This article on global health reviews the environment surrounding health strategies and plans, as well as lessons learned from the first 15 years of the 21st century, followed by a discussion on the quest for a new paradigm for disease control efforts and challenges and opportunities for Japan. The paradigm of global health is rapidly changing. In particular, disease-control communities are nervous about the future of global efforts, which have drastically reduced the disease burden related to major infections and maternal and child health. In this paper, the author first reviews the environment surrounding health strategies and plans, as well as lessons learned from the first 15 years of global health in the 21st century. Then, the quest for a new paradigm of disease-control efforts and challenges and opportunities for Japan are discussed. The article is based on a keynote speech presented at the 2015 Global Health Workshop of the Association of Pacific Rim Universities (APRU), which was hosted by Osaka University, on October 30–31, 2015, in Osaka, Japan.The year 2015 marks the last year of the Millennium Development Goals (MDGs). This year’s Nobel Prize in Physiology or Medicine could not be more relevant to the conclusion of the MDGs era. Professor Satoshi Omura was awarded the Prize for his discovery of ivermectin, a very innovative and powerful drug for onchocerciasis, or river blindness. Until recently, it was a common experience at riversides throughout Western Africa to see a child guiding an elderly person blinded by onchocerciasis. A statue depicting this scene has been erected in front of the World Health Organization (WHO) main building. The second good example celebrating the closure of the MDG is Professor Youyou Tu’s receiving of the Prize for her discovery of artemisinin, a very powerful anti-malaria drug. The incidence of malaria is now declining year by year.The transition from MDGs to Sustainable Development Goals (SDGs) is the central issue in the changing environment surrounding health strategies and plans. Figure The MDGs were relatively simple. Health occupied the central position, with health-specific MDGs accounting for three of a total of eight goals. One was MDG 4, to reduce child mortality, for which the targets were relatively simple: reduce the 5-year mortality rate by 2/3 between 1990 and 2015. MDG 5 aimed to improve maternal health. The target was to reduce the maternal mortality rate by 3/4 between 1990 and 2015. MDG 6 was to combat human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), malaria, and other diseases. The targets were to halt their increase by 2015, begin to reverse the spread of HIV/AIDS, and begin to decrease the incidence of malaria and other diseases. The goals were therefore clear and few, and the targets were relatively quantitative. This simple framework was agreed on and invested in by everybody.1In contrast, the SDGs have two characteristics. One is that they are more complex. Of 17 goals, only SDG 3, to ensure healthy lives and promote well being for all ages, specifically addresses health issues. As shown in Table In addition, there is a basic change in concept between the MDGs and SDGs. SDGs are not only for developing countries and official development assistance (ODA) communities, but for all countries, both developed and developing. Therefore, SDGs are for everyone. The goals are categorized into five groups, the so-called 5Ps: People, Planet, Partnership, Peace, and Prosperity, which need to be promoted by all countries to create a sustainable world.Another feature is that the SDGs emphasize linkage between goals more strongly than the MDGs. Health is not a monopoly of the health sector; interlinkage is very important. A typical example is onchocerciasis, an indigenous parasitic disease which occurs at riversides, particularly in West Africa. In the past, this disease often led to the abandonment of rich riverside farmland. But now, after regular mass treatment, people can return to these farming areas and resume farming. According to a World Bank estimate, the recovered farmland is producing food for a population of 17 million. Hence, control of onchocerciasis has contributed to the alleviation of hunger through food production and income generation. Health contributes to other goals and vice versa. Other examples are water quality and gender equality, both of which have a positive synergy with health. Accordingly, the SDGs represent a unique environment within which all health strategies and plans are required to work for the next 15 years.3 which shaped the health research agenda for health security.In the first 15 years of the 21st century, global health has become a central agenda of international communities. After the 9/11 terrorist attacks, the G7 leaders felt it critical to address the root issues of terrorism by interrupting the vicious cycle of poverty and ill health. During this era, the number one disease burden for the working population in developing countries was HIV/AIDS, followed by tuberculosis. MDGs were already chosen, at the UN Assembly in 2000, and served as an excellent platform for attracting international commitments and resources to fight against poverty and ill health through investment in priority disease-control efforts. This led to the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria . Furthermore, two other important outcomes arose from the response to 9/11 which have shaped today’s global health landscape. One is strengthening of health security, triggered by the severe acute respiratory syndrome (SARS) experience in Asia in 2003. While 9/11 was physical terrorism, it is natural to be concerned about bio-terrorism as well. These combined concerns over terrorism and unusual new infections drove the world to drastically overhaul the quarantine system, resulting