Mycoplasma capricolum subsp. capripneumoniae, the causal agent of contagious caprine pleuropneumonia (CCPP). The complement fixation test, the test prescribed for international trade purposes, uses a crude antigen that cross-reacts with all the other mycoplasma species of the “mycoides cluster” frequently infecting goat herds. The lack of a more specific test has been a real obstacle to the evaluation of the prevalence and economic impact of CCPP worldwide. A new competitive ELISA kit for CCPP, based on a previous blocking ELISA, was formatted at CIRAD and used to evaluate the prevalence of CCPP in some regions of Kenya, Ethiopia, Mauritius, Tajikistan and Pakistan in an international collaborative study.Few serological tests are available for detecting antibodies against The strict specificity of the test was confirmed in CCPP-free goat herds exposed to other mycoplasma species of the “mycoides cluster”. Prevalence studies were performed across the enzootic range of the disease in Africa and Asia. Seroprevalence was estimated at 14.6% in the Afar region of Ethiopia, whereas all the herds presented for CCPP vaccination in Kenya tested positive . In Mauritius, where CCPP emerged in 2009, nine of 62 herds tested positive. In Central Asia, where the disease was confirmed only recently, no positive animals were detected in the Wakhan District of Afghanistan or across the border in neighboring areas of Tajikistan, whereas seroprevalence varied between 2.7% and 44.2% in the other districts investigated and in northern Pakistan. The test was also used to monitor seroconversion in vaccinated animals.This newly formatted CCPP cELISA kit has retained the high specificity of the original kit. It can therefore be used to evaluate the prevalence of CCPP in countries or regions without vaccination programs. It could also be used to monitor the efficacy of vaccination campaigns as high-quality vaccines induce high rates of seroconversion. M. capricolum subsp. capripneumoniae (Mccp) *100 and are expressed as the “percentage inhibition” (PI).http://www.oie.int/en/international-standard-setting/terrestrial-manual/access-online/).Whenever possible, the kit was validated according to the rules laid down in chapter 1.1.5 of the OIE manual of standards (M. mycoides subsp. capri (Mmc) or M. capricolum subsp. capricolum (Mcc) strains were isolated from the bulk tank milk and/or from at least one individual milk sample.This cutoff point was established by analyzing 478 serum samples from 16 goat herds from France, which is a CCPP-free country. The status of each herd, in terms of the circulation of mycoplasmas from the “Mycoides cluster”, was determined before the study, by culturing various samples, as previously described . For eacOnce the cutoff point had been established, the confidence interval around this value was established in the CIRAD laboratory, taking several factors into account. First, an “internal reference material” (IRM) serum with a titer slightly higher than the cutoff point was produced and freeze-dried. This IRM serum was tested on four different occasions, by three technicians and at various positions in the plates, with the generation of 392 results in total.All the ELISA tests were conducted in accordance with the general guidelines of ISO17025 at CIRAD-UMR15, which has obtained accreditation from the French Committee for Accreditation for this cELISA test (COFRAC certificate N° 1–2207).The cELISA was used to investigate the presence of CCPP in remote districts of Afghanistan, Pakistan and Tajikistan centered on the Pamir mountain range. In each country, two (Pakistan) or three  sampling areas at least 50 km apart were selected, to ensure broad geographical coverage Figure . In AfghSerum samples were collected from Kenya, in the area around Narok, 300 km west of Nairobi, where CCPP is known to be enzootic. Herds were selected on the basis of the willingness of their owners to participate in a vaccination campaign organized by the VACNADA project. There was no evidence of clinical signs of CCPP in the herds at the time of sampling. All animals from the selected herds were sampled . In Ethiopia, samples were obtained from the Afar region, in which CCPP is known to have been present since its introduction in 1990, in the eastern part of the country . One thoN = 720).In addition, serum samples were also collected from Mauritius, where CCPP has recently been identified . Sixty-tg for 15 minutes and washing with PBS. The concentrated suspension (1 mg/ml) was inactivated by the binary ethylenimine procedure [A reference batch of CCPP vaccine was produced by CIRAD, as described by Rurangirwa , but witrocedure ,24 and fSix-year old naive goats were immunized at CIRAD with a vaccine meeting OIE requirements: 0.15 mg of antigen and 3 mg of saponin per dose. The immunization protocol was approved by the local ethics committee and the goats were housed in an animal facility controlled by French veterinary services (certificate: C34-172-20). Serum samples were collected at weekly intervals for two months and then after five months. Various combinations of antigen and saponin doses were then prepared and used to immunize goats at the African Union Pan African Veterinary Vaccine Center . Saponin-adjuvanted vaccines are registered in Ethiopia and do not require specific authorization for use. The animal facilities at AU-PANVAC are located within the National Veterinary Institute, Debre-Zeit, which is the reference laboratory for vaccine production and quality testing in Ethiopia. We tested the following ratios, expressed in mg mycoplasma protein/mg saponin per dose: A = 0.15/3; B = 0.15/0.3; C = 0.05/3; D = 0.05/0.3; E = 0/3; F = 0.15/0. Sera were collected weekly for six weeks and tested by cELISA.When the kit was stored at 37°C, the values for the control monoclonal antibody (Mab) declined over time. They remained above the accepted limit (0.5 OD) for three weeks, after which, the percentage inhibition (PI) value obtained for the laboratory internal positive reference serum decreased slightly, from a mean of 61PI to 54PI, but clearly remained within acceptable limits.Mycoplasma mycoides subsp. capri (Mmc) was the most frequently isolated mycoplasma species (six of the seven herds for which infection was detected on the basis of tests on milk), whereas Mycoplasma capricolum subsp. capricolum (Mcc) was detected only once. The 40 serum samples with the highest titers, including two individual serum samples with PI values of 56 and 57, were retested twice, to determine the titer more precisely. The highest mean PI value for a negative serum was 54. A cutoff point of 55PI was applied, so the test was strictly specific.Once the kit had been formatted and a preliminary batch had been produced in an industrial production process by IDEXX-Montpellier SAS, the specificity of the test was assessed on 478 serum samples of French origin of known infection status. The distribution of results followed a Gaussian curve, with a mean PI of 25.5. There was no correlation between mean cELISA titer and mycoplasma infection status. Indeed, An internal reference serum, with a titer close to the cutoff point, was tested in 392 replicates, on four different dates, by three technicians. All the results were pooled and the distribution was evaluated. The curve obtained was strictly Gaussian, with a mean PI value of 56. The standard deviation (SD) of this mean was 3.5. Further testing over a one-year period showed the uncertainty of measurement around the mean to be 8PI for serum samples with titers around the cutoff point. This uncertainty was estimated taking into account all the reagents, equipment and parameters critical for a cELISA test, as specified by the ISO-17025 standard. The most important factors are the kit itself, the precision of the pipettes, the training and experience of the technicians, and the linearity and repeatability of the ELISA reader. This uncertainty of measurement has two main components: the performance of the kit itself and the way the test is implemented in the laboratory. The same kit may therefore yield different uncertainties in different laboratories.We present here only the data generated at CIRAD. However, the test was also performed locally elsewhere, notably in Ethiopia, Kenya, Mali, Mauritania, Pakistan, Senegal and Tajikistan. At all these sites, correct results were obtained for the controls, demonstrating the robustness of the kit.Five sites were selected for the evaluation of CCPP seroprevalence with this cELISA Figure -A. FrancA preliminary test was performed on seven serum samples collected during a CCPP outbreak confirmed by PCR, in South-West Tajikistan. These serum samples were collected from goats that had shown respiratory signs in the previous weeks or months. Six of the seven samples tested positive and titers were very high in some cases, with PI values of up to 90.The 359 serum samples collected from the Wakhan District in Afghanistan and the 199 serum samples retrieved from the contiguous Ishkoshim and Murghob districts in Tajikistan tested negative. These results are highly consistent with the absence of clinical signs of CCPP in this part of the Central Asian highlands . By contrast, in the Diamer District, 115 of the 260 serum samples tested were positive, giving a prevalence of 44.2% (95% CI: 38.1%-50.5%), a value significantly higher than that obtained for Gilgit. The reasons for this difference are unknown, but further sampling, with the testing of a larger sample spread over a broader geographical area should increase our understanding of the variation of CCPP seroprevalence in Gilgit-Baltistan.In the Shuro-Obod District and the contiguous Darvoz District in southern Tajikistan, 20 of the 197 serum samples analyzed tested positive, giving a prevalence of 10.1% (95% CI: 6.3%-15.2%), confirming the clinical observations suggestive of CCPP in this region bordering Afghanistan [We tested 1000 goat serum samples from the Afar region of Ethiopia, from sites at which vaccination had never been carried out; 146 of these samples tested positive  Figure -E. Herd Three goats vaccinated at CIRAD with a batch of the reference vaccine displayed rapid marked seroconversion, which was detectable after as little as one week. PI values peaked three weeks after vaccination  and remained stable at for at least five weeks thereafter. The same animals were retested five months after vaccination: two continued to test positive , whereas the third tested negative.At AU-PANVAC, groups of two to three goats were vaccinated with various proportions of antigen and adjuvant. Goats vaccinated with the reference vaccine displayed seroconversion of a similar intensity to that seen at CIRAD Figure -A. By coThis newly formatted CCPP cELISA kit performed significantly better than the previous version. The new version of the kit includes highly heat-stable precoated plates in sealed packaging, and the test performs well after incubation for three weeks at 37°C. An additional advantage of this kit is its modification to use the same protocol as the contagious bovine pleuropneumonia cELISA kit . Laboratories that are familiar with the bovine test can therefore easily perform the caprine test.The very high specificity of the CCPP cELISA, at close to 100%, was similar to that of the previous blocking ELISA. In this study, we did not use goat herds and animals chosen at random from a CCPP-free country. Instead, we deliberately also included goat herds infected with other mycoplasmas of the “mycoides cluster”, to increase the stringency of the test. Such animals would probably have given cross-reactions in the less specific complement fixation test (CFT), which uses a crude antigen ,26. ThisThe results of cELISA tests confirmed that CCPP was enzootic in the lowlands of Kenya and Ethiopia, with a high