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Clinical Director, Edward Via College of Osteopathic Medicine

Use of sequentially administered stable lead isotopes to investigate changes in blood lead during pregnancy in a nonhuman primate (Macaca fascicularis). Determinants of elevated blood lead during pregnancy in a population surrounding a lead smelter in Kosovo, Yugoslavia. Dietary and environmental determinants of blood and bone lead levels in lactating postpartum women living in Mexico City. The influence of bone and blood lead on plasma lead levels in environmentally exposed adults. Bone lead as a new biologic marker of lead dose: recent findings and implications for public health. Bone lead as a biological marker in epidemiologic studies of chronic toxicity: conceptual paradigms. High accuracy (stable isotope dilution) measurements of lead in serum and cerebrospinal fluid. Cadmium, copper, iron, lead, manganese, and zinc in evaporated milk, infant products, and human milk. Lead in human blood and milk from nursing women living near a smelter in Mexico City. Pregnancy, lactation, and menopause: how physiology and gender affect the toxicity of chemicals. Variation in blood lead and hemato crit levels during pregnancy in a socioeconomically disadvantaged population. Maternally mediated exposure of the fetus: in utero exposure to lead and other toxins. Methodological considerations for the accurate determination of lead in human plasma and serum. Use of endogenous, stable lead isotopes to determine release of lead from the skeleton. Pregnancy and lactation as risk factors for subsequent bone loss and osteoporosis. Impact of bone lead and bone resorption on plasma and whole blood lead levels during pregnancy. The independent contribution of bone and erythrocyte lead to urinary lead among middle-aged and elderly men: the normative aging study. High concentrations of heavy metals in neighborhoods near ore smelters in northern Mexico. Determinants of bone and blood lead concentrations in the early postpartum period. State health department issues health warning on lead- contaminated chapulines (grasshoppers). Lead poisoning associated with use of traditional ethnic remedies-California, 1991-1992. Lead poisoning associated with imported candy and powdered food coloring-California and Michigan. Blood lead levels in residents of homes with elevated lead in tap water-District of Columbia, 2004. Children with elevated blood lead levels related to home renovation, repair, and painting activities - New York State, 2006-2007. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. Use of complementary and alternative medicine among women in New York City: a pilot study. Lead poisoning from do-it -your self heat guns for removing lead paint: report of two cases. Reasons for testing and exposure sources among women of childbearing age with moderate blood lead levels.

Effectiveness of Ebola treatment units and community care centers - Liberia, September 23-October 31, 2014. Community Knowledge, Attitudes, and Practices Regarding Ebola Virus Disease - Five Counties, Liberia, September-October, 2014. Community quarantine to interrupt Ebola virus transmission - Mawah Village, Bong County, Liberia, AugustOctober, 2014. Evolution of ebola virus disease from exotic infection to global health priority, Liberia, mid-2014. Rapid intervention to reduce Ebola transmission in a remote village - Gbarpolu County, Liberia, 2014. Assessment of ebola virus disease, health care infrastructure, and preparedness - four counties,Southeastern Liberia, august 2014. Global health security: the wider lessons from the west African Ebola virus disease epidemic. Global Health Security Demands a Strong International Health Regulations Treaty and Leadership From a Highly Resourced World Health Organization. In wake of Ebola epidemic, Margaret Chan wants countries to put their money where their mouth is [Internet]. World Health Organisation "intentionally delayed declaring Ebola emergency" [Internet]. This political economy analysis identifies structural reasons why Sierra Leone and the international health community failed to respond in a timely and effective manner to the Cholera and Ebola epidemics or to translate learning from the Cholera epidemic to the Ebola response. Cholera is a fast spreading disease, easily prevented by modern water treatment and health care. The poorest and most disadvantaged population groups have borne the brunt of the burden for both Cholera and Ebola. These are diseases of inequity, spreading rapidly in ill-prepared communities served by health systems with inadequate public health capacity. Cholera, a waterborne infectious disease and key indicator for lack of social development, is endemic among Sierra Leone, Guinea and Liberia. This commentary will adopt a problem-driven political economy analysis based on the framework developed by Fritz, Levy and Or,iii see figure 1, which adapts and modifies the framework to respond to the question `Why did Sierra Leone and the international community fail to respond to Cholera and Ebola epidemics in a timely and effective manner? In the event of disease outbreak, there is need for pre-existing effective disease surveillance and vigilance, with effective health information systems and laboratory capacity to rapidly identify and diagnose cases and an ability to rapidly deploy contact tracing teams to line