Vigilância epidemiológica: breve histórico e a experiência dos Estados Unidos e do estado de São Paulo / Inteligencia epidemiológica: breve histórico y la experiencia de los Estados Unidos y del estado de São Paulo, en Brasil / Epidemiological surveillance: a brief history and the experiences of the United States and the state of São Paulo

Objetivo: O objetivo desta revisão narrativa foi elencar alguns aspectos históricos da vigilância epidemiológica, modelo tecnológico de intervenção inicialmente desenhado para auxiliar no controle das doenças transmissíveis, no último século. Métodos: Narrativa construída a partir de textos selecionados, para registrar o desenvolvimento da vigilância epidemiológica nos Estados Unidos e no estado de São Paulo, Brasil. Resultados: São apresentadas as origens de algumas das ações componentes do repertório da vigilância epidemiológica, e uma breve história da construção do originalmente nomeado Center for Disease Control, agência dos Estados Unidos exemplar na forma como se faz vigilância em praticamente todo o mundo. Do mesmo modo, são delineados os caminhos que levaram à organização do sistema de vigilância no estado de São Paulo, traçando alguns paralelos com o sistema brasileiro. Conclusão: A narrativa é concluída com uma diferenciação conceitual entre vigilância epidemiológica, monitoramento e vigilância em saúde.

Objetivo: El objetivo de esta revisión narrativa es enumerar algunos aspectos históricos de la vigilancia epidemiológica modelo tecnológico de intervención diseñado para apoyar en el control de las enfermedades transmisibles en el último siglo. Métodos: Narrativa construida a partir de textos seleccionados y la experiencia del autor, para registrar el desarrollo dsen en los Estados Unidos y en el estado de São Paulo, Brasil. Resultados: Se presentan los orígenes de algunas de las acciones que componen el repertorio de la vigilancia epidemiológica, así como una breve historia de la construcción del Center for Disease Control, una agencia de Estados Unidos que es ejemplar por la forma en que realiza la vigilancia en, prácticamente, todo el mundo. Asimismo, se delinean los caminos que llevaron a la organización del sistema de vigilancia en el estado de São Paulo, trazando algunos paralelos con el sistema brasileño. Conclusión: Finalmente, concluye con la diferenciación entre vigilancia epidemiológica, monitoreo y vigilancia en salud.

Objective: The objective of this narrative review was to list some historical aspects of epidemiological surveillance, a technological intervention model initially designed to help control communicable diseases in the last century. Methods: This narrative was built based on texts selected to record the development of epidemiological surveillance in the United States and in the state of São Paulo, Brazil. Results: The origins of some of the actions that constitute epidemiological surveillance activities are presented, as well as a brief history of the establishment of the originally named Center for Disease Control, a United States agency that is held up as an example in relation to the way surveillance has been performed, practically all over the world. Likewise, we outline the paths that led to the establishment of the surveillance system in the state of São Paulo, drawing some parallels with the Brazilian system. Conclusion: The narrative concludes with a conceptual differentiation between epidemiological surveillance, monitoring and health surveillance.

Urological Cancer Treatment by a Multidisciplinary Teamthroughout the Covid-19 Pandemic: What Have We Learned? / Tratamiento del cáncer urológico por un equipo multidisciplinario durante la pandemia de Covid-19: ¿Qué hemos aprendido?

Introduction It is known that cancer care is best approached by a multidisciplinary team (MDT). This became specifically true in the Covid-19 pandemic in which choices for urological cancer treatment are influenced by many factors. In some cases, delayed treatment may have consequences regarding the patient's oncological outcomes. The aim of the present article is to report our experience throughout the Covid-19 pandemic treating patients with urological neoplasms at a high-volume center. Methods We used a convenience sampling method. Cases were evaluated and discussed on an individual basis at the MDT meetings, and, after a consensus regarding delaying or scheduling treatment, patients were scheduled according to the risk of postponing the procedures. The Medically Necessary, Time-Sensitive (MeNTS) scoring system was measured in each patient; all patients answered the Centers for Disease Control and Prevention (CDC) Covid-19 self-screening questionnaire prior to surgery. The Covid-19-free survival rate was estimated. Results A total of 194 patients were assessed by themultidisciplinary team and finally treated, with median follow-up of 4 (interquartile range [IQR]: 2.75 to 6) months. Only two patients had Covid-19 confirmed by real-time polymerase chain reaction (RT-PCR). In total, 54 patients underwent oncological surgery, 129 were treated with radiotherapy, and 11 were treated with intravenous chemotherapy. Themedian age was 66 years (IQR: 59 to 94 years), and the median MeNTS score in the surgically-treated cohort was 35 points (IQR: 31 to 47 points). Conclusions The evaluation and treatment of urological cancer should be conducted by an MDT; this is of utmost importance, especially during the Covid-19 pandemic. The data collected in our institution showed that most patients could be safely treated by taking all necessary precautions and discussing each case individually in the MDT meetings and performing a close follow-up.

Introduccion La atención del cáncer se aborda mejor con un equipo multidisciplinario (EMD), aspecto que se tornó más importante en la pandemia por Covid-19, en que las opciones para tratar el cáncer urológico están influenciadas por muchos factores. En algunos casos, el tratamiento retrasado puede tener consecuencias en los resultados oncológicos del paciente. El objetivo de este estudio es describir nuestra experiencia en un centro de referencia y de alto volumen para el tratamiento de neoplasias urológicas durante la pandemia por Covid-19. Métodos Realizamos un muestreo por conveniencia. Posteriormente, los casos fueron evaluados y discutidos de forma individual en las reuniones del EMD. Posterior a la obtención de un consenso sobre el tratamiento del paciente, los pacientes fueron programados según el riesgo individual de posponer el manejo. Se midió la puntuación de cada paciente en el sistema Medically Necessary Time-Sensitive (MeNTS, "Médicamente necesario, sensibles al tiempo"). Todos los pacientes respondieron el cuestionario de autoevaluación del Centers for Disease Control and Prevention (CDC) COVID-19 antes de la cirugía. Se estimó la tasa de supervivencia libre de Covid-19. Resultados Un total de 194 pacientes fueron evaluados por el EMD y finalmente tratados, con una mediana de seguimiento de 4 (rango intercuartil [RIC]: 2,75 a 6) meses. Solo dos tenían Covid-19 confirmado por reacción en cadena de la polimerasa en tiempo real (RCP-TR). Un total de 54 pacientes fueron sometidos a cirugía oncológica, 129 fueron tratados con radioterapia, y 11 fueron tratados con quimioterapia intravenosa. La mediana de edad fue de 66 años (RIC: 59 a 94 años), la puntuación mediana en el MeNTS de la cohorte tratada quirúrgicamente fue de 35 puntos (RIC: 31 a 47 puntos). Conclusiones La evaluación y el tratamiento del cáncer urológico debe ser realizado por un EMD durante la pandemia de Covid-19. Los datos recopilados en nuestra institución mostraron que la mayoría de los pacientes podrían ser tratados de manera segura, discutiendo cada caso individualmente y haciendo un seguimiento cercano.

