June 2021 - The Epidemiology Monitor

Point-Counterpoint Article Highlights Enduring Tension About The Proper Role Of Epidemiologists In Public Health Fact Finders Only Or Fact Purveyors Also?

Should epidemiologists be devoted primarily to producing findings and publishing them objectively or should they also encourage the use of their findings in formulating evidenceinformed control measures? This question was posed almost 40 years ago in the early days of The Epidemiology Monitor (October 1982) by a Florida-based epidemiologist who encountered resistance to implementing sanitary control 2 measures. (See reprint this issue).

He had recommended these measures based on his investigation of a foodborne outbreak at a health care facility. As reported in letters to the editor at the time, the epidemiologist wondered to what extent he had a responsibility to be simply “an attack rate calculator” or also “a hell raiser” so that his data-based recommendations to protect the at-risk population would be adopted.

- Point con't on page 5

In This Issue -3Reflections on Decades of Public Health Service at CDC -4Neurological Symdrome in Canada Under Investigation

Expert Group Forecasts That SARS-CoV-2 Is Here To Stay Enhanced Outbreak Control Strategy Is Proposed To Lessen Impact And Return To Relative Normalcy Writing in a recent issue of Foreign Affairs, Larry Brilliant an epidemiologist and Chief Executive Officer of Pandefense Advisory and five other health professionals with varying backgrounds and expertise in epidemiology, infectious disease and other subject matters have assessed the status of the pandemic in the world, the international response to it, and

given their opinions of what the most likely future of the disease will be. The article is entitled “The Forever Virus--A Strategy for the Long Fight Against COVID-19”.

Here To Stay They begin their assessment exclaiming - Strategy cont'd on page 2

June 2021

•

Volume Forty Two •

Number Six

-12Near Term Epi Event Calendar

-14Marketplace

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

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“It is time to say it out loud: the virus behind the COVID-19 pandemic is not going away…Rather than die out, the virus will likely ping-pong back and forth across the globe for years to come…The virus is here to stay” The authors advance several reasons for believing the virus will become endemic, including the growth of the virus in more than a dozen animal species, the practical difficulties in reaching herd immunity through vaccination, and the circulation of variants.

The authors mince no words in explaining how the world got into this situation. They identify leaders in multiple countries who showed parochialism and political insecurity and thus downplayed the crisis, ignored the science, and rejected international cooperation. “The result of all the chaos, delay, and stupidity was a largely uncontrolled spread and a heightened death toll.”

Outbreak Control Revisited To meet the challenge of an endemic situation, the authors propose to modify and update the surveillance and containment strategy or ring vaccination strategy that was used successfully to eradicate smallpox.

According to the authors, “the key lies in treating vaccines as transferable resources that can be rapidly deployed where they are needed most.” In short, this is an outbreak control strategy which will require an enhanced capacity to detect cases, sequence viral genomes, notify exposed persons, and collaborate more effectively between countries.

US Leadership The US is tagged for being in the best position to take on the global leadership in this targeted outbreak control strategy. In part this is because the US is no longer seeing cases nationwide and could begin to deploy vaccine to areas with high infection rates to carry out basic outbreak control activities. Unlike smallpox, SARS-CoV2 produces a high percentage of asymptomatic cases making case identification difficult. However, the authors believe that “powerful new tools for detecting outbreaks and developing vaccines exist today that were not available during smallpox eradication. These tools as described by the authors can provide the “situational awareness” in real time needed to effectively use an outbreak control strategy. Thus, “If the United States solves the puzzle of controlling outbreaks of COVID-19 at home and shields itself against importations of the virus from abroad, it will have a blueprint that it can share globally. It should do so, turning outward to help lead what will be the largest and most complicated disease-control campaign in human history.

In concluding their overview, the authors state that “Sustaining our way of life thus requires deep changes in the way we interact with the natural world, the way we think about prevention, and the way we respond to global health emergencies.”

