IDSR as a platform for implementing IHR in African countries

Of the 46 countries in the World Health Organization (WHO) African region (AFRO), 43 are implementing Integrated Disease Surveillance and Response (IDSR) guidelines to improve their abilities to detect, confirm, and respond to high-priority communicable and noncommunicable diseases. IDSR provides a framework for strengthening the surveillance, response, and laboratory core capacities required by the revised International Health Regulations [IHR (2005)]. In turn, IHR obligations can serve as a driving force to sustain national commitments to IDSR strategies. The ability to report potential public health events of international concern according to IHR (2005) relies on early warning systems founded in national surveillance capacities. Public health events reported through IDSR to the WHO Emergency Management System in Africa illustrate the growing capacities in African countries to detect, assess, and report infectious and noninfectious threats to public health. The IHR (2005) provide an opportunity to continue strengthening national IDSR systems so they can characterize outbreaks and respond to public health events in the region.

EU./U.S. CTAD Task Force on Alzheimer's Trial Populations

Successful therapeutic trials require well-targeted populations to demonstrate the effectiveness of a drug candidate. Most trials in the field of Alzheimer's disease (AD) have been conducted in patients with mild to moderate dementia. However, the advent of amyloid PET imaging has demonstrated that a significant proportion of individuals enrolled in such studies do not have evidence of brain amyloidosis and may in fact not have Alzheimer's disease. Further, dementia represents an advanced stage of neurodegeneration, perhaps too late for significant benefits of disease-modifying interventions. The successful development of effective disease-slowing therapies requires a study population selected in accordance with the mechanism of the specific intervention. An international task force of investigators from academia, industry, non-profit foundations, and regulatory agencies met in San Diego, California, USA, on November 13, 2013, to address issues related to screening and identification of clinical trial participants, and the ramifications of decisions made in this regard for drug development in AD and other dementias.

State Foodborne Illness Surveillance and Response Laws: Compilation and Analysis

Objective

To document and assess the variation in state legislation relating to foodborne disease surveillance and outbreak response for all 50 states and the District of Columbia by creating a database and appendix of laws and regulations that will be made available to researchers and policymakers.

Introduction

Foodborne illnesses sicken 48 million and kill 3,000 Americans every year, presenting an enduring threat to the public’s health. In just the past three years alone, the United States has experienced at least four major multistate outbreaks in food. Despite this growing problem, efforts to prevent foodborne illness pose a particular public health challenge due in part to the widely variable laws governing foodborne illness surveillance and outbreak response. The recent passage of the Food Safety Modernization Act (FSMA) presents an opportunity for researchers, program managers, and policy makers to assess and correct the legal barriers that may hinder states in effectively implementing the FSMA’s vision with regard to increased state and local capacity for surveillance and outbreak response.

Methods

We conducted a systematic review and analysis of laws and regulations relating to foodborne illness surveillance and outbreak response in all 50 states and the District of Columbia, using the following methods: (1) we created a database to record state laws and regulations relating to foodborne illness surveillance and outbreak response in all 50 states and the District of Columbia; (2) we conducted a basic gap analysis of state foodborne illness surveillance and outbreak response laws and policies collected in the database; and (3) we conducted case study analyses of previous multistate outbreaks from 2008–2011.

Results

Through compilation of the state foodborne illness surveillance and outbreak response laws and regulations and analysis of previous multistate outbreaks, we are able to present trends, variations, and gaps in the legislation that directly impacts the ability of public health officials to conduct foodborne outbreak investigations. We also present policy recommendations for strengthening state laws and regulations.

Increased incidence of herpes zoster among patients with systemic lupus erythematosus

Herpes zoster (HZ) is the painful reactivation of latent varicella zoster virus infection. The incidence of HZ may be increased in some autoimmune diseases, including systemic lupus erythematosus (SLE). We examined the incidence and risk factors for HZ in a prospective cohort of patients with physician-diagnosed SLE compared to those diagnosed with non-inflammatory musculoskeletal conditions (MSK). After excluding participants with a history of prior HZ at enrollment, we followed 1485 SLE patients and 2775 MSK with semi-annual mailed questionnaires for incident HZ between 2001 and 2010. Age-adjusted incidences were calculated for each group and Cox proportional hazard models were used to identify predictors of HZ. Zostavax® vaccination rates were compared between groups. Participants had a mean age of 60 years at enrollment, with 13.9 years of disease. SLE patients had more HZ at all ages, with an age-adjusted incidence of 12.0/1000 person-years compared to MSK (8.7/1000 person-years) and a hazard ratio of 1.7 (95% CI 1.08-2.71) for SLE. Increasing age and reduced functional status were independent predictors of HZ. In SLE, prednisone and mycophenolate mofetil use conferred additional risk. SLE had the lowest HZ vaccination rates among age-eligible subjects.