Diffusion of scientific concepts on obesity in the global context: a historical review / Difusão de conceitos científicos sobre obesidade no contexto mundial: análise histórica

ABSTRACT This article aimed to carry out a historical analysis of the dissemination of the scientific concepts on obesity, overweight and excess weight in the field of nutritional epidemiology in the world. The methodological procedures comprised: (1) Systematic search in the PubMed® database using single keywords and without date filter; (2) Documentary analysis of normative instruments on the websites of the World Health Organization, the Centers for Disease Control and Prevention and the World Obesity Federation; and (3) Analysis of the scientific production of scientists participating in the obesity classification of the International Obesity Task Force. The historical analysis showed that, considering the volume of publications on obesity, it appears that in the 1940-1949 decade the problem of obesity emerged on the world scenario. From the number of publications issued in the last 20 years, which corresponds to 85% of the investigated period, we can deduct that scientists' concern to investigate the subject as a phenomenon coincides with the World Health Organization declaration of obesity as a global epidemic issued in the year 2000. In accordance with normative procedures established by international organizations, there has been a hegemonic use of the concepts of obesity and overweight, in this order of priority, by scientists worldwide. The concept of excess weight has experienced a relative rise since the year 2000, but its use has been very restricted, expressing dissonance in face of the recommendations of international standardization organizations, a fact that suggests discussion and review of its use by the world scientific community.

RESUMO O artigo teve por objetivo realizar uma análise histórica da difusão dos conceitos científicos sobre obesidade, sobrepeso e excesso de peso no campo da epidemiologia nutricional no contexto mundial. Os procedimentos metodológicos compreenderam: (1) Busca sistemática na base PubMed® utilizando unitermos isolados e sem filtro temporal para data; (2) Busca e análise documental de instrumentos normativos nas páginas eletrônicas da Organização Mundial de Saúde, do Centers for Disease Control and Prevention e da World Obesity Federation e (3) Análise da produção científica de cientistas participantes da classificação de obesidade da International Obesity Task Force. A análise histórica mostrou que, pelo volume de publicações sobre obesidade, a emergência da problemática no cenário universal ocorreu na década de 1940-1949. Pelo número de publicações dos últimos 20 anos, que corresponde a 85% do período investigado, pode-se deduzir que a preocupação dos cientistas em investigar a temática é um fenômeno coincidente com a declaração de obesidade como epidemia global feita pela Organização Mundial de Saúde no ano 2000. Em concordância com procedimentos normativos estabelecidos pelas organizações internacionais, verificou-se uma hegemonia do uso dos conceitos de obesity e overweight, nessa ordem de prioridade, pelos cientistas no contexto internacional. O conceito de excess weight experimentou relativa ascensão desde os anos 2000, mas teve seu uso bem restrito, expressando dissonância frente às recomendações das organizações internacionais de normatização - o que sugere uma discussão e revisão de seu uso pela comunidade científica global.

Infection Control in the Dental Practice with Emphasis on Intraoral Scanners and Semi-Critical Complex Instruments / Control de Infecciones en la Práctica Dental Con Énfasis en Escáneres Intraorales e Instrumentos Complejos Semicríticos

ABSTRACT: We present an integrative review of the literature conducted to find and analyse specific measures for disinfection and/or sterilization of intraoral complex instruments, applicable to intraoral scanners. We performed a two-stage search in the PubMed/MEDLINE, SciELO, REDALYCS, and LILACS databases, and the Google Scholar website, which included full articles in Spanish, Portuguese, and English. The strategy associated the terms 'disinfection', 'biosecurity', 'decontamination', and (a) 'intraoral scanners', and (b) other 'semi-critical' intraoral complex instruments, according to the American Dental Association definition (e.g., 'turbine', etc). Strategy (a) produced just one outcome, whereas (b) produced nine articles, which only suggested low-level disinfectants.The lack of empirically based protocols that allow effective microbiological control makes it necessary to create a new categorization for these instruments when trying to comply with American Dental Association recommendations for dental practice.

RESUMEN: Presentamos una revisión integradora de la literatura realizada para encontrar y analizar medidas específicas de desinfección y / o esterilización de instrumentos complejos intraorales, aplicables a los escáneres intraorales. Realizamos una búsqueda en dos etapas en las bases de datos PubMed / MEDLINE, SciELO, REDALYCS y LILACS, y en el sitio web Google Scholar, que incluía artículos completos en español, portugués e inglés. La estrategia asoció los términos 'desinfección', 'bioseguridad', 'descontaminación' y (a) 'escáneres intraorales', y (b) otros instrumentos complejos intraorales 'semicríticos', según la definición de la Asociación Dental Ameri- cana (p. Ej., 'turbina', etc.). La estrategia (a) produjo un solo resultado, mientras que (b) produjo nueve artículos, que solo sugirieron desinfectantes de bajo nivel. La falta de protocolos de base empírica que permitan un control microbiológico efectivo hace necesario crear una nueva categorización para estos instrumentos, cuando se trata de cumplir con las recomendaciones de la Asociación Dental Americana para la práctica dental.

Guía de atención remota para pacientes pediátricos con covid-19 / Covid-19: a remote assessment for pediatric patients

En China a finales del 2019 se puso en conocimiento esta nueva enfermedad denominada SARS-CoV-2, múltiples centros mundiales encargados de la salud pública entre ellos el Centers of Disease Control and Prevention (CDC) de Atlanta, Estados Unidos y la Orgaizacion Mundial de la Salud (OMS) publicaron diferentes clasificaciones acordes a cada grupo etáreo, dando mucha importancia a la población pediátrica, el riesgo comparativo en adultos/niños, la importancia de pruebas laboratoriales (prueba en cadena a la polimerasa (PCR) y anticuerpos), y finalmente, se discuten los tratamientos acorde al caso y la gravedad de los pacientes. Por la alta demanda de pacientes y el colapso de los sitemas de salud en todo el mundo y especialmente en los países de latinoamerica donde los sistemas de salud son muy frágiles se llegas a recurrir de herramientas técnológicas como la “Teleconsulta”, recomendada por la OMS. En el presente artículo de revisión se plantea múltiples conceptos clínicos propios de la enfermedad en niños, imágenológicos, tipo de presentación de la enfermedad incluyendo factores de riesgo. Criterios de hospitalización y tratamiento. Medidas de bioseguridad, aislamiento y supervisión médica. Y como pilar fundamental de atención la Telemedicina en la era COVID-19.