Denial Stage The authors frame the losses the world has experienced because of COVID-19 in terms of the five stages of grief that have been described whenever loss occurs. They claim the world is - Strategy con't on page 3

Retiring CDC Official Shares Her Reflections On Decades Of Service In Public Health “Our World Needs You” She Tells A New Generation In a guest essay published in the New York Times in early June, Anne Schuchat, principal deputy director of the Centers for Disease Control and Prevention, has reflected on her more than three decades of service to the public health agency.

According to Schuchat, “public service is a privilege” and for her it has also been a joy. In reviewing her service at the agency, she offered several observations she wanted to share with the American public.

The Little Engine First, public service is difficult. This Schuchat ascribed mostly to the chronic underinvestment in public health that has characterized the US situation for many years. She compares the progressive weakening of core capacities in public health with the much rosier picture in funding for basic research and development in biomedicine. In the past, the public health system has managed with limited or delayed funding to be the little engine that could. But the COVID situation was too much and the system became the little engine that couldn’t. Schuchat adds, “…I hope that it has become clear to the nation and its policymakers that when we don’t invest in public health, everyone is vulnerable.”

Saving Lives Second, public service is meaningful. To make her point, Schuchat relates the impact of new guidelines for screening of pregnant women to help prevent group B strep which she helped to

develop in the late 1990’s. The new guidance is credited with preventing over 100,000 life threatening infections since then. Bottom line: public health work matters and makes a difference. By implication, the message is that not all jobs provide this type of satisfaction.

"...public service is difficult."

Teamwork Thirdly, public service is also joyful, according to Schuchat, because she was able to experience the benefits of teamwork, namely achieving things greater as a group than you could hope to do alone.

Schuchat closed her essay by noting the historic magnitude of the disruption caused by SARS-CoV-2 and the pandemic and stated “I hope this is also a moment when a new generation is called to action, to experience the difficulty and the meaning and joy of public service.

Our world needs you.” ■

“...public health work matters and makes a difference."

-Strategy cont'd from page 2 currently stuck in denial of the fact that the pandemic is far from over.

This is only the first stage and they urge everyone to move ahead to a final stage of finding meaning in the devastation by doing more to mitigate this pandemic and preventing the next one.

To read the article in Foreign Affaris, visit: https://fam.ag/2TrMIBY ■

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Neurological Syndrome Of Unknown Cause Being Investigated In New Brunswick

“These cases... proved to be a source of concern nevertheless because the cases had common symptoms."

“...6 deaths have been associated with this cluster with onset dates between 2013 and 2020."

A cluster of 48 cases as of early June of neurological illness of unknown cause (NSUC) has been reported and is under investigation by Public Health New Brunswick.

Common Symptoms The cluster became apparent as a result of a series of case referrals from New Brunswick to the Canadian national Creutzfeldt-Jakob Disease Surveillance System. These cases proved negative for Creutzfeldt-Jakob Disease but proved to be a source of concern nevertheless because the cases had common symptoms. Some of these symptoms include memory problems, muscle spasms, balance issues, blurred vision or visual hallucinations, unexplained and significant weight loss, behavior changes, and pain in the upper or lower limbs.

The Creutzfeldt-Jakob Disease Surveillance group contacted Public Health New Brunswick in December 2020 to launch a joint investigation. A case definition was developed in January and physicians in New Brunswick were asked to report any suspect cases beginning in March 2021.

Acadian Risk?

Interestingly, at the time of referral to the Surveillance System, most of the individuals were living in northeastern New Brunswick on the Acadian peninsula and near the city of Moncton. There has been no new evidence collected to suggest that residents of these areas are at increased risk relative to New Brunswick residents in other areas of the province.

So far, 6 deaths have been associated with this cluster with onset dates between 2013 and 2020. Exactly half of the cases are male and half female ranging in age from 18-85 years old. No clusters have been identified outside of New Brunswick.

