Ethical considerations for vaccination programmes in acute humanitarian emergencies.

Humanitarian emergencies result in a breakdown of critical health-care services and often make vulnerable communities dependent on external agencies for care. In resource-constrained settings, this may occur against a backdrop of extreme poverty, malnutrition, insecurity, low literacy and poor infrastructure. Under these circumstances, providing food, water and shelter and limiting communicable disease outbreaks become primary concerns. Where effective and safe vaccines are available to mitigate the risk of disease outbreaks, their potential deployment is a key consideration in meeting emergency health needs. Ethical considerations are crucial when deciding on vaccine deployment. Allocation of vaccines in short supply, target groups, delivery strategies, surveillance and research during acute humanitarian emergencies all involve ethical considerations that often arise from the tension between individual and common good. The authors lay out the ethical issues that policy-makers need to bear in mind when considering the deployment of mass vaccination during humanitarian emergencies, including beneficence (duty of care and the rule of rescue), non-maleficence, autonomy and consent, and distributive and procedural justice.

Les urgences humanitaires entraînent une rupture des services de soins de santé essentiels et elles rendent souvent les communautés vulnérables dépendantes des organismes externes pour leurs soins. Dans les milieux où les ressources sont comptées, cela peut se produire sur fond d'extrême pauvreté, de malnutrition, d'insécurité, de faible niveau d'alphabétisation et d'infrastructures insuffisantes. Dans ces circonstances, fournir nourriture, eau et abri, tout en limitant les épidémies de maladies transmissibles, devient une préoccupation centrale. Lorsqu'il existe des vaccins sûrs et efficaces pour limiter les risques d'épidémies, leur éventuel déploiement est un facteur clé pour satisfaire les besoins sanitaires d'urgence. Les considérations éthiques sont essentielles pour se prononcer sur le déploiement de la vaccination. La distribution de vaccins en quantités limitées, les groupes cibles, les stratégies de vaccination, la surveillance et la recherche lors de situations d'urgence humanitaire graves impliquent tous des considérations éthiques souvent nées de la tension entre le bien individuel et le bien commun. Les auteurs exposent les questions éthiques que les décideurs doivent garder à l'esprit lorsqu'ils envisagent le déploiement d'une vaccination de masse pendant les urgences humanitaires, notamment la bénéficience (devoir de diligence et devoir d'assistance), la non-maléficience, l'autonomie et le consentement, ainsi que la justice de répartition et l'équité procédurale.

Las emergencias humanitarias causan el desplome de los servicios de atención de salud esenciales y, a menudo, provocan que la atención sanitaria de las comunidades vulnerables pase a depender de organismos externos. En entornos con recursos limitados esto puede darse en un contexto de pobreza extrema, desnutrición, inseguridad, bajos niveles de alfabetización e infraestructuras deficientes. Bajo estas circunstancias, suministrar alimentos, agua y refugio, así como limitar la aparición de brotes de enfermedades transmisibles representan las principales preocupaciones. Cuando se dispone de vacunas eficaces y seguras para reducir el riesgo de aparición de brotes de enfermedades, la distribución potencial de las mismas constituye un factor clave en las situaciones de emergencia sanitaria. Las consideraciones éticas son fundamentales a la hora de decidir sobre la distribución de las vacunas. La asignación de vacunas con suministro limitado, los grupos destinatarios de las mismas, las estrategias de entrega, así como la monitorización y los estudios durante las emergencias humanitarias graves implican consideraciones éticas que, a menudo, derivan de un enfrentamiento entre el beneficio individual y el bien común. Los autores exponen los problemas éticos que los responsables políticos deben tener en cuenta a la hora de considerar cómo distribuir la vacunación masiva durante las emergencias humanitarias, lo cual incluye principios como la beneficencia (el deber de atención y la regla del rescate), la no maleficencia, la autonomía y el consentimiento, así como la justicia distributiva y procesal.

Norovirus GI and GII and hepatitis A virus in berries and pomegranate arils in Canada.