In China at the end of 2019, this new disease called SARS-CoV-2 was made known, multiple world centers in charge of public health, including the Centers of Disease Control and Prevention (CDC) of Atlanta USA and the world health organization (WHO), published different classifications according to each age group, with more emphasis on the pediatric population. Comparative risk in adults/children. In addition to the results of laboratory tests (Polymerase Chain Reaction (PCR) and antibodies). And later its treatment is denoted according to the case and the severity. Where, due to the demand of patients, technological tools are resorted to through “Teleconsultation”, recommended by the WHO. In this review article, multiple clinical concepts typical of the disease in children, imaging, type of presentation of the disease including risk factors are proposed. Criteria for hospitalization and treatment. Biosecurity measures, isolation, and medical supervision. And as a pillar of Telemedicine Care in the COVID-19 era.

Social distancing measures could have reduced estimated deaths related to COVID-19 in Brazil / Medidas de distanciamento social podem ter reduzido as mortes estimadas relacionadas à COVID-19 no Brasil

Social distancing was planned as a preventive measure to control the extensive spread of COVID-19. COVID-19-related deaths in Brazil were analyzed during the period of social distancing measures. Mortality data for COVID-19 was obtained from the Worldometer website (www.worldometer.info). Deaths were estimated up to the 31st day after the occurrence of the 5th COVID-19-related death in Brazil. Social distance was measured using Google's community mobility reports (https://www.google.com/covid19/mobility/). The Brazilian epidemic curves were interconnected, and mathematical models were evaluated to fit the mortality estimation curves. The optimistic model was defined in the opening period of social distancing and, therefore, in the lower mobility (40-60%). The realistic model was calculated according to relaxed social distance measures (<40%) and the pessimistic model was calculated based on the transmission rate between 2-3. Thus, the equations of the mathematical models provided the outcomes for the date of June 9, 2020, as follows: realistic model with 40,623 deaths, pessimistic model with 64,310 deaths and the optimistic model with a projection of 31,384 deaths. As a result of these analyzes, on May 24, 2020, there were a total of 22,965 deaths related to COVID-19, and those deaths included within the proposed mathematical models were 17,452 for the optimistic model, 22,623 for the realistic model and 32,825 for the pessimistic model. Thus, it is concluded that social distancing measures promoted by the Brazilian public managers contributes to the reduction in approximately ten thousand deaths related to COVID-19 in the current pandemic scenario.

INTRODUÇÃO: O distanciamento social foi planejado como uma medida preventiva para controlar a disseminação extensiva da COVID-19. Nós analisamos as mortes relacionadas à COVID-19 no Brasil durante o período de medidas de distanciamento social. Os dados de mortalidade do COVID-19 foram obtidos no site da Worldometer (www.worldometer.info). As mortes foram estimadas até o 31º dia após a 5ª morte. O distanciamento social foi medido por meio dos relatórios de mobilidade comunitária COVID-19; Google (https://www.google.com/covid19/mobility/). As curvas epidêmicas brasileiras foram interligadas e os modelos matemáticos foram avaliados para se ajustarem às curvas de estimativa de mortalidade. O modelo otimista foi fundado no período de abertura da distância social e, portanto, na menor mobilidade (40-60%). O modelo realista foi calculado de acordo com medidas de distanciamento social relaxado (<40%) e o modelo pessimista foi calculado com base em R0 entre 2-3. Sob essa situação, o modelo matemático realista estimou 40.623 mortes em 9 de junho de 2020, enquanto o modelo pessimista antecipou 64.310 mortes e o modelo otimista projetou 31.384. Até hoje (24 de maio de 2020), um total de 22.965 foram relatadas, enquanto nosso modelo projetou 17.452 para o modelo otimista, 22.623 para o modelo realista e 32.825 para o modelo pessimista. Observamos movimento reduzido ao longo deste período. Em resumo, o modelo matemático sugere que a mobilidade reduzida da comunidade diminuiu o total estimado de mortes relacionadas à COVID-19 no Brasil. Enfatizamos que mais procedimentos metodológicos serão necessários para confirmar esta teoria

Pesquisa activa, contribución desde la Atención Primaria de Salud para el control de la COVID-19 / Active research, contribution from the Primary Health Care for the control of COVID-19

RESUMEN Los primeros casos de enfermos por la COVID-19 o Síndrome respiratorio agudo severo por coronavirus 2, (SARS-CoV-2) se reportaron en China, extendiéndose rápidamente por todo el mundo, lo que hizo considerarla como una nueva pandemia. El objetivo fue describir algunas particularidades de la pesquisa activa, en la Atención Primaria de Salud, para la detección de casos sintomáticos, contactos y sospechosos de la enfermedad. La pesquisa activa posibilita utilizar los recursos humanos propios de cada territorio: médicos, enfermeras, tecnólogos, estudiantes, promotores de salud, debidamente capacitados sobre el problema que se va a investigar. Logra la cobertura, amplitud y sostenibilidad necesarias para detectar precozmente la enfermedad, de ahí que sea una peculiaridad de Cuba en el enfrentamiento a la COVID-19. Esta experiencia de intervención social, ha sido utilizada como una herramienta para el control de este problema de salud, junto a otras, que logran aumentar los conocimientos de la población, fomentar la participación comunitaria y promover cambios en los comportamientos de riesgo, incluyendo el incremento de la precepción y la auto- responsabilidad. La pesquisa activa de la COVID-19, constituye un método de trabajo en la Atención Primaria de Salud. Esta tecnología sanitaria, contribuye a detectar casos presuntivos o sospechosos y sus contactos, y diagnosticar la enfermedad en estadios iniciales. La educación para la salud durante el enfrentamiento antipandémico, contribuye a la disminución del número y la gravedad de los enfermos (AU).

SUMMARY The first cases of patients with COVID-19 or Severe Acute Respiratory Syndrome due to Coronavirus 2, (SARS-CoV-2) were reported in China, spreading rapidly throughout the world, which made it consider as a new pandemic. To describe some peculiarities of active research in Primary Health Care, for the detection of symptomatic cases, contacts and suspects of the disease. Active research makes it possible to use the human resources of each territory: doctors, nurses, technologists, students, health promoters, duly trained on the problem to be investigated. It achieves the necessary coverage, breadth and sustainability to detect the disease early, hence it is a peculiarity of Cuba in the confrontation with COVID-19. This experience of social intervention has been used as a tool for the control of this health problem, along with others, which manage to increase the knowledge of the population, encourage community participation and promote changes in risk behaviors, including increasing of perception and self-responsibility. The active investigation of COVID-19 constitutes a working method in Primary Health Care. This health technology contributes to detecting suspected or suspected cases and their contacts, and diagnosing the disease in early stages. Health education during the pandemic confrontation contributes to the decrease in the number and severity of patients (AU).

