The need for global planned mobilization of essential medicine: lessons from a massive Thai botulism outbreak

A Systems Perspective of DoD Global Health Engagement

INTRODUCTION

A systems perspective was used to describe U.S. Department of Defense (DoD) Global Health Engagement (GHE). This description was based on DoD instructions and higher-level documents related to DoD GHE. A complex system of systems such as health care can benefit from using modeling approaches to help understand the interactions among major components. Models (conceptual, computer-based programs, realistic simulations, or training exercises) can be used to help stakeholders prioritize options and to identify important components and gaps for making performance improvements. Based on the cited documents, we identified major DoD GHE components to create a conceptual model.

MATERIALS AND METHODS

Components were selected from DoDI 2000.30 for DoD GHE. Definitions of these interacting components are given and assigned to our network model that consists of three levels: strategic, operational, and tactical. These levels are linked by critical nodes (decision points) that allow feedback to previous levels for modifying appropriate components. A network that is reminiscent of this structure is Boyd's observe-orient-decision-act diagram. Acceptable strategic and operational plans are linked to the tactical level. Acceptable tactical components lead to the desired outcome of accomplishing the DoD GHE goals. Complex systems also have feedback loops to allow for component evaluations and modifications. Accomplishing DoD GHE goals need to have adaptable components in dynamic permissive environments.

RESULTS

The network that we considered is multicomponent and interdisciplinary. The network uses DoD GHE goals as the input (observing in the observe-orient-decide-act loop) to provide relevant information. It consists of three levels of adaptable, interacting (orienting) components that are linked by critical nodes (decision points) involving the evaluation of plans and desired outcomes. Strategic components (eg, sharing, personal interactions, agreements, planning, readiness, etc.) are required to develop strategic plans, the first critical node. If these plans are acceptable, the information is passed on (feed forward, action) to the operational components (define problems, understand strategic direction and guidance, understand the operational environment, etc.). At the second critical node, the decision is made about moving the operational plans to the tactical components (eg, evaluation, data, training, etc.). Tactical components are essential to provide further information to the third critical node, desired outcomes, in accomplishing DoD GHE goals. Feedback from all critical nodes is essential to allow modifications of various components and to attain health-related interoperability in supporting security policies and military strategies.

CONCLUSIONS

Examining the composition of DoD GHE and creating a defined model can help identify interacting features of this complex system. All of the identified components have been associated with gaps, such as the need for monitoring and measuring tools, and standards. The current state of this system is dynamic and is evolving when confronting gaps. DoD GHE represents an intersection of global health and security in supporting U.S. national security objectives by establishing access and influence with partner nations and among health care-related government and non-government organizations, and as a result, improves the readiness, health, and safety of our military personnel.

Genomes, neurotoxins and biology of Clostridium botulinum Group I and Group II

Recent developments in whole genome sequencing have made a substantial contribution to understanding the genomes, neurotoxins and biology of Clostridium botulinum Group I (proteolytic C. botulinum) and C. botulinum Group II (non-proteolytic C. botulinum). Two different approaches are used to study genomics in these bacteria; comparative whole genome microarrays and direct comparison of complete genome DNA sequences. The properties of the different types of neurotoxin formed, and different neurotoxin gene clusters found in C. botulinum Groups I and II are explored. Specific examples of botulinum neurotoxin genes are chosen for an in-depth discussion of neurotoxin gene evolution. The most recent cases of foodborne botulism are summarised.

Clostridium botulinum in the post-genomic era

Foodborne botulism is a severe neuroparalytic disease caused by consumption of botulinum neurotoxin formed by strains of proteolytic Clostridium botulinum and non-proteolytic C. botulinum during their growth in food. The botulinum neurotoxin is the most potent substance known, with as little as 30-100 ng potentially fatal, and consumption of just a few milligrams of neurotoxin-containing food is likely to be sufficient to cause illness and potentially death. In order to minimise the foodborne botulism hazard, it is necessary to extend understanding of the biology of these bacteria. This process has been recently advanced by genome sequencing and subsequent analysis. In addition to neurotoxin formation, endospore formation is also critical to the success of proteolytic C. botulinum and non-proteolytic C. botulinum as foodborne pathogens. The endospores are highly resistant, and enable survival of adverse treatments such as heating. To better control the botulinum neurotoxin-forming clostridia, it is important to understand spore resistance mechanisms, and the physiological processes involved in germination and lag phase during recovery from this dormant state.

International emergency medicine: a review of the literature from 2007

The subspecialty of international emergency medicine (IEM) continues to grow within the United States, just as the specialty of emergency medicine (EM) continues to spread to both developed and developing countries around the world. One of the greatest obstacles, however, faced by IEM researchers and practitioners alike, remains the lack of a high-quality, consolidated, and easily accessible evidence-base of literature. In response to this perceived need, members of the Emergency Medicine Resident Association (EMRA) International Emergency Medicine Committee, in conjunction with members of the Society for Academic Emergency Medicine (SAEM) International Health Interest Group, have embarked on the task of creating a recurring review of IEM literature. This publication represents the third annual review, covering the top 30 IEM research articles published in 2007. Articles were selected for the review according to explicit, predetermined criteria that included both methodologic quality and perceived impact of the research. It is hoped that this annual review will act as a forum for disseminating best practices, while also stimulating further research in the field of IEM.

Health security as a public health concept: a critical analysis

There is growing acceptance of the concept of health security. However, there are various and incompatible definitions, incomplete elaboration of the concept of health security in public health operational terms, and insufficient reconciliation of the health security concept with community-based primary health care. More important, there are major differences in understanding and use of the concept in different settings. Policymakers in industrialized countries emphasize protection of their populations especially against external threats, for example terrorism and pandemics; while health workers and policymakers in developing countries and within the United Nations system understand the term in a broader public health context. Indeed, the concept is used inconsistently within the UN agencies themselves, for example the World Health Organization's restrictive use of the term 'global health security'. Divergent understandings of 'health security' by WHO's member states, coupled with fears of hidden national security agendas, are leading to a breakdown of mechanisms for global cooperation such as the International Health Regulations. Some developing countries are beginning to doubt that internationally shared health surveillance data is used in their best interests. Resolution of these incompatible understandings is a global priority.