Costing framework for International Health Regulations (2005)

The revised International Health Regulations (IHR [2005]) conferred new responsibilities on member states of the World Health Organization, requiring them to develop core capacities to detect, assess, report, and respond to public health emergencies. Many countries have not yet developed these capacities, and poor understanding of the associated costs have created a barrier to effectively marshaling assistance. To help national and international decision makers understand the inputs and associated costs of implementing the IHR (2005), we developed an IHR implementation strategy to serve as a framework for making preliminary estimates of fixed and operating costs associated with developing and sustaining IHR core capacities across an entire public health system. This tool lays the groundwork for modeling the costs of strengthening public health systems from the central to the peripheral level of an integrated health system, a key step in helping national health authorities define necessary actions and investments required for IHR compliance.

Detection of prostate cancer by radio-frequency near-field spectroscopy in radical prostatectomy ex vivo specimens

BACKGROUND

The aim of radical prostatectomy (RP) is the complete removal of the prostate gland with negative surgical margins. The presence of cancer at the surgical margin is associated with higher probability of disease progression. Current methods of intraoperative margin assessment are inaccurate or time-consuming.The study goal was to evaluate the ability of a novel device (Dune Medical Devices) to differentiate between cancer and BPH.

METHODS

A total of 49 patients undergoing RP in four medical centers between November 2007 and May 2008 were enrolled in this study.The device was applied to numerous intra- and extra-capsular sites of freshly excised RP specimens. Measurement sites were accurately marked and analyzed histologically. The ability of the device to differentiate between malignant and nonmalignant sites was assessed.

RESULTS

A total of 15,156 measurements from 45 patients were analyzed. Differentiation of the intra-capsular malignant sites from extra-capsular nonmalignant sites (bladder neck and apex regions) depends on the cancer feature size. Differentiation was achieved with sensitivity and specificity of 93.6 (95% confidence interval (CI): 88-98) and 94.1 (95% CI: 93-95), respectively, at feature sizes at or >0.8 mm in diameter. The device was able to discriminate between all intra-capsular malignant (with feature sizes down to a few cells) and nonmalignant measurement sites, with sensitivity and specificity of 80.8 (95% CI: 73-87) and 68.4 (95% CI: 67-69), respectively.

CONCLUSIONS

First results from a radio-frequency near-field spectroscopy sensor look promising for differentiation between cancer and benign prostate tissue. The sensor's dimensions (radius of ~ 1 mm) and design enable use in open, laparoscopic and robotic RP to evaluate the surgical margins intraoperatively.

H1N1 preventive health behaviors in a university setting

BACKGROUND

When H1N1 emerged in 2009, institutions of higher education were immediately faced with questions about how best to protect their community from the virus, yet limited information existed to help predict student preventive behaviors.

METHODS

The authors surveyed students at a large urban university in November 2009 to better understand how students perceived their susceptibility to and the severity of H1N1, which preventive behaviors they engaged in, and if policies impacted their preventive health decisions.

RESULTS

Preventive health behavior messaging had a mixed impact on students. Students made simple behavior changes to protect themselves from H1N1, especially if they perceived a high personal risk of contracting H1N1. Although policies were instituted to enable students to avoid classes when ill, almost no student self-isolated for the entire duration of their illness.

CONCLUSIONS

These findings can help inform future decision making in a university setting to best influence preventive health behaviors.

Effects of afferent stimulation rate on inhibitory spinal pathways in hemiplegic spastic patients

OBJECTIVE

It has recently been demonstrated in the cat and in healthy subjects that the effects of repetitive afferent fibre stimulation depends on the target spinal neurones. The purpose of this series of experiments was therefore to determine whether central nervous system lesions modify the behaviour of the inhibitory spinal pathways in response to repetitive activation of afferent fibres.

