USACHPPM
HEALTH INFORMATION OPERATIONS (HIO) UPDATE
25 July 2002
The HIO Weekly Update provides information regarding global
medical and veterinary issues of interest to the US Army. The weekly update
does not attempt to analyze the information regarding potential strategic or
tactical impact to the US Army and as such, should not be regarded as a medical
intelligence product. Medical intelligence products are available at http://mic.afmic.detrick.army.mil/.
The information in the HIO Weekly Update should provide an increased awareness
of current and emerging health-related issues.
HOT ISSUES..
2
Anthrax Tests White House.
2
Childhood Vaccinations CDC.
2
HIV/AIDS Low-Cost Technologies
Developing World.
2
Homeland Security White House.
2
Hormone Replacement Therapy
(HRT) NIH.
3
Implantable Cardioverter Defibrillators
(ICDs) FDA Approval
3
Poliovirus Synthesis Implications
for Eradication and Bioterrorism..
3
Smallpox Attack Mathematical
Model US.
3
Smallpox Vaccine Trials US.
4
Water Distribution Systems
Targeted by Terrorists FBI
4
USCENTCOM..
4
Acute Diarrheal Syndrome
Afghanistan.
4
Malaria Kyrgyzstan.
4
USEUCOM..
4
Anthrax Albania, Bosnia,
Bulgaria, and Romania.
4
BICHAT European Union (EU)
Response to Bioterrorism..
5
BSE-Risk Material in Beef
France.
5
Chicken Breasts Possible BSE
Risk Ireland.
5
Crimean-Congo Hemorrhagic Fever
(CCHF) Kosovo.
5
Foot and Mouth Disease (FMD)
UK.
5
Gene Tests UK.
5
Hantavirus Hemorrhagic Fever
with Renal Syndrome Bosnia and Serbia.
6
Meningococcal Meningitis
Rwanda.
6
Unknown Illness Namibia.
6
USJFCOM..
6
Anthrax Russia.
6
Anthrax South Dakota.
6
Escherichia coli O157:H7
Multi-state Outbreak US.
6
Hepatitis B Virus (HBV) Vaccination
US.
7
HIV Seroconversion after Blood
Transfusions Florida.
7
Malaria Surveillance US,
2000.
7
Pertussis Deaths US, 2000.
7
Pertussis Texas.
8
West Nile Virus (WNV) Activity
US.
8
World Trade Center (WTC) Registry
ATSDR.
8
USPACOM..
8
Dengue Fever Malaysia.
8
Dengue Fever Philippines.
9
Diet Pill Linked to Deaths
China, Japan, and Singapore.
9
Hepatitis E Virus (HEV) Japan.
9
Malaria South Korea.
9
USSOUTHCOM..
9
Dengue Fever El Salvador
and Honduras.
9
Hantavirus Pulmonary Syndrome
(HPS) Brazil
10
Rickettsiosis, Spotted Fever
Group (SFG) Peru.
10
Report Preparation.
10
ACRONYMNS..
11
On 19 July, the Associated
Press reported the White House is warning that anthrax field tests widely used
since last falls bioterrorism attacks give fast but often incorrect results,
prompting authorities to shut down buildings prematurely and distribute unneeded
antibiotics. The report stated that the White House Office of Science and Technology
would send a memo to more than 250 federal agencies and to firefighters, police,
and local officials across the country, advising federal agencies to stop buying
field test kits and to cancel any contracts that are pending. The memo advises
authorities to send results to a lab, where they can get initial readings within
six hours. The memo will also reportedly recommend federal agencies stop routinely
testing their mailrooms for anthrax, given that most [federal] mail is now irradiated.
[View
report]
On 12 July, the CDC
announced that supplies of diphtheria and tetanus toxoids and acellular pertussis
(DTaP) vaccine and measles, mumps, and rubella (MMR) vaccine in the US have
become sufficient
to permit the resumption of the routine schedule for DTaP and MMR use as recommended
by the ACIP.
Child care and school attendance provisions requiring children to receive a
DTaP booster and a second dose of MMR vaccine at age 4-6 years can be reinstituted.
