11 March 2015

Research Committee Articles, March 9, 2015

Articles from March 9, 2015

Research Committee Selected Articles for the Week of March 9th, 2015

Zoonotic disease emergence is not a purely biological process mediated only by ecologic factors; opportunities for transmission of zoonoses from animals to humans also depend on how people interact with animals. While exposure is conditioned by the type of animal and the location in which interactions occur, these in turn are influenced by human activity. The activities people engage in are determined by social as well as contextual factors including gender, age, socio-economic status, occupation, social norms, settlement patterns and livelihood systems, family and community dynamics, as well as national and global influences. This paper proposes an expanded "One Health" conceptual model for human-animal exposure that accounts for social as well as epidemiologic factors. The expanded model informed a new study approach to document the extent of human exposure to animals and explore the interplay of social and environmental factors that influence risk of transmission at the individual and community level. The approach includes a formative phase using qualitative and participatory methods, and a representative, random sample survey to quantify exposure to animals in a variety of settings. The paper discusses the different factors that were considered in developing the approach, including the range of animals asked about and the parameters of exposure that are included, as well as factors to be considered in local adaptation of the generic instruments. Illustrative results from research using this approach in Lao PDR are presented to demonstrate the effect of social factors on how people interact with animals. We believe that the expanded model can be similarly operationalized to explore the interactions of other social and policy-level determinants that may influence transmission of zoonoses.

The One Health approach integrates health investigations across the tree of life, including, but not limited to, wildlife, livestock, crops, and humans. It redresses an epistemological alienation at the heart of much modern population health, which has long segregated studies by species. Up to this point, however, One Health research has also omitted addressing fundamental structural causes underlying collapsing health ecologies. In this critical review we unpack the relationship between One Health science and its political economy, particularly the conceptual and methodological trajectories by which it fails to incorporate social determinants of epizootic spillover. We also introduce a Structural One Health that addresses the research gap. The new science, open to incorporating developments across the social sciences, addresses foundational processes underlying multispecies health, including the place-specific deep-time histories, cultural infrastructure, and economic geographies driving disease emergence. We introduce an ongoing project on avian influenza to illustrate Structural One Health's scope and ambition. For the first time researchers are quantifying the relationships among transnational circuits of capital, associated shifts in agroecological landscapes, and the genetic evolution and spatial spread of a xenospecific pathogen.

'One World One Health' (OWOH), 'One Medicine' and 'One Health' are all injunctions to work across the domains of veterinary, human and environmental health. In large part they are institutional responses to growing concerns regarding shared health risks at the human, animal and environmental interfaces. Although these efforts to work across disciplinary boundaries are welcome, there are also risks in seeking unity, not least the tendency of one health visions to reduce diversity and to under-value the local, contingent and practical engagements that make health possible. This paper uses insights from Geography and Science and Technology Studies along with multi-sited and multi-species qualitative fieldwork on animal livestock and zoonotic influenzas in the UK, to highlight the importance of those practical engagements. After an introduction to one health, I argue that there is a tendency in OWOH visions to focus on contamination and transmission of pathogens rather than the socio-economic configuration of disease and health, and this tendency conforms to or performs what sociologist John Law calls a one world metaphysics. Following this, three related field cases are used to demonstrate that health is dependent upon a patchwork of practices, and is configured in practice by skilled people, animals, micro-organisms and their social relations. From surveillance for influenza viruses to tending animals, good health it turns out is dependent on an ability to construct common sense from a complex of signs, responses and actions. It takes, in other words, more than one world to make healthy outcomes. In light of this, the paper aims to, first, loosen any association between OWOH and a one world-ist metaphysics, and, second, to radicalize the inter-disciplinary foundations of OWOH by both widening the scope of disciplinarity as well as attending to how different knowledgesare brought together.

Among the most relevant elements contributing to define the One World One Health programme we find epidemics. The reason is that in recent decades, infectious diseases such as HIV/SIDA, SARS and Influenza have shown that we need new approaches and concepts in order to understand how biological emergencies and health alerts deploy new scales of action. Especially relevant has been the case of A(H1N1) influenza. This reached the status of global threat virtually from its onset, triggering an international response with a diffusion, visibility and rapidity unparalleled in previous health alerts. This article maintains that this global condition cannot be explained solely by the epidemiologic characteristics of the disease, such as mortality rate, severe cases, propagation capacity, etc. Resorting to the approach proposed by the Actor-Network Theory (ANT), this paper suggests that the action of certain socio-technical operators was what built a heterogeneous network of ideas, concepts and materials that turned the A (H1N1) influenza into a global-scale phenomenon with unprecedented speed. Among these operators, the most important ones were: the speaking position, a discourse about threat, the protocols and guidelines that were used and, lastly, the maps that allowed a real-time monitoring of the influenza. The paper ends with the notion of panorama, as defined by Bruno Latour: a suggestion to describe the common denominator of the aforementioned operators, and a means to foresee the development of global scales for certain health alerts. The paper will conclude by proposing that this type of analysis would allow the One World One Health to understand with greater precision the dynamic of epidemics and thus make its principles of action much more specific as well as its definition of what global health should be.

