Precision public health-the Emperor's new clothes

Conceptual frameworks for the integration of genetic and social epidemiology in complex diseases

Uncovering the root causes of complex diseases requires complex approaches, yet many studies continue to isolate the effects of genetic and social determinants of disease. Epidemiologic efforts that under-utilize genetic epidemiology methods and findings may lead to incomplete understanding of disease. Meanwhile, genetic epidemiology studies are often conducted without consideration of social and environmental context, limiting the public health impact of genomic discoveries. This divide endures despite shared goals and increases in interdisciplinary data due to a lack of shared theoretical frameworks and differing language. Here, we demonstrate that bridging epidemiological divides does not require entirely new ways of thinking. Existing social epidemiology frameworks including Ecosocial theory and Fundamental Cause Theory, can both be extended to incorporate principles from genetic epidemiology. We show that genetic epidemiology can strengthen, rather than detract from, efforts to understand the impact of social determinants of health. In addition to presenting theoretical synergies, we offer practical examples of how genetics can improve the public health impact of epidemiology studies across the field. Ultimately, we aim to provide a guiding framework for trainees and established epidemiologists to think about diseases and complex systems and foster more fruitful collaboration between genetic and traditional epidemiological disciplines.

Extending an Antiracism Lens to the Implementation of Precision Public Health Interventions

Precision public health holds promise to improve disease prevention and health promotion strategies, allowing the right intervention to be delivered to the right population at the right time. Growing concerns underscore the potential for precision-based approaches to exacerbate health disparities by relying on biased data inputs and recapitulating existing access inequities. To achieve its full potential, precision public health must focus on addressing social and structural drivers of health and prominently incorporate equity-related concerns, particularly with respect to race and ethnicity. In this article, we discuss how an antiracism lens could be applied to reduce health disparities and health inequities through equity-informed research, implementation, and evaluation of precision public health interventions. (Am J Public Health. 2023;113(11):1210-1218. https://doi.org/10.2105/AJPH.2023.307386).

Advancing precision public health for obesity in children

Worldwide, far too many children and adolescents are living with the disease of obesity. Despite decades of public health initiatives, rates are still rising in many countries. This raises the question of whether precision public health may be a more successful approach to preventing obesity in youth. In this review, the objective was to review the literature on precision public health in the context of childhood obesity prevention and to discuss how precision public health may advance the field of childhood obesity prevention. As precision public health is a concept that is still evolving and not fully identifiable in the literature, a lack of published studies precluded a formal review. Therefore, the approach of using a broad interpretation of precision public health was used and recent advances in childhood obesity research in the areas of surveillance and risk factor identification as well as intervention, evaluation and implementation using selected studies were summarized. Encouragingly, big data from a multitude of designed and organic sources are being used in new and innovative ways to provide more granular surveillance and risk factor identification in obesity in children. Challenges were identified in terms of data access, completeness, and integration, ensuring inclusion of all members of society, ethics, and translation to policy. As precision public health advances, it may yield novel insights that can contribute to strong policies acting in concert that ultimately lead to the prevention of obesity in children.

Are We Ready for Whole Population Genomic Sequencing of Asymptomatic Newborns?

The introduction of genomic sequencing technologies into routine newborn screening programs in some form is not only inevitable but also already occurring in some settings. The question is therefore not "if" but "when and how" genomic newborn screening (GNBS) should be implemented. In April 2022, the Centre for Ethics of Paediatric Genomics held a one-day symposium exploring ethical issues relating to the use of genomic sequencing in a range of clinical settings. This review article synthesises the panel discussion and presents both the potential benefits of wide-scale implementation of genomic newborn screening, as well as its practical and ethical issues, including obtaining appropriate consent, and health system implications. A more in-depth understanding of the barriers associated with implementing genomic newborn screening is critical to the success of GNBS programs, both from a practical perspective and also in order to maintain public trust in an important public health initiative.

Is It Just for a Screening Program to Give People All the Information They Want?

