Assessment of serosurveys for H5N1.

BACKGROUND: It has been suggested that the true case-fatality rate of human H5N1 influenza infection is appreciably less than the figure of approximately 60% that is based on official World Health Organization (WHO)-confirmed case reports because asymptomatic cases may have been missed. A number of seroepidemiologic studies have been conducted in an attempt to identify such missed cases. METHODS: We conducted a comprehensive literature review of all English-language H5N1 human serology surveys with detailed attention to laboratory methodology used (including whether investigators used criteria set by the WHO to define positive cases), laboratory controls used, and the clades/genotypes involved. RESULTS: Twenty-nine studies were included in the analysis. Few reported using unexposed control groups and one-third did not apply WHO criteria. Of studies that used WHO criteria, only 4 found any seropositive results to clades/genotypes of H5N1 that are currently circulating. No studies reported seropositive results to the clade 2/genotype Z viruses that have spread throughout Eurasia and Africa. CONCLUSIONS: This review suggests that the frequency of positive H5 serology results is likely to be low; therefore, it is essential that future studies adhere to WHO criteria and include unexposed controls in their laboratory assays to limit the likelihood of false-positive results.

The role of research in viral disease eradication and elimination programs: lessons for malaria eradication.

By examining the role research has played in eradication or regional elimination initiatives for three viral diseases--smallpox, poliomyelitis, and measles--we derive nine cross-cutting lessons applicable to malaria eradication. In these initiatives, some types of research commenced as the programs began and proceeded in parallel. Basic laboratory, clinical, and field research all contributed notably to progress made in the viral programs. For each program, vaccine was the lynchpin intervention, but as the programs progressed, research was required to improve vaccine formulations, delivery methods, and immunization schedules. Surveillance was fundamental to all three programs, whilst polio eradication also required improved diagnostic methods to identify asymptomatic infections. Molecular characterization of pathogen isolates strengthened surveillance and allowed insights into the geographic source of infections and their spread. Anthropologic, sociologic, and behavioural research were needed to address cultural and religious beliefs to expand community acceptance. The last phases of elimination and eradication became increasingly difficult, as a nil incidence was approached. Any eradication initiative for malaria must incorporate flexible research agendas that can adapt to changing epidemiologic contingencies and allow planning for posteradication scenarios.

Comments from the Center for Biosecurity of UPMC on proposed revisions to federal quarantine rules.

On November 30, 2005, the U.S. Centers for Disease Control and Prevention (CDC) proposed changes to federal quarantine regulations (42 CFR Parts 70 and 71). As stated in the proposed rules, the intent of changes is "to clarify and strengthen existing procedures to enable CDC to respond more effectively to current and potential communicable disease threats." Parts 70 and 71 of 42 CFR authorize the Secretary of the Department of Health and Human Services (HHS) to make and enforce regulations "as in his judgement are necessary to prevent the introduction, transmission, and spread of communicable diseases" from foreign countries (Part 71) and between states (Part 70). The Center for Biosecurity of UPMC reviewed the proposed revisions to the quarantine regulations and submitted to CDC the following analysis as its official comments on the revised rules.

Navigating the storm: report and recommendations from the Atlantic Storm exercise.

Atlantic Storm was a tabletop exercise simulating a series of bioterrorism attacks on the transatlantic community. The exercise occurred on January 14, 2005, in Washington, DC, and was organized and convened by the Center for Biosecurity of UPMC, the Center for Transatlantic Relations of Johns Hopkins University, and the Transatlantic Biosecurity Network. Atlantic Storm portrayed a summit meeting of presidents, prime ministers, and other international leaders from both sides of the Atlantic Ocean in which they responded to a campaign of bioterrorist attacks in several countries. The summit principals, who were all current or former senior government leaders, were challenged to address issues such as attaining situational awareness in the wake of a bioattack, coping with scarcity of critical medical resources such as vaccine, deciding how to manage the movement of people across borders, and communicating with their publics. Atlantic Storm illustrated that much might be done in advance to minimize the illness and death, as well as the social, economic, and political disruption, that could be caused by an international epidemic, be it natural or the result of a bioterrorist attack. These lessons are especially timely given the growing concerns over the possibility of an avian influenza pandemic that would require an international response. However, international leaders cannot create the necessary response systems in the midst of a crisis. Medical, public health, and diplomatic response systems and critical medical resources (e.g., medicines and vaccines) must be in place before a bioattack occurs or a pandemic emerges.

