The United Nations and One Health: the International Health Regulations (2005) and global health security.

The One Health approach encompasses multiple themes and can be understood from many different perspectives. This paper expresses the viewpoint of those in charge of responding to public health events of international concern and, in particular, to outbreaks of zoonotic disease. Several international organisations are involved in responding to such outbreaks, including the United Nations (UN) and its technical agencies; principally, the Food and Agriculture Organization of the UN (FAO) and the World Health Organization (WHO); UN funds and programmes, such as the United Nations Development Programme, the World Food Programme, the United Nations Environment Programme, the United Nations Children's Fund; the UN-linked multilateral banking system (the World Bank and regional development banks); and partner organisations, such as the World Organisation for Animal Health (OIE). All of these organisations have benefited from the experiences gained during zoonotic disease outbreaks over the last decade, developing common approaches and mechanisms to foster good governance, promote policies that cut across different sectors, target investment more effectively and strengthen global and national capacities for dealing with emerging crises. Coordination among the various UN agencies and creating partnerships with related organisations have helped to improve disease surveillance in all countries, enabling more efficient detection of disease outbreaks and a faster response, greater transparency and stakeholder engagement and improved public health. The need to build more robust national public human and animal health systems, which are based on good governance and comply with the International Health Regulations (2005) and the international standards set by the OIE, prompted FAO, WHO and the OIE to join forces with the World Bank, to provide practical tools to help countries manage their zoonotic disease risks and develop adequate resources to prevent and control disease outbreaks, particularly at the animal source. All these efforts contribute to the One Health agenda.

Audit on the use of thromboprophylaxis during caesarean section.

Thromboembolic disease is still a main cause of maternal morbidity and mortality. In 1995 the RCOG working party on prophylaxis against thromboembolism has suggested that patients undergoing caesarean section should have a risk assessment and be given heparin prophylaxis if deemed to be high risk. In Stepping Hill Hospital this was audited. The outcome was that 0% of emergency caesarean sections, and only 25% of elective caesarean sections who were considered to be high risk had heparin prophylaxis. A structured risk assessment form was introduced for every patient undergoing caesarean section and the outcome was re-audited; 72.7% and 85.7% of emergency and elective caesarean sections, respectively,that were deemed high risk had adequate heparin thromboembolic prophylaxis. Filling in a risk assessment form before performing a caesarean section reminds and reinforces the need to consider thromboprophylaxis. A risk assessment form has been formally incorporated into all the maternity case records.

New geographical approaches to control of some parasitic zoonoses.

The advent of new technology for geographical representation and spatial analysis of databases from different sectors offers a new approach to planning and managing the control of tropical diseases. This article reviews the geographical and intersectoral aspects of the epidemiology and control of African trypanosomiasis, cutaneous and visceral leishmaniasis, Chagas disease, schistosomiasis, and foodborne trematode infections. The focal nature of their transmission, increasing recognition of the importance of animal reservoirs, and the need to understand environmental factors influencing their distribution are common to all these diseases. Geographical information systems (GIS) open a completely new perspective for intersectoral collaboration in adapting new technology to promote control of these diseases.

The efficacy and acceptability of a low-dose levonorgestrel intravaginal ring for contraception in a UK cohort.

The efficacy and acceptability of a levonorgestrel-releasing intravaginal ring (IVR) for contraception was assessed in a British cohort studied as part of a multicentre, multinational clinical trial performed under the auspices of the World Health Organisation. One-hundred-and-fifty women took part in the study in two UK centres and completed 1417.5 months of method use. Fifty-nine women discontinued use of the IVR before the end of one year giving an overall discontinuation rate of 39.9 per 100 woman-years. The discontinuation for pregnancy with the ring in situ, was 3.0 per 100 woman-years (life table analysis). Menstrual disturbance, vaginal problems and involuntary expulsion resulted in discontinuation rates of 8.9, 8.4 and 1.6 per 100 woman-years, respectively. This method is an acceptable and effective method of contraception for women.

[Monitoring and treatment of toxoplasmosis in the pregnant woman, fetus and newborn]. / Surveillance et traitement de la toxoplasmose chez la femme enceinte, le foetus et le nouveau-né.

A protocol of monitoring and treatment in toxoplasmosis is suggested by the authors. During pregnancy, the administration of spiramycine at a 9 m UI daily dose remains the basic preventive treatment when a seroconversion occurs after a 4 week post-conception period. In the fetus, the antenatal diagnosis is made by ultrasound started on the 18th week after conception and repeated every 4 weeks, amniocentesis and eventually umbilical cord puncture associated with a pyrimethamine-sulfamide drug treatment in case of positive diagnosis. A therapeutic pregnancy termination is considered when lesions have been detected by ultrasound. In the newborn (neonatal or post-natal period), the diagnosis is made by transfontanel ultrasonography, ocular fundi and spinal fluid examination, detection of specific IgM antibodies in cord blood and the evolution and importance of serum antibodies response requiring a drug treatment during 15-18 months with spiramycine and pyrimethamine + sulfadoxine (Fansidar).

The progestagen releasing vaginal ring.