Genomic screening at population scale generates many ethical considerations. One is the normative role that people's preferences should play in determining access to genomic information in screening contexts, particularly information that falls beyond the scope of screening. We expect both that people will express a preference to receive such results and that there will be interest from the professional community in providing them. In this paper, we consider this issue in relation to the just and equitable design of population screening programs like reproductive genetic carrier screening (RGCS). Drawing on a pluralistic public health ethics perspective, we claim that generating and reporting information about genetic variants beyond the scope of the screening program usually lacks clinical, and perhaps personal, utility. There are both pragmatic and ethical reasons to restrict information provision to that which fits the stated purpose of the program.

Time and risk preferences and the perceived effectiveness of incentives to comply with diabetic retinopathy screening among older adults with type 2 diabetes

Behavioral economics has the potential to inform the design of incentives to improve disease screening programs by accounting for various behavioral biases. We investigate the association between multiple behavioral economics concepts and the perceived effectiveness of incentive strategies for behavioral change among older patients with a chronic disease. This association is examined by focusing on diabetic retinopathy screening, which is recommended but very variably followed by persons living with diabetes. Five time and risk preference concepts (i.e., utility curvature, probability weighting, loss aversion, discount rate, and present-bias) are estimated simultaneously in a structural econometric framework, based on a series of deliberately-designed economic experiments offering real money. We find that higher discount rates and loss aversion and lower probability weighting are significantly associated with lower perceived effectiveness of intervention strategies whereas present-bias and utility curvature have an insignificant association with it. Finally, we also observe strong urban vs. rural heterogeneity in the association between our behavioral economic concepts and the perceived effectiveness of intervention strategies.

Challenges for precision public health communication in the era of genomic medicine

Although still in the early stages of development, the advent of fast, high-output, and cost-effective next-generation DNA sequencing technology is moving precision medicine into public health. Before this shift toward next-generation sequencing in public health settings, individual patients met geneticists after showing symptoms and through limited family screening. In the new era of precision public health, everyone is a possible participant in genetic sequencing, simply by being born (newborn screening), by donating blood (biobanking), or through population screening. These initiatives are increasingly offered to individuals throughout their life and more individuals are encountering opportunities to use DNA sequencing. This article raises awareness of these growing areas and calls for different models of public engagement and communication about genomics, including screening asymptomatic populations, obtaining consent for unspecified and unforeseen future uses of genomic data, and managing variants of uncertain significance. Given that such communication challenges loom large, established norms of practice in genomic medicine and research should be reconsidered.

Mapping precision public health definitions, terminology and applications: a scoping review protocol

INTRODUCTION

Precision public health is an emerging and evolving field. Academic communities are divided regarding terminology and definitions, and what the scope, parameters and goals of precision public health should include. This protocol summarises the procedure for a scoping review which aims to identify and describe definitions, terminology, uses of the term and concepts in current literature.

METHODS AND ANALYSIS

A scoping review will be undertaken to gather existing literature on precision public health. We will search CINAHL, PubMed, Scopus, Web of Science and Google Scholar, and include all documents published in English that mention precision public health. A critical discourse analysis of the resulting papers will generate an account of precision public health terminology, definitions and uses of the term and the use and meaning of language. The analysis will occur in stages: first, descriptive information will be extracted and descriptive statistics will be calculated in order to characterise the literature. Second, occurrences of the phrase 'precision public health' and alternative terms in documents will be enumerated and mapped, and definitions collected. The third stage of discourse analysis will involve analysis and interpretation of the meaning of precision public health, including the composition, organisation and function of discourses. Finally, discourse analysis of alternative phrases to precision public health will be undertaken. This will include analysis and interpretation of what alternative phrases to precision public health are used to mean, how the phrases relate to each other and how they are compared or contrasted to precision public health. Results will be grouped under headings according to how they answer the research questions.

ETHICS AND DISSEMINATION

No ethical approval will be required for the scoping review. Results of the scoping review will be used as part of a doctoral thesis, and may be published in journals, conference proceedings or elsewhere.