This paper traces the emergence and tensions of an internationally constructed and framed One World-One Health (OWOH) approach to control and attempt to eliminate African Trypanosomiasis in Uganda. In many respects Trypanosomiasis is a disease that an OWOH approach is perfectly designed to treat, requiring an integrated approach built on effective surveillance in animals and humans, quick diagnosis and targeting of the vector. The reality appears to be that the translation of global notions of OWOH down to national and district levels generates problems, primarily due to interactions between: a) international, external actors not engaging with the Ugandan state; b) actors setting up structures and activities parallel to those of the state; c) actors deciding when emergencies begin and end without consultation; d) weak Ugandan state capacity to coordinate its own integrated response to disease; e) limited collaboration between core Ugandan planning activities and a weak, increasingly devolved district health system. These interrelated dynamics result in the global, international interventionalist mode of OWOH undermining the Coordinating Office for Control of Trypanosomiasis in Uganda (COCTU), the body within the Ugandan state mandated expressly with managing a sustainable One Health response to trypanosomiasis outbreaks in Uganda. This does two things, firstly it suggests we need a more grounded, national perspective of OWOH, where states and health systems are acknowledged and engaged with by international actors and initiatives. Secondly, it suggests that more support needs to be given to core coordinating capacity in resource-poor contexts. Supporting national coordinating bodies, focused around One Health, and ensuring that external actors engage with and through those bodies can help develop a sustained, effective OWOH presence in resource-poor countries, where after all most zoonotic disease burden remains.

The development of the One World, One Health agenda coincides in time with the appearance of a different model for the management of human-animal relations: the genetic manipulation of animal species in order to curtail their ability as carriers of human pathogens. In this paper we examine two examples of this emergent transgenic approach to disease control: the development of transgenic chickens incapable of shedding avian flu viruses, and the creation of transgenic mosquitoes refractory to dengue or malaria infection. Our analysis elaborates three distinctions between the One World, One Health agenda and its transgenic counterpoint. The first concerns the conceptualization of outbreaks and the forms of surveillance that support disease control efforts. The second addresses the nature of the interspecies interface, and the relative role of humans and animals in preventing pathogen transmission. The third axis of comparison considers the proprietary dimensions of transgenic animals and their implications for the assumed public health ethos of One Health programs. We argue that the fundamental difference between these two approaches to infectious disease control can be summarized as one between strategies of containment and strategies of competition. While One World, One Health programs seek to establish an equilibrium in the human-animal interface in order to contain the circulation of pathogens across species, transgenic strategies deliberately trigger a new ecological dynamic by introducing novel animal varieties designed to out-compete pathogen-carrying hosts and vectors. In other words, while One World, One Health policies focus on introducing measures of inter-species containment, transgenic approaches derive their prophylactic benefit from provoking new cycles of intra-species competition between GM animals and their wild-type counterparts. The coexistence of these divergent health protection strategies, we suggest, helps to elucidate enduring tensions and con

Emerging infectious diseases from animals pose significant and increasing threats to human health; places of risk are simultaneously viewed as conservation and emerging disease 'hotspots'. The One World/One Health paradigm is an 'assemblage' discipline. Extensive research from the natural and social sciences, as well as public health have contributed to designing surveillance and response policy within the One World/One Health framework. However, little research has been undertaken that considers the lives of those who experience risk in hotspots on a daily basis. As a result, policymakers and practitioners are unable to fully comprehend the social and ecological processes that catalyze cross-species pathogen exchange. This study examined local populations' comprehension of zoonotic disease. From October 2008-May 2009 we collected data from people living on the periphery of Kibale National Park, in western Uganda. We administered a survey to 72 individuals and conducted semi-structured, in-depth interviews with 14 individuals. Results from the survey showed respondents had statistically significant awareness that transmission of diseases from animals was possible compared to those who did not think such transmission was possible (x2=30.68, df=1, p<0.05). However, individual characteristics such as gender, occupation, location, and age were not significantly predictive of awareness. Both quantitative and qualitative data show local people are aware of zoonoses and provided biomedically accurate examples of possible infections and corresponding animal sources (e.g., worm infection from pigs and Ebola from primates). Qualitative data also revealed expectations about the role of the State in managing the prevention of zoonoses from wildlife. As a result of this research, we recommend meaningful discourse with people living at the frontlines of animal contact in emerging disease and conservation hotspots in order to develop informed and relevant zoonoses prevention pr

