Laura H. Kahn

Confronting zoonoses, linking human and veterinary medicine.

Greater collaboration is needed between human and veterinary medicine to better control zoonoses.

Preparing for Disaster: Response Matrices in the USA and UK

Disasters, whether man-made or naturally occurring, require complex responses across multiple government agencies and private sector elements, including the media. These factors mandate that, for effective disaster management and because of the unpredictability of such events, response structures must be in place in advance, ready to be activated on short notice, with lines of responsibility clearly delineated and mechanisms for coordination of efforts already established. Disaster response experiences in the USA and the UK were reviewed at a conference convened by the New York Academy of Medicine and the Royal Society of Medicine in June 2007. Lessons to be drawn from these comparisons were sought. The importance of careful advance planning, clear delineation of spheres of responsibility and response roles, effective mechanisms for communication at all levels, and provision for adequate communication with the public were all identified as key elements of effective response mechanisms.

'ONE HEALTH' and Parasitology

Address: 14748 Hamlets Grove Drive, Sarasota, Florida 34235, USA, 2Program on Science and Global Security, Woodrow Wilson School of Public and International Affairs, Princeton University, 221 Nassau Street, 2nd floor, Princeton, New Jersey 08542, USA, 3Kleiner Perkins Caufield & Byers, Pandemic & Biodefense Fund, 21 Finn Road, Harvard MA 01451, USA and 4Nucleus for the Investigation of Emerging Infectious Diseases, Institute of Medical Biochemistry, Center for Health Sciences, Federal University, Rio de Janeiro, Brazil

Feasibility of Eliminating the Use of Highly Enriched Uranium in the Production of Medical Radioisotopes

Significant quantities of highly enriched uranium (HEU)—more than enough to make a Hiroshima bomb—are used annually as neutron target material in Canadian, European, and South African reactors to produce the short-lived fission products used in nuclear medicine. The most important of these fission products is 99Mo, which decays into 99mTc, which is the most widely used medical radioisotope. The U.S. supplies weapon-grade uranium to the Canadian radioisotope producer and might in the future provide it to the European producers as well. As a condition for receiving U.S. HEU, the 1992 Schumer Amendment to the U.S. Atomic Energy Act requires that a foreign producer cooperate with the United States in converting to low-enriched uranium (LEU) targets. Some smaller producers have already done so. The Canadian producer has asserted, however, that the cost of conversion would be too high. The 2005 Burr amendment therefore exempted radioisotope producers in Canada and Europe from the Schumer amendments requirements but requested a National Academy of Sciences study of the feasibility of conversion, setting as a feasibility test that the production cost be increased by no more than 10 percent. We show that paying for the conversion for the largest European production facility would increase the cost of 99Mo production there by only a few percent. For the Canadian facility the production cost could be more than 10 percent but the increase in the cost of the final 99mTc-containing radiopharmaceutical would be only about 1 percent. It is also pointed out that savings in security could well dwarf the costs of converting to LEU if HEU were no longer present at the production and radioactive waste sites.

Checklist for One Health Epidemiological Reporting of Evidence (COHERE)

One Health is defined as the intersection and integration of knowledge regarding humans, animals, and the environment, yet as the One Health scientific literature expands, there is considerable heterogeneity of approach and quality of reporting in One Health studies. In addition, many researchers who publish such studies do not include or integrate data from all three domains of human, animal, and environmental health. This points to a critical need to unify guidelines for One Health studies. This report details the Checklist for One Health Epidemiological Reporting of Evidence (COHERE) to guide the design and publication format of future One Health studies. COHERE was developed by a core writing team and international expert review group that represents multiple disciplines, including human medicine, veterinary medicine, public health, allied professionals, clinical laboratory science, epidemiology, the social sciences, ecohealth and environmental health. The twin aims of the COHERE standards are to 1) improve the quality of reporting of observational or interventional epidemiological studies that collect and integrate data from humans, animals and/or vectors, and their environments; and 2) promote the concept that One Health studies should integrate knowledge from these three domains. The 19 standards in the COHERE checklist address descriptions of human populations, animal populations, environmental assessment, spatial and temporal relationships of data from the three domains, integration of analyses and interpretation, and inclusion of expertise in the research team from disciplines related to human health, animal health, and environmental health.

Incorporating one health into medical education

One Health is an emerging concept that stresses the linkages between human, animal, and environmental health, as well as the need for interdisciplinary communication and collaboration to address health issues including emerging zoonotic diseases, climate change impacts, and the human-animal bond. It promotes complex problem solving using a systems framework that considers interactions between humans, animals, and their shared environment. While many medical educators may not yet be familiar with the concept, the One Health approach has been endorsed by a number of major medical and public health organizations and is beginning to be implemented in a number of medical schools. In the research setting, One Health opens up new avenues to understand, detect, and prevent emerging infectious diseases, and also to conduct translational studies across species. In the clinical setting, One Health provides practical ways to incorporate environmental and animal contact considerations into patient care. This paper reviews clinical and research aspects of the One Health approach through an illustrative case updating the biopsychosocial model and proposes a basic set of One Health competencies for training and education of human health care providers.

The need for one health degree programs

This commentary offers suggestions for improving public health and public health education by emphasizing One Health principles, the integrating of human, veterinary, and environmental sciences. One Health is increasingly recognized as a powerful approach to the prevention and control of zoonotic diseases, increasing food productivity and safety, improving biosecurity, and enhancing many areas of biomedical research.