prevalence in the herds tested. These findings are consistent with those of participatory enquiries , which hThe epidemiological situation for CCPP in Mauritius differs from that in East Africa. The disease was not introduced into Mauritius until 2009, and it will be interesting to follow the progress of this disease in the coming years and to analyze it in terms of the control strategies that may be implemented.Results for Central Asia were highly variable and depended on the geographical origin of the samples. These findings highlight the need for widespread serological investigations, to clarify the distribution of the disease across Asia, which is currently poorly understood.The absence of CCPP in the Wakhan District of North-East Afghanistan may, to some extent, reflect the remoteness of this district, which provides some protection against the introduction of infected animals.The high seroprevalence observed in East Africa indicates a lack of success of the control strategies implemented in this region, despite the local production of CCPP vaccines. However these vaccines are difficult to produce. This makes them expensive and limits their use in the field.The widespread presence of mycoplasmas of the “mycoides cluster” around the Mediterranean basin may potentially mask the emergence of CCPP. These mycoplasmas induce a wide range of lesions in affected goats, including CCPP-like pleuropneumonia. Hence, goat owners and veterinary surgeons may not detect CCPP quickly enough to warn local health authorities and curtail the risk of epizootics. The cELISA may, therefore, prove very useful for the development of epidemiological surveillance activities in regions at risk of CCPP introduction, such as the Balkans.Finally the preliminary results obtained in this study indicate that this serological test could be used to evaluate the quality of CCPP vaccines or vaccination campaigns, by monitoring the seroconversion induced in vaccinated animals. The collection of serum samples before vaccination and then one and two months after vaccination should provide clear evidence of seroconversion if the vaccine was produced according to the OIE standards. Seroconversion indicates that sufficient Mccp antigen and adjuvant were present in the vaccine to induce the proper response. This cELISA could therefore be used as an initial test of potency, such tests currently being absent from the reference quality control protocols. Further trials are required to determine whether there is a strict correlation between antibody levels, as assessed with this cELISA, and protection. Such trials would also be useful to determine the true sensitivity of the test, which is difficult to evaluate with serum samples collected in the field. Quality control is particularly important for vaccines, as the industrial product used is generated on a large scale and may behave differently from the original laboratory product for which efficacy was demonstrated ,30. The The newly formatted CCPP cELISA proved to be highly specific and robust. Localized prevalence studies confirmed that the prevalence of CCPP was high in the lowlands of East Africa, where goat-rearing is a key activity in rural communities. Prevalence studies in central Asia showed that some regions may still be CCPP-free, whereas others are clearly highly infected. These findings could lead to better control strategies, including the use of cELISA for the monitoring of vaccination campaign efficacy. Finally, this cELISA could be used as a surveillance tool in CCPP-free regions at risk of disease introduction, including all the regions bordering infected zones.Goat serum samples were collected in field studies carried out in various countries without ethics committees . Serum sampling was organized by the national veterinary services in accordance with local legislation. It included only blood sampling from the jugular vein, which is not considered to cause any animal pain.When CCPP vaccination was performed, notably in Ethiopia, the vaccines used were preparations that had already been authorized for market release in the country concerned, or vaccine preparations with similar constituents but at lower doses.OIE: World Organization for Animal Health; FAO: Food and Agriculture Organization of the United Nations; WHO: World Health Organization; ISO: International Organization for Standardization.The authors have no competing interests to declare. IDEXX Montpellier SAS is to produce and market this CCPP cELISA kit in the near future. CIRAD, acting as reference laboratory for CCPP for the OIE, is to control the conformity of every batch produced by IDEXX.AP developed the new kit, analyzed the serum samples and set up quality management at CIRAD. FTh coordinated the study and drafted the manuscript. FTa, SO, HW, SJ, CB, EC were responsible for selecting study areas and coordinated the serum sampling in France, Central Asia, Kenya, Ethiopia, vaccine control experiments and Mauritius respectively. SO, LMS, FTa, FP, AP provided critical feedback on the manuscript. KH, TT, MA, KT, IGN, MY, DM, MRJ, TY, MZS, NM, MH, GMZ, WS, HN, AMR participated in the study design in their respective countries and gathered epidemiological data on CCPP. All authors read and approved the final manuscript.


Few studies have examined how various lifestyle factors in midlife predict longevity, and none of these studies have examined the impact of physical fitness. The present study aimed to examine longevity in relation to smoking, overweight and physical fitness.We prospectively studied longevity (defined as reaching at least 85 years of age) in relation to smoking status, body mass index and physical fitness in 821 healthy men between 51 and 59 years of age. Of these, 369 were smokers, 320 were overweight, and 31 were obese. The associations were adjusted for age, systolic blood pressure and cholesterol level, using multivariate logistic regression analysis. Deaths were registered until the 31st of December, 2006. Physical fitness was measured as the total work performed in a maximal exercise tolerance bicycle test.252 men survived to the age of 85 years (30.7%). Smoking status was significantly and independently related to longevity; 37.2% of the non-smokers survived to the age of 85, and 22.8% of the smokers. Among non-smokers, overweight and physical fitness were significantly and independently related to longevity after adjustment for age, blood pressure and cholesterol level, but not among smokers. Among non-smokers with high physical fitness, 48.8% reached the age of 85 years, compared to 27.9% among non-smokers with low physical fitness.Lifestyle variables appear to be strong and independent predictors of longevity in initially healthy middle-aged men. The probability of longevity may be a useful concept when informing the general public about the benefits of a healthy lifestyle. Risk factors for mortality have been thoroughly examined in a large number of studies over the last three decades. Several prospective studies have provided evidence of how various lifestyle factors in midlife are linked to mortality in initially healthy subjects -3. Thus,Life expectancy is increasing in most industrialized countries, as is the number of people reaching the age of 85, a group often designated as the “oldest old”. Only a few prospective studies have addressed how lifestyle predicts the probability of surviving to the age of 85 or higher, hereafter denoted as longevity. In a study including 5820 Japanese-American middle-aged men without cardiovascular diseases and diabetes, non-smoking, normal weight and high grip strength were independent predictors of longevity ,5. CardiThe present study aimed to examine the associations between lifestyle factors in midlife and the probability of reaching the age of 85. The study was based on a cohort of initially healthy middle-aged Norwegian men constituting the Oslo Ischemia Study ,7,8.The study has a prospective cohort design with long term follow-up of mortality.The participants were recruited from five companies in Oslo, Norway, between August 28, 1972 and March 26, 1975. They were all male, both white- and blue-collar workers that were considered to be representative of the healthy, working male population of Norway. Healthy men, aged 40 to 60 years, were recruited based on a thorough evaluation of their company health records, which included annual or biannual health examinations. Exclusion criteria were known or suspected coronary or other heart diseases, advanced pulmonary diseases, diabetes mellitus, hypertension treated with drugs, advanced renal disease, liver disease, cancer and miscellaneous other diseases including neurological, muscular or joint diseases which would interfere with a planned exercise test. Furthermore, nobody was allowed to take drugs regularly. In total, 2341 employees fulfilled these criteria and were subsequently invited to take part in the study. 2014 of them (86 percent) accepted to participate and completed the study protocol.st of January 1951. Participants not found in the mortality register by December 31, 2006, were traced through another registry at Statistics Norway, and found to live in Norway at this date. Thus, our mortality data was 100% complete by December 31, 2006.Information about mortality until December 31, 2006, was obtained from the mortality registry of Statistics Norway. This registry contains information on all recorded deaths of Norwegian citizens living in Norway at time of death since 1Individuals born later than December 31, 1921, could not have reached the age of 85 by the year 2006, and were therefore not included in our study, remaining 821 study participants. Age at enrolment ranged from 51 to 59 years with a mean of 55.3 years (SD = 2.8).The study was approved by the Norwegian Social Data Services and the South-East Norway Committee for Medical Research Ethics. Approval to carry out and publish the study was given, knowing that a written consent from participants had not been obtained.The study protocol encompassed a comprehensive medical history, physical examination, a panel of blood tests (including a lipid profile), and a maximal exercise tolerance bicycle test , which wAn independent sample t-test was used to compare mean differences between smokers and non-smokers, whereas a chi-square test was used for the BMI categories. We used cross-tables and logistic regression analysis to investigate the associations between longevity (reaching the age of 85) and the independent baseline variables: age, body mass index, physical fitness, cholesterol level, systolic blood pressure, and daily number of cigarettes. Age, systolic blood pressure, and cholesterol level were modeled as continuous variables. BMI scores were categorized as normal (BMI < 25), overweight (BMI: 25–29.9) and obese (≥ 30). Physical fitness was categorized into tertiles. Daily number of cigarettes was recorded as 0, 1–9, and ≥10. Statistical analysis was performed separately for smokers and non-smokers.The results obtained from the regression analysis are presented as odds ratios with p-values and 95% confidence intervals.For each covariate in each multivariable logistic regression model, we checked collinearity by calculating the variance inflation factor (VIF) statistic . All VIFIn both the univariate and multivariate regression analysis we confirmed that the logits of the continuous variables were linear. For each multivariable model, interactions and model assumptions were inspected using Pearson- and Deviance-residuals as well as DIFBeta and the HAT matrix diagonal . No signA 5% significance level was used throughout. The models were computed with the use of the statistical package SPSS version 18.0.Baseline characteristics of smokers and non-smokers are presented in Table During follow-up, 252 of the 821 