Bacaba beverage produced by Umutina Brazilian Amerindians: Microbiological and chemical characterization

Bacaba chicha is a beverage prepared by the indigenous Umutina people from the bacaba fruit (Oenocarpus bacaba), a purple berry that is rich in fat and carbohydrates, as well as a source of phenolic compounds. In this study, samples of bacaba chicha beverage were collected, and the microbial community was assessed using culture-dependent and -independent techniques. The nutritional composition and metabolite profiles were analyzed, and species belonging to lactic acid bacteria (LAB) and yeasts were detected. The LAB group detected by culture-dependent analysis included Enterococcus hormaechei and Leuconostoc lactis. Polymerase chain reaction and denaturing gradient gel electrophoresis (PCR-DGGE) detected additional Propionibacterium avidum, Acetobacter spp., and uncultured bacteria. Pichia caribbica and Pichia guilliermondii were detected in a culture-dependent method, and Pichia caribbica was confirmed by PCR-DGGE analysis. The pH value of the beverage was 6.2. The nutritional composition was as follows: 16.47 ± 0.73 g 100 mL-1 dry matter, 2.2 ± 0.0 g 100 mL-1 fat, 3.36 ± 0.44 g 100 mL-1 protein, and 10.87 ± 0.26 g 100 mL-1 carbohydrate. The metabolites detected were 2.69 g L-1 succinic acid, 0.9 g L-1 acetic acid, 0.49 g L-1 citric acid, 0.52 g L-1 ethanol, and 0.4 g L-1 glycerol. This is the first study to identify microbial diversity in bacaba chicha spontaneous fermentation. This study is also the starting step in the immaterial record of this Brazilian indigenous beverage prepared from bacaba fruit.

Comparação entre um método de diagnóstico clínico e a técnica de vigilância do Center for Disease Control and Prevention para identificação de pneumonia associada à ventilação mecânica / Comparison between a clinical diagnosis method and the surveillance technique of the Center for Disease Control and Prevention for identification of mechanical ventilator-associated pneumonia

RESUMOObjetivo:Avaliar a concordância entre um novo método de vigilância epidemiológica do Center for Disease Control and Prevention e o Clinical Pulmonary Infection Score para detecção de pneumonia associada à ventilação mecânica.Métodos:Coorte prospectiva que avaliou pacientes internados nas unidades de terapia intensiva de dois hospitais que permaneceram intubados por mais de 48 horas no período de agosto de 2013 a junho de 2014. Os pacientes foram avaliados diariamente pelos fisioterapeutas com o Clinical Pulmonary Infection Score. De forma independente, um enfermeiro aplicou o novo método de vigilância proposto pelo Center for Disease Control and Prevention. Avaliou-se a concordância diagnóstica entre os métodos. Clinical Pulmonary Infection Score ≥ 7 foi considerado diagnóstico clínico de pneumonia associada à ventilação mecânica, considerando-se diagnóstico definitivo a associação de Clinical Pulmonary Infection Score ≥ 7 com germe isolado em cultura semiquantitativa ≥ 104 unidades formadoras de colônias.Resultados:De 801 pacientes admitidos nas unidades de terapia intensiva, 198 estiveram sob ventilação mecânica. Destes, 168 permaneceram intubados por mais de 48 horas. Identificaram-se 18 (10,7%) condições infecciosas associadas à ventilação mecânica e 14 (8,3%) pneumonias associadas à ventilação mecânica possíveis ou prováveis, representando 35% (14/38) diagnósticos clínicos de pneumonia associada à ventilação mecânica. O método do Center for Disease Control and Prevention identificou casos de pneumonia associada à ventilação mecânica com sensibilidade de 0,37 e especificidade de 1,0, com valor preditivo positivo de 1,0 e negativo de 0,84. As diferenças implicaram em discrepâncias na densidade de incidência de pneumonia associada à ventilação mecânica (CDC: 5,2/1000 dias de ventilação mecânica; Clinical Pulmonary Infection Score ≥ 7: 13,1/1000 dias de ventilação mecânica).Conclusão:O método do Center for Disease Control and Prevention falhou na detecção de casos de pneumonia associada à ventilação mecânica e pode não ser satisfatório como método de vigilância.Objective: To evaluate the agreement between a new epidemiological surveillance method of the Center for Disease Control and Prevention and the clinical pulmonary infection score for mechanical ventilator-associated pneumonia detection.

ABSTRACTObjective:>To evaluate the agreement between a new epidemiological surveillance method of the Center for Disease Control and Prevention and the clinical pulmonary infection score for mechanical ventilator-associated pneumonia detection.Methods:This was a prospective cohort study that evaluated patients in the intensive care units of two hospitals who were intubated for more than 48 hours between August 2013 and June 2014. Patients were evaluated daily by physical therapist using the clinical pulmonary infection score. A nurse independently applied the new surveillance method proposed by the Center for Disease Control and Prevention. The diagnostic agreement between the methods was evaluated. A clinical pulmonary infection score of ≥ 7 indicated a clinical diagnosis of mechanical ventilator-associated pneumonia, and the association of a clinical pulmonary infection score ≥ 7 with an isolated semiquantitative culture consisting of ≥ 104 colony-forming units indicated a definitive diagnosis.Results:Of the 801 patients admitted to the intensive care units, 198 required mechanical ventilation. Of these, 168 were intubated for more than 48 hours. A total of 18 (10.7%) cases of mechanical ventilation-associated infectious conditions were identified, 14 (8.3%) of which exhibited possible or probable mechanical ventilatorassociated pneumonia, which represented 35% (14/38) of mechanical ventilator-associated pneumonia cases. The Center for Disease Control and Prevention method identified cases of mechanical ventilator-associated pneumonia with a sensitivity of 0.37, specificity of 1.0, positive predictive value of 1.0, and negative predictive value of 0.84. The differences resulted in discrepancies in the mechanical ventilator-associated pneumonia incidence density (CDC, 5.2/1000 days of mechanical ventilation; clinical pulmonary infection score ≥ 7, 13.1/1000 days of mechanical ventilation).Conclusion:The Center for Disease Control and Prevention method failed to detect mechanical ventilatorassociated pneumonia cases and may not be satisfactory as a surveillance method.