Pandemic Influenza School Closure Policies

To the Editor: Holmberg et al. (1) are rightly concerned that state pandemic plans in the United States represent a patchwork without central coordination or direction. These concerns are particularly relevant for school closure decisions during an influenza pandemic. The US Department of Health and Human Services’ checklist regarding school closures gives conflicting messages (2). For example, it recommends that schools stay open during a pandemic and develop school-based surveillance systems for absenteeism of students and sick-leave policies for staff and students. It also recommends developing alternate procedures to ensure the continuity of instruction in the event of district-wide school closures. These vague recommendations may reflect the paucity of data to recommend school closure. To assess the current status of school closure decisions in the United States, I conducted an internet survey of all 50 state health commissioners during the spring of 2006. I asked the respondents 2 questions: “Who makes the school closure decisions in your state?” and “What absenteeism rate, if any, would prompt a school in your state to close during a typical influenza year and/or during a pandemic influenza year?” Of the 44 responding states, I found that school closure decisions were primarily a local-level responsibility in half. Of these 22 states, closure decisions would be made either on a school-by-school or a school district–by–school district basis. Only 6 states indicated that school closure decisions would be made at the state level, and 16 states would have decisions made jointly at the state and local levels (Table). Table Number of states reporting influenza pandemic school closure policies at various levels, USA* For a typical influenza season, only 6 states indicated that they close schools if a certain absenteeism rate due to illness were reached. For 5 of these states, the absenteeism rates ranged from 10% to 30%; the sixth state said its schools would close if the rates were anywhere from 7% to 31%. However, only 1 state reported a threshold absenteeism rate for closure during an influenza pandemic. Another state said that it was developing an absenteeism rate that would prompt closure for pandemic influenza. Forty-two states did not have threshold absenteeism rates that would prompt school closures during an influenza pandemic. In July 2006, the Department for Education and Skills in the United Kingdom published guidelines regarding school closure (D. O’Gorman, pers. comm.). Although the final decision for school closure would lie with local school officials, the national government might advise all schools and childcare facilities to close when a pandemic reached their area to reduce the spread of infection among children (3). It is believed that all would comply with closure advice and that use of emergency powers under the UK Civil Contingency Act 2004 to require services to close would not be necessary. If all British schools in an area were advised to close during a pandemic, the situation would be reviewed after a period of time, such as 2 to 3 weeks, by local officials acting on information from the UK government, to decide whether to remain closed. Although the United States is a nation dedicated to federalism, an uncoordinated approach for community response measures such as school closure decisions could jeopardize our efforts in containing a deadly pandemic. If schools were to remain open until a certain percentage of students and faculty became ill, as they do during typical influenza seasons, then control measures to contain the outbreaks would likely be far more difficult to achieve because a chain of transmission would be established. Some might consider it unethical for schools to stay open in the face of a pandemic with a high death rate. I therefore think a national policy, or at least specific national guidelines, should be developed jointly by the Centers for Disease Control and Prevention and the Department of Education, so that states’ school districts can develop rational, coherent, and coordinated closure plans to protect children and communities during an influenza pandemic.

Biodefense research: can secrecy and safety coexist?

Over the next 10 years, the United States will spend 6 billion US dollars to develop countermeasures against biological and chemical weapons. Much of this research on highly virulent pathogens will be done in academic settings around the country. This article explores the challenges in ensuring secrecy to protect national security while accommodating the right of local communities to have access to safety information regarding select agents and laboratory-acquired infections. Secrecy has been defended as being vital for protecting national security. Problems with secrecy can include the misinterpretation of intentions, particularly in laboratories located in nuclear weapons design facilities, and the restricted access to information relevant to public health and safety. While federal select agent legislation requires laboratories to have emergency plans in place with first responders, these plans do not necessarily include public health professionals, who will be responsible for any future public health action, such as quarantine, surveillance, or mass vaccinations, in the unlikely event that a laboratory-acquired infection spreads into a community. Laboratory-acquired infections do occur, even with the best safety mechanisms in place; however, the epidemiology of the incidence and severity of these infections are not known since there is no national surveillance reporting system. Evidence suggests that many of these infections occur in the absence of an actual laboratory accident. The best emergency plans and surveillance systems are only as good as the participation and vigilance of the laboratory workers themselves. Thus, laboratory workers have a responsibility to themselves and others to report all laboratory accidents and spills, regardless how minor. In addition, they should have a lower threshold than normal in seeking medical attention when feeling ill, and their physicians should be aware of what pathogens they work with to reduce the risk of a delay in diagnosis.

Can biosecurity be embedded into the culture of the life sciences

The global brouhaha over research involving induced mutations in the deadly H5N1 avian influenza virus to make it highly contagious between mammals, a condition that does not exist in the natural world, raises important questions about whether or not biosecurity can be integrated into the culture of the life sciences. Ron Fouchier in the Netherlands and Yoshihiro Kawaoka of the University of Wisconsin, Madison, and the University of Tokyo’s Institute of Medical Sciences independently conducted research that met 2 of the criteria for the 7 ‘‘experiments of concern’’ as delineated in a 2004 National Academy of Sciences report, Biotechnology Research in an Age of Terrorism. (This report is referred to as the ‘‘Fink Report,’’ after the NAS committee chairman, Dr. Gerald Fink, Professor of Genetics, Massachusetts Institute of Technology.) The 7 ‘‘experiments of concern’’ are those that would: