Bioterrorism and smallpox planning: information and voluntary vaccination

Although smallpox was declared eradicated in 1980, there are fears that stocks of the virus manufactured for military purposes by the Soviet Union may have fallen into the hands of "rogue nations" or terrorists. Worries about bioterrorism have thus sparked debate about whether or not the smallpox vaccine, which can be dangerous, should be offered to the general public. Meaningful public debate on this issue requires expert information about the likelihood that the virus will in fact be used as a weapon. Informed voluntary individual decision making, about whether to get vaccinated if vaccine is made available to the public, would similarly require appreciation of the likelihood of attack. Public deliberation and private deliberation thus both require briefing by the intelligence community.     

Time frame and reasons of Kangxi Emperor adopted variolation

This paper is concerned with the time frame and the reasons why the Kangxi Emperor adopted variolation in the Qing Imperial family. The Manchus, especially the Qing Imperial family, lived in the fear of contracting smallpox. They took various strategies to protect themselves from smallpox. One of the most conspicuous methods was adopting variolation in royal family in the Kangxi reign. The purpose of this important action was to maintain the superiority of the Manchu minority and to reduce the mortality rate of smallpox in the Imperial family. In this paper, I would like to point out the time when the Kangxi Emperor intended to use variolation was earlier than we had known through the previous studies. The Emperor's decision of variolation was mainly stimulated by his personal experiences and his practical character.     

Responsibility to or for in the physician-patient relationship?

The threat of malpractice litigation in the United States is encouraging physicians again to assume responsibility for their patients. The fundamental ethical problem, however, is that this approach denies the patient's moral agency. In this essay, responsibility to patients, rather than for them, is discussed as an alternative to the emerging neo-paternalism. Responsibility to avoids the ethical problems of assuming responsibility for moral agents and could reduce the threat of litigation as well.     

Ring vaccination versus mass vaccination in event of a smallpox attack

Since vaccination is critical in responding to smallpox exposure, vaccination strategies must be evaluated during bioterrorism preparedness. Information on historical factors, smallpox characteristics, public health capabilities and hypothetical attack scenarios was used to evaluate major vaccination strategies. In event of a smallpox attack, the optimal strategy is situational, mass vaccination may be best for dense island populations such as Oahu.     

“胎毒外感说”与中国古代防治天花的成就

“胎毒外感说”对中国古代防治天花的实践起了决定性的指导作用，使中国不仅在琴纳之前近６００年就在理论和实践两方面认识到人类以外的其他温血胎生动物也有可能患上天花这一事实，而且达到了近代天花病毒被发现之前关于天花致病因的最科学的认识     

中国人痘接种术向西方的传播及影响

人痘接种预防天花是中国古代医学家的伟大发明。人痘接种技术最先直接从中国传入 英国,在１７２１－１７２２年由英国皇家学会主持进行用人痘接种预防天花的人体实验,并产生了很大的影响。人痘接种向西方的传播及实践,是中西医学交流史上的重要事件,值得予以重视并深入的研究。     

Smallpox Control in Canada

During the period 1961 to 1963 there were 10 separate importations of smallpox cases by aircraft into England and Wales, Germany, Sweden, Poland and Canada. A feature of the resulting outbreaks was the number of cases and deaths of physicians and other health personnel. With the increasing volume of international air traffic there is a risk of importing incubating cases of smallpox into Canada, as occurred in 1962. Millions of Canadians have been protected against smallpox. Some complications of smallpox vaccination have occurred in Canada; such complications can be minimized by proper attention to contraindications to vaccination. The Food and Drug Directorate, Department of National Health and Welfare, has circularized all physicians in Canada to request their co-operation in reporting adverse reactions to drugs. This includes serious, unusual or unsuspected reactions to immunizing agents (vaccines, toxoids and antitoxins). The latter information will be shared with the Epidemiology Division, Department of National Health and Welfare, and the provincial epidemiologist and manufacturer concerned. The importance of maintaining the smallpox immunity of physicians, nurses and other hospital and health personnel in Canada is emphasized.     

民国时期广东的天花流行与防治

民国时期,广东几乎每年都有天花疫情发生.为了应对传染病,广东省建立了卫生行政及传染病防治机构,并自制牛痘疫苗;相关机构按周、月、年对疫情进行统计,并定期上报,以了解疫情进展.同时,还成立了传染病医院收容天花患者.港口检疫则将天花列为重点检查对象.为了推广牛痘接种,政府与社会合作,组织大规模的“种痘运动”,以儿童、学生和年轻人作为主要接种对象,并借助媒体积极宣传天花防治知识.     

