Michael H. Merson

Towards a common definition of global health

This commentary makes the argument for the necessity of a common definition of global health.

Disease caused by a marine Vibrio. Clinical characteristics and epidemiology.

We studied the clinical characteristics and epidemiology of disease associated with a rare, unnamed halophilic lactose-fermenting Vibrio species in 39 persons from whom the organism had been isolated. Two distinct clinical presentations were seen. In the first, the illness began with septicemia, often within 24 hours after raw oysters had been eaten; 18 of 24 such patients had pre-existing hepatic disease, and 11 of the 24 died. In the second, there was a wound infection after exposure to seawater or an injury incurred during the handling of crabs; none of these persons had pre-existing hepatic disease, and one of 15 died. Most cases (85 per cent) occurred during relatively warm months (May to October) in men (90 per cent) 40 or more years of age (95 per cent). This Vibrio species is a pathogen and should be considered in the differential diagnosis of septicemia with secondary skin lesions and of wound infections after exposure to seawater.

The history and challenge of HIV prevention

The HIV/AIDS pandemic has become part of the contemporary global landscape. Few predicted its effect on mortality and morbidity or its devastating social and economic consequences, particularly in sub-Saharan Africa. Successful responses have addressed sensitive social factors surrounding HIV prevention, such as sexual behaviour, drug use, and gender equalities, countered stigma and discrimination, and mobilised affected communities; but such responses have been few and far between. Only in recent years has the international response to HIV prevention gathered momentum, mainly due to the availability of treatment with antiretroviral drugs, the recognition that the pandemic has both development and security implications, and a substantial increase in financial resources brought about by new funders and funding mechanisms. We now require an urgent and revitalised global movement for HIV prevention that supports a combination of behavioural, structural, and biomedical approaches and is based on scientifically derived evidence and the wisdom and ownership of communities.

A Two-Year Study of Bacterial, Viral, and Parasitic Agents Associated with Diarrhea in Rural Bangladesh

Abstract Enteric pathogens associated with diarrhea were studied for two years at a diarrhea treatment center in rural Bangladesh. Enterotoxigenic Escherichia coli (ETEC) was the most frequently identified pathogen for patients of all ages. Rotavirus and ETEC were isolated from ∼50% and ∼25%, respectively, of patients less than two years of age. A bacterial or viral pathogen was identified for 70% of these young children and for 56% of all patients with diarrhea. Most ETEC isolates were obtained in the hot dry months of March and April and the hot wet months of August and September. Rotavirus identification peaked in the cool dry months of December and January, but infected patients were found year-round. The low case-fatality rates for patients with watery diarrhea and substantial dehydration further document the usefulness of treating patients with diarrhea with either a glucose- or sucrose-base electrolyte solution such as those used in this treatment center.

Clinical Features of Types A and B Food-borne Botulism

Medical records of 55 patients with type A and type B food-borne botulism reported to the Centers for Disease Control during 2 years were reviewed to assess the clinical features and severity of illness, diagnostic test results, nature of complications, amd causes of death. Some patients had features not usually associated with botulism including paresthesia (14%), asymmetric extremely weakness (17%), asymmetric ptosis (8%), slightly elevated cerebrospinal fluid protein values (14%), and positive responses to edrophonium chloride(26%). Several observation suggest that type A was more severe than type B disease. Although the case-fatality ratio was not significantly greater, patients with type A disease saw a physician earlier in the course of illness, were more likely to need ventilatory support, and were hospitalized longer. Patients who died were older than those who survived. Deaths within the first 2 weeks resulted from failure to recognized the severity of the disease or from pulmonary or systemic infection whereas the three late deaths were related to respirator malfunction.

Contamination of weaning foods and transmission of enterotoxigenic Escherichia coli diarrhoea in children in rural Bangladesh

In longitudinal studies of infectious diseases and nutrition in Bangladesh, we determined the degree of bacterial contamination of traditional weaning foods and evaluated the role of these foods in the transmission of diarrhoeal diseases. 41% of samples of food items fed to weaning aged children contained Escherichia coli; these organisms were used as indicators of faecal contamination. Milk and foods prepared particularly for infants were more frequently and heavily contaminated with E. coli than was boiled rice, and E. coli levels were found to be related to the storage of cooked foods at high environmental temperatures. 50% of drinking water specimens also contained E. coli, but colony counts were approximately 10-fold lower than in food specimens. The proportion of a childs food samples that contained E. coli was significantly related to the childs annual incidence of diarrhoea associated with enterotoxigenic E. coli. This observation underscores the importance of seeking locally available foods that are hygienic as well as nutritious to supplement the diets of breastfeeding children in developing countries.

INCIDENCE AND SEVERITY OF ROTAVIRUS AND ESCHERICHIA COLI DIARRHOEA IN RURAL BANGLADESH: Implications for Vaccine Development

In a 1 year study of diarrhoea in a village in rural Bangladesh, enterotoxigenic Escherichia coli (ETEC) were the most frequently detected enteropathogens; shigellae were the second most commonly detected enteropathogens and rotaviruses the third. ETEC and rotavirus were found in 31% of diarrhoea episodes experienced by children aged less than 2 years and in 70% of episodes associated with dehydration. Furthermore these two pathogens were identified in the stools of 77% of young children with life-threatening dehydration seen at a diarrhoea treatment centre. The association of ETEC and rotavirus with such a substantial proportion of cases of dehydrating diarrhoea suggests that immunoprophylaxis to reduce the high incidence of deaths from diarrhoea in developing countries may be feasible and that vaccine development should concentrate on these two enteropathogens.