Precision Public Health and Structural Racism in the United States: promoting health equity in the COVID-19 pandemic response

UNSTRUCTURED

The COVID-19 pandemic has revealed deeply entrenched structural inequalities that resulted in an excess of mortality and morbidity in certain racial and ethnic groups in the US. Therefore, this paper examines from the US perspective how structural racism and defective data collections on racial and ethnic minorities can negatively influence the development of precision public health approaches to tackle the ongoing COVID-19 pandemic. Importantly, the effects of structural and data racism on the elaboration of fair and inclusive data-driven components of precision public health interventions are discussed, such as with the use of machine learning algorithms to predict public health risks. The objective of this viewpoint is thus to inform public health policy-making with regard to the development of ethically sound precision public health interventions against COVID-19. Particular attention is given to components of structural racism (e.g. hospital segregation, implicit and organizational bias, digital divide and sociopolitical influences) that are likely to hinder such approaches from achieving their social justice and health equity goals.

Socioeconomic disparities in asthma health care utilization, exacerbations, and mortality: A systematic review and meta-analysis

BACKGROUND

Prior studies investigating the effect of socioeconomic status (SES) on asthma health care outcomes have been heterogeneous in the populations studied and methodologies used.

OBJECTIVE

We sought to systematically synthesize evidence investigating the impact of SES on asthma health care utilization, exacerbations, and mortality.

METHODS

We searched Embase, Medline, and Web of Science for studies reporting differences in primary care attendance, exacerbations, emergency department attendance, hospitalization, ventilation/intubation, readmission, and asthma mortality by SES. Study quality was assessed using the Newcastle Ottawa Scale, and meta-analyses were conducted using random-effects models. We conducted several prespecified subgroup analyses, including by health care system (insurance based vs universal government funded) and time period (before vs after 2010).

RESULTS

A total of 61 studies, comprising 1,145,704 patients, were included. Lower SES was consistently associated with increased secondary health care utilization including emergency department attendance (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), hospitalization (OR, 1.63; 95% CI, 1.34-1.99), and readmission (OR, 1.31; 95% CI, 1.19-1.44). Substantial associations were also found between SES and ventilation/intubation (OR, 1.76; 95% CI, 1.13-2.73), although there was no association with primary care attendances (OR, 0.79; 95% CI, 0.51-1.24). We found evidence of borderline significance for increased exacerbations (OR, 1.18; 95% CI, 0.98-1.42) and mortality (OR, 1.12; 95% CI, 0.92-1.37) among more deprived groups. There was no convincing evidence that disparities were associated with country-level health care funding models or that disparities have narrowed over time.

CONCLUSIONS

Patients with a lower SES have substantially increased secondary care health care utilization. We found evidence suggestive of increased exacerbations and mortality risk, although CIs were wide. These disparities have been consistently reported worldwide, including within countries offering universally funded health care systems. Systematic review registration: CRD42020173544.

Agricultural labor, COVID-19, and potential implications for food security and air quality in the breadbasket of India

To contain the COVID-19 pandemic, India imposed a national lockdown at the end of March 2020, a decision that resulted in a massive reverse migration as many workers across economic sectors returned to their home regions. Migrants provide the foundations of the agricultural workforce in the 'breadbasket' states of Punjab and Haryana in Northwest India.There are mounting concerns that near and potentially longer-term reductions in labor availability may jeopardize agricultural production and consequently national food security. The timing of rice transplanting at the beginning of the summer monsoon season has a cascading influence on productivity of the entire rice-wheat cropping system. To assess the potential for COVID-related reductions in the agriculture workforce to disrupt production of the dominant rice-wheat cropping pattern in these states, we use a spatial ex ante modelling framework to evaluate four scenarios representing a range of plausible labor constraints on the timing of rice transplanting. Averaged over both states, results suggest that rice productivity losses under all delay scenarios would be low as compare to those for wheat, with total system productivity loss estimates ranging from 9%, to 21%, equivalent to economic losses of USD $674 m to $1.48 billion. Late rice transplanting and harvesting can also aggravate winter air pollution with concomitant health risks. Technological options such as direct seeded rice, staggered nursery transplanting, and crop diversification away from rice can help address these challenges but require new approaches to policy and incentives for change.

