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Although SARS-CoV-2 was first reported in China and neighbouring countries, the pandemic quickly spread around the globe. This paper explores national drivers of the pandemic and the radically different epidemiology and response in the West and in the East. We studied coronavirus disease (COVID-19) mortality until 31st December 2020, using an ecological study design, considering baseline characteristics and responses that might account for the uneven impact of the pandemic. A multivariable regression model was developed to explore key determinants. Key variables in the West were contrasted with those in the East, and speed of response was examined. Worldwide, 2.24 million COVID-19 deaths were documented in 2020. Western countries reported a median mortality 114 times that of the East (684 vs. 6.0 per million). Significant correlates of mortality in countries with at least 1 million population were median age, obesity prevalence, and democracy index; political stability and experience of SARS in 2002–2003 were protective; health system variables and income inequality were not associated. Outputs of the model were consistent when adjusted for stringency index, timeliness of stay-at-home requirements, and geographical autocorrelation. The West experiences a much higher COVID-19 mortality than the East. Despite structural advantages in the West, delays in national responses early on resulted in a loss of control over the spread of SARS-CoV-2. Although the early success of the East was sustained in the second half of 2020, the region remains extremely vulnerable to COVID-19 until enough people are immunized.

The initial trials of SARS-CoV-2 vaccines were randomised control trials (RCT) with a placebo as control. The use of a placebo was ethically justified because, as with any new and emerging infectious disease, there was no known vaccine. There are now at least eight vaccines that have been shown to be effective and approved for emergency use, so the use of a placebo in the control group is no longer ethically justified. This article discusses why ethical guidelines should be continually evaluated in a changing landscape and why trust is so important.

Threat of Nuclear Holocaust and Physician Activism Dissolution of nuclear arms control agreements and the failure to limit the expansion of nuclear arms have heightened the risk of nuclear confront...

Air pollution is a growing public health concern in developing countries and poses a huge epidemiological burden. Despite the growing awareness of ill effects of air pollution, the evidence linking air pollution and health effects is sparse. This requires environmental exposure scientist and public health researchers to work more cohesively to generate evidence on health impacts of air pollution in developing countries for policy advocacy. In the Global Environmental and Occupational Health (GEOHealth) Program, we aim to build exposure assessment model to estimate ambient air pollution exposure at a very fine resolution which can be linked with health outcomes leveraging well-phenotyped cohorts which have information on geolocation of households of study participants. We aim to address how air pollution interacts with meteorological and weather parameters and other aspects of the urban environment, occupational classification, and socioeconomic status, to affect cardiometabolic risk factors and disease outcomes. This will help us generate evidence for cardiovascular health impacts of ambient air pollution in India needed for necessary policy advocacy. The other exploratory aims are to explore mediatory role of the epigenetic mechanisms (DNA methylation) and vitamin D exposure in determining the association between air pollution exposure and cardiovascular health outcomes. Other components of the GEOHealth program include building capacity and strengthening the skills of public health researchers in India through variety of training programs and international collaborations. This will help generate research capacity to address environmental and occupational health research questions in India. The expertise that we bring together in GEOHealth hub are public health, clinical epidemiology, environmental exposure science, statistical modeling, and policy advocacy.

Ethical concerns in using a lower dose of equine rabies immune globulin (eRIG) to irrigate wounds from dog bites to prevent rabies are discussed. A lower dose of eRIG was used because of a general shortage of eRIG and the high market cost in the Himachal Pradesh state of India. The cost and availability of drugs in low- and middle-income countries (LMIC) often necessitates testing a lower dose of a vaccine or treatment than that recommended by international organizations (eg WHO). It raises the issue that recommendations may be designed for higher income countries without taking into consideration issues of supply and cost. Secondly a case-control design to compare dosages or delivery systems is usually not an option so investigators must often use historical data for comparison or other study designs. The ethical issues in the testing of drugs and vaccines in LMIC must be continuously reviewed by the international community.

In the last 25 years, India has experienced rapid economic growth, industrialization and urbanization, which has resulted in high levels of air pollution exposure across major urban centres. The Wo...

The Zika virus (ZIKV) epidemic is spreading: 67 countries are now reporting transmission, and over 2,000 cases of congenital Zika syndrome (CZS) have been confirmed. The heaviest burden has been borne by those living where poverty, poor infrastructure, and lack of access to health services are common and the penetration of Aedes aegypti is high. Because most cases are asymptomatic, the most dramatic signs of the disease appear through the CZS cases. In spite of the need for disaggregated epidemiological data to understand transmission patterns and evaluate interventions in vulnerable populations, there is no reliable count of ZIKV cases by sex and ethnicity (1).

