Develop an internal memorandum, Create a workflow analysis flow chart

Toward a New Strategic Public Health Science for Policy, Practice, Impact, and Health Equity Rebecca Bunnell, PhD, MEd, Juliet Ryan, MPH, Charlotte Kent, PhD, and the CDC Office of Science and CDC Excellence in Science Committee

See also Brownson, p. 1389.

The COVID-19 pandemic and its social and health impact have underscored the need for a new strategic

science agenda for public health. To optimize public health impact, high-quality strategic science addresses

scientific gaps that inform policy and guide practice.

At least 6 scientific gaps emerge from the US experience with COVID-19: health equity science, data science

and modernization, communication science, policy analysis and translation, scientific collaboration, and

climate science. Addressing these areas within a strategic public health science agenda will accelerate

achievement of public health goals.

Public health leadership and scientists have an unprecedented opportunity to use strategic science to

guide a new era of improved and equitable public health. (Am J Public Health. 2021;111(8):1489–1496.

https://doi.org/10.2105/AJPH.2021.306355)

COVID-19 has exposed majorunmet needs in our nation’s public health system related to workforce,

diagnostics, preparedness, health dis-

parities, information systems, and

response capacity. While there have

been numerous calls for creating and

sustaining a robust public health infra-

structure and for prioritizing science,

antiscience sentiments have also been

widespread. Without a thoughtful,

strategic approach to scientific

research; rigorous evaluation of pro-

grams; and development of evidence-

based public health policy and com-

munication strategies, the United

States will be underprepared again

when the next pandemic occurs.

Ensuring impactful science as the bed-

rock for decision-making will set a

sound foundation for the future, and

lessons from COVID-19 can provide

direction for a strategic approach to

public health science.1

Public health has a mandate to

reduce morbidity and mortality and

advance health equity at the popula-

tion level. Metrics and frameworks

used to rank the impact and value of

public health science vary, often

reflecting stakeholder perspectives.

They frequently include a focus on

tangible health benefits, concern about

return on investment, interest in spe-

cific diseases, or prioritization of bib-

liometrics and scientometrics.2,3 Ret-

rospective metrics alone are

insufficient to guide strategic science;

effective action requires a prospective

approach. We believe strategic science

begins with a public health goal in mind,

systematically identifies and then

builds an evidence base to inform

practice and policy, and ultimately

results in improvement in health and

equity outcomes. To optimize public

health impact, high-quality strategic

science addresses scientific gaps that

inform policy and guide practice.

A prioritized strategic science agenda

can help guide use of limited public

health scientific resources to fill the evi-

dence gaps that will have the largest

impact on population health. Many

examples of the impact of strategic sci-

ence exist,4 ranging from counterbio-

terrorism efforts informed by the small-

pox research agenda,5 smoke-free

policies that protect millions based on

research documenting adverse effects

of second-hand smoke exposure,6

increased vaccine coverage following

implementation research, coordinated

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evidence-based actions to reduce anti-

microbial resistance informed by sur-

veillance,7 and millions of lives saved by

HIV antiretroviral therapy resulting from

applied research on effective delivery

strategies. A strategic pursuit of public

health science that provides direction,

has delineated measurable goals, and

provides opportunities for stakeholders

and affected communities to engage is

needed more than ever. Developing and

implementing an effective strategy is

crucial for a new public health era.

The COVID-19 pandemic has illumi-

nated at least 6 key themes that are

central to a science strategy for improv-

ing public health: health equity science;

data science and modernization; com-

munication science; policy analysis and

translation; scientific, including labora-

tory, collaboration; and climate science.

With a US domestic focus, for each of

these 6 themes, we first summarize

related COVID-19 lessons. Second, we

discuss their implications to help inform

a strategic public health science agenda

for a new era (Box 1).

