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At a critical and high-profile time for epidemiology, what challenges are ahead?

Introduction by Croakey: The World Congress of Epidemiology opened on 4 September with a short silence to remember more than 4.5 million people who have died from COVID-19 to date, with particular mention of epidemiologists and public health workers.

Hosted by the Australasian Epidemiological Association, the Congress this year is a virtual event, and began with a Welcome to Country from Wurundjeri Elder, Aunty Diane Kerr.

Also at the opening ceremony, President of the International Epidemiology Association, Professor Henrique Barros, reflected on how COVID-19 had provided a “critical moment” for epidemiology.

He contrasted the epidemiological tools used to combat the spread of COVID with approaches taken century ago when the 1918 influenza pandemic posed a similar threat to global health.

Clear messages from other keynotes and presentations included the need to celebrate the positive contribution epidemiology has played in worldwide efforts to combat COVID, while also applying a critical lens and learning from past mistakes to meet the challenges of COVID and other public health threats in the future.

Another strong theme was the need for epidemiology to be more effective in addressing health inequities, especially for First Nations people.

Below Jennifer Doggett reports for the Croakey Conference News Service on COVID-related presentations made at #WCepi2021 on 4 September. Bookmark our ongoing coverage here, and follow the conference Twitter list.


Jennifer Doggett writes:

Victoria’s Chief Health Officer, Professor Brett Sutton, has been at the heart of Australia’s COVID-19 response, and in his keynote address stressed the central role of epidemiology in informing Victoria’s public health response to the pandemic.

From the first alerts of a new disease coming out of Wuhan, signalling the emergence of a new infectious disease threat, through to the recent efforts to combat the Delta variant outbreak, Sutton described how he and his colleagues had relied on epidemiological data in their decision making.

“Epidemiology has informed our response all along, strategising, strengthening ongoing planning preparedness and prioritisation,” he said.

Sutton described how COVID posed new and pressing challenges to the Victorian Government and health system, requiring dynamic policy responses and innovative public health approaches.

He said that epidemiological data and evidence had been crucial in equipping government, health and social services with the agility and adaptiveness required to make decisions quickly in uncertain and stressful conditions.

Sutton also noted that one benefit of the pandemic has been greater community interest in public health and a deeper understanding and appreciation of how epidemiological data is used in government decision making.

He welcomed the ongoing involvement of public health and epidemiology experts in informing the government’s ongoing COVID response.

Data matters

The use of epidemiology data to identify the inequitable impact of COVID-19 on specific populations was a recurring theme of the presentations on the first day of the conference.

In a keynote address, Abigail Echo-Hawk, director of the Urban Indian Health Institute, reported epidemiological data which showed American Indians and Alaskan Natives were 3.5 times more likely to be infected with COVID than non-Hispanic whites and 1.8 times more likely to die from the disease.

She also identified key limitations in this epidemiological data due to the fact that only 23 US states captured 70% of race and ethnicity data on COVID.

“This under-reporting of indigenous people in the data can mean whether indigenous people live or die,” she said.

Echo-Hawke called on epidemiologists to push for systematic change and to ask why data on indigenous peoples is not being collected, arguing that this inhibits the ability of epidemiologists to do good science and to serve communities.

Epidemiology data from Australia presented at the conference also showed the disproportionate impact of COVID on communities under-served by health and social services.

Professor Catherine Bennett from Deakin University looked at data from Victoria, which demonstrated that COVID risk is associated with lower sociodemographic profiles, including suburbs with higher rates of renting and more financial strain. She also highlighted evidence showing an association between race, ethnicity and poorer COVID outcomes.

Case rates

Bennett outlined how this data highlighted challenges in the COVID response:

“Those with insecure work are disincentivised to get tested if they are concerned their work will be taken away if they take two weeks off… people who cannot work from home are over-represented in those who are infected.

“Essential workers are often casual workers working across multiple sites which not only increases the risk for these workers but makes it harder to track the exposure, slowing our outbreak response,” she said.

Bennett also cautioned against stigmatising communities experiencing higher rates of COVID:

“Being a well-connected community provides many advantages but can work against you in an outbreak setting. We must try not to overlay the findings on higher COVID risks with stigma at being from that community or ‘that part of town’.”

Adelle Mansour, from the University of Melbourne, presented her research into the development of a pilot tool constructed from a combination of six employment, housing and financial indicators that affect people’s capacity to remain in place and distance from others.

This tool – The Neighbourhood Employment and Housing Precarity (NEHP) Index – is intended to assist authorities in developing appropriate and equitable policies in response to the pandemic and future infectious disease outbreaks.

In a poster presentation, Professor Sanjay Rampal, from the University of Malaya, described how he used epidemiological techniques to obtain more accurate understanding of COVID transmission, a critical component in developing effective public health responses.

Dr Eli Sukarime, a Consultant Obstetrician and Gynaecologist, presented research on adherence to COVID protocols among healthcare workers at teaching hospital in Nigeria.

This study highlighted the need to focus on the health workforce as both potential vectors for transmission of COVID and crucial in the treatment of people affected by this disease.

 Lessons

The lessons learned from COVID stem both from identifying successful applications of epidemiology during the pandemic and also from recognising the failures and challenges.

Sutton described how epidemiological data used to combat COVID is informing Victoria’s response to other health threats, such as the development of a syndrome surveillance tool to identify rare events like thunderstorm asthma.

