Public Health Warnings Research Articles

Public health warning concerning the Peruvian cinema flu

Public health warning concerning the Peruvian cinema flu

Vaginal mesh – the controversy

Pelvic organ prolapse is a condition that can cause significant symptoms that affect a woman's quality of life. It is the result of defects in the supporting structures of the vagina and, depending on the location and size, can alter the functions of the organs contained within the female pelvis. Approximately 11% of women will undergo surgical intervention for their prolapse or for incontinence in their lifetime. Unfortunately, one third of these will require reoperation for failed procedures. Pelvic floor surgeons have sought to improve these outcomes. Based largely on the success of midurethral slings (MUS), transvaginal mesh has been implanted, and commercial kits developed with the intent of improving these outcomes. In 2008, the Food and Drug Administration (FDA) issued a Public Health Notification in response to possible increased adverse events associated with the use of mesh compared to traditional repairs. The 2011 update required that further study be conducted for the use of transvaginal mesh. In this article, we wish to discuss the background of mesh use and the evolution of the public health warnings, and focus on future prospects.

A Multistate Outbreak of Hepatitis A Associated With Semidried Tomatoes in Australia, 2009

A large outbreak of hepatitis A affected individuals in several Australian states in 2009, resulting in a 2-fold increase in cases reported to state health departments compared with 2008. Two peaks of infection occurred (April-May and September-November), with surveillance data suggesting locally acquired infections from a widely distributed food product. Two case-control studies were completed. Intensive product trace-back and food sampling was undertaken. Genotyping was conducted on virus isolates from patient serum and food samples. Control measures included prophylaxis for close contacts, public health warnings, an order by the chief health officer under the Victorian Food Act 1984, and trade-level recalls on implicated batches of semidried tomatoes. A multijurisdictional case-control study in April-May found an association between illness and consumption of semidried tomatoes (odds ratio [OR], 3.0; 95% CI 1.4-6.7). A second case-control study conducted in Victoria in October-November also implicated semidried tomatoes as being associated with illness (OR, 10.3; 95% CI, 4.7-22.7). Hepatitis A RNA was detected in 22 samples of semidried tomatoes. Hepatitis A virus genotype IB was identified in 144 of 153 (94%) patients tested from 2009, and partial sequence analysis showed complete identity with an isolate found in a sample of semidried tomatoes. The results of both case-control studies and food testing implicated the novel vehicle of semidried tomatoes as the cause of this hepatitis A outbreak. The outbreak was extensive and sustained despite public health interventions, the design and implementation of which were complicated by limitations in food testing capability and complex supply chains.

Reducing barriers to sun protection – Application of a holistic model for social marketing

Reducing high rates of sunburn occurrence, linked to the development of skin cancers, has been the focus of sustained social marketing campaigns in Australasia. Despite substantial investment in public health warnings, barriers to preventing sunburn and associated skin cancers remain. The purpose of this article is to illustrate through a holistic model of sunburn how social marketing interventions can be made at both the macro- and micro-environmental levels to minimise the remaining barriers to sun protection. This is achieved though a review of population studies that identify the barriers to preventable sunburn. Integration of the barriers suggests that a holistic approach is needed to understand sun protection behaviour among the general population. This approach supplements existing public health promotion approaches which tend to target an individual’s knowledge and attitude toward sun protection and tanning. From this holistic model of sunburn, the implications for social marketers and directions for future research are presented.

Predictability of anthrax infection in the Serengeti, Tanzania.

Anthrax is endemic throughout Africa, causing considerable livestock and wildlife losses and severe, sometimes fatal, infection in humans. Predicting the risk of infection is therefore important for public health, wildlife conservation and livestock economies. However, because of the intermittent and variable nature of anthrax outbreaks, associated environmental and climatic conditions, and diversity of species affected, the ecology of this multihost pathogen is poorly understood.We explored records of anthrax from the Serengeti ecosystem in north-west Tanzania where the disease has been documented in humans, domestic animals and a range of wildlife. Using spatial and temporal case-detection and seroprevalence data from wild and domestic animals, we investigated spatial, environmental, climatic and species-specific associations in exposure and disease.Anthrax was detected annually in numerous species, but large outbreaks were spatially localized, mostly affecting a few focal herbivores.Soil alkalinity and cumulative weather extremes were identified as useful spatial and temporal predictors of exposure and infection risk, and for triggering the onset of large outbreaks.Interacting ecological and behavioural factors, specifically functional groups and spatiotemporal overlap, helped to explain the variable patterns of infection and exposure among species.Synthesis and applications. Our results shed light on ecological drivers of anthrax infection and suggest that soil alkalinity and prolonged droughts or rains are useful predictors of disease occurrence that could guide risk-based surveillance. These insights should inform strategies for managing anthrax including prophylactic livestock vaccination, timing of public health warnings and antibiotic provision in high-risk areas. However, this research highlights the need for greater surveillance (environmental, serological and case-detection-orientated) to determine the mechanisms underlying anthrax dynamics.