The social environment has changed rapidly as technology has facilitated communication among individuals and groups in ways not imagined 20 years ago. Communication technology increasingly plays a role in decision-making about health and environmental behaviors and is being leveraged to influence that process. But at its root is the fundamental need to understand human cognition, communication, and behavior. The concept of 'One Health' has emerged as a framework for interdisciplinary work that cuts across human, animal, and ecosystem health in recognition of their interdependence and the value of an integrated perspective. Yet, the science of communication, information studies, social psychology, and other social sciences have remained marginalized in this emergence. Based on an interdisciplinary collaboration, this paper reports on a nascent conceptual framework for the role of social science in 'One Health' issues and identifies a series of recommendations for research directions that bear additional scrutiny and development.

This article contributes to the literature on One Health and public health ethics by expanding the principle of solidarity. We conceptualise solidarity to encompass not only practices intended to assist other people, but also practices intended to assist non-human others, including animals, plants, or places. To illustrate how manifestations of humanist and more-than-human solidarity may selectively complement one another, or collide, recent responses to Hendra virus in Australia and Rabies virus in Canada serve as case examples. Given that caring relationships are foundational to health promotion, people's efforts to care for non-human others are highly relevant to public health, even when these efforts conflict with edicts issued in the name of public health. In its most optimistic explication, One Health aims to attain optimal health for humans, non-human animals and their shared environments. As a field, public health ethics needs to move beyond an exclusive preoccupation with humans, so as to account for moral complexity arising from people's diverse connections with places, plants, and non-human animals.

Background: Influenza is a contagious disease with high transmissibility to spread around the world with considerable morbidity and mortality and presents an enormous burden on worldwide public health. Few mathematical models can be used because influenza incidence data are generally not normally distributed. We developed a mathematical model using Extreme Value Theory (EVT) to forecast the probability of outbreak of highly pathogenic influenza. Methods: The incidence data of highly pathogenic influenza in Zhejiang province from April 2009 to November 2013 were retrieved from the website of Health and Family Planning Commission of Zhejiang Province. MATLAB "VIEM" toolbox was used to analyze data and modelling. In the present work, we used the Peak Over Threshold (POT) model, assuming the frequency as a Poisson process and the intensity to be Pareto distributed, to characterize the temporal variability of the long-term extreme incidence of highly pathogenic influenza in Zhejiang, China. Results: The skewness and kurtosis of the incidence of highly pathogenic influenza in Zhejiang between April 2009 and November 2013 were 4.49 and 21.12, which indicated a "fat tail" distribution. A QQ plot and a mean excess plot were used to further validate the features of the distribution. After determining the threshold, we modeled the extremes and estimated the shape parameter and scale parameter by the maximum likelihood method. The results showed that months in which the incidence of highly pathogenic influenza is about 4462/2286/1311/487 are predicted to occur once every five/three/two/one year, respectively. Conclusions: Despite the simplicity, the present study successfully offers the sound modeling strategy and a methodological avenue to implement forecasting of an epidemic in the midst of its course.

Timely outbreak investigations are central in containing communicable disease outbreaks; despite this, no guidance currently exists on expectations of timeliness for investigations. A literature review was conducted to assess the length of epidemiological outbreak investigations in Europe in peer-reviewed publications. We determined time intervals between outbreak declaration to hypothesis generation, and hypothesis generation to availability of results from an analytical study. Outbreaks were classified into two groups: those with a public health impact across regions within a country and requiring national coordination (level 3) and those with a severe or catastrophic impact requiring direction at national level (levels 4 and 5). Investigations in Europe published between 2003 and 2013 were reviewed. We identified 86 papers for review: 63 level 3 and 23 level 4 and 5 investigations. Time intervals were ascertained from 55 papers. The median period for completion of an analytical study was 15 days (range: 4–32) for levels 4 and 5 and 31 days (range: 9–213) for level 3 investigations. Key factors influencing the speed of completing analytical studies were outbreak level, severity of infection and study design. Our findings suggest that guidance for completing analytical studies could usefully be provided, with different time intervals according to outbreak severity.