Between 2016 and 2021, the Canadian Food Inspection Agency (CFIA) collected 4218 samples of fresh and frozen berries (blackberries, blueberries, raspberries, strawberries and mixed berries) and pomegranate arils at retail across 11 major cities in Canada and tested these samples for the presence of norovirus GI, norovirus GII and hepatitis A virus RNA. The purpose of this testing was to provide information on the prevalence of these viruses in berries and pomegranate arils on the Canadian marketplace. Of the 926 fresh fruit samples tested, norovirus GI RNA was detected in one raspberry sample and norovirus GII RNA was detected in one strawberry sample. Of the 3292 frozen fruit samples tested, norovirus GI RNA was detected in one blackberry sample, one raspberry sample and one strawberry sample, and norovirus GII RNA was detected in one blueberry sample, three raspberry samples, four strawberry samples, one pomegranate arils sample and one mixed berry sample. None of the fresh or frozen fruit samples tested positive for hepatitis A virus RNA. No statistically significant associations were observed between the prevalence of viral RNA in samples of fresh and frozen fruit, between the prevalence of viral RNA in samples of domestic and imported fruit or between the prevalence of viral RNA in samples of specific fruit types. Overall, the prevalence of norovirus GI and GII RNA together in fresh and frozen fruit samples in Canada was 0.36 %. The results of this study may be used to refine surveillance programs for norovirus and hepatitis A virus in fresh and frozen berries and pomegranate arils, e.g. by adapting the commodities tested and/or the numbers of planned samples to better target these hazards. This information may also be used to inform other Government of Canada approaches to better understand the controls associated norovirus and hepatitis A virus in fresh and frozen berries and pomegranate arils.

Microbiological Survey of Wheat Flour Sold at Retail in Canada, 2018 to 2019.

ABSTRACT: Following two O121 Shiga toxin-producing Escherichia coli (STEC) outbreaks linked to wheat flour, this study was conducted to gain baseline information on the occurrence of bacterial pathogens and levels of indicator organisms in wheat flour in Canada. A total of 347 prepackaged wheat flour samples were analyzed for Salmonella species, STEC, Listeria monocytogenes, aerobic colony count (ACC), total coliforms, and Escherichia coli. Salmonella spp. and O157 STEC were not detected in any of the samples. L. monocytogenes was identified in two samples (0.6%) at levels below the limit of detection (<0.7 log CFU/g). Non-O157 STEC were isolated from six samples (1.7%) and were characterized for the presence of STEC virulence genes: stx1, stx2, and their subtypes, eae, hlyA, and aggR. One O103:H25 STEC isolate carried virulence genes (stx1a+eae) that are known to be capable of causing diarrhea and/or bloody diarrhea in humans. Of the five remaining non-O157 STEC isolates, four carried single stx2a or stx2c genes and were considered to have the potential of causing diarrhea. The remaining non-O157 STEC isolate (stx2), while not a priority non-O157 STEC, was not available for sequencing; thus, its potential to cause illness is unknown. ACC, total coliforms, and E. coli were detected (≥0.48 log CFU/g) in 98.8, 72.6, and 0.6% of the flour samples. The mean counts of ACC were greater in whole wheat flour compared with the other flour types tested (P < 0.001). The results of this study suggest that the occurrence of O157 STEC and Salmonella is low but that the occurrence of non-O157 STEC in wheat flour with the potential to cause human illness of diarrhea is relatively common. Therefore, the consumption of raw flour could increase the likelihood of STEC infections. Further research is merited for potential risk mitigation strategies within the food production system and with consumers.

Becoming a global citizen through nursing education: lessons learned in developing evaluation tools.

While global health practica are being increasingly described in nursing education literature, course evaluation of same receives comparatively less attention. In this article, authors report on an evaluation project, undertaken to rigorously examine the existing evaluation methods for an elective global health practicum with placements in India and northern Canada. Sixteen students were interviewed and course evaluation tools were reviewed. Resulting themes include students' sense of preparedness, the centrality of the student-preceptor relationship, the importance of supported self-reflection, and the usefulness of evaluation methods. Participants viewed existing course evaluation methods as generally useful, therefore requiring only minor adjustments. There were also structural revisions to the preparation, placement, and post-placement phases of the course and broader lessons learned. Lessons include the importance of critical social perspectives and the value of past students revisiting their experiences in such a way as make conscious connections between placement experiences and their current professional practice.

Microbial safety of cheese in Canada.

