The IHR (2005), disease surveillance, and the individual in global health politics

Since the revisions to the International Health Regulations (IHR) in 2005, much attention has turned to two concerns relating to infectious disease control. The first is how to assist states to strengthen their capacity to identify and verify public health emergencies of international concern (PHEIC). The second is the question of how the World Health Organization (WHO) will operate its expanded mandate under the revised IHR. Very little attention has been paid to the potential individual power that has been afforded under the IHR revisions – primarily through the first inclusion of human rights principles into the instrument and the allowance for the WHO to receive non-state surveillance intelligence and informal reports of health emergencies. These inclusions mark the individual as a powerful actor, but also recognise the vulnerability of the individual to the whim of the state in outbreak response and containment. In this paper we examine why these changes to the IHR occurred and explore the consequence of expanding the sovereignty-as-responsibility concept to disease outbreak response. To this end our paper considers both the strengths and weaknesses of incorporating reports from non-official sources and including human rights principles in the IHR framework.

The international politics of disease reporting : towards post-Westphalianism?

Since the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003, there has been much discussion about whether the international community has moved into a new post-Westphalian era, where states increasingly recognize certain shared norms that guide what they ought to do in responding to infectious disease outbreaks. In this article I identify this new obligation as the ‘duty to report’, and examine competing accounts on the degree to which states appreciate this new obligation are considered by examining state behaviour during the H5N1 human infectious outbreaks in East Asia (since 2004). The article examines reporting behaviour for H5N1 human infectious cases in Cambodia, China, Indonesia, Thailand and Vietnam from 2004 to 2010. The findings lend strong support to the claim that East Asian states have come to accept and comply with the duty to report infectious disease outbreaks and that the assertions of sovereignty in response to global health governance frameworks have not systematically inhibited reporting compliance.

What does it mean to 'securitize' infectious diseases?

This paper seeks to explain how the selective securitization of infectious disease arose, and to analyze the policy successes from this move. It is argued that despite some success, such as the revised International Health Regulations (IHR) in 2005, there remain serious deficiencies in the political outputs from the securitization of infectious disease.

Systematic Review Protocol : "Are community-based interventions effective in identifying and responding to emerging zoonotic infectious diseases?"

Review question/objective The objective of this review is to identify the effectiveness of surveillance systems and community-based interventions in identifying and responding to emerging and re-emerging zoonotic infections in Southeast Asia (SE Asia). More specifically the research questions are: 1. What is the effectiveness of community-based surveillance interventions designed to identify emerging zoonotic infectious diseases? 2. What is the effectiveness of non-pharmaceutical community-based interventions designed to prevent transmission of emerging zoonotic infectious diseases? 3. How do factors related to the emergence and management of emerging zoonotic infectious diseases impact the effectiveness of interventions designed to identify and respond to them?

The potential impact of climate change and ultraviolet radiation on vaccine preventable infectious diseases and immunisation service delivery system

Climate change and solar ultraviolet radiation may affect vaccine-preventable infectious diseases (VPID), the human immune response process and the immunization service delivery system. We systematically reviewed the scientific literature and identified 37 relevant publications. Our study shows that climate variability and ultraviolet radiation may potentially affect VPID and the immunization delivery system through modulating vector reproduction and vaccination effectiveness, possibly influencing human immune response systems to the vaccination, and disturbing immunization service delivery. Further research is needed to determine these affects on climate-sensitive VPID and on human immune response to common vaccines. Such research will facilitate the development and delivery of optimal vaccination programs for target populations, to meet the goal of disease control and elimination.

Hand, foot and mouth disease in China: Evaluating an automated system for the detection of outbreaks

Objective To evaluate the performance of China’s infectious disease automated alert and response system in the detection of outbreaks of hand, foot and mouth (HFM) disease. Methods We estimated size, duration and delay in reporting HFM disease outbreaks from cases notified between 1 May 2008 and 30 April 2010 and between 1 May 2010 and 30 April 2012, before and after automatic alert and response included HFM disease. Sensitivity, specificity and timeliness of detection of aberrations in the incidence of HFM disease outbreaks were estimated by comparing automated detections to observations of public health staff. Findings The alert and response system recorded 106 005 aberrations in the incidence of HFM disease between 1 May 2010 and 30 April 2012 – a mean of 5.6 aberrations per 100 days in each county that reported HFM disease. The response system had a sensitivity of 92.7% and a specificity of 95.0%. The mean delay between the reporting of the first case of an outbreak and detection of that outbreak by the response system was 2.1 days. Between the first and second study periods, the mean size of an HFM disease outbreak decreased from 19.4 to 15.8 cases and the mean interval between the onset and initial reporting of such an outbreak to the public health emergency reporting system decreased from 10.0 to 9.1 days. Conclusion The automated alert and response system shows good sensitivity in the detection of HFM disease outbreaks and appears to be relatively rapid. Continued use of this system should allow more effective prevention and limitation of such outbreaks in China.