list contacts. Weak surveillance and contact tracing allowed continued transmission, through delayed early identification and isolation of cases during the peak of the outbreak and facilitated ongoing transmission during the many months of the fight to reach zero. As recently as 6th May 2015 Sierra Leone identified nine new cases in the preceding week, only two of which were identified as registered contacts of a previous caseix. Despite tripling the number of health workers between 2005 and 2010x Sierra Leone continues to be a human resources for health crisis country with only 0. Not only this but health workers were inadequately prepared and trained to respond to an infectious disease outbreak. During the Ebola epidemic low absolute numbers of health workers limited the ability to respond to the Ebola epidemic and to continue to provide routine health services. Many health workers put their lives at risk, heroically providing services, despite the absence of protective measures. Involvement and mobilisation of local councils, district and chiefdom structures was deemed inadequate and the need for advance preventive activities (in areas as yet unaffected), with messaging and materials available in local languages was identified as a leading area for improvement. This initial response often blamed communities for continuing unsafe practices, such as avoiding treatment centres or conducting unsafe burials, without dealing with underlying cultural and religious beliefs and practices which explained reasoning for decisions. Subsequent reports have described how it was later in the response (when communities were engaged with in planning and there was collaboration with local stakeholders) that the approach of communities radically changed, with self-imposed quarantines organised by communities playing a significant role in stopping the epidemicxxiii. Figures 2 and 3 highlight the weekly case load for Cholera (figure 2) and Ebola (figure 3) in Sierra Leone. In both figures, the delayed National declaration of an emergency is visible, occurring only after cases had already started to increase. Similarly, during the Ebola epidemic the first case was confirmed in Guinea in March 2014 and subsequently spread to Sierra Leone, where the outbreak was declared on 26th May 2014.

The ability to reassemble ribosomes from their isolated components greatly facilitates structural studies. A ribosome can be partially assembled, for example, and then antibody against a component in the immature ribosome can be added. If the presence of the antibody blocks the subsequent association of a ribosomal protein added later, it is reasonable to expect that the antibody directly blocks access of the protein to its site. If all ribosomal proteins were spherical, their complete spatial arrangement would be determined by knowing the distances between the centers of proteins. Some of the requisite measurements can be made with fluorescence techniques or slow neutron scattering. Fluorescent molecules possess an absorption spectrum such that illumination by photons within this wavelength band excites the molecule, which then emits a photon of longer wavelength within what is called the emission spectrum of the molecule (Fig. In vitro assembly of ribosomes can be used to construct a ribosome in which two of the proteins contain the fluorescent probes. By illuminating the rebuilt ribosomes with light in the excitation spectrum of the 600 Biological Assembly, Ribosomes and Lambda Phage Intensity 1 Wavelength 2 Excitation wavelength Emission wavelength measured Figure 21. Dotted line is the excitation and emission spectrum of fluorescent molecule 1 and the solid line is the excitation and emission spectra for molecule 2. The amount of light in the second emission spectrum varies as the sixth power of the distance separating the molecules: E= R6 0 R6 0 + R6 where R is the distance between the fluorescent molecules and Ro is a constant that depends on the orientations of the molecules, the spectral overlap of the fluorescent emission and excitation spectra, and the index of refraction of the medium separating the molecules. Neutron diffraction is another method of measuring distances between ribosomal proteins. This method has yielded the most information and the most reliable information on ribosome structure. Since the neutron scattering properties of hydrogen and deuterium are different, an interference pattern is generated by the presence in the ribosome of the two proteins with different scattering properties. The angular separation in the peaks of the interference pattern can be related to the distance separating the two altered proteins in the reconstituted ribosome. Overall, the results of crosslinking, assembly cooperativity, immune General Aspects 601 React with ribosomes Bases exposed in the ribosome Elongate radioactive primers Denature and run on sequencing gel Figure 21. The elongation by reverse transcriptase ends at the modified bases, and the locations of protected bases can be determined (Fig. Lambda Phage Assembly General Aspects the presence of a coat on phage lambda, and most other virus particles as well, can be broken down into three basic problems. How is the nucleic acid released from the virus particle into the appropriate cell? Not only is the structure of lambda phage dramatically different from a ribosome, but its assembly process also is notably