participants reached the age of 85. Smoking status was strongly and significantly related to longevity in the unadjusted analysis, and as well as after adjusting for age, BMI, physical fitness, cholesterol and blood pressure (Table Among non-smokers, low BMI and high physical fitness were significantly related to longevity, both with and without adjustment for confounders Tables  and 4. AAmong smokers, BMI was not significantly associated with longevity. High physical fitness was significantly associated with longevity in the unadjusted analysis, but not after adjustment Tables  and 4.Blood pressure and cholesterol level were not significantly associated with longevity among smokers or non-smokers when adjusting for age and life style variables Table .In our prospective study of healthy middle-aged men, we found that smoking, avoidance of overweight and high or medium physical fitness were strong and independent predictors of longevity. Overweight and physical fitness were significant predictors of longevity in non-smokers, but not in smokers. Further, avoidance of overweight was a predictor of longevity in the medium and high fitness group, but not in the low one. Similarly, the predictive effect of physical fitness was stronger among men with normal weight than among overweight men.Our findings confirm previous studies showing that cigarette smoking is strongly associated with reduced longevity, and that overweight is associated with decreased longevity in non-smoking men -6. The aThe importance of physical fitness in midlife is in agreement with previous studies showing that high grip-strength  and highIn our study, blood pressure and cholesterol level were not significantly associated with longevity. This is in contrast to studies on predictors of long-term mortality -3. HowevSmoking is associated with low BMI and high mortality . ControlStudies investigating the relationship between lifestyle and longevity will generally be complicated by the fact that some participants might have developed obesity , and chaStrengths of our study include that it is among the longest and most complete follow-up studies of initially healthy middle-aged men. Furthermore, physical fitness was measured in our study, as opposed to similar studies of longevity which typically rely on self-reported physical activity. This is important because self-reported physical activity may underestimate the relationship between physical activity and health outcomes .In most similar studies of overweight, obesity and their health consequences, BMI has generally been calculated from self-reported height and weight ,18. UsinIncreased BMI may be due to both increased muscle mass and increased body fat . As incrThe wide confidence intervals for the association between fitness and longevity illustrate the relatively low test power in our study. Thus, further studies with larger number of subjects reaching 85 years are needed to provide more precise estimates of this association.Lifestyle factors in midlife are strongly related to mortality. Our study shows the advantage of avoiding smoking and overweight, as well as being in good physical shape, in the sense of a greater probability of reaching at least 85 years of age. The prevalence of overweight and physical inactivity is increasing in high-income countries. This underlines the importance of informing the general population about the benefits of a healthy lifestyle. Increased probability of longevity may be easier to understand for the general public than reduced mortality rates.BMI: Body mass index.The authors declare that they have no competing interests.TH and LS analyzed and interpreted data, and worked together to draft the manuscript. JE conceived the study and revised the manuscript critically. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/831/prepub


The aim of this study is to establish a risk appraisal model for GDM by identifying modifiable factors that can help predict the risk of GDM in a large population of 2194 women living in Spain. They were recruited between 2009-2010 when screening for GDM was performed. Participants completed a questionnaire on socio-demographic, anthropomorphic and behavioral characteristics, and reproductive and medical history. A total of 213 (9.7%) women were diagnosed as having GDM. Age, pregestational body weight (BW) and body mass index (BMI), and number of events of medical, obstetric and family history were significantly associated with GDM. After logistic regression model, biscuits and pastries intake <4 times/week, red and processed meats intake <6 servings/week, sugared drinks <4 servings/week, light walking >30 minutes/day, and 30 minutes/day of sports at least 2 days/week, compared with opposite consumption, was associated with less GDM risk. Our study identified several pregestational modifiable lifestyle risk factors associated with an increase in the risk of developing GDM. This may represent a promising approach for the prevention of GDM and subsequent complications. Further intervention studies are needed to evaluate if this appraisal model of risk calculation can be useful for prevention and treatment of GDM. Gestational diabetes mellitus (GDM) has been defined for many years as any degree of glucose intolerance with onset or first recognition during pregnancy . AccordiBecause the prevalence of GDM is increasing in a similar way to the ongoing epidemic of obesity and type 2 diabetes in women of child-bearing age , understThe aim of this study is to establish a risk appraisal model for GDM by identifying modifiable factors that can help predict the risk of GDM in a large population of women living in Spain and target early intervention, at the time of screening for GDM, with the potential of preventing the development of or ameliorating GDM.Participants were recruited from women attending prenatal care at our Hospital during the years 2009-2010, at 24–28 weeks of gestation, when screening for GDM was performed. A total of 2194 women were invited to participate and gave their written informed consent. The study was approved by the Ethical Committee of the Hospital Clínico San Carlos and was carried out following the principles expressed in the Helsinki Declaration. Women were screened for GDM based on the two-step American Diabetes Association recommendations: at week 24–28 of gestation, women with no previous history of diabetes mellitus were assessed, after a 12-hour fasting and no diet restriction on previous days, via the O'Sullivan test (OS). When plasma glucose levels one hour after glucose load were ≥7.2 mmol/L (≥140 mg/dL), a further 100-gram OGTT was performed, and new glucose levels were measured while fasting and 1, 2, and 3 hours after the intake. GDM was diagnosed according to Coustan and Carpenter criteria.At enrollment, participants completed a questionnaire with supervision of a trained nurse. These questionnaires were used to gather information on sociodemographic, anthropomorphic and behavioral characteristics, and reproductive and medical histories. The following were stratified in a semiquantitative way: history of smoking habit , pregestational and gestational physical activity , and pregestational and gestational weekly intake of vegetables, salads, fruit, dried fruits, nuts, blue fish, whole wheat bread, legumes, skimmed dairy products, red and processed meats, sauces, sugared drinks and sodas, juices, biscuits, pastries, alcohol, coffee and water. This questionnaire has been previously reported , 10.Regarding medical history, three groups were analyzed: obstetric history, which included previous abortion, GDM and hypertension; personal medical history, which considered overweight, dyslipidemia, hypertension and altered glucose metabolism; family history, which grouped diabetes, obesity, dyslipidemia and hypertension. Answers were reorganized according to the number of events in each category, and the differences between the GDM and non-GDM groups were analyzed .IBM SPSS program version 19.0 was used for data processing. The relationship between the nonmodifiable factors age, pregestational weight, ethnicity, and personal and family past medical history, and the independent variable GDM, was assessed. The population's lifestyle habits were evaluated, and the chi-square test was used to investigate the existence of possible differences in their association to the characteristic of GDM/non-GDM.To analyze the effects of the different items of lifestyle habits, a generalized lineal model of binary logistic type was performed. The dependent variable was the diagnosis or not of GDM; reference category was taken as value 0, meaning non-GDM, whilst diagnosis of GDM was taken as value 1. Seventeen items were selected as predictors of GDM: ten related to pregestational intake of nutrients ; four regarding pregestational consumption of beverages ; three related to pregestational physical activity . For each of the previous indicators, intensity was graded according to an ordinary increasing scale with three category levels; low, medium, and high. Missing values were excluded from the analysis. A model of the principal effects of each of the factors considered was chosen, including the intercept. Hybrid method was selected to estimate the different parameters. Type III analysis was used because of the fact that the items considered do not follow any specific arrangement.To be able to refine and improve the interpretation of the results of the generalized lineal model of binary logistic type, an automatic lineal regression analysis of the model was elaborated. The characteristic of GDM was again considered the outcome, and all of the items previously referred to regarding lifestyle habits were taken as entry predictors. The option of automatic preparation of data was selected; this option may group some of the categories of the items so that the procedure's predictive capacity can be optimized.P ≤ 0.05), although it must be pointed out that the number of African and Asian women in the sample was small.Mean age of the pregnant women enrolled in the study was 31.35 years old [range 13–47]. Diagnosis of GDM was confirmed in 213 (9.7%) women . DiffereP < 0.001 in all cases). Independent samples of Mann-Whitney U Test used to compare the effect of these variables on the diagnosis of GDM showed significant differences between the GDM and non-GDM groups. However, some of these differences were not observed when comparisons according to the different ethnicities were made , sugared drinks (P = 0.035), and coffee (P = 0.022) were found. We observed a trend for differences in biscuits and pastries (P = 0.068) and lifestyle habits related to sports and light walking . Differences among the remaining factors were not found.When comparing distributions by pairs, the following significant differences were found: high intake of biscuits and pastries (>4/week), red and processed meats (>6/week), sugared drinks (>4/week), and coffee (>3/day), and low level of practice of sports (<2 days/week) and light walking (<30 minutes/day) was greater amongst GDM. Low intake (<2/week) of sugared drinks was greater in non-GDM.B = −0.423; P = 0.015); coffee = 2-3 times/day ; sauces = 2–4/week ; practice of sports = less than 2 times/week .Logistic regression model is shown in P = 0.118), red and processed meats <6/week (P = 0.017), sugared drinks <4/week (P = 0.146), coffee <3/day (P = 0.066), light walking <60 minutes/day (P = 0.310), and sports <2 days/week (P = 0.026). The corresponding odds ratio (OR) at 95% CI are represented in Automatic lineal modeling discarded all except the following factors: biscuits and pastries, red and processed meats, sugared drinks, coffee, light walking, and sports. The model reclassified the values as shown in The prevalence of GDM in different ethnic populations has been reported between 1 and 