objective. To identify clinical signs and symptoms (ie, “terms”) that accurately predict laboratory-confirmed influenza cases and thereafter generate and evaluate various influenza-like illness (ILI) case definitions for detecting influenza. A secondary objective explored whether surveillance of data beyond the chief complaint improves the accuracy of predicting influenza. design. Retrospective, cross-sectional study. setting. Large urban academic medical center hospital. participants. A total of 1,581 emergency department (ED) patients who received a nasopharyngeal swab followed by rRT-PCR testing between August 30, 2009, and January 2, 2010, and between November 28, 2010, and March 26, 2011. methods. An electronic surveillance system (GUARDIAN) scanned the entire electronic medical record (EMR) and identified cases containing 29 clinical terms relevant to influenza. Analyses were conducted using logistic regressions, diagnostic odds ratio (DOR), sensitivity, and specificity. results. The best predictive model for identifying influenza for all ages consisted of cough (DOR =5.87), fever (DOR = 4.49), rhinorrhea (DOR = 1.98), and myalgias (DOR =1.44). The 3 best case definitions that included combinations of some or all of these 4 symptoms had comparable performance (ie, sensitivity =89%–92% and specificity= 38%–44%). For children <5 data-blogger-escaped-0="" data-blogger-escaped-37.1="" data-blogger-escaped-a="" data-blogger-escaped-achieved="" data-blogger-escaped-addition="" data-blogger-escaped-age="" data-blogger-escaped-ages="" data-blogger-escaped-all="" data-blogger-escaped-and="" data-blogger-escaped-balance="" data-blogger-escaped-based="" data-blogger-escaped-be="" data-blogger-escaped-better="" data-blogger-escaped-between="" data-blogger-escaped-case="" data-blogger-escaped-cases="" data-blogger-escaped-chief="" data-blogger-escaped-complaint="" data-blogger-escaped-conclusions.="" data-blogger-escaped-cough="" data-blogger-escaped-data.="" data-blogger-escaped-definition="" data-blogger-escaped-detection="" data-blogger-escaped-did="" data-blogger-escaped-emr="" data-blogger-escaped-entire="" data-blogger-escaped-fever="" data-blogger-escaped-finally="" data-blogger-escaped-for="" data-blogger-escaped-further="" data-blogger-escaped-group.="" data-blogger-escaped-guardian="" data-blogger-escaped-identified="" data-blogger-escaped-ili="" data-blogger-escaped-implementation="" data-blogger-escaped-improve="" data-blogger-escaped-inclusion="" data-blogger-escaped-influenza="" data-blogger-escaped-is="" data-blogger-escaped-it="" data-blogger-escaped-may="" data-blogger-escaped-more="" data-blogger-escaped-of="" data-blogger-escaped-on="" data-blogger-escaped-only="" data-blogger-escaped-recommended.="" data-blogger-escaped-rhinorrhea="" data-blogger-escaped-sensitivity="" data-blogger-escaped-simplified="" data-blogger-escaped-specificity="" data-blogger-escaped-suitable="" data-blogger-escaped-surveillance="" data-blogger-escaped-than="" data-blogger-escaped-the="" data-blogger-escaped-to="" data-blogger-escaped-using="" data-blogger-escaped-while="" data-blogger-escaped-year-old="" data-blogger-escaped-years="">

objective. Contact patterns and microbiological data contribute to a detailed understanding of infectious disease transmission. We explored the automated collection of high-resolution contact data by wearable sensors combined with virological data to investigate influenza transmission among patients and healthcare workers in a geriatric unit. design. Proof-of-concept observational study. Detailed information on contact patterns were collected by wearable sensors over 12 days. Systematic nasopharyngeal swabs were taken, analyzed for influenza A and B viruses by real-time polymerase chain reaction, and cultured for phylogenetic analysis. setting. An acute-care geriatric unit in a tertiary care hospital. participants. Patients, nurses, and medical doctors. results. A total of 18,765 contacts were recorded among 37 patients, 32 nurses, and 15 medical doctors. Most contacts occurred between nurses or between a nurse and a patient. Fifteen individuals had influenza A (H3N2). Among these, 11 study participants were positive at the beginning of the study or at admission, and 3 patients and 1 nurse acquired laboratory-confirmed influenza during the study. Infectious medical doctors and nurses were identified as potential sources of hospital-acquired influenza (HA-Flu) for patients, and infectious patients were identified as likely sources for nurses. Only 1 potential transmission between nurses was observed. conclusions. Combining high-resolution contact data and virological data allowed us to identify a potential transmission route in each possible case of HA-Flu. This promising method should be applied for longer periods in larger populations, with more complete use of phylogenetic analyses, for a better understanding of influenza transmission dynamics in a hospital setting.

