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Precision Public Health: What Is It?

Posted on by Muin J Khoury, Director, Office of Public Health Genomics, Centers for Disease Control and Prevention

Precision Public Health with a figure looking through a magnifying glass at a globe surrounded by DNAIn the past two years the term “precision public health” has been increasingly used in the scientific literature and at professional meetings. A quick PubMed search of the term shows 28 papers (as of April 30, 2018) dating back to our 2016 paper, “Precision Public Health for the Era of Precision Medicine.” The papers cover a wide range of topics from infectious to noninfectious diseases, in developed and developing countries, but focus mostly on the use of technologies (e.g., genomics, spatial analysis, big data) in public health practice. But what exactly is precision public health? And why should the term be used and for what purpose?

In their recent editorial in Frontiers in Public Health, Weeramanthri et al discussed the rapidly evolving field of precision public health and its various proposed definitions. As an introduction to several articles published as part of a special research topic, they posed important questions to help clarify the scope of this emerging field. A primary focus of the articles is the use of new precision technologies to improve public health policy and practice. These discussions are an important prelude to a Precision Public Health Asia Symposium that will be held in October 2018 to continue work on a consensus definition of precision public health, to explore ethical and social implications of the field, and to develop further collaboration in the region.

… if precision medicine is about the individual, precision public health is about populations. It is essentially about delivering “the right intervention at the right time, every time to the right population.”

In the midst of this evolution, one can only wonder what is the scope of precision public health and when the term should be used. One way to answer this question is to revisit the concept of “precision medicine”. Between the 2011 National Science Foundation report on precision medicine, and the launch of the 2015 US Precision Medicine Initiative, precision medicine has evolved in its definition and use. More and more, precision medicine is used instead of “personalized medicine,” as we discussed in an earlier blog. Increasingly, precision
medicine has been defined as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.” Of course, a main driver of precision medicine is better technology (genomics and various omics to all the ways of measuring environmental factors). But the distinguishing feature of precision medicine is its unit of intervention, which is “each person.” In lay terms, precision medicine can be thought of as giving “the right treatments at the right time, every time to the right person.” Of course, this has always been the goal of medicine, but the tools and technologies from genomics to big data are beginning to be applied—even though there is still a lot of hype about such applications. In other words, there is still quite a bit of imprecision and uncertainty in precision medicine.

In our original paper on precision public health, we provided three examples of the use of technologies to better enhance precision in public health, including the use of pathogen genomics, enhanced surveillance and informatics, and targeted interventions. But ultimately, precision public health is more than just the use of technologies. It is about “populations” as the unit of intervention that use these technologies. The same technologies that fuel precision medicine can also fuel more precision in public health activities. But as the field matures, we should not lose sight of what we are trying to do at the population level, namely to use better and more precise data to target disease prevention and control, and to improve health and health equity worldwide. Using better public health surveillance, laboratory investigations and geospatial modelling may allow more precise targeted population interventions. For example, Dowell et al showed that 90% of the mosquito-related infectious disease burden worldwide (e.g. Dengue, Chikungunya) could be addressed by focusing on just 14% of the high risk geographic areas. Simply put, if precision medicine is about the individual patient in front of us, precision public health is essentially about implementing “the right intervention at the right time, every time to the right population.”

While precision medicine and precision public health can be viewed as next generation medicine and next generation public health, they still have much unfulfilled potential and a long way to go in terms of methodologic applications and success stories. We look forward to the interesting dialogue and discussions before, at, and after the 2018 precision public health Asia symposium and the concrete ideas for collaborative projects that will be developed in the next few years.

Posted on by Muin J Khoury, Director, Office of Public Health Genomics, Centers for Disease Control and Prevention

One comment on “Precision Public Health: What Is It?”

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    For a somewhat differing interpretation and anticipation of “Precision Public Health”:

    BMC Infect Dis. 2019 Feb 6;19(1):120. doi: 10.1186/s12879-019-3715-y.
    Precision public health to inhibit the contagion of disease and move toward a future in which microbes spread health.
    Thaler DS1, Head MG2, Horsley A3.
    Author information
    Abstract
    Antimicrobial resistance continues to outpace the development of new chemotherapeutics. Novel pathogens continue to evolve and emerge. Public health innovation has the potential to open a new front in the war of “our wits against their genes” (Joshua Lederberg). Dense sampling coupled to next generation sequencing can increase the spatial and temporal resolution of microbial characterization while sensor technologies precisely map physical parameters relevant to microbial survival and spread. Microbial, physical, and epidemiological big data could be combined to improve prospective risk identification. However, applied in the wrong way, these approaches may not realize their maximum potential benefits and could even do harm. Minimizing microbial-human interactions would be a mistake. There is evidence that microbes previously thought of at best “benign” may actually enhance human health. Benign and health-promoting microbiomes may, or may not, spread via mechanisms similar to pathogens. Infectious vaccines are approaching readiness to make enhanced contributions to herd immunity. The rigorously defined nature of infectious vaccines contrasts with indigenous “benign or health-promoting microbiomes” but they may converge. A “microbial Neolithic revolution” is a possible future in which human microbial-associations are understood and managed analogously to the macro-agriculture of plants and animals. Tradeoffs need to be framed in order to understand health-promoting potentials of benign, and/or health-promoting microbiomes and infectious vaccines while also discouraging pathogens. Super-spreaders are currently defined as individuals who play an outsized role in the contagion of infectious disease. A key unanswered question is whether the super-spreader concept may apply similarly to health-promoting microbes. The complex interactions of individual rights, community health, pathogen contagion, the spread of benign, and of health-promoting microbiomes including infectious vaccines require study. Advancing the detailed understanding of heterogeneity in microbial spread is very likely to yield important insights relevant to public health.

    KEYWORDS:
    Bioethics; Epidemiology; Healthy buildings; Infectious disease; Infectious vaccines; Microbiome; Precision medicine; Precision public health; Public health; Vaccines

    PMID: 30727964 DOI: 10.1186/s12879-019-3715-y

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