METHODS

The H-reflex technique was used to study the effect of increasing the conditioning stimulus rate from 0.16 to 1 Hz on disynaptic inhibition and on presynaptic Ia inhibition on the affected side of 36 hemiplegic patients.

RESULTS

The major finding was that, similar to results previously obtained in healthy subjects, increasing the conditioning stimulus rate in hemiplegic patients leads to an increase in the synaptic efficiency of inhibitory spinal circuits. Furthermore, a significant correlation was found between the severity of flexor carpi radialis muscle spasticity and the amount of disynaptic inhibition.

CONCLUSIONS

The reinforcement of inhibitory spinal networks induced by repetitive stimulation of afferent fibres is preserved in spastic patients, whereas the mechanisms underlying this phenomena might be altered.

SIGNIFICANCE

The results of these experiments open up a number of possibilities for novel spasticity therapies based on non-invasive techniques.

Redefining syndromic surveillance

With growing concerns about international spread of disease and expanding use of early disease detection surveillance methods, the field of syndromic surveillance has received increased attention over the last decade. The purpose of this article is to clarify the various meanings that have been assigned to the term syndromic surveillance and to propose a refined categorization of the characteristics of these systems. Existing literature and conference proceedings were examined on syndromic surveillance from 1998 to 2010, focusing on low- and middle-income settings. Based on the 36 unique definitions of syndromic surveillance found in the literature, five commonly accepted principles of syndromic surveillance systems were identified, as well as two fundamental categories: specific and non-specific disease detection. Ultimately, the proposed categorization of syndromic surveillance distinguishes between systems that focus on detecting defined syndromes or outcomes of interest and those that aim to uncover non-specific trends that suggest an outbreak may be occurring. By providing an accurate and comprehensive picture of this field's capabilities, and differentiating among system types, a unified understanding of the syndromic surveillance field can be developed, encouraging the adoption, investment in, and implementation of these systems in settings that need bolstered surveillance capacity, particularly low- and middle-income countries.

The role of treaties, agreements, conventions, and other international instruments in global health

As nations become more reliant on each other for cohesive development of global health policies and practice, and globalization increasingly makes health challenges in one part of the world concerns for all nations, the importance and use of international agreements in framing policy and national commitments have increased. This article reviews international agreements, looking specifically at multilateral instruments or partnerships, to identify those that either directly focus on or encompass health. It defines the different types of agreements, describes the process through which governments enter into these agreements, evaluates the legality of agreements under international law, and assesses participation by member states.

Defining health diplomacy: changing demands in the era of globalization

CONTEXT

Accelerated globalization has produced obvious changes in diplomatic purposes and practices. Health issues have become increasingly preeminent in the evolving global diplomacy agenda. More leaders in academia and policy are thinking about how to structure and utilize diplomacy in pursuit of global health goals.

METHODS

In this article, we describe the context, practice, and components of global health diplomacy, as applied operationally. We examine the foundations of various approaches to global health diplomacy, along with their implications for the policies shaping the international public health and foreign policy environments. Based on these observations, we propose a taxonomy for the subdiscipline.

FINDINGS

Expanding demands on global health diplomacy require a delicate combination of technical expertise, legal knowledge, and diplomatic skills that have not been systematically cultivated among either foreign service or global health professionals. Nonetheless, high expectations that global health initiatives will achieve development and diplomatic goals beyond the immediate technical objectives may be thwarted by this gap.

CONCLUSIONS

The deepening links between health and foreign policy require both the diplomatic and global health communities to reexamine the skills, comprehension, and resources necessary to achieve their mutual objectives.

Carol Anne Bond v the United States of America: how a woman scorned threatened the Chemical Weapons Convention

The case of Carol Anne Bond v the United States of America stemmed from a domestic dispute when Ms. Bond attempted to retaliate against her best friend by attacking her with chemical agents. What has emerged is a much greater issue--a test of standing on whether a private citizen can challenge the Tenth Amendment. Instead of being prosecuted in state court for assault, Ms. Bond was charged and tried in district court under a federal criminal statute passed as part of implementation of the Chemical Weapons Convention (CWC). Ms. Bond's argument rests on the claim that the statute exceeded the federal government's enumerated powers in criminalizing her behavior and violated the Constitution, while the government contends legislation implementing treaty obligations is well within its purview. This question remains unanswered because there is dispute among the lower courts as to whether Ms. Bond, as a citizen, even has the right to challenge an amendment guaranteeing states rights when a state is not a party to the action. The Supreme Court heard the case on February 22, 2011, and, if it decides to grant Ms. Bond standing to challenge her conviction, the case will be returned to the lower courts. Should the court decide Ms. Bond has the standing to challenge her conviction and further questions the constitutionality of the law, it would be a significant blow to implementation of the CWC in the U.S. and the effort of the federal government to ensure we are meeting our international obligations.

