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Social Epidemiologist Interviewed in Epidemiology Pinpoints His Most Influential---And His Least Appreciated---Publications.

“I really am only interested in work that will make the world a different place.” That also  means looking for pivotal issues to investigate and not doing “ordinary research”, according to Leonard Syme, University of California Berkeley epidemiologist speaking out in an interview in the latest issue of Epidemiology.

Syme, described as one of progenitors of the field of social epidemiology, was inspired early in his career by the findings of sociologist Emile Durkheim indicating the  undeniable influence of underlying social factors in causing suicide in different populations. Syme has devoted his career to elucidating these “causes of the causes”.

He told the interviewer, the University of British Columbia’s W Thomas Boyce, he considers “Rethinking Disease: Where Do We Go From Here”, published in the Annals of Epidemiology in 1996, as his most influential paper. In it he called for a greater focus on defining diseases by what social and environmental causes increase susceptibilities to them, much as infectious diseases are referred to as water-borne or food-borne since these broad, fundamental causes are responsible for multiple different diseases.

In his career, Syme has also sought to change the way epidemiologists seek to use data to intervene in population health by calling for less top down messaging about risk factors to a more participatory approach which involves more intensively the persons affected by the diseases being targeted. Syme called his paper "Social Determinants of Health: The Community As An Empowered Partner” his most underappreciated paper. It sought to point out the need for researchers to become experts in working with the people who are the intended recipients of  interventions. “ And that message I don’t think has gotten through,” according to Syme.

New HIV Infections Down 21% And Agencies Are Talking About Ending The AIDS Epidemic

An estimated 34 million people are now living with HIV, an increase of 17% over the last decade, according to UNAIDS. Why? The number of persons dying from AIDS in 2010 has fallen to 1.8 million from a peak of 2.2 million in the mid-2000’s, and an estimated 2.5 million deaths have been averted in middle to low income countries since 1995 due to the introduction of antiretroviral therapy.

There were 2.7 million new infections in 2010. This was 15% less than in 2001 and 21% below the number of new infections at the peak of the epidemic in 1997. About 1.2 million of the persons living with HIV are in the USA.

There appears to be added momentum to World AIDS Day on December 1 this year because the tools to halt AIDS are now in hand. According to UNAIDS, “We are on the verge of a significant breakthrough in the AIDS response. The vision of a world with zero new HIV infections, zero discrimination, and zero AIDS-related deaths has captured the imagination…Just a few years ago, talking about ending the AIDS epidemic in the near term seemed impossible, but science, political support, and community responses are starting to deliver clear and tangible results.

Epidemiologist Uses Animated Clay Cartoon To Help Translate Data Into Practice

An editorial in the November 19 issue of The Lancet has brought attention to an animated clay cartoon (claymation) produced by Ian Roberts, an epidemiologist at the Clinical Trials Unit of the London School of Hygiene and Tropical Medicine. What makes the animation interesting for epidemiologists is that the video was created to help translate into practice the positive results of a clinical trial of tranexamic acid for bleeding trauma patients.  Roberts was interested in using social media to deliver the message about the life-saving potential of the drug when survey data revealed that the drug is being underutilized despite the compelling RCT results about the drug’s benefits were compelling. In the animation, according to Lancet, a clay trauma victim bleeding profusely from the abdomen happily avoids bleeding to death by means of a timely injection of the drug. The goal is for the YouTube video to go viral and make an impact on treatment for trauma victims. According to one report, Robert estimates that full use of the drug could save 140,000 lives worldwide each year.

Watch the claymation at:

Canadians Recommend Against Routine Breast Cancer Screening for Women 40-49 Years of Age

The Canadian Task Force on Preventive Health Care now recommends against routinely screening for breast cancer for women aged 40-49, but does recommend screening every 2-3 years for women 50-69 and 70-74 (Canadian Medical Association Journal, November 22, 2011) The estimated number needed to screen (NNS) to prevent one death from breast cancer in the youngest age group is 2108 for screening conducted once every 2-3 years for about 11 years. According to the recommendations, preventing this one death would also result in about 690 women having a false positive mammogram, leading to additional testing and to an estimated 75 women having an unnecessary biopsy. Estimates of overdiagnosis of breast cancer were not available for this age group but in women 39 years and older, the group estimates 5 women will have an unnecessary lumpectomy or mastectomy for every 1000 women screened. The Task Force judgment is that “this ratio of potential benefit to harm does not justify routine screening in women 40-49 years of age". The Task Force acknowledged that women who place a higher value on a small reduction in mortality and are less concerned about undesirable consequences are likely to choose screening.

