Context A critical question in pandemic influenza planning is the role nonpharmaceutical interventions might play in delaying the temporal effects of a pandemic, reducing the overall and peak attack rate, and reducing the number of cumulative deaths. Such measures could potentially provide valuable time for pandemic-strain vaccine and antiviral medication production and distribution. Optimally, appropriate implementation of nonpharmaceutical interventions would decrease the burden on health care services and critical infrastructure.Objectives To examine the implementation of nonpharmaceutical interventions for epidemic mitigation in 43 cities in the continental United States from September 8, 1918, through February 22, 1919, and to determine whether city-to-city variation in mortality was associated with the timing, duration, and combination of nonpharmaceutical interventions; altered population susceptibility associated with prior pandemic waves; age and sex distribution; and population size and density.Design and Setting Historical archival research, and statistical and epidemiological analyses. Nonpharmaceutical interventions were grouped into 3 major categories: school closure; cancellation of public gatherings; and isolation and quarantine. Main Outcome MeasuresWeekly excess death rate (EDR); time from the activation of nonpharmaceutical interventions to the first peak EDR; the first peak weekly EDR; and cumulative EDR during the entire 24-week study period.Results There were 115 340 excess pneumonia and influenza deaths (EDR, 500/ 100 000 population) in the 43 cities during the 24 weeks analyzed. Every city adopted at least 1 of the 3 major categories of nonpharmaceutical interventions. School closure and public gathering bans activated concurrently represented the most common combination implemented in 34 cities (79%); this combination had a median duration of 4 weeks (range, 1-10 weeks) and was significantly associated with reductions in weekly EDR. The cities that implemented nonpharmaceutical interventions earlier had greater delays in reaching peak mortality (Spearman r=−0.74, PϽ.001), lower peak mortality rates (Spearman r=0.31, P =.02), and lower total mortality (Spearman r = 0.37, P =.008). There was a statistically significant association between increased duration of nonpharmaceutical interventions and a reduced total mortality burden (Spearman r = −0.39, P =.005). ConclusionsThese findings demonstrate a strong association between early, sustained, and layered application of nonpharmaceutical interventions and mitigating the consequences of the 1918-1919 influenza pandemic in the United States. In planning for future severe influenza pandemics, nonpharmaceutical interventions should be considered for inclusion as companion measures to developing effective vaccines and medications for prophylaxis and treatment.

When patients present to specialized clinics after travel to the developing world, travel destinations are associated with the probability of the diagnosis of certain diseases. Diagnostic approaches and empiric therapies can be guided by these destination-specific differences.

Multidrug-resistant pneumococci are common and are increasing. Because a limited number of serotypes account for most infections with drug-resistant strains, the new conjugate vaccines offer protection against most drug-resistant strains of S. pneumoniae.

No abstract

Drug-resistant strains of S. pneumoniae are common among both children and adults in Atlanta. Although blacks had a higher incidence of invasive pneumococcal infections than whites, whites were more likely to be infected with a drug-resistant isolate. Control of drug-resistant pneumococci will require more judicious use of antimicrobial agents and wider use of the pneumococcal polysaccharide vaccine.

We report the results of a national survey conducted to help public health offi cials understand the public's response to community mitigation interventions for a severe outbreak of pandemic infl uenza. Survey results suggest that if community mitigation measures are instituted, most respondents would comply with recommendations but would be challenged to do so if their income or job were severely compromised. The results also indicate that community mitigation measures could cause problems for persons with lower incomes and for racial and ethnic minorities. Twentyfour percent of respondents said that they would not have anyone available to take care of them if they became sick with pandemic infl uenza. Given these results, planning and public engagement will be needed to encourage the public to be prepared.

SummaryBackgroundThe WHO declared the 2014 west African Ebola epidemic a public health emergency of international concern in view of its potential for further international spread. Decision makers worldwide are in need of empirical data to inform and implement emergency response measures. Our aim was to assess the potential for Ebola virus to spread across international borders via commercial air travel and assess the relative efficiency of exit versus entry screening of travellers at commercial airports.MethodsWe analysed International Air Transport Association data for worldwide flight schedules between Sept 1, 2014, and Dec 31, 2014, and historic traveller flight itinerary data from 2013 to describe expected global population movements via commercial air travel out of Guinea, Liberia, and Sierra Leone. Coupled with Ebola virus surveillance data, we modelled the expected number of internationally exported Ebola virus infections, the potential effect of air travel restrictions, and the efficiency of airport-based traveller screening at international ports of entry and exit. We deemed individuals initiating travel from any domestic or international airport within these three countries to have possible exposure to Ebola virus. We deemed all other travellers to have no significant risk of exposure to Ebola virus.FindingsBased on epidemic conditions and international flight restrictions to and from Guinea, Liberia, and Sierra Leone as of Sept 1, 2014 (reductions in passenger seats by 51% for Liberia, 66% for Guinea, and 85% for Sierra Leone), our model projects 2·8 travellers infected with Ebola virus departing the above three countries via commercial flights, on average, every month. 91 547 (64%) of all air travellers departing Guinea, Liberia, and Sierra Leone had expected destinations in low-income and lower-middle-income countries. Screening international travellers departing three airports would enable health assessments of all travellers at highest risk of exposure to Ebola virus infection.InterpretationDecision makers must carefully balance the potential harms from travel restrictions imposed on countries that have Ebola virus activity against any potential reductions in risk from Ebola virus importations. Exit screening of travellers at airports in Guinea, Liberia, and Sierra Leone would be the most efficient frontier at which to assess the health status of travellers at risk of Ebola virus exposure, however, this intervention might require international support to implement effectively.FundingCanadian Institutes of Health Research.

As part of ongoing national surveillance, serotyping and antimicrobial susceptibility testing were done on all pneumococcal isolates recovered from normally sterile body sites of patients at 12 hospitals in 11 states during 1993-1994. Of 740 isolates, 14.1% were penicillin-nonsusceptible Streptococcus pneumoniae (PNSP; MIC > or = 0.1 microgram/mL), 3.2% were penicillin-resistant (MIC > or = 2.0 micrograms/mL), and 25.5% were nonsusceptible to more than one antimicrobial agent. PNSP were more prevalent among children < 6 years old (18.4%) than patients > or = 18 years old (11.7%) and among white persons (16.2%) than black persons (12.1%). PNSP represented 15 serotypes, but 89% of PNSP were serotypes in the 23-valent pneumococcal vaccine. The proportion of isolates with reduced susceptibility and the number of serotypes of nonsusceptible strains are increasing in the United States. Improved local surveillance for PNSP infections, judicious use of antibiotics, and development and use of effective pneumococcal vaccines will be required to treat and prevent disease caused by these strains.