also detect
other markers for strain type, resistance virulence, and
also detect variability within those markers so that
we can detect differences between strains, illustrated
here in the colored bars. And these should not be
confused with similar sort of regions in our pathogens. Of course, when we’re
actually doing these tests, we don’t have any
of that information. In fact, what we’re actually
dealing with is many millions of pieces, little pieces
of DNA or short reads as in some of our assays. And there’s two major
problems that we confront. One is signal-to-noise,
finding our pathogen which may be very
rare when compared to the background flora. And the second is
called phasing. Getting all the pieces together
that we find of the pathogen, specifically connected
to the marker, and not including any
pieces that may be from some of the commensal flora. There’s three general
strategies that we’re pursuing to accomplish this task. The first is called
amplicon sequencing, a method that’s been around, especially for the viral
pathogens for quite a while. We believe that this can be
accomplished using technology that is readily available today. And we’re currently
pursuing two approaches. The first, we’re
looking at for STEC, we’ve identified a
heterogeneous region in Shiga-toxin-converting phage,
which is normally integrated into the circular chromosome. And here is a map
of the phage genome. Within the phage is a region
containing the regulatory genes, and also the Shiga-toxin gene,
which defines the pathotype, which helps us solve
the phasing problem. Our scientists have developed
a multiplex PCR assay using conserved primer binding sites which yield overlapping
amplicons covering an 11 to 17 KB region. These amplicons can
then be assembled into a single continuous strand
of DNA or consensus sequence, also known as the contig. The contig, then can be compared
to sequences from other patients to find genetic differences,
represented here in red, which in turn can be used
to assign strain types. And the strain type
information is what we use to detect clusters
and are used as part of epidemiological
case definitions. For salmonella, we’re taking
a slightly different approach, since it’s less related to
commensal flora of an STEC. We’ve developed a pipeline,
or a series of processes that are listed in the bullets
here, to identify specific and informative targets to approximate a whole genome
multilocus sequence typing or wgMLST. The second major strategy that we’re pursuing is
shotgun metagenomics, as was mentioned earlier. What is metagenomics,
it’s the sequencing of all the nucleic
acids in a sample. This is widely used already to characterize the whole
microbial community, or microbiome. In our case, the
stool environment. Researchers here at
CDC, and elsewhere, have shown that it is possible
to both detect pathogens and differentiate strains for
epidemiological studies directly in stool using shotgun
metagenomics. However, the method is
still fairly insensitive, expensive, slow. It produces a lot of data
that has to be handled. But the potential power of metagenomics really
can’t be overestimated. It likely will make it
possible to find solutions to a whole array of
public health problems that are currently
difficult to address. Our group, and other groups, here at CDC are exploring
multiple approaches at various points in the
specimen to sequence process, to solving these signal-to-noise
and phasing problems, some of which are listed here. These approaches, if successful
should also reduce the amount of sequencing and data for
public health surveillance. We’ve also begun to explore
with external collaborators, droplet based single cell
sorting or barcoding, which should allow us
to obtain the same type of information we’re
currently obtaining through whole genome
sequencing of isolates. Individual cells
are encapsulated in the lipid droplets which
are subject to PCR and run through a high-speed
cell sorter. In this animation, there’s
a laser below the red arrow, which elicits a signal
from PCR positive cells. Positive cells, which are
shown here as solid circles, are then routed down a different
path from the other bacteria, shown as empty circles. At least in theory, this
technology could result in a tube of cells
from a single pathogen, which could then be subject
to whole genome sequencing. In summary, direct from
specimen tests could increase compatibility between CIDTs and
our public health activities. And we believe that the current
technological limitations will likely be overcome with
research that’s occurring with multiple partners. And in the end, we
believe that all of these advancements
will make PulseNet and our food supply safe, more
efficient and more effective. In summary for our
entire session today, CIDT technology has been used
for improving patient care and as Dr. Braden has showed
us, and public health is in the process of adapting to these changes in