Arbovirus Models to Provide Practical Management Tools for Mosquito Control and Disease Prevention in the Northern Territory, Australia

Ross River virus (RRV) causes the most common human arbovirus disease in Australia. Although the disease is nonfatal, the associated arthritis and postinfection fatigue can be debilitating for many months, impacting on workforce participation. We sought to create an early-warning system to notify of approaching RRV disease outbreak conditions for major townships in the Northern Territory. By applying a logistic regression model to meteorologic factors, including rainfall, a postestimation analysis of sensitivity and specificity can create rainfall cut-points. These rainfall cut-points indicate the rainfall level above which previous epidemic conditions have occurred. Furthermore, rainfall cut-points indirectly adjust for vertebrate host data from the agile wallaby (Macropus agilis) as the life cycle of the agile wallaby is intricately meshed with the wet season. Once generated, cut-points can thus be used prospectively to allow timely implementation of larval survey and control measures and public health warnings to preemptively reduce RRV disease incidence. Cut-points are location specific and have the capacity to replace previously used models, which require data management and input, and rarely provide timely notification for vector control requirements and public health warnings. These methods can be adapted for use elsewhere.

MARINE AND COASTAL SCIENCE: Faster Test for Detecting Contamination of Recreational Waters

Vol. 118, No. 5 NewsOpen AccessMARINE AND COASTAL SCIENCE: Faster Test for Detecting Contamination of Recreational Waters Carol Potera Carol Potera Search for more papers by this author Published:1 May 2010https://doi.org/10.1289/ehp.118-a201aAboutSectionsPDF ToolsDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InReddit Swimmers and surfers face the risk of contracting gastrointestinal illnesses from exposure to water contaminated with human sewage. The current method for monitoring fecal indicator bacteria (FIB) in recreational waters requires collecting water samples, then culturing and counting microbes in the laboratory, a process that takes 24 hours. This delay may expose swimmers to tainted water or, conversely, unnecessarily close beaches that are no longer contaminated. Now engineers at the University of California, Los Angeles (UCLA) have designed a better rapid-detection method that directly analyzes FIB onsite in recreational waters in less than 1 hour.Called the covalently linked immunomagnetic separation/adenosine triphosphate (Cov-IMS/ATP) technique, the portable process uses magnetic beads linked covalently to antibodies that bind FIB. The bead-captured FIB are ruptured and treated with an enzyme (luciferase) that catalyzes a light-emitting reaction powered by ATP. A luminometer measures the amount of light emitted, which correlates with bacterial concentrations.UCLA’s Jennifer Jay, an associate professor of civil and environmental engineering, graduate student Christine Lee, and coworkers collected ocean samples from a California beach and from freshwater streams that flow into the beach area. They checked for two common FIB—Escherichia coli and Enterococcus. The Cov-IMS/ATP method correctly identified 87% of E. coli and 94% of Enterococcus in the samples, producing results similar to standard culture-based methods performed for comparison. Moreover, the new method detected FIB at limits below what the U.S. Environmental Protection Agency deems healthy for recreational waters. The findings were published online 24 December 2009 ahead of print in the Journal of Applied Microbiology.Other efforts to develop rapid tests for recreational water quality are based on the quantitative polymerase chain reaction (for example, see EHP 114:24–28 [2006]). A field test based on Cov-IMS/ATP would be easier to use, according to Mark Gold, president of Heal the Bay, an environmental group in Santa Monica, California, that monitors aquatic habitats. That’s because quantitative polymerase chain reaction takes about 3 hours and requires cumbersome equipment, plus samples must be transported to a laboratory.Now the UCLA team is adapting the method to identify Bacteroidales species, microbes that can be definitively linked specifically to human fecal pollution. “E. coli and Enterococcus are not ideal fecal indicators because they do not tell you the source of the fecal pollution, and they grow naturally in the environment,” says Jay. In contrast, bacteria in the Bacteroidales family grow only in the intestines of warm-blooded animals, with different species targeting different animals. These bacteria also do not replicate well in the environment. So the detection of Bacteroidales signals recent fecal pollution. “Even more important,” says Jay, “you can tell whether Bacteroidales comes from humans or an animal to target cleanup efforts.” The team’s measurements of FIB in freshwater streams to test whether the method could track beach pollution to a particular storm drain will be submitted for publication separately.The Cov-IMS/ATP method could potentially become a tool for beach managers to analyze water samples in the morning and post public health warnings within a few hours. Gold says, “This would protect public health better than the current system, where beaches are closed based on yesterday’s results.”FiguresReferencesRelatedDetails Vol. 118, No. 5 May 2010Metrics About Article Metrics Publication History Originally published1 May 2010Published in print1 May 2010 Financial disclosuresPDF download License information EHP is an open-access journal published with support from the National Institute of Environmental Health Sciences, National Institutes of Health. All content is public domain unless otherwise noted. Note to readers with disabilities EHP strives to ensure that all journal content is accessible to all readers. However, some figures and Supplemental Material published in EHP articles may not conform to 508 standards due to the complexity of the information being presented. If you need assistance accessing journal content, please contact [email protected]. Our staff will work with you to assess and meet your accessibility needs within 3 working days.

