Kenya is a developing country in sub-Saharan Africa, facing a triple disease burden, with an increase in non-communicable diseases (NCDs); uncontained infectious diseases; coupled with significant morbidity and mortality from environmental causes such as droughts and flooding. The limelight has been on infectious diseases, leaving few resources for NCDs. As NCDs start to gain attention, it is becoming apparent that essential information on their epidemiology and risk factor trends—key in evidence-based decision-making—is lacking. As a consequence, policies have long relied on information derived from unreliable data sources such as vital registries and facility-level data, and unrepresentative data from small-scale clinical and academic research. This study analyzed the health policy aspects of NCD risk factor surveillance in Kenya, describing barriers to the successful design and implementation of an NCD risk factor surveillance system, and suggests a strategy best suited for the Kenyan situation. A review of policy documents and publications was augmented by a field-study consisting of interviews of key informants identified as stakeholders. Findings were analyzed using the Walt and Gilson policy analysis triangle. Findings attest that no population baseline NCD burden or risk factor data was available, with a failed WHO STEPs survey in 2005, to be undertaken in 2013. Despite the continued mention of NCD surveillance and the highlighting of its importance in various policy documents, a related strategy is yet to be established. Hurdles ranged from a lack of political attention for NCDs and competing public interests, to the lack of an evidence-based decision making culture and the impact of aid dependency of health programs. Progress in recognition of NCDs was noted and the international community and civil society's contribution to these achievements documented. While a positive outlook on the future of NCD surveillance were encountered, it is noteworthy that overcoming policy and structural hurdles for continued success is imperative. However, this action requires as a precursor, knowledge of the extent of the problem. Accurate data on the disease burden, risk factor profile and mortality and morbidity statistics from Kenya is scanty. Emphasis has for a long time been on infectious diseases; with underreporting, missed diagnoses, misdiagnosis, and misclassification of NCDs. Therefore, the actual extent of NCDs and their associated risk factors at population level remain largely unknown In recognition of a prevailing problem of a lack of accurate data and information on NCD mortality statistics and risk factor profiles from many countries, the global status report on NCDs 2012 urges the improvement of national-level surveillance and monitoring as a high priority agenda in the fight against NCDs, stressing that simple and sustainable systems can viably produce valuable data even in resource-poor settings Surveillance, defined as the “systematic collection and use of epidemiologic information for the planning, implementation, and assessment of disease control”, NCD risk factor surveillance, the first component of NCD surveillance, aims to provide a platform for systematic data collection on trends and emerging patterns of NCD behavioral and biological risk factors By the time of the start of this research (April 2013), no information was available on any attempt to undertake a survey on NCD risk factors in Kenya, nor on the existence of an NCD risk factor surveillance initiative or strategy. Kenyan policy makers alluded to the importance of a surveillance system in the country, most prominently at the First National Forum on Noncommunicable Diseases in 2011 Pursuant to this gap in information, this study was undertaken analyze the policy environment surrounding NCD risk factor surveillance in Kenya, attempting to identify and describe hurdles, if any, which have been barriers to the successful design and implementation of an NCD risk factor surveillance strategy.2.2.1.The study was a prescriptive analysis of policy case study of the Kenyan policy environment surrounding noncommunicable disease risk factor surveillance. Public health surveillance is a matter of public policy, and therefore, in attempting to understand the situation, a study of the policy environment surrounding NCDs was found to be the most tenable approach pursuant to this aim.Health policy, in this case “is assumed to embrace courses of action (and inaction) that affect the set of institutions, organizations, services and funding arrangements of the health system” The study was based on a policy analysis literature through review of the augmented by qualitative data collection amongst stakeholders.The study was designed based on the Walt and Gilson policy triangle Purposeful sampling was used to identify the relevant key informants. This was done by performing a thorough stakeholder analysis. Relevant organizations and institutions were identified, followed by the identification of the relevant offices within the institutions. The office holders were deemed to have influence, direct or indirect, to the policy process involved in NCD surveillance.Key informants in positions relevant to NCD risk factor surveillance were identified for interviewing from each of these groups.Snowball sampling was also used during the data collection process, with key informants explicating other offices, organizations or persons from whom relevant information could be attained.2.2.The field study entailed data collection through interviews guided by open ended, researcher administered questionnaires. The questionnaires were formulated based on the objectives, and were intended as a guide for obtaining the necessary information from the key informants.A thorough literature search was carried out to identify material for analysis. An initial search for information from official web pages representing the stakeholders was carried out, which aided in identification and at times access to policy documents, reports, releases and publications. Further documents not accessible online were requested for from the relevant offices.Further, keyword and mesh terms searches such as “noncommunicable disease risk factor surveillance”, “disease surveillance”, “NCD surveillance policies”, “health policy”, “policy analysis” were carried out on internet search engines, including Google and Google Scholar and on health research databases including PubMed, Elsevier, Science Direct and Web of Science. Press releases, newspaper articles and other unpublished grey literature were also used as necessitated.Data triangulation was achieved by augmenting the analysis of available literature and policy documents with stakeholder interviews, and theory triangulation done by application of various theoretical frameworks in the analysis of findings; to ensure validity of the research.2.3.The principal investigator conducted the field study between the dates of 20th April 2013 and 20th May 2013. Questionnaire guided interviews were conducted amongst the following key informants:Head of Non-Communicable Diseases Division, MoH, KenyaNon-Communicable Diseases Advisor to World Health Organization Country Office, KenyaThe immediate former Head of Non-Communicable Diseases Division, MoH, KenyaResearch Officer, Kenya Medical Research Institute, KenyaChair of Kenya Non-Communicable Disease Alliance and Chair of Kenya Cardiac Society, KenyaChairman, Diabetes Management & Information Centre, Nairobi, KenyaTeam Leader, Surveillance. Surveillance and Population-based Prevention Unit Prevention of Noncommunicable Diseases Department. World Health Organization Headquarters, GenevaThe interviews were recorded with a recording device with consent from the interviewees, who were assured of anonymity in the presentation of their responses and the highest reasonably attainable standard of discretion and confidentiality in the handling of information obtained and in the presentation of research findings.The data collected above was transcribed verbatim, and running themes were identified. As stated above, the Walt and Gilson Policy Triangle framework of policy analysis 2.4.Authority to conduct the study was obtained in writing from the Ministry of Health as granted by the office of the Director of Medical Services.Informed consent was also obtained verbally from each key informant after a thorough elaboration of the research background, in accordance with the provisions of the Declaration of Helsinki 3.The findings of this study confirmed that there were currently no comprehensive baseline data on NCD indicators such as incidence, morbidity and mortality and of risk factor patterns, based on any large scale survey or that is nationally representative.The Ministry of Health in Kenya has a Non-Communicable Diseases Division, which is staffed and currently has a budgetary allocation. There is no comprehensive NCD policy document; however, there are several disease specific strategies and guidelines, namely: Kenya Cancer Control Strategy, Diabetes Control Strategy and Treatment Guidelines and the Tobacco Control act. Other strategies are in the process of formulation, including an NCD action plan document, the national Non-Communicable Diseases Strategic Plan 2012–2017.A national NCD risk factor survey, utilizing the WHO STEPwise approach, was carried out in 2005, but the results of the survey were deemed inadmissible by the stakeholders and policy makers, and were therefore not published and have not been used to inform any decision making. The confirmation of a failed attempt at a survey was resounding throughout all the interviews, however, no records of this were available, therefore, the explanation behind the causes of failure varied from respondent to respondent, with some recurring themes.A repeat survey was proposed in 2009 and, according to information gleaned from the Kenya NCD Alliance office, the survey is tentatively set to be rolled out within the month of October 2014. This nation-wide household survey also utilizing the WHO STEPwise approach is being carried out by the Ministry of Health (MoH) in conjunction with the CDC, WHO and the Kenya Medical Research Institute (KEMRI).The analysis of the results was done in accordance to the Walt and Gilson Policy Triangle 3.1.The term “actors” denotes individuals and organizations (including the State) whose actions influence policy 3.2.This component refers to systemic factors—political, economic and social, both national and international—which affect health policy, and will be categorized according to a system proposed by Leichter 3.2.1.A disease