in the agreement of the International Health Regulations (IHR) public health treaty in 2005. Since then, all countries are requested to report unusual health events. Japan has reported a few incidents, such as the Tohoku Earthquake and Tsunami, the Fukushima nuclear accident in 2011, and more recently, dengue fever in 2014. WHO receives some 300 reports annually and assesses each for its significance to global health. Major influence also came from the report of the National Academy of America: Making the Nation Safer,2 studied the growth of health ODA and found that it increased from some 5 billion United States Dollars (USD) in 1990 to 27 billion USD in 2010. It should be noted that the composition of providers for this health ODA is changing. Resources from bilateral donors grew after 9/11, but contributions from international organizations remained quite modest. In contrast, the largest growth was observed from the private sector and from new funding mechanisms, such as the Global Fund, Global Alliance for Vaccines and Immunization, and the Bill and Melinda Gates Foundation (BMGF). The growing activities of non-state actors in global health are noteworthy. For example, the annual budgets of the BMGF and Médecins sans frontiers (MSF) are almost equal to the budget of WHO. Global health has evolved from the individual or philanthropic efforts of outstanding individuals and international organizations acting in this high-profile domain within international communities, and now represent a multi-polar field with many actors, particularly non-state actors.Reflecting these and related developments, health ODA has increased massively. Chris Murray4 which listed the 10 greatest public health achievements worldwide from 2001 to 2010, as shown in Table These increased resources have been preferentially allocated to MDG 4, 5, and 6. The outcome appears in a special article of the Morbidity and Mortality Weekly Report,Table In the communicable disease area, the Global Health Sector Strategy on HIV/AIDS 2011–2015 was adopted by the World Health Assembly in 2011. The adoption of this strategy carries much weight because it means that the health ministers of all 194 member countries agree with it. This is very important. This strategy defines who and how many to treat. Because the target set by the MDGs expired at the end of 2015, WHO started to produce new-generation strategies and plans aimed at the post-MDG era. A new strategy was adopted for tuberculosis in 2014 and for malaria in 2015. In 2016, a new strategy will be developed for HIV/AIDS. Strategy building is a resource-intensive process. WHO needs to consult with the member states, bring in scientific communities, and listen to civil societies. Informally, WHO has conversations with donors to determine whether they will financially support the proposed new strategy, in order that it be rendered a useful tool for affected countries, in terms of both resource mobilization and for the donors in terms of investment planning.Figure 5 with clear targets to achieve by 2020. The unique part is resource mobilization. As the name NTD implies, the populations most affected tend to be marginalized and voiceless. Hence, little attention was given to this group of diseases until WHO and its partners bundled together 17 tropical diseases, which are not significant individually but collectively present serious public health and human rights challenges. The humanitarian gesture to help “the poorest among the poor” attracted the corporate social responsibility arms of major pharmaceutical companies, resulting in drug donation programs. Replacing direct ODA contributions, such drug donation programs are forming a unique private-public partnership in the case of NTD.The control of neglected tropical disease (NTD) follows a slightly different cycle. The consensus is clear, with relevant resolutions adopted at the World Health Assembly. WHO has also developed various technical guidelines and road map,This global health cycle operated well for communicable diseases, such as HIV and NTD, which were designated goals in the MDGs era. What will be the new paradigm for emerging health challenges in the SDG era, covering 2016–2030? One needs to understand the health challenges that serve as parameters to shape our forthcoming global health. The first parameter is mortality. Figure The second parameter is population pattern. Life expectancy worldwide is 70 years, and has shown drastic improvements in Africa, Southeast Asia, and Latin America. The third parameter is prosperity. At the beginning of the 21st century, countries such as China and India were low-income countries, but have now become middle-income countries. China is the frontrunner, and India follows. Other resource-rich countries in the southern hemisphere may become high-income countries by 2020.6 of WHO from 2004 for 2030 indicate that the number one disease burden will be depression, followed by ischemic heart disease.These changes are shaping the global health agenda and geopolitics. Reflecting the aging and affluence trends, causes of mortality are projected to include more cancer, ischemic heart disease, and cerebrovascular diseases, but less communicable diseases, including HIV and tuberculosis. Also, longevity necessitates long-term care, which is better assessed by disability-adjusted life years (DALY) instead of mortality. The DALY projectionsTaking these changes in parameters in mind, the global health cycle for NCD control needs to be studied. In the case of hepatitis as a cause of hepatic cancer, linkage within the cycle is not complete, despite the clear consensus, expressed by the World Health Assembly Resolutions in 2010 and 2013, to expand hepatitis programs. The first challenge has been the development of guidelines for hepatitis C, because a new but highly expensive