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Congo Ebola Outbreak Declared An International Emergency Unparalleled Situation Is Impeding Control Measures Epidemiologists Banned From Participating In Hot Zone An outbreak of Ebola in the Congo has persisted for a year with 2,512 probable or confirmed cases and killed at least 1,650 persons as of mid-July without showing signs of abating. An estimated 12 new cases are being reported each day or about 80 per week, and this number is believed to be an underestimate. The case fatality rate for confirmed cases is 67% and there is

special concern that approximately 30% of the cases are children under 18 years. Health workers are accounting for 5% of the cases. Expanded Risk Now, the report of a new case in the highly populated region of Goma, a - Congo cont'd on page 2

University Of Michigan Psychiatric Epidemiologist Now Blogging For Psychology Today Magazine Recognized Problem

Briana Mezuk, an Associate Professor of Epidemiology at the University of Michigan School of Public Health is adding another dimension to her public health career. Starting in July, Mezuk initiated a feature in Psychology Today entitled “Ask an Epidemiologist”. Her column is aimed at helping readers of the magazine better assess the quality of the research findings they read about.

July 2019

The problem Mezuk addresses is a familiar one to epidemiologists concerned about maintaining public confidence in research findings, especially epidemiologic studies. Such studies can and do report findings that appear to contradict one another, and they confuse the public. According to - Blogger cont'd on page 4 •

Volume Forty •

Number Seven

In This Issue -3Saxon Graham Lecture -5Update: 10 Commandments Contest -9Notes on People -11Near Term Epidemiology Event Calendar -12Marketplace


-Congo cont'd from page 1 The Epidemiology Monitor ISSN (0744-0898) is published monthly by Roger Bernier, Ph.D., MPH at 33 Indigo Plantation Rd, Okatie, SC, 29909, USA.

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large population center in the Democratic Republic of the Congo on the border with Rwanda, has sounded alarm bells even more loudly. The World Health Organization, triggered by the case in Goma, has declared a public health emergency. The declaration means the outbreak is “an extraordinary event that poses a public health risk to other countries through international spread and that potentially requires a coordinated international response.” WHO’s assessment is that risk remains very high at national and regional levels but still low at global level. There is cause for special concern linked to the recent case in Goma because the city is a provincial capital with an airport which has international flights

good because of unintended consequences. A similar declaration five years ago in West Africa caused travel bans, visa cancellations, trade freezes, cancelled flights and other hardships which amplified the negative social and economic effects of the outbreak and actually backfired to impede control measures. 

Lack of Resources The resources needed to properly combat the outbreak have not been provided. “Unless we get substantially more financial resources immediately, it will not be possible to end the outbreak,” according to Mark Lowcock, a United Nations Emergency Relief Coordinator. Previous decisions not to declare an emergency have meant less leverage for those arguing for more resources, which hopefully will now be forthcoming.

Tenuous Security Insecurity is the greatest concern, especially after two more community health workers were killed recently. Media Express reports “as many as 134 separate armed rebel groups have sparred for control of the mineral-rich region in recent years, and an explosion of ethnically motivated kidnappings, maimings, and sexual violence displaced at least 300,000 people in June alone. There is a humanitarian crisis underway with millions of people displaced from their homes and on the move.

Complex Environment Because of the lessons learned from the last outbreak in West Africa five years ago and the development of an effective vaccine since then, it is puzzling to understand why the current year-old outbreak has not yet been halted. Official reports, eyewitness observations, and multiple media articles all point to a complex and uniquely challenging situation in which lessons learned from West Africa may not really apply. The major factors which have proven to be serious impediments to the control of this outbreak include the following: 

Fear of unintended consequences Three previous meetings by the WHO Advisory Committee have not recommended declaring an emergency out of fear of doing more harm than