Hunt For Risk Factors Public Health New Brunswick has developed a questionnaire to gather exposure information from the cases and look for common exposures related to food, the environment, or animals.

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-Point cont'd from page 1 Agreement on Purpose The question of the proper role for academic or applied epidemiologists as public health scientists has been debated for decades with apparently no consensus emerging on how epidemiologists can best navigate the gap between data and action. On one question the consensus has not been in doubt, and that is that epidemiology exists not as a basic science but for the sake of improving public health. How best to do that is the perennial question on the table.

AJE Articles Recently, two senior epidemiologists, David Savitz at Brown University and Rodolfo Saracci, formerly at the International Agency for Research on Cancer have taken on the dilemma and tried again to explain the differing viewpoints on the proper role for epidemiologists in Point-Counterpoint articles in June 2021 in the American Journal of Epidemiology. Also, in this issue of the Epi Monitor we publish answers to follow-up questions we asked the authors such as one about the impact of the pandemic on their thinking. (see related article in this issue).

Rigor and Objectivity As Paramount Savitz is keen to protect the scientific rigor and integrity of epidemiologic work and is quick to caution that epidemiologists should not overpromise or over-interpret their findings. He believes that epidemiologists are particularly vulnerable in this regard because of pressures or incentives to overpromise about the significance of research to

obtain funding, and similar pressures after the research is completed to exaggerate the significance of the findings.

He would prefer to leave careful balanced assessments of findings to independent assessors charged with connecting evidence to action. He does not assign any responsibility to epidemiologists who have actually conducted the research to make that connection. Particularly in what Savitz calls the “heat of battle” in referring to public health policy controversies, he cautions that researchers tend to be defensive about studies that support their desired policies rather than carefully examining criticisms. This is especially the case when the stakes are high and the battles are intense.

Depending on the positions of stakeholders in different controversies, there are both welcome and unwelcome results and these are scrutinized differently, according to Savitz.

“He believes that epidemiologists are particularly vulnerable..."

Being Doggedly Dispassionate In concluding his article, Savitz states that “the fundamental nature and challenge of epidemiology is to balance the goal of generating knowledge that advances public health and maintaining absolute allegiance to scientific rigor and objectivity. In fact, epidemiologists make their greatest contributions to advancing public health when they design and conduct studies to interpret their findings with a neutral, doggedly dispassionate perspective.” Savitz even considers it an “obligation” not to connect evidence to action but to actually keep separate the role of scientist from the other interests epidemiologists might have as - Point con't on page 6

“...researchers tend to be defensive about studies that support their desired policies..."

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-Point cont'd from page 5 advocates, ambitious scholars, or people with preconceptions and desires for certain outcomes.

Counterpoint

“...non-neutrality is actually helpful..."

In his counterpoint article, Saracci challenges Savitz’s singular focus on the epidemiologist’s role as scientist and posits that epidemiology underwrites a contract either formally or informally with society to deliver on its goal to improve public health and thus has a dual commitment to science and to people’s health.

Saracci questions whether epidemiologists can maintain the “absolute allegiance to scientific rigor and objectivity” called for by Savitz.

According to Saracci, objectivity can be sought but is beyond the reach of an individual epidemiologist. He goes further to suggest that non-neutrality is actually helpful because it favors research questions that are relevant and applicable to population health and because it can influence the interpretation of uncertain findings in the direction of protecting public health. Finally, non-neutrality can help

“If it has practical importance, it must entail also practical responsibility..."

According to Saracci, epidemiologic findings need to be entered into decision making processes to produce actual benefits for health and this transfer from field to policy “…implies proactively driving the results into the decision process and supporting them from a science-for-health viewpoint in the same way as other participants…will argue from their viewpoints.” According to Saracci, epidemiologic findings with any implications for public health become like the germ of an idea “the germ of a decision” and a co-responsibility. He says, “If it has practical importance, it must entail also practical responsibility, or else it does not possess either.