Manipulation of a quasi-natural cell block for high-efficiency transplantation of adherent somatic cells

Recent advances have raised hope that transplantation of adherent somatic cells could provide dramatic new therapies for various diseases. However, current methods for transplanting adherent somatic cells are not efficient enough for therapeutic applications. Here, we report the development of a novel method to generate quasi-natural cell blocks for high-efficiency transplantation of adherent somatic cells. The blocks were created by providing a unique environment in which cultured cells generated their own extracellular matrix. Initially, stromal cells isolated from mice were expanded in vitro in liquid cell culture medium followed by transferring the cells into a hydrogel shell. After incubation for 1 day with mechanical agitation, the encapsulated cell mass was perforated with a thin needle and then incubated for an additional 6 days to form a quasi-natural cell block. Allograft transplantation of the cell block into C57BL/6 mice resulted in perfect adaptation of the allograft and complete integration into the tissue of the recipient. This method could be widely applied for repairing damaged cells or tissues, stem cell transplantation, ex vivo gene therapy, or plastic surgery.

Diabetes among Latinos in the Southwestern United States: border health and binational cooperation / Diabetes en la población de origen latino del sudoeste de los Estados Unidos: salud fronteriza y cooperación binacional

This analysis reviews cooperation between the four border states of the United States of America (Arizona, California, New Mexico, and Texas) and international partners in Mexico with regard to type 2 diabetes among Latinos. Binational cooperation, academic collaboration, preventative health initiatives, and efforts to improve health care access for the border population are highlighted. This meta-analysis of the literature points out causative factors of the increased type 2 diabetes prevalence among Latinos in the United States; an inverse correlation between diabetes and education and socioeconomic level; contributing factors, including barriers with language, health care payment, transportation, and underestimating diabetes implications; and a lack of social and environmental support for disease management. Medical and indirect costs in socioeconomic terms are also included. Cooperation between the United States and Mexico may be beneficial to promoting further collaborative efforts between these nations, and serve as a template for greater cooperative efforts to mitigate the substantial public health and socioeconomic implications of type 2 diabetes globally.

Este análisis examina la cooperación de los cuatro estados fronterizos de los Estados Unidos de América (Arizona, California, Nuevo México y Texas) y los socios internacionales de México con respecto a la diabetes de tipo 2 en la población de origen latino. Se destacan la cooperación binacional, la colaboración académica, las iniciativas de prevención en salud, y las actividades orientadas a mejorar el acceso a la atención de salud por parte de la población de la frontera. Este metanálisis de la bibliografía señala los factores causales del aumento de la prevalencia de la diabetes de tipo 2 en la población de origen latino de los Estados Unidos; una correlación inversa entre la diabetes y el grado de formación y el nivel socioeconómico; los factores contribuyentes, incluidas las barreras relacionadas con el idioma, el pago de la atención de salud, el transporte, y la infravaloración de las consecuencias de la diabetes; y una falta de apoyo social y ambiental para el tratamiento de la enfermedad. También se incluyen los costos médicos y los indirectos en términos socioeconómicos. La cooperación entre los Estados Unidos y México - podría ser beneficiosa para promover nuevas iniciativas de colaboración entre estas naciones y servir como mo-delo a otras iniciativas más amplias de cooperación dirigidas a mitigar las sustanciales consecuencias de salud pública y socioeconómicas de la diabetes de tipo 2 a escala mundial.

Estado nutricional definido pelo índice de massa corporal e pelo percentual de gordura corporal / Nutritional status defined by body mass index and percentage of body fat

Introdução: O índice de massa corporal (IMC) é amplamente utilizado para identificar o estado nutricional de crianças e adolescentes. Objetivo: Determinar a concordância da classificação do estado nutricional de crianças e adolescentes, conforme cinco referências de IMC com a classificação do percentual de gordura corporal (%GC) de Lohman (1987). Métodos: Foram avaliados 615 meninos e 826 meninas, com idade entre 6 e 16 anos. Foram mensuradas variáveis para a determinação do IMC e do %GC. Utilizou-se o índice Kappa (k) para a análise de concordância. Resultados: Os grupos masculino e feminino apresentaram concordâncias entre o IMC e o %GC que variaram de k=0,49 a 0,61 (regular a boa) e k=0,23 a 0,39 (discreta a regular), nesta ordem. Conclusão: Existe maior concordância entre as referências da OMS (2007) e de Conde e Monteiro (2006) para classificação do estado nutricional e diagnóstico de excesso de gordura corporal de meninos e meninas, respectivamente.

Introduction: The body mass index (BMI) is widely used to identify the nutritional status of children and adolescents. Objective: To determine the concordance of the nutritional status of children and adolescents using five references to the body mass index (BMI) classifications with the classification of body fat percentage (BF%) by Lohman (1987). Methods: The study included 615 boys and 826 girls aged between 6 and 16 years. Were measured variables for the determination of BMI and% BF. We used the Kappa (k) for the analysis of agreement. Results: The male and female showed concordance between BMI and% BF ranging from k= 0.49 to 0.61 (regular to good) and k= 0.23 to 0.39 (discrete to good), respectively. Conclusion: There is greater agreement between the reference WHO (2007) and Conde and Monteiro (2006) for classification of nutritional status and diagnosis of excess body fat of boys and girls, respectively.

Prevalencia de sobrepeso y obesidad en escolares jujeños de diferente nivel altitudinal según las referencias IOTF, CDC y OMS / Prevalence of overweight and obesity in students from different altitudinal zones of Jujuy according to three intvernational references (IOTF, CDC and WHO)

Introducción. Se comparan las prevalencias de sobrepeso (SP) y obesidad (OB) en escolares jujeños de distintos niveles altitudinales utilizando las referencias de la International Obesity Task Force (IOTF), de los Centers for Disease Control (CDC) y de la Organización Mundial de la Salud (OMS), y la concordancia entre ellas. Materiales y métodos. Los datos de peso y talla de 15 541 escolares (PROSANE) se agruparon en tierras altas (TA) (= 2500 msnm) y bajas (TB) (< 2500 msnm), y en dos grupos de edad (5 a 6,99 y 11 a 12,99 años). Se calcularon las prevalencias de SP, OB y SP+OB según las referencias. Las diferencias entre variables y prevalencias se establecieron con la prueba de la ?² y la prueba de la t, y la concordancia entre criterios, con el índice kappa. Resultados. Los escolares de las TA presentaron menor peso, talla e índice de masa corporal (IMC) (p< 0,05). Las prevalencias de SP, OB y SP+OB con OMS fueron superiores, excepto para SP en ambos sexos de 11 a 12,99 años de TB y TA. Independientemente de las referencias, el sexo y la edad, las prevalencias de SP, OB y SP+OB fueron, en general, mayores en las TB. La concordancia entre las referencias IOTF/CDC fue buena-muy buena, y entre estas y las de la OMS, regular-moderada. Conclusiones. Los escolares de TA presentaron menor prevalencia de SB y OB. La mejor concordancia se dio entre las referencias IOTF y CDC.