Large Danish Cohort Study Of Mobile Phone Use Finds No Association With Brain Cancer
Case Closed? Not Yet Say Researchers

It is impressive to read about the type of epidemiological studies which the Danes can carry out. The latest example is a nationwide cohort study of over 350,000 residents born after 1925 and divided into subscribers and non-subscribers of cell phones. The cohort accrued almost 4 million person years of followup in the period 1990-2007. The risk was close to 1.0 for both men and women and no there was no evidence of a dose response relationship by duration of exposure or by anatomical location of the tumor nearby where the handset is usually held.

The results were not as subject to the biases associated with previous studies,but nevertheless, the authors concluded conservatively that additional studies with longer followup and with large populations with minimal exposure and selection bias “are warranted.” It looks as if it will be years away before researchers are willing to give cell phones a clean bill of health, but for now the preponderance of evidence is negative. If the goal of the research is to establish “safety” as one epidemiologist has said, one can wonder what the definition of that will require and whether agreement can ever be reached that “safety” has been proven since it requires proving a negative.

One interesting comment came from a physician on Long Island who noted that the biggest cell phone risk is using it while driving to speak, text, or check emails. That’s worth acting on.  

Pregnant Women With 2009 H1N1 Infection Have Much Poorer Pregnancy Outcomes

A cohort of 256 hospitalized pregnant women with confirmed H1N1 infection in late 2009 and early 2010 and 1220 pregnant woman controls were followed-up by researchers at Oxford University to ascertain pregnancy outcomes. Results reported in BMJ showed that perinatal mortality among infected women was 39 per 1,000 live births versus 7 in controls, mostly due to an increase in stillbirths among the cases. These findings reinforce those which call for vaccination of pregnant women, not only for the sake of the mother, but also for the sake of the fetus.   


It’s Not Just Prostate Cancer Screening Coming Under Fire But Breast Cancer Screening As Well

The recent guidelines on prostate cancer screening from the US Preventive Services Task Force call for discouraging the use of PSA screening because reviewers could not adequately demonstrate a net benefit of screening, or that the benefits in terms of lives saved outweighed the harms caused by treatment. The prevalence of screening is high in the US and many men and doctors believe their lives have been saved by the test. Now mammography screening, which caused a controversy two years ago when the Task Force withdrew its recommendation for routine screening, has come under close scrutiny by a group of investigators from Dartmouth.

They report in the Archives of Internal Medicine that, as with men surviving prostate cancer, most women with screen detected breast cancer have not had their lives saved by screening. The researchers estimated that the probability of having a life saved for breast cancer was always less than 25% under the conditions of their study, and in all likelihood was probably well below 10%.  It is not clear how the authors expect women to use this information. They claim it should “put cancer survivor stories in their proper context”. That seems to translate into don’t believe most of what you hear!    

Public Broadcasting System Examines The Health Effects Of Income Inequality By Talking With Epidemiologists

Because of the Occupy Wall Street movement, everyone’s awareness of income inequality has been heightened recently. Also, a new report from the nonpartisan Congressional Budget Office shows just how bad the situation has become in the United States with the wealthiest segment experiencing triple digit increases (275%) in income compared to more meager increases ranging from 18-75% in other income classes. An interview with British epidemiologists Michael Marmot and Richard Wilkinson by the Public Broadcasting Service helps to understand the health consequences of these disparities. Below are excerpts from the interview in late September.

Wilkinson: Societies with bigger income differences between rich and poor do worse on a whole range of measures. They have worse health. They have more violence. They have more drug problems. Standards of child well-being are worse.

Wilkinson: Perhaps two or three times the mental illness as the more equal countries. Because, in a more unequal society, there is more status competition. We judge each other more by status, and we feel more judged.

Marmot: Health and disease are the good and bad effects of where you are in the hierarchy, mediated by the effects of chronic stress.

Wilkinson: Money becomes more important because it says what your’re worth. So people in more unequal societies work longer hours, much longer hours, are more likely to get into debt. They save less of their income.

Wilkinson: We sometimes say, if you want to live the American dream, you should move to Finland or Denmark, which have much higher social mobility.

New Movie “Contagion” Receives High Marks From Epidemiologists

“Contagion”, a new thriller described by one commentator as an ‘Oh God Oh God We’re All Going To Die’ movie, is receiving positive reactions from epidemiologists both for its realism and its entertainment value. The story involves the spread of a new emerging ME-1 virus from bats to humans which spreads quickly around the world and kills many of those infected.