Decisions regarding vaccine regulation and use made by institutions in industrialized countries can have an unintended impact on vaccines' availability in disease-endemic countries. However, regulatory and programmatic decision making by such countries, taking into consideration local risks and benefits, requires adequate resources, both human and financial. Such differing risk-benefit determinations between industrialized and disease-endemic countries will increase product divergence. We propose a single universal standard for risk assessment, based on maximizing net benefit, and an action plan to improve access to priority vaccines through a more robust determination of risk and benefit.

2208 www.thelancet.com Vol 383 June 28, 2014 announcement, India had mandated that any Indian citizen travelling from a polio affected country needed to have this documentation (non-Indian citizens are exempt), a decision now supported by WHO. This new WHO recommendation is likely to have minimal eff ects on preventing the spread of polio for a number of reasons: much crossborder traffi c between listed countries (such as between Pakistan and India) is undocumented—International Certificates have no meaning for those illegally crossing the borders; certifi cates will need to be checked on entry, because qualifi ed staff are not in-place; and a cottage industry of selling fake documents is likely to develop. Pakistan has done a good job of immunising its citizens and controlling the spread of polio, especially given the political situation, and should not be punished because of factors over which it has limited control. The refusal of tribal groups in Waziristan to participate in immunisation campaigns and the opposition of the Taliban, both of which have led to the killing of more than 20 vaccinators and security personnel, have placed understandable limits on Pakistan’s programme. It is time for the public health community to move beyond country borders in the overall control of infectious diseases.

The reduction in deaths from diarrheal diseases is one of the significant public health successes of the twentieth century. That said, the disease still accounts for a significant burden of childhood morbidity and mortality in low- and middle-income countries. Progress made in the past has, to a significant extent, been supported by a variety of both bilateral and multilateral donors aiming to make an impact in reducing this burden. We review the history of international aid in the context of disease control, and the variety of ways in which international aid has driven the international agenda, including a description of the activities of key players during this period, as well as the experiences of national control programmes. We conclude with a discussion of what is known to date about the effectiveness of international aid in supporting national control programmes, as well as some important areas of focus for future efforts. The control of diarrheal diseases remains an unfinished agenda in global health and international aid still stands to make an important impact in the burden.

Summary Bangladesh, with a population of 151 million people, is a country that is particularly prone to natural disasters: 26% of the population are affected by cyclones and 70% live in flood-prone regions. Mortality and morbidity from these events have fallen substantially in the past 50 years, partly because of improvements in disaster management. Thousands of cyclone shelters have been built and government and civil society have mobilised strategies to provide early warning and respond quickly. Increasingly, flood and cyclone interventions have leveraged community resilience, and general activities for poverty reduction have integrated disaster management. Furthermore, overall population health has improved greatly on the basis of successful public health activities, which has helped to mitigate the effect of natural disasters. Challenges to the maintenance and reduction of the effect of cyclones and floods include rapid urbanisation and the growing effect of global warming. Although the effects of earthquakes are unknown, some efforts to prepare for this type of event are underway.

Richard Cash and Vasant Narasimhan look at how globalization has increased the speed and scale of infectious disease spread. They show how international efforts are being launched to efficiently control the spread of infectious disease using global surveillance. Development (1999) 42, 115–120. doi:10.1057/palgrave.development.1110097

To assess possible differences in risk factors for the sexual acquisition of HIV/AIDS among Japanese and Western (European) tourists 179 women 17-30 years of age traveling alone were recruited at two beach resort areas in southern Thailand in July-August 1995. 7% of Japanese travelers compared with 31% of Western women had engaged in sexual intercourse with a new partner during past travels. 10% of Japanese and 44% of Thai women indicated they would be open to entering a sexual relationship with a new partner on the current trip but most would do so with a fellow tourist rather than a local Thai. A Principle Components Analysis was conducted to characterize attitudes toward sexual relations while traveling. Four such categories were identified but there were significant differences between Japanese and Western tourists in the acceptance of these attitude profiles: Sexual Adventure (19% vs. 82%) Relaxation/Romance (67% vs. 72%) Escape from Home (51% vs. 43%) and Simple Friendliness (28% vs. 54%). Compared to their Western counterparts Japanese women had less knowledge about AIDS in Thailand were less confident that they would insist on condom use at next sexual intercourse were less inclined to carry condoms with them and were uncomfortable with widespread distribution of condoms and AIDS prevention literature. However 91% of Japanese and 68% of Western women stated they would read a handbook on HIV/AIDS written especially for tourists. Preparation of a booklet that promotes awareness of HIV risk suggests strategies for communicating with a potential partner about HIV risk and gives tips regarding carrying concealed condoms is thus recommended. However the findings of this study demonstrate the need for varied HIV/AIDS prevention strategies for women travelers from different cultures.