The eradication of smallpox--an overview of the past, present, and future.

The 30th anniversary of the declaration of smallpox eradication is a propitious time to look back on the evolutionary history of the program, its execution, and its legacy for the future. The eradication of history's most feared disease culminated a decade-long World Health Organization campaign which began despite skepticism and doubt and succeeded despite a never ending array of obstacles occasioned by floods, civil war, famine, and bureaucratic inertia. New concepts in public health management, surveillance, and the application of large-scale programs for vaccination were fostered and matured. A new generation of young health workers emerged who applied new approaches and experienced the gratification of public health achievement. A definitive legacy for the future was the extension of the program into an "Expanded Program on Immunization", now functioning world-wide and resulting in dramatic improvements in health through control of vaccine-preventable diseases. No less important are the growing number of multi-national programs whose foundations rest on the development of active case surveillance to measure achievement and to guide progress - poliomyelitis, measles, guinea worm, and rubella.

Anthrax as a biological weapon, 2002: updated recommendations for management.

OBJECTIVE: To review and update consensus-based recommendations for medical and public health professionals following a Bacillus anthracis attack against a civilian population. PARTICIPANTS: The working group included 23 experts from academic medical centers, research organizations, and governmental, military, public health, and emergency management institutions and agencies. EVIDENCE: MEDLINE databases were searched from January 1966 to January 2002, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Reference review identified work published before 1966. Participants identified unpublished sources. CONSENSUS PROCESS: The first draft synthesized the gathered information. Written comments were incorporated into subsequent drafts. The final statement incorporated all relevant evidence from the search along with consensus recommendations. CONCLUSIONS: Specific recommendations include diagnosis of anthrax infection, indications for vaccination, therapy, postexposure prophylaxis, decontamination of the environment, and suggested research. This revised consensus statement presents new information based on the analysis of the anthrax attacks of 2001, including developments in the investigation of the anthrax attacks of 2001; important symptoms, signs, and laboratory studies; new diagnostic clues that may help future recognition of this disease; current anthrax vaccine information; updated antibiotic therapeutic considerations; and judgments about environmental surveillance and decontamination.

Prioridades de salud: problemas por resolver y nuevos retos / Unfinished problems and new challenges

En los últimos 25 años hemos sido testigos de cambios verdaderamente revolucionarios en el campo de la salud, en especial en los países de ingresos bajos y medios. En este artículo se discuten algunos de los problemas de salud que se deben resolver y los retos que habrán de enfrentarse. Dentro de ellos destacan el financiamiento de los servicios de salud, la atención a una población con un problema de edad cada vez mayor, la mejoría en la calidad de los servicios y la capacitación de recursos humanos para enfrentar futuras necesidades de salud dentro de un contexto de recursos cada vez mas limitados

In the last 25 years we have witnessed revolutionary changes in the field of health, particularly in the low and middle income countries. This paper discusses some of the new problems which need to be solved and some of the challenges which lie ahead Among the former we can mention the financing of health care services and the provision of health care to an aging population. Among the latter we include the need for improvement of the quality of health services and the training of appropriate health manpower.

Smallpox eradication : A WHO success story

The erradication of smallpox marked the end of the pain and suffering of its victims who, as recently as 1967, were estimated to have numbered 10-15 million each year and among whom possibly 1.5-2 million died. It marked the end of the blindness, severe disfigurement and other disabling conditions among those who survived. It meant that all countries could utilize resources previously devoted to smallpox control for other health purpose, that they could stop vaccinaton programmes and that travellers would no longer need to present certificates attesting that they had been successfully vaccinated. On 26 October 1987 it will be 10 years since the last natural outbreak os smallpox on spaceship earth (1). World Health Forum presents an interview with Dr. A. Handerson, who has head of WHO's smallpox eradication programme from 1966 to 1977