HEALTH EQUITY SCIENCE

Structural racism, long-standing injusti-

ces, and neglect of factors that cause

health inequities in the United States

have worsened the consequences of the

COVID-19 pandemic and resulted in

substantial disparities in COVID-19

incidence, hospitalization, and mortality.

Social determinants of health (SDOH)

andvitalconditions such as employment

settings lacking employee protections

and insecure or crowded housing have

impeded the use of mitigation measures

like social distancing and mask wearing.

These factors contributed to 1.4- to 1.8-

times-higher COVID-19 incidence, 2- to

3-times-higher hospitalization, and 3- to

5-times-higher mortality rates among

Black and Hispanic/Latino persons

compared with White persons.8 In addi-

tion to elevated environmental expo-

sure risk, racial/ethnic minority popula-

tions have less access to health care and

higher prevalence of uncontrolled

chronic lung, heart, kidney, liver, and

metabolic conditions associated with

more severe COVID-19 outcomes.9 Race

and ethnicity data have been incom-

plete, particularly in the beginning of the

epidemic, and SDOH data were not

widely leveraged, leaving the effects of

structural racism, environmental injus-

tice, and other socioeconomic factors

largely unexplored. In addition, adverse

impacts of the pandemic on employ-

ment, education, and other determi-

nants of health could widen future dis-

parities as well because Black, Hispanic/

Latino, older, rural, and underinsured

populations were more likely to experi-

ence unemployment and education

setbacks.10,11

Future strategic scientific work can

advance health equity by both building

on existing recommendations and

identifying new effective program and

policy interventions. Rigorous evalua-

tions of clinical, community, environ-

mental, and policy interventions that link

social determinants with health out-

comes and assess impact on health

inequities are essential.12 To expand the

evidence base, evaluation of real-world

impact and the effect of interlocking

contextual systems will be important to

supplement experimental efficacy stud-

ies.12 Expanding use of validated meth-

ods to document SDOH and assess

social and environmental factors will be

fundamental to this work.13 This work

can also elucidate how failure to address

health disparities leads to less-effective

preparedness and how health dispar-

ities can be exacerbated during a crisis.

Research is needed to identify ways in

which better data from modernization

and innovation can be used to acceler-

ate health equity.14 Given how SDOH,

structural racism, and health disparities

contributed to the impact of this pan-

demic, implementation science should

inform preparedness approaches that

recognize health equity as a core pillar of

future pandemic preparedness efforts.

DATA SCIENCE AND MODERNIZATION

Existing surveillance and data systems

have proven inadequate for COVID-19

response efforts. Public health data

systems have been historically under-

supported and were unable to acquire,

share, and transmit data efficiently. The

lack of systematic data collection and

automated linkages between

laboratory-derived data, clinical data,

andcase investigationdata hasimpeded

COVID-19 response speed. Outdated

policies and regulatory processes inhibit

data collection and sharing at local,

state, national, and international levels.

Interconnectivity across a vast array of

public–private sector systems in the

United States has been nascent, slowing

utilization of electronic health records in

response efforts. While contact tracing

can be an important public health tool to

interrupt disease transmission, its

application for COVID-19, particularly in

the initial months of the pandemic and

during spike periods, was largely inade-

quate. Data science could have greatly

improved contact-tracing efforts by

providing real-time information to those

exposed to reduce transmission. Finally,

the public health workforce has had

limited expertise and access to new

tools, policies, and approaches to data

visualization, methods, and analytics

including epidemiological modeling and

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BOX 1— COVID-19 Lessons and Implications for Strategic Public Health Science

Themes COVID-19 Lessons Public Health Science Opportunities

Health equity science � COVID-19 magnified and widened health disparities and other inequities.

� Incomplete data on race, ethnicity, and SDOH limited some analyses.

� Race/ethnicity interacted with causal SDOH factors and historical inequities.

� Historic neglect of factors that cause health disparities resulted in worse pandemic outcomes.

� Assess how addressing health disparities is part of pandemic preparedness.