Moving Health Literacy Research and Practice towards a Vision of Equity, Precision and Transparency

Over the past two decades, health literacy research has gained increasing attention in global health initiatives to reduce health disparities. While it is well-documented that health literacy is associated with health outcomes, most findings are generated from cross-sectional data. Along with the increasing importance of health literacy in policy, there is a lack of specificity and transparency about how to improve health literacy in practice. In this study, we are calling for a shift of current research paradigms from judging health literacy levels towards observing how health literacy skills are developed over the life course and practised in the real world. This includes using a life-course approach, integrating the rationale of precision public health, applying open science practice, and promoting actionable knowledge translation strategies. We show how a greater appreciation for these paradigms promises to advance health literacy research and practice towards an equitable, precise, transparent, and actionable vision.

Patient Preferences in Surveillance: Findings From a Discrete Choice Experiment in the "My Follow-Up" Study

OBJECTIVES

Approximately 800 000 people die globally from colorectal cancer (CRC) every year. Prevention programs promote early detection, but for people with precancerous lesions, tailoring surveillance to include lifestyle-change programs could enhance prevention potential and improve outcomes.

METHODS

Those with intermediate or high-risk polyps removed during CRC screening colonoscopy within the Northern Ireland CRC Screening Programme were invited to complete 8 discrete choice questions about tailored surveillance, analyzed using random-parameters logit and a latent class modeling approach.

RESULTS

A total of 231 participants (77% male) self-reported comorbid hypertension (53%), high cholesterol (48%), and mean body mass index of 28.7 (overweight). Although 39% of participants were unaware of their CRC risk status, 30.9% indicated they were already making changes to reduce their risk. Although all respondents were significantly risk- and cost-averse, the latent class analysis identified 3 segments (classes): 1. Class 1 (26.8%) significantly favored phone or email support for a lifestyle change, a 17-month testing interval, and noninvasive testing. 2. Class 2 (48.4%) preferred the status quo. 3. Class 3 (24.7%) significantly favored further risk reduction and invasive testing.

CONCLUSIONS

This is the first documented preference study focusing on postpolypectomy surveillance offering lifestyle interventions. Although current care is strongly preferred, risk and cost aversion are important for participants. Latent class analysis shows that some respondents are willing to change diet and lifestyle behaviors, reflecting a teachable moment, with opportunities to personalize and optimize surveillance. Significant discordance between perceived and known risk of recurrence and limited recall of risk information provided within current practice suggest necessary improvements to surveillance programs.

The intersection of genomics and big data with public health: Opportunities for precision public health

Muin Khoury and co-authors discuss anticipated contributions of genomics and other forms of large-scale data in public health.

'There is a lot of good in knowing, but there is also a lot of downs': public views on ethical considerations in population genomic screening

Publics are key stakeholders in population genomic screening and their perspectives on ethical considerations are relevant to programme design and policy making. Using semi-structured interviews, we explored social views and attitudes towards possible future provision of personalised genomic risk information to populations to inform prevention and/or early detection of relevant conditions. Participants were members of the public (n=30) who had received information on their personal genomic risk of melanoma as part of a research project. The focus of the analysis presented here is participants' views regarding ethical considerations relevant to population genomic screening more generally. Data were analysed thematically and four key themes related to ethical considerations were identified: (i) personal responsibility for health: 'forewarned is forearmed'; (ii) perceptions of, and responses to, genetic fatalism; (iii) implications for parenting and reproduction; (iv) divided views on choosing to receive genomic risk information. Ethical considerations underlying these themes include the valorisation of information and choice, paternalism, non-directiveness and increasing responsibilisation of individuals in health and healthcare. These findings arguably indicate a thin public conceptualisation of population genomic testing, which draws heavily on how these themes tend to be described in existing social discourses. Findings suggest that further public engagement is required to increase complexity of debate, to consider (for example) the appropriate place of individual and social interests in population genomic testing. Further discernment of relevant ethical approaches, drawing on ethical frameworks from both public health and clinical settings, will also assist in determining the appropriate implementation of population genomic screening for complex conditions.