surveillance system exists; however, it is limited to targeting diseases of “public health importance” and diseases for eradication and epidemic prone diseases, with no NCD coverage. The most successful of these is the HIV surveillance, which is done through continuous antenatal clinic data collection, augmented by five-yearly Kenya Demographics and Health Survey (KDHS), done in 1993, 1998, 2003 and 2008 A Division of Health Information System responsible for collection, collation and analysis of data from health facilities, research institutions, census and surveys exists in MoH. Under this division, a District Health Information Software (DHIS2), a web-based software, was created to electronically manage aggregated countrywide data Cancer registries reportedly exist in regions and large health facilities, and are hence unreliable as they are not representative. A diabetes registry was piloted but is yet to be rolled out nationally.The Kenyan healthcare system is grossly underfunded and unprioritized by the government and policy makers, a factor recounted by the key informants across the board as an umbrella problem overlying all that ails the system. The system, heavily funded privately through out-of-pocket payments and by donors, is decrepit and unsustainable. According to the National Health Accounts 2009/10, the total health expenditure (THE) per capita was $42, with the government contributing only 29% of the THE Furthermore, within this dilapidated system, focus has long been on infectious diseases such as malaria and HIV, and maternal and child health. In the generally underfunded system, these competing interests have taken precedence, draining the meager resources and therefore playing a major role in the lack of NCD recognition.In 1998, the MoH responded to external pressure to form a Division of Non-Communicable Diseases (DNCD), however, as reported by key informants, the division was understaffed and underfunded, remaining dormant for almost a decade to follow. As recently as 2007, NCDs did not feature in the Ministerial annual operating plan (AOP), meaning that the division remained without a budget line, making it impossible to undertake any public NCD intervention activities. This was attributed to the lack of evidence of NCD burden (i.e. lack of data) and therefore lack of evidence of NCD importance.However, through collaborative efforts between the division and the civil society, on whose funding, existing structure and strong support systems the division leveraged itself, the NCD agenda was further driven, finally gaining recognition and resource allocation in the form of inclusion in the 2008/9 Ministerial AOP. Another important milestone for NCDs in Kenya is the upcoming Health Sector Strategic Plan III, where three out of the six key agendas have been dedicated to NCDs Beyond the aforementioned factors, other political factors which hindered the efforts to create a policy included the fragmentation of the healthcare system. In 2008, following a highly contested presidential election, the ministry of health was fragmented into two ministries, the Ministry of Medical Services, responsible for treatment and secondary care and the Ministry of Public Health and Sanitation responsible for prevention and primary care; to accommodate the two opposing political parties which formed a coalition government. This stretched policy making efforts between the two ministries, complicating consensus. Fortunately, as of 2013, with the formation of a new government, the two will be reconsolidated.A final and crucial factor which was also cited as hindering resource allocation to NCDs was the non-immediate visualization of results of interventions for NCDs, hence presenting little political appeal. Interventions with quickly visible results, such as those for infectious diseases, are apparently preferable, as they appeal to the public and cast the politician behind the initiative in good light. It takes years, even decades, for the results of NCD prevention and control measures to produce tangible results.A major theme in the NCD advocacy in Kenya has been the central role played by Professional and Civil society groups and research organizations in the setting of the NCD agenda in Kenya. It is noteworthy, however, that the most visible and active group was the professional associations. The organizations have been fundamental in driving the creation of, and thereafter advising and supporting the DNCD and in the lobbying for the various legislations and disease specific strategies and management guidelines. This has been accomplished through their involvement in technical working groups which coordinate initiatives for the various activities in NCD advocacy, with the DNCD leveraging itself on their financial and technical resources.The professional societies had internal factors which hindered reaching of a collective agenda. One such factor was reported as scattered initiatives by the different disease specific societies, described as “a traditional approach where we split NCDs into different components because we came from different specialist societies. We had activities for diabetes devoid of CVD though the two diseases are actually one we ended up with a Cancer Act, respiratory initiatives leading to an Asthma Action Plan and Asthma Guidelines; a Diabetes Action Plan, something on epilepsy instead of a comprehensive NCD plan which would address common causative root of NCDs.”The strong civil movement's impact in setting the NCD agenda in Kenya is a scenario mirrored globally. Highly visible and vocal non-state actors such as the global NCD Alliance Civil society has historically been considered weak and fragmented While civil society participation is largely encouraged, there should be an awareness of pitfalls such as “development ventriloquism”, a phenomenon where civil society experts base research and advocacy on their own objectives and from their point of view, overlooking the needs of the society in which they participate To incorporate all stakeholders and minimize shortcomings presented by their different limitations, the WHO proposes the establishment of an independent autonomous legally mandated body overarching all national activities on NCDs, with multi-sectoral composition, monitoring the MoH's NCD activities, monitoring progress on indicators  and monitoring leadership commitment. The creation of such a body would be highly advantageous, not only in ensuring progress in NCD control, but also in the implementation of a surveillance system, as one would be essential in aiding the unit's monitoring activities. No plans, however, are underway for the development of such a body, with no mention of such in the Action Plan document or by the respondents.3.2.2.Situational factors, variously referred to as “Focusing Events”, are described as the more or less transient, impermanent, or idiosyncratic conditions which can have an impact on policy The most consistent factor encountered in this theme was international focus on NCDs, which has gained momentum in the recent past, consequently driving the agenda locally. As recounted by informants, the build-up towards the UNHLM was a key driving force, denoting the period during which most progress was made legislatively and in strategy formulation towards NCDs.With pressure from the WHO and support from international NCD-related bodies such as the Global NCD Alliance, the ICDRC, the World Diabetes Foundation, the Centre for Disease Prevention and Control, and others, the agenda for NCDs was set in Kenya, gaining the them recognition and focus. As an example, legislations such as the Tobacco Control Act received a lot of support from the Framework Convention on Tobacco Control (FCTC), International Development Research Centre (IDRC) and the Bloomberg Initiative.The recently unveiled Global Monitoring Framework It was a matter of surprise and concern, according to the interviewees, that Kenya remains far behind its regional counterparts as far as surveillance is concerned, despite having a relative competitive advantage as far as resources are concerned.The second recurring theme in situational factors is the media, which has given NCDs and their lack of political recognition great attention in the recent past. Media has incorporated NCDs into their health segments with focus on behaviour change, nutrition and providing information on diseases such as cancer and diabetes. This attention has been highly beneficial in national sensitization and most importantly, has acted as a platform for the civil society and professional bodies on which to relay their message and lobby for political recognition and resource allocation.East African StandardIn 2011, the two health ministers in Kenya were both diagnosed with cancer. Their public struggle with the disease was a crucial driving force for NCD agenda. Then Minister of Medical Services detailed his struggle with prostate cancer in newspaper articles. The Minister expressed his dismay at the status quo of cancer treatment in the public healthcare system, making a statement that “my experience is a wake-up call for us in Kenya to build comprehensive cancer care centres for our own people, and for the East Africa region. I know we can do it if we begin by walking the talk” Both ministers publicly declared a renewed commitment to the fight against cancer and NCDs in general. This was the platform on which a Cancer Control Strategy was formulated and a Cancer Control Act legislated by government, both in the process of implementation.3.2.3.As recounted by respondents, there has continuously been little political will to fund research within the country. Research in Kenya is primarily funded and undertaken by donor and academic institutions and individual students.To blame for this status, as conveyed by informants, is the lack of a “research culture” amongst policy makers and government officials. A system whereby decision and policy making is either completely devoid of evidence basis, or is informed by unreliable/unrepresentative data has existed unchallenged for a long time, favoured by the wholesome adoption of global policy directives in response to international pressure and as conditions set for donor funding.The first comprehensive policy document on NCDs by the government, the National Non Communicable Diseases Strategic Plan 2012–2017 This problem is not unique to LMICs such as Kenya, with a study of high income countries reporting figures as low as 28% of policy makers in Australia referring to research in decision making, with comparable findings elsewhere This repetitive and deeply concerning