Increasing trend of African dust, over 49 years, in the eastern Mediterranean

Dust observations in Israel were carried out since 1958. During 1958–2006, 966 dust days were observed. The dust days have been analyzed through their association with the regional eastern Mediterranean synoptic types, as classified by the Tel Aviv University method. Among the synoptic types, the most contributing were winter lows (with 368 days), Red Sea Troughs (214 days), and highs (211 dust days). Association of dust with highs is a new result, not found in the literature to date. Out of the total occurrences of Sharav lows, 36% are associated with dust, out of total winter lows 13%, with a winter low south to Cyprus having a 30% probability to produce a dust day, and of Red Sea Trough days 6% were associated with dust. Annual occurrence of dust days follows the changes in the occurrence of the regional synoptic systems: the number of dust days associated with Red Sea Troughs has increased by 2.3 d/10 yr, and with highs by 0.9 d/10 yr. The total incidence of dust days has increased with an average rate of 2.7 days per decade. This increasing trend in dust storm occurrence fits with previous results for the eastern Mediterranean and south Europe. Since dust storms are a regional phenomenon and reach south, central, and western Europe, this increase has implications for the entire Mediterranean and European regions. The results show potential for statistical forecasting of dust 1 day in advance. Such forecasts are important for public health warnings and for air transportation.

Public Health Warnings And Mouthwashes

Public Health Warnings And Mouthwashes

Public Health Warnings And Mouthwashes: Authors’ Reply

Editor’s comment: I thank all of those who have taken the time to comment on the “alcohol in mouthwashes” issue. This topic has been given ample exposure and it is now time to close this debate. No further correspondence is to be published on this particular topic. Mark Bartold

Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents

Objective.In 2003 and 2004, U.S. and European regulators issued public health warnings about a possible association between antidepressants and suicidal thinking and behavior. The authors assessed whether these warnings discouraged use of antidepressants in children and adolescents and whether they

Personal UV exposure in high albedo alpine sites

Abstract. Mountain sites experience enhanced UV radiation levels due to the concurrent effects of shorter radiation path-length, low aerosol load and high reflectivity of the snow surfaces. This study was encouraged by the possibility to collect original data of personal dose on a specific anatomical site (erythemally effective UV dose on the forehead) of two groups of volunteers (ski instructors and skiers) in the mountainous areas of Italy (the Alpine site of La Thuile-Les Suches in Valle d'Aosta region). Personal doses were assessed using polysulphone dosimetry. Exposure Ratio (ER), defined as the ratio between the personal dose and the corresponding ambient dose (i.e. erythemally weighted dose received by a horizontal surface) during the same exposure period was taken into account. In addition measuring skin colours as biological markers of individual response to UV exposure, was also carried out on the forearm and cheek of each volunteer before and after exposure. The median ER, taking into account the whole sample, is 0.60 in winter, with a range of 0.29 to 1.46, and 1.02 in spring, ranging from 0.46 to 1.72. No differences in ERs were found between skiers and instructors in spring while in winter skiers experienced lower values. Regarding skin colorimetric parameters the main result was that both skiers and instructors had on average significantly lower values of luminance after exposure i.e.~they became darker. It was found that the use of sunscreen and individual skin photo-type did not produce significant variations in ER across instructor/skier group by day and by seasons (p>0.05). It seems that sunscreen use only at the beginning of the exposure or in a few cases a couple of times during exposure (at difference with the specific instructions sheets), was not sufficient to change significantly skin colorimetric parameters across participants. In conclusion UV personal doses on the ski-fields are often significantly higher than those on horizontal surfaces and consistently more intense respect to personal doses received by sunbathers on the beach in central Italy (ER range: 0.09–0.42). Given the high levels of exposure observed in the present study, specific public health warnings with regards to the efficacy of sun-protection behaviours (proper application and re-application of sunscreen and protective measures such as hats and sun glasses) should be adopted.