[View
report]
On 8 July, the CDC
reported that new study data from several African countries revealed progress
in identifying practical solutions for improving HIV testing in highly affected
countries. The study results include a new method of monitoring CD4+ cell levels
in blood at one-fourth the cost of current CD4+ tests, and a new technology
for monitoring viral load at one-fifth the cost of existing tests. Panleucogating
(PLG) is the new technology that looks for CD4+ markers on white blood cells.
With fresh blood samples PLG obtained results that correlated closely with FACSCount,
the standard CD4+ test, while superior results were obtained when analyzing
three-day old, stabilized blood. Another alternative approach known as lymphocyte
gating showed much poorer results in both fresh and stabilized blood analysis.
[View
report]
On 16 July, The Guardian
reported that the White House released a 90-page strategy on homeland security.
The document proposes new federal laws and initiatives that would include (1)
the creation of red teams that would think like terrorists and identify potential
methods and targets and (2) the updating of procedures that order emergency
quarantines in cases of bioterrorism. The strategy also identifies eight priority
areas for substantial spending in the next budget. [View
report]
On 11 July, the Rhode
Island Department of Health (HEALTH) reported that on 10 July NIH had stopped
a major clinical trial involving combined estrogen and progestin (Premproฎ)
in healthy menopausal women early due to an increased risk of invasive breast
cancer. The large multi-center trial, originally scheduled to run until 2005,
also found increased risk for coronary heart disease, stroke, and pulmonary
embolism in study participants. Some benefits included fewer cases of hip fractures
and colon cancer. On balance, however, the harm was greater than the benefit.
HEALTH recommended women on the combined estrogen-progestin HRT see their healthcare
provider for follow-up. A separate NIH study of estrogen alone in women who
had a hysterectomy before joining the hormone program continues unchanged because,
at this point, the balance of risks and benefits of estrogen alone is still
being studied. [View
HEALTH report
or View
BBC report]
On 18 July, the FDA approved
a new indication for Guidant Corporations ICDs that expands the target population
to include patients with a history of a heart attack and depressed heart function.
With approval of this new indication, some patients may not be required to undergo
invasive electrical testing using a catheter from the groin to the heart prior
to implantation of the ICD. [View
report]
On 18 July, the Eurosurveillance
Weekly reported on the 11 July Science study funded by DARPA,
which reported that researchers had synthesized infectious poliovirus cDNA de
novo in a laboratory for the first time by using the genome sequence available
on the Internet and genetic material made to order by a company which constructs
and sells DNA. According to the Boston Globe, DARPA wanted to know whether
potential weapons of bioterrorism could be made in a laboratory. This information
has implications for future decisions about polio vaccination strategy as global
polio eradication approaches. If poliovirus is contained and mass vaccination
not continued, population immunity against polio will be lost, and synthesized
poliovirus could then become a potential bioterrorism weapon. Science
published online July 11, 2002: 10.1126/science.1072266 (Science Express Reports). [View
Euro report
or View
The Boston Globe report]
On 8 July, the New
York Times reported that a PNAS
study found large differences in how four different vaccination strategies would
fight a smallpox bioterrorism attack. The study used a mathematical model to
compare how an attack on a large city that infected 1,000 people would progress
when countered with diverse vaccination plans meant to halt the spread of the
highly contagious disease. In all cases, the mass vaccination of the US population
worked far better than ring vaccination or ring vaccination followed by delayed
mass vaccination [View
NYT report
or View
PNAS report]
On 9 July, ProMED reported
that about 330 volunteers would be inoculated with diluted doses of smallpox
vaccine over the next two weeks at four sites across the country. Healthcare
workers will inject the vaccine and bandage the area, which is monitored. Subsequent
blood tests will determine if the test subjects develop protective antibodies.
The CDC
is considering vaccinating as many as 500,000 healthcare workers and emergency
personnel who would be first to see any smallpox cases. The New England Journal
of Medicine published two preliminary studies in March. [View
report]
On 22 July, Time
reported that an executive of the American Water Works Association last week
confirmed an FBI warning that cautioned the nations water utilities to prepare
to defend themselves against possible terrorist attacks on pumping stations
and pipes that serve its cities and suburbs. While no specific plans to attack
a water system were found, documents were discovered in Afghanistan that indicate
al-Qaeda terrorists were investigating ways to disrupt the US water supply on
a massive scale. Captured terrorist suspects in Pakistan reportedly told their
interrogators that al-Qaeda was dabbling with such toxins as cyanide and botulinum.
