Vaccine Innovations — Past and Future Remarkable progress has been made by the use of vaccines. The future holds great promise for vaccine-mediated control of global pathogens, but providing afford...

From the Centers for Disease Control and Prevention, Atlanta (J.L.G.); the Department of Radiology (J.M.R.) and the Clinical Microbiology Laboratory and Department of Pathology (M.J.F.), Massachusetts General Hospital, Boston; and the Departments of Radiology (J.M.R.) and Pathology (M.J.F.), Harvard Medical School, Boston.

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A 58-year-old woman was transferred to this hospital because of severe neck pain, fever, and a spinal epidural mass extending from the level of the fourth to the seventh cervical vertebrae, with evidence of mild cord compression seen on imaging studies. Shortly before transfer to this hospital, a diagnostic test result was received.

Influenza pandemic preparedness planning is critical for reducing human suffering and negative effects on the economy and society. The Centers for Disease Control and Prevention (CDC) is working to ensure a rapid, efficient, and successful response to an outbreak if, when, and where it appears. The CDC's context for strategic planning is based on experiences with seasonal influenza and what is known about past influenza pandemics. From a public health perspective, pandemic preparedness can be achieved with a plan that builds a network of shared responsibility from the local to the global level, with a focus on saving lives with vaccines, antiviral drugs, medical supplies, containment, and communication.

PURPOSE:Pharmacist involvement in antimicrobial use at small rural hospitals in four Western states was studied.METHODS:Surveys were mailed in July 2000 to hospitals with a daily patient census of <150 in Idaho, Nevada, Utah, and eastern Washington.RESULTS:Seventy-seven (77%) of 100 hospitals returned completed surveys. Only 5% of the hospitals had onsite pharmacists 24 hours per day. An onsite pharmacist was present for a median of 26 hours per week in hospitals without 24-hour pharmacist coverage (range, 0-116 hr/wk). Many hospitals (71%) had policies for monitoring or controlling antimicrobial use, but only 28% had a system capable of monitoring compliance with such policies. Few hospitals had systems for recommending changes in antimicrobial selection on the basis of susceptibility test results (27%) or for monitoring physician compliance with dosage recommendations by pharmacists (21%). Onsite pharmacist hours were significantly associated with pharmacists being involved in the initial ordering of antibiotics and providing active oversight of antimicrobial use. There was a negative correlation between onsite pharmacist hours and use of third-generation cephalosporins and carbapenems.CONCLUSION:A survey showed that rural hospital pharmacists in four Western states spent relatively little time monitoring and influencing antimicrobial prescribing.

depar depar depar depar department of health and human ser tment of health and human ser tment of health and human ser tment of health and human ser tment of health and human services vices vices vices vices MMWR On the Cover: A hazardous materials technician in a protective suit analyzes the contents of the environment after a toxic explosion. Summary When human illness results from an unintentional or intentional release of a toxin (chemicals produced by metabolism in an organism [e.g., ricin]) or a toxicant (natural or synthetic chemicals not metabolically produced by an organism [e.g., nerve agents]) into the environment, uniform reporting is necessary to direct appropriate resources, assess the extent of morbidity and mortality, track poisoned persons, and monitor response to intervention. In this report, CDC presents case definitions to facilitate uniform reporting among local, state, and federal public health agencies of illness resulting from a chemical release. The report also explains the rationale for the structure of the case definitions, the audience for whom it is intended, the setting in which the case definitions might be used, and reasons each chemical presented in the report was selected. Clinical knowledge and diagnostic tools (e.g., biologic laboratory tests) for detecting chemical poisoning are likely to improve over time. CDC will create new case definitions and revise existing definitions to meet the needs related to emerging threats and to enhance case definition sensitivity and specificity, when possible, with developing clinical information.

Context Modifiable behavioral risk factors are leading causes of mortality in the United States. Quantifying these will provide insight into the effects of recent trends and the implications of missed prevention opportunities.Objectives To identify and quantify the leading causes of mortality in the United States.Design Comprehensive MEDLINE search of English-language articles that identified epidemiological, clinical, and laboratory studies linking risk behaviors and mortality. The search was initially restricted to articles published during or after 1990, but we later included relevant articles published in 1980 to December 31, 2002. Prevalence and relative risk were identified during the literature search. We used 2000 mortality data reported to the Centers for Disease Control and Prevention to identify the causes and number of deaths. The estimates of cause of death were computed by multiplying estimates of the cause-attributable fraction of preventable deaths with the total mortality data.Main Outcome Measures Actual causes of death.Results The leading causes of death in 2000 were tobacco (435000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400000 deaths; 16.6%), and alcohol consumption (85000 deaths; 3.5%). Other actual causes of death were microbial agents (75000), toxic agents (55000), motor vehicle crashes (43000), incidents involving firearms (29000), sexual behaviors (20000), and illicit use of drugs (17000).Conclusions These analyses show that smoking remains the leading cause of mortality. However, poor diet and physical inactivity may soon overtake tobacco as the leading cause of death. These findings, along with escalating health care costs and aging population, argue persuasively that the need to establish a more preventive orientation in the US health care and public health systems has become more urgent.

Cough, fever, and myalgias developed in an 18-year-old college student; five days later he was admitted to the hospital in shock. Despite intensive fluid resuscitation and pressor administration, his condition deteriorated, and he died the next day. An autopsy was performed.