Standing the Poor World on its Head (Innovations Case Discussion: Barefoot College of Tilonia)

inspiring successive generations of wildly innovative social entrepreneurs, it is tempting to heap further laurels upon his head. Others, less generous in spirit, might be tempted to seek out his Achilles Heel. But with the world headed towards a population of nine billion-plus sometime mid-century, perhaps there is a higher task. Perhaps we should try to dig a little deeper into the question: For all its wonders, does Barefoot College provide a model that is sustainable, replicable and scalable? Roy and his co-author Jesse Hartigan have done us all a great service with their presentation of the Barefoot approach, but our aim in what follows is to reframe the achievements of what the more brand-savvy might call “The Barefoot Way.” For, much as we may love the Barefoot Way and community, the reptilian part of the brain keeps nagging away, asking whether there is not something about all of this that is more like a set of locally reported modern miracles, together with an accompanying spray of parables, rather than a global revolution in the making. And why is this important? Well, given the sheer scale and intransigence of global poverty, it seems inevitable that there will be a growing number of calls to turn the current development system on its head, to let the poor find their own way. Handing over responsibility for the future to the poor would provide a very useful alibi for some to do nothing—or, worse, to continue with forms of businessas-usual that undermine the world of the grindingly poor. In this scenario, the Barefoot parables could be used to reinforce strategies that were about as remote from the Barefoot principles as could be imagined—rather like what happened with the crusading Christian Church in the Middle Ages. Not that we are looking for revolution. History shows that such social convulsions rarely produce the sort of sustained changes their instigators hoped they would. Indeed, many of these people end up under the guillotine or with their backs to pock-marked walls. Instead, accelerated evolution should be our goal. And here is a public health warning: while we aim to be analytical about the processes of—and trends in—social entrepreneurship, we often find ourselves John Elkington

Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents

In 2003 and 2004, U.S. and European regulators issued public health warnings about a possible association between antidepressants and suicidal thinking and behavior. The authors assessed whether these warnings discouraged use of antidepressants in children and adolescents and whether they led to increases in suicide rates as a result of untreated depression. The authors examined U.S. and Dutch data on prescription rates for selective serotonin reuptake inhibitors (SSRIs) from 2003 to 2005 in children and adolescents (patients up to age 19), as well as suicide rates for children and adolescents, using available data (through 2004 in the United States and through 2005 in the Netherlands). They used Poisson regression analyses to determine the overall association between antidepressant prescription rates and suicide rates, adjusted for sex and age, during the periods preceding and immediately following the public health warnings. SSRI prescriptions for youths decreased by approximately 22% in both the United States and the Netherlands after the warnings were issued. In the Netherlands, the youth suicide rate increased by 49% between 2003 and 2005 and shows a significant inverse association with SSRI prescriptions. In the United States, youth suicide rates increased by 14% between 2003 and 2004, which is the largest year-to-year change in suicide rates in this population since the Centers for Disease Control and Prevention began systematically collecting suicide data in 1979. In both the United States and the Netherlands, SSRI prescriptions for children and adolescents decreased after U.S. and European regulatory agencies issued warnings about a possible suicide risk with antidepressant use in pediatric patients, and these decreases were associated with increases in suicide rates in children and adolescents.