drug has come onto the market in high-income countries. For the Japanese market, one tablet costs about 500 USD, and patients need to take the tablets daily for 12 weeks. Whether to put this new drug in the guideline or to stick to the traditional interferon-based treatment regimen is controversial: everyone wishes to bring new drugs into the guideline, but if the treatment is not implementable, it will not be useful for practice. A second challenge is the development of a new global strategy for hepatitis, including treatment targets. Setting targets is difficult because the majority of heavily affected countries are middle-income countries, where ODA is not available. Hence, all resources should be mobilized domestically under the responsibility of national governments. Such responsibility will be scrutinized by monitoring organizations, which encourage governments to set targets low to avoid issues of government accountability. Linkage of technical components with financial realities is essential to any completion of this circle.What is the status of the global health cycle for NCD? In 2012, NCD suddenly became a popular subject in the UN agenda. WHO was requested to make a global strategy and plan, bypassing guideline development, which requires a lot of work, such as simplifying the complicated treatment regimens of cancer. In addition, since NCD are most common in countries not eligible to receive ODA, as in the case of hepatitis, crafting strategies and setting treatment targets are very challenging. This is why the circle is not yet complete, and may account for the empty cells in Table 7 has identified the above issues and urged WHO to expedite reforms to better prepare for future epidemics. In addition, a high-level UN panel report and an Institute of Medicine report are coming soon. The major foci will be full implementation of IHR to detect signals of international health concerns, governance of response , as well as strengthening WHO’s global health infrastructure to support all these activities. Here, governance specifically means accountability, division of labor, and funding, and will require additional discussion at high policy levels. A test case for this is the division of labor in developing funding mechanisms currently hosted by WHO and the World Bank for funding reactions to large-scale epidemics. The former is called the WHO Contingency Emergency Fund8 and the latter is termed Pandemic Emergency Facilities.9While the SARS outbreak contributed to shaping global health policy in the last decade, the implications of the recent Ebola outbreak need to be explored. The statistics of the Ebola outbreak to date read nine countries infected, transmission across three continents, 26 000 cases, and 11 000 deaths, with the heaviest burden in three West African countries. Indeed, this is the largest Ebola epidemic but not the first. In previous outbreaks, patients were confined to remote villages, and the outbreak subsided after several dozen cases. However, this most recent outbreak was distinguished by the increased mobility within and between countries after the end of civil wars in some of the countries, and also the employment of many mobile workers by the booming mineral industry. These characteristics enhanced transmission into capital cities, where health infrastructure has not caught up with the growing population. WHO has been criticized for responding to the Ebola pandemic too late, handling it inefficiently, and coordinating poorly with other agencies. These shortcomings are partly the consequence of the shifting of priorities from communicable disease control to NCD control, which resulted in insufficient funding for the relevant programs. An independent review panel of WHO10 and monitored their health status changes to investigate factors contributing to and impeding longevity. Indeed, longevity poses many challenges, not only for public health, but also for other social aspects. For example, persons with cognitive impairment face difficulties in making rational decisions, which are a fundamental aspect of our society. If we look at the prospect of population aging, more than 30% of the Japanese population already exceeds 60 years of age.This section will discuss the challenges and opportunities of these changes, as well as contributions from the Japanese public health community. For Japan, the greatest challenge is aging. Beginning in 2010, we have witnessed a gradual decline in the Japanese population, together with a sharp increase in the ratio of persons over 65 years old, particularly those exceeding 75 years. Japan has a very large population of centenarians aged over 100 years. Keio University has studied a cohort of centenarians11 now headed by Professor Iso, has reported the evidence for public health interventions for stroke prevention and control. A second contribution from Japan could be our experience in policy development, as shown in Figure 12 Japan started to prepare for the growing elderly population from the 1970s. Our experience offers case studies of both success and failure. For example, free medical care for the elderly was introduced in 1973, triggered by a very populist governor. As governor of a big city with a small aging population, this politician thought that his policy was both affordable and sustainable. However, it soon became obvious that the free medical care program was very difficult to continue when the urban population aged and economic slowdown decreased tax revenue. Nevertheless, every politician who raised the possibility of discontinuing the program paid a great political cost at election time. The program was finally discontinued only after several elections.Other Asian countries are following the same course, particularly the Republic of Korea, Singapore, and Taiwan. China and Thailand are aging rapidly