theme of lack of a “research culture” encountered in the study as a major impediment to prioritization of NCDs and by extension the establishment of NCD surveillance structures can be explained by both endogenous and exogenous factor.Lack of the technical know-how to analyze, interpret and therefore apply information from research was a running theme used to explain the lack of a research culture in Kenya. A study carried out in four low income countries  reported similar lack of research culture attributed to the lack of research interpretation know-how amongst policy-makers, who would therefore not fully understand how to interpret and apply available information ad hoc emergent issues requiring attention (such as the unprecedented HIV emergence), or political factors.Other factors include competing interests, which more likely than not influence policy making. These factors may be External factors contributing to the non-use of evidence based material in informing decision making can be explained by two interlinked concepts, both directly attributable to the international community's involvement in the country's policies. In the first instance, foreign aid being the primary driver of research locally and the detriments of that system will be discussed. Secondly, the country's system of policy making through which international directives govern local policy making with little reference to context-specific evidence.The finding of international focus as a major factor in the punctuation of health policy with regards to NCDs in the Kenyan case is not surprising as the country has a strong history of policy-making highly reflective of global tidal waves which is exacerbated by the reliance on foreign bilateral and multilateral aid for the funding of policy implementation. Donor funds contributed to 35% of the total health expenditure in Kenya in 2009/10, according to the NHA Studies of aid dependency in Sub Saharan Africa show that States which derive large proportions of revenue from international communities are less accountable to the electorate and are under less pressure to maintain popular legitimacy, consequently having less incentive to invest in public institutions, the aid hence doing more harm than good in the long run While foreign aid in Kenya has had a positive effect in causes such as HIV control, polio eradication and improvement of maternal and child health, detrimental effects of aid dependence have also been experienced. Budgets highly supplemented by donor funds are unreliable, as demonstrated by the global economic crisis, with major donor agencies cutting back aid as demonstrated by the Global Fund to Fight AIDS, Tuberculosis and Malaria announcing in 2011 that it would make no new grants until 2014 Donor-funded research has been reported as unused and unusable in the developing world contexts described by the study on evidence-based policy making cited above, citing shortcomings such as the inability of external research organizations to identify priorities and understand cultural and contextual issues surrounding the research, rendering results irrelevant due to disengagement of policy makers A shift away from aid-dependent research will prove a beneficial move for the country, as that will pave way for internally funded and sustainable research mechanisms and systems. Research initiated and funded internally is more likely to reflect the public health priorities of the country as the choice of focus areas will be endogenous to the area of which benefits will be accrued. Another benefit of a shift away from aid-funded research is the increased relevance of the research findings in informing policy making and the ownership of the process will instigate the application of the findings in policy making as internally generated findings present greater motivation for their subsequent utilization. This will eliminate the third-party stance of government, effectively creating a “research culture”. This change will also create the need for accountability and efficiency, which will be achieved through monitoring, a process which in essence demands the establishment of a surveillance program.The second aspect of foreign aid's detriment to the research culture in Kenya is the country's unquestioning and wholesome adoption of policies set by global institutions in response to pressure, and as conditionalities for aid set by development partners, rather than reliance on evidence-based context-tested self-generated policies. This system nullifies the need for derivation of local data for planning, therefore serving as an obvious detriment to the establishment of disease and risk factor surveillance programs.An example of the implications of this blind shadowing of international trends has been described in a paper explicating the policy environment surrounding family planning in Kenya, recounting the commitment displayed by the government to family planning in the 1980s, in keeping with international political trends and pressure Departure from wholesome adoption of international prescriptions into local policy in favour of homegrown evidence-based policy making will automatically inspire motivation to produce national data on which to base these policies, and therefore, would serve as a key driver of the development of an NCD risk factor surveillance program.A symbiotic relationship between the government and international agencies should be fostered to replace the current opportunistic interaction; with internal initiative guiding policy making with international community offering a second-order driving force. In such an environment, nationally representative data will prove imperative for progress, motivating the NCD surveillance plan.3.3.The policy process has been defined as “the way in which policies are initiated, developed or formulated, negotiated, communicated, implemented and evaluated” The theoretical model of Baumgartner and Jones, namely, the Punctuated Equilibrium theorem explains the policy making as occurring in transient bursts proceeding and following periods of relative inertia While long periods of intensive effort were applied by local advocates in an endeavour to widen the policy stance, according to the findings, the major shifts made in policy and activities surrounding NCDs followed transient endogenous and exogenous incidents, described as the “Situational Factors” above. Of these, the most significant changes have been in response to international focus on NCDs and to the public cancer battles of key political figures.The timeline above  illustraWith this knowledge in mind, the process is hereby described using the Sabatier and Jenkins-Smith “stages heuristic” approach which uses a four step system as outlined below 3.3.1.As pointed out by most of the stakeholders interviewed, one of the greatest challenges to the creation of a comprehensive NCD policy, beyond the political contextual factors discussed above, is the lack of supporting evidence in the form of nationally representative data on the magnitude of the NCD problem in Kenya.As one informant stated “while attempting to identify problem areas, we looked at the HMIS, we were surprised to find that NCDs are not even properly captured in the data system and the reporting system in the Ministry. This was our problem, if they are not well captured, how do you measure the burden of the problem you're trying to sell?”An unambiguous acknowledgment of the necessity of a baseline NCD risk factor survey was recounted. The importance of the exposition of the current NCD disease burden and its risk factor pattern was deemed crucial for evidence-based prevention and control strategy formulation.A focus on risk factors was advanced as particularly important, and was urged as a starting point in creating the NCD picture in Kenya, as risk factor pattern information was considered “easiest to act on immediately with the most significant results”. Of particular interest was risk factor data in the young, as this was assumed the best entry point for intervention strategies.Repetition of the surveys and integration of NCD risk factors in the HMIS, forming a viable surveillance system was also identified as a critical undertaking. The arguments reported for the formulation of a surveillance strategy included the importance of surveillance in tracking progress made by interventions, and therefore reorganization and re-strategization accordingly.3.3.2.Following the identification of the need for risk factor data, and in the heels of the failed 2005 STEPS survey, a repeat survey is underway for implementation tentatively within 2014. The process is led by the MoH, with prime collaborations with WHO, CDC and KEMRI, and wide consultation of stakeholders within private sector, professional associations and civil society.The survey is receiving financial support from the CDC. The WHO involvement includes the provision of technical support, along with technical equipment  data collection instruments), training of data collecting personnel and sensitization of communities through direct supervision of the pilot. KEMRI, beyond technical and implementation support, is also mandated with the responsibility of guidance on matters of ethics, as the third step involving biochemical testing which requires invasive procedures presents an ethical quandary.3.3.3.The upcoming STEPS survey is a household-based national survey, with sampling being carried out by the Kenya National Bureau of Statistics. The sample population will include everyone aged 15 years and above, a change from the recommended 17 years and above, introduced to capture the alcohol consumption, smoking and unprotected sex aspects, which have been previously identified in various studies as initiating in a younger age group in Kenya.The STEPwise approach includes a section with optional questions of which countries can choose to include or not include in their surveys. Kenya has included injuries as that is an aspect of NCDs of critical importance.While a consensus was found on the need for a long term risk factor surveillance strategy, a clear outline is yet to be formulated, with most quarters citing the success and results of the impending STEPs survey as a foundation for the designing the long term system. This section will therefore present the variety of options suggested by stakeholders on a surveillance program formulation.A multiplicity of opinions on the design of a risk factor surveillance component was encountered due to the fact that facility data cannot reliably be representative of population level exposure. One school of thought proposed the setting up of sentinel