� Document SDOH, including how they intersect to magnify risk.

� Build evidence on intervention effectiveness. � Generate health equity evidence needed by policymakers. � Research how data modernization and innovation can

accelerate health equity.

Data science and modernization

� Public health data systems were unable to acquire, share, and transmit data efficiently.

� Lack of systematic linkages among laboratory, clinical, and case investigation data impeded response speed.

� Outdated policies and regulatory frameworks inhibited data sharing at local, state, national, and international levels.

� Public health workforce expertise was insufficient for data linkages and new analytic methods.

� Public- and private-sector partnerships were nascent, slowing progress.

� Accelerate modernization to make public health science current.

� Expand methods for use of multisectoral data sources, including environmental and climate, community SDOH, geospatial, genomic, and biomarker data.

� Evaluate new surveillance and outbreak signal approaches. � Equip public health workforce with data science, genomics,

informatics, and analytic skills. � Provide scientific leadership using public health data.

Communication science

� A COVID-19 “infodemic” occurred together with more than 90 million Facebook misinformation warnings

� Misinformation and disinformation undermined public health messaging and response efforts.

� Public trust in scientific integrity was undermined during COVID-19.

� Evaluate approaches to counter misinformation, such as engaging online influencers.

� Expand communication science; assess impact of new technologies and social media.

� Strengthen communication strategy as part of research planning.

� Evaluate effective methods to amplify research dissemination.

� Accelerate pace of science dissemination. Policy analysis and translation

� Need for universal access to free testing, treatment, and vaccination for COVID-19 was evident.

� COVID-19 made intersection of health and other sectors visible, raising plethora of policy issues (e.g., employment, housing, transportation).

� Policy barriers hindered consistent mitigation approaches across jurisdictions, (e.g., mask, restaurant, and business opening policies).

� Clear, consistent messaging was needed across all levels of policymakers.

� COVID-19’s postacute health effects (cardiovascular, pulmonary, mental health, and neurologic) raised policy issues in other health care domains.

� Telehealth expansion demonstrated both feasibility and need for attention to equitable access.

� Expand use of policy analyses to assess public health impacts.

� Utilize strongest methods possible for public health policy research, including randomized and nonrandomized designs.

� Leverage partnerships to accelerate dissemination and implementation of evidence-based policy options.

� Assess core capacities, policies, and systems, and ethical frameworks needed for future preparedness and resource distribution during public health threats.

� Assess incidence, duration, severity, and societal impact of long-term sequelae.

� Evaluate approaches to address policy and resource barriers that ensure equitable access as telework expands.

Scientific collaboration � SARS-CoV-2 sequence was published online in 72 h, setting precedent.

� Proliferation of COVID-19 preprints and rapid publications accelerated pace of dissemination.

� Community engagement was critical to build trust and mitigation adherence.

� Data from multiple sectors and disciplines helped to identify risks and assess mitigation feasibility and effectiveness, including political science, behavioral science, and data science.

� Implement transdisciplinary and convergence research studies.

� Pursue research innovation; develop novel methods, such as improving specimen collection or using host genomics to explain health outcomes and responses to treatments and vaccines.

� Conduct community participatory research; use tools of collaborative implementation science to enhance public health outcomes.

� Facilitate rapid sharing of applied laboratory advances. Climate science � Air pollution can aggravate underlying respiratory conditions

that lead to more severe COVID-19 outcomes. � Extreme heat, fire, and severe weather complicated COVID-19

mitigation efforts. � New COVID-19 guidance was needed for climate-related

emergency response. � Lockdowns and reduced mobility and travel rapidly improved

air quality.

� Implement research focused on climate-vulnerable populations.

� Leverage predictive analytics to forecast adverse climate effects and intervention needs.

� Expand methods and routinely incorporate a climate lens into public health research.

� Evaluate effectiveness and impact of interventions designed to mitigate climate change to build evidence base.