as well. Such population aging is a global phenomenon, and not exclusive to Asia, Europe, and North America; Chile, for example, is also seeing remarkable aging of its population. In other words, aging is a common challenge for all APRU member countries. The Japanese experience of response to population aging can serve as a relevant case study for the world, Pacific Rim countries in particular. In the 1950s, the Japanese focus was on tuberculosis control. In 1952, 25% of the national medical expenditure was allocated to tuberculosis treatment, and 50% of all national hospital beds were occupied by TB patients. After a sharp decline in tuberculosis, Japan then transformed such service infrastructure to NCD control, particularly to the prevention and treatment of stroke. The Osaka University group,13 to reduce the prices of commodities by collecting an international solidarity levy.Finally, innovations can turn challenges to opportunities. As discussed above, the world faces multiple challenges at the same time, and their solution requires novel approaches through innovations in public health. For example, the Medicine Patent Pool is expected to serve as a one-stop shop to handle complicated intellectual property and patent issues for the manufacture of generic drugs. Another important innovation is the various attempts to introduce different pricing policies for targeted populations based on their affordability. UNITAID is introducing innovative financing14 has published his firm commitment on global health through his contribution to The Lancet.How do all of these pieces come together to form a big picture? Japan has the unique opportunity in 2016 to host the G7 summit meeting and the Tokyo International Conference on African Development, which offers an international consensus-building forum for the new era of global public health. Already, Prime Minister AbeA new era of global public health is on the horizon.


Background. The Journal Citation Reports journal impact factors (JIFs) are widely used to rank and evaluate journals, standing as a proxy for the relative importance of a journal within its field. However, numerous criticisms have been made of use of a JIF to evaluate importance. This problem is exacerbated when the use of JIFs is extended to evaluate not only the journals, but the papers therein. The purpose of this study was therefore to investigate the relationship between the number of citations and journal IF for identical articles published simultaneously in multiple journals.Methods. Eligible articles were consensus research reporting statements listed on the EQUATOR Network website that were published simultaneously in three or more journals. The correlation between the citation count for each article and the median journal JIF over the published period, and between the citation count and number of article accesses was calculated for each reporting statement.Results. Nine research reporting statements were included in this analysis, representing 85 articles published across 58 journals in biomedicine. The number of citations was strongly correlated to the JIF for six of the nine reporting guidelines, with moderate correlation shown for the remaining three guidelines . There was also a strong positive correlation between the number of citations and the number of article accesses , although the number of data points for this analysis were limited. When adjusted for the individual reporting guidelines, each logarithm unit of JIF predicted a median increase of 0.8 logarithm units of citation counts (95% CI [−0.4–5.2]), and each logarithm unit of article accesses predicted a median increase of 0.1 logarithm units of citation counts (95% CI [−0.9–1.4]). This model explained 26% of the variance in citations .Conclusion. The impact factor of the journal in which a reporting statement was published was shown to influence the number of citations that statement will gather over time. Similarly, the number of article accesses also influenced the number of citations, although to a lesser extent than the impact factor. This demonstrates that citation counts are not purely a reflection of scientific merit and the impact factor is, in fact, auto-correlated. The journal impact factor (JIF) was introduced as a method to compare journals regardless of the number of articles they publish, to help select journals for the Science Citation Index (SCI), recognizing that small but important journals would not be chosen based solely on absolute publication or citation counts .Today, JIFs are widely used to rank and evaluate journals, as a proxy for the relative importance of a journal within its field; journals with higher JIFs are in general deemed to be more important than those with lower ones . This apThere have been many criticisms levelled at the use of JIF to evaluate a journal’s importance. It has been demonstrated that JIFs, and citation analysis in general, are affected by field-dependent factors , which mThese problems are exacerbated when the use of JIFs is extended to evaluate not only the journals, but papers therein . A numbeHowever, the number of citations a paper receives has been found to be an extremely error-prone measure of scientific merit, with poor correlation observed between article quality as rated by external assessors and the number of citations the article receives . FurtherDue to these influences, evaluating whether the JIF is correlated with citations counts requires identical articles published simultaneously across multiple journals. Unlike research papers, reporting guidelines are often published simultaneously to encourage wider adoption and dissemination, as they are not scientific publications, but rather recommendations for authors. The advantage of investigating the Matthew effect for journals using reporting guidelines is that they