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Volume 18, Number 7—July 2012

Volume 18, Number 7—July 2012   PDF Version [PDF - 6.15 MB - 191 pages]


  • World Health Organization Perspective on Implementation of International Health Regulations PDF Version [PDF - 195 KB - 6 pages]
    M. Hardiman
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    The regulations have substantially helped prevent and control the international spread of diseases, but their full potential has yet to be realized.

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    In 2005, the International Health Regulations were adopted at the 58th World Health Assembly; in June 2007, they were entered into force for most countries. In 2012, the world is approaching a major 5-year milestone in the global commitment to ensure national capacities to identify, investigate, assess, and respond to public health events. In the past 5 years, existing programs have been boosted and some new activities relating to International Health Regulations provisions have been successfully established. The lessons and experience of the past 5 years need to be drawn upon to provide improved direction for the future.

  • Medscape CME Activity
    Assessment of Public Health Events through International Health Regulations, United States, 2007–2011 PDF Version [PDF - 228 KB - 7 pages]
    K. S. Kohl et al.
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    People and goods travel rapidly around the world, and so do infectious organisms. Sometimes a disease has already become widespread before it is detected and reported, which makes control efforts much more difficult. In response to this threat, the World Health Assembly enacted International Health Regulations that require participating countries to report public health events of international concern to the World Health Organization within 72 hours of detection. These health regulations went into effect in 2007 for all WHO Member States including the United States. By December 2011, 24 events reported by the United States were posted on a secure WHO web site, 12 of which were associated with influenza. Others reported were salmonellosis outbreaks, botulism, E. coli infections, Guillain-Barré syndrome, contaminated heparin, Lassa fever, an oil spill, and typhoid fever. International Health Regulations have improved global connectivity through rapid information exchange and increased awareness of threatening situations.

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    Under the current International Health Regulations, 194 states parties are obligated to report potential public health emergencies of international concern to the World Health Organization (WHO) within 72 hours of becoming aware of an event. During July 2007–December 2011, WHO assessed and posted on a secure web portal 222 events from 105 states parties, including 24 events from the United States. Twelve US events involved human influenza caused by a new virus subtype, including the first report of influenza A(H1N1)pdm09 virus, which constitutes the only public health emergency of international concern determined by the WHO director-general to date. Additional US events involved 5 Salmonella spp. outbreaks, botulism, Escherichia coli O157:H7 infections, Guillain-Barré syndrome, contaminated heparin, Lassa fever, an oil spill, and typhoid fever. Rapid information exchange among WHO and member states facilitated by the International Health Regulations leads to better situation awareness of emerging threats and enables a more coordinated and transparent global response.

  • International Health Regulations—What Gets Measured Gets Done PDF Version [PDF - 130 KB - 4 pages]
    K. Ijaz et al.
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    Focus on goals and metrics for 4 core capacities illustrates 1 approach to implementing IHR.

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    The global spread of severe acute respiratory syndrome highlighted the need to detect and control disease outbreaks at their source, as envisioned by the 2005 revised International Health Regulations (IHR). June 2012 marked the initial deadline by which all 194 World Health Organization (WHO) member states agreed to have IHR core capacities fully implemented for limiting the spread of public health emergencies of international concern. Many countries fell short of these implementation goals and requested a 2-year extension. The degree to which achieving IHR compliance will result in global health security is not clear, but what is clear is that progress against the threat of epidemic disease requires a focused approach that can be monitored and measured efficiently. We developed concrete goals and metrics for 4 of the 8 core capacities with other US government partners in consultation with WHO and national collaborators worldwide. The intent is to offer an example of an approach to implementing and monitoring IHR for consideration or adaptation by countries that complements other frameworks and goals of IHR. Without concrete metrics, IHR may waste its considerable promise as an instrument for global health security against public health emergencies.


  • Lessons Learned from Influenza A(H1N1)pdm09 Pandemic Response in Thailand PDF Version [PDF - 312 KB - 7 pages]
    K. Ungchusak et al.
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    The strengths and weaknesses of this response can inform planning for pandemics and other prolonged public health emergencies.

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    In 2009, Thailand experienced rapid spread of the pandemic influenza A(H1N1)pdm09 virus. The national response came under intense public scrutiny as the number of confirmed cases and associated deaths increased. Thus, during July–December 2009, the Ministry of Public Health and the World Health Organization jointly reviewed the response efforts. The review found that the actions taken were largely appropriate and proportionate to need. However, areas needing improvement were surveillance, laboratory capacity, hospital infection control and surge capacity, coordination and monitoring of guidelines for clinical management and nonpharmaceutical interventions, risk communications, and addressing vulnerabilities of non-Thai displaced and migrant populations. The experience in Thailand may be applicable to other countries and settings, and the lessons learned may help strengthen responses to other pandemics or comparable prolonged public health emergencies.


  • Seroprevalence of Schmallenberg Virus Antibodies among Dairy Cattle, the Netherlands, Winter 2011–2012 PDF Version [PDF - 449 KB - 7 pages]
    A. Elbers et al.
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    Seroprevalence was highest in the eastern part of the country, bordering Germany, where the virus was first identified.