sites in high-risk zones, as informed by the findings of the upcoming survey. Periodic surveys would then be carried out in these areas to track the trend of exposure and the efficacy of interventions installed.A second proposition suggested integration of risk factor indicators such as smoking, alcohol intake and anthropometric measures into the existing national household-based Kenya Demographics and Health Survey, carried out 5 yearly by the Kenya National Bureau of Statistics nationwide. Yet another school of thought is the periodic repetition an independent national STEPS survey on a 5-yearly basis.3.3.4.The 2014 STEPS survey is yet to be implemented and therefore cannot be evaluated. Concerns that came up prior to implementation ranged from technical capacity, funding to quality.The STEPS survey is set to be funded by the CDC, which is reportedly funding a parallel national survey on tobacco use, namely Global Adult Tobacco Survey (GATS). Concern over the MoH capacity to run two large-scale surveys of such magnitude simultaneously has been cited. Competition for resources is feared to cause failure of one or both surveys, or the production of questionable quality of data.The question of the MoH's capacity to carry out large scale studies, GATS notwithstanding, also came up as a repetitive concern, especially in light of past failures. Other quarters differed with this proposition, displaying faith in the present strength of the NCD agenda and its consequent effect on the heightened commitment of the government in the success of NCD related activities such as the survey.An important point worth noting is the lack of any records or information on the failed 2005 STEPS survey. The different sources cited different opinions on the reasons for the failure, reiterating the lack of information on the same. This implies that no evaluation post-survey was carried out to ascertain the problem areas for the benefit of future attempts.However, the findings generally pointed to the factors below as the causative elements in the failure of the previous survey:Most of the interviewed stakeholders claimed lack of consultation and involvement in the survey process. Resources at the disposal of the various offices including technical assistance, training and intellectual input in the design process, were not exploited as afforded. The Ministry seemed, as one informant puts it, “to want to go it alone”.Unclear sampling procedure was indicated as making the resultant data unusable, due its unreliability, inability to be weighted and inability to establish its representatively. In the process of designing the study, multiple subtle alterations were reportedly made to the questionnaire collectively changing the nature of the indicator being tested, therefore making the process unstandardized. An example of such an alteration was the change of the question “Do you smoke daily?” to “Do you smoke regularly?”, two questions whose answers imply completely different aspects of the indicator in question. Also, advancements in data collection tools from hand-written records to hand-held electronic devices less capable of error occurred in 2006, a year after the Kenyan survey attempt, during which data was collected in the archaic manual fashion. Accurate and detailed accounts of the survey process were also not readily available, bringing into question the scientific rigor applied, consequently resulting in dubious findings.3.4.This section outlines the policy provisions and recommendations of the various NCD related policy documents and directives, both at national and international level, with regards to risk factor surveillance.3.4.1.The issue of risk factor surveillance has been at the heart of the NCD discussion on a global level for a significant period of time. The illustrious 2011 UN High Level Meeting (UNHLM) culminated with attending Heads of State signing a resolution document whose declarations included a pledge by member states “…….to increase and prioritize budgetary allocation for addressing non-communicable disease risk factors and for surveillance, prevention, early detection…….” Prior to the UNHLM, the Action Plan for Global Strategy for the Prevention and Control of Non-communicable Diseases, 2008–2013 As part of the resolution of the sixty-sixth World Health Assembly in May 2013, a Global Monitoring Framework which outlined nine targets and 25 indicators was duly adopted by member states 4.The two major documents analyzed are both drafts of yet to be released policy papers, namely the Health Sector Strategic Plan III Three of the proposed six objectives in the HSSP III relate to NCDs, aiming to a) halt and reverse the rising burden of NCDs, b) reduce the burden of violence and injuries, and c) minimize exposure to health risk factors. The third mentioned objective, however, serves the whole spectrum of diseases and is not restricted to NCDs.The strategy places emphasis on the strengthening of the health information system to provide adequate health information for evidence-based decision making. It goes on to outline the weaknesses of the existing health information system (DHIS2), the health system limitations including technology, infrastructure and human resources which limit DHIS2s efficacy, finally proposing various methods of improving it.The document also emphasizes the importance of surveys and surveillance systems which should be developed and fostered to provide population data on disease and risk factor trends. Although the document does not explicitly address the issue of NCD risk factor surveillance, it does demonstrate intent by policy makers on prioritizing surveillance.The National Non Communicable Diseases Strategic Plan 2012–2017 has been modelled on the 61st WHAs Global Strategy for NCDs 2008–2013 Strategy 1 proposes the undertaking of a national situation analysis for NCD burden and risk factors through STEPS survey and patient outcome indicator data collection within the 2012–3 period by the MoH and DNCD. Strategy 4, dedicated to the promotion of research for the prevention and control of NCDs, outlines the conduction of baseline surveys and periodic surveillance of NCDs and their risk factors as a research objective.Strategy 6 is dedicated to surveillance, reading “To promote monitoring and surveillance of non-communicable diseases and their determinants and evaluate progress at the national and county levels”, going on to explain the importance of the establishment of effective monitoring and evaluation systems in continuously measuring the progress and impact of the implementation of NCD policies in assuring achievement of planned interventions; impact evaluation for assessment of collective efforts by stakeholders; and effective and sustainable program implementation.The strategy proposes the development of NCD M&E indicators and integrating them into the DHIS, dissemination of the same and establishment of a database to strengthen collection, reporting, analysis and utilization of NCD data at all levels of the healthcare system. It also proposes periodic review of NCD plans being implemented.5.Progress has positively been achieved in Kenya in the recognition of NCDs. The upcoming STEPS survey is a good starting point for the formation of a long-term NCD risk factor surveillance strategy. However, the hurdles likely to be encountered in moving forward, as elucidated above, include the lack of a “research culture”, fostered by international policy and aid dependency, and manifested in policy making devoid of context-specific evidence-based interventions. This external reliance has played a role in the absence of baseline NCD risk factor and epidemiologic data, with a failed STEPS survey in 2005 due for repetition in 2014. Dissociation from this dependency is encouraged, in favour of a symbiotic health diplomatic angle, from which Kenya's policies and funding primarily derive internally, with collaboration with international initiatives serving to provide second-order technical advice and guidance.Areas of opportunity include the highly active, visible and vocal civil and professional societies, unified into the Kenya National NCD Alliance. The exploitation of this resource for technical leverage both nationally and globally for sensitization and promotion of the NCD agenda would prove highly beneficial, as this network extends into a global umbrella system.Finally, it is imperative for the stakeholders to get back to the drawing table and outline a strategic approach to NCD risk factor surveillance in Kenya. Recommendations to undertake a large-scale situational analysis prior to the establishment of an NCD risk factor surveillance system have been made, and this research can be considered to set the stage for one.


Populations are expected to age rapidly in the Arab countries during the coming few decades. However, the current evidence base indicates that many countries in the region are not paying attention to this demographic phenomenon. This is a particular concern as longevity is often accompanied by many years of ill health and disability and most of the countries in the region continue to rely on the family as the primary source of elder care. While the family, and particularly women, are expected to provide increasing support for longer, they are faced by a set of socio-demographic changes that may hinder their ability to provide such care. This paper focuses on the ageing demographics in the Arab region and reflects on the multiple-roles for women by utilising quantitative analysis of international population and socio-economic indicators as well as reviewing the background literature and current ageing policies in the region. The paper then discusses possible strategies to address increasing long-term care needs through a social capital lens, where support to informal carers particularly women is emphasised. As in many other parts of the world, most Arab countriesMost people in the Arab countries share similar historical and cultural backgrounds, founded in the main around religion, yet they are not a homogenous group. The cultural and political status of women, their fertility levels as well as the laws governing family and marriage, vary widely across the region. Levels of life expectancy in many Arab countries is a great success story of social and economic development, however, it is also one of the most profound public policy challenges of the 21st century. This is particularly the case for many countries in the region, which appear not to be equipped to address the multiple implications of such changes  to review the current socio-demographic position, in