To read the article by Savitz, visit: https://bit.ly/2Twa6xT To read the article by Saracci, vist: https://bit.ly/3gAGzuU ■

Post-Publication Question and Answer Series with David Savitz and Rodolfo Saracci On the Proper Role for Epidemiologists Following the publication of their point-counterpoint articles in the American Journal of Epidemiology in June, Drs. Savitz and Saracci kindly agreed to field these additional questions from the editor of The Epidemiology Monitor.

1.

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build public trust in epidemiologic findings when trust in those findings is essential to be being able to implement recommended public health actions.

Epi Monitor: As you know, the

question or dilemma you each addressed in your AJE article has been around for many years and no definite consensus has emerged in the profession as far as I know. Is there something very specific about the current period of time which prompted you to write now about the proper role for epidemiologists?

- Q&A con't on page 7

-Q&A cont'd from page 6 Saracci: Actually there was not a specific circumstance related to the pandemic that prompted my intervention. We can safely say that the issue "always" existed, as shown - just an example - in a paper of 1978 [Epidemiological strategies and environmental factors. Int J Epidemiol 1978; 7: 101-110 ] in which discussing the problematic aspects of epidemiologists' responsibilities I wrote: "More likely to be affected is the newer generation of epidemiologists who, however, are less likely than the classic communicable disease epidemiologists to have had the benefit of direct experience of decision making (for example in the control of an epidemic)".

What it meant is that older time 'classic' epidemiologists had very often at least some experience as public health officials, obliged to take (with others) decisions : there is nothing better than this to grasp all terms of the 'scientific evidence - practical decision' problem. I never had that experience but my clinical practice years presented problems that, at the individual rather than at the population level, are not dissimilar.

Savitz: Epidemiologists are affected by the social and political climate of the times, which is notably antagonistic. In calmer, more civil times, we can be confident that evidence will speak for itself, limitations can and should be acknowledged with trust that the research won’t be inappropriately dismissed, and that reasoned debate is beneficial and can change interpretations. When engaged in ideological warfare, such reasoned examination and debate tends to be replaced with hyperbole and defensiveness, which we need to consciously avoid to maintain the integrity of the discipline.

2.

Epi Monitor: Epidemiologists have had a great deal of work to do during the pandemic and have never been as much in the spotlight as they have been during the pandemic. Has anything you have observed during the pandemic altered your thinking about the proper role of epidemiologists as public health scientists? Should they be doing more or less of something?

Savitz: I believe the pandemic and our our heightened visibility has accelerated an ongoing shift in our focus from the esoteric to the practical, which I personally believe is beneficial to the discipline and society. While there may be longterm scientific payoffs from delving into arcane biological, social, and theoretical avenues of research, epidemiology is at its best in addressing practical, real-world topics that only epidemiology can tackle – When is wearing masks beneficial?

What settings and activities increase risk of infection and which ones are safe? Why is the magnitude of social disparity so profound and how can we mitigate it?

Saracci: In this respect I can elaborate a little more on what I wrote in the Counterpoint. I am well aware of the danger of becoming an advocate and I know more than one scientist-cumadvocate whose science has become thinner and thinner, in the end spoiling the very purpose of soundly based advocacy. I think that epidemiologists while keeping constant attention to the danger should not evade from making - Q&A con't on page 8

“...there is nothing nothing better than this to grasp all terms of the 'scientific evidence practical decision' problem."

“...reasoned debate is beneficial and can change interpretations."

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-Q&A cont'd from page 7

“...epidemiology is at its best in addressing practical, realworld topics that only epidemiology can tackle..."

their case, even forcefully, rather than simply letting the results at the door of "decision makers". The rationale for this is that in the real (as opposed to an ideal, conflict-free) world the other parties (technologists, economists, sociologists, citizen's groups, corporations etc.) which provide inputs to the "decision makers" rarely if ever depose their inputs at the door, most often they cross the door and enter at least a few steps into the decision room.