The nuclear weapons freeze and a cancer metaphor. A physician's view

The nuclear arms race has been described as a cancer spreading through human society and threatening its existence. Bruwer characterizes the current superpower reaction to this nuclear threat, deterrence through a mutual weapons buildup, as a palliative approach that can only postpone death. He compares a bilateral weapons freeze to a hypothetical cancer freeze, a strategy that would not get rid of existing arsenals, but would buy negotiating time to work toward the elimination of these weapons. Answering critics who say that a freeze is unrealistic, or does not go far enough, Bruwer reminds them that it would be a beginning.     

Smallpox: A Retrospect

Smallpox has been known as a disease of man since the earliest times. However, its severity increased greatly during the eighteenth century, stimulating physicians and others to find methods of protection against it. Variolation (the inoculation of smallpox material into the skin) was tried, and for a while found general approval, although its practice was not without danger. In 1796, Edward Jenner began his investigations into the use of cow-pox material (vaccination) as a prophylactic against smallpox, and later showed that vaccination could confer protection. Although vaccination centres were first set up in Canada early in the nineteenth century, the disease on occasion assumed epidemic proportions, such as occurred in Montreal in 1885. Sporadic outbreaks have occurred since then, including the recent case in Toronto. From the public health point of view, maintenance of a high level of immunity to smallpox throughout the general population is necessary if serious epidemics are to be avoided.     

Bioterrorism: a threat for which we are ill prepared

Of the weapons of mass destruction, the biological ones are the most feared and bioterrorism has become one of the most vicious threats to civilized society in recent times. Biological weapons have been sporadically used for centuries. Despite international regulations, there has been a global re-emergence of the threat of biological warfare. As many as 17 countries are suspected of either including or developing biological agents in their weapons programmes. In the past decade, a number of terrorist organizations with access to bioweapons technology have emerged. Current surveillance systems may be inadequate to detect biological attacks. The onset of illness is often delayed, thus the timing and location of such an event may be extremely difficult to identify. We are unfamiliar with most of the agents of biological warfare and are ill-equipped to handle the consequences of such an attack. In addition, there is no apparent coherent policy to handle a biological terrorist incident. Given the enormity of what is possible in the event of a biological attack, we must be prepared to detect, diagnose, epidemiologically characterize and respond appropriately to biological weapons. Of the potential biological weapons, smallpox and anthrax pose the greatest threats.     

Are Saudi Arabian hospitals prepared for the threat of biological weapons?

The use of biological weapons has been recorded repeatedly in history. Until recently, biological terrorism had been little discussed or written about. However, events over the past 12 to 18 months have made it clear that likely perpetrators already envisage every possible scenario. Nations and dissident groups exist that have both the motivation and access to utilize biological weapons. In April 1994, a Russian biological weapons expert presented the conclusions of the Russian experts as to the agents most likely to be used: smallpox, anthrax, and plague. Health care workers in the Kingdom of Saudi Arabia (physicians, nurses, and emergency medical technicians) need to be aware of the seriousness of the threat of biological weapons, and to have an approach for the early identification, triage, and management of biological weapons victims. Clues to the occurrence of a bioterrorism attack include the abrupt onset of a large number of cases of a similar disease or syndrome, the occurrence of diseases with unusual geographic or seasonal distribution, and epidemics of non-endemic diseases. Health care workers must maintain a high index of suspicion, involve the hospital epidemiologist or infectious diseases specialist, identify a clear administrative chain-of-command to minimize confusion, and rely on existing networks such as the hospital disaster-and-safety committee to ensure a multidisciplinary response. Maximum readiness can be achieved by periodic readiness drills.     

中国的人痘接种术是现代免疫学的先驱

天花在汉末流入中国,晋代葛洪在《肘后救卒方》中首次作了描述并开始有治疗方药,至北宋已可能有种人痘预防天花方法出现,而明代隆庆年间则可肯定有一种人痘中心存在于安徽宁国府太平县。清代康熙帝大力提倡、推广,人痘术同时传到了国外。其中英国的种人痘医生琴纳将之改造成种牛痘术,并最后导致了现代免疫学的诞生和发展,终于在１９８０年由ＷＨＯ宣布全球消灭天花。本文论证了从人痘到牛痘发展的历史过程,并且指出：经中国改良以后的人痘术有相当大的安全可靠性,西方人仅仅学去了中国早期的痘浆法,所以危险性相对较大。     

A suggestion for unification of present limb lead systems into a single "F" lead system

Department Ⅲ, PLA General Hospital, Beijing 100853, China (Huang W) In this paper it is intended to unify the standard lead and the augmented unipolar limb lead (aV lead) system into a single lead system. Viewing from the angle of lead axes, the standard leads and the aV leads are not only reflecting the frontal plane vector, but are also actually complementary to each other.     