relation to ageing, of the Arab region reflecting on current model of care provision and policy strategies in the region; (2) to propose a new model of care and new sets of policies for elderly care which moves beyond the over-reliance on women and addresses the new realities posed by changing family and demographic structures in the Arab region. To this end, the paper draws on key policies and strategies that can be adopted to meet the growing multiple roles placed on women as providers of growing long term care needs in Arab region.The paper starts with an overview of demographic and ageing patterns in the region in relation to other socio demographic indicators, such as female labour participation and literacy rates. This will provide the background discussion for the policy analysis that will follow, focusing on current ageing policy initiatives adopted by some countries in the region. The discussion will pay special attention to the unsustainable burden on women in informal long-term care provision. The paper then reflects upon the potential for new models of long-term care support in the Arab region both by reflecting on examples of elderly care provision that have been adopted by governments in more developed countries and by considering the specific cultural context of the Arab region.The data sources for the analysis presented here are both qualitative and quantitative based on development and demographic databases published by various international bodies such as the World Bank and the United Nations. In addition, the authors make use of a systematic literature review of the role of women in long-term care in the Arab region. This entailed extensive searches of Several social science databases including AgeInfo, the Social Science Research Network (SSRN), Applied Social Science Index and Abstracts (ASSIA); Health Management Information Consortium Database (HMIC); Social Care Online (SCO); and Sociological Abstracts and Social Services Abstracts (SSA/SA) covering the period from 1995 to 2014. Systematic search terms were used to extract articles related to long-term care, informal care, and ageing/aging and multiple roles of informal caregivers, particularly women.The Arab region is characterized by demographic, socioeconomic and political diversity. Some countries such as Egypt have very large populations, 84 millions, while others such as Qatar have much smaller population of only 110,000 inhabitants. In the majority of countries, despite an observed ‘Youth Bulge’, population ageing is also occurring  systems of long-term care for the elderly in the Arab region: informal care providers, such as unpaid family members, as well as formal care providers, such as nursing aides, home care assistants, and other paid care workers. Most care delivered to older people, or people with disabilities or long-term care needs, in the Arab region is provided by family members, mainly women, or by other informal caregivers Hoodfar . Long teNevertheless, the continued availability or indeed willingness of family members to care for elderly relatives is uncertain, due to a number of interacting demographic and socioeconomic trends. In particular, changes in family structure and youth migration, combined with increases in women’s participation in the labour force, may negatively affect the availability and willingness of family members to provide care for their older relatives  most countries in the Arab region view population ageing to be a ‘minor’ concern. Nevertheless, some Governments have recognised the need to meet future challenges associated with expected population ageing. An ESCWA study , New Zealand and Australia have developed Other policies relate to offering financial assistance to informal carers through tax relief and other allowances. For example, the United Kingdom provides a cash benefit known as Carer’s Allowance, which is means tested based on level of income and employment level of carer. Similarly informal carers in Australia, Germany, Norway and Sweden can draw on a cash allowance, which they can use to purchase formal care if they wished.The literature highlights the importance of flexible and supportive work environments in enabling people who provide informal care to participate in the labour market  is a summary measure of average achievement in key dimensions of human development: a long and healthy life, being knowledgeable and have a decent standard of living. The HDI is the geometric mean of normalized indices for each of the three dimensions.iii.http://hdr.undp.org/en/dataGender Inequality Index measures the human development costs of gender inequality, thus the higher the GII value the more disparities between females and males. The GII values vary tremendously across countries, they range from 2.1 % to 73.3 %. Source: World Economic Forum, The Global Gender Gap Report 2010-


Water is an essential element and highly valuable resource in life. Between the priorities of environment, people and economy, it is of increasing importance to fully understand the fundamental force of water to be capable of handling waterborne events—such as flooding—manage and ensure water quality and availability, and utilize hydraulic energy. The Institute of Hydraulic Engineering and Water Resources Management (IWW) at RWTH Aachen University has a long research tradition in this field. Going back to the founding year of the university in 1870, the chair is based on the work of civil engineer Otto Intze, who is best known for his pioneering contributions in construction of dams and elevated water tanks. Ever since then, the institute has broadened its research spectrum and is today focusing on flood protection structures, hydraulic engineering design, integrated coastal zone management, morphodynamics and ethohydraulics. In a comprehensive approach, physical model experiments are combined with field measurements and numerical simulations to investigate a wide range of projects. With its annually organized International Symposium on Hydraulic Engineering (IWASA), the institute also offers information to a wide audience on highly topical aspects in the field of water engineering works and water management, while at the same time bridging the gap between science and industry. The institute is part of the “Project House Water”, a research network at RWTH Aachen University that was established within the framework of the German excellence initiative. Here, scientific competencies from the fields of ecotoxicology, process engineering, geography, sociology, economy and hydraulic engineering are focussed to allow for an interdisciplinary, holistic assessment of flooding events and their impacts. First Prussian Institute of Technology: With his first lectures in hydraulic engineering, Intze prepared the ground for fundamental and applied research in the field of water engineering, flood control and dam construction in Aachen. The name of the Institute of Hydraulic Engineering and Water Resources Management (IWW) and its professoriate changed in the following decades, but the research focus was always kept. In 2013, the chair was provided with a new office building and experimental laboratory hall: a floor area of 2250 m2 housing permanently installed tilting, stepped and annular flumes and a water circulation system with flow rates of up to 1500 l/min and a volume of 400 m3 provide excellent opportunities for large-scale model experiments. Apart from that, the hall is equipped with a modular 30 m flow channel, used for ethohydraulic studies, overflow and dike experiments. The open space can be used for temporary installations and smaller physical model experiments  is held every January, for almost 50 years. It is renowned among experts and gives the opportunity to discuss highly topical water themes as well as to establish contacts for future ventures.The research area of the IWW is broadly based and includes key topics from the fields of high water risk management, hydraulic engineering structures, navigable waterway constructions, hydroelectric power, pumped-storage plants, fish protection elements, sediment transport and morphodynamics, coastal engineering and water quality improvement. Projects are typically assessed both in fundamental and applied research, to not just give an understanding of the involved processes but recommend options for tailor-made solutions. Within its projects, the institute is working in close cooperation with research facilities and administrative boards in Germany and worldwide, such as the Federal Waterways Engineering and Research Institute (BAW), the German Federal Institute of Hydrology (BfG), the Ministry for Climate Protection, Environment, Agriculture, Conservation and Consumer Protection of the State of NRW (MKULNV) or the Israel Institute of Technology. The IWW is further integrated into the Project House Water , a jointHigh water events recurrently pose an existential threat to life and property of individuals, infrastructure, agriculture and industry in flood-prone regions. Within minimal time, personal and cultural assets can be damaged or irretrievably destroyed during a flood disaster. These events have lasting effects for human and nature and echo for a long time, such as the disastrous flooding alongside Elbe and Danube in 2013 or the flooding of the Oder river in 2010.Yet, flooding risks are not limited to inland waters but also occur at open waters as a result of weather phenomena such as Hurricane Matthew in the Western Atlantic (2016) or the tsunami in Japan in 2011, which also led to a nuclear disaster at the Fukushima plant. While the private, non-material loss can hardly be quantified, flooding events cause substantial costs amounting to billions, such as hurricane Katrina in the US (2005) which killed more than 1800 people and caused damage of over 80 billion US$. These numbers clearly emphasize the importance for the development of flood protection and flood management tools. Due to human intervention, like river regulations and land sealing, as well as an increasing dense settlement in flood-prone regions, the need for research in this field is also underlined.For about 20 years, high water risk management is a core topic at IWW: as an important element in flood control is the technical protection by construction measures, IWW is evaluating the physical processes of flooding to identify weak points, which lead to structural breakdowns upon flood events. Through this, suggestions for improvement of existing and new flood defence systems are defined [Further current projects at IWW address issues related to revetment stability during swell load . In