The NIH’s Anthony Fauci, director of the Allergy and Infectious Diseases Institute told CIDRAP news “It’s one of the most accurate movies I have seen on infectious disease outbreaks of any type…It did depict what would be an extremely rare possibility of a worst-case scenario…Audiences will look at this and say, ’Could it happen?’ Certainly it could happen, but it’s extremely unlikely to happen.”

The film’s chief science advisor was Columbia University’s Ian Lipkin who is John Snow Professor of Epidemiology and Director of the Center for Infection and Immunity in the School of Public Health. In an interview in Wired Science, Lipkin said the fictional ME-1 virus is a paramyxovirus that infects the lungs and brain and was modeled on Nipah virus. “We considered casting other viruses, he said, “but this was the best.”

Experts from CDC were consulted about the story and some scenes were actually filmed at CDC in Atlanta. In addition to being dubbed accurate and entertaining, epidemiologists are seeing other benefits because the film educates the public about a possible threat and helps make the case for a strong, well-funded public health system. A New York Times reviewer called the movie “a giant in-your-face public service advertisement for the world’s beleaguered health agencies.”

Forbes Article Questions Scientific Soundness of IARC Conclusion On Cell Phones

A recent provocative article in Forbes online magazine entitled “Behind the World Health Organization’s ‘Cancerous’ Pronouncement on Cell Phones’ has called into question the scientific soundness of the recent IARC report which called radiation frequency from cell phones a “possible carcinogen”. The reason for the critique by Geoffrey Kabat, a cancer epidemiologist at Albert Einstein and author of “Hyping Health Risks: Environmental Hazards in Daily Life and the Science of Epidemiology”, is his conclusion and that of other epidemiologists that the bulk of the evidence shows no increased risk.

If so, how could the committee conclude that cell phones are a possible carcinogen? Kabat’s view is that non-science related factors such as the inclusion of a Swedish investigator on the committee--a vocal promoter of his finding that phone use is associated with an increased risk of glioma--gave excessive weight to this limited evidence considered potentially very flawed by some epidemiologists familiar with the study.

Another explanation is contained in the remarks of a committee member who told Kabat that the IARC “wanted to send a message” that we still have limited information about the possible effects of cell phones, particularly among children, and that a clean bill of health for cell phones is premature. That seems hard to argue with from a public health perspective.

Actually, Kabat’s objection appears not to be with the IARC’s conclusion, since indeed the data on cell phone risk are still limited and monitoring has not been carried out long enough to be fully convinced about the safety, but with the IARC’s terminology. He calls the term “possible carcinogen” as it applies to cell phones an “ambiguous label” and “unfortunate” because it means one thing to scientists working for IARC and something different to the general public. Thus, it seems the IARC report is problemmatic more from a communication than a scientific perspective.

Kabat warns that the label chosen—possible carcinogen-- is likely to be misused in the future to make it seem that we have more of a risk than the evidence justifies. He reminds readers that we need to rely on scientists to use clear language to tell us what things are worth worrying about.

To read the Forbes article, visit:


9/11 Tenth Year Remembrance Provides Opportunity To Highlight Public Health’s Role

The ten year anniversary of the events of 9/11 this month have been the occasion for remembrance ceremonies, but also for preparation of a report reminding Americans of the importance of public health preparedness. Prepared by the Trust for America’s Health (TFAH) and entitled “Remembering 9/11 and Anthrax: Public Health’s Vital Role in National Defense”, the report includes 30 first-hand, on the ground accounts of public health professionals who were directly involved in the response to 9/11 and the anthrax tragedies.

Additionally, the report inventories the significant improvements in preparedness since 9/11. According to TFAH’s Jeff Levi, “Public health had not traditionally been considered among the first responders, but ten years ago, that changed forever.”

The report also catalogues the list of ongoing gaps in preparedness and states that “the top lesson we learn and relearn in each tragedy and emergency is that being prepared means we must sustain enough resources and vigilance so we can prevent what we can and respond when we have to…the current economic climate and budget cuts at federal, state, and local level mean that the progress made over the past decade could be lost.”

Perhaps public reaction to the new movie “Contagion” will help reverse the complacency which is at the heart of failure to achieve full public health preparedness.