- Congo cont'd on page 6


Saxon Graham Lecture At Buffalo Focuses On “Eras In Epidemiology: Embracing Our Past To Chart The Future” Talk Concludes On Need For Creativity And Other Attributes For Successful Action John Vena, Professor and Founding Chair Department of Public Health Sciences Medical University of South Carolina, and a former student and faculty member at the University of Buffalo, delivered the Saxon Graham Lecture on the occasion of the 100th anniversary celebration held at the University in late May. Vena brought together a remarkable collection of previous work by major figures in epidemiology and public health who were trained or affiliated with Buffalo over the years. He presented snapshots of papers, photos, quotes, and other memorabilia that helped the audience to better understand the contributions of wellknown epidemiologists such as Morton Levin, Warren Winkelstein, Abraham Lilienfeld, and Milton Terris as well as Saxon Graham who chaired the Department of Epidemiology in the 1980’s and 90’s. Graham Subtitled Embracing Our Past To Chart The Future, Vena’s talk recalled the ideas of Saxon Graham about the importance of creativity in allowing epidemiology to meet the challenges facing the field. Graham was President of the Society for Epidemiologic Research in 1987 and he discussed enhancing creativity in his presidential address at the meeting in Amherst that year and in a subsequent paper in the American Journal of Epidemiology. Graham was interested in learning about what stimulates creativity and he

highlighted the importance of exposing epidemiologists to ideas from new sources. Cause of Creativity Graham stated in his paper “creative production is often the result of the innovative joining of two disparate elements already in the field or of elements in the primary field with elements from the new field.” He recognized that innovative epidemiologists would likely make errors in trying new approaches and he worried about the role that excessive criticism and skepticism in epidemiology might play in discouraging creativity.

"...he highlighted the importance of exposing epidemiologists to ideas from new sources."

Elements of Achievement Vena himself has long been interested in the elements of creativity and achievement in epidemiology and published a paper in 1999 on “Innovative Multidisciplinary Research In Environmental Epidemiology: The Challenges And Needs”. He revisited and modified some of the key points from that work in presenting the concluding parts of his Saxon Graham Lecture. Among the important qualities for action, according to Vena, are the following: (slightly edited for inclusion here).

"...he worried about the role that excessive criticism and skepticism in epidemiology might play in discouraging creativity."

1. Being values driven. 2. Being connected to others and fostering intellectual interactions. - Lecture cont'd on page 4

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“Coming together is a beginning. Keeping together is progress. Working together is success.”

“appreciating who is in a study and how they were recruited is an important first step to becoming a knowledgeable consumer of health research. “

-Lecture cont'd from page 3

-Blogger cont'd from page 1

3. Being introspective about how you can make a difference in this world. 4. Pacing yourself to make time for selfrenewal, and using contact with nature to facilitate this needed renewal. 5. Having courage to attempt the novel and a sense of humor to laugh at the mistakes that will be made. 6. Pursuing the best options when perspectives change. 7. Overcoming adversity by learning the lessons which life experiences provide. 8. Envisioning scenarios of a different future.

Mezuk, contradictory findings can cause some in society to dismiss the entire scientific enterprise. She compares research findings to cars which have different reputations for reliability. “Rather than concluding that some scientific evidence is more reliable than others, some people dismiss the entire scientific enterprise. But I still drive to work, and if you are like three-fourths of Americans, you do too, even though some cars do have transmission problems.”

In his talk, Vena was also keen to point out the importance of collaboration for success in science. He pointed listeners to the NIH Field Guide on Collaboration and Team Science (teamscience.nih.gov) and quoted Henry Ford “Coming together is a beginning. Keeping together is progress. Working together is success.” Readers interested in learning more about the productive history of the Buffalo Department over the years can visit https://bit.ly/2YfwNao to view the video of Vena’s presentation which included more than 100 slides and pictures. ■

Mazuk's first article is devoted to explaining selection bias for a lay audience. She writes in a very clear, colloquial language and uses multiple examples and metaphors that can be easily understood by lay readers.

Writing Style

She says about selection bias, “appreciating who is in a study and how they were recruited is an important first step to becoming a knowledgeable consumer of health research. “ She adds, “Hopefully this will give you some tools to ‘look under the hood’ of studies the next time a flashy headline comes across your newsfeed.” Her goal is to help readers “better calibrate the amount of belief” they should impart to study findings. Motivations

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Given her credentials—a doctoral degree in mental health from the Johns Hopkins School of Public Health, it is perhaps not surprising that she was recruited by Psychology Today to write

- Blogger cont'd on page 8


On The Light Side - New Contest Last Chance To Enter Our 10 Mock Serious Commandments Contest $500 Prize Offered Deadline Extended To August 31 Winner To Be Announced In September Issue We continue to receive entries for our mock serious 10 epidemiology commandments contest, but the deadline is fast approaching. To give everyone adequate time after reading this reminder, we are extending the deadline for submission to August 31, 2019 and will announce the winner in our September issue. Readers are encouraged to work together with colleagues to formulate and submit entries which include a full set of 10 mock serious commandments. If you are very creative but cannot come up with a full set of 10 commandments, we will consider any number of commandments less than 10 for special mention in the newsletter. Rules for the contest are reprinted below. To help stimulate your creative talents, below are samples of commandments we have received to date:        

Honor thy interactions in the presence of main effects. Thou shalt not stratify in vain. Thou shalt not intimately involve thyself with what befell an individual, only I know that. Thy domain is with the population. Thou shalt not claim to have proven something. Thou comparest observed vs expected, and that is enough. Thou shalt not add co-author that does none. Let your will be done reviewers. Not mine. Fishing expeditions are for the weekend. Know thy purpose! And stay true to it, even as thou produceth and discusseth thine analyses.

 Don’t eat at buffets. Rules All entries must be received by August 31, 2019 at editor@epimonitor.net. If similar entries are received, the earliest received will have precedence. All entries must be original, created by the contestant, and not previously published elsewhere. The editor reserves the right to make the final selection of the contest winner, and all submissions become the property of the Epidemiology Monitor. Individuals may join together as a group and submit an entry or entries by department, school or other entity. A set must contain at least 10 commandments to win. Fewer than 10 compete for special mention. We reserve the right to nullify the contest if too few entries are submitted, though we think this is unlikely given all the creative entries we have received from our previous contests!


-Congo cont'd from page 2 

Political considerations Epidemiologists and Ebola experts from CDC have been banned from full participation. “High income countries fear a Benghazi moment: If they let trained experts into the hot zone and they got killed—or worse—kidnapped—it would be a political crisis,” reported Medical Express in speaking with Georgetown University’s Larry Gostin who directs an institute on national and global health law. Lack of trust Contact tracing has not been possible in a place where there is distrust of the government and other authorities and the population is mobile. If they can be found, families which are identified for preventive measures hide loved ones behind closed doors for fear they will be hauled away.

Contacts who need the proven effective vaccine do not get it. 

Lack of Information & Misinformation Conspiracy theories and misinformation circulates on social media. Lancet reported that a quarter of residents of North Kivu do not believe the virus is real. Other claims are that it is a biological attack by white Westerners or deliberate spread by the Congolese government.

According to the latest situation report from WHO, “The continuous transmission in major hotspots and the involvement of new health areas remain a grave concern, and thus necessitates both the continuation of proven and the introduction of novel outbreak control interventions in all affected areas.” ■

Graph from WHO: Ebola Virus Disease / External Situation Report 50

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https://bit.ly/2XQ5PHg

- Ebola reporting cont'd on page 7


World Health Organization Issues New Recommendations To Intensify Ebola Control Measures Triggered by its Declaration of a Public Health Emergency of International Concern and citing the International Health Regulations, the WHO has issued new recommendations for officials in the Democratic Republic of the Congo and for neighboring countries. The spread of the infection to a large population of 2 million persons in Goma on the border with Rwanda has heightened regional and international risk. The recommendations include: Temporary Recommendations In its emergency declaration, WHO makes the following temporary recommendations under international health regulations to improve control of the outbreak. Recommendations for the Congo • Communication: Continue to strengthen community awareness, engagement, and participation, including at points of entry, with at-risk populations, in particular to identify and address cultural norms and beliefs that serve as barriers to their full participation in the response. • Screening Continue cross-border screening and screening at main internal roads to ensure that no contacts are missed and enhance the quality of screening through improved sharing of information with surveillance teams. . • Security Continue to work and enhance coordination with the UN and partners to reduce security threats, mitigate security risks, and create an enabling

environment for public health operations as an essential platform for accelerating disease-control efforts. •Surveillance Strengthen surveillance with a view towards reducing the proportion of community deaths and the time between detection and isolation, and implementing real-time genetic sequencing to better understand the dynamics of disease transmission. • Vaccination Optimal vaccine strategies that have maximum impact on curtailing the outbreak, as recommended by WHO’s Strategic Advisory Group of Experts (SAGE), should be implemented rapidly. • Nosocomial infections Strengthen measures to prevent nosocomial infections, including systematic mapping of health facilities, targeting of IPC interventions and sustain support to those facilities through monitoring and sustained supervision.