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    Infections with Schmallenberg virus (SBV) are associated with congenital malformations in ruminants. Because reporting of suspected cases only could underestimate the true rate of infection, we conducted a seroprevalence study in the Netherlands to detect past exposure to SBV among dairy cattle. A total of 1,123 serum samples collected from cattle during November 2011–January 2012 were tested for antibodies against SBV by using a virus neutralization test; seroprevalence was 72.5%. Seroprevalence was significantly higher in the central-eastern part of the Netherlands than in the northern and southern regions (p<0.001). In addition, high (70%–100%) within-herd seroprevalence was observed in 2 SBV-infected dairy herds and 2 SBV-infected sheep herds. No significant differences were found in age-specific prevalence of antibodies against SBV, which is an indication that SBV is newly arrived in the country.

  • Predicting Risk for Death from MRSA Bacteremia PDF Version [PDF - 272 KB - 9 pages]
    M. Pastagia et al.
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    Methicillin-resistant Staphylococcus aureus (MRSA) in the bloodstream is often fatal. Vancomycin is the most frequently prescribed drug for treatment of MRSA infections with demonstrated efficacy. Recently, however, some MRSA infections have not been responding to vancomycin, even those caused by strains considered susceptible. To provide optimal treatment and avoid vancomycin resistance, therapy should be tailored, especially for patients at highest risk for death. But who are these patients? A study that looked back at medical records and 699 frozen isolates found that risk for death from MRSA infection was highest among certain populations, including the elderly, nursing home residents, patients with severe sepsis, and patients with liver or kidney disease. Risk for death was not affected by the type of MRSA strain (vancomycin susceptible, heteroresistant, or intermediate resistant). Risk was lower among those who had consulted an infectious disease specialist. Thus, when choosing treatment for patients with MRSA infection, it is crucial to look at patient risk factors, not just MRSA strain type. For those at high risk, consultation with an infectious disease specialist is recommended.

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    Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is often fatal. To determine predictors of risk for death, we conducted a retrospective cohort study. We examined 699 episodes of MRSA bacteremia involving 603 patients admitted to an academic medical center in New York City during 2002–2007. Data came from chart reviews, hospital databases, and recultured frozen MRSA specimens. Among the 699 episodes, 55 were caused by vancomycin–intermediate resistant S. aureus strains, 55 by heteroresistant vancomycin-intermediate S. aureus strains, and 589 by non–vancomycin-resistant strains; 190 (31.5%) patients died. We used regression risk analysis to quantify the association between clinical correlates and death. We found that older age, residence in a nursing home, severe bacteremia, and organ impairment were independently associated with increased risk for death; consultation with an infectious disease specialist was associated with lower risk for death; and MRSA strain types were not associated with risk for death.

  • Adenoviruses in Fecal Samples from Asymptomatic Rhesus Macaques, United States PDF Version [PDF - 389 KB - 8 pages]
    S. Roy et al.
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    Isolates contained fiber genes similar to those of adenovirus strains that cause infectious diarrhea in humans.

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    Adenoviruses can cause infectious diarrheal disease or respiratory infections in humans; 2 recent reports have indicated probable human infection with simian adenoviruses (SAdVs). To assess the possibility of animal-to-human transmission of SAdVs, we tested fecal samples from asymptomatic rhesus macaques housed in 5 primate facilities in the United States and cultured 23 SAdV isolates. Of these, 9 were purified and completely sequenced; 3 SAdV samples from the American Type Culture Collection (SAdV-6, SAdV-18, and SAdV-20) were also completely sequenced. The sequence of SAdV-18 was closely related to that of human adenovirus F across the whole genome, and the new isolates were found to harbor 2 fiber genes similar to those of human adenovirus (HAdV) strains HAdV-40 and HAdV-41, which can cause infectious diarrhea. The high prevalence of adenoviruses in fecal samples from asymptomatic rhesus macaques and the similarity of the isolates to human strains indicates the possibility of animal-to-human transmission of SAdVs.

  • Spike Protein Fusion Peptide and Feline Coronavirus Virulence PDF Version [PDF - 479 KB - 7 pages]
    H. Chang et al.
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    Mutations can occur erratically and accompany tropism changes, resulting in unpredictable new diseases.

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    Coronaviruses are well known for their potential to change their host or tissue tropism, resulting in unpredictable new diseases and changes in pathogenicity; severe acute respiratory syndrome and feline coronaviruses, respectively, are the most recognized examples. Feline coronaviruses occur as 2 pathotypes: nonvirulent feline enteric coronaviruses (FECVs), which replicate in intestinal epithelium cells, and lethal feline infectious peritonitis viruses (FIPVs), which replicate in macrophages. Evidence indicates that FIPV originates from FECV by mutation, but consistent distinguishing differences have not been established. We sequenced the full genome of 11 viruses of each pathotype and then focused on the single most distinctive site by additionally sequencing hundreds of viruses in that region. As a result, we identified 2 alternative amino acid differences in the putative fusion peptide of the spike protein that together distinguish FIPV from FECV in >95% of cases. By these and perhaps other mutations, the virus apparently acquires its macrophage tropism and spreads systemically.