Impact of precision grip tasks on cervical spinal network excitability in humans

Motor skill acquisition in the lower limb may induce modifications of spinal network excitability. We hypothesized that short-term motor adaptation in precision grip tasks would also induce modifications of cervical spinal network excitability. In a first series of experiments, we studied the impact of two different precision grip force control tasks (a visuomotor force-tracking task and a control force task without visual feedback) on cervical spinal network excitability in healthy subjects. We separately tested the efficacy of two key components of the spinal circuitry: (i) presynaptic inhibition on flexor carpi radialis (FCR) Ia terminals, and (ii) disynaptic inhibition directed from extensor carpi radialis (ECR) to FCR. We found that disynaptic inhibition decreased temporarily after both force control tasks, independently of the presence of visual feedback. In contrast, the amount of presynaptic inhibition on FCR Ia terminals decreased only after the visuomotor force tracking task. This temporary decrease was correlated with improved tracking accuracy during the task (i.e. short-term motor adaptation). A second series of experiments confirmed these results and showed that the visuomotor force-tracking task resulted also in an increase of the Hmax/Mmax ratio and the slope of the ascending part of the H-reflex recruitment curve. In order to address the role of presynaptic inhibition in the motor adaptation process, we conducted a third series of experiments during which presynaptic inhibition was recorded before and after two consecutive sessions of visuomotor force tracking. The results showed that (i) improved tracking accuracy occurred during both sessions, and (ii) presynaptic inhibition decreased only after the first session of visuomotor force tracking. Taken together, these results suggest thus that the nature of the motor task performed has a specific impact on the excitability of these cervical spinal circuits. These findings also suggest that early motor adaptation is associated with a modulation of presynaptic Ia inhibition in the upper limb.

Effects of anodal transcranial direct current stimulation over the leg motor area on lumbar spinal network excitability in healthy subjects

In recent years, two techniques have become available for the non-invasive stimulation of human motor cortex: transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). The effects of TMS and tDCS when applied over motor cortex should be considered with regard not only to cortical circuits but also to spinal motor circuits. The different modes of action and specificity of TMS and tDCS suggest that their effects on spinal network excitability may be different from that in the cortex. Until now, the effects of tDCS on lumbar spinal network excitability have never been studied. In this series of experiments, on healthy subjects, we studied the effects of anodal tDCS over the lower limb motor cortex on (i) reciprocal Ia inhibition projecting from the tibialis anterior muscle (TA) to the soleus (SOL), (ii) presynaptic inhibition of SOL Ia terminals, (iii) homonymous SOL recurrent inhibition, and (iv) SOL H-reflex recruitment curves. The results show that anodal tDCS decreases reciprocal Ia inhibition, increases recurrent inhibition and induces no modification of presynaptic inhibition of SOL Ia terminals and of SOL-H reflex recruitment curves. Our results indicate therefore that the effects of tDCS are the opposite of those previously described for TMS on spinal network excitability. They also indicate that anodal tDCS induces effects on spinal network excitability similar to those observed during co-contraction suggesting that anodal tDCS activates descending corticospinal projections mainly involved in co-contractions.