The Population Health OutcomEs aNd Information EXchange (PHOENIX) Program - A Transformative Approach to Reduce the Burden of Chronic Disease

This concept article introduces a transformative vision to reduce the population burden of chronic disease by focusing on data integration, analytics, implementation and community engagement. Known as PHOENIX (The Population Health OutcomEs aNd Information EXchange), the approach leverages a state level health information exchange and multiple other resources to facilitate the integration of clinical and social determinants of health data with a goal of achieving true population health monitoring and management. After reviewing historical context, we describe how multilevel and multimodal data can be used to facilitate core public health services, before discussing the controversies and challenges that lie ahead.

The building blocks of precision oral health in early childhood: the ZOE 2.0 study

Improving children's oral health is a long-standing area of priority and sustained efforts by many stakeholders. Despite these efforts, dental caries, particularly early childhood caries (ECC), persists as a clinical and dental public health problem with multilevel consequences. Despite recent successes in the non-restorative management of dental caries, remarkably little has been done in the domain of ECC prevention. There is promise and expectation that meaningful improvements in early childhood oral health and ECC prevention can be made via the advent of precision medicine in the oral health domain. We posit that precision dentistry, including genomic influences, may be best examined in the context of well-characterized communities (versus convenience clinical samples) and the impact of contextual factors including geography and social disadvantage may be explainable via mechanistic (i.e., biological) research. This notion is aligned with the population approach in precision medicine, which calls for the latter to be predictive, preventive, personalized, and participatory. The article highlights research directions that must be developed for precision dentistry and precision dental public health to be realized. In this context, we describe the rationale, activities, and early insights gained from the ZOE 2.0 study - a large-scale, community-based, genetic epidemiologic study of early childhood oral health. We anticipate that this long-term research program will illuminate foundational domains for the advancement of precision dentistry and precision dental public health. Ultimately, this new knowledge can help catalyze the development of effective preventive and therapeutic modalities via actions at the policy, community, family, and person level.

Scientific challenges for precision public health

The notion of ‘precision’ public health has been the subject of much debate, with recent articles coming to its defence following the publication of several papers questioning its value.

Critics of precision public health raise the following problems and questionable assumptions: the inherent limits of prediction for individuals; the limits of approaches to prevention that rely on individual agency, in particular the potential for these approaches to widen inequalities; the undue emphasis on the supposed new information contained in individuals’ molecules and their ‘big data’ at the expense of their own preferences for a particular intervention strategy and the diversion of resources and attention from the social determinants of health.

In order to refocus some of these criticisms of precision public health as scientific questions, this article outlines some of the challenges when defining risk for individuals; the limitations of current theory and study design for precision public health; and the potential for unintended harms.

A pediatric perspective on genomics and prevention in the twenty-first century

We present evidence from diverse disciplines and populations to identify the current and emerging role of genomics in prevention from both medical and public health perspectives as well as key challenges and potential untoward consequences of increasing the role of genomics in these endeavors. We begin by comparing screening in healthy populations (newborn screening), with testing in symptomatic populations, which may incidentally identify secondary findings and at-risk relatives. Emerging evidence suggests that variants in genes subject to the reporting of secondary findings are more common than expected in patients who otherwise would not meet the criteria for testing and population testing for variants in these genes may more precisely identify discrete populations to target for various prevention strategies starting in childhood. Conversely, despite its theoretical promise, recent studies attempting to demonstrate benefits of next-generation sequencing for newborn screening have instead demonstrated numerous barriers and pitfalls to this approach. We also examine the special cases of pharmacogenomics and polygenic risk scores as examples of ways genomics can contribute to prevention amongst a broader population than that affected by rare Mendelian disease. We conclude with unresolved questions which will benefit from future investigations of the role of genomics in disease prevention.

Perspective: Advancing Understanding of Population Nutrient-Health Relations via Metabolomics and Precision Phenotypes

Diet and lifestyle are vital to population health, but their true contribution is difficult to quantify using traditional methods. Nutrient-health relations are typically based on epidemiological associations that are assessed at the population level, traditionally using self-reported dietary and lifestyle data. Unfortunately, such measures are inherently inaccurate. New technologies such as metabolomics can measure nutritional and micronutrient profiles in body fluids, providing objective evaluation of nutritional status. A critical step toward accurate health prediction models would be the building of integrated repositories of nutritional measures combining subjective methods of reporting with objective metabolomics profiles and precise phenotypic data. Here we outline a roadmap to achieve this goal and discuss both the advantages and risks of this approach. We also highlight the uncertain associations between the complexity of high-dimensional data generated in 'omics research (along with the public confusion this may engender) and the rapid adoption of 'omics approaches by nutrition and health companies to develop nutritional products and services.

Driving Precision Policy Responses to Child Health and Developmental Inequities

The growing evidence base on the extent of and opportunities to reduce inequities in children's health and development still lacks the specificity to inform clear policy decisions. A new phase of research is needed that builds on contemporary directions in precision medicine to develop precision policy making; with the aim to redress child inequities. This would include identifying effective interventions and their ideal time point(s), duration, and intensity to maximize impact. Drawing on existing data sources and innovations in epidemiology and biostatistics would be key. The economic and social gains that could be achieved from reducing child inequities are immense.

Publish or the Population Perishes: The Challenges of Regional Publishing in Public Health

The publication of information is essential for expanding the benefits of public health throughout the Asia-Pacific region. All academics are familiar with the adage "Publish or perish," but for public health, this should be rewritten as "Publish or the population perishes." Publication and communication in public health continues to undergo rapid change. There are many challenges that a regional journal faces. The number of printed journals is beginning to decline. Digital publishing and extensive databases and search engines have become the only practical way to access data. But the advent of digital publishing has seen the arrival of profit-making entrepreneurs. Whether a Journal is in the printed form or digital, it remains the key communication in public health and ultimately improve the health of the people. The Asia-Pacific Journal of Public Health (APJPH), which is owned by Asia Pacific Academic Consortium for Public Health (APACPH) and published by Sage ensures that your data gets maximum digital exposure in the region where it can make a difference. Over the years, APJPH has increased its impact factor and gained in prestige. Although impact factor of a journal is important in documenting the recognition of work by academics, it does not necessarily reflect importance to our region. There needs to be a re-evaluation of publication and communication strategies so that all citizens of the Asia-Pacific region benefit.

The Development of a Personalised Training Framework: Implementation of Emerging Technologies for Performance

Over the last decade, there has been considerable interest in the individualisation of athlete training, including the use of genetic information, alongside more advanced data capture and analysis techniques. Here, we explore the evidence for, and practical use of, a number of these emerging technologies, including the measurement and quantification of epigenetic changes, microbiome analysis and the use of cell-free DNA, along with data mining and machine learning. In doing so, we develop a theoretical model for the use of these technologies in an elite sport setting, allowing the coach to better answer six key questions: (1) To what training will my athlete best respond? (2) How well is my athlete adapting to training? (3) When should I change the training stimulus (i.e., has the athlete reached their adaptive ceiling for this training modality)? (4) How long will it take for a certain adaptation to occur? (5) How well is my athlete tolerating the current training load? (6) What load can my athlete handle today? Special consideration is given to whether such an individualised training framework will outperform current methods as well as the challenges in implementing this approach.

Precision public health to inhibit the contagion of disease and move toward a future in which microbes spread health

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.