  • Enterococcus faecalis Clones in Poultry and in Humans with Urinary Tract Infections, Vietnam PDF Version [PDF - 164 KB - 5 pages]
    L. Poulsen et al.
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    Transmission routes and reservoirs need to be elucidated.

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    Enterococcus spp. as pathogens have increased, but the sources of infection often remain unclear. To investigate whether poultry might be a reservoir for E. faecalis–associated urinary tract infections (UTIs) in humans, we characterized E. faecalis isolates from patients in Vietnam with UTIs during January 2008–January 2010 and poultry living in close contact with them by multilocus sequence typing (MLST), pulsed-field gel electrophoresis, analysis of antimicrobial drug susceptibility patterns, and sequencing of virulence genes. In 7 (23%) of 31 UTI cases, we detected identical MLST, indistinguishable or closely related pulsed-field gel electrophoresis patterns, and similar antimicrobial drug susceptibility patterns. Isolates from urine and poultry showed identical virulence gene profiles, except for 1 variation, and individual genes showed identical sequences. The homology of isolates from urine and poultry further indicates the zoonotic potential and global spread of E. faecalis sequence type 16, which recently was reported in humans with endocarditis and in pigs in Denmark.

  • Loss of Household Protection from Use of Insecticide-Treated Nets against Pyrethroid-Resistant Mosquitoes, Benin PDF Version [PDF - 174 KB - 6 pages]
    A. Asidi et al.
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    Restoring protection requires innovation combining pyrethroids and novel insecticides.

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    Pyrethroid resistance is becoming widespread in Anopheles gambiae mosquitoes, coinciding with expanded use of insecticide-treated nets (ITNs) throughout Africa. To investigate whether nets in use are still protective, we conducted household trials in northern and southern Benin, where An. gambiae mosquitoes are susceptible and resistant, respectively, to pyrethroids. Rooms were fitted with window traps and monitored for mosquito biting and survival rates before and after the nets were treated with pyrethroid. Sleeping under an ITN in the location with resistant mosquitoes was no more protective than sleeping under an untreated net, regardless of its physical condition. By contrast, sleeping under an ITN in the location with susceptible mosquitoes decreased the odds of biting by 66%. ITNs provide little or no protection once the mosquitoes become resistant and the netting acquires holes. Resistance seriously threatens malaria control strategies based on ITN.

  • Retrospective Evaluation of Control Measures for Contacts of Patient with Marburg Hemorrhagic Fever PDF Version [PDF - 198 KB - 8 pages]
    A. Timen et al.
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    Measures had substantial effects on contacts and household members.

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    After an imported case of Marburg hemorrhagic fever was reported in 2008 in the Netherlands, control measures to prevent transmission were implemented. To evaluate consequences of these measures, we administered a structured questionnaire to 130 contacts classified as either having high-risk or low-risk exposure to body fluids of the case-patient; 77 (59.2%) of 130 contacts responded. A total of 67 (87.0%) of 77 respondents agreed that temperature monitoring and reporting was necessary, significantly more often among high-risk than low-risk contacts (p<0.001). Strict compliance with daily temperature monitoring decreased from 80.5% (62/77) during week 1 to 66.2% (51/77) during week 3. Contacts expressed concern about development of Marburg hemorrhagic fever (58.4%, 45/77) and infecting a family member (40.2%, 31/77). High-risk contacts had significantly higher scores on psychological impact scales (p<0.001) during and after the monitoring period. Public health authorities should specifically address consequences of control measures on the daily life of contacts.

  • Validity of International Health Regulations in Reporting Emerging Infectious Diseases PDF Version [PDF - 143 KB - 6 pages]
    M. Edelstein et al.
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    Use of more prescriptive criteria and training of persons responsible for reporting could improve results.

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    Understanding which emerging infectious diseases are of international public health concern is vital. The International Health Regulations include a decision instrument to help countries determine which public health events are of international concern and require reporting to the World Health Organization (WHO) on the basis of seriousness, unusualness, international spread and trade, or need for travel restrictions. This study examined the validity of the International Health Regulations decision instrument in reporting emerging infectious disease to WHO by calculating its sensitivity, specificity, and positive predictive value. It found a sensitivity of 95.6%, a specificity of 38%, and a positive predictive value of 35.5%. These findings are acceptable if the notification volume to WHO remains low. Validity could be improved by setting more prescriptive criteria of seriousness and unusualness and training persons responsible for notification. However, the criteria should be balanced with the need for the instrument to adapt to future unknown threats.

  • Costing Framework for International Health Regulations (2005) PDF Version [PDF - 244 KB - 7 pages]
    R. Katz et al.
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    Costs can be estimated by identifying functional pathways toward achieving all 8 core capacities and global indicators.

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    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.


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