are published in multiple journals and control for many of the factors that influence citation counts. However, Perneger’s study did not take into account the number of article accesses, which has also been shown to be correlated with the number of citations . FurtherThe purpose of this study was to investigate the correlation between JIF and the number of citations to consensus research reporting statements published simultaneously in multiple journals, and the correlations between the total article accesses according to the COUNTER code of practice  and numbhttp://www.equator-network.org/) that were published simultaneously in identical formats in three or more journals, each with different citations details. Republished articles—those which cited another version of the guideline, stated that they were republished within the article or not published simultaneously (or in the next available issue)—were excluded. Research reporting statements that directly cited another version of the reporting guideline as definitive were excluded, as were those published after 31 December 2013, because the citation data were not yet fully available at the time of data extraction.Eligible articles were consensus statements on research reporting listed on the EQUATOR Network website , with a one-year offset , as this would have been the JIF attributed to the journal during the citation accumulation period. Journals that were not indexed in the JCR were included in this analysis for completeness as they would also accumulate citations and article accesses, which would impact on those received by the other journals, but were assigned an JIF of zero, to represent their position at the bottom of the relevant JCR category.http://www.scopus.com), on the same day (22/07/2015); this allowed coverage of journals without an JIF, but restricted the citation counts to those accumulated within the scientific literature.Total citations counts were obtained for all these articles using the abstract and citation database Scopus  distribution , the medThe number of citations predicted by the JIF and the number of article accesses were also calculated in a general linear model, stratified by reporting statement. As the distributions of citations, JIFs and article accesses are skewed towards high-values, these variables were transformed using the logarithm in base 10 for this calculation . For each statement and comparison, Pearson’s correlation coefficient was also calculated for the transformed values.Finally, multivariate regression analysis was performed, considering the combination of both JIF and total article accesses as a predictor for citations.Overall, 280 reporting guidelines were evaluated for inclusion in this analysis; of these, 13 were associated with three or more publications. Four guidelines were excluded: one as it was published too recently for there to be robust citation data (TRIPOD), and three as the articles were republications, citing a single definitive version . Therefore, nine reporting guidelines were included in this analysis, representing 85 articles published across 58 journals in biomedicine. The journals included in this analysis are included in the The number of citations to individual articles ranged between 0 and 2,941. The median number of citations varied depending on the guideline in question, and ranged between 5 and 962. The number of individual article accesses ranged between 137 and 49,961. The median number of articles accesses according to reporting guideline varied between 951 and 10,696.p < 0.05). The four guidelines that did not reach statistical significance demonstrated a weaker correlation between JIF and the number of citations . Analysis of logarithm-transformed values using Pearson’s correlation coefficient revealed a median correlation of 0.83 between JIF and the number of citations , but only reach statistical significance for STROBE (p = 0.0001).I also conducted multivariate analysis at the reporting guideline level, considering both JIF and total article accesses as predictors for citations . When adThis analysis extends the work by The results demonstrated a strong correlation between the number of citations and the JIF and between the number of citations and the number of accesses for most of the reporting guidelines included, suggesting the presence of a Matthew effect. The regression slope for citations and article accesses demonstrated a weaker influence of article accesses on the total number of citations. This was also supported by the multivariate regression analysis, in which the coefficient for article accesses was lower than for JIF for every consensus reporting statement analysed, except PRISMA and STREGA. This suggests that JIF has a proportionally greater effect on the number of citations to an article.The calculated correlation coefficients for STARD and STROBE were higher than those calculated by Perneger  (2010). Similarly, the influence of article accesses on the number of citations generally increased with the time since publication. This could be explained by early citation counts influencing later and total article citations, as was previously demonstrated by A number of factors have been previously shown to influence the citation rate of articles , includiThe results of the current study suggest that, rather than the JIF serving as a proxy for scientific value of the journal or article, it is instead auto-correlated, with articles being cited simply because they are published in a high-JIF journal. This may help to explain the stability of journal rankings within the JCR.There are a number of limitations to this analysis, requiring a more cautious interpretation of the results. As JIF are associated with prestige and audience size, high-JIF journals are often able to dedicate more resources to promotional activity surrounding