Note. SARS-CoV-2 5 severe acute respiratory syndrome coronavirus 2; SDOH 5 social determinants of health.

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disease forecasting as a routine part of

pandemic planning and response.15

As public health strives to keep pace

with rapidly advancing technologic

innovation, scientists are poised to ben-

efit from advanced data analytic skills,

including those for conducting natural

language processing and leveraging

machine learning and artificial intelli-

gence. Strategic public health science

coupled with innovative use of technol-

ogy could help transform contact tracing

methods for the future. Furthermore,

development of, building consensus

around, and utilization of new and nim-

ble regulatory, legislative, and ethical

frameworks for data collection, sharing,

quality, and privacy are needed to

reduce risks and maximize benefits

associated with rapid modernization.

Strategic public health science will require

expanded scientific methods and analytic

approaches for multisectoral data sour-

ces, including community SDOH, envi-

ronmental and climate, genomic and

bioinformatics, social media, and geo-

spatial data. As transdisciplinary data sci-

entistsincreasinglyusepublichealthdata,

public health scientific leadership is

needed to establish core method, ana-

lytic, ethical, and policy approaches.

COMMUNICATION SCIENCE

The COVID-19 pandemic has called

attention to the cultural, structural, and

technological barriers that hamper dis-

semination and acceptance of accurate

messages informed by science. Misin-

formation and disinformation have

spread rapidly in social media. Face-

book, for example, reported placing

warning labels on more than 90 million

pieces of content deemed COVID-19

misinformation.16 COVID-19

misinformation undermined accurate

public health messaging; greater expo-

sure to misinformation was associated

with lower compliance with mask wear-

ing and social distancing guidelines.17

Disinformation, defined as deliberately

misleading or biased information, has

been used to intentionally fuel anti-

science views and sentiments, particu-

larly among targeted subpopulations.18

In addition, the sheer volume of

evidence-based information and the

speed and frequency with which infor-

mation evolved made consistent and

effective risk communication more

challenging and led the World Health

Organization (WHO) to declare an

“infodemic” around COVID-19 in May

2020.19 The inconsistency of clear

COVID-19 messaging across public-

sector authorities at local, national, and

global levels further undercut mitigation

efforts.

Strategic science can leverage com-

munity engagement, behavioral eco-

nomics, and communications science to

study the impact of new technologies

and strategies to counter misinforma-

tion and antiscience disinformation,

including engagement of online influ-

encers and trusted messengers to pro-

vide a steady flow of evidence-based

information.20 Research to identify

effective interventions can assist both

health organizations and social media

platforms as they work to counter mis-

and disinformation.21 Planning for

strategic dissemination, monitoring

audience knowledge and sentiment, and

countering misinformation are standard

practices for all public health scientists to

incorporate into daily practice. Coupled

with proactive, consistent messaging

that employs sound risk communication

principles, strategic science can help

rebuild trust in public health.22–24

POLICY ANALYSIS AND TRANSLATION

COVID-19 has illuminated the potential

of policy as a public health tool and

impediment. For example, policy deci-

sions to reduce economic barriers for

vaccination and testing increased

uptake.25 COVID-19 has also raised

a plethora of multisectoral policy chal-

lenges that have an impact on trans-

mission risk, including workplace

safety, housing density, and transpor-

tation. Inconsistent mitigation policies

have hindered the response across

sectors and jurisdictions, including

mask mandates and restaurant, bar,

and other business operating policies.