addition, coupling mechanisms of high and ground water are analysed  to minimWhile the aforementioned topics relate to the immediate effects of flooding, a consequential problem originates from pollutants (soluble as well as sediment associated) that are spread during high waters and which can impair entire ecosystems. Whereas the hazardous potential of chemicals is mostly known, the long-term effects of so-called emerging pollutants  is not fully understood yet and, for this reason, is investigated at IWW in interdisciplinary projects , 5 Fig..Fig. 3HyIn general, it is observed that high water models and surveys from past decades have to be adapted to take into account the ongoing influence of the global climate change. In consequence, related recommendations towards flood risk management have to be critically reviewed .Hydraulic structures cover a variety of waterside buildings that can basically be categorized into two groups: the first set comprises constructions with a protective function, like retention reservoirs, dikes, bank reinforcement structures or flood barriers. The second group includes constructions that enable the personal and industrial use of water, such as drinking water networks, irrigation facilities, waterways, wastewater treatment systems or hydropower stations. Against the background of the European Water Framework Directive of 2000, which aims to ensure a good chemical and ecological quality of water bodies, hydraulic engineering is set in a sense between conflicting priorities, namely the requirements of engineering itself and those of sustainability and environmental protection. In accordance with the directive, alternative fish protection structures up- and downstream of water facilities are developed and optimized to allow for a safe fish passage. In this context, studies are performed at IWW, to analyse the orientation and search behaviour of fish in front of bar racks that are typically used to prevent flotsam and animals from entering pipes and turbines Fig. .Fig. 4BeBy understanding the movement habits of fish at such barriers, alternative solutions can be engineered to improve animal welfare without significant loss in value for the affected companies.The combination of hydraulic engineering and environmental sustainability is approached in further projects at IWW: with phasing out nuclear energy in Germany until 2022, alternative energy sources have to be exploited. An overall challenge with renewable energies is their volatility: for instance, solar power is limited by day/night cycles and wind farms are dependent on weather conditions. Therefore, an important aspect in promoting alternative energy concepts is the development of reliable energy storage systems. Overground pumped-storage plants have been used for this purpose for over 100 years: in a first step, electricity is used to pump water to a higher elevated reservoir. Once, energy is needed, the water is released to a lower basin using the difference in altitude to drive generators. As this operating mode requires special topological conditions , the construction of such plants has not only a high environmental impact but is limited to mountainous landscapes. To overcome these restrictions, pumped-storage plants should be developed to work underground using for example existing caverns from former ore or coal mining. Thus, the main disadvantages of overground pump storage reservoirs  can be bridged. A major challenge of this new type of pump storage plant is the filling and emptying process of the underground caverns to ensure energy storage and energy production in a given time interval. Therefore, researchers from IWW numerically and experimentally analyse hydrodynamic processes during filling and draining of cavities, to define requirements for the underground reservoirs Fig. . These sCoastal regions have always had an attraction to people and business: some of the most influential cities reside at waterside, where they represent gateways to the world; enormous values have accumulated there in the past centuries. Moreover, coastal habitats also pose a high ecological value as they substantially contribute to the overall ecosystem services (up to 40%) . Yet, thYarn-like carbon sensor fibres are attached to a geotextile in parallel strands and the fabric is then placed between the sand core and the clay layer of a dike, facing landwards. With two types of sensor fibres, this setup allows for monitoring humidity and structural stability of the dike: if water is intruding the structure, it will be signalled by a change in conductivity between two parallel sensor strands. A strain of the fabric, as caused by deformation of the dike, can also be detected through the specific sensor fibres. Both parameters are captured real-time and allow for quick protective and action measures in case of an impending dike failure . The stuAnother extreme water-related incident that affects coastlines are tsunamis, which originate from storms or seaquakes. Due to their infrequent, but sudden occurrence, the data situation is limited and it is rather difficult to determine physical parameters from recent events. For this reason, researchers at IWW take a look back in history: large boulders have been found close and distant to coastal regions, covered by marine sediments, indicating that they originate from open waters. These rocks and their position in relation to the sea are used in a numerical, inverse approach to calculate forces necessary to move the boulders to the mainland Fig. . ResultsRiver systems are dynamic structures, shaped by movement of water and sediments; the riverbed is thereby subject to a continuous accumulation and erosion of geological and biological materials. The field of morphodynamics focuses on these changes in river structure and sediment fluxes on various timescales, ranging between minutes and centuries. Here, the morphology of rivers is affected not only by natural factors, such as a rise in precipitation levels but also ecological processes and anthropogenic interventions can have major influences . The steady growth of waterway transport increases the demand for improved inland waterways and ports, resulting in substantial changes of river morphology due to dredging activities at riverbeds, straightening of watercourses and building of hydraulic structures. In a comprehensive approach, covering the complete river course from spring to estuary, the sediment balance of the river Rhine was analysed over a period of 20 years as a collaborative work of IWW and BfG . It showGathered information from the Federal Waterways and Shipping Administration as well as the federal provinces has been merged with own data collected at IWW. This includes, for example, measurements to assess the transport of fine and medium sand, as the bed-load collectors used in the included studies have a mesh size larger than those particles. To estimate the amount of sand that was not captured in the previous studies, bed-load collectors identical in construction were installed in the tilted flume at IWW and flushed with water and a defined sediment mixture, representative of the Rhine bed. Comparing the dry weights of the sediments accumulated in the collector and those initially applied revealed average sand losses between 10 and 50% depending on the type of collector used and the composition of the bed-load sample. Based on these results, a correction factor was determined to allow for adjusting previously acquired data to display the actual amount of transported sand.As an overall result, the sediment balance study of the river Rhine offers a baseline for future research on the river Rhine as well as concepts for technical and constructional measures, including sediment management.While the mere relocation of sand, gravel or clay is a visible sign of sediment flux, an associated issue is not noticeable at first sight: as noted before, sediments are often contaminated with harmful substances arising from pharmaceuticals, chemically loaded wastewaters or fertilisers. By movement of these sediments, the contaminants are further spread and constitute an ecological hazard. This last aspect is leading back to the research field of flood risk management presented at the very beginning of this article and nicely demonstrates the cross-linking of research projects at IWW.The Institute of Hydraulic Engineering and Water Resources Management is a member of the faculty of civil engineering at RWTH Aachen University. It offers lectures and seminars as part of the study programs civil engineering, business administration and engineering, environmental engineering, and mobility and transport. The institute also provides interdisciplinary and cross-faculty teaching in the fields of ecotoxicology, wastewater management and georesources management. The range of courses includes not only basic subjects such as hydromechanics, hydrology and hydropower, but also allows specialization in the disciplines of navigable waterway construction, water management and surface mining, and risk management. The course portfolio is expanded by domestic and international field trips, internships at engineering consultancies and in the construction industry and gives the opportunity to work on topical research projects at the institute. With its experimental hall and its teaching equipment—e.g., a mobile, modular laboratory system to demonstrate operating modes of hydraulic tubes and turbines—IWW allows students to study hydraulic engineering not only from a fundamental perspective but also from an applied point of view.The importance of water-focussed research is expected to further increase in the next years: changes in climate conditions as well as population growth will provoke an active confrontation with these topics to not only ensure availability and quality of drinking water but also to protect nature and human beings from water-borne events. Resource-preserving action is also required to protect water bodies on one hand and to foster a rethinking in terms of energy production on the other hand. The work of hydraulic engineering institutes—such as IWW—will contribute to these challenges by investigating related processes and developing effective tools and measures.