A profile of the microbial safety of cheese in Canada was established based on the analysis of 2955 pasteurized and raw-milk cheeses tested under Canada's National Microbiological Monitoring Program (NMMP) and 2009 raw-milk cheeses tested under the Targeted Survey Program. 97.8% of NMMP and 99.6% of Targeted Survey cheese samples were assessed as being of satisfactory microbiological safety. Under the NMMP, Salmonella spp. was detected in 2 samples, Listeria monocytogenes was detected in 15 samples and no Escherichia coli O157/H7:NM (non-motile) was detected. Cheese samples assessed as having unsatisfactory levels of S. aureus and generic E. coli were found in 18 and 41 samples, respectively. Under the Targeted Survey, L. monocytogenes was detected in 2 samples, while no Salmonella spp. or E. coli O157/H7:NM were detected. Cheese samples assessed as having investigative and unsatisfactory levels of S. aureus were found in 4 and 2 samples respectively. No samples were found to have investigative or unsatisfactory levels of generic E. coli. For cheese samples collected under the NMMP, logistic regression models indicated that contamination was more frequent in raw-milk cheeses compared to pasteurized-milk cheeses (OR = 5.0, 95% CI (3.0, 8.3)), and in imported cheeses compared to domestic cheeses (OR = 8.2, 95% CI (4.1, 16.1)). A statistically significant association was found between cheese samples assessed as having unsatisfactory levels of generic E. coli and detection of L. monocytogenes, Salmonella spp. or levels of S. aureus that were assessed as unsatisfactory (p < .001). These test results will help support risk analysis and inform food safety decisions.

Associations of processing level variables with Salmonella prevalence and concentration on broiler chicken carcasses and parts in Canada.

A national baseline study was conducted between December 2012 and December 2013 to determine the pre-packaging prevalence and concentration of foodborne pathogens on broiler chicken carcasses and parts at processing; a survey was implemented simultaneously to collect data on the processing practices used to control these pathogens. Thirty federally-registered Canadian poultry processing establishments completed the questionnaire. A total of 2,732 samples of carcasses and parts (breast and thigh pieces) were collected over the study period from these establishments. For Salmonella, the overall proportion positive was 0.22 (95% CI 0.20, 0.23), and the mean concentration was 0.67 (95% CI 0.51, 0.83) MPN/mL of rinse fluid. Multivariable regression models with random intercepts for the establishment and the date of sampling were used to identify associations between Salmonella prevalence and concentration and processing practices. In the final logistic regression model for the prevalence outcome (positive or negative sample), there were three statistically significant variables: product type (carcass or part); chilling method (water or air); and chlorine use in the establishment (chlorine, cetylpyridinium chloride, or neither). The likelihood of testing positive for Salmonella was higher on parts than carcasses (OR 3.03, 95% CI 2.38, 3.86), and higher when cetylpyridinium chloride was used (OR 2.00, 95% CI 1.36, 2.95), or when other processing aids were used (OR 1.99, 95% CI 1.26, 3.15), than when chlorine was used. Water chilling was negatively associated with testing positive for Salmonella when compared with air chilling (OR 0.68, 95% CI 0.48, 0.96). In the final linear regression model for the concentration outcome (log10 MPN/mL), there was one statistically significant variable chilling method, where water chilling was associated with a decrease in concentration (ß -0.23, 95% CI -0.38, -0.08 log10 MPN/mL). The intraclass correlation coefficients for establishment and date sampling were 0.02 and 0.23 in the linear regression model, and 0.01 and 0.34 in the logistic regression model, respectively. Further studies to explore the methods to reduce microbial contamination during the air chilling and cut-up and boning processes in broiler chicken establishments in Canada are recommended.

Four-Weekly Benzathine Penicillin G Provides Inadequate Protection against Acute Rheumatic Fever in Some Children.

This study aimed to identify recurrent acute rheumatic fever (ARF) episodes which occurred despite adherence to prophylactic benzathine penicillin G (BPG). Data from Australia's Northern Territory were analyzed; ARF recurrences between 2012 and 2017 diagnosed while the person was prescribed BPG were identified. Days at risk (DAR)-median and interquartile range-preceding ARF onset were calculated. The timing of BPG doses was examined for individuals with no DAR. One hundred sixty-nine ARF recurrences were analyzed; median DAR in the previous 8 weeks before ARF onset was 29. Most recurrences occurred following > 7 DAR (87%). Eight recurrences (5%) occurred despite no DAR; all were aged less than 16 years at the time of their recurrence/s. Recurrent ARF most commonly occurs after delayed BPG doses, but in some cases, receiving every prescribed BPG dose on time did not prevent recurrent ARF. A method to identify high-risk individuals before recurrent ARF is needed.

A cluster of acute rheumatic fever cases among Aboriginal Australians in a remote community with high baseline incidence.