Hence I feel almost obliged to exercise my part of results support and advocacy. A closely related argument was made, in his usual sharp style, by Geoffrey Rose when he wrote (The strategy of preventive medicine, 2nd ed, page 151) "...the difficulty is the massive amount of persuasion that comes from the other side ("Drink more vodka!"

"Drive bigger and faster cars!").Maybe freedom [of choice] suffers less if it is attacked from both sides, not from only one. On that ground alone I grudgingly allow that persuasion [as opposed to information that he had discussed before] has some place in health education".

3. “...epidemiologists while keeping constant attention to the danger should not evade from making their case..."

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Epi Monitor: Presumably, agreeing on the proper role for epidemiologists would improve what epidemiologists are able to accomplish. Since no consensus has emerged about the proper role of epidemiologists in regard to the transfer of findings from the world of science to the world of public health, what do you believe it will take beyond your articles for such a consensus to develop?

Savitz: I continue to believe epidemiologists have much to contribute to many realms of society but what we need is a seat at the table

where those decisions are made and not to be prescriptive regarding what should be done. We should not take it on ourselves to remove the pump handle but to provide research findings in a clear and balanced way to those who manage the water distribution system who need to take other considerations into account to make the best decisions. This goes well beyond the conventional public health arena and should include generating and providing evidence to decision-makers in the realms of urban design, transportation systems, criminal justice, agriculture, immigration, etc.

Saracci: As usual we can organize, also in the light of the pandemic experience, some kind of conference or workshop with ample discussion time on the topic: it can be highly enjoyable coming after months and months of confinement. Its main value would be to ensure that, more than a consensus, an open and healthy spectrum of views and attitudes is alive. Given the dual commitment of epidemiology it would be dangerous if only one attitude would uniformly prevail, it would end by obscuring the awareness that more than one commitment is at stake and that the two cannot be automatically reconciled by any fixed formula to be memorized by all epidemiologists. ■

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Reprint (Oct 1982)

Letters to the Editor

On the proper role for an epidemiologist.

In May 1982, a large mental hospital in Florida was involved in an epidemic of vomiting and diarrhea. The same hospital was involved in a similar epidemic affecting the same ward areas in 1979. At that time, a top- notch CDC– type epidemiologist investigated the situation. He did not find the causative agent, but he did prepare a good protocol to prevent and limit spread.

The protocol was formally adopted, but never effectively implemented.

Recent outbreak Investigation of the most recent outbreak revealed that for the preceeding six months and continuing through day eight of the outbreak, the institution had an overflowing drain with sewage leaking onto the kitchen floor. Food preparers lifted contaminated boxes from the floor to food preparation counters. Soap, towels, and thorough application of them in proper order after going to the toilet was lacking on the part of the employees. Toilets with open doors led directly to the kitchen in the midst of a massive presence of flies. The serving of tea was by means of a glass dipped by hand in a large tub. The person serving had one thumb with grossly visible dirt under the nail.

Results In a meeting with management, the epidemiologist investigating the outbreak "raised hell;" "read the riot act;" or "lowered the boom" as variously described by those present. The epidemiologist did this to stress the importance of basic hygienic practices.

The net result was that the management requested removal of the

epidemiologist rather than hurrying to correct the grossly apparent unhygienic practices. State officials agreed to management’s demands since in their words "the epidemiologist’s effectiveness in the situation had been compromised beyond repair… And he had upset some people at the hospital."

Questions The above episode raises a number of questions about the proper role and responsibility of an epidemiologist. I suggest a dialogue might be useful between epidemiologists who believe their primary task is only to record the facts and count the wells, iills, and dead (includes most CDC’ers) and some epidemiologists, including myself, who believe that a more active role is appropriate. The former group believes an epidemiologist’s task is to determine the cause of the outbreak; make recommendations for prevention; and bow out leaving enforcement solely in the hands of an administrator, inept or not. In contrast, I believe that if a series of obviously bad breaks in basic hygienic practices are noted, an epidemiologist should seek to change conditions then and there, without waiting to prove that these conditions have something to do with the specific problem under investigation.