17.8% , 12. ThePrevious risk factors established for GDM, including prepregnancy BW and BMI, age and history of GDM , 15, werRegarding the distribution of eating habits, the results show that intake of certain foods can modify the GDM risk. Several published case-control and prospective cohort studies have examined associations of diet with GDM –21. TheyBy using generalized logistic regression and an automatic lineal regression model, we could identify the factors related to GDM. We could further analyze them according to age, weight or ethnicity. This stratification would not be possible for all of the items in the questionnaire because for some of the options data would be insufficient. To be able to assure the influence of these factors despite other circumstances such as age or ethnicity, our study population should be greater, allowing a greater number of women diagnosed with GDM.If we look at the results regarding coffee intake, although its association with type 2 diabetes has been widely studied , 23, theAnother emerging factor whose influence in GDM is being evaluated is physical activity. Previous data have described that this is one of the strongest predictors contributing to the inverse association to GDM , 25–27, Our study has some limitations that are worth mentioning. Firstly, data regarding information on sociodemographic anthropometric and behavioral characteristics was gathered via self-report in questionnaires. Although these were completed with supervision of a trained nurse, we cannot rule out possible imprecision of pregestational BW and misclassification of food frequency intake and lifestyle habits. This is a common bias in any nutritional epidemiological study, but we assume, however, that bias would occur in a constant and random way, especially because women were unaware of their GDM diagnosis at the time of assessment, and the resulting error would be minimized.Another possible source of bias is the differential reporting by participant subgroups. For example, women with higher BMI may tend to underreport their food intake, either globally or with specific foods, such as “junk foods.” This introduces a source of confounding that is difficult to account for statistically, although, again, we assume that the magnitude of the error is low, because women were unaware of the OGTT result.Instructions for women attending prenatal care for GDM screening were the same for all participants, all had no previous history of diabetes mellitus and all glucose determinations were made in the same laboratory. This avoids possible measurement errors and misclassification of GDM.The fact that information on lifestyle habits was reported to be “pregestational” allows a plausible temporal relationship between behavioral characteristics and GDM, which usually develops after the second trimester.In conclusion, promoting healthy lifestyle habits among women of reproductive age, such as moderate intake of coffee, low intake of biscuits and pastries, sugared drinks and red and processed meats, and regular physical activity, may represent a promising approach for the prevention of GDM and subsequent complications of children born from pregnancies affected by GDM. Moreover, if we know what a woman's pregestational lifestyle habits are before the screening for GDM, we can predict how the risk is modified, in relation to the population's prevalence. However, further intervention studies are needed to evaluate if this appraisal model of risk calculation can be useful for prevention and treatment of altered glucose metabolism during pregnancy. It is still unknown whether intervention in dietary habits and beginning an exercise routine before pregnancy results in GDM prevention. Further research and cost-effectiveness studies are warranted to establish the possible risk reduction and economic benefit.


Extant studies universally document a positive gradient between socioeconomic status (SES) and health. A notable exception is the apparent concentration of HIV/AIDS among wealthier individuals. This paper uses data from the Demographic Health Surveys and AIDS Indicator Surveys to examine socioeconomic inequalities in HIV/AIDS prevalence in 24 sub-Saharan African (SSA) countries, the region that accounts for two-thirds of the global HIV/AIDS burden.The relative and generalized concentration indices (RC and GC) were used to quantify wealth-based socioeconomic inequalities in HIV/AIDS prevalence for the total adult population (aged 15-49), for men and women, and in urban and rural areas in each country. Further, we decomposed the RC and GC indices to identify the determinants of socioeconomic inequalities in HIV/AIDS prevalence in each country.Our findings demonstrated that HIV/AIDS was concentrated among higher SES individuals in the majority of SSA countries. Swaziland and Senegal were the only countries in the region where HIV/AIDS was concentrated among individuals living in poorer households. Stratified analyses by gender showed HIV/AIDS was generally concentrated among wealthier men and women. In some countries, including Kenya, Lesotho Uganda, and Zambia, HIV/AIDS was concentrated among the poor in urban areas but among wealthier adults in rural areas. Decomposition analyses indicated that, besides wealth itself , urban residence  was the most important factor contributing to the concentration of HIV/AIDS among wealthier participants in SSA countries.Further work is needed to understand the mechanisms explaining the concentration of HIV/AIDS among wealthier individuals and urban residents in SSA. Higher prevalence of HIV/AIDS could be indicative of better care and survival among wealthier individuals and urban adults, or reflect greater risk behaviour and incidence. Moreover, differential findings across countries suggest that effective intervention efforts for reducing the burden of HIV/AIDS in the SSA should be country specific. Notwithstanding general improvement in health status worldwide, inequalities in health among different socioeconomic groups still remain one of the main challenges for public health . Extant Research showing socioeconomically disadvantaged groups, including women, are disproportionately affected by HIV/AIDS  suggest Several studies e.g., ,6,13-18),13-186,1Studies assessing the relation between SES (as measured by education) and HIV/AIDS prevalence in SSA, a region that accounts for two thirds of the global epidemic , show a Prior work also supports a positive relation between individual- and household-level wealth and HIV/AIDS prevalence across SSA countries ,24-26. HThe determinants of socioeconomic inequalities in HIV/AIDS are poorly understood. Socio-demographic factors such as age, gender, and marital status may be associated with levels of household wealth, as well as risk of HIV infection, and contribute to differences in prevalence of HIV/AIDS among SES groups. Age, for example, is associated with the accumulation of household wealth and risk of HIV infection ,26. Womefirst measured socioeconomic inequalities in HIV/AIDS within 24 SSA countries using the concentration approach. Second, since other factors  might explain the socioeconomic gradient in HIV/AIDS, we then used the decomposition property of the RC and GC indices to identify the factors that contribute to socioeconomic inequalities in HIV/AIDS prevalence.Previous work has measured the magnitude of socioeconomic inequality by comparing the prevalence of HIV/AIDS at the extremes of the socioeconomic distribution. Unlike summary measures, such as the relative and generalized concentration (RC and GC) indices, that quantify inequality across the entire SES gradient , this apThe main source of data in this study is based on data collected through the Demographic Health Surveys programme in sub-Saharan African countries. The DHS programme has collected data from more than 85 low-and-middle-income countries (LMICs) around the world since 1984 . DHS surThe primary outcome of interest in the study, HIV/AIDS infection, was determined using confirmatory HIV antibody testing. We calculated socioeconomic inequalities in HIV/AIDS using a constructed wealth index provided in all DHS. The DHS employs a method proposed by Filmer and Pritchett  to constviz. voice and accountability, political stability and absence of violence, government effectiveness, regulatory quality, rule of law and control of corruption were used as measures of a country’s quality of governance  per capita  was used as an indicator of country-level socioeconomic status. The World Bank’s estimated Gini index and the Country Policy and Institutional Assessment (CPIA) gender inequality rating were used as measures of state-level income and gender equality, respectively. The CPIA gender equality indicator (1 = low to 6 = high) measures the degree to which a country has installed institutions and programs to promote gender equality in access to health, the economy, education and protection under law . The Wortors see ).We collected information on demographic, socioeconomic, behavioural and ecological determinants of HIV/AIDS, based on the relevant literature  concentration curve, quantifies the degree of socioeconomic inequality in a health-related outcome variable of interest. The concentration curve is obtained by plotting the cumulative share of the population, ranked in ascending order of SES , against the cumulative share of the outcome variable (i.e. HIV/AIDS). The RC index is twice the area between the line representing perfect inequality and the concentration curve. The “convenient regression” approach to compute the RC index can be formulated as follows :yi is the outcome variable of interest (i.e. HIV/AIDS) for individual i, μ is the mean of the outcome variable for the whole sample, ri = i/N, is the fractional rank of individual i in the distribution with i = 1 for the poorest and i = N for the wealthiest individual, and φ is the RC [φ provides an estimate of the standard error of the RC which is inaccurate. The Newey-West estimator [where s the RC . As the stimator  can be ustimator . The RC stimator . The valμ. In such cases the index can be normalized by multiplying the estimated index by 1/1 - μ. As the outcome variable in our study is binary, we used the normalized RC to quantify wealth-related inequalities in HIV/AIDS prevalence.Wagstaff  demonstrμ and reflects absolute, rather than relative, differences in health between socioeconomic groups. The generalized concentration curve is the standard concentration curve multiplied by the μ. It represents the cumulative share of population, ranked based on a socioeconomic factor, against the cumulative amount of health-related variable. The generalized (absolute) concentration index (GC) is defined as twice the area between the generalized concentration curve and the diagonal . The GC can be formulated as:The RC is attractive to those who are interested in relative differences in health outcomes between different SES groups. We can also generalize the concentration curve such that it becomes sensitive to variations in μ to μ, with zero indicating “no disparity” [The GC ranges from -sparity” .The RC and GC do not take into account the contribution of demographics (unavoidable factors) to overall socioeconomic inequalities in health. Thus, using the direct standardisation approach  we correWe estimated a summary measure of socioeconomic inequality in HIV/AIDS prevalence across sampled countries by ranking countries based on their GDP per capita and estimating the RC and GC. We measured wealth-related inequalities in HIV/AIDS prevalence by gender and place of residence to examine gender and urban/rural differences in the association between socioeconomic status and HIV/AIDS prevalence. A method suggested by Altman and Bland  was usedTo examine patterns of socioeconomic inequalities