Introduction. Prevalences of overweight and obesity in students from different altitudinal zones of Jujuy are compared using the International Obesity Task Force (IOTF), the Centers for Disease Control (CDC) and the World Health Organization (WHO) references, and the agreement among them. Material and Methods. Weight and height data from 15 541 students were grouped in highlands (HL) (=2500 MASL) and lowlands (LL) (<2500 MASL) and in two age groups (5-6.99 years old and 11-12.99 years old). Overweight and obesity prevalences were calculated according to the different references. The differences in outcome measures and prevalences were established using the ?2 test and the t test, and agreement among the criteria was calculated using the kappa index. Results. Students from the HL had lower weight, height and body mass index (BMI) values (p< 0.05). Overweight and obesity prevalences compared to the WHO reference were higher, except for overweight in students of both sexes, from 11 to 12.99 years old, from the HL and the LL. Regardless of the references, gender and age, overweight and obesity prevalences were generally higher in the LL. Agreement between the IOTF and the CDC was good-very good, and agreement among them and the WHO was fair-moderate. Conclusions. Students from the HL had a lower overweight and obesity prevalence. The greatest agreement was observed between the IOTF and the CDC references.

Comparação das curvas NCHS, CDC e OMS em crianças com risco cardiovascular / Comparison of NCHS, CDC, and WHO curves in children with cardiovascular risk

OBJETIVO: O objetivo deste trabalho foi comparar a prevalência de sobrepeso e obesidade de acordo com três curvas de crescimento: OrganizaçãoMundialde Saúde(OMS/2006), National Centre for Health Statistics (NCHS/1977) e Centers for Disease Control and Prevention (CDC/2000) em crianças com fatores de risco cardiovascular. MÉTODOS: Foram avaliados dados de 118 crianças e adolescentes, com idade entre 2 e 19 anos, atendidos entre os anos de 2001 a 2009 no Ambulatório de Cardiologia Pediátrica Preventiva do Instituto de Cardiologia de Porto Alegre. As variáveis analisadas foram: peso, altura, idade e sexo. Estas foram classificadas quanto aos critérios peso/idade, estatura/idade e índice de massa corpórea (IMC). Os pontos de corte adotados foram de três curvas de crescimento OMS/2006, NCHS/1977, CDC/2000. RESULTADOS: Quanto ao critério peso/idade pelo NCHS, 18% das crianças foram classificadas com eutrofia e 82% com peso elevado; pelo CDC, 28% eutróficas e 72% peso elevado; e pela OMS, 16,0% com eutrofia e 84% com peso elevado. Segundo o IMC, foram classificadas com baixo peso 0,8% da população, segundo CDC e OMS; eutróficos 7,6% e 6,8%, sobrepeso 26,3% e 11,9%, e com obesidade 65,3% e 80,5%, pelo CDC e OMS, respectivamente. Quanto ao critério estatura/idade, não houve diferença significativa entre os referenciais; em média, 98,3% da população estudada apresentou estatura adequada para idade. CONCLUSÃO: Conclui-se que as novas curvas da OMS são mais sensíveis para identificar obesidade em uma população de risco, o que tem importantes implicações para o manejo preventivo e terapêutico.

OBJECTIVE: The study aimed to compare the prevalence of overweight and obesity according to three growth curves, created by theWorld Health Organization (WHO/2006), by the National Center for Health Statistics (NCHS/1977), and by the Centers for Disease Control and Prevention (CDC/2000) in children with cardiovascular risk factors. METHODS: Data from 118 children and adolescents, aged between 2 and 19 years, treated between the years 2001 to 2009 at the Pediatric Preventive Cardiology Outpatient Clinic of the Instituto de Cardiologia de Porto Alegre were evaluated. The variables analyzed were: weight, height, age, and gender. Variables were classified according to the following criteria: weight/age, height/age, and body mass index (BMI). The cutoff points used were obtained from the three growth curves: WHO/2006, NCHS/1977, and CDC/2000. RESULTS: Regarding the criterion weight/age by the NCHS curve, 18% of the children were classified as having normal weight, and 82% had excess weight; by the CDC curve, 28% had normal and 72% had excess weight; by the WHO curve, 16.0% had normal weight and 84% had excess weight. According to the BMI, 0.8% of the population was underweight. According to the CDC and WHO curves, 7.6% and 6.8% had normal weight; 26.3% and 11.9% were overweight; and 65.3% and 80.5% were obese, respectively. Regarding the height/age criterion, there was no significant difference between the references and, on average, 98.3% of the population showed adequate height for age. CONCLUSION: The new WHO curves are more sensitive to identify obesity in a population at risk, which has important implications for preventive and therapeutic management.

Comparing three body mass index classification systems to assess overweight and obesity in children and adolescents / Comparación de tres sistemas de clasificación de los índices de masa corporal para evaluar el sobrepeso y la obesidad en niños y adolescentes

OBJECTIVE: To compare the International Obesity Task Force (IOTF) 2005, Centers for Disease Control and Prevention (CDC) 2000, and World Health Organization (WHO) 2007 body mass index (BMI) classification systems in terms of prevalence estimation and association with demographic factors. METHODS: The 18 265 children and adolescents ages 5 to 18 years (mean = 11.2 years, standard deviation = 3.9 years) in the nationally representative Colombian National Nutrition Survey of 2005 were classified as overweight or obese according to IOTF, CDC, and WHO criteria. Prevalence estimates were compared according to each system and associations with age, sex, socioeconomic status, and population density were tested. RESULTS: Prevalence estimates of combined overweight and obesity differed by system (males: IOTF = 8.5%, CDC = 10.8%, WHO = 14.1%; females: IOTF = 14.6%, CDC = 13.8%, WHO = 17.1%; P < 0.001). The association between combined overweight and obesity and age and sex varied by system. The odds of having overweight and obesity in children (5 to 10 years) compared with adolescents (11 to 18 years) were: IOTF, odds ratio (OR) = 0.87 and 95% confidence interval (CI) = 0.77-0.98; CDC, OR = 1.27 and CI = 1.14-1.42; WHO, OR = 1.21 and CI = 1.08-1.35. The values for females compared with males were: IOTF, OR = 1.84 and CI = 1.6-2.10; CDC, OR = 1.33 and CI = 1.17-1.51; WHO, OR = 1.25 and CI = 1.12-1.41. CONCLUSIONS: There is a lack of consistency among the three main international systems in assessing overweight and obesity in children and adolescents. Appreciably different estimates of prevalence and associations with age and sex are obtained depending on which system is used. Future studies should assess how well each system reflects valid measures of body composition.