OBJECTIVES: We report a cluster of acute rheumatic fever (ARF) cases and the public health response in a high-burden Australian setting. METHODS: The public health unit was notified of an increase in ARF cases in a remote Australian Aboriginal community. A multi-disciplinary group coordinated the response. Household contacts were screened for ARF or group A Streptococcus (GAS) infection by questionnaire and swab collection, offered an echocardiogram if aged 5-20 years, and intramuscular benzathine benzylpenicillin if aged over one year or if less than one year with impetigo. RESULTS: Fifteen definite and seven probable ARF cases were diagnosed in the community in July-December 2014 (all-age incidence of definite ARF: 1,473/100,000). The public health response identified two additional cases of ARF. A total of 81 contacts were screened; GAS was detected in 3/76 (4%) throat swabs and 11/24 (46%) skin swabs. Molecular typing revealed high GAS strain diversity. CONCLUSIONS: The incidence of ARF during this cluster was very high. Carriage and infection with GAS was observed, but no outbreak strain identified. Implications for public health: A national public health guideline has since been developed that includes advice on the investigation of an ARF outbreak/cluster. Sustained efforts with strong community engagement are required to tackle high ARF rates.

Trends in incidence and outcome of stroke in Perth, Western Australia during 1989 to 2001: the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: We studied temporal trends in major stroke outcomes in Perth, Western Australia (WA), comparing 3 12-month periods, roughly 5 years apart, between 1989 and 2001. METHODS: The Perth Community Stroke Study (PCSS) used uniform definitions and procedures in a representative segment (approximately 143,000 people in the year 2000) of Perth, WA. Crude and age-standardized incidence and 28-day case fatality for stroke in the different study periods were compared using Poisson regression. We also undertook temporal comparisons of severity, risk factors, and management of stroke to define the basis for any changes in rates. Data are reported with 95% confidence intervals (CI). RESULTS: There were 251, 213, and 183 first-ever strokes identified in the first, second, and third study periods, respectively, reflecting significant declines in stroke rates overall, for major age groups, and for both ischemic stroke and intracerebral hemorrhage. The decline in rates was greater in men than women. Compared with the 1989 to 1990 period, sex- and age-adjusted rates declined by 25% (95% CI 10% to 37%) in 1995 to 1996, and by 43% (95% CI 31% to 53%) in 2000 to 2001, corresponding to a 5.5% average annual decrease overall. There were correspondingly significant reductions in the frequencies of key risk factors among cases. However, early case fatality remained stable, both overall and for major pathological subtypes of stroke. CONCLUSIONS: These data confirm significant declines in the incidence of stroke on the western side of Australia, coincident with some improvement in the vascular risk profile of cases in the population. Decreasing risk rather than improving survival appears to be the main driver of falling mortality from stroke in this population.

Rheumatic Heart Disease Prophylaxis in Older Patients: A Register-Based Audit of Adherence to Guidelines.

BACKGROUND: Prevention of rheumatic heart disease (RHD) remains challenging in high-burden settings globally. After acute rheumatic fever (ARF), secondary antibiotic prophylaxis is required to prevent RHD. International guidelines on recommended durations of secondary prophylaxis differ, with scope for clinician discretion. Because ARF risk decreases with age, ongoing prophylaxis is generally considered unnecessary beyond approximately the third decade. Concordance with guidelines on timely cessation of prophylaxis is unknown. METHODS: We undertook a register-based audit to determine the appropriateness of antibiotic prophylaxis among clients aged ≥35 years in Australia's Northern Territory. Data on demographics, ARF episode(s), RHD severity, prophylaxis type, and relevant clinical notes were extracted. The determination of guideline concordance was based on whether (1) national guidelines were followed; (2) a reason for departure from guidelines was documented; (3) lifelong continuation was considered appropriate in all cases of severe RHD. RESULTS: We identified 343 clients aged ≥35 years prescribed secondary prophylaxis. Guideline concordance was 39% according to national guidelines, 68% when documented reasons for departures from guidelines were included and 82% if patients with severe RHD were deemed to need lifelong prophylaxis. Shorter times since last echocardiogram or cardiologist review were associated with greater likelihood of guideline concordance (P < .001). The median time since last ARF was 5.9 years in the guideline-concordant group and 24.0 years in the nonconcordant group (P < .001). Thirty-two people had an ARF episode after age 40 years. CONCLUSIONS: In this setting, appropriate discontinuation of RHD prophylaxis could be improved through timely specialist review to reduce unnecessary burden on clients and health systems.

Enhanced surveillance during a public health emergency in a resource-limited setting: Experience from a large dengue outbreak in Solomon Islands, 2016-17.