in HIV/AIDS prevalence, in a framework similar to , we alsoy, to a set of k explanatory factors, xk, such as:A decomposition technique was employed to quantify and compare the extent to which observed determinants of HIV/AIDS, such as education, age, gender, and marital status, contributed to the socioeconomic inequality in HIV/AIDS in each country. Suppose we start with a linear regression model linking our variable of interest, y can be decomposed into the contribution of factors which determine HIV/AIDS. They demonstrated that the RC index for y, can be formulated as:Wagstaff et al.  showed txk, RCk is the RC index for xk, and GCϵ is the generalized concentration index for the error term defined as ri is the fractional rank of the ith person in the relevant distribution [xk across wealth groups [RC index yields:where ribution . The resh groups . Using tThe decomposition of the generalized concentration index can be written as:GCk indexes the generalized concentration index for the determinant k. According to Equation 6 the extent of the contribution of each factor (xk) to the GC in HIV/AIDS prevalence depends on the βk and GCk. A factor that influences the probability of HIV/AIDS and is distributed unequally by wealth can contribute to socioeconomic inequality in HIV/AIDS prevalence.where A limitation of this decomposition approach is that it only works with linear models. Thus, although it is preferable to use a non-linear estimator in our application because our outcome is binary variable, we employed a linear probability model (LPM) in the analysis. Some approaches have been proposed to address the issue . These mTable As illustrated in Figure Table Within countries HIV/AIDS prevalence was concentrated among the socioeconomically advantaged, based on household wealth, in the majority of SSA countries. Swaziland and Senegal were the only countries with negative RC/SRC and/or GC/SGC. Results of the RC/SRC suggested that the relative concentration of HIV/AIDS prevalence among the better-off was higher in countries such as Ethiopia, Burkina Faso, Sierra Leon, Liberia, Niger, and Congo Democratic Republic, whereas the absolute concentration of HIV/AIDS among wealthier individuals was greatest in Zambia, Mozambique, Malawi, Ethiopia, Lesotho, and Tanzania. Although, the calculated RC/SRC and/or GC/SGC generally suggested similar patterns of socioeconomic inequality in HIV/AIDS within countries for men and women, the concentration of HIV/AIDS prevalence among individuals from wealthier households was greater for women than for men  showed the opposite pattern. Greater educational attainment (i.e. secondary and above) was associated with higher probability of being HIV positive in Cameroon, Ghana, Zambia, and Zimbabwe; this association was negative in countries such as Senegal, Swaziland, and Tanzania. Compared to agriculture workers, individuals with other occupations had higher prevalence of HIV/AIDS in Liberia, Malawi, Rwanda, Uganda, and Zambia, but lower prevalence in Sao Tome & Principe and Swaziland.Multiple partners and early sexual activity were positively associated with HIV/AIDS in some countries. For example, number of sexual partners was positively associated with HIV/AIDS in Ghana, Malawi, Niger, Swaziland, and Zimbabwe. Additionally, younger age of first sexual experience was associated with the probability of being HIV positive in Ghana, Malawi, Sao Tome & Principe, Senegal, Sierra Leone, Tanzania, Uganda, Zambia and Zimbabwe. Results also showed that residing in urban areas was associated with higher probability of being HIV positive in most SSA countries.RCk and GCk, for all explanatory variables included in the decomposition analysis. A positive value of the RCk and GCk indicates that variable xk is concentrated among socioeconomically advantaged individuals, and vice versa. Results of the RCk and GCk suggest that individuals who were never married, reported completion of secondary school, worked in white collar occupations, had sexual partners outside their marriage and resided in urban areas were relatively wealthier in all countries studied.Table βk × GCk/(μ - μ2) and βk × GCk/1 - μ, respectively. The “contribution” indicates how much of the association between wealth and HIV/AIDS in each country is explained by variation in a given explanatory factor among different socioeconomic groups. A positive contribution of a given factor to the RC and GC suggests that the socioeconomic distribution of the factor and the association of the relevant factor with HIV/AIDS contribute to a greater prevalence of HIV/AIDS among wealthier respondents and vice versa.Based on the regression coefficients and generalized concentration index of each explanatory variable, we measured the contribution of each factor to the overall RC and GC as Figure Apart from wealth, urban residence increased the absolute and relative concentration of HIV/AIDS among wealthier individuals in the majority of countries. According to the decomposition results of the RC and GC for the total population, the median percentage contribution of urban residence to wealth-based inequality in HIV/AIDS across the 24 countries was 54% (IQR = 81%). In general, occupation status also contributed to the concentration of HIV/AIDS among the better-off. The education factor increased the concentration of HIV/AIDS prevalence among poorer individuals in Swaziland and Lesotho. This factor, however, increased the concentration of HIV/AIDS among the rich in Cameroon. Sexual behaviours, in general, did not contribute significantly to observed SES inequalities in HIV/AIDS in SSA countries.We used data from the DHS and AIDS Indicator Surveys to measure inequalities in HIV/AIDS prevalence in 24 SSA countries. The generalized concentration index was used to quantify and decompose wealth-based inequalities in HIV/AIDS for the whole population, for men and women, as well as for urban and rural regions in each country. Our results suggested that HIV/AIDS is more prevalent among relatively wealthier countries and individuals in the SSA region. Separate analysis by gender also showed HIV/AIDS was concentrated among wealthier men and women in the majority of countries. These results confirm the findings of recent studies ,24,55,56per se, urban residence was the most important factor contributing to the relative and absolute concentration of HIV/AIDS prevalence among the better-off. Urban residents were wealthier than their rural counterparts .Contribution of each factor to the relative inequality of HIV/AIDS prevalence in SSA region (detailed results). Click here for file


Although maternal and infant mortality has been reduced in China over the past several years, the country is still facing big challenges in reproductive health (Fang and Kaufmann 2008). In 2001, the prevalence of birth defects reported in China was higher than that in most developed countries , and theOne possible contributor to the reproductive health burden in China may be environmental pollution. The most populous country in the world, China has under-gone rapid economic develop-ment during the past 30 years. Nevertheless, this success also increases energy use and industrial waste, resulting in severely polluted air and water. Air quality in China is among the worst in the world, with air pollution levels in many cities well above permissible limits, and half of the water resources in China are considered too polluted for human use . Many inSurveys in China have shown associations between environmental pollution and reproductive health, and specific environ-mental pollutants have been correlated with increased prevalence of reproductive damage. For example, polychlorinated biphenyls (PCBs) were used mainly in eastern and central China; in a survey of birth defects in China, o,p-dichloro-diphenyl-trichloro-ethane , and α-hexa-chloro-cyclo-hexane , including pesticides, heavy metals, phthalates, and PAHs, are suspected risk factors for infertility . DecliniChild growth and development are also serious health concerns in China. In a national survey by the Chinese Medical Association during 2003–2005, 19.6% of 20,654 girls had evidence of breast develop-ment at 8 years of age (among the earliest recorded worldwide), and the median age of menses was 12.27 years—1.23 years earlier than in 1979 . EarlierChildhood and adolescent overweight and obesity are also becoming problems in China. Data from the China Health and Nutrition Survey showed that the prevalence of over-weight for school-children and adolescents doubled from 1991 to 2004, increasing from 6.5% to 16.1% in children 6–11 years of age and from 3.3% to 6.2% in adolescents 12–18 years of age . In epidThe annual gross domestic product (GDP) in China is predicted to quadruple by 2020, which could pose more serious environmental challenges to the country. Because of China’s high levels of environmental pollutants as a result of industrialization, reproductive health risks need to be assessed. There is a lack of comprehensive and persuasive reproductive health studies in China; thus, large epidemiological studies—especially prospective cohort studies— are needed to examine populations in highly polluted areas.China is taking more aggressive steps to support reproductive health research. Its unique family planning service network, established in 1978, has become a comprehensive vertical system for reaching villages and communities, which can be used in epidemiological studies. For example, China’s “Birth Defect Intervention Project,” which is based on this network, was launched by the National Population and Family Planning Commission of China in 1999 and is aimed at covering all cities nationwide. Furthermore, reproductive health research was listed as one of the priority items in China’s Long-term Science and Technology Development Program Outline for 2006–2020 . Even th


Urban slums in developing countries that are not recognized by the government often lack legal access to municipal water supplies. This results in the creation of insecure “informal” water distribution systems  that may increase water-borne disease risk. We evaluate an informal water distribution system in a slum in Mumbai, India using commonly accepted health and social equity indicators. We also identify predictors of bacterial contamination of drinking water using logistic regression analysis.Data were collected through two studies: the 2008 Baseline Needs Assessment survey of 959 households and the 2011 Seasonal Water Assessment, in which 229 samples were collected for water quality testing over three seasons. Water samples were collected in each season from the following points along the distribution system: motors that directly tap the municipal supply , hoses going to slum lanes, and storage and drinking water containers from 21 households.E. coli and 76% for coliform bacteria. In the multivariate logistic regression analysis, monsoon and summer seasons were associated with significantly increased odds of drinking water contamination.Depending on season, households spend an average of 52 to 206 times more than the standard municipal charge of Indian rupees 2.25 (US dollars 0.04) per 1000 liters for water, and, in some seasons, 95% use less than the WHO-recommended minimum of 50 liters per capita per day. During the monsoon season, 50% of point-of-source water samples were contaminated. Despite a lack of point-of-source water contamination in other seasons, stored drinking water was contaminated in all seasons, with rates as high as 43% for Our findings reveal severe deficiencies in water-related health and social equity indicators. All bacterial contamination of drinking water occurred due to post-source contamination during storage in the household, except during the monsoon season, when there was some point-of-source water contamination. This