“...the epidemiologist investigating the outbreak "raised hell;" "read the riot act;" or "lowered the boom"..."

"...the epidemiologist’s effectiveness in the situation had been compromised beyond repair…“

More Also, in presenting findings, should an epidemiologist state, for example, a kitchen inspection revealed numerous deficiencies in food handling practices, equipment - 1982 con't on page 10

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-1982 cont'd from page 9 8

"...he did not cleave to the neutrality that his office could have afforded.“

maintenance,--any one of which could have led to a foodborne outbreak, or should a more explicit approach describing all the observations be used (e.g., kitchen floor was flooded with water and sewage; ward and food preparers did not have soap and towels; a food server dipped hand in ice tea, etc.). Would this latter explicit method be more informative, although more embarrassing to management?

Getting Invited It appears that CDC and many state employed epidemiologists depend on being “invited in” to assist in epidemic situations. They state, therefore, that they cannot bear down too heavily on management by using open, explicit forms of expression. Managers might take their epidemic business elsewhere but where? What do your readers think?

Editor’s note: [Two additional outbreaks have occurred at the above institution in August and September 1982.

Clostridium perfringens was implicated in the latter outbreak.

In discussing the proper role of modern epidemiologists, Alexander Langmuir has suggested that they would do well to emulate the precedent set by William Farr ( IJE 1976; 5; 13-18 ). For example "he did not cleave to the neutrality that his office could have afforded. He presented his analysis with objectivity but then stated his own interpretations forcefully and argued fearlessly for his recommended changes regardless of what vested interests might be involved."

Published October 1982 ■

Oscar Sussman DVM, MPH, JD

Reprint (Nov 1982)

Letters to the Editor

On the proper role for an epidemiologist---Another view

“...the impetus for change should be directed to those officials who bear the responsibility and line authority to rectify problems."

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In at the October 1982 Epi Monitor Dr. Oscar Sussman wrote a thoughtprovoking piece on the epidemiologist’s role during outbreaks.

While I was not directly involved with the outbreak Dr. Sussman described, I was the epidemiologist who investigated the subsequent two outbreaks. Thus, I have direct knowledge of the institution and problems involved.

An epidemiologist is a consultant often invited to investigate a specific problem. As Dr. Sussman suggests, the epidemiologist should not be expected

to function with blinders on. For example, suppose witnessed a hospital staff member choking a patient. What should be done? Nobody would argue with Dr. Sussman that under these circumstances "and epidemiologists should seek to change conditions then and there." However, in less dramatic and obvious circumstances, the impetus for change should be directed to those officials who bear the responsibility and line authority to rectify problems.

"Raising hell;" "reading the riot act; and” lowering the boom” are - Sacks con't on page 11

-Sacks cont'd from page 10 generally poor techniques of communication. Often such an approach is polarizing.

If an adversary role is created from a consultant being perceived as overly aggressive, the main points of the consultant’s thesis are lost in the ensuing battle of personalities. Issues become obscured as each party seeks to be “right.” Rather, the consultant should seek to convince through gentle persuasion, logical argument, and demonstration of strong evidence in support of the hypothesis and recommendations. The choice of intervention strategy should be geared to the urgency of the situation. It is well to bear in mind however, that the carrot often works better than the stick.

Two camps Dr. Sussman implies that epidemiologists dichotomize into two camps: the uninvolved attack rate calculators (“most CDC’ers") and the “hell raisers." I suggest that we are distributed along a continuous spectrum and the two camps he describes lie outside two standard deviations from the mean. Clustering about the mean are those epidemiologists whose findings are supported by data, and whose communications are tactful, objective, and still forceful.