OBJETIVO: Comparar los sistemas de clasificación de los índices de masa corporal (IMC) del Grupo de Trabajo Internacional sobre la Obesidad (IOTF) de 2005, de los Centros para el Control y la Prevención de Enfermedades (CDC) de 2000, y de la Organización Mundial de la Salud (OMS) de 2007, en cuanto a la estimación de la prevalencia y la asociación con factores demográficos. MÉTODOS: Los 18 265 niños y adolescentes de ambos sexos y de edades comprendidas entre 5 y 18 años (media = 11,2 años, desviación estándar = 3,9 años) que participaron en la Encuesta Nacional de la Situación Nutricional en Colombia del 2005, representativa a escala nacional, fueron clasificados como afectados de sobrepeso u obesidad según los criterios del IOTF, los CDC y la OMS. Se compararon los cálculos de la prevalencia según cada sistema y se analizaron las asociaciones con la edad, el sexo, la situación socioeconómica y la densidad de población. RESULTADOS: Los cálculos de la prevalencia del sobrepeso y la obesidad combinados diferían según el sistema (varones: IOTF = 8,5%, CDC = 10,8%, OMS = 14,1%; mujeres: IOTF = 14,6%, CDC = 13,8%, OMS = 17,1%; P < 0,001). La asociación entre el sobrepeso y la obesidad combinados y la edad y el sexo también variaban según el sistema de clasificación. Las probabilidades de tener sobrepeso y obesidad en los niños (de 5 a 10 años) en comparación con los adolescentes (de 11 a 18 años) fueron: IOTF, razón de posibilidades (OR) = 0,87 e intervalo de confianza del 95% (IC) 0,77-0,98; CDC, OR = 1,27 e IC 1,14-1,42; OMS, OR = 1,21 e IC 1,08-1,35. Los valores observados en las mujeres en comparación con los varones fueron: IOTF, OR = 1,84 e IC 1,6-2,10; CDC, OR = 1,33 e IC 1,17-1,51; OMS, OR = 1,25 e IC 1,12-1,41. CONCLUSIONES: Existe una falta de uniformidad entre los tres principales sistemas internacionales en la evaluación del sobrepeso y la obesidad en niños y adolescentes. Se obtienen cálculos apreciablemente diferentes de la prevalencia y de las asociaciones con la edad y el sexo según el sistema que se adopte. Los estudios futuros deben evaluar hasta qué punto cada sistema refleja adecuadamente mediciones válidas de la composición corporal.

CHROMagar KPC. Comparación con el método propuesto por los Centros para el Control y Prevención de Enfermedades (CDC, EE.UU.) para el estudio de portación rectal y evaluación de falsos positivos / CHROMagar KPC. Comparison with the method proposed by the Centers for Disease Control and Prevention (CDC, USA) for rectal screening and evaluation of false positive results

Se cultivaron 81 hisopados rectales en el medio CHROMagar KPC y por el método del CDC. Fueron positivos para Klebsiella pneumoniae KPC en CHROMagar KPC, 9/81 y 6/81 con el método del CDC. El medio CHROMagar KPC tuvo dos falsos positivos: 1 K. pneumoniae y 1 Acinetobacter sp. Los falsos positivos del método CDC fueron: 25 Acinetobacter spp., 2 Escherichia coli y4K. pneumoniae. El empleo del medio CHROMagar KPC resultó ser un método con mayor recuperación de aislamientos productores de KPC y menos falsos positivos que el método del CDC. Para evaluar los falsos positivos en el medio CHROMagar KPC se cultivaron 1247 hisopados rectales. Se obtuvieron 1021 negativos, 171 K. pneumoniae KPC y 55 (4,4 %) falsos positivos. Debido al desarrollo de falsos positivos en el medio CHROMagar KPC, se debe confirmar por caracterización fenotípica la presencia de KPC en las bacterias aisladas.

Eighty one rectal swabs (RS) were cultured on CHROMagar KPC and the CDC method. Of the 81 samples, 9 were positive for KPC-producing Klebsiella pneumoniae on CHROMagar KPC, and 6 for the CDC method. CHROMagar KPC had two false positive (FP) results: 1 K. pneumoniae and 1 Acinetobacter sp. FP results on the CDC method were: 25 Acinetobacter spp., 2 Escherichia coli and 4 K. pneumoniae. CHROMagar KPC yielded a better recovery of KPC-producing bacteria and less FP results than CDC method. In order to evaluate FP results on CHROMagar KPC, 1247 RS were cultured and yielded 1021 negatives, 171 KPC-producing K. pneumoniae and 55 FP (4.4 %). Because of the FP results growing on CHROMagar KPC, KPC must be phenotypically confirmed in the bacteria isolated.

Performance of a commercial assay for the diagnosis of influenza A (H1N1) infection in comparison to the Centers for Disease Control and Prevention protocol of real time RT-PCR / Evaluación del desempeño de un equipo comercial para el diagnóstico de influenza A (H1N1) en comparación con el protocolo de RT-PCR en tiempo real diseñado por los Centros de Control y Prevención de Enfermedades (CDC)

At the time of influenza A (H1N1) emergency, the WHO responded with remarkable speed by releasing guidelines and a protocol for a real-time RT-PCR assay (rRT-PCR). The aim of the present study was to evalúate the performance of the "Real Time Ready Influenza A/H1N1 Detection Set" (June 2009)-Roche kit in comparison to the CDC reference rRT-PCR protocol. The overall sensitivity of the Roche assay for detection of the Inf A gene in the presence or absence of the H1 gene was 74.5 %. The sensitivity for detecting samples that were only positive for the Inf A gene (absence of the H1 gene) was 53.3 % whereas the sensitivity for H1N1-positive samples (presence of the Inf A gene and any other swine gene) was 76.4 %. The specificity of the assay was 97.1 %. A new version of the kit (November 2009) is now available, and a recent evaluation of its performance showed good sensitivity to detect pandemic H1N1 compared to other molecular assays.