ORAL HYDRATION IN ROTAVIRUS DIARRHŒA: A DOUBLE BLIND COMPARISON OF SUCROSE WITH GLUCOSE ELECTROLYTE SOLUTION

Of 57 male children, aged 5 months to 2 1/2 years with rotavirus diarrhoea, 28 were given oral therapy with sucrose electrolyte solution and 29 were given glucose electrolyte solution in a randomised double-blind trial. All were rehydrated and remained so on oral therapy alone. These patients were compared with 44 children, also with rotavirus, who were treated only with intravenous hydration. The oral therapy and intravenous therapy groups did not differ clinically in the rate of rehydration or the rate of purging. Vomiting did not prevent the giving of oral therapy during hospital admission. Bangladeshi children with rotavirus diarrhoea have a defect of carbohydrate digestion but this defect does not prevent the use of a sugar electrolyte solution for oral hydration.

Fish and Shellfish Poisoning

Vertebrate fish containing toxins capable of causing human illness are divided into three categories based on the location of the toxin.1 Ichthyosarcotoxic fish contain toxin in their musculature, ...

The role of academic health science systems in the transformation of medicine

The challenges facing the health of communities around the world are unprecedented, and the data are all too familiar. For 5 billion people living in developing countries, environmental factors and inadequacies in hygiene, economic development, and health-care access are the main causes of shortened life expectancies. Improvements in health status, including reductions in infant mortality and declining incidence of infectious diseases, are being met by the new epidemics of obesity, diabetes mellitus, and cardiovascular disease. Developed countries are beset by disparities in access to care and health outcomes, unreliable quality, and high costs. Increased demand for services, ageing populations, inadequate evidence to guide practice, and a misdirected emphasis on research and treatment in late-stage disease contribute to the high cost of health care. In many countries, these diffi culties are exacerbated by fragmented health-care delivery systems, resulting in inadequate continuity of care across community, primary-care, and tertiary-care settings. The creation of novel treatments remains protracted and expensive, new discoveries are not delivered swiftly to patients, and population-wide strategies using cheap, simple, and effi cient interventions are not eff ectively implemented. Many countries, including the USA, the UK, Singapore, the Netherlands, and Canada, have focused on the promise of academic health science centres (AHSCs) to improve health locally and globally while also supporting economic development. In this Viewpoint, we draw attention to the potential of these organisations in leading the transformation of medicine through the development of a discovery-care continuum—a network to disseminate knowledge and innovations globally—and describe a few activities that are underway with the aim to make the potential a reality. To resolve the diffi culties described above, AHSCs should create not only novel drugs, devices, and other technologies, but also new ways of deploying broad, inexpensive preventive and treatment strategies among populations. An amalgamation of broad public health and individualised care might seem contradictory, but a vision of transformation supported by a radical reorganisation of AHSCs can initiate a creative synthesis in which technological innovations, eff ective treatments, and delivery of care combine to formulate common solutions that can be applied to individuals and large populations. The discovery-care continuum (fi gure 1A) represents such a pathway, in which innovative ideas can be put into practice to improve patient care, irrespective of where on the continuum they arise. In order to achieve transformation, two distinct translational blocks or gaps in the discovery-care continuum must be overcome. The fi rst is the gap between a scientifi c discovery and its clinical translation (ie, from bench to bedside); the second is the gap between expert acceptance of the application and its broad adoption in practice by local and global communities (ie, from bedside to population). AHSCs traditionally give their discoveries to industry at the fi rst gap and to practising physicians at the second gap, thereby creating barriers and ineffi ciencies. We believe that AHSCs are ideally poised to become system integrators that are capable of bridging these translational gaps, thereby greatly reducing delays and ineffi ciencies between discovery and global adoption. These system integrators do not replace industry or non-academic providers, rather, they improve the capacity to develop and deliver new treatments by fi lling the spaces between academic discovery, science, industry, and the general health-care delivery system. In the USA, the Roadmap Initiative of the National Institutes of Health (Bethesda, MD), and resulting Clinical and Translational Science Awards have shown this perspective. Examples of US institutions that have begun to develop models of integrated translational research and care-delivery systems include the University of Pennsylvania (Philadelphia, PA), Johns Hopkins University (Baltimore, MD), and Harvard University-Partners Healthcare (Boston, MA). At Duke, we have developed an AHSC (Duke Medicine) that includes the Duke University Schools of Medicine and Nursing, the Duke University Health System, and related organisations. The UK is also creating AHSCs through the integration of academic (eg, education and research) and care-delivery systems, enabled by partnerships between universities and the National Health Service Trusts, such as Imperial College’s Academic Health Science Centre in London. To transform health care, we believe that AHSCs should evolve further into academic health science systems (AHSSs). The term AHSC connotes a specifi c location where patients receive care (eg, a medical campus), whereas AHSSs are thought of as integrated health-care delivery systems that not only include the traditional medical centre but also a network of community hospitals and practices. Ideally, each AHSS has missions, resources, and standards that are shared by the system to improve the way in which it helps patients and communities. To catalyse the needed transformation, we believe that AHSSs should focus on organisational structures, external partnerships, research translation, models of care delivery, new Lancet 2010; 375: 949–53