"The spread of the infection to a large population of 2 million ...has heightened regional and international risk."

Recommendations for neighboring countries: • Preparedness At-risk countries should work urgently with partners to improve their preparedness for detecting and managing imported cases, including the mapping of health facilities and active surveillance with zero reporting. At-risk countries should put in place approvals for investigational medicines and vaccines as an immediate priority for preparedness. - WHO cont'd on page 8

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-WHO cont'd from page 7 • Mapping Countries should continue to map population movements and sociological patterns that can predict risk of disease spread.

"She also noted that faculty are increasingly expected to be engaged with the public..."

•Communication and Engagement Risk communications and community engagement, especially at points of entry, should be increased. Recommendations for all States: • No country should close its borders or place any restrictions on travel and trade. • National authorities should work with airlines and other transport and tourism industries to ensure that they do not exceed WHO’s advice on international traffic. • The Committee does not consider entry screening at airports or other ports of entry outside the region to be necessary. ■ -Blogger cont'd from page 4

"...public argumentation is the best way to learn about the world..."

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for that audience. And it was the existing publishing infrastructure at Psychology Today and the existing audience base that convinced her to take on the role for at least 12 months to see how successful she could be as a communicator. She plans to write a series of 3 or 4 articles on the topic of helping readers to assess the quality of health research findings before moving on to write about other topics she is interested in and knowledgeable about such as suicide.

Guest Epidemiologists Invited The arrangement with Psychology Today gives Mezuk the option to invite other guest scientists to contribute to her Ask An Epidemiologist feature. She told the Monitor she welcomes inquiries from colleagues who may have an interest in contributing and she welcomes suggestions for topics that could be included in her future columns. Other Motives Mezuk told The Epi Monitor she was also motivated to accept the invitation from Psychology Today because she is a tenured faculty member now and has the freedom to explore topics which may or may not have the same likelihood of payoff as some of her other academic activities have had. She also noted that faculty are increasingly expected to be engaged with the public and being evaluated for promotions in this way and this is one means she is using to pursue that goal. Mezuk learned from her debating experiences that public argumentation is the best way to learn about the world and she looks forward to engaging in evidence based policy debates through her writings. To read Mezuk’s first column for Psychology Today, visit : https://bit.ly/2Y4d2yI ■

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Notes on People Do you have news about yourself, a colleague, or a student? Please help The Epidemiology Monitor keep the community informed by sending relevant news to us at this address for inclusion in our next issue. people@epimonitor.net Newsmaker: Þórólfur Guðnason, chief epidemiologist in Iceland, garnered headlines this month for his proposal to distribute condoms in primary schools. The country’s high incidence of syphilis—the highest per capita in Europe— as well as a high incidence of chlamydia have prompted the proposal. “There are a lot of people against this idea, many parents,” he told reporters. “But we need to have a thorough discussion about this and to do everything we can to stop the spread of these diseases, which can turn very serious.” Primary schools in Iceland typically have students who are as old as 15 years.

Profiled: Marie-Roseline Darnycka Bélizaire, an epidemiologist from Haiti, is helping to coordinate the World Health Organization’s Ebola response in Katwa, a town in the Democratic Republic of the Congo’s North Kivu province. “It is very intense, but I am totally devoted to serving the people,” she says, adding “even if you are down, you cannot be down because when you are a leader, you need to be strong. “If I am not strong, they will say this job is not for women."