Durante la pandemia de influenza A (H1N1), la OMS recomendó algoritmos y protocolos de detección del virus mediante RT-PCR en tiempo real. El objetivo del presente estudio fue evaluar el desempeño del equipo que comercializa la empresa Roche, Real Time Ready Influenza A/H1N1 Detection Set (junio de 2009), en comparación con el protocolo de RT-PCR en tiempo real de los CDC. La sensibilidad global del ensayo de Roche para la detección del gen Inf A en presencia o ausencia del gen H1 fue 74,5 %. La sensibilidad para la detección de muestras positivas solo para el gen Inf A (ausencia del gen H1) fue 53,3 % y la sensibilidad para la detección de muestras positivas para H1N1 (presencia del gen Inf A y cualquier otro gen porcino) fue 76,4 %. La especificidad fue 97,1 %. Existe una nueva versión del equipo (noviembre 2009) que, según se ha descrito, presenta buena sensibilidad en comparación con otros ensayos moleculares para detectar H1N1 pandémica.

Directriz para reducir el riesgo de transmisión de infecciones con objetos punzocortantes durante la práctica clínica odontológica / Sharps safety guidelines for infection control and occupational exposure in dental health care settings

Las medidas de bioseguridad están destinadas a disminuir el riesgo de transmisión de microorganismos de fuentes reconocidas o no reconocidas de infección en clínicas dentales relacionadas a accidentes por exposición a sangre y fluidos corporales. En este trabajo se propone una directriz que tiene como objetivos primordiales, la educación del personal delconsultorio de atención de salud bucodental y la prevención para evitar la transmisión de patógenos por instrumentos punzocortantes. Estas recomendaciones están destinadas para la protección de los profesionales de la salud que se dedican a la práctica clínica odontológica.

Concordância dos referenciais de crescimento propostos pelo Center of Disease Control e Organização Mundial de Saúde / Agreement between center of disease control and word health organization reference growth / Concordancia de los referenciales de crecimiento propuestos por el center of disease control y la organización mundial de la salud

O objetivo deste estudo foi verificar a concordância dos referenciais recomendados pelo Center of Disease Control (CDC) e pela Organização Mundial da Saúde (OMS) na avaliação do estado nutricional. Trata-se de um estudo transversal, com participação de 254 crianças de 3 a 11 meses e 29 dias de idade de São Paulo e Ribeirão Preto, nos meses de junho de 2005 a julho de 2006. Os índices antropométricos foram calculados em programas disponibilizados nos sites do CDC e OMS, respectivamente. Aplicado Teste Kappa para as variáveis nominais (comprimento/idade) e Kappa-ponderado para variáveis ordinais (peso/comprimento) evidenciou-se que os referenciais CDC e OMS apresentam diferenças na avaliação nutricional infantil, sendo encontrados resultados com maior discordância nas crianças de 3 a 6 meses.

The objective this study was to verify the agreement of the guidelines recommended by CDC and WHO to evaluate the nutritional state. This is a cross-sectional study, which counted with the participation of 254 children of ages 3 to 11 months and 29 days from São Paulo and Ribeirão Preto, performed from June 2005 to July 2006. The anthropometric indexes were obtained using the software available on the CDC and WHO websites. The Kappa Test was used for nominal variables (length/age) and weighted-Kappa for ordinal variables (weight/length). It was found that there are differences between the CDC and WHO guidelines regarding the evaluation of child nutrition, with greater differences in the results for children of ages 3 to 6 months.

El objetivo deste estudio fue verificar la concordancia de referenciales recomendados por CDC y OMS en evaluación del estado nutricional. Se trata de un estudio transversal, con participación de 254 niños de 3 a 11 meses y 29 días, de São Paulo y Ribeirão Preto, entre junio 2005 y julio 2006. Los índices antropométricos fueron calculados en programas disponibilizados en los portales del CDC y de OMS, respectivamente. Se aplicó Test Kappa para variables nominales (altura/edad) y Kappa-ponderado para variables ordinales (peso/altura). Se evidenció que los referenciales CDC y OMS presentan diferencias en la evaluación nutricional infantil, encontrándose resultados de mayor discordancia en niños de 3 a 6 meses.

"A wild and wondrous ride": CDC field epidemiologists in the east Pakistan smallpox and cholera epidemics of 1958 / "Uma louca e maravilhosa jornada": epidemiologistas de campo do CDC nas epidemias de varíola e cólera do Paquistão Oriental em 1958

In mid-April of 1958 the Government of Pakistan summoned the press to announce a grave need for international aid to cope with smallpox and cholera epidemics in East Pakistan. In response, and with the backing of the US State Department, Dr. Alexander D. Langmuir, chief epidemiologist of the CDC, led a team of epidemiologists to assist authorities in Dacca strengthen their immunization programs. Langmuir's superiors hoped for a Cold War advantage, but he saw an opportunity for trainees in the Epidemic Intelligence Service to learn about public health in a developing country. Langmuir later described the episode as a "wild and wondrous ride," but it had been more like a nightmare: the East Pakistan health department had collapsed; a popular movement had taken over vaccination and squandered vaccine supplies; hostile journalists had questioned the Americans' deeper motives; and a professional rivalry opened between the Americans and a British epidemiologist named Aidan Cockburn. By the time the epidemic subsided in July 1958, 30 million Bengalis had been vaccinated for smallpox but another 20,000 had succumbed to the disease. This episode was CDC's first sustained foreign intervention, a precursor to its extensive role in the 1970s helping WHO eradicate smallpox from Bangladesh.

Em meados de abril de 1958, o Governo do Paquistão convocou a imprensa para anunciar a urgente necessidade de auxílio internacional para lidar com epidemias de varíola e cólera no Paquistão Oriental. Em resposta, e com o apoio do Departamento de Estado dos Estados Unidos, Dr. Alexander D. Langmuir, chefe de epidemiologia do CDC em Atlanta, liderou um time de epidemiologistas para auxiliar as autoridades em Dacca a reforçar seus programas de imunização. Os superiores de Langmuir ansiavam por demonstrações de capacidade dos EUA na Guerra Fria, mas ele vislumbrou uma chance para o Serviço de Inteligência Epidemiológica aprender sobre saúde pública em países em desenvolvimento. Langmuir descreveu o episódio como uma "jornada louca e maravilhosa", porém pareceu mais um pesadelo: o departamento de saúde do Paquistão Oriental entrou em colapso; um movimento popular assumiu a vacinação e desperdiçou suprimentos de vacinas; jornalistas hostis questionaram as motivações ocultas dos americanos; e iniciou-se uma rivalidade profissional entre americanos e o epidemiologista britânico Aidan Cockburn. No final da epidemia, em julho de 1958, tinham sido vacinados trinta milhões de bengalis contra varíola, mas outros vinte mil sucumbiram. Esse episódio foi a primeira intervenção sistemática do CDC no exterior.