publications, which could directly influence both the article accesses and citation counts; however, this was not accounted for in this study. Similarly, while translations were included if they were published simultaneously with the other statements, the effect of language on citation distribution was not investigated in the current study.There are a limited number of data points included in the correlation calculations, which could lead to an overestimation of the correlation coefficients, particularly for analysis of article accesses. This was due to errors in the article counters, data being lost during system migrations or the publishers’ not collecting that data. There is also the confounding issue of publishers collecting article access statistics in a non-COUNTER compliant manner, and the rapid increase in e-journal use between 2001 and 2006 , which dWhile this study restricted the citation data to the Scopus database, citation data might be obtained from different sources, including the Web of Science, Google Scholar, PubMed and others, with known inconsistencies between them . TherefoThe analysis was also limited to biomedical consensus research reporting statements, rather than original research. As these articles are typically published simultaneously in multiple journals under an open access licence, I was able to control for many confounding variables. However, different article types are known to display different citation patterns  and, as These guidelines were also published in journals from quite a heterogeneous selection of medical specialties. Field-dependent factors are known to affect citation analysis, even within disciplines ; therefoIn this study, the impact factor of the journal in which a consensus reporting statement was published was shown to correlate with the number of citations that statement will gather over time. Similarly, the number of article accesses also influenced the number of citations, although to a lesser extent than the impact factor. These findings suggest that citation counts are not purely a reflection of scientific merit, and the journal impact factor is, in fact, auto-correlated.10.7717/peerj.1887/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.1887/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.1887/supp-3Supplemental Information 3A JIF of zero was allocated for journals not in the JCR, to represent their position at the bottom of the ISI category.Click here for additional data file.


A 42-year-old female patient, who had been diagnosed with an occlusion of her left internal carotid artery (ICA) following Doppler ultrasonographic (US) and digitally-subtracted angiographic (DSA) examinations performed in an outer healthcare center in order to eliminate the underlying cause of her complaint of amorosis fugax, later applied to our hospital with the same complaint. At Doppler US performed in our hospital's radiology department, her right common carotid artery (CCA) was normal, but her left CCA was hypoplastic. The right internal artery (ICA) was validated as normal. At the left side, however, the ICA was apparent only as a stump and it did not demonstrate a continuity. The diagnosis of ICA agenesis was confirmed by the utilization of Doppler US, CT, and DSA imaging, and it was concluded also that ipsilateral CCA hypoplasia could be evaluated as an important clue to the diagnosis of ICA agenesis. A 42-year-old woman applied to the ophthalmology department with a complaint and history of a half-hour-long visual loss of her left eye one day ago. At clinical examination, both of her eyes were found to have full vision, and also microscopic fundus examinations revealed no pathological conditions. The patient gave a history of a prior application to an outer medical center with the same complaint, and there she had been diagnosed with a left ICA occlusion, following Doppler US and angiographic examinations. The patient applied to our department with the demand of an extracranial carotid Doppler US examination. At Doppler US, the right CCA diameter was found to be 8 mm, whereas the left one came out to be 4 mm Figures . The rigAgenesis of the internal carotid artery system is a rare entity , and itsSonographic findings suggestive of ICA agenesis include nonvisualization of the the carotid bifurcation, ipsilateral hypoplasia of the CCA, and a normal ipsilateral CCA Doppler waveform , 4. At DAn ICA agenesis may be misdiagnosed as an occlusion as was in our case . In the The differentiation of ICA agenesis from occlusion is rather important because of the increase in the risk of the presence of an aneurysm in association with the agenesis, in comparison to the normal population . The incICA agenesis may show an association with other different vascular anomalies of the aortic arch , 14. ThiIn case of an ICA agenesis, neurologic deficits are usually absent or minimized, due to the collateral circulation which saves the situation . CollateIt is essential to visualize the carotid canal in order to make a proper decision in the differential diagnosis of ICA agenesis and occlusion. Unilateral CCA hypoplasia is an important clue in the diagnostic process.ICA agenesis is usually asymptomatic due to the presence of collaterals. But because the incidence of intracranial aneurysms is in an increase, the risk of intracranial bleeding is in an increase as well, and this is why the differentiation between an occlusion and agenesis of the ICA has become of utmost importance. Besides, association with certain symptoms such as headache, hearing and visual loss, and cranial nerve palsies may also be present.Another important fact is that ICA agenesis may be together with other vascular anomalies of the aortic arch. Due to this reason, other vascular structures at the aortic arch and in the carotid system must also be demonstrated.