Between August-2016 and April-2017, Solomon Islands experienced the largest and longest-running dengue outbreak on record in the country, with 12,329 suspected cases, 877 hospitalisations and 16 deaths. We conducted a retrospective review of related data and documents, and conducted key informant interviews to characterise the event and investigate the adaptability of syndromic surveillance for enhanced and expanded data collection during a public health emergency in a low resource country setting. While the outbreak quickly consumed available public and clinical resources, we found that authorities were able to scale up the conventional national syndrome-based early warning surveillance system to support the increased information demands during the event demonstrating the flexibility of the system and syndromic surveillance more broadly. Challenges in scaling up included upskilling and assisting staff with no previous experience of the tasks required; managing large volumes of data; maintaining data quality for the duration of the outbreak; harmonising routine and enhanced surveillance data and maintaining surveillance for other diseases; producing information optimally useful for response planning; and managing staff fatigue. Solomon Islands, along with other countries of the region remains vulnerable to outbreaks of dengue and other communicable diseases. Ensuring surveillance systems are robust and able to adapt to changing demands during emergencies should be a health protection priority.

Apparent involvement of a beta1 type integrin in coral fertilization.

Integrins are involved in a wide variety of cell adhesion processes, and have roles in gamete binding and fusion in mammals. Integrins have been also discovered in the scleractinian coral Acropora millepora (Cnidaria: Anthozoa). As a first step toward understanding the molecular basis of fertilization in corals, we examined the effect of polyclonal antisera raised against recombinant coral integrins on gamete interactions in A. millepora. Antiserum raised against integrin betacn1 dramatically decreased the binding of Acropora sperm to eggs and significantly decreased fertilization rates relative to preimmune serum and seawater controls. However, the antiserum against AmIntegrin alpha1 did not affect significantly either sperm-egg binding or fertilization. One possible explanation for this is that AmIntegrin alpha1 may preferentially mediate interactions with RGD-containing ligands, whereas mammalian alpha6 integrin (which is most directly implicated in gamete interactions) preferentially interacts with laminin-related ligands. Our results suggest that beta1 type integrins are involved in the fertilization process in Acropora and that some functions of these molecules may have been conserved between corals and mammals.

Lessons learnt from a three-year pilot field epidemiology training programme.

PROBLEM: The Pacific region has widely dispersed populations, limited financial and human resources and a high burden of disease. There is an urgent need to improve the availability, reliability and timeliness of useable health data. CONTEXT: The purpose of this paper is to share lessons learnt from a three-year pilot field epidemiology training programme that was designed to respond to these Pacific health challenges. The pilot programme built on and further developed an existing field epidemiology training programme for Pacific health staff. ACTION: The programme was delivered in country by epidemiologists working for Pacific Public Health Surveillance Network partners. The programme consisted of five courses: four one-week classroom-based courses and one field epidemiology project. Sessions were structured so that theoretical understanding was achieved through interaction and reinforced through practical hands-on group activities, case studies and other interactive practical learning methods. OUTCOME: As of September 2016, 258 students had commenced the programme. Twenty-six course workshops were delivered and one cohort of students had completed the full five-course programme. The programme proved popular and gained a high level of student engagement. DISCUSSION: Face-to-face delivery, a low student-to-facilitator ratio, substantial group work and practical exercises were identified as key factors that contributed to the students developing skills and confidence. Close engagement of leaders and the need to quickly evaluate and adapt the curriculum were important lessons, and the collaboration between external partners was considered important for promoting a harmonized approach to health needs in the Pacific.

Risk posed by the Ebola epidemic to the Pacific islands: findings of a recent World Health Organization assessment.

OBJECTIVE: To assess the public health risk posed by the ongoing Ebola virus disease (EVD) epidemic in West Africa to Pacific island countries and areas and to highlight priority risk management actions for preparedness and response. METHOD: The likelihood of EVD importation and the magnitude of public health impact in Pacific island countries and areas were assessed to determine overall risk. Literature about the hazard, epidemiology, exposure and contextual factors associated with EVD was collected and reviewed. Epidemiological information from the current EVD outbreak was assessed. RESULTS: As of 11 March 2015, there have been more than 24,200 reported cases of EVD and at least 9976 deaths in six West African countries. Three EVD cases have been infected outside of the West African region, and all have epidemiological links to the outbreak in West Africa. Pacific island countries' and areas' relative geographic isolation and lack of travel or trade links between countries with transmission means that EVD importation is very unlikely. However, should a case be imported, the health and non-health consequences would be major. The capacity of Pacific island countries and areas to respond adequately varies greatly between (and within) states but in general is limited. DISCUSSION: This risk assessment highlights the needs to enhance preparedness for EVD in the Pacific by strengthening the capacities outlined in the World Health Organization Framework for Action on Ebola. Priority areas include the ability to detect and respond to suspected EVD cases quickly, isolation and management of cases in appropriately resourced facilities and the prevention of further cases through infection prevention and control. These efforts for Ebola should enhance all-hazards public health preparedness in line with the International Health Regulations (2005).