The gap between voluntary admission and detention in mental health units

This paper presents the case of a young man with a diagnosis of schizophrenia, who agreed to inpatient treatment primarily to avoid being formally detained. I draw on Peter Breggin's early critique of coercion of informal patients to supply an updated discussion of the ethical issues raised. Central questions are whether the admission was coercive, and if so, whether unethical. Whether or not involuntary admission would be justified, moral discomfort surrounds its appearance as a threat. This arises in part from ambivalence about autonomy: although a 'choice' is made, the threat of detention impinges on the patient's choice. Recent legal developments provide some experience of safeguarding those whose consent is not obtained. This highlights the lack of safeguards in this 'gap' and suggests that we have the tools with which to begin to deal with the problem.     

瑞士专家Drs，Agnes and Bijan Ghaznavi写给灾区孩子的一封信

这封信应该分到每一个失去父母的孩子手里，如果能在每一封信上写上孩子的名字，这就最好了，这样的话，孩子们可以反复地去阅读这封属于他们的信。     

为制造生命辩护——有关合成生物学的伦理争论

合成生物学是近几年快速发展起来的交叉前沿学科,其进展使合成与制造生命成为现实,这对发展经济和研究生物学基本规律有很大的意义,但也带来伦理问题及对可能的潜在威胁的担忧。制造生命的研究可以在伦理上得到辨护,但必须在严格地控制和有效地监督下进行。     

A review of psychiatric aspects for termination of pregnancy

Referring to articles published by specialists in the field, the discussion focuses on the controversial and poorly reported subject of the psychiatric aspects of abortion. The views on this topic vary from country to country. The psychiatric morbidity occurring in pregnancy is examined as well as indications for abortion. A workable frame of reference indicating psychiatric illness, where abortion could be instituted, is presented. In Denmark and Sweden special laws, liberalizing abortion on psychiatric grounds, have been introduced. These include psychotic states, reactive depressions with psychotic states, reactive depressions with suicidal risks, psychasthenic conditions, as well as eugenic and social reasons. As puerperal psychoses have a good prognosis, Sim has stated that there are no psychiatric grounds for abortion. In Japan psychiatric indications for abortion need not be supported by medical evidence, but in Italy and Spain such indications however urgent are not permitted. In Britain the abortion act passed in 1967 liberalized the law in relation to psychiatric grounds for abortion. In a patient who has had a number of pregnancies each of which had precipitated exacerbations of schizophrenic illness, abortion could be recommended. Manic depressive illness has a good outcome with antidepressant medication, electroconvulsive therapy, lithium prophylaxis, and supportive therapy and would not by itself constitute grounds for abortion. Suicide is a very real threat in this group of diseases especially in the presence of agitation. Another problem would be a mother who has shown an aggressive psychopathic personality deviation. Patients who have had a psychotic or other obvious psychiatric illness constitute only a proportion of cases where a decision about therapeutic abortion may have to be considered. Often a psychiatrist would be called upon to express an opinion regarding therapeutic abortion in an unwed, neurotic, anxiety ridden mother, threatening suicide. The psychiatrist would then have to assess the seriousness of the suicidal threat. Suicidal acts are not rare in pregnancy. It is useful to obtain confirmation of serious suicidal inclinations from a close relative when assessing the mental states of patients. Ekblad following up 479 cases of abortion found that 11% expressed serious self reproach and 24% showed a mild form of guilt reaction, but these reactions are easily amenable to psychotherapy. If there is a grave risk to the mental health of the mother, if serious physical harm or death should ensue in an attempted suicide, or if there is a substantial risk that the child would develop a serious mental or physical handicap, then therapeutic abortion is justified. Another important legal consideration is the question of consent. In giving an opinion for abortion on psychiatric grounds obtaining a 2nd opinion of another psychiatrist is prudent. The laws in Sri Lanka do not recognize dangers to the mother's mental health or fetal deformities as indications for therapeutic abortion.     

Post-nuclear war

Cassel reviews Selection of Casualties for Treatment After Nuclear Attack (British Medical Association; 1988), issued by the BMA's Board of Science and Education. The publication contains a detailed set of guidelines for medical triage after a "limited" nuclear attack on England resulting in millions of dead and seriously injured, and an analysis of the ethical issues in triage and treatment choices. Cassel questions the ethical underpinnings of the report's recommendations on selecting persons for treatment according to social usefulness. Her major concern about the BMA document, however, is that it may mislead people into believing that nuclear war is an eventuality that can be planned for rather than a threat that must be prevented.     

HIV/AIDS患者免疫重建炎性综合征研究进展

免疫重建炎性综合征发生于艾滋病患者应用高效抗反转录病毒疗法后的免疫重建过程中,本文分别对其概念、发病机制、诊断、临床表现和治疗等方面进行了综述。综合文献资料认为在病人的诊治上最重要的一点是提高对免疫重建炎性综合征的诊断和鉴别,以免延误病情。免疫重建的特征之一是恢复了针对机会性感染致病原的免疫反应,因此除非有可能威胁患者生命或导致高致残率外,都应继续应用高效抗反转录病毒疗法。