July 2021 - The Epidemiology Monitor

Times Article Says CDC Is Broken And Questions Whether It Can Be Fixed Reader Exclaims “Heal Thyself, CDC, And Hurry Up About It!” It has often been stated in print and other media that the COVID-19 pandemic and the US response to it has been and continues to be a window onto American society. Some of what we see such as the vaccine development initiative reveals impressive accomplishments. Perhaps the most glaring proof of existing problems is that Americans have accounted for 20% of the world’s

deaths while having only 4% of the world’s population. And this outcome is all the more alarming because the US is home to the Centers for Disease Control and Prevention, widely considered both domestically and internationally as the gold standard in disease control work.

- CDC con't on page 2

WHO Experts Assess The Current COVID Pandemic Situation Worldwide To Be Blunt-“The Global Situation Is…We’re Not In A Good Place” An early July press conference held with the leaders of the World Health Organization reveals that “the world is at a perilous point in this pandemic,” according to the WHO Director General Tedros Adhanom Ghebreyesus. The reasons for this gloomy assessment are multiple. 

The world has just recorded over 4 million deaths and this number is a likely an underestimate of the overall toll.

July 2021

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Countries in every region are seeing sharp spikes in cases and hospitalizations. These are causing an acute shortage of oxygen and driving a wave of deaths in parts of Africa, Asia, and Latin America.

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A handful of nations have taken the lion’s share of the available vaccines. WHO considers this morally indefensible and points - WHO cont'd on page 4

Volume Forty Two •

Number Seven

In This Issue -5Hopkins Epidemiologist Shares Tips -7Pandemic Fame: Challenges And Rewards -8Notes On People -10Near Term Epi Event Calendar -13Marketplace

-CDC cont'd from page 1 Authority The Epidemiology Monitor ISSN (0744-0898) is published monthly

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No Surprise Thus it is not surprising that one of the first institutions to come under closer scrutiny for lesson learning should be the CDC. In a lengthy NY Times magazine article entitled “COVID Proved the CDC Is Broken. Can It Be Fixed?”, multiple public health professionals inside and outside the agency were interviewed to get their opinions about the problems at the agency and what might be done to repair it.

Problems Politicization of the agency that has prided itself on strictly following the science appears to account for many of the problems or failings reported, particularly those around guidance documents and messages communicated to the public. However influential a role political considerations may have played in CDC’s performance, the Times article identifies more fundamental problems existing at the agency. These are 1) a lack of funding, 2) a lack of authority, and 3) a culture that has been warped by both. “Some of these problems come down to politics, but most are a result of flaws in the agency’s very foundation,” according to the Times.

Funding Among the funding problems identified is the fact that the budget is too small for the mission and the funds come with too many restrictions which limit the agency’s flexibility. In addition, there are no funds for emergencies or dealing with the unexpected.

In terms of authority, the CDC has a broad mission but little authority to compel jurisdictions or individuals to follow its advice. According to the Times, “Aside from a few quarantine powers, the most the CDC can do is issue guidance, which is unenforceable and, ---as the past year has repeatedly shown---just as likely to be weaponized as meaningfully employed.” This is a new phenomenon because prior to the pandemic CDC guidance , especially about vaccines, was regularly followed even though not mandatory.

Culture In terms of culture, some within the agency believe there is a delusion that the agency is more capable than it really is because of some past successes. There is a felt need, according to the article, for CDC staff to be able to correctly identify and truly acknowledge what the problems are.

Insiders told the Times reporters “the biggest barrier to modernizing the CDC was the agency’s own lack of imagination.”

Surveillance One of the key activities of the agency is disease surveillance, that is, identifying and monitoring disease incidence to spot outbreaks and epidemics and bring about control measures. The Times article makes a case that the agency is not up to date and sufficiently modernized to fulfill this basic role the country expects of it.

During the pandemic many non-CDC sites such as one at Johns Hopkins and one at the NY Times appeared to have - CDC con't on page 3

-CDC cont'd from page 2 more up to date and more user friendly tracking information about the pandemic than did CDC. According to the Times, “COVID is the biggest crisis the CDC has faced, by far, in all its history. It is exactly the kind of threat for which the agency was created in the first place. But when it finally arrived, by most accounts, officials there had very little to meet it with.”