Bioaccumulation of the hepatotoxic microcystins in various organs of a freshwater snail from a subtropical Chinese Lake, Taihu Lake, with dense toxic Microcystis blooms

In this paper, we describe the seasonal dynamics of three common microcystins (MCs; MC-RR, MC-YR, and MC-LR) in the whole body, hepatopancreas, intestine, gonad, foot, remaining tissue, and offspring of a freshwater snail, Bellamya aeruginosa, from Gonghu Bay of Lake Taihu, China, where dense toxic Microcystis blooms occur in the warm seasons. Microcystins were determined by liquid chromatography electrospray ionization mass spectrum. Microcystin (MC-RR + MC-YR + MC-LR) content of the offspring and gonad showed high positive correlation, indicating that microcystins could transfer from adult females to their young with physiological connection. This study is the first to report the presence of microcystins in the offspring of the adult snail. The majority of the toxins were present in the intestine (53.6%) and hepatopancreas (29.9%), whereas other tissues contained only 16.5%. If intestines are excluded, up to 64.3% of the toxin burden was allocated in the hepatopancreas. The microcystin content in the intestine, hepatopancreas, and gonad were correlated with the biomass of Microcystis and intracellular and extracellular toxins. Of the analyzed foot samples, 18.2% were above the tolerable daily microcystin intake recommended by the World Health Organization (WHO) for human consumption. This result indicates that public health warnings regarding human ingestion of snails from Taihu Lake are warranted. In addition, further studies are needed to evaluate the occurrence by Microcystis in relation to spatial and temporal changes in water quality.

Use and Perceived Benefits of Handheld Computer-based Clinical References

ObjectiveClinicians are increasingly using handheld computers (HC) during patient care. We sought to assess the role of HC-based clinical reference software in medical practice by conducting a survey and assessing actual usage behavior. DesignDuring a 2-week period in February 2005, 3600 users of a HC-based clinical reference application were asked by e-mail to complete a survey and permit analysis of their usage patterns. The software includes a pharmacopeia, an infectious disease reference, a medical diagnostic and therapeutic reference and transmits medical alerts and other notifications during HC synchronizations. Software usage data were captured during HC synchronization for the 4 weeks prior to survey completion. MeasurementsSurvey responses and software usage data. ResultsThe survey response rate was 42% (n = 1501). Physicians reported using the clinical reference software for a mean of 4 years and 39% reported using the software during more than half of patient encounters. Physicians who synchronized their HC during the data collection period (n = 1249; 83%) used the pharmacopeia for unique drug lookups a mean of 6.3 times per day (SD 12.4). The majority of users (61%) believed that in the prior 4 weeks, use of the clinical reference prevented adverse drug events or medication errors 3 or more times. Physicians also believed that alerts and other notifications improved patient care if they were public health warnings (e.g. about influenza), new immunization guidelines or drug alert warnings (e.g. rofecoxib withdrawal). ConclusionCurrent adopters of HC-based medical references use these tools frequently, and found them to improve patient care and be valuable in learning of recent alerts and warnings.

Modeling wind-blown desert dust in the southwestern United States for public health warning: A case study

A model for simulating desert dust cycle was adapted and applied for a dust storm case in the southwest United States (US). This is an initial test of the model's capability as part of a future public health early warning system. The modeled meteorological fields, which drive a dust storm, were evaluated against surface and upper-air measurement data. The modeled dust fields were compared with satellite images, in situ surface PM2.5 and PM10 data, and visibility data in the areas affected by the dust event. The model predicted meteorological fields reasonably well. The modeled surface and upper-air field patterns were in agreement with the measured ones. The vertical profiles of wind, temperature, and humidity followed closely with the observed profiles. Statistical analyses of modeled and observed meteorological variables at surface sites showed fairly good model performance. The modeled dust spatial distributions were comparable with the satellite-observed dust clouds and the reduced visibility patterns. Most encouragingly, the model-predicted and observed PM2.5 peak hours matched reasonably well. The model produced better PM2.5 peak hours than PM10 peak hours. The temporal varying trends of daily and hourly PM2.5 and PM10 concentrations at most of the measurement sites were similar to those observed. Discrepancies between the values of the modeled and the measured surface PM2.5 and PM10 concentrations differed with time and location. Sometimes the modeled and measured concentrations can have one order of magnitude differences. These revealed there were possible deficiencies in the simulation of the dust production strength and location, and the representation of dust particle size in the modeling. Better land surface data and size representation of the dust production are expected to further improve model performance.