Dr. Sussman suggests that epidemiologists are protected from not “being invited in” to investigate because where else would managers take their epidemic epidemic business?

The answer I fear, is nowhere. Most epidemiologists are aware of past outbreaks that were allowed to rage on because of ignorance, indifference,

coverups and publicity concerns. Let us not add fear of adversity to the litany of reasons that managers choose not to investigate problems.

While the adversary “hell-raising” approach may occasionally work in the short term (it did not work in Dr. Sussman’s case), it may lessen the likelihood that future problems(and opportunities to learn from them) will be investigated. I am not suggesting that an epidemiologist should refrain from forcefully stating the cases. I suggest that this be done dispassionately, and in a manner that allows management to be a partner and not an adversary. Farr’s “arguing fearlessly for recommended changes regardless of what vested interest may be involved" does not mean that the epidemiologist must shout to be heard.

“I suggest that we are distributed along a continuous spectrum..."

Jeffrey Jay Sacks, MD, MPH Published November 1982 ■

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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 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.

July 2021 July 5

http://bit.ly/2K4p3Dl

Short Course / Advanced Survival Analysis / University of Bristol / VIRTUAL July 6-7

http://bit.ly/2K4p3Dl

Short Course / Introduction to Research Governance / University of Bristol / VIRTUAL July 7-23 https://bit.ly/2RWT7iZ Summer Program / 12th Annual Summer Institute in Statistics and Modeling in Infectious Diseases (SISMID) / University of Washington / VIRTUAL

July 7-30 http://bit.ly/2LSdUmP Summer Program / 7th Annual Summer Institute in Statistics for Clinical & Epidemiological Research (SISCER) / University of Washington / VIRTUAL July 8-9 http://bit.ly/2K4p3Dl Short Course / Introduction to Diagnostic Research / University of Bristol / VIRTUAL July 9-12 https://bit.ly/2DnMCBW Conference / 30th European Congress of Clinical Microbiology & Infectious Diseases / ESCMID / Vienna, Austria July 12-14 https://bit.ly/2VOPv61 Conference / Inaugural ISPE Africa Section Conference / Multiple / Accra, Ghana July 12-15 http://bit.ly/2RB5xja Summer Program / 27th Annual RAND Summer Institute / RAND / Santa Monica, CA July 12-16 http://bit.ly/3mY8tSN Short Course / Exploring the Linkages Between Mental Well-Being & Physical Health Outcomes / University College London & Harvard University / London, England (may also be offered virtually or in a combination format - check back in early 2021 for an update) July 12-23 http://bit.ly/3mOlFtn Summer Program / 7th Annual Summer Institute in Statistics for Big Data (SISBID) / University of Washington / VIRTUAL July 12-31 https://bit.ly/2QnqkHv Summer Program / 56th Summer Session in Epidemiology / University of Michigan / VIRTUAL

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July 2021 continued Help complete the epi calendar for 2021 The events listed on the next page in blue have traditionally run in July 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 / IGES 2021 / International Genetic Epidemiology Society / http://bit.ly/2s9SgmP Conference / 7th International Conference on Public Health (ICOPH 2021) / Multiple / http://bit.ly/356q2In Summer Program / 3rd Manchester Digital Epi Summer School / Centre for Epi Versus Arthritis / http://bit.ly/3484U2W Short Course / Integrative Molecular Epidemiology / American Association for Cancer Research / http://bit.ly/2Psf4q3 Short Course / Statistical Methods for Mediation Analysis / University of Bristol / https://bit.ly/2UxLYaj Short Course / Analysis of Repeated Measures / University of Bristol / https://bit.ly/2DnMCBW Summer Program / Summer Institute of Advanced Epidemiology & Preventive Medicine / Tel Aviv University & a partner university / http://bit.ly/2WO6wOg Summer Program / 31st International Summer School of Epi at Ulm University / Ulm University / http://bit.ly/38Agng0

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

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