Guidance Another key activity is providing technical guidance for disease control and again in this area the article documents multiple failings on the part of the agency. Criticisms center on the fact that guidance was either too slow in coming, too out of touch with reality on the ground to be useful, or based on flawed science or flawed interpretation of science. Political interference in the guidance development process has been reported in the media and may account for some of these failings.

Able to Learn?

Additional funding has been made available to the agency and more may be on the way. However, the Times questions whether or not the CDC is really undertaking an honest effort to identify and learn from recent mistakes and shortcomings. Also, some of the needed reforms such as changes in the funding structure and a grant of more authority, are not really within the power of the agency as much as they are in the power of the Congress.

Finally, the article acknowledges that more money, new laws, or a more imaginative or innovative spirit can’t be the whole answer. Despite what many in epidemiology and science might like to think, public health is politics and the

science cannot ever be purely apolitical. The science often is uncertain and requires judgment calls and competing values require tradeoffs which someone must decide and others have to accept. In other words, there is no getting around the need for public trust to do public health science.

Unfortunately, the pandemic appeared in an environment of unprecedented low trust in government.

System Challenge

“COVID is the biggest crisis the CDC has faced, by far, in all its history."

Also, CDC is only one agency and it is part of a national system that also needs to function well and to cooperate for the whole system to work correctly. A distressing observation made in the article is lack of real understanding among all of the players in the system of what exactly federal disease control is supposed to do and what the limits of the current system actually are.

The Times article concludes “In retrospect, it seems clear that only a strong CDC ---a well-funded, wellrun federal authority, grounded in science and resistant to political pressure but also mindful of lived reality---could have rescued American policymakers from the worst of their COVID confusion. And only a stronger CDC stands a chance of correcting these errors when the next pandemic comes along…”

A reader comment following the Times article appears to miss the mark by only focusing on the agency itself to bring about reform, but the sentiment expressed may be widely shared by all Americans. The reader exclaimed “Heal thyself, CDC, and hurry up about it!” ■

“...public health is politics and the science cannot ever be purely apolitical."

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-WHO cont'd from page 1 out this “vaccine nationalism” may actually be an ineffective strategy against a respiratory virus since it is being allowed to circulate internationally and mutate into more dangerous variants.

“WHO calls this 'abhorrent'.”



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“This is not the situation we should be in when we have tools at hand.”

Millions of health care workers have still not been vaccinated.

WHO calls this “abhorrent.”

Some countries which have had the opportunity to vaccinate their adult populations are now considering vaccinations for children. WHO considers this younger population to be a lower priority than older populations in other countries which have not had the opportunity to be vaccinated.

WHO would like to see sharing of these potential pediatric doses to other parts of the world where the doses are needed much more. A similar argument could be made against using limited supplies of vaccine to provide booster doses to persons already vaccinated.

Increasing Incidence

An increase in COVID cases has been occurring in all regions of the world except the Americas as of the beginning of July. The rates of increase are 17% in Africa, 16% in the Eastern Mediterranean, 33% in Europe, a 9% increase in Southeast Asia, and a 10% increase in the Western Pacific.

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Looking at individual countries in the Americas, there are more than two dozen countries that have epidemic curves that are almost vertical right

now. "...We need to be blunt when we need to be blunt,” said Maria Van Kerkhove, WHO’s Technical Lead on COVID-19. She added, “The global situation is…We’re not in a good place…This is not the situation we should be in when we have tools at hand.”

Factors Driving Transmission In recapping the situation, Van Kerkhove said there are four major factors that are currently driving COVID transmission.

1. The virus and its properties, now including more transmissible variants, are widespread throughout the world with three of the four variants (Delta, Alpha, and Beta) to be found in over 100 countries each, and Gamma in 74 countries.

2. Increasing social mobility of people (gatherings of all types and sizes) around the world. WHO is urging countries to open carefully while paying attention to proper risk management. WHO is asking governments not to lose the gains that have been made.

3. Reduced or inappropriate use of public health and social measures. There appears to be a desire on the part of some governments to shift more of the focus for controlling risks on personal responsibility rather than the dictates of government.