suggests that safe storage and household water treatment interventions may improve water quality in slums. Problems of exorbitant expense, inadequate quantity, and poor point-of-source quality can only be remedied by providing unrecognized slums with equitable access to municipal water supplies. In 2004, the World Health Organization (WHO) and UNICEF estimated that 961 million urban dwellers worldwide must gain access to an improved water supply by 2015 to achieve the Millennium Development Goal of halving the proportion of people without access to safe water -7.As of 2011, India is estimated to have a slum population of approximately 93 million people . ApproxiIn this paper, we evaluate an informal water distribution system in Kaula Bandar (KB), a non-notified slum in Mumbai, using the following commonly accepted health and social equity indicators: cost of water, quantity of water consumed at the household level, microbiological and chemical quality of water, and residents’ opinions of hardships associated with water access . For eacKB is a non-notified slum of approximately 10,000 people located on a wharf on Mumbai’s eastern waterfront. Like other slums, living spaces consist of shanties built of corrugated metal, wood, and cement. Only 3% of homes have a latrine inside. As a result, the vast majority of children and 14% of adults engage in open defecation, while the remainder of adults use a handful of pay-for-use toilets in the community or travel long-distances to access pay-for-use toilets outside of the slum . KB is lThe sources of KB’s water supply are two underground pipes that were installed decades ago by the fire department for emergency use. Water vendors, nearly all of whom are residents of KB, have created entry points in the fire brigade pipes from which water is extracted using motorized pumps. Water is then pumped through rubber hoses that extend hundreds of meters to reach community lanes. Given the absence of space on the main road of the community and the lack of underground piping infrastructure, the hoses travel through the surrounding ocean and trash dumps and are often visibly compromised by holes. Tracing each vendor’s water distribution area  formed the basis for sample selection in the SWA, as is described further below.Within each household, water is stored in two types of containers. Large plastic drums with capacities of 100 to 300 liters are placed outside the home and hold “storage water,” which is used for bathing, toileting, and washing clothes Figure . NotablyKB’s informal water distribution system is vulnerable to widespread failure. Local officials  occasionally raid and confiscate motors tapping into the fire brigade pipes, cutting off water access to KB’s residents. Such episodes of “system failure” occur a few times a year. When this happens, most KB residents roll large storage drums at least one kilometer, and as far as two kilometers, to access taps in the next closest community, while others get water from private tankers.The water vendors who run the informal water distribution system incur significant costs to maintain the system, all of which are passed on to community residents who purchase this water. For example, based on interviews with multiple water sellers, we estimated that they pay Indian rupees (INR) 15,000 to 20,000 for a new motorized pump (used for extracting water from underground pipes), which is US dollars (USD) 273 to 364. A used motorized pump costs INR 10,000 to 12,000 (USD 182 to 218); however, these require frequent repair every few months, which generally costs INR 500 (USD 9) per repair. When local officials confiscate motorized pumps every few months, water vendors pay bribes of INR 500 to 1000 (USD 9 to 18) to get motorized pumps back, though they are often unable to get the pumps back and are forced to buy new ones. The rubber hoses used to distribute water to community lanes cost INR 5000 (USD 91) per 100 meters, and a few hundred meters of hose are often required to provide water to community lanes from each motorized pump. Finally, each water vendor usually hires one or two other people to facilitate water distribution, and these individuals are remunerated by receiving free water.The BNA is a 92-question household survey covering five domains: income and assets, access to government benefits, access to education, access to water and sanitation, and common causes of morbidity. Only the water-related data are reported here. The survey was implemented from August to December 2008 by a group of 15 uniformly trained interviewers. The questionnaire was administered to a head of household greater than 18 years of age after receiving written informed consent. Since men in KB work long hours outside of the home, 71% of respondents were women.Researchers coded every living space in KB. Every occupied household was requested to answer the questionnaire at least once during the study period. Due to migrancy, many households were empty and locked at any given time. Out of 2,439 total living spaces, 900 were permanently locked with no identifiable occupants. Of the remaining 1539 occupied households, 959 responded to the survey, yielding an estimated 37.7% non-response rate. This relatively high non-response rate is attributable to the long work days of many adults, who return home at hours when the community is not safely accessible to researchers.The SWA evaluated microbiological and chemical quality of water, quantity of water used, and cost of water during four study periods: winter (February 2011), summer (early May 2011), monsoon (August 2011), and an episode of “system failure” in late May 2011 (see above), when KB residents had to seek out alternative water sources. This seasonal design originated from findings of prior studies ,13 and fResearchers uniformly trained in sterile technique collected water samples in autoclaved bottles from many points along the informal distribution network. These points included: three motorized pumps that extract water from fire brigade pipes , six hoses that transport water from the three pumps to lanes in KB , and three randomly selected households supplied with water by each of the six hoses . An additional point-of-source sample was collected from a household with a tap that directly accesses a fire brigade pipe. Since some households buy water directly from this tap , three such households were also selected for water collection, bringing the total household sample size to 21 Figure . The samFor comparison to KB point-of-source samples, control point-of-source tap water samples were obtained from chawls (low-income housing) and from Dharavi, a notified slum with legal water access Figure . During E. coli, and chemical parameters, as per protocols recommended by the American Public Health Association and the Indian Standards Chemical Division Council [All 229 water samples were transported to Equinox Labs, which is certified by the International Organization for Standardization (ISO 9001:2008) and the National Accreditation Board for Laboratories (NABL), within four hours of collection. Equinox Labs performs external quality testing by cross-checking multiple samples with five other NABL certified labs at least once a year, and internal quality checks for water testing are carried out on a daily basis. Samples were tested for total coliform counts,  Council .°C for 24 hours, at which time coliform bacterial colonies were counted using an automated colony counter. E. coli was reported as being present or absent after interpretation of indole, methyl red, Voges-Proskauer, and citrate tests.The chemical parameters tested included pH , total dissolved solids , turbidity , total hardness , calcium , magnesium , and sulphates . Given the fact that water from the motorized pumps and distribution hoses in KB is at risk for contamination with ocean water, we also tested these samples in the winter season for salinity . Microbiological testing was performed as follows: 100 mL of each sample were filtered through a 0.22-micron, 47 mm diameter membrane using a vacuum pump. The filter was subsequently transferred to an m-Endo agar plate for culturing. Samples were incubated at 35In addition to water sample testing, in all four study periods, researchers administered questionnaires to an adult older than age 18 in each of the 21 households. Since questionnaires were administered around the time of water collection, they were usually administered to the adults who most commonly interact with water vendors and who therefore were most likely to provide accurate information on water spending. The questionnaire assessed common health and social equity indicators, specifically monthly and weekly water charges and quantity of water used in the last week -17: grosQuantity of water used was assessed through a detailed inventory of every drinking and storage water container in each household. Prior to starting data collection in the field, researchers were uniformly trained to recognize the volume of water held by containers of various sizes and shapes commonly used to store water in the community. In each household surveyed, researchers carefully estimated the capacity in liters of each container and the number of times it had been filled in the last week. These numbers were tabulated to estimate the total amount water used in the last week by each household.E. coli) and other drinking water and container characteristics  Institutional Ethics Committee, which is registered under federal-wide assurance number FWA00016911.We summarize findings from the BNA and SWA according to the following categories: water costs and hardships, water quantity, water quality and storage, environmental exposures, and residents’ opinions on water access.Table Based on income data for 521 households from another study , we estimate the mean monthly household income in KB to be INR 6411 (USD 116.56) . Using tA 2010 PUKAR census of KB found a population of approximately 10,000 people and an average household size of 4.8 people. Using these figures, we calculated the approximate yearly amount spent on water by the entire community to be INR 13,498,083 . We compared this cost to an ideal scenario in which all 10,000 residents receive the WHO-recommended minimum of 50 liters per capita per day (l/c/d) of water for every day of the year at the standard government charge of INR 2.25 (USD 0.04) per 1000 liters. In such an ideal scenario, the entire community would spend INR 410,625  on water yearly.This suggests that residents spend an excess amount of INR 13,087,458  yearly on water in the current informal system. We compared this excess amount to the cost of placing comprehensive water infrastructure in KB (in the form of a new pipeline with community taps), which is INR 2,500,000, or approximately USD 45,455.00 . Based on this figure, the excess amount spent on water under the informal system could pay for entirely new water infrastructure in KB more than five times every year.The BNA provides additional data on water-related hardships. In the BNA, 952 households (99.3%) report having to regularly purchase water. The majority, 529 (55.2%), are only able to access water every three or more days Table . Most ho2 = 0.329), total money spent on purchasing water was positively associated with the quantity of water consumed , while the cost of water in INR per 1000 liters was negatively associated with the quantity of water consumed .Data from the SWA show that, in different seasons, 81-95% of households do not meet the WHO recommendation that all human beings use a minimum of 50 liters per capita per day (l/c/d) of water , do not use any method of water purification, while 25.8% use a cloth filter and 17.2% boil their drinking water prior to consumption Table . Of noteTable E. coli contamination of any of the point-of-source