a variety of ways. Advances in technology
in the public and private realms will make
our lives safer in general, but we must pursue a path that
benefits both patient care and the public’s health. Now I’d like to turn the podium over to Dr. Braden
again, thank you. [ Applause ]>>Well I’ll stay here at the
panelist desk and as we go into the question and answer
session, so first of all I would like to know if we
have any questions from the external audience.>>We do, thank you. Reports are being
charted as final results at some facilities, and I suspect they should be
considered screening tests. On average do these panels
have acceptable sensitivities and specificities, precision
and accuracy, etcetera?>>I’m going to turn to
Dr. Besser and Brad for comments.>>There are some
studies in the literature that address the sensitivity
and specificity of these tests. Frankly, we don’t
know all the answers. Some kits are more specific
and sensitive than others. And this actually has
created some problems in creating the probable and confirmed case
definitions with CIDTs. But I think as time goes
on we will learn more and it’s incumbent upon
us to encourage studies of the performance
characteristics of these tests so that this question
can be answered.>>Yeah, just a comment
on industry. So our tests do go through
the FDA review process and the FDA looks at
what’s our intended use. Is it for screening,
diagnosis, and the sensitivity and specificities related
to that intended use. So FDA would not
approve or clear a test that didn’t meet a
certain threshold. That said, I think
the FDA and industry, as well as labs will
look at is it better than what we have today. So I think when you
look at that, it’s hard to say
is it good enough, but at least it may be better
than what we have now, so. Can’t quite answer on that
on the screening tests.>>However, to add from a
disease reporting perspective, it it’s a reportable condition that the person asking the
question is asking about, then yes, we would still
want that reported to us, along with what type
of test was performed. We need to have all
of that reported to us so we can understand
what’s going on with disease surveillance
and with these tests.>>I would also add that
as the tests, culture and diagnostic tests
have advanced over time, I think the sensitivity and
specificity has improved. And these new multi-analyte
PCR panels have been shown to be quite sensitive. Another question? How about from the audience? Yes, Steve.>>I’m Stephen Rose
Associate Director for Laboratory Science
and Safety. My question is really directed
toward Alicia and falls on the previous question about
sensitivity and specificity. And I think if I heard
you correctly you said that if the CIDT only,
then it’s a probable case. Do you code the cases
that you alluded to that are CIDT positive,
culture negative any differently from one that is CIDT only?>>We try to collect
that level of information and we strongly encourage
laboratories to report pertinent
negatives to us. So if it’s antigen positive
and culture negative, we surely would like to have that culture negative
piece in our dataset. From a coding standpoint to
meet case classification, those would both be
coded as a probable case.>>Peter Gunersmidt from Enteric Diseases
Laboratory branch here at CDC. This is more a question
for Dr. Spring I guess. The metagenomics that
we’re working on trying to develop some methods. Those methods, they
really belong in the clinical laboratories,
don’t they? So my question to
you is where are the, what are the diagnostic industry
doing with this technology and how far are you before
we can implement metagenomics in the clinical laboratories.>>Yeah, I’m probably not going to give you the answer
you’re expecting, which is I don’t really know. But I will say this, that
there are companies out there, and most of the time
they’re startups, right. They’ll get venture capital
funding to investigate this. And I know there is one
company at least that I’m aware of out there that does
provide testing services using metagenomics. I don’t believe they have a
commercial kit for laboratories. I don’t know how
far away we are. Again I haven’t seen
any come through FDA. I think FDA has to set
up standards for these. You know how do you
validate them analytically and clinically. So I think they’re probably
going to be shown more in a laboratory maybe as
an LDT before they show up as a commercially
available assay.>>I believe that metagenomics
will be used regularly, sooner rather than
later for specimens from normally sterile
sites like CSF and blood. And I think that
in the short term that probably will
occur in laboratories. But I would imagine in the very
long-term it’s probably most appropriate for this to happen
in the clinical setting. And then the state and local
public health agencies retrieve information that they need, federal agencies