4. The inequitable and uneven distribution of vaccines.

Said Dr Tedros, “From a moral, epidemiological, or economic point of view, now is the time for the world to come together to tackle this pandemic collectively.” That means funding to scale up the equitable manufacturing and distribution of health tools and increasing vaccination rates to 40% by the end of 2021 and reaching 70% of people in all countries by 2022. ■

Hopkins Epidemiologist Shares Her Approach For Communicating With Vaccine Hesitant Persons “…I’m not a clinician---I haven’t had to put my life on the line to care for people like so many of my colleagues have---but I know stuff…Those of us with knowledge have, I think, a moral responsibility to try to share it in as many venues as possible.” These are the views of Jennifer Nuzzo, an epidemiologist with the Johns Hopkins Center for Health Security who has interacted frequently with the media during the pandemic to provide the latest case and death counts and other information. She was interviewed about herself last month by the Hub, the Hopkins news publication.

ensure the abundant presence and dissemination of factual information.

However, these recommendations are targeted primarily at the organization and higher levels. Nuzzo, in contrast, has been acting on these recommendations more as an individual scientist, and she shares her lessons learned in the interview. These lessons will be of interest to epidemiology colleagues who want to share their expertise to help combat misinformation and contribute to improved control of the pandemic.

In a story headlined “Winning Hearts and Minds”, readers are given a closer look and better appreciation for the work of this now popular epidemiologist. She is only one of many to become well-known as a resource person during the pandemic.

(See related story in this issue on what the public role of epidemiologists has been in Australia).

Asked for her guidance on how to talk with persons who have decided not to get vaccinated or might need more facts, Nuzzo offered this advice—“Just try to hear people out and hear what their concerns are…and try to empathize with them a little bit. The fears they’re expressing come from somewhere. So the first step is just checking yourself and what baggage you bring to these conversations... If we don’t do a good job of connecting with people and addressing their concerns and fears, we’re ultimately not going to get where we need to be.

Fighting Disinformation According to the Hub, Nuzzo has spent the entire pandemic fighting the spread of deadly disinformation. Her Center for Health Security published a report in March 2021 entitled National Priorities to Combat Misinformation and Disinformation for COVID-19 and Future Public Health Threats: A Call for a National Strategy.

That report identified five priorities and the first two of these are 1) to intervene against false and damaging content as well as the sources propagating it, and 2) promote and

“---but I know stuff…"

Approach

“Just try to hear people out and hear what their concerns are…“

Questions Always Good Asked for advice on how to talk with persons who say they won’t get vaccinated because they know too much or have done a lot of research, Nuzzo acknowledged that some persons have very entrenched opposition. However, others still do have questions and doing the research - Hopkins con't on page 6

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-Hopkins cont'd from page 5

“I say I’m not going to judge anybody ...“

to find the right information is challenging because of the volume of misinformation available through social media. According to Nuzzo, “I say I’m not going to judge anybody, I’m here to provide information. I don’t necessarily assume I’m going to change your mind, but I’m going to try to give you more information to help you make your decision.”

Differing Values Nuzzo made the point that not all persons have the same values or feel the same way about issues related to vaccines and the medical system. She said “…I think we’re very quick to judge people, but we don’t realize that we haven’t all had the same life experiences and we don’t all have the same privileges.” ■

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New Found Pandemic Fame For Epidemiologists Has Its Challenges And Rewards How would you like to be recognized at the supermarket for your epidemiologic expertise and be told “I love you” or to become a household name in your area?

That’s the experience of several Australian epidemiologists who have become resource persons for the media and the public during the COVID pandemic. A recent article in the US edition of The Guardian chronicles these experiences for several Australian epidemiologists during the pandemic.

Among them are the following: Catherine Bennett, the inaugural chair in epidemiology at Deakin University, has given media interviews and written analysis during the pandemic. Says Bennett, “As a researcher at a university…you want to actually make people’s lives healthier and safer. But you rarely get to hear from the public in the way we are now. It’s a mark of how strange these time are, but at the same time it’s the bit that reinforces your drive to contribute…It’s just been an extraordinary time to be thrust in the middle in a public role…that somehow connects you across all of this.”

Mary-Louise McLaws, professor of epidemiology at the University of New South Wales (NSW), member of a NSW COVID taskforce, and a WHO COVID advisor, told the Guardian “People will come up and say, ‘thank you very much for talking to us apolitically’, or ‘you make me feel calm about what’s happening’…When I’m asked for opinions in Australia, I have been criticized that I’m not considering the economy or mental health. But I try to remind the listeners or readers that that’s not part of an epidemiologist’s responsibility—that’s leadership. So you focus on one thing only, and that is your understanding of outbreak and

you focus on one thing only, and that is your understanding of outbreak and pandemic management.”