During a foodborne crisis, risk assessors are often scrambling to assemble data needed to trace suspected foods along very complex supply chains. Although traceability systems ensure that stakeholders in the supply chain record lot-specific trace-back and trace-forward data, there are few databases available that describe in detail the flow of product in the complex web of supply chains. This paper presents the methodological approach used to design and assemble a relational database of nation-wide trade data for packaged ready-to-eat lettuce and leafy greens. The database was used in the development of an integrated simulation tool (Canadian GIS-based Risk Assessment, Simulation and Planning for food safety tool, i.e. CanGRASP) that can predict the spatial distribution and public health risk associated with contaminated food. The database includes the geographical coordinates of 5 domestic processors, 28 produce distribution centres and 2946 retail outlets from five of the top ten retail chains in Canada. It also includes other critical information to predict the fate of pathogens during distribution of contaminated product through the supply chain including: (a) product volumes handled by each stakeholder, (b) flow of product between stakeholders, (c) temperatures of product each season, and (d) times products spend in each step or during transit between steps, for each season. The database is used by both the simulation and mapping components of the integrated simulation tool during risk assessment exercises associated with emergency preparedness planning and training. Using the database, CanGRASP was able to assess the spread of the population at risk during a simulation of a hypothetical outbreak caused by fresh-cut leafy vegetables contaminated with Escherichia coli O157:H7 in the Canadian food distribution systems during both summer and winter seasons.

Purpose: To enhance speedy communication between the patient and the doctor through newly proposed routing protocol at the mobile node. Materials and Methods: The proposed model is applied for a telemedicine application during disaster recovery management. In this paper, Energy Efficient Link Stability Routing Protocol (EELSRP) has been developed by simulation and real time. This framework is designed for the immediate healing of affected persons in remote areas, especially at the time of the disaster where there is no hospital proximity. In case of disasters, there might be an outbreak of infectious diseases. In such cases, the patient's medical record is also transferred by the field operator from disaster place to the hospital to facilitate the identification of the disease-causing agent and to prescribe the necessary medication. The heterogeneous networking framework provides reliable, energy efficientand speedy communication between the patient and the doctor using the proposed routing protocol at the mobile node. Results: The performance of the simulation and real time versions of the Energy Efficient Link Stability Routing Protocol (EELSRP) protocol has been analyzed. Experimental results prove the efficiency of the real-time version of EESLRP protocol. Conclusion: The packet delivery ratio and throughput of the real time version of EELSRP protocol is increased by 3% and 10%, respectively, when compared to the simulated version of EELSRP. The end-to-end delay and energy consumption are reduced by 10% and 2% in the real time version of EELSRP.

[No abstract available]

objective. While incidence, mortality, morbidity, and recurrence rates of C. difficile infection (CDI) among the critically ill have been investigated, the impact of its recurrence on 30-day rehospitalization (ReAd), an important policy focus, has not been examined. design. Secondary analysis of a multicenter retrospective cohort study patients. Adult critically ill patients who survived their index hospitalization complicated by CDI methods. CDI was defined by diarrhea or pseudomembranous colitis and a positive assay for C. difficile toxins A and/or B. CDI recurrence (rCDI) was defined as diarrhea, positive C. difficile toxin and need for retreatment after cessation of therapy. Descriptive statistics and a logistic regression examined ReAd rates and characteristics, and factors that impact it. results. Among 287 hospital survivors, 76 (26.5%) required ReAd (ReAd+). At baseline, the ReAd+ group did not differ significantly from the ReAd– group based on demographics, comorbidities, APACHE II scores, or ICU type. ReAd+ patients were more likely to have hypotension at CDI onset (48.7% vs 34.1%, P=.025) and to require vasopressors (40.0% vs 27.1%, P=.038); they were less likely to require mechanical ventilation (56.0% vs 77.3%, P<.001). A far greater proportion of ReAd+ than ReAd– had developed a recurrence either during the index hospitalization or within 30 days after discharge (32.89% vs 2.84%, P<.001). In a logistic regression, rCDI was a strong predictor of ReAd+ (adjusted odd ratio, 15.33, 95% confidence interval, 5.68–41.40). conclusions. Greater than 25% of all survivors of critical illness complicated by CDI require readmission within 30 days of discharge. CDI recurrence is a strong predictor of such rehospitalizations.

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