Pulmonary hypertension (PH) is diagnosed using cardiac catheterization and is defined as an elevation of mean pulmonary artery pressure (PAP) greater than 25 mmHg. Although invasive hemodynamics remains the gold standard and is mandatory for disease confirmation, transthoracic echocardiography (TTE) is an extremely useful non-invasive and widely available tool that allows for screening and follow-up, in particular, in the acute setting. TTE may be a valuable alternative, allowing for direct measurement and/or indirect assessment of PAP. Because of the complex geometric shape and pattern of contraction of the right ventricle (RV), as well as the inherent complexity of cardiac repair, no single view or measurement can provide definite information on RV function and PAP and/or pulmonary vascular resistance. In addition, specific training and expertise may be necessary to obtain the views and measurements required. Some simple measurements may be of help when rapid evaluation is mandatory and potentially life saving: the assessment of tricuspid and/or pulmonary valve regurgitant jet and the use of the Bernoulli equation allow for measurement of PAP. Measurements such as the analysis of the pulmonary Doppler wave flow, the septal curvature, or the eccentricity index, assessing ventricular interdependence, are useful for indirect assessment. A four-chamber view of the RV gives information on its size, hypertrophy, function , and tricuspid annular plane systolic excursion as an evaluation of the longitudinal function. Based on these simple measurements, TTE can provide detection of PH, measurement or estimation of PAP, and assessment of cardiac function. TTE is also of importance in follow up of PH as well as providing an assessment of therapeutic strategies in the postoperative setting of cardiac surgery. However, PAP may be misleading as it is dependent on cardiac output and requires accurate measurements. In the presence of residual lesions, analyses of some Doppler measurements may be misleading and not reflect real PAP. Should the TTE evaluation reveal non-conclusive, invasive hemodynamics remains the gold standard. Despite major advances in the understanding of the regulation of the pulmonary circulation, and in spite of the improvement in surgical results and the discovery of potential therapies targeting the pulmonary vascular bed in the pre- and postoperative period, pulmonary hypertension (PH) still remains a major problem in congenital heart disease after surgery .Acute or chronic PH may punctuate the postoperative course despite accurate surgery. The primary therapeutic goal is to decrease pulmonary vascular resistance (PVR) and pressure and, if not possible, avoid stimulation of the pulmonary circulation; but the most important goal is to maintain right ventricular function and to support cardiac output through the balance of pulmonary to systemic vascular resistance .However, there is no clear value of pulmonary artery pressure (PAP) or PVR that indicates a need for therapy in the postoperative period. A consensus would indicate that a mean PAP >25 mmHg or >60% the systemic pressure associated with signs of low cardiac output would indicate the need of specific therapy.It is still difficult to predict the patients who would present with PH in the immediate postoperative period but patients older at time of repair of a left-to-right shunt with syndromes  and elevated post capillary pressures  seem to be at increased risk.Because of the difficulty to predict which patient may develop symptomatic PH it also difficult to decide which patient may benefit from a pulmonary arterial catheter for monitoring PAP. Placement of pulmonary artery catheters should be minimized, and moreover the use of PA catheters may focus the attention of physician on PAP and delay progress. This underscores the need of non-invasive techniques to assess the PAP and right ventricular function such as transthoracic echocardiography (TTE). Several recent reviews describe the use and importance of TTE in the diagnosis and follow up of pediatric PH, but they mostly focus on chronic PH and are not specifically dedicated to the specific postoperative situation –5. Kaestvia different modalities that we will discuss hereafter , an increase in PVR, or an increase in pulmonary venous pressure. An increase in post capillary pressure should be suspected in the presence of dilated and poorly functioning left ventricle, a severe mitral stenosis or regurge, or a dilated left atrium. Residual right ventricular outflow tract, pulmonary arterial or pulmonary venous obstruction must be excluded after surgical repair. This needs to be kept in mind. In addition, in the postoperative period, access to high-quality pictures and tracings are not always possible and extrapolations have to be made.2 + right atrial pressure. As for all Doppler evaluations, an accurate alignment of the beam of the ultrasound as well a complete envelope image is mandatory if accurate measurement is to be obtained. The right atrial pressure can be estimated using the inferior vena cava evaluation during inspiration in the subcostal view. The inferior vena cava can be dilated in patients with high PAP and RV dysfunction. It is measured in the subcostal view with the inferior vena cava entering the right atrium. Right atria pressure is estimated through the IVC diameter and the presence, or not, of inspiratory collapse. The IVC diameter of less than 2 cm that collapse >50% suggest a normal RA pressure of 3–5 mmHg, an IVC diameter >2 cm that collapse >50% suggest an RA pressure of >15 mmHg. It seems clear that, in children of different ages and size, these 2 cm are a problem and in small children the pressure may be evaluated on the percentage of the collapse during inspiration rather than as an absolute number  jet, if present, and using the Bernoulli equation Figure . The TR Once this RVSP value is obtained it must be remembered that the value of pressure is dependent of the cardiac output, and a low PAP or a decrease of PAP is not always a positive sign, if the cardiac output is low or has decreased. In addition, the RV systolic pressure reflects the PAP only in absence of any obstruction of the right ventricular outflow tract  .Mean and diastolic PAP can also be estimated using the same Bernoulli equation through the pulmonary valve insufficiency jet Doppler assessment Figure . The folThe pulmonary insufficiency jet is usually obtained in the short axis view. As for the TR jet, high-quality tracing and alignment of the Doppler beam is a prerequisite for accurate measurements.In the presence of a post-tricuspid communication between the systemic and pulmonary circulation such as a ventricular septal defect or a ductus arteriosus, there is the possibility of measuring the systolic PAP using the velocity of the jet through these communications Figure . The DopIf the PAP cannot be measured with the previously described Doppler assessments, either because there are no leaks through the pulmonary and tricuspid valves or because the Doppler envelopes are not of good enough quality, some other simple indirect assessments can be performed. In general, these measurements are more indicative of the presence, rather than the absolute measure of PH.There are several measurements of the RV Doppler pattern that allow for evaluation of the PAP, but without giving a real value of this pressure –11. ThesAs the heart is encircled by the pericardium, a change in the pressure or size of one of the ventricles will affect the other . This caThis parameter can be considered as extremely useful in the intensive care setting as the importance of ventricular interaction is increasingly recognized, and it allows a simple assessment of ventricular interdependence.In an ideal world, a measurement of the PVR would really reflect the severity of PH as it will include cardiac output . SeveralEvaluation of the RV is difficult, even for experienced sonographers. All the difficulties related to the RV function assessment by echocardiography have been described before, and the multiple reports using different methods attest for the difficulty to easily measure RV function by TTE, even more in the acute setting , 14. SomThe RVFAC measures the change of the surface of the RV between systole and diastole in the apical four-chamber view using the following equation: RVFAC = (end diastolic area − end systolic area/end diastolic area)/100. The major problem is to obtain an excellent apical four-chamber view, showing the complete RV as well as an accurate delineation of the endocardial border both in systole and diastole Figure . Even ifZ score have been published (Tricuspid annular plane systolic excursion evaluates the systolic excursion of the tricuspid valve annulus in four-chamber view. The M mode cursor is placed through the lateral tricuspid annulus. As the RV function major contributor are the longitudinal fibers, it allows to measure the longitudinal function Figure . This meublished . Reportsublished . FurtherEven if a bit major complex, and requiring a specific software in the echo machine, this evolution seems attractive and useful. The scope of this manuscript is not to describe the technique of tissue Doppler imaging, but it measures the myocardial velocities in the apical four-chamber view, using the pulse wave Doppler placed at the level of the lateral tricuspid annulus, basal interventricular septum, and left ventricle lateral mitral annulus. Considering the RV, the s′ wave seems to be the most interesting measurement and correlates with RV function and also with PAP and PVR . Even ifMultiple other modalities are available for the assessment of RV function but seems too complex, and not easy, to acquire for acute evaluation in the immediate postoperative evaluation and for non-expert sonographers. These are the TEI myocardial performance index, the strain and strain rate, and the three-dimensional assessment , 20. ThiIn summary, echocardiography can provide detection of PH, estimation of PAP, and assessment of cardiac function both of the right and left ventricles. In the acute setting, and potentially unstable patients, it is important to have simple, rapid, accurate, and reproducible measurements. The TR jet, the mean and diastolic PAP septal morphology, as well as RV size and function through the use of RV fractional area and TAPSE are measurements that provide important information. As such, TTE is of importance in detection, follow-up, and assessment of therapeutic strategies in the postoperative setting of cardiac surgery. However, PAP may be misleading as it is dependent on cardiac output and requires accurate measurements. In the presence of residual lesions, analyses of some Doppler measurements may be misleading and not reflect real PAP. Should the TTE evaluation reveal not conclusive, invasive hemodynamics remains the gold standard!MB is the only author of the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor declared a past co-authorship with the author MB.