samples from the two comparison groups, chawls (low-income housing) and Dharavi . In winter and summer, none of the water samples collected from KB’s motorized pumps (which represent the point-of-source) or from KB’s hoses (which represent the distribution network) showed any evidence of contamination with coliforms or E. coli. Despite the absence of bacterial contamination of water at the point-of-source or in the distribution network of hoses in KB, there was significant contamination of drinking water and storage water at the household level . For example, in the summer, 52.4% of drinking water samples were contaminated with coliform bacteria, and 42.9% were contaminated with E. coli. This suggests that all bacterial contamination of water during the winter and summer was happening at the household-level  and not at point-of-source or in the distribution hoses.During winter and summer, there was no coliform or E. coli. Again, despite receiving uncontaminated point-of-source water, 23.8% of drinking water samples were contaminated with both coliform bacteria and E. coli.During the episode of “system failure,” the pattern of water contamination was similar to the pattern in the winter and summer seasons, in that all contamination of water happened at the household level. The Reay Road tap, which represents the point-of-source for water during the episode of “system failure,” was not contaminated with coliform bacteria or E. coli and coliforms. Two samples from KB’s motorized pumps (50.0%) were contaminated with coliforms but not E. coli, highlighting significant point-of-source contamination of water in KB in the monsoon season. During the monsoon, three hoses (50.0%) were contaminated with coliforms and one (16.7%) was contaminated with E. coli. Of note, all three of these contaminated hoses were connected to the motors in KB that showed evidence of contamination with coliform bacteria, suggesting that the water in these hoses became contaminated at the point-of-source and not secondarily as it ran through the distribution hoses. During the monsoon, at the household level, there was a very high rate of contamination of drinking water and storage water, with 76.2% of drinking water samples being contaminated with coliform bacteria. Of note, 75.0% of these contaminated drinking water samples were from households receiving water from uncontaminated distribution hoses. This suggests that, even in the monsoon, when there was significant point-of-source contamination of water, there was also superimposed household-level contaminated of stored drinking water at the point-of-use.In contrast, during the monsoon season, we found multiple point-of-source samples to be contaminated. In the comparison groups, there was no contamination of any point-of-source samples from Dharavi, but one sample (25.0%) from the chawls was contaminated with both E. coli contamination of drinking water . During winter season, we also specifically tested the point-of-source water samples  as well as the KB hose samples for salinity levels, given the risk for ocean water contamination of KB motor and hose samples. All of these samples had salinity levels of approximately 0.017 to 0.021 dS/m, which is well within the normal limit for human consumption of 0.8 dS/m.E. coli and 6/6 testing positive for coliform bacteria.In the BNA, 414 households (43.2%) reported flooding in their locality during the monsoon, while 291 (30.3%) reported flooding with waterlogging of their own homes during monsoon. Based on researchers’ observations, most flooding occurs during high tide in homes adjacent to the ocean, where most open defecation also takes place. Ocean water collected during the SWA was highly contaminated in all seasons, with 5/6 samples testing positive for Table Our findings have implications for future research and interventions that may improve water security in urban slums, especially in India where an estimated 50% of slums are non-notified communities that are frequently excluded from municipal water supplies. With regard to water quality, bacterial contamination occurred at two key points: in point-of-source water from KB pipelines during the monsoon season and in household level stored drinking water during all seasons. Household level water contamination was especially notable in the winter and summer, given the lack of point-of-source water contamination in those seasons. Even in the monsoon, when half of point-of-source water from motors was contaminated, most contaminated drinking water samples were from households that had received clean source water, suggesting superimposed household level contamination.Our finding on the importance of household level contamination is similar to results of studies from other urban slums ,16,20. IOur data also highlight seasonal variations in contamination, with summer and monsoon having higher contamination rates than winter. The higher contamination rate in monsoon is partly attributable to point-of-source water contamination, though augmented household level contamination from ambient fecal matter due to flooding of homes is likely another major contributing factor. The higher contamination rate in summer may be due to frequent accessing of water containers due to heat-related body fluid losses.The finding of seasonal variation in contamination rates may have practical implications for interventions. Given higher rates of vector and water-borne diseases in the monsoon , many municipal health departments in India, including Mumbai’s, dedicate resources in this season for public education campaigns. Public education on household water treatment could be paired with these larger campaigns in a cost-effective manner. Seasonal chlorination may be especially beneficial given the presence of point-of-source contamination during the monsoon, which is not addressable solely by switching to safe storage containers. Some studies question the sustainability of household chlorination of water, since changes in taste may decrease long-term adherence . EncouraWhile this study highlights household level issues, it also highlights major structural problems with KB’s core water supply that are probably more detrimental to health and social equity outcomes, given their impact on water quality, quantity and cost. Contamination of point-of-source water samples during the monsoon season is a case in point. Such point-of-source contamination likely reflects adulteration that occurs due to backflow of dirty water into the corroded fire brigade pipes that are the community’s primary water source. Since water is only provided to KB’s area for a couple of hours a day, there is no water pressure in these fire brigade pipes for most of the day. The absence of pressure in these pipes leaves them vulnerable to backflow from adjacent leaking sewer lines or from above-ground flooding, which is common during the monsoon season. One study suggests that point-of-source water contamination may be more detrimental to health than household-level contamination, since contaminated point-of-source water introduces new pathogens against which people are unlikely to have immunity .In addition, the failure of the informal water distribution system to provide an adequate per capita quantity of water is another major structural problem. Use of an inadequate quantity of water may be as detrimental to health as poor water quality . A consiCost of water was a significant predictor of inadequate water consumption, which is not surprising given the extremely high cost of water in KB compared to the standard municipal rate. In addition, delivery of an inadequate volume of water for the population’s needs, the absence of community taps, limited water delivery timings, and long lines at water collection points may explain the low levels of water use. Periodic failures of the informal distribution system (as captured by our data collected during “system failure”) also introduce huge variability and escalation in the cost of water, as well as being a major cause of chronic stress and emotional distress .Since point-of-source quality and quantity of water used are functions of these structural issues, these problems can only be remedied by providing equitable access to the municipal water supply, including a new pipeline, public water taps, and improved water provision timings. Furthermore, most remedies may provide only partial benefit unless piped water is provided directly to individual homes, as this is the only intervention that would obviate the need for in-home storage of water. Indeed, data suggest that provision of direct water connections to individual households decreases diarrheal morbidity much more than improving water quantity and access through public water taps alone .The current informal distribution system exacts a massive economic toll: KB’s residents spend 8.4% of their yearly income on water, and the excess amount paid for water by the entire community could pay for comprehensive water infrastructure in the slum five times over every year. In addition to saving money for residents by lowering water costs, new water infrastructure would generate revenue for the municipality, as most residents are willing to pay for improved water access. Citywide data show that Mumbai’s operating ratio  is 0.49, suggesting that the municipality generates twice as much revenue supplying water as it spends on operating costs .In summary, extending formal water infrastructure to slums such as KB would be a “win-win” situation for everyone. It would improve quality of life, reduce water costs, and improve health outcomes for slum dwellers while also decreasing waterborne disease burden in municipal hospitals, generating revenue for the municipality, and decreasing conflicts between the government and slum residents . If widely applied, a policy of extending water access to non-notified slums would also facilitate meeting the Millennium Development Goal for water in urban India .One limitation of this study is the relatively small sample of households chosen for the seasonal assessment of per capita water consumption and water quality. Future community-based studies with larger sample sizes may help to reinforce our findings, especially with regard to seasonal variations in water quality. In addition, our data on the economic costs borne by community residents only reflect the high cost of obtaining water under informal circumstances. The lack of an adequate quantity of uncontaminated, potable water likely exacts additional costs by greatly increasing the burden of diarrheal, upper respiratory, helminthic, and skin diseases. These diseases may take an economic toll on households by contributing to lost days of work, increased spending on medications, increased health care provider visits, and decreased productivity . Indeed,This paper highlights major failures in the quantity, quality, and reliability of water provided through an informal distribution system in a non-notified slum in Mumbai. While we have presented data from a single slum community, we would argue that this case study sheds light on similar situations faced by a significant proportion of urban dwellers in India and other cities in developing countries, and such circumstances may get worse in the context of rapid urbanization. Approximately half of urban slums in India are non-notified , making it extremely difficult, if not impossible, to access formal municipal water supplies . In the In circumstances where household storage of water is unavoidable, our water quality findings suggest a beneficial role for household-level interventions, including provision of narrow-mouthed safe storage containers and chlorination. More crucially, our findings regarding point-of-source quality, quantity of use, and cost of water highlight the need for equitable access to the municipal water supply to improve the water situation in KB. Since KB’s lack of formal water access arises from its legal status as a non-notified slum, transformation of this situation will not happen without confronting larger questions of social exclusion, social justice, and urban governance. The critical importance of connecting communities such as KB to the formal municipal water supply cannot be overstated. Indeed, this may be the only way to ensure that residents of marginalized slums can attain universally accepted minimum health and social equity standards for this most fundamental of human needs.BNA: Baseline needs assessment; INR: Indian rupees; KB: Kaula Bandar; l/c/d: Liters per capita per day; PUKAR: Partners for urban knowledge action, and research; SWA: Seasonal water assessment; WHO: World health organizationThe authors declare that they have no competing interests.RS made contributions to the study design, data collection, interpretation of data, and drafting of the manuscript. SS, TS, and KS contributed to the study design, data collection, interpretation of the data, and critical revision of the manuscript. JO contributed to the study design, statistical analysis, interpretation of data, and critical revision of the manuscript. DEB contributed to study design, interpretation of data, and critical revision of the manuscript. APD contributed to study design, data collection, interpretation of data, and critical revision of the manuscript. All authors read and approved the final paper.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/173/prepub