Furthermore, the public has often been

confused by inconsistent communica-

tions about the importance of mitiga-

tion policies. COVID-19 has had

numerous collateral and lasting

impacts, both at the societal and indi-

vidual level. Public- and private-sector

entities will be confronted with poten-

tially millions of people with long-term

cardiovascular, pulmonary, mental

health, and neurological sequelae,26

raising policy needs across health care

domains.27 One success has been the

rapid expansion of telehealth28; poli-

cies to ensure equitable access going

forward will be needed.29

Assessment of the positive and nega-

tive impacts of policies and use of

mathematicalmodelingtopredictfuture

impacts are key tools for scientific

inquiry. A component of this work will be

the identification of the core capacities,

policies, and systems needed for pre-

paredness. This includes advance

assessment of the epidemiological and

ethical implications of policy approaches

to distribute resources during public

health emergencies. Characterizing

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overall COVID-19 collateral impacts will

be an important research area to inform

broader health care policy, starting with

assessment and monitoring of the inci-

dence, duration, severity, and societal

impact of long-term sequelae. Transla-

tional science, which includes both

implementation and dissemination

approaches and moves knowledge to

action by ensuring effective and wide-

spread use of evidence-based policies,

can leverage policy analysis and imple-

mentation research to accelerate

action.30 For example, policy analysis can

be used to identify effective mitigation

interventions to support those

experiencing long-term impacts, assess

SDOH, and achieve widespread impact

by applying findings through implemen-

tation and dissemination strategies. Suc-

cessofthispolicyresearchwilldependon

utilization of the strongest designs pos-

sible, including both randomized and

nonrandomized methods.12

SCIENTIFIC COLLABORATION

Within 72 hours of the Chinese and WHO

announcement of a novel coronavirus,

Chinese researchers shared the full

sequence for SARS-CoV-2 online, spur-

ring a global effort toward vaccine and

therapeutics development.31 UNESCO

accelerated Open Science efforts with

122 nations32; the Open COVID Pledge

engaged patent holders and the private

sector33; and more than 150 scientific

institutions and journals reaffirmed their

commitment to share data and expand

open access during the public health

emergency.34 Peer-review timelines

have shortened dramatically for COVID-

19 scientific information, with rapid

review processes and preprint post-

ings.35 Dissemination of COVID-

19–related information exploded; more

than 16 000 scientific publications,

including greater than 6000 on preprint

servers, were posted in just 4 months.

Online and digital technologies sup-

ported low-cost and timely remote sci-

entific collaborations.36 Collaborative

scientific innovation on mRNA technol-

ogy greatly accelerated vaccine devel-

opment,37 and scientists in multiple

settings worked rapidly to build the evi-

dence base on the effectiveness of

masking for both source control and

user protection. The pandemic acceler-

ated scientific collaboration and pro-

moted new norms around transparency

and sharing.

Sustaining a culture of scientific col-

laboration positions public health sci-

ence to be enriched with innovation and

cross-sectoral expertise, including with

sectors outside of health.38 Concerted

effort by scientists will be needed to

implement transdisciplinary and con-

vergence research39; advance applied

laboratory science; conduct community

participatory research; pursue research

innovation and develop novel methods,

such as transdisciplinary environmental

health disparities research40; and host

transparent genomics studies to explain

health outcomes and vaccine

response.41 Creative public health prac-

tice and academic linkages as well as

transdisciplinary team-based research

approaches could help drive innovation

going forward, including laboratory

advancements.42,43 Improved labora-

tory capacities are foundational to

enhanced public health science, includ-

ing not only laboratory quality and safety

but also advancements in specimen

collection, pathogen inactivation, trans-

port, and rapid characterization; multi-

pathogen and point-of-care assays; and

biomarker-based diagnostics. Collabo-

rative sequence-based pathogen sur-

veillance reinforced by a global network

of reference laboratories can more

swiftly identify new and emerging

pathogens. Scientists can improve pro-

cesses for rapidly posting sequences

and early findings to accelerate evidence

generation for diagnostics, program

implementation, and policy develop-

ment. Modelingthecostsandbenefitsof

reducing chronic disease burden before

the next infectious disease outbreak

could inform a new paradigm for pre-

paredness. Scientists are poised to

continue greater collaboration, which

could be enhanced with local, national,

and global leadership.