President of the International Epidemiology Association, Professor Henrique Barros, highlighted the need to build on epidemiology’s “time in the sun” to build an epidemiological workforce for the future, including giving the new generation of epidemiologists time and space to grow their influence.

He also emphasised the need for epidemiology to focus more on equity.

If we want a fair society and healthy world we need to understand social inequalities and make epidemiology central,” he said.

Echo-Hawke stressed the need for epidemiologists to recognise their own implicit biases and to identify both strengths and deficits in communities experiencing inequities in health.

“Come to us because you know we have the answers not because you think we have a problem,” she said.

Key epidemiological data challenges identified by Echo-Hawke include the need to both aggregate and disaggregate data and to develop skills in dealing with small populations data, often required in research involving Indigenous peoples.

She also emphasised the importance of respecting Indigenous data sovereignty and including Indigenous peoples in data collection and analysis, in order to overcome system biases.

“In an Indigenous community to each person a story is told comes a responsibility. I have told you a story today – what changes will you make in your practice, organisation or government to ensure inclusion,” she said.

Communications

A roundtable session on communicating epidemiology to the public had a number of important lessons for future engagement by epidemiologists in public health responses.

Session chair, David White, started the session by asking participants to reflect on what they have learned over the course of the pandemic about communicating with the public.

One common theme throughout the discussion was the need for a better partnership with the media.

Michaela Riddell identified the media ecosystem as one barrier to effective communication and described how the media look for soundbites and do not provide space for nuanced discussion or extended explanations.

She urged the group to think about other avenues of communicating with the public in order to bypass traditional gatekeepers.

The tension between keeping things simple and getting things right was raised by Rosemary Korda who highlighted the challenges of communicating in the complex and dynamic environment in the early days of the pandemic. “It’s the art not just the science,” she said.

A delegate from Indonesia stressed the importance of considering factors like education, age, race and in communicating on COVID. Her overarching advice is to ‘speak using their language’.

Other participants commented on the importance of media training for epidemiologists and epidemiology training for journalists – highlighting what both sides can learn from each other.

Policy making

The role of epidemiology in informing Australia’s move into a post-COVID era was discussed in a session which brought together a panel of policy experts and epidemiologists.

Panellists had diverse views on how to move forward with urgency in a rapidly changing and uncertain environment but all agreed on the need to balance the benefits of opening with the potential harms of greater infections, hospitalizations, and deaths.

Political scientist, Professor Marc Stears reflected on the political use of evidence during the pandemic and contrasted the approach taken by epidemiologists and political scientists in informing policies.

 

Bennett drew a distinction between the role of epidemiologists whose advice can inform policy with that of politicians who make policy.

“The interpretation of modelling to create policies like the curfew is very complex. The wish to reduce spread and assumptions about human behaviours [usually around breaking rules] is a huge challenge. How do we balance trade-off individual and human rights?” she asked.

Bennett supported the need to contextualise policy recommendations within the political context, highlighting the many steps between epidemiological modelling and policymaking.

She urged epidemiologists to avoid defensiveness and learn from experiences during COVID, both in Australia and internationally.

Professor Tony Blakely from the University of Melbourne, discussed the role of epidemiology in Australia’s COVID response arguing that not many epidemiologists actually have the ear of the Government.

He said that epidemiologists had been politically scapegoated during the COVID response and it was important to make clear that epidemiology was only one factor governments took into account when developing COVID responses, along with other political and social issues.

As evidence, he cited policies such as the closure of our borders with China, which were not supported by epidemiological evidence.

The role of epidemiology in informing vaccination and other measures required to move to a post-COVID environment was raised in a number of presentations.

Dr Jesse Whitehead discussed vaccine access for priority populations in Aotearoa New Zealand (Māori, Pasifika, aged, comorbid, lower SES and non-white). He described how these populations are often concentrated in rural and remote areas and highlighted the importance of developing connections between communities and policy makers for an equitable program delivery. The key takeaway message was that current vaccine efforts are upholding privilege and we need to proactively plan for equity.

Inequalities in vaccination coverage in South Asia were discussed by Dinesh Dharel who emphasised the critical role of maternal education (more significant than level of wealth) in determining vaccine status across the region.

Health literacy

Dr David Muscatello from the University of New South Wales discussed how the pandemic has seen the ascendancy of disease modelling which is now driving advice to both national and state governments.

While acknowledging the benefits of this modelling, Muscatello also noted its limitations, including a lack of nuance for the dynamics of socioeconomic status and inequities affecting the impact of COVID on communities.

He argued that epidemiology can play an important role in identifying gaps in the vaccination rollout and emphasised the central importance of equity in Australia’s move away from an elimination strategy

Muscatello identified health literacy as a large missing piece in the puzzle, saying that most media commentary on COVID was far too complex for many in the community.

Some less well known impacts of COVID were also addressed during the day, including in a poster presentation on hearing loss before and after COVID-19 pandemic by Kaori Daimaru from the University of Tsukuba in Japan.

She described how COVID has dramatically changed people’s lifestyle, including increasing the use of earphones which her research found was associated with a higher rate of hearing loss in 2020, compared to 2019.

From Twitter

Croakey thanks and acknowledges those sharing the #WCepi2021 news by Twitter. By 10pm on 5 September, 597 Twitter accounts had sent 4,152 tweets, creating almost 33 million Twitter impressions, according to Symplur analytics.

Jennifer Doggett will cover other presentations from September 4 in our next conference report.



See here for more information on Croakey’s conference news service.

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