Not all of the experts profiled in the article are equally focused on being apolitical in giving advice or on being single-mindedly focused on the science. Sharon Lewin, an infectious disease physician and inaugural director of the Peter Doherty Institute for Infection and Immunity describes her role a bit differently. She told the Guardian “I think my role as a scientist is to ensure that the government and leaders have access to the best synthesis of science at the time, and for their policy to be influenced by the science…You can’t beat a public health crisis with science alone. You need political leadership, and you need civil society.”

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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

Died: Ralph Katz, age 77, on May 26, 2021 after a brief illness. According to his obituary, Dr. Katz had a long career as an epidemiologist and professor at Walter Reed, the University of Minnesota, the University of Connecticut, and as chair of the Department of Epidemiology and Health Promotion at the New York University College of Dentistry. About Dr Katz as a person, his obituary states “His enthusiasm in life extended well beyond academics. He navigated life with unbridled optimism, good humor, and balance. He was compassionate, saw potential in everyone, and, even in his last days, he showed great positivity, strength, and thoughtfulness.”

Winner: Lauren De Crescenzo, of the 208 mile Unbound Gravel endurance cycling race in Emporia Kansas in early June 2021. De Crescenzo, age 30, is an epidemiologist at CDC and a pro cyclist. After winning the race she was asked by the publication Bicycling how she is able to train working forty hours a week. She answered, “Keeping things as simple as possible is the way to go. At this point, I’m just doing what’s going to get me through the day, what absolutely needs to be done today. I’m just trying to continue this lifestyle for the moment, but I know this pace is ultimately unsustainable.”

Selected: Vasan Ramachandran, as winner of the 2021 Louis and Artur Lucian award to one researcher from around the world who has made outstanding contributions to the field of circulatory diseases, especially for his work on hypertension and cardiovascular risk. Dr Ramachandran is a professor at the Boston University School of Medicine, professor of epidemiology at the BU School of Public Health, and is also Director of the Framingham study.

Named: Raynard Washington, as Director-designee of the Mecklenburg County North Carolina Health Department. Washington has been serving as the Deputy Public Health Director for the county. He previously was chief epidemiologist and deputy commissioner with the Philadelphia Department of Public Health.

Notes on People, continued from page 8 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

Appointed: David Shoham, as Chair of the East Tennessee State University Department of Epidemiology and Biostatistics in the College of Public Health. Dr Shoham was formerly with Loyola University Chicago as an associate professor and director of the Institute of Public Health, Public Health Programs, and the Master of Public Health program. “We are pleased to welcome Dr. Shoham to the ETSU College of Public Health,” said Dr. Randy Wykoff, dean. “He is a widely regarded researcher in his field and also brings strong leadership and vision that will guide and continue to grow our Department of Biostatistics and Epidemiology.

Filing Lawsuit: Jennifer Smith, former Hawaii Department of Health epidemiologist, against the state and the Director of the Department of Health.

Smith was terminated from her job in May according to media accounts. Smith alleges that she was terminated because she spoke out publicly last year to criticize the state’s contact tracing program practices and reporting.

Hired: Victoria Zigmont, to join the faculty at the School of Applied Sciences at the University of Mississippi. She comes to Mississippi from the Department of Public Health at Southern Connecticut State University. She currently works as a clinical data scientist consultant for the Department of Data Science for OhioHealth.

Zigmont is described by the associate dean at the University of Mississippi as possessing strong leadership capabilities, enthusiasm for working with students, and knowledge in the field of epidemiology that will enhance the school’s undergraduate and graduate programs in public health.

Selected: Gabby Thomas, UT Austin epidemiology student, to represent the U.S. at the Tokyo Olympics. She posted the 3rd best time in the U.S. history for the 200 meters at the USOC qualifying event in Michigan this year and just below the record set by Florence Griffith-Joyner in 1988. She is enrolled to earn a graduate degree in epidemiology and health care management.

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8 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 upcoming year. Thus an online copy exists on our website that is updated regularly.

To view the full year please go to: http://www.epimonitor.net/Events The events that we are aware of for the next two months follow below.