Tadpole mouthpart depigmentation as an accurate indicator of chytridiomycosis, an emerging disease of amphibians

Chytridiomycosis is an emerging infectious disease of amphibians caused by the fungal pathogen Batrachochytrium dendrobatidis, and its role in causing population declines and species extinctions worldwide has created an urgent need for methods to detect it. Several reports indicate that in anurans chytridiomycosis can cause the depigmentation of tadpole tnouthparts, but the accuracy of using depigmentation to determine disease status remains uncertain. Our objective was to determine for the Mountain Yellow-legged Frog (Rana muscosa) whether visual inspections of the extent of tadpole mouthpart depigmentation could be used to accurately categorize individual tadpoles or R. muscosa populations as B. dendrobatidis-positive or negative. This was accomplished by assessing the degree of mouthpart depigmentation in tadpoles of known disease status (based on PCR assays). The depigmentation of R. muscosa tadpole mouthparts was associated with the presence of B. dendrobatidis, and this association was particularly strong for upper jaw sheaths. Using a rule that classifies tadpoles with upper jaw sheaths that are 100% pigmented as uninfected and those with jaw sheaths that are <100% pigmented as infected resulted in the infection status of 86% of the tadpoles being correctly classified. By applying this rule to jaw sheath pigmentation scores averaged across all tadpoles inspected per site, we were able to correctly categorize the infection status of 92% of the study populations. Similar research on additional anurans is critically needed to determine how broadly applicable our results for R. muscosa are to other species.

Disease Diplomacy

In the age of air travel and globalized trade, pathogens that once took months or even years to spread beyond their regions of origin can now circumnavigate the globe in a matter of hours. Amid growing concerns about such epidemics as Ebola, SARS, MERS, and H1N1, disease diplomacy has emerged as a key foreign and security policy concern as countries work to collectively strengthen the global systems of disease surveillance and control. The revision of the International Health Regulations (IHR), eventually adopted by the World Health Organization’s member states in 2005, was the foremost manifestation of this novel diplomacy. The new regulations heralded a profound shift in international norms surrounding global health security, significantly expanding what is expected of states in the face of public health emergencies and requiring them to improve their capacity to detect and contain outbreaks. Drawing on Martha Finnemore and Kathryn Sikkink’s "norm life cycle" framework and based on extensive documentary analysis and key informant interviews, Disease Diplomacy traces the emergence of these new norms of global health security, the extent to which they have been internalized by states, and the political and technical constraints governments confront in attempting to comply with their new international obligations. The authors also examine in detail the background, drafting, adoption, and implementation of the IHR while arguing that the very existence of these regulations reveals an important new understanding: that infectious disease outbreaks and their management are critical to national and international security. The book will be of great interest to academic researchers, postgraduate students, and advanced undergraduates in the fields of global public health, international relations, and public policy, as well as health professionals, diplomats, and practitioners with a professional interest in global health security.

The Politics of Surveillance and Response to Disease Outbreaks: The New Frontier for States and Non-state Actors

The capacity to conduct international disease outbreak surveillance and share information about outbreaks quickly has empowered both State and Non-State Actors to take an active role in stopping the spread of disease by generating new technical means to identify potential pandemics through the creation of shared reporting platforms. Despite all the rhetoric about the importance of infectious disease surveillance, the concept itself has received relatively little critical attention from academics, practitioners, and policymakers. This book asks leading contributors in the field to engage with five key issues attached to international disease outbreak surveillance - transparency, local engagement, practical needs, integration, and appeal - to illuminate the political effect of these technologies on those who use surveillance, those who respond to surveillance, and those being monitored.

The politics of disease surveillance

The capacity to conduct international disease outbreak surveillance and share information about outbreaks quickly has empowered both State and Non-State Actors to take an active role in stopping the spread of disease by generating new technical means to identify potential pandemics through the creation of shared reporting platforms. Despite all the rhetoric about the importance of infectious disease surveillance, the concept itself has received relatively little critical attention from academics, practitioners, and policymakers. This book asks leading contributors in the field to engage with five key issues attached to international disease outbreak surveillance - transparency, local engagement, practical needs, integration, and appeal - to illuminate the political effect of these technologies on those who use surveillance, those who respond to surveillance, and those being monitored.

A Generalist Predator Regulating Spread of a Wildlife Disease: Exploring Two Infection Transmission Scenarios

Ecoepidemiology is a well-developed branch of theoretical ecology, which explores interplay between the trophic interactions and the disease spread. In most ecoepidemiological models, however, the authors assume the predator to be a specialist, which consumes only a single prey species. In few existing papers, in which the predator was suggested to be a generalist, the alternative food supply was always considered to be constant. This is obviously a simplification of reality, since predators can often choose between a number of different prey. Consumption of these alternative prey can dramatically change their densities and strongly influence the model predictions. In this paper, we try to bridge the gap and explore a generic ecoepidemiological system with a generalist predator, where the densities of all prey are dynamical variables. The model consists of two prey species, one of which is subject to an infectious disease, and a predator, which consumes both prey species. We investigate two main scenarios of infection transmission mode: (i) the disease transmission rate is predator independent and (ii) the transmission rate is a function of predator density. For both scenarios we fulfil an extensive bifurcation analysis. We show that including a second dynamical prey in the system can drastically change the dynamics of the single prey case. In particular, the presence of a second prey impedes disease spread by decreasing the basic reproduction number and can result in a substantial drop of the disease prevalence. We demonstrate that with efficient consumption of the second prey species by the predator, the predator-dependent disease transmission can not destabilize interactions, as in the case with a specialist predator. Interestingly, even if the population of the second prey eventually vanishes and only one prey species finally remains, the system with two prey species may exhibit different properties to those of the single prey system.