[View
report]
On 17 July, the WHO
reported that an outbreak of watery diarrheal disease involving 6,691 cases
(three deaths) has been ongoing in Kabul during the last three weeks. Among
these cases, three cases of Vibrio cholerae have been laboratory confirmed.
The Ministry of Public Health reactivated the Cholera Task Force, which has
implemented preventive measures such as health education and water chlorination.
Surveillance activities are continuing. According to the WHO, an increase in
diarrheal diseases, including cholera, is a normal occurrence in this area
during this time of year. [View
report]
On 18 July, AFMIC
reported that up to 100 cases of suspected malaria were reported in the Batken
area since mid-June. Rice farmers in the area have been requested to drain
their fields to destroy mosquito-breeding sites. [View
report; requires registration]
On 11 July, AFMIC
reported the following anthrax outbreaks in humans: 226 cases (126 hospitalized)
in Gjinokastru, Albania; occupationally related cases in Bosnia, and one human
case in Romania associated with consumption of an infected veal calf. Additionally,
Bulgaria reported cases in early July in livestock. Animal vaccination campaigns
are ongoing. [View report;
registration required]
On 11 July, the Eurosurveillance Weekly
reported that a Health Security Committee, formed under a directive issued by
the EU health ministers, has developed a program of cooperation on preparedness
and response to biological and chemical agent attacks, abbreviated to BICHAT,
which comprises 25 actions grouped under four objectives: (1) establish a EU
coordination mechanism, (2) ensure rapid detection and identification of agents
and cases, (3) evaluate inventory and use of medicines and services, and (4)
establish EU rules, guides, and international links. [View
report]
On 19 July, Reuters reported that French
veterinary services had found over 10% of cattle carcasses about to enter the
food chain still contained banned spinal cord in an inquiry conducted last year.
Significant amounts of other specified risk materials, such as tonsils and thymus,
were also found in 32 abattoirs last year. The EU has banned spinal cord in
food made from cattle since 1996. The inquiry was conducted prior to the enactment
of a French law, which now requires slaughterhouses to use vacuum pumps to strip
cattle carcasses instead of manual cutting. [View
report]
On 8 July, the Guardian reported
that last month the Irish Food Safety Authority (FSA) had found more than half
its chicken breast fillet samples contained foreign DNA which was not declared
on the label: a total of seven samples contained bovine DNA, seven pork DNA,
and three both. The Irish authorities have now impounded the meat, but the
UK
FSA had not acted to remove the same brands from sale. All the chicken products
were imported from Thailand and Brazil through the Netherlands where they had
been tumbled with water and additives containing hydrolyzed proteins. [View
report]
On 18 July, AFMIC
reported at least three people have died of CCHF in Kosovo and another 35 are
listed as suspected cases since May. Confirmed cases were found in Lebane,
Medvedja, and Leskovac. The route of exposure was not specified but expected
to be tick bites. [View report;
requires registration]
On 16 July, the BBC reported that the Royal
Society had recommended in a government-commissioned report that vaccination
should be part of any strategy to control a future FMD outbreak in the UK.