Tree nuts are rich in macro and micronutrients, phytochemicals, tocopherols and phenolic compounds. The development of nut spreads would potentially increase the food uses of nuts and introduce consumers with a healthier, non-animal breakfast snack food. Nut spreads are spreadable products made from nuts that are ground into paste. Roasting and milling (particle size reduction) are two important stages for the production of nut spreads that affected the textural, rheological characteristic and overall quality of the nut spread. Textural, color, and flavor properties of nut spreads play a major role in consumer appeal, buying decisions and eventual consumption. Stability of nut spreads is influenced by its particle size. Proper combination of ingredients  is also required to ensure a stable nut spread product is produced. Most of the nut spreads behaved like a non-Newtonian pseudo-plastic fluid under yield stress which help the producers how to start pumping and stirring of the nut spreads. Similar to other high oil content products, nut spreads are susceptible to autoxidation. Their oxidation can be controlled by application of antioxidants, using processing techniques that minimize tocopherol and other natural antioxidant losses. In general, tree nuts are dry fruits with one seed in which the outer wall becomes hard upon maturing. The most popular tree nuts in the world are almond, Brazil nut, cashew, hazelnut, macadamia, pecan, pine nut, pistachio and walnut. Considering the production of world’s most popular tree nuts, cashew nut ranks first on a global basis with a production of 2,760,000 MT, followed by almond , walnut , Brazil nut , pistachio  and hazelnut  in 2010. The production of remaining tree nuts  was around 1.85 MT in the same year [1) level of nuts increased to more than the maximum allowance level, the nuts cannot used by the consumers. There are some reports of rejection of exported nuts due to aflatoxin levels [The consumption of nuts in roasted and salted form is limited. Children and elderly people cannot easily open the nuts (such as pistachio) and consume them. Another problem after processing and before consumption of nuts is their storage and handling which influence the quality of the product. There are many reports about presence of mycotoxins, especially aflatoxin in nuts –11. Incrn levels ,14. DeveThe term “nut butter” refers to a product that contains at least 90% nut ingredients whereas, the term “nut spread” refers to a spreadable product having at least 40% nut ingredients, which can be added in various forms, e.g., as nuts, a paste and/or a slurry ,16. Nut In general, the quality of nut spreads depends on the formulations used .There is a wide variation in the quality of nut spreads as many types of ingredients can be used for the production of spread. Proper combination of these ingredients during production is required to ensure a stable nut spread product. The basic formulation of nut spread usually contains the following ingredients: (a) selected, blanched, dry roasted nuts; (b) sweeteners; (c) vegetable oils; (d) emulsifiers; (e) protein sources; and (f) flavorings ,25.One of the famous nut spreads is prepared from peanuts. According to the USDA, peanut butter and peanut spread shall conform to the classification shown in Peanut spread is a paste made from ground roasted peanuts, with or without addition of oil. It is popular across the world and is produced in some emerging markets. It is used as a sandwich spread. Besides peanuts, other types of nuts can be used to make nut spreads –28. Nut et al. (2010) pointed out that the most suitable roasting temperature and time for macadamia nuts were 135 °C and 20 min, respectively [Raw nuts contain lipoxygenase, which accelerate the oxidation of damaged nuts . The lipectively .In contrast, the best roasting conditions for peanuts were at 180 °C for 45 min  or 160 °et al. (2007) [et al. (2008) observed that reduction in particle size of sesame paste increased the stability of the product [et al., in order to reduce the grittiness of peanut butters, the average particle size must be about 20 μm [et al. (1992) employed a series of colloid mills or homogenizer to obtain the desirable particle size and viscosity of peanut butters [Milling process is carried out to reduce the size of kernel for the production of pistachio paste. This step is critical in the production of nut spread because the particle size and particle distribution are important parameters that influence the overall quality of final product . Optimiz. (2007) ,49. Cift product . Another product . Accordiut 20 μm . Wong et butters . Accordi butters .The overall quality of nut spread is related to the quality of nut paste which is used as the main ingredient. The quality of nut paste is influenced by raw kernel quality, processing conditions such as roasting temperature and time, and storage conditions . Effortsin situ, or whether it will be difficult to start pumping or stirring. Good rheological product design will enhance processing and end use. Although many researchers have investigated the time-dependent rheological behavior of materials, in general, the thixotropic characteristics of many other foodstuffs in food processing are not extensively studied. Viscoelasticity is also one of the rheological properties of materials. In viscoelastic tests, the elasticity part is defined as storage modulus (G’), the viscosity part as loss modulus (G”) and ratio of G”/G’ as damping factor. Shakerardekani (2012) reported that storage modulus, loss modulus and damping factor for pistachio paste were 42943 Pa, 6370 Pa and 0.15, respectively [Rheology is the science of flow and deformation of materials under stress and strain. In the food industry, rheological data are needed for studying the functionality of ingredients in product development, determination of food texture by correlation to sensory data, immediate or final product control and process engineering calculation for equipment such as pumps, heat exchangers, extruders and mixers. Many semi solid food products are made of dispersions of colloidal sized particles such as solids or immiscible liquids and their polymers. The presence of these suspended particles and polymers may affect the stability and the rheology of the suspensions as a result of interactions between them. Several works on the rheological properties of semi solid pastes such as peanut butter  and pistectively . A rheolectively . All emuectively . The floectively ,75.et al. (2002) among important qualities of peanut butter include texture, color, flavor and nutritive value [et al. (1991) [A broad spectrum of sensory characteristics, including appearance, aroma, flavor, and texture are used by consumers to make purchasing and consumption decisions related to foods . Trainedve value . Textureve value . Spreadave value . Beside ve value . Flavor ve value . With a ve value ,82. Patt. (1991)  showed t. (1991) . Color i. (1991) . It can Lipid oxidation is initiated by compounds known as sensitizers which include heat, light and metal ions. Lipid oxidation produces undesirable flavors, aromas and compromises the nutritional quality of fats and oils leading to the production of toxic compounds . The chaet al. (2003) found that the addition of 1% (w/w) soy lecithin was effective in delaying the oxidation in rapeseed, soy, walnut, and palm oils by increasing the induction time by 1.7–1.8 times when measured at 110 °C and decreasing the peroxide values by 2.2–4.6 folds when heated at 40 °C for 35 days [The protective effects of various antioxidants on the oxidative stability of plant-derived oils and fats have been the subject of intense research, showing great potential to protect oils and fats against oxidation. The use of natural antioxidants and natural products has been widely studied by several researchers –97. Judd 35 days . Accordi 35 days . The oxi 35 days ,100,101.The main gaps in nut spread production are as follows:et al. (2005) investigated the effects of various additives such as palm oil, soy protein isolate, gelatin, lecithin, gum arabic, pectin, and ground sugar on oil separation in tahin helva (sesame spread) [Since most nut spreads are rich in oil, oil separation is one of the problems faced by this industry. The separated oil contaminates the packaging material and affected the quality and appearance of nut spreads . Stabili spread) . They fo spread) ,108.Prevalence of food allergy in the United States is about 6% in children (≤5 years) and 3.7% in adults . More thAflatoxin is one of the serious constraints in the marketing of tree nuts. Contamination of human foods and animal feeds by these compounds has become an important international food safety and trade issue since aflatoxins are considered to be potent carcinogens to humans ,111. ResSalmonella typhimurium in peanut butter led to a recall of over 3900 products by over 200 companies. More than 700 people became sick, 100 were hospitalized, and 9 people died from this outbreak [The ability of salmonella to survive in high fat content, low water activity foods like peanut butter has been demonstrated by large foodborne illness outbreaks in recent years . About 1outbreak . Using Toutbreak , high-proutbreak ,114 and outbreak  can reduRecently, much consumer attention has focused on those who follow reduced carbohydrates and fats or protein and vitamin fortified nut spreads. Low-calorie pistachio butter , milk-baNut spreads are spreadable products made from roasted nuts. In addition to the ingredients , the roasting conditions of nuts, particle size distribution and type and amount of stabilizer affected consumers acceptability, rheological behavior and oxidative stability of nut spreads. The oxidation of oils and fats can be controlled by application of antioxidants, using processing techniques that minimize tocopherol and other natural antioxidant losses. Recently, much consumer attention has focused on reduced carbohydrate and fat nut spreads. Although much of the literature has reported on nut spread production, most studies were related to peanut butter and peanut spread. It is recommended that further research be undertaken to develop other types of nut spreads with prolonged shelf life.