different. First, as in the case of many larger viruses, one virus-encoded protein is used 602 Biological Assembly, Ribosomes and Lambda Phage Figure 21. Other bacterial virus genomes are similarly squeezed, and it is likely that survival of many types of viruses depends on their packing as much information as possible into as short a genome as possible. For example, 24 identical subunits could form a cube with one subunit at Figure 21. Note that each of the 24 subunits would make identical contacts with its neighbors. The maximum volume that could be enclosed by a set of subunits, each making identical contact with its neighbors, is based on the 20-sided icosahedron (Fig. Thus the maximum number of subunits that can be utilized to enclose a volume in which each subunit is exactly equivalent to any other is 60. Experimentally, however, many viruses, lambda included, are found to be approximately icosahedral but to possess more than 60 subunits in their coats. Caspar and Klug have investigated the structures that can be constructed when the constraint that each subunit be exactly equivalent to any other is weakened to permit them to be only quasi-equivalent. That is, each subunit will have nearly the same shape, but will still make homologous contacts with its neighbors. Using the same contact points over and over necessitates that the final structure be symmetrical.

Contact identification will occur when a patient names a contact to the case being investigated. If a contact to a case is located out of El Paso County, notify the Surveillance Specialist. Discussions about such cases should occur with the nurse supervisor as to why cases are not interviewed or closed within required timeframes. Interview Record Management Fulfilling interview record requirements should not alter the interview process. Information not required for initiating partners and clusters should be collected at the end of the interview. For example, questions relating to risk assessment that are not answered during the normal course of the interview should be gathered after locating information has been taken for all partners and contacts. Types of Re-interviews/Investigations Re-interviews are expected in order to collect information, not gained in the original interview and when information gained in the original interview is illogical or inconsistent. A reinterview may be especially beneficial when a patient has clearly evaded discussion for referring all partners or suspects during the original interview or when an investigator believes more partners will be recalled by the original patient as time goes on. Conduct re-interviews with a plan to accomplish specific objectives that are the product of careful view and analysis. Maintaining 3 day intervals between the original interview and the re-interview allows the patient enough time to be likely to share additional information while keeping the investigation swift enough to interrupt disease spread. Occasionally, additional information on partners will become available after initial closure of case. Cluster Interviews/Investigations Cluster interviewing is to be used with extreme selectivity. A cluster interview is a controlled discussion with a person who received a medical examination because of exposure or some other relationship to a case, but for whom physical examination and clinical tests show an apparent absence of infection. The purpose of a cluster interview is to gather information about previously unidentified partners or contacts of known cases and about individuals of concern (such as those with symptoms) who should be provided an examination. The objective of the cluster interview is to expedite disease intervention by expanding the base of information about a 6 high risk group. As a part of a special effort to address an outbreak situation, clustering may have a more extensive role than under normal program circumstances. Given logical reasons to conclude that it is in their personal interest to discuss partners or contacts, and the behavior of others, to reduce the disease risk in their peer group. Provided easily understood information about a disease, to which he/she has been exposed and practical, acceptable ways to avoid similar risks in the future. Lost to Follow-up Patients Lost to Follow-up may be either unable to locate or unable to be treated. It is important to document all information on the field record regarding attempts to locate the individual. The following is the acceptable follow up interval for all disease investigations: 1. Two Field or home visits to each possible address/ location patient is suspected to be at. At no time will internet notification be initiated on a Friday or a day before a holiday. If a leave is planned, internet notification will not be used prior to the day they are scheduled to be off. If email is sent before a leave is scheduled, instructions will be provided in the email of who to contact and your schedule. This is a very urgent matter, and because of the confidential nature of this information, it is vital you contact me. Monday through Thursday or you can contact me using my email address JohnDoe@elpasotexas. The method should be used after the traditional method of phone contact has been unsuccessful. If the patient replies back and wants more information about why you are contacting them, text the person back and request phone call or in person meeting.