retrieve what they need. But it seems closer to the patient the more
efficient the system gets. But I think the technology
is a long way from operating at that level.>>Do we have another
question external?>>We do from Twitter. Are there any national
summaries on CIDT surveillance and impact on patient care?>>So there are some summaries
of CIDT use that are provided by the FoodNet publications. Every April FoodNet, as a surveillance system
provides interim reports of the previous year’s
surveillance data and within that data there is
reports of CIDT use. However, we don’t
gather the information about how it’s affecting
clinical care, which I think is the other
part of that question. Putting on my clinician’s hat, you know if I can get the
information about the pathogen that may be causing an illness
faster, same-day or even within hours, that makes
a lot of difference. And so I just, you know in that
antidotal way it really does improve what we can
do with patient care. Any other comments?>>There’s a very good
publication by IDSA [inaudible] on CIDTs and clinical care
that one can find for free on the web, that’s
worth reading. Another question from
the external audience.>>We get laboratory
reports indicating more than one positive on
the same specimen. Do you know if the labs are then
obligated to perform cultures, serology tests, etcetera,
depending on the microorganism?>>Brad, do you know that? Or Alicia?>>I’m not sure I
understand the question. It seems like the laboratories,
if the condition is reportable, they need to report,
I would guess all of the conditions is
that correct Alicia?>>Yeah. Yep. So from a public health
standpoint, they would need to report anything
that was positive. And depending on the state
where they’re located, they might be required to
perform reflexive culture. Or, they might be
required to send some of the clinical material to
the state public health lab, depending on the state
and the pathogen. But I think the question is
more from a clinical perspective and asking about determining which pathogen is
making the patient ill. And I think that’s a
very difficult question that I believe clinicians are
trying to sort out as well.>>As we are hearing from the
community that the incidents of multiple positive signals
from CIDTs is fairly hard. And I think there are
many aspects of CIDTs that we’re going to need
to resolve over the years in interpretation,
that being one of them, and it could be the
polymicrobial infections are much more common than
we knew, or perhaps some of these findings are spurious and we just don’t know,
and time will tell.>>I think, there’s
not some kind of regulatory responsibility
for the laboratories to do more testing to see which
pathogen may be causing illness, but certainly the
physician may follow up with additional tests
requested in order to clarify.>>Any other questions
from the audience?>>David Bell, Division
of Viral Diseases. Could you say anything
more about the role of quantifying some
of these results and assisting with
the diagnosis? You know in PCR we have CT
values and I don’t know as much about the other, but in some
of the issues you raised, it might be relevant if
the pathogen was present in a higher quantity as
opposed to a lower quantity. You know some of these
dual findings and so on.>>So just one comment,
that I mean as you look at the microbium
and normal flora, you know sometimes you
have to distinguish between what is the causative
agent and what is normal flora. So quantification, or
quantitation is required for some of these assays, because you may be actually
detecting a healthy level of some bacteria. So it depends on the test, and depends on what the
treatment options may be. But I think there is
value in quantitation.>>If you’re referring to
clinical diagnosis, is that? Or the? Is that what
you’re referring to?>>Well, well both. Also surveillance because
it’s not clinically relevant. It may or may not be public
health, but it’s both.>>Sure, I believe most of the,
or all of the CIDTs operate with thresholds built
into the system already. So the positive result you
get is a quantitative result. In the area of metagenomics,
and sequencing, and shotgun metagenomics,
quantification is, quantitation is an approach
that we’re exploring extensively to help with phasing, have been
re-binning clinical quantitation of pathogens to align our
various bits together. So for characterization of
our pathogens, what we call in situ pathogen
characterizations, quantitation is an important
part of our overall strategy.>>So to follow up on David
Bell’s question on quantitation and the issue of exclusion
either from workplace or daycare, and of course, my
experience is with norovirus where it’s quite clear that
the virus is detectable much, much longer than somebody
is probably a real risk for transmission. And so is there any thought
of using quantitation in making those determinations
about when somebody is or is not excluded from the