CLIMATE SCIENCE

Health threats from climate change are

well-documented,44 and the interplay

between COVID-19 and climate and

environmental factors is multifaceted.40

Environmental determinants of health,

including deforestation and increasing

human presence in wildlife habitats,

have fueled both climate change and

emergence of zoonotic infections.45 Cli-

mate change, especially changes in

temperature and precipitation, can

result in changes in the distribution,

seasonality, and prevalence of infectious

diseases.46 Air pollution can aggravate

underlying respiratory conditions that

lead to more severe COVID-19 out-

comes.47 Extreme weather events,

including fires and storms, complicated

COVID-19 mitigation efforts48; in turn,

COVID-19 complicated responses to

these disasters.49 COVID-19 also com-

plicated the ability of local health

departments to run climate-relevant

congregate facilities, such as cooling

centers and disaster shelters.50,51 Lock-

downs and reduced mobility and travel

improved air quality, but these positive

impacts rapidly eroded as mobility

increased again.52 Our collective

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response to COVID-19 has been

described as “a rapid learning experi-

ment about how to cope with climate

change.”53 Indeed, COVID-19 and cli-

mate change mitigation share similar

policy challenges, including the impor-

tance of speedy and decisive action to

avoid global financial and public health

impact, the difficulties of gaining public

support for stringent mitigation policies

given politicization of the issues, and the

need to address health disparities and

counter misinformation.54

A strategic public health science

agenda creates the opportunity to

identify effective approaches for these

shared policy challenges. Other key pri-

orities include expanding research on

the relationship between climate and

health outcomes and emerging pan-

demic threats and improving surveil-

lance for climate-sensitive pathogens

and vectors that identify locations and

populations at greatest risk. In addition,

use of predictive analytics and forecast-

ing can help build an evidence base for

early warning systems and for interven-

tions that effectively counter adverse

climate effects, particularly for popula-

tions experiencing environmental injus-

tice,55 such as migrant and refugee

populations.56 Given that climate

impacts span across public health, from

environmental health to chronic and

infectious disease and mental health, an

interdisciplinary approach can support

scientists to expand methods and dem-

onstrate the value of new mandates to

routinely incorporate a climate lens in

public health research.57,58

A NEW ERA OF PUBLIC HEALTH STRATEGIC SCIENCE

The COVID-19 pandemic and its impacts

continue to grow, fueling the imperative

to create a new era of public health

guided by strategic science. The 6

themes emerging from COVID-19 expe-

rience discussed here—health equity

science, data science and moderniza-

tion, communication science, policy

analysis and translation, scientific col-

laboration, and climate science—can

help formulate a strategic public health

science agenda that accelerates

achievement offuture public health goals

(Box 1). To succeed, public health science

should be grounded in scientific integrity

and supported by a larger, sustained,

well-trained, and innovative workforce.

Workforce expansion,diversification, and

development will be needed at multiple

levels, including for epidemiologists, data

scientists, and leadership.59 This

enhanced public health workforce could

help break the cycle of panic and neglect

that has characterized public health

attention and resources for decades.60

Given the impact of COVID-19, it is pos-

sible that public health will remain

prominent, especially as vaccination cov-

erage expands, other efforts to reduce

community transmission continue, and

researchers learn more about COVID-

19’s long-term effects. Public health

leaders and scientists have an unprece-

dented opportunity to use strategic sci-

ence to guide and implement a new era

of improved and equitable public health.

ABOUT THE AUTHORS Rebecca Bunnell and Juliet Ryan are with the Office of Science, Centers for Disease Control and Pre- vention (CDC), Atlanta, GA. Charlotte Kent is with Morbidity and Mortality Weekly Report, Center for Surveillance, Epidemiology, and Laboratory Serv- ices, CDC.

Note. The findings and conclusions in this report are those of the authors and do not nec- essarily represent the views of the CDC or the Agency for Toxic Substances and Disease Registry.