Modelling within-host spatiotemporal dynamics of invasive bacterial disease

Mechanistic determinants of bacterial growth, death, and spread within mammalian hosts cannot be fully resolved studying a single bacterial population. They are also currently poorly understood. Here, we report on the application of sophisticated experimental approaches to map spatiotemporal population dynamics of bacteria during an infection. We analyzed heterogeneous traits of simultaneous infections with tagged Salmonella enterica populations (wild-type isogenic tagged strains [WITS]) in wild-type and gene-targeted mice. WITS are phenotypically identical but can be distinguished and enumerated by quantitative PCR, making it possible, using probabilistic models, to estimate bacterial death rate based on the disappearance of strains through time. This multidisciplinary approach allowed us to establish the timing, relative occurrence, and immune control of key infection parameters in a true host-pathogen combination. Our analyses support a model in which shortly after infection, concomitant death and rapid bacterial replication lead to the establishment of independent bacterial subpopulations in different organs, a process controlled by host antimicrobial mechanisms. Later, decreased microbial mortality leads to an exponential increase in the number of bacteria that spread locally, with subsequent mixing of bacteria between organs via bacteraemia and further stochastic selection. This approach provides us with an unprecedented outlook on the pathogenesis of S. enterica infections, illustrating the complex spatial and stochastic effects that drive an infectious disease. The application of the novel method that we present in appropriate and diverse host-pathogen combinations, together with modelling of the data that result, will facilitate a comprehensive view of the spatial and stochastic nature of within-host dynamics. © 2008 Grant et al.

In utero domoic acid toxicity: a fetal basis to adult disease in the California sea lion (Zalophus californianus)

California sea lions have been a repeated subject of investigation for early life toxicity, which has been documented to occur with increasing frequency from late February through mid-May in association with organochlorine (PCB and DDT) poisoning and infectious disease in the 1970's and domoic acid poisoning in the last decade. The mass early life mortality events result from the concentrated breeding grounds and synchronization of reproduction over a 28 day post partum estrus cycle and 11 month in utero phase. This physiological synchronization is triggered by a decreasing photoperiod of 11.48 h/day that occurs approximately 90 days after conception at the major California breeding grounds. The photoperiod trigger activates implantation of embryos to proceed with development for the next 242 days until birth. Embryonic diapause is a selectable trait thought to optimize timing for food utilization and male migratory patterns; yet from the toxicological perspective presented here also serves to synchronize developmental toxicity of pulsed environmental events such as domoic acid poisoning. Research studies in laboratory animals have defined age-dependent neurotoxic effects during development and windows of susceptibility to domoic acid exposure. This review will evaluate experimental domoic acid neurotoxicity in developing rodents and, aided by comparative allometric projections, will analyze potential prenatal toxicity and exposure susceptibility in the California sea lion. This analysis should provide a useful tool to forecast fetal toxicity and understand the impact of fetal toxicity on adult disease of the California sea lion.

Molecular testing of respiratory swabs aids early recognition of meningococcal disease in children

Early meningococcal disease (MD) diagnosis is difficult. We assessed rapid molecular testing of respiratory specimens. We performed genotyping of respiratory swabs, blood, and cerebrospinal fluid from children with suspected disease and nasal swabs (NSs) from matched controls. Thirty-nine of 104 suspected cases had confirmed disease. Four controls were carriers. Throat swab ctrA and porA testing for detection of disease gave a sensitivity of 81% (17/21), specificity of 100% (44/44), positive predictive value (PPV) of 100% (17/17), negative predictive value (NPV) of 92% (44/48), and relative risk of 12. NS ctrA and porA testing gave a sensitivity of 51% (20/39), specificity of 95% (62/65), PPV of 87% (20/23), NPV of 77% (62/81), and relative risk of 4. Including only the 86 NSs taken within 48 h of presentation, the results were sensitivity of 60% (18/30), specificity of 96% (54/56), PPV of 90% (18/20), NPV of 82% (54/66), and relative risk of 5. Swab type agreement was excellent (kappa 0.80, P

Genomic meningococcal load in the nasopharynx of children with meningococcal disease

This study demonstrates the feasibility of using quantitative real time PCR to measure genomic bacterial load in the nasopharynx of children with invasive meningococcal disease and shows that these loads are exceptionally high (median 6.6 x 105 (Range 1.2 x 105 to 1.1 x 108) genome copies of Neisseria meningitidis per swab).