Cyclooxygenase Inhibition and Cardiovascular Risk

Over the past several months clinicians have been confronted at an escalating rate with reports describing the risks of COX-2 inhibitors (coxibs). Information on this class of drugs appears not only in traditional medical journals and textbooks, but also on the Web sites of regulatory agencies, professional societies, and pharmaceutical manufacturers.1–9 An unusual, but noteworthy, aspect of the state of affairs is the high rate of reporting new findings and opinions (at times voiced in a strident tone) in the lay press.10–13 Understandably, patients are concerned about the potential risks associated with their antiinflammatory medications, and now, either spontaneously or in response to a public health warning, call their healthcare professional with questions or arrive for an office visit armed with publicly accessed information they wish to discuss. Owing to the widespread use of antiinflammatory drugs and the fact that the reported risks are cardiovascular in nature, we offer the readers of Circulation this special article. Our goals are to provide an overview of the relevant biology and pharmacology, to synthesize the data on the cardiovascular risks associated with antiinflammatory medications, to offer suggestions on strategies for prescribing these medications, and to make observations on the regulatory and research implications of the data and their interpretation. Eicosanoids are oxidized derivatives of the polyunsaturated long-chain fatty acids, arachidonic acid and eicosapentaenoic acid, that serve many roles in cardiovascular biology and disease. Eicosanoid biosynthesis can be initiated by release of arachidonic acid from membrane phospholipids by lipases (predominantly of the phospholipase A2 type) (Figure 1). Once mobilized, arachidonic acid is oxygenated into eicosanoids along the following 4 pathways: (1) prostaglandin (PG) endoperoxide synthase (cyclooxygenase [COX]), (2) lipoxygenase (LO), (3) P450 epoxygenase, and (4) (nonenzymatic) isoprostane synthesis. Details of the pharmacology of products of the LO, epoxygenase, and isoprostane pathways, …

Tidal Forcing of Enterococci at Marine Recreational Beaches at Fortnightly and Semidiurnal Frequencies

Marine beach water quality is typically monitored in early morning once a week without respect to tidal condition. To assess the effect of tide on this public health warning system, we analyzed enterococci (ENT) data from 60 southern California marine beaches with differing geomorphology, orientation, and proximity to runoff sources. ENT concentrations during spring tides were significantly higher (p < 0.1) than those during neap tides at 50 of the beaches, and at the majority of these, water samples were also more than twice as likely to be out of compliance with the ENT single-sample standard during spring tides compared to neap tides. When tide range (spring/neap) and tide stage (ebb/flood) conditions were considered together, spring-ebb tides yielded the highest ENT concentrations and the greatest chance of exceeding the single-sample standard at the majority of beaches. The proximity to a terrestrial runoff source, the slope of the runoff source, the slope of the beach, and the orientation of the beach had minimal influence on the tidal modulation of ENT concentrations. The presence of spring and spring-ebb tide signals at such a great percentage of beaches suggests that tide should be considered in the design and interpretation of beach monitoring program data. It also suggests that ENT delivered by tidally forced sources other than terrestrial surficial runoff are widespread. Possibilities include ENT-laden groundwater (saline and fresh) from the beach aquifer as well as ENT-enriched sands, decaying wrack, and bird feces near the high water line.

The Global Threat of Counterfeit Drugs: Why Industry and Governments Must Communicate the Dangers

The production of substandard and fake drugs is a vast and underreported problem, particularly affecting poorer countries. It is an important cause of unnecessary morbidity, mortality, and loss of public confidence in medicines and health structures. The prevalence of counterfeit drugs appears to be rising (see “The Scale of the Problem”) and has not been opposed by close cooperation between drug companies, governments, or international organizations concerned with trade, health, customs and excise, and counterfeiting. In this article we suggest that many pharmaceutical companies and governments are reluctant to publicize the problem to health staff and the public, apparently motivated by the belief that the publicity will harm the sales of brand-name products in a fiercely competitive business. Publicly, at least, several industry sources say the justification for secrecy is to avoid any alarm that could prevent patients taking their genuine medicines. We argue that this secrecy, and the subsequent lack of public health warnings, is harming patients and that it is also not in the long-term interests of the legitimate pharmaceutical industry. We urge a change to mandatory reporting to governmental authorities, which should also have a legal duty to investigate, issue appropriate public warnings, and share information across borders. This is not a role for the pharmaceutical industry, which has a serious conflict of interest. While some drug companies have given public warnings to protect patients, others have been criticized for withholding information and, in a recent development in the United States, taken to court for failing to act. The industry is addressing the problem. In 2003, US pharmaceutical companies made an agreement with the US Food and Drug Administration (FDA) that they would report suspected counterfeit drugs to the FDA within five days of discovery (see “Companies That Have Warned”), although this remains a voluntary arrangement. In many poorer countries, where the problem is at its worst, there are no similar governmental and industry initiatives.