workplace or from daycare?>>It would be great. I don’t know if it’s at all in
the horizon, but even before that I think that some follow up
studies are desperately needed to track how long people shed. I think that we exclude
people fairly routinely from occupations if they have,
say E. coli 0157 or Shigella, we will exclude them
from their jobs, which has a tremendous impact
on them and their lives. And so form a public
health standpoint, we are very concerned
about doing that based on a PCR positive and are very
eager to participate in studies, perhaps where stool is
collected, and both cultured and then put through
a multiplex PCR so we understand that better. I don’t believe those
studies have been done yet.>>Do we have another question?>>FoodNet depends on public
health lab surveillance to describe changes in
illness incident rates overtime and the incident rates
have targets that come from healthy people 2020. How has CDC incorporated
the impact of CIDT in tracking illness
incidents overtime and marking our progress in meeting foodborne illness
national health objectives.>>I will start and
Alicia may comment also. So there were a couple of times,
and especially Alicia alluded to the fact that CSTE is
revising case definitions. When we revise case
definitions it is going to affect the surveillance
data trends. What is going to have to occur
is to the extent possible to take the data that we
have about the increase in specificity and sensitivity
of some of these tests, and apply that to the
models that we use to then generate our
surveillance trends to be able to translate what
we’ve seen before with what we’re seeing now. That’s not an easy task, but
it is something that a number of groups are trying to do. So that we can then determine if
we are actually still on track with meeting our
goals, or we’re not. Alicia?>>As Dr. Braden alluded,
we’re working on a variety of data collection projects and
thinking about different ways to model the data to assess
the impact of these changes on our trends so that we can
accurately say whether disease is going up or down to meet
these national objectives. One key piece of information
that we didn’t have time to discuss during the formal
presentations, is another way in which we hope to partner
with clinical microbiology labs, which is the collection
of information from them about how much testing
they’re performing and who they’re performing
testing on. And this is absolutely
critical information, so that we can understand the
data that’s flowing to us. One area with CIDT it’s possible that more testing
is being performed, or testing is being performed
on different groups of people than it used to be performed in. And we need to understand that to understand the
surveillance data that’s coming to us. So in addition to the
partnerships that we’ve talked about with clinical microbiology
labs and submitting isolates or clinical material to state
public health laboratories, another key area for
participation in partnership between public health
and clinical micro labs in the near future is going to
be working with us to figure out how to obtain this, what
we’re calling test volume data.>>Another question
from the audience.>>Hi. Lee Katz
Foodborne Diseases Laboratory branch. I was wondering from the panel if there are any products being
used for source attribution. So in Dr. Besser’s
presentation, he noted that some food
might also be in a sample, in a stool sample, if there
are products that might be used to detect them that are being
in research and development. And if those food sources
are detected, I’m wondering if at Colorado and other state
health labs, if it might be used to inform epidemiology.>>That’s a very good question. No there is no such test
out there that I’m aware of, but it’s an excellent
suggestion. If you were able, I’m sure
that if Alicia were able to tell her cases what
they ate and ask them where they got it from,
that would be very helpful.>>I think there are
some technologies that may adapt a
clinic test, right, and maybe a sample preparation
that has to be modified and then allow it
to work in a CIDT. I know there are some
next generation sequencing technology, well the technology
itself of NGS is used in say in some food screening. I know they even use it in like
looking for male and female eggs in selecting, you know which ones go forward
and which ones don’t. I think they’re also using those in detecting potential
pathogens.>>One area where this
technology has been used for a while has been
in food fraud. So for instance, fish,
the fist that you buy at the supermarket may or may
not be what it says it is. And the FDA has been using
technology of the sort to confirm the identification
of seafood.>>Thank you so much for joining
us and I’d like to take a moment to thank our speakers. Thank you very much. [ Applause ] And please join us next month
for Public Health Grand Rounds.