To access the full report, visit

Times Reports Death of Bruce Dan Who Helped Link Tampons and Toxic Shock Syndrome

Bruce Dan, a medical television personality, who helped link tampons and toxic shock syndrome while working as an EIS Officer at the CDC, died in Baltimore on September 6 at age 64, according to a recent obituary in the NY Times. The obituary details the history of the investigations in 1980 which found that a large group of cases occurred in menstruating women using tampons. One brand of tampons, Rely, carried a higher risk because its lubricant increased the level of toxins in the bacterium. According to the Times, Rely was removed from the market and other brands were redesigned to help prevent bacterial growth. In 1981, Dan and others received the Langmuir Prize for epidemic investigation and a US Public Health Service Commendation Medal. To read the full obituary, visit the Times online at:


Facebook Used In An Outbreak Investigation

The recent statement in Science Times was attention-grabbing---“Social media…are changing the way epidemiologists discover and track the spread of disease.” Using an example from a Los Angeles outbreak of a flu-like illness with chest pains, chills, and fever, the Times reported that attendees at a Playboy Mansion fund raising party posted their illness information on Facebook and had arrived at their own diagnosis—legionellosis-- by the time a CDC epidemiologist arrived.

These results are all the more astonishing since the attendees at the party were all dispersed around the world by the time they got sick. While the Times says CDC will not comment yet on the outbreak, legionella bacteria were reportedly isolated from a hot tub. CDC’s deputy director for information science told the Times, “we can’t turn the clock back…it just makes perfect sense to adapt the speed and flexibility of social networking to disease surveillance.”

Another example of growing use of social media is the fact that the CDC epidemiologist used Facebook to document the symptoms, recommend diagnostic tests to followers on the Facebook page, and recruited study subjects to fill out CDC’s online questionnaire. Other uses of online information to assist epidemiologists include investigating search terms to identify early cases of flu and a new project to track dengue. However, none of the examples are quite as startling as the one related to the Playboy Mansion investigation. Stay tuned to learn if CDC eventually confirms legionnella or some other agent as the cause of the outbreak.

What Is A Computational Epidemiologist?

The recent article in Science Times described above referred to an assistant professor of pediatrics at Harvard as a leader among self-described “computational epidemiologists”. Since the term was unfamiliar to us and we are always on the lookout for new applications of epidemiology, we made an inquiry. Wikipedia has a short three sentence definition as “a multi-disciplinary field utilizing techniques from computer science, mathematics, geographic information science, and public health to develop tools and models to aid epidemiologists in their study of the spread of diseases. It differs from bioinformatics in that it is centered more around studying how diseases spread, and not the actual disease itself.”

Another unfamiliar term in the article was “crowdsourced epidemiology”. According to Wikipedia, crowdsourcing is “the act of outsourcing tasks, traditionally performed by an employee or contractor to an undefined, large group of people or community (a "crowd"), through an open call.” In epidemiology, one application of this is the mobile application Outbreaks Near Me which has been downloaded by thousands of persons and through which persons have reported outbreaks. Questions arise as to whether or not this type outbreak detection has any advantages over the more traditional approaches because the reporters may not be representative and can skew the information. This limitation applies to many other potential uses of  “public science”.

Epidemiologists Seek To Put Numbers Behind The Deaths Caused By Social Factors

“When you can measure what you are speaking about, and express it in numbers, you know something about it. But when you cannot, your knowledge is of a meager and unsatisfactory kind.” This quote attributed to Lord Kelvin seems to have been taken to heart by Columbia University epidemiologist Sandro Galea and colleagues. They surveyed the literature between 1980 and 2007 to identify studies with estimates about the link between social factors and adult all-cause mortality, calculated summary relative risk estimates, obtained population level estimates of the prevalence of each factor, and calculated the population attributable fraction for each factor. They found that approximately 245K deaths in 2000 attributable to low education, 176K to racial segregation, 162K to low social support, 133K to individual level poverty, 119K to income inequality, and 39K to area level poverty.

Galea was quoted in the NY Times saying “If you say that 193,000 deaths are due to heart attack, then heart attack matters. If you say 300,000 deaths are due to obesity, then obesity matters. Well, if 291,000 deaths are due to poverty and income inequality, then those things matter too.” In their paper, Galea and colleagues conclude that “these findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations.”  Co-authors in the AJPH June issue were Melissa Tracy, Katherine Hoggatt, Charles DiMaggio, and Adam Karpati.

European E Coli Outbreak Traced Back To Lot of Fenugreek Seeds Imported From Egypt

The outbreak of shiga-toxin producing E.coli (STEC) in May and June 2011 in Europe has now totaled 265 cases with Hemolytic Uremic Syndrome (HUS) and 3151 non-HUS cases and there have been 42 deaths, all but one in Germany. A report from the European Food Safety Authority in early July implicated a particular lot of fenugreek seeds imported from Egypt in December 2009 [].

Several seed types (alfalfa, fenugreek, lentils, adzuki beans, and radish) were suspected in Germany, however, a separate cluster of cases occurring in France in June 2011 gave investigators an important clue. While three types of sprouting seeds were implicated in France (fenugreek, mustard, and rocket), only fenugreek seeds were common to both outbreaks. They became the focus of the investigation and were traced back to Egypt. Results from the microbiological tests carried out on seeds have been negative, possibly due to the limitations of the tests used or the sampling plan used to select the seeds for testing.