Pakistan has faced a number of significant healthcare challenges over the past decade. In 2000, one of these events - a deadly epidemic of Crimean Congo Haemorrhagic Fever (CCHF) - struck Pakistan. The people of Pakistan are at a very high risk of acquiring CCHF, due to a number of factors which emerge from a scoping review of the literature. First, the underdeveloped healthcare system of the country is currently not prepared to cope with challenges of this nature. Healthcare professionals and medical institutes are not sufficiently equipped to properly diagnose, manage and prevent CCHF. Second, a large percentage of the general public is unaware of the spread and control of the vector. The agricultural sector of Pakistan is vast and thus many people are involved in animal husbandry and the handling of livestock which can lead to the transmission of the CCHF virus. Even in urban areas the risk of transmission is significantly higher around the time of Eid-ul-Azha, when Muslims slaughter animals. Finally, the political upheavals faced by the country have also increased Pakistan’s vulnerability because a large number of refugees from Afghanistan, a CCHF endemic country, have migrated to Pakistan as a result of the Afghan war. Most of the refugees and their animals settle in Baluchistan and Khyber Pakhtunkhwa provinces, which consequently have a higher prevalence of CCHF. This scoping review of the literature highlights the potential causes of high risk CCHF and draws conclusions and makes recommendations that policy-makers in Pakistan may wish to consider in-order to improve on the current situation. Bunyaviridae, and genus Nairovirus and is the world’s most prevalent tick-borne virus [Hyalomma. The environmental conditions in Pakistan are optimal for the replication of ticks, and this further increases the chances of spread of CCHFV infection [Crimean Congo Haemorrhagic Fever (CCHF) is a potentially fatal tick-borne zoonosis characterized by haemorrhage, with a fatality rate of between 10 and 50% [ne virus . The ticnfection .Basic medical amenities are available in the healthcare system in urban areas of Pakistan, but unfortunately this is not consistent throughout the whole country . As far During the recent past, the public health sector of Pakistan has been challenged by a series of epidemics and this is ongoing. Once the outbreak of polio and dengue fever was successfully under control, CCHF emerged as a significant public health concern. This put undue pressure on the health system for sustained periods of time. Pakistan was recognized as a victim of CCHF as early as 1976 when the first case was reported in Rawalpindi General Hospital , 9.The CCHF virus is transmitted to humans through tick bites or by direct contact with infected animal blood often via farmers, slaughterhouse workers, veterinarians and so forth. In addition, person-to-person transmission can then occur due to direct or indirect contact with the skin, mucous membranes, or body fluids of infected patients . Tick biIn 2016 a total of 20 patients died in Pakistan from CCHF , the majIn line with a lack of mortality pattern there is no appropriate arrangement for monitoring the outbreak and spread of CCHF in Pakistan. The approach is largely reactive and relies almost exclusively upon the assessment of individual cases related to location, prevalence and lethality . TherefoThere are many different options for conducting literature reviews and this is a scoping review of the literature. Scoping reviews provide for theoretically informed discussions of the “big issues” in a topic area that has not been well studied in a particular context. To do this a broad range of literature in the CCHF field is reviewed and analysed for key issues. To achieve our objective, the search of the literature included those papers that discuss and highlight the pertinent issues. Scoping reviews often contain research questions that are broad and the inclusion/exclusion criteria is often developed post hoc. Quality of publication is initially not a priority as an understanding of the overall discourse is to be attained. Raw data extraction may or may not be required and in this study raw data is not analysed. The synthesis is more qualitative than quantitative and this is demonstrated by the development of key themes which identify parameters and significant gaps in the body of literature .Identifying the research questionIdentifying relevant studiesStudy selectionCharting the dataCollating, summarising and reporting the resultsTherefore the scoping literature review fits nicely as a method for this study as it involves a process of “summarizing a range of evidence in order to convey the breadth and depth of a field” . The aimst January 2000 and 31st October 2016) was generated using Embase, EconLit, Google Scholar, Medline, PubMed, ProQuest, Scopus, Springer Link and Science Direct databases. Search terms included “Tick”, “Viral infections”, “Hemorrhagic fever”, “Nosocomial”, “Crimean Congo hemorrhagic fever”, “Crimean Congo hemorrhagic fever virus”, “CCHF”, “CCHFV” and “Eid-ul-Azha”. The keywords were used in diverse combinations with BOOLEAN and MeSH searches. Further publications were recognized by a manual search of references of related papers, and review articles were also cited where applicable. Initially, 154 studies were retrieved. Out of these, 52 were duplicates and therefore were excluded. Out of 102 remaining articles, 3 were excluded based on irrelevant titles and/or abstracts. Subsequently, full text of 99 articles were read and 80 studies were further removed as these failed to provide relevant details. Finally, 19 articles were selected based on the inclusion and exclusion criteria  suffering from haemorrhagic peritonitis. The lack of precautionary measures at BVH, inadequate knowledge by healthcare professionals and absence of a proper diagnosis resulted in the death of the imminent surgeon. Nosocomial infections arise due to the inadequacies in provision of the most basic services in an otherwise stretched Pakistani healthcare system. In an ideal world doctors should be very well prepared and educated about the prevention, diagnosis and management of CCHF so that they can provide high quality care to the patients all the while protecting themselves [Those of high socio-economic standing working within urban health care facilities are not immune to the impact of this viral disease. CCHFV infection led to the death of a senior surgeon at the Bahawalpur Victoria Hospital (BVH)  on 30emselves . UnfortuIn Pakistan the population is comprised of approximately one-third urban (36%) and two-thirds rural (64%). There are a number of factors which place both of these populations, especially the rural population, at high risk of acquiring CCHF. First, Pakistan is a developing country with a very low literacy rate. Specifically, most people live in rural areas who are in direct contact with livestock are illiterate. Lack of knowledge and awareness among the animal handlers contributes significantly to the rapid spread of CCHF . MoreoveIn addition to the rural folk who keep animals, urban and rural butchers are another high risk group for CCHF. There are countless meat shops in every city in Pakistan but very few maintain conditions including proper hygiene that would be expected to reduce CCHF transmission. These shops are open aired stalls where the butcher chops the meat, barehanded, in front of the customers, while the un-skinned, whole bodies of animals hang in front of the stalls. Without gloves, the butchers can easily get infected through minor cuts while chopping the meat of an infected animal.Sarhad) and the Federally Administered Tribal Areas  of Pakistan  which is commonly called an Table . These rThe people residing in these areas are also prone to vector borne diseases because they do not have access to vector control vaccines and other preventative strategies. Furthermore, animal husbandry is the major source of income for 70% of the population in KPK and FATA and the majority of people are living in poverty in these areas . These rPakistan has a vast livestock population, owned by either commercial dairy farms and husbandries or the rural dwelling community. Currently farm animals in Pakistan comprise of 22.42 million cattle, 23.34 million buffalos, 49.14 million goats and 24.24 million sheep . As a reUnfortunately, people living in the high risk areas (for CCHF) of Pakistan are also involved in work practices that increase their risk. Furthermore, they routinely take their cattle to other regions of the country to sell them, mainly for consumption of meat, particularly at the time of Eid-ul-Azha . As a result, a greater number of CCHF cases are reported around Eid-ul-Azha , 39. TheMuslims purchase cattle and keep them at their houses for a few days before the Eid-ul-Azha festival. This poses a risk of transmission of CCHFV in humans via the bite of an infected tick. People usually perform the sacrifice of the animal themselves or appoint a butcher on Eid-ul-Azha day for slaughtering the animals at their homes. In both cases, no gloves or long sleeved shirts are used, as there is no formal training or awareness provided to either the people or the butchers. Thus, the likelihood that the person performing the sacrifice might acquire the infection from an animal is very high . FurtherAnother problem is that after slaughtering the animals, the remains are thrown in open places and most cities do not have a proper system for disposal of offal. Apart from this domestic butchering, animals which die in road accidents or from natural illness are also sometimes left on the roads for weeks to rot. This flaw in the sanitary system regarding proper disposal of dead animals can lead to problems in addition to CCHF transmission. The Ministry of National Health Services, Pakistan issued a revised awareness letter in June 2015 focusing on the prevention of CCHFV spread. Unfortunately however it does not describe guidelines for animal slaughtering or control on migration of animals from high risk areas .There are a number of tribes in Pakistan which lead a nomadic lifestyle, moving from one place to the other, looking for food and water. Pakistan is bestowed with a colossal river named the Indus River, which extends across the entire length of the country and drains into the Arabic ocean. Some tribes in Pakistan reside in tents along the banks of this river, and move as the weather and water supply shifts. The people of Cholistan, a desert in the Punjab province of Pakistan, also lead a semi-nomadic life, shifting from one place to the other to fulfil their needs of food gathering and water supply. Similarly, there are nomadic tribes present in the KPK, FATA and Baluchistan regions of Pakistan. Most of these tribes possess animals such as; goats, sheep, cows, buffalos and they also migrate along with them. These groups and their animals can be a real threat to the public health of Pakistan because they have the potential to transmit vector borne disease such as CCHF from endemic areas to what were previously safe areas. A study from Turkey reported that sleeping in the open air with animals during migrations is a major risk factor for CCHF infection . It is aPakistani’s are at high risk of contracting CCHF and the reasons for this are outlined in this scoping review and include; ticks and the environment, the health care system, the rural community, livestock and Eid-ul-Azha and having a nomadic lifestyle. Some of these factors are cultural and others are physical, and they need to be addressed in different ways. The recent death of a prominent surgeon from an urban Pakistani hospital highlights the ongoing levels of transmission from rural to urban settings. It also highlights the need for robust strategies to be developed in-order to educate the general public, as well as Pakistani healthcare professionals about CCHFV. This would make people associated with the handling of livestock aware of the risks associated with animal handling and CCHFV transmission but would also help to halt the transmission of nosocomial infections. Checks and balances must be ensured with regards to the hygienic conditions of the Pakistani healthcare system.The media can play a vital role in providing awareness about the modes of transmission and symptoms of CCHFV, usage of proper clothes to reduce contact with ticks in the process of cleaning animal folds and the importance of spraying animal folds in-order to protect them from attacks by ticks. Moreover, specialized workshops, informative seminars and educational programs are required for healthcare professionals. The government must refocus their energies and provide sufficient finances in-order to vaccinate agricultural livestock . This is