The report, from Britains foremost academy of science, is the first of two
major studies into the governments handling of the epidemic last year. [View
report]
On 15 July, the BBC reported that the Human
Genetic Commission would launch a three-month survey asking whether genetic
tests should be sold direct to the public, or should only be available through
a doctor. Technological developments that have made genetic testing easier
and more readily available coupled with a growing public interest and understanding
of medical information have fueled the demand for these tests. The survey results
are expected by the end of the year. [View
report]
On 18 July, AFMIC
reported that officials in Banovici have declared an epidemic due to the rising
number of Hantavirus cases since May. A total of 43 reported cases have been
reported with most cases located in the Central Bosnia Canton. In neighboring
Serbia, 10 cases have been reported. [View report;
requires registration]
On 18 July, AFMIC
reported 40 deaths and an unspecified number of cases of meningococcal meningitis
(type unspecified) in Rwanda. [View report;
requires registration]
On 18 July, AFMIC
reported 14 human cases (eight deaths) of an unknown illness were reported from
Malengalenga village in the Caprivi Region. The first case was reported in
December 2001. A Namibian veterinarian visiting the village reportedly suspected
anthrax. A local health education program was launched to warn people not to
eat, skin, or open any animal that has died mysteriously. [View report;
requires registration]
On 16 July, ProMED reported a resident of Kalmykia
died due to cutaneous anthrax contracted from a sick cow. The man killed the
sick cow and sold its meat in the Rostov region. Family members and people
who bought the infected meat were vaccinated and placed under observation through
the incubation period with no further cases noted. The incident is reportedly
not connected to the flood-stricken areas in southern Russia. [View
report]
On 11 July, ProMED reported a Jerauld County veterinarian
was diagnosed with cutaneous anthrax as a result of blood and tissue exposure
during an autopsy of an unvaccinated cow that was recently added to a herd of
vaccinated cattle in a pasture adjacent to the premises where buffalo were lost
due to anthrax in August 2001. Two individuals who assisted with the autopsy
are on prophylaxis. [View
report]
On 19 July, the CDC
reported that a cluster of 16 cases of E. coli O157:H7, indistinguishable
by pulsed field electrophoresis using two enzymes, were reported in Colorado
with onset dates between 13 and 30 June. Based on patient interviews, molecular
fingerprinting methods, and initial traceback, these cases have been associated
with consumption of ground beef products voluntarily recalled by ConAgra Beef
Company on 30 June. Using PulseNet and epidemiological information, six additional
cases of E. coli O157 infection that might be related to the Colorado
cluster have been identified in five other states including California, Michigan,
South Dakota, Washington, and Wyoming. The CDC is recommending that consumers
thaw frozen ground beef in the refrigerator and cook thoroughly to internal
temperatures of at least 160 degrees Fahrenheit. [View report]
On 19 July, the CDC
reported that the national strategy to eliminate HBV transmission, which is
composed of four objectives, has largely been successful except for the last
objective of vaccinating adolescents and adults in groups at increased risk
for infection. According to the report, adults and older adolescents with high-risk
sex and drug behaviors are still not getting routinely vaccinated. For instance,
the CDC recommends healthcare providers offer the HBV vaccine to all persons
seeking care for a sexually transmitted infection, but programs have had only
limited success rates. The report suggested that a sustained vaccination program
might achieve higher levels of vaccine acceptance if combined with a short counseling
session. [View report]
HIV Seroconversion after Blood Transfusions Florida
On 19 July, CBS News reported that two people contracted
HIV from blood transfusions provided from a regional blood bank. The donor
gave infected blood on 11 May, but had contracted the disease so recently that
tests did not detect the infection. The HIV virus generally takes seven to
10 days to build up sufficiently for detection. When the donor returned to
give blood again on 30 May, a positive HIV was detected. The blood was destroyed,
the donor notified, and a traceback initiated. The incident is the second time
since the nations blood banks implemented new screening technology in 1999
that HIV has been transmitted through a transfusion. [View
report]
On 12 July, the CDC
reported that during 2000, 1,402 cases of malaria were reported in the US or
one of its territories, representing a 9.0% decrease from 1999. The decrease
is probably a result of expected variation in the reporting system. Six deaths
were attributed to malaria, four caused by P. falciparum, one caused
by P. malariae, and one by P. ovale. Cases among US military
personnel decreased from 55 in 1999 to 46 in 2000; of the 45 cases for which
information regarding chemoprophylaxis use was available, seven patients were
not using any prophylaxis. In over 70% of reported imported cases, U.S. civilians
were not taking any chemoprophylaxis or were not on an appropriate chemoprophylaxis
regimen for the country in which they acquired malaria. Healthcare providers
are encouraged to contact CDC rapidly whenever they suspect chemoprophylaxis
failure, thus enabling measurement of serum drug levels of the antimalarial
drugs in question. [View report]
On 19 July, the CDC
reported that 17 deaths due to pertussis (whooping cough) were reported in the
US during 2000. All deaths occurred in US-born infants who became sick before
four months of age. Infants vulnerable to Bordetella pertussis infection
are those aged less than six months or those who have not yet received three
doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine.
B. pertussis can be transmitted to vulnerable infants by infected parents,
siblings, and others. Antibiotics can be used to treat persons with pertussis
and their close contacts, including exposed infants. Timely vaccination of
infants and children according to the current ACIP recommendations remains
the most effective way for parents and healthcare providers to prevent pertussis.