The hypothesis is that the fenugreek seeds became contaminated with STEC 0104:H4, the implicated agent, at some point prior to leaving the Egyptian importer. According to the report, this reflects a production or distribution process which allowed contamination of fecal material of human or animal origin, possibly at the farm level but still not established.

Sweet and Vicious—The Case Against Sugar

The science writer Gary Taubes was being his provocative self as he has been in the past about the field of epidemiology and about dietary components and chronic diseases. The occasion for his latest report came as the cover story about sugar for a health and wellness issue of the New York Times Sunday magazine in April.

Taubes has been persuaded that sugar is toxic by the evidence and arguments made principally by Robert Lustig of the University of California San Francisco School of Medicine. The mechanism envisaged is for high levels of sugar consumption to cause fat to accumulate in the liver, followed by insulin resistance and metabolic syndrome which in turn can lead to heart disease, diabetes, and obesity. According to Taubes, sugar and high fructose corn syrup “…could be toxic, but they take years to do their damage. It doesn’t happen overnight. Until long term studies are done, we won’t know for sure.” And some cancers such as breast cancer may also be one consequence of insulin resistance and metabolic syndrome.

Taubes confesses in the article that sugar scares him. “I’d like to eat it in moderation, I’d certainly like my two sons to be able to eat it in moderation, to not overconsume it, but I don’t actually know what that means, and I’ve been reporting on this subject and studying it for more than a decade…Officially I’m not supposed to worry because the evidence isn’t conclusive, but I do.”

Cell Phones and Cancer—A Journalist’s Highly Regarded Review of the Evidence

In a review article of cell phones and brain cancer which an epidemiology colleague has called a model of balanced investigation and presentation, Columbia University’s Siddhartha Mukherjee, has concluded that “…as of now, the evidence remains far from convincing.” He bases this conclusion on the fact that casting a wide-net to incriminate cell phones “has yet to find solid proof of risk for cellphone radiation. And while more definitive studies are needed, he raises the possibility that even these studies might not give us the degree of proof we want.

 In the article, he seeks to remind those who may be disappointed by the failure to incriminate cell phones that we need standards by which not only to rule in carcinogens, but also to rule them out. Otherwise, he says, the effect is like crying wolf too often. People get numb to your warnings. Thus, failing to rule potential carcinogens in or out leads to a degeneration of our scientific language about cancer.

This Time Harvard Study Says Coffee May Reduce The Risk of Cancer

Senior epidemiologists easily remember the study reported in the NEJM on March 12, 1981 by investigators at Harvard about a possible relationship between coffee and pancreatic cancer. The report is infamous in the annals of epidemiology because of the publicity it received and because the association is often referred to by epidemiologists as the example of a false positive association. At the time, the lead investigator and well known epidemiologist Brian MacMahon was quoted as saying that he had stopped drinking coffee.

Now it is ironic that another report should come from Harvard, this time pointing to the potential benefits of coffee in protecting against the most lethal or advanced forms of prostate cancer. Investigators studied 47,911 men in the Health Professionals Follow Up Study who reported their coffee consumption patterns every four years between 1986 and 2008. Over this period, 5,035 cases of prostate cancer were found, including 642 that were lethal. In the Harvard study, consuming six or more cups daily produced an 18% lower risk of any form of prostate cancer and a 60% lower risk of developing lethal prostate cancer. The risk reductions were found with either regular or decaffeinated coffee.

The authors did not go out on a limb to recommend coffee drinking as a cancer preventive measure at this point, stating “it is premature to recommend that men increase their coffee intake to reduce advance prostate cancer risk based on this single study. However, our findings are potentially important given the lack of identified modifiable risk factors for advanced prostate cancer.”

CDC Tongue In Cheek Blog Post Gets Wide Circulation

You just never know. CDC routinely posts information on its public health preparedness blog and gets a few thousand hits. Then it posts one about preparing for a “zombie apocalypse” and the servers crash because so many people want to read about the upcoming disaster. In the process, hopefully they learn what it takes to be prepared for a public disaster and CDC gets its message, or at least part of it, across to a wide range of Americans. Go figure. Perhaps epidemiologists and other scientists with a message to convey that is not getting through, say on climate change or autism and vaccines could use this approach. Maybe a tongue in cheek post about how Gravity Is Not A Law After All or How Evolution Has Not Really Happened.  To read the original “Preparedness 101: Zombie Apocalypse” visit

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