Abstract P3-10-41: Quantitative Immunohistochemical Analysis and Prognostic Significance of TRPS-1, a New GATA Transcription Factor Family Member, in Breast Cancer

The Trichorhinophalangeal Syndrome-1 gene (TRPS-1) is a novel GATA transcription factor family member expressed in >90% of human breast cancers. In this study, we developed a new quantitative IHC (qIHC) method to study TRPS-1 as a possible indicator ofprognosis in BC. Using this method, a quantitative parameter for TRPS-1 expression called a Quick Score (QS) was derived from the measured Labeling Index (LI) and Mean Optical Density (MOD) after IHC and applied to a set of 152 Stage II/III BC patients from 1993-2006 who did not receive preoperative chemotherapy. Although highly prevalent in BC, a wide range of TRPS-1 QS was found among the sample set with higher TRPS-1 QS significantly associated with tumor ER-alpha (p= 0.023 for QS, and p= 0.028 for Allred score), PR (p= 0.009), GATA-3 (P<0.0001), and E-cadherin (p< 0.001). TRPS-1 QS was also positively associated with HER2 status (p=0.026). Analysis of different ductal structures revealed that TRPS-1 was expressed at low levels in normal ducts and in usual ductal hyperplasia, but showed a marked increase in DCIS and invasive carcinoma lesions. An analysis of TRPS-1 expression in association with overall survival revealed that TRPS-1 QS (≥4.0) was significantly associated with improved survival (p=0.0165). Patients with TRPS-1 QS <4 had a hazard ratio of 2 (p=0.019) after univariate Cox proportional hazards analysis. Further analysis of the patient samples revealed an ER-/lo, HER2+ (amplified) BC subset in which TRPS-1 expression above a critical quantitative threshold was predictive of greatly improved survival (median survival not reached after 10 years), while patients in this subset with TRPS-1 expression below this threshold having a median survival of less than 5 years. In summary, this new qIHC approach revealed critical differences in TRPS-1 expression in primary BC samples and found that this new GATA family member may be a promising positive prognostic marker that may regulate BC progression. In addition, TRPS-1 may also be a relevant new marker in a luminal ER-/low, HER2+ BC subset.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-41.

Challenging custom: rethinking national population surveillance policy in a global public health age

This article examines the current state of disease surveillance and reporting in the United States and seeks to answer two central questions: first, whether the increasing emphasis on the global importance of public health policies compels a fundamental reexamination of the long-standing deferential approach to state power where matters of population health surveillance are concerned and, second, how the nation's long-standing deferential legal customs might be modified to address the growing emphasis on global public health policy that is undergirded by technological advances. We examine the International Health Regulations, or IHR (2005), and suggest that these regulations offer a powerful impetus for reevaluating U.S. legal custom concerning the policy and practice of population health surveillance, not only as a matter of U.S. law but also as a core dimension of U.S. legal obligations to other nations, as embodied in international agreements and treaties. We find that if the political will exists to change the domestic disease surveillance and reporting system, the federal government has the power to act. Questions remain, however, about whether the public health and legislative communities are willing to challenge current customs or even if they desire to do so.

Assessing physicians' in training attitudes and behaviors during the 2009 H1N1 influenza season: a cross-sectional survey of medical students and residents in an urban academic setting

Please cite this paper as: May et al. (2010) Assessing physicians’ in training attitudes and behaviors during the 2010 H1N1 influenza season: a cross‐sectional survey of medical students and residents in an urban academic setting. Influenza and Other Respiratory Viruses DOI: 10.1111/j.1750‐2659.2010.00151.x.

Background  Despite concern for hospital‐based transmission of influenza, little research has been carried out on perceptions and behaviors of physicians in training with regard to influenza‐like illness (ILI), especially in light of the recent H1N1 pandemic.

Objectives  We aimed to evaluate self‐reported episodes of ILI among medical students and residents to determine the impact of ILI on school and clinical performance, absenteeism, and patterns of preventive measures used by this population both in and out of the healthcare setting.

Methods  We anonymously surveyed medical students and residents at an urban institution between November 3 and December 11, 2009. Data were analyzed separately for medical students and residents for frequency of close‐ended responses. Open‐ended answers were analyzed thematically. Our Institutional Review Board exempted this study from review.

Results  Forty‐five percent of medical students and 53% of resident respondents perceived the risk of acquiring H1N1 at school or work as high, and although 43% of medical students and 66% of resident respondents had received the influenza vaccination and most reported increasing non‐pharmaceutical preventive measures, 9% of medical students and 61% of residents with one or more episodes of ILI chose to continue to attend class or work when ill.

Conclusions  Although students and residents report high risk of infection because of work‐ or school‐related activities, many involved in patient care activities do not comply with recommended infection control precautions. Educational campaigns should be developed and infection control guidelines should be included in routine medical student and resident curricular activities.