CORRESPONDENCE Correspondence should be sent to Rebecca E. Bunnell, PhD, MEd, Centers for Disease Control

and Prevention, Atlanta, GA 30333 (e-mail: rrb7@ cdc.gov). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link.

PUBLICATION INFORMATION Full Citation: Bunnell R, Ryan J, Kent C, CDC Office of Science, and CDC Excellence in Science Committee. Toward a new strategic public health science for policy, practice, impact, and health equity. Am J Public Health. 2021;111(8):1489–1496.

Acceptance Date: April 15, 2021.

DOI: https://doi.org/10.2105/AJPH.2021.306355

CONTRIBUTORS R. Bunnell wrote the article with the support of C. Kent and J. Ryan. Senior scientists from CDC's Office of Science and Excellence in Science Com- mittee, listed in the Acknowledgments, all reviewed and contributed to multiple drafts and the final version of this publication.

ACKNOWLEDGMENTS The CDC Office of Science and CDC Excellence in Science Committee provided critical ideas and feedback to help shape the article and revisions. Members of the CDC Excellence in Science Com- mittee were Elise Beltrami, MD, MPH (National Center for Emerging and Zoonotic Infectious Dis- eases), Amy M. Branum, MSPH, PhD (National Center for Health Statistics), Dogan Eroglu, PhD (Office of the Associate Director for Communica- tion), Susan Goldstein, MD (National Center for Immunization and Respiratory Diseases), Arlene Greenspan, DrPH, MS, MPH (National Center for Injury Prevention and Control), Kimberly Hummel, PhD (National Center for Emerging and Zoonotic Infectious Diseases), Vikas Kapil, DO, MPH (Center for Global Health), Rachel Kaufmann, PhD, MPH (National Center for Chronic Disease Prevention and Health Promotion), Wendi Kuhnert-Tallman, PhD (Office of the Deputy Director for Infectious Diseases), Aun Lor, PhD, MA, MPH (Center for Global Health), Sandra Naoom, PhD, MSPH (Office of the Deputy Director for Public Health Service and Implementation Science), Sherry M. Owen, PhD (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention), Ana Penman-Aguilar, PhD, MPH (Office of Minority Health and Health Equity), Celeste M. Philip, MD, MPH (Office of the Deputy Director for Non-infectious Diseases), John D. Pia- centino, MD, MPH (National Institute for Occupa- tional Safety and Health), Richard Puddy, PhD, MPH (Office of Associate Director for Policy and Strat- egy), Tom Savel, MD (Office of Chief Information Officer), James W. Stephens, PhD (Center for Sur- veillance, Epidemiology, and Laboratory Services), Benedict Truman, MD, MPH (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention), Robin Wagner, PhD, MS (Office of the Deputy Director for Public Health Science and Surveil- lance), David Williamson, PhD, MS (National Center for Environmental Health and Agency for Toxic Substances and Disease Registry), and Andrea Young, PhD, MS (Center for State, Tribal, Local, and Territorial Support). Members of the CDC Office of Science were Micah Bass, MPH, Joanne Cono, MD,

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ScM, Juliana Cyril, PhD, Maryam Daneshvar, PhD, MS, Julie Fishman, MPH, Locola Hayes, MBA, Rosa Herrera, BS, Muin Khoury, MD, PhD, Jennifer Lay- den, MD, PhD, Mary Reynolds, MS, PhD, Shambavi Subbarao, MSc, PhD, and Bao-Ping Zhu, MD, PhD.

CONFLICTS OF INTEREST The authors have no potential or actual conflicts of interest with the content presented in this article.

HUMAN PARTICIPANT PROTECTION This activity did not involve human participant research, was reviewed by CDC, and was con- ducted consistent with applicable federal law and CDC policy (see, e.g., 45 CFR 46; 21 CFR 56; 42 USC §241(d); 5 USC §552a; 44 USC §3501 et seq.).

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