Infants should receive the first DTaP vaccine at age two months, followed by
doses at ages 4, 6, and 15-18 months, and a booster dose at age 4-6 years. [View report]
On 18 July, the Texas Department of Health (TDH) reported
that 378 cases of pertussis or whooping cough, including four infant deaths,
have been recorded in 41 counties so far this year. About 30% of the cases
have been in children under one year of age. Last year some 615 cases of pertussis
were reported in 70 counties, the highest number of cases since 1968 when 802
cases were reported. The illness has been on an upward trend in the US for
several years. The TDH is advising physicians to consider giving antibiotics
immediately to patients with pertussis symptoms and to their family members,
instead of waiting for results of lab tests to confirm the illness. The TDH
is also advising parents that a healthcare provider should see any infant with
cough or difficulty breathing. [View report]
On 23 July, ProMED reported that a 50-year-old man
from Orange County was confirmed as the first human case of WNV in Texas. Test
results are pending on four other suspected adult cases. On 19 July, the Mississippi
State Department of Health confirmed the states first human case of WNV in
a middle-aged man from Hinds County. On 18 July, the CDR Weekly reported seven human
cases of WNV encephalitis or meningitis have been reported in towns east of
Baton Rouge, Louisiana during 2002. The first three cases were all male; one
case was 78 years of age and was diagnosed on 8 July, and two further cases,
aged 62 and 53 were diagnosed on 11 July. The CDC
reported that dates of illness onset ranged from 10 to 28 June, with no fatalities.
This week, state health officials reported that one 34-year-old woman and three
men, aged 17, 62, and 76, have been diagnosed with WNV. All cases have been
hospitalized. In addition, 23 WNV infections in horses have been reported from
four states (Florida, Kentucky, Louisiana, and Texas). Additionally, CDC officials
at the AVMA convention reported confirmation
of the first horse in North Dakota (Grand Forks County). WNV maps are maintained
at the USGS
website. [View
ProMed report or View
MS report or View CDC report
or View
CDR report]
On 8 July, the ATSDR announced that will it assist
the New York City Department of Health and Mental Hygiene in creating a registry
of people who may have been exposed to the WTC site, either from working, living,
or cleaning up in the area affected by the disaster. The registry will follow
the health of the 100,000 200,000 people exposed to substances emanating from
the collapse and cleanup of the WTC to help determine whether their exposure
has any relationship to short- or long-term health problems they may experience.
The registry was made possible through $20 million provided by FEMA.
The registry is expected to launch in late fall 2002. [View report]
On 18 July, AFMIC reported about 2,000 cases were reported in Kuala
Lumpur between January and June, which is four times that of the same period
last year. The health department is launching a preventive campaign that focuses
on elimination of mosquito breeding areas. [View report; requires registration]
On 18 July, AFMIC reported 316 dengue fever cases and two deaths occurred
between January and early July. Last year the province only reported 123 cases.
Health officials are focusing preventive efforts on the use of mosquito nets
and screens and on removal of any potential mosquito breeding places. [View report; requires registration]
The Japanese Health Ministry reported 64 Japanese people
most of them women have suffered liver damage and other ailments believed
to be caused by fenfluramine, an ingredient in a Chinese herbal slimming supplement.
Of the 64 people, four have died and 28 remain in the hospital. The supplement,
sold in China under the name Yuzhitang and in Singapore as Slim 10, was banned
earlier this year. South Korean officials are strengthening measures to prevent
import of the pills. [View
report]
On 21 July, The Daily Yomiuri reported that
researchers in Japan have retrospectively found HEV in 10 patients with acute
hepatitis since the 1990s. At least seven of the patients from Tokyo, Saitama
Prefecture, and Hokkaido had not traveled abroad where the disease is prevalent.
Researchers began investigating the number of cases of HEV after Europe and
the US reported increased instances of the disease in recent years. Examinations
found three variations of HEV among the seven people who contracted the virus
in Japan all of which were different from the types of virus found overseas.