The results of the Manchester study and its reinforcement from data from the multicenter study indicate that the ring is a well-tolerated delivery system for low-dose progestagens. The expulsion rate is low and vaginal tolerance satisfactory. The pregnancy rate and bleeding pattern is of the same order as oral low-dose progestagens. Indeed, there is an indication that the pregnancy rate and abnormal bleeding rate may be even lower. Data from other more extensive phase 3 studies will be required to confirm this impression. The subjective assessment is that the majority of patients are enthusiastic about this method of contraception, bearing in mind that many of them had become disenchanted with existing marketed contraceptive methods. Because of its high level of acceptability, the gap between theoretical and use-effectiveness in narrowed and once inserted, a high degree of motivation is not required since the existing ring only needs to be reinserted after 90 days of use. The acceptability of vaginal methods of contraception as evidenced by the rapid uptake of the vaginal sponge suggests that there is considerable potential for increased use of vaginal methods. In the present state of knowledge, it would appear that the woman for whom the progestagen only conception is particularly appropriate is the one who is lactating or for the older woman whose fertility is on the wane. For the woman who wishes to space her family, the progestagen only contraceptive is also appropriate. With increased refinements and experience of this method, there is a likelihood that the ring may extend the use and application of progestagen only contraception to a wider range of potential patients.

The effect of ethinyl estradiol 20 mcg and levonorgestrel 250 mcg on the pituitary-ovarian function during normal tablet-taking and when tablets are missed.

A new combined pill containing 20 micrograms of ethinyl estradiol and 250 micrograms of levonorgestrel has been developed. The safety margin of this type of low-dose preparation needed to be assessed and this was done by evaluating daily levels of LH, FSH, estradiol, progesterone, 1-NG and EE2 as well as cervical mucus characteristics in six patients when one and then two consecutive pills were deliberately omitted mid-way through the cycle. Results demonstrated that there was no evidence of breakthrough ovulation, although there was some continued ovarian steroidogenesis, a feature consistent with previous studies using combined preparations. Existing instructions to patients regarding missed pills should continue in order to ensure maximal contraceptive safety.

The effect of norethisterone (500 mcg) and ethinyl estradiol (35 mcg) capsules on the pituitary-ovarian axis.

PIP: 12 normal female volunteers were recruited to examine the effects of capsules containing 35 mcg ethinyl estradiol (EE) and 500 mcg norethisterone (NET) and suspended in an oily medium of polyethylene glycol 400 surrounded by a soft gelatin capsule on the pituitary-ovarian axis. These women were studied for 2 cycles; in the 1st cycle no capsules were taken and daily blood samples were drawn from days 5-21. FSH, LH, estradiol, and progesterone were assayed. In the next cycle, 35 mcg EE and 500 mcg NET were taken on days 5-21 with daily blood samples drawn. Capsules were taken 2 hours before blood sampling and FSH, LH, estradiol, and progesterone as well as EE and NET were assayed. Hormone profiles are displayed in Figures 1 and 2. 10 of 12 volunteers showed a control cycle suggestive of ovulation (serum progesterone levels greater than 30 nmol/1 and a significant midcycle LH surge). During the pill cycle, these same 10 patients experienced suppression of ovulation as demonstrated by low progesterone levels in the second 1/2 of the cycle. NET and EE levels varied to the extent that they indicate a resonably physiologic variation. Results indicate that ovulation was suppressed in 11 of 12 subjects and cervical mucus studies showed that the local sperm blocking mechanism of the progestogen was operating whenever this parameter was assessed. This capsule formulation did suppress pituitary-ovarian function satisfactorily and the capsule is mainly acting by suppressing the positive feedback of estradiol on LH and not as strongly by suppressing follicular activity. Increased bioavailability may help in devising future formulations with a lesser amount of progestogen while still maintaining similar efficacy. Research is presently in process to examine the possibility of using a progestogen-only formulation which has increased bioavailability and which could be used cyclically.^ieng

Steroid-releasing vaginal rings.

PIP: The main hormonal contraceptive method of the future may well be an intravaginal, progestin-releasing ring. Such devices have the advantages of operating locally and avoiding the side effects associated with systemic administration of steroid compounds. They can administer longterm contraception and be removed at any time for immediate reversibility. There is low risk associated with the use of such devices. Progestagen-only contraception had been widely known and accepted for many years. The synthesis of the 19-nor steroids provided an impetus to its use. Several methods of delivery of slow-release progestagen are available. Unfortunately, most suffer form the common problem of progestagen-only administration--i.e., breakthrough bleeding. The development process for the contraceptive vaginal rings is described. A WHO (World Health Organization)-sponsored test is being conducted to determine the effectiveness and acceptability of progestagen-releasing rings. Trials in 8 centers showed the pregnancy rate with norethisterone-releasing rings to be unacceptably high. The tests continue with levonorgestrel-releasing rings to be unacceptably high. The tests continue with levonorgestrel-releasing rings. These rings have produced no pregnancies in the tests so far. It is hoped that the vaginal rings will be generally available within a few years.^ieng

A suppurative ovarian cyst in pregnancy due to Salmonella typhi.

A 23-year-old primigravida with suppurative ovarian dermoid cyst due to Salmonella typhi is presented. The organism could not be isolated from the blood, faeces or urine and it was felt that the patient was an example of non-excretory carrier in whom S. typhi was lying dormant in the ovarian tissue for a long time.

Perforation of a placental fetal vessel by an intrauterine pressure catheter.

Perforation of a fetal vessel on the placental surface by an intrauterine catheter is reported. The immediate recognition of this unusual complication is important. To minimize the risks of perforation, haemorrhage and infection, several precautions should be observed when inserting the catheter.