Ten-year risk of first recurrent stroke and disability after first-ever stroke in the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: Limited information exists on the long-term prognosis after first-ever stroke. We aimed to determine the absolute frequency of first recurrent stroke and disability and the relative frequency of recurrent stroke over 10 years after first-ever stroke in Perth, Western Australia. METHODS: For a 12-month period beginning February 1989, all individuals with suspected acute stroke or transient ischemic attack who lived in a geographically defined and representative region of Perth were registered prospectively. Patients with a definite first-ever stroke were followed up 10 years after the index event. RESULTS: Over 10 years of follow-up, the cumulative risk of a first recurrent stroke was 43% (95% confidence interval [CI], 34 to 51). After the first year after first-ever stroke, the average annual risk of recurrent stroke was approximately 4%. Case fatality at 30 days after first recurrent stroke was 41%, which was significantly greater than the case fatality at 30 days after first-ever stroke (22%) (P=0.003). For 30-day survivors of first-ever stroke, the 10-year cumulative risk of death or new institutionalization was 79% (95% CI, 73 to 85) and of death or new disability was 87% (95% CI, 81 to 92). CONCLUSIONS: Over 10 years of follow-up, the risk of first recurrent stroke is 6 times greater than the risk of first-ever stroke in the general population of the same age and sex, almost one half of survivors remain disabled, and one seventh require institutional care. Effective strategies for prevention of stroke need to be implemented early, monitored frequently, and maintained long term after first-ever stroke.

Ten-year survival after first-ever stroke in the perth community stroke study.

BACKGROUND AND PURPOSE: Very few studies have provided information regarding long-term prognosis after stroke. We aimed to determine the absolute and relative survival over 10 years among patients with first-ever stroke from a population-based study in Perth, Western Australia. METHODS: For a 12-month period beginning February 1989, all individuals with a suspected acute stroke or transient ischemic attack who were resident in a geographically defined and representative region of Perth, Western Australia, were registered prospectively and assessed according to standardized diagnostic criteria. Patients with a definite first-ever stroke were followed up prospectively at 4 months, 12 months, 5 years, and 10 years after the index event. RESULTS: A total of 251 patients with first-ever stroke were registered, and 244 (97%) were followed up at 10 years, by which time 197 (79%; 95% confidence interval [CI], 74 to 84) had died. The major causes of death were the direct effects of the initial stroke (27%; 95% CI, 21 to 33) and cardiovascular disease (26%; 95% CI, 20 to 32). Among 1-year survivors of stroke, the average annual case fatality was 4.8%, which was 2.3 (95% CI, 1.9 to 2.7) times greater than for the general population of the same age and sex. CONCLUSIONS: One in 5 patients with first-ever stroke survived to 10 years. The average annual case fatality was 4.8% between years 1 and 10 after stroke, which was twice that expected for the general population. Vascular disease is the major cause of death among long-term survivors of stroke.

Operation crash and surge: lessons learned from a region-wide exercise.

The Homeland Security Exercise and Evaluation Program (HSEEP) provides base guidance for planning all levels of public safety exercises, from simple seminars to complex full-scale exercises. However, the recent emphasis placed on the Federal Emergency Response Agency Whole Community approach to emergency management involves broadening the spectrum of participants to include multiple community partners. The magnitude and complexity of these exercises necessitates the incorporation of additional planning strategies beyond HSEEP guidance. The objective of this paper is to offer insight on effectively planning, running and learning from a region-wide multi-agency, multi-discipline, full-scale exercise. This will be achieved by utilising a case study to outline the planning process and lessons learned from managing the interaction of components, with an emphasis on achieving common goals without compromising individual needs. Additionally, this article complements 'Plane down in the city: Operation Crash and Surge', written by Duane F. Kann and Thomas W. Draper, and published in Volume 7 Number 3 of this journal.