Historically, HEV has not been considered a serious risk in Japan because it
has been associated with countries with underdeveloped water supplies. HEV
can live and grow in the body of animals without causing serious problems to
the host; therefore, pigs, goats, and rats are thought to carry the virus in
some foreign countries. [View
report]
On 18 July, AFMIC reported four deaths due to malaria had recently occurred
near the demilitarized zone (DMZ) and 15 additional suspected cases are under
observation. Transmission typically occurs from April thru October. As of
5 July, a total of 206 malaria cases had been officially reported in Korea.
[View report; requires registration]
On 19 July, the WHO reported that as of 6 July, there have been 2,249
cases (six deaths) of dengue fever and 156 cases of dengue hemorrhagic fever
(DHF) in El Salvador. The epidemic curve suggests the outbreak has peaked.
The WHO also
reported that as of 29 June there have been 3,993 reported cases (eight deaths)
of dengue fever and 545 cases of DHF in Honduras. Preventive efforts have focused
on community participation. Coordination efforts involving surveillance and
vector control are being undertaken in the bordering areas between the two countries.
[View
report on El Salvador; View
report on Honduras]
On 16 July, ProMED reported a third case of HPS is
under investigation in Minas Gerais. This case is in a 40-year-old man who
is in stable condition but hospitalized. Two cases of HPS have been confirmed
this year one fatal case in a rural worker and one non-fatal case. A not-yet-confirmed
case under investigation occurred in an administrator of a farm, who died on
13 July after being hospitalized. [View
report]
On 13 July, ProMED reported that an investigation conducted
during May and June in the community of Coletas, district of Sapillica, department
of Piura, Peru found that out of 141 samples, 14 cases were positive for SFG
rickettsia and 25 cases were positive for leptospira. Patients reported fever,
headache, myalgias, jaundice, cyanosis, and seizures. Two deaths occurred.
This is the first outbreak of SFG rickettsiosis reported in the north coast
of Peru. [View
report]
Barbara E. Davis, DVM
This report is also available on
the USACHPPM
website.
Approved:
Kevin
Delaney
Chief, Health Information Operations
(410) 436-5217 or DSN 584-5217
ACIP - Advisory
Committee on Immunization Practices
AFMIC
- Armed Forces Medical Intelligence Center
AFPS American
Forces Press Service
ATSDR
Agency for Toxic Substances and Disease Registry
AVIP - Anthrax
Vaccine Immunization Program
AVMA - American Veterinary
Medical Association
BSE Bovine Spongiform
Encephalopathy
CDC
Centers for Disease Control and Prevention
CDR
Communicable Disease Report (England)
DARPA
Defense Advanced Research Projects Agency; http://www.darpa.mil/
DHHS Department of Health and
Human Services
DoD - Department
of Defense
EPA
Environmental Protection Agency
ESSENCE
Electronic Surveillance System for the Early Notification of Community-Based
Epidemics
FBI Federal
Bureau of Investigation
FDA Food and Drug Administration
FEMA
Federal Emergency Management Agency
FMD
Foot and Mouth Disease
FSIS
Food Safety Inspection Service
GAO
US General Accounting Office
HIV/AIDS
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
IAEA
- International Atomic Energy Agency
IDP
Internally Displaced Persons
ICRC
International Committee of the Red Cross
IRCS
International Red Cross Society'
MOU
- Memorandum of Understanding
MRI
Magnetic Resonance Imaging
MSDS
- Material Safety Data Sheet
NAS
National Academy of Sciences
NGO
- Non-Governmental Organization
NIH
National Institutes of Health
NIOSH
National Institute for Occupational Safety and Health
NRC
Nuclear Regulatory Commission
OCHA
- Office for the Coordination of Humanitarian Affairs
OIE
World Organisation [sic] for Animal Health
OSHA
- Occupational Safety and Health Administration
PAHO
- Pan American Health Organization
PCR
Polymerase Chain Reaction
PNAS
Proceedings of the National Academy of Sciences
PPE
- Personal Protective Equipment
TB
Tuberculosis
UK
United Kingdom England, Northern Ireland, Scotland, and Wales
UN
United Nations
UNAIDS
Joint United Nations Programme [sic] on HIV/AIDS
UNHCR
United Nations High Commissioner for Refugees
USAID
- United States Agency for International Development
USAMRIID
- United States Army Medical Research Institute of Infectious Diseases
USDA
United States Department of Agriculture
USPS
- United States Postal Service
vCJD
- variant Creutzfeldt-Jakob Disease
VOA
Voice of America, an international multimedia broadcasting service funded
by the US Government
WHO
World Health Organization
WMD
- Weapons of Mass Destruction