Appointed: Stephanie Shiau, PhD, as Instructor in the department of biostatistics and epidemiology at the Rutgers School of Public Health. Rutgers dean Perry N. Halkitis said “The Rutgers School of Public Health is proud to welcome Dr. Shiau to our ranks…Dr. Shiau is a rigorous epidemiologist who focuses on designing and implementing clinical trials and observational research studies to improve the health of populations living with and affected by HIV locally and globally. Shiau joins the Rutgers School of Public Health from the G.H. Sergievsky Center at Columbia University Medical Center, where she is currently a postdoctoral research scientist. Featured & Interviewed: Meru Sheel, by Women’s Agenda in a feature designed to introduce women and their work. Dr Sheel is an infectious disease epidemiologist at the Australian National University Research School of Population Health. She told the interviewer that her passion lies in improving health outcomes for marginalized populations amid a rapidly changing global health landscape. She added that the most rewarding part of her job is being out in the field responding to infectious disease outbreaks and emergencies.

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- People cont'd on page 11


Notes on People - con't from page 10

Died: August Hale Vandermer, from hepatic failure earlier this year in Prince Frederick Maryland. He was a senior epidemiologist during his career with the US Environmental Protection Agency and had served as EPA’s representative to the United Nations Environmental Program.

Honored: Aniekeme Uwah, with a medal of honor from the African Union for his role in the Ebola control efforts in Liberia in the outbreak five years ago. Dr Uwah told the Premium Times publication that “the medal of honor means so much to me. I value it so much because coming four years after I left Liberia, it goes to show that my contribution to the containment of Ebola has been appreciated.” He was initially scared of going to Liberia but later asked himself who else would go to Liberia to do the job if he as a trained medical personnel refused to.

Honored: Allen Wilcox, with Emeritus Investigator status by the National Institute of Environmental Health Science for his discoveries in fertility and pregnancy. The new position will allow him to focus exclusively on research at NIEHS according to the agency newsletter.

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Near Term Epidemiology Event Calendar Every December The Epidemiology Monitor dedicates that issue to a calendar of events for the upcoming year. However that often means we don't have full information for events later in the year. Thus an online copy exists on our website that is updated regularly. This year we will print upcoming events in the Monitor monthly. To view the full year please go to: http://www.epimonitor.net/Events

August 2019 August 12-16 https://bit.ly/2RTmaDL Short Course: Advanced Epidemiologic Methods: Rethinking Basic Epidemiologic Concepts / Berlin School of Public Health / Location TBA August 19-21 https://bit.ly/2G9aQlC Meeting: Science Policy: Improving the Uptake of Research into UK Policy / Wellcome Trust / Location TBA August 24-28 https://bit.ly/2UzGFHE Conference: 35th ICPE / International Society for Pharmacoepidemiology / Philadelphia, PA August 25-28 https://bit.ly/2UCxLsW Conference: ISEE 2019 - 35th Annual Conference / International Society for Environmental Epidemiology / Utrecht, The Netherlands August 27-29 https://bit.ly/2PwpHWM Conference: GEOMED 2019 / University of Glasgow / Glasgow, Scotland August TBA https://bit.ly/2QFJqbh Short Course: Primary and Secondary Prevention Research / Erasmus MC / Rotterdam, The Netherlands August TBA https://bit.ly/2C4bEEa Summer Program: Erasmus Summer Programme 2019 / Erasmus MC / Rotterdam, The Netherlands August TBA http://ecte.org/ Summer Program: European Course in Tropical Epidemiology / European Course in Tropical Epidemiology (ECTE) / Location TBA September 7-10 https://bit.ly/2LcQpTM Conference: ACE 2019 / American College of Epidemiology / Pasadena, CA September 23-25 https://bit.ly/2L9Cb6b Conference: 2019 Citymatch Maternal & Child Health Leadership Conference / CityMatch / Providence, RI Sept 30-Oct 25 https://bit.ly/2UxFVT9 Short Course: Intl Course in Applied Epidemiology with Epi Info Training / Emory University / Atlanta, GA Sept 30-Nov 1 https://bit.ly/2EzTHQB Short Course: Intl Course in Applied Epidemiology with Maternal and Child Health Add-on Course / Emory University / Atlanta, GA

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Profile for The Epidemiology Monitor

July 2019 - The Epidemiology Monitor  

This month we report on a rather different mix of happenings in epidemiology, some of them on a broad international scale and others on a mo...

July 2019 - The Epidemiology Monitor  

This month we report on a rather different mix of happenings in epidemiology, some of them on a broad international scale and others on a mo...