In the Indian subcontinent description of a disease resembling cholera has been mentioned in Sushruta Samita, estimated to have been written between ~400 and 500 BC. It is however not clear whether the disease known today as cholera caused by Vibrio cholerae Vibrio cholerae O1 is the evolutionary progression of the ancient disease. The modern history of cholera began in 1817 when an explosive epidemic broke out in the Ganges River Delta region of Bengal. This was the first of the seven recorded cholera pandemics cholera pandemics that affected nearly the entire world and caused hundreds of thousands of deaths. The bacterium responsible for this human disease was first recognised during the fifth pandemic and was named V. cholerae which was grouped as O1, and was further differentiated into Classical and El Tor biotypes. It is now known that the fifth and the sixth pandemics were caused by the V. cholerae O1 of the Classical biotype Classical biotype and the seventh by the El Tor biotype El Tor biotype . The El Tor biotype of V. cholerae, which originated in Indonesia Indonesia and shortly thereafter began to spread in the early 1960s. Within the span of 50 years the El Tor biotype had invaded nearly the entire world, completely displacing the Classical biotype from all the countries except Bangladesh. What prompted the earlier pandemics to begin is not clearly understood, nor do we know how and why they ended. The success of the seventh pandemic clone over the pre-existing sixth pandemic strain remains largely an unsolved mystery. Why classical biotype eventually disappeared from the world remains to be explained. For nearly three decades (1963-1991) during the Seventh cholera pandemic seventh pandemic, cholera in Bangladesh has recorded a unique history of co-existence of Classical and El Tor biotypes of V. cholerae O1 as epidemic and endemic strain. This long co-existence has provided us with great opportunity to improve our understanding of the disease itself and answer some important questions.

The paper briefly outlines some of the ethical issues involved in community-based research particularly in developing countries. It focuses on informed consent, confidentially and the obligations to the community or its members who participate in the study. Most ethical guidelines are focused on the individual participants. Yet increasingly the community may be the unit of study. More attention will need to be directed towards developing guidelines for community-based research.

Demonstration of the benefits of oral therapy for cholera in 1968 soon led to application of the method to all forms of infectious diarrheal diseases. The original oral rehydration solution (ORS) formulation developed by the World Health Organization (WHO) struck a compromise between the ideal solutions for these diverse disorders to meet the programmatic goal of a single formulation and packaging for global use in cholera and noncholera diarrheas in both adults and children. Recently WHO recommended a new oral solution for all acute diarrheas including cholera. This new formula would replace the original ORS which saved millions of lives with a new formulation containing less sodium and glucose. This change was ostensibly to reduce gross stool volume and use of unscheduled intravenous therapy by lowering solution osmolarity. However the reduced-osmolarity formulation is particularly unsuitable for universal use because it contains an amount of sodium insufficient to maintain sodium balance in cholera patients in whom its use induces negative sodium balance and may lead to hyponatremia polyuria and a small but clinically significant risk of neurologic complications. The new reduced-osmolarity formulation stretches the original compromise to the breaking point. It may be time to promote use of different solutions for patients with cholera beginning in controlled settings such as cholera treatment centers and hospitals. (authors)

Objectives : To test the range of beliefs regarding the ethics of testing, in resource poor settings, new therapies that are less efficacious but more affordable and feasible than the best current therapeutic standard. Design : Using a web-based survey, we presented a hypothetical scenario proposing to test a therapy for HIV disease ("therapeutic inoculation") known to be less efficacious than highly active antiretroviral therapy (HAART). Respondents evaluated various trial designs as ethical or unethical. Participants : 604 subscribers to two listservs for individuals interested in international health research ethics. Main outcome measures : Proportion of respondents endorsing trials testing this "substandard" therapy, and proportion endorsing placebo-controlled trials. Results : There were 215 respondents from 47 countries. Forty-five percent of respondents were from low or middle income countries; 96% devoted at least some time to research activities; and 75% had "some" or "considerable" research expe...