August 2021 August 7-12

https://bit.ly/34bPNIB

Conference / JSM 2021 (Joint Statistics Meeting) / American Statistical Association / Seattle, WA August 21-25 https://bit.ly/2Lsl0ki Conference / 37th International Conference on Pharmacoepidemiology & Therapeutic Risk Management / International Society for Pharmacoepidemiology / Seattle, WA August 25-26 http://bit.ly/2RzkcLF Conference / Swiss Public Health Conference 2021 / University of Bern / Bern Switzerland August TBA (late in month) http://bit.ly/2Yu6zij Conference / 32nd Annual Conference of the Intl Society of Environmental Epidemiology / ISEE / TBA

Help complete the epi calendar for 2021 The events listed on the next page in blue have traditionally run in August each year.

As of the date of publication, we cannot locate updated information for these specific events for 2021. We will be updating our calendar monthly throughout 2021. If you have any information on these events please contact us at events@epimonitor.net Please check our website and newsletter issue often for new information.

Conference / 28th International Epidemiology in Occupational Health (EPICOH) / Multiple / http://bit.ly/36h3epu Summer Program / Erasmus Summer Program / Erasmus MC / http://bit.ly/38pSFlY Summer Program / Epi on the Island / University of Prince Edward Island / http://bit.ly/3prmLgk Summer Program / Summer Program in Population Health / Ohio State University / http://bit.ly/3nQ5zkg

September 2021 Sept 3-6 http://bit.ly/2DZRyeq Conference / 22nd IEA World Congress of Epidemiology 2021 / Multiple / Melbourne, Australia Sept 7 http://bit.ly/2KBdHGu Event / Inaugural World Field Epidemiology Day / TEPHINET / Worldwide Sept 19-21 https://bit.ly/2pNWzQF Conference / 2021 IAPHS Conference / Interdisciplinary Association for Population Health Science / Baltimore, MD

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September 2021 continued Sept 22-24 http://bit.ly/2LDvjQ2 Conference / ECVPH AGM & Annual Scientific Conference 2020 / European College of Veterinary Public Health / Athens, Greece Sept 26 - Oct 3 https://bit.ly/2Iu3ds4 Conference / ID Week / Multiple / San Diego, CA

Help complete the epi calendar for 2021 The events listed on the next page in blue have traditionally run in September each year. As of the date of publication, we cannot locate updated information for these specific events for 2021. We will be updating our calendar monthly throughout 2021. If you have any information on these events please contact us at events@epimonitor.net Please check our website and newsletter issue often for new information.

Conference / 6th World Congress & Expo on Public Health, Epidemiology and Nutrition / Multiple / http://bit.ly/2qL5aHx Conference / 2021 American College of Epidemiology Annual Meeting / ACE / http://bit.ly/38mGTZg

VIRTUAL 5-Day Autumn School in Clinical Epidemiology 13 - 17 September 2021 (early booking deadline 02 August 2021)

Course Faculty: Albert Hofman, MD, PhD Stephen B. Kay Family Professor of Public Health and Clinical Epidemiology, Harvard Chan School of Public Health; Uwe Siebert, MD, MPH, MSc, ScD Professor of Public Health, Medical Decision Making and HTA (UMIT TIROL), Adjunct Professor of Epidemiology and Health Policy & Management (Harvard Chan School of Public Health); Ursula Rochau, MD, MSc Ass.-Prof. Priv.-Doz. (UMIT TIROL).

The Virtual Autumn School in Clinical Epidemiology takes place 13 - 17 September 2021. This online course will provide a comprehensive overview of epidemiologic principles and methods to problems encountered in public health and clinical medicine. It provides important information for clinicians and health policy makers in order to identify risk factors for diseases and to determine optimal preventive, diagnostic and therapeutic strategies for individuals and populations. The course combines synchronous online lectures, discussions and case study group work. Main lecturer will be Prof. Albert Hofman, Professor of Public Health and Clinical Epidemiology at Harvard University.

For more information please click here. (www.htads.org) Further Courses: Modeling Approaches for HTA: A Practical Hands-on Workshop 08 - 10 September 2021 (early booking deadline 25 July 2021) This practical hands-on workshop provides an overview on five different modeling techniques applied in Public Health & Outbreak Research with an emphasis on reals world case examples from different acute and chronic diseases.

For more information please click here. (www.htads.org)

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