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Today we recognize that knowledge is not only a public good but also a global public good. We have also come to recognize that knowledge is central to successful development. The international community has a collective responsibility for the creation and dissemination of one global public good – knowledge for development. But how can we deal with the dilemma of reconciling the often contradictory incentives for the production and for the dissemination of knowledge? States must decide to what extent there should be public provision and to what extent private production should be encouraged through strengthened intellectual property rights. Designing the appropriate intellectual property rights regime entails balancing static and dynamic efficiency. Indeed, because research (knowledge) is one of the most important inputs into the production of further knowledge, raising the “price” of knowledge may actually reduce follow‐on research and slow the pace of innovation. Thus, it is essential to reward research and innovation by firms while ensuring widespread access to knowledge and protection against monopoly rents. Issues of equity and efficiency interplay here, as most innovations incorporate ideas that are part of the common pool of knowledge. Narrowing the knowledge gap between developing and developed countries requires the construction of strong domestic knowledge infrastructures, most notably in education. Because knowledge is a global public good, Stiglitz argues that successfully meeting the challenges posed by knowledge externalities depends critically on cooperative efforts at the international level.

In urban and rural areas alike, people in India tend to prefer private medical care to the existing government health services. Nevertheless, the large private health care sector has hitherto been virtually alienated from activities of public health importance including priority disease control programmes. This study of 106 private general practitioners (GPs), practising in low socioeconomic areas of Bombay, shows a gross lack of knowledge and awareness among private doctors about leprosy and also about the National Leprosy Control Programme. The possible reasons are discussed. Effective involvement of GPs in the National Leprosy Control Programme should facilitate both integration and better implementation of leprosy control activities. The study also highlights some areas for future interventions at both primary and secondary health care levels and the need for a strategy, based on larger studies, to train and make private doctors participate in controlling diseases of major public health concern like leprosy.

The development of the quadrivalent rotavirus vaccine evaluated in the study by Perez-Schael et al., reported in this issue of the Journal, 1 represents the culmination of a long and highly creativ...

The pathogenesis clinical effects public health importance and treatment of diarrhea by oral rehydration therapy (ORT) are discussed in this review. ORT (oral-glucose electrolyte solution) when used to treat mild to moderately dehydrated patients can eliminate the need for intravenous supplementation. It also has the advantage of wide availability simplicity of use safety and low cost. Since next to respiratory diseases diarrhea is a most common disease in tropical and semi-tropical countries ORT availability in developing areas is most desirable. The following formula for an ORT solution is given (in mmol/liter): sodium 90; potassium 20; chloride 80 bicarbonate 30; and glucose 110 or sucrose 220. Glucose is preferred. Children with oral therapy seem to gain weight at a greater rate than children treated in more traditional ways. Also essential is the proper feeding of children during diarrheal episodes. ORT has been used extensively since 1969 at the Cholera Research Laboratory in Bangladesh with as much as an 80% decrease in need to apply parenteral fluids.

Twenty-two adult cholera patients were treated with a combination of trimethoprim (80 mg) and sulfamethoxazole (400 mg) (TMP-SMZ) every 6 hr in addition to iv and oral hydration. Twenty-three children were treated in similar fashion with one-half this dose of the drug combination. Results were compared with those in 51 patients treated concomitantly with tetracycline. Stool volume, duration of diarrhea, and duration of excretion of vibrio were slightly greater in the patients treated with TMP-SMZ, although differences from those treated with tetracycline were neither constant nor significant. No clinical or bacteriologic relapses were seen. Sensitivity studies by tube dilution showed similar MICs of the TMP-SMZ and tetracycline for Vibrio cholerae. These results, considered with other published data, indicate that the TMP-SMZ is a practical alternative to tetracycline in the treatment of cholera.

A double-blind study was conducted to test the prophylactic effect of a non-absorbable broad-spectrum antimicrobial (oral colistin sulfate) against acute diarrhea in Apache children. Children 1 to 6 months old had over twice the morbidity from diarrhea if assigned to the antimicrobial group as compared to placebo, while the toddler group (7–30 months) taking the antimicrobial had somewhat less diarrhea. Enterpathogenic E. coli were significantly more often isolated from the antimicrobial group (but only in well children). No special effect on the children's growth by the antimicrobial was discerned.