Translating government-funded cancer research into clinical practice can be accomplished via virtual communities of practice that include key players in the process: researchers, health care practitioners, and intermediaries. This study, conducted from November 2012 through January 2013, examined issues that key stakeholders believed should be addressed to create and sustain government-sponsored virtual communities of practice to integrate cancer control research, practice, and policy and demonstrates how concept mapping can be used to present relevant issues.Key stakeholders brainstormed statements describing what is needed to create and sustain virtual communities of practice for moving cancer control research into practice. Participants rated them on importance and feasibility, selected most relevant statements, and sorted them into clusters. I used concept mapping to examine the issues identified and multidimensional scaling analyses to create a 2-dimensional conceptual map of the statement clusters.Participants selected 70 statements and sorted them into 9 major clusters related to creating and sustaining virtual communities of practice: 1) standardization of best practices, 2) external validity, 3) funding and resources, 4) social learning and collaboration, 5) cooperation, 6) partnerships, 7) inclusiveness, 8) social determinants and cultural competency, and 9) preparing the environment. Researchers, health care practitioners, and intermediaries were in relative agreement regarding issues of importance for creating these communities.Virtual communities of practice can be created to address the needs of researchers, health care practitioners, and intermediaries by using input from these key stakeholders. Increasing linkages between these subgroups can improve the translation of research into practice. Similarities and differences between groups can provide valuable information to assist the government in developing virtual communities of practice. Communities of practice exist within and across organizations and in our personal and professional lives. They are made up of people who share a common concern, passion, or interest in a topic and choose to actively engage with others to share information and learn from each other. Research on communities of practice has proliferated over the past decade; however, there is limited information on how to create and sustain government-sponsored virtual (Web-based) communities –3. AlthoCrossing the Quality Chasm, recommends developing new infrastructures to facilitate the translation of research into practice  with multivariate statistical analyses  to create visual representations of data ,9. The rI chose concept mapping for this research because it allows for broad input from a variety of stakeholders across the United States, which is important because the anticipated participants in the community are located throughout the country. In addition, because the focus of the research was on “virtual” communities, it was necessary to conduct research with stakeholders in a virtual environment, that is, via Web-based interaction.One issue that should be addressed in order to create successful government-sponsored virtual communities of practice designed to move cancer control research into practice is . . ..” I was unable to determine the number of participants in the brainstorming phase because responses to the focus prompt are anonymous, no log-in is required to participate, and participants could enter multiple responses. During this first phase 193 original statements were generated.The first phase of the study was brainstorming. From November 21, 2012, through December 2, 2012, members of the Cancer Control P.L.A.N.E.T.  website listserv  were invited to brainstorm ideas on a dedicated website. This listserv was selected because it included a broad range of researchers, practitioners, and intermediaries from across the country. The goal of the brainstorming was to have a mix of researchers, practitioners, and intermediaries come up with from 100 to 250 statements with each statement setting forth an idea that could facilitate transfer of research into practice. Participants were asked to contribute a statement formed by completing the following focus prompt: “At the conclusion of phase 1, following brainstorming, a small advisory group of experts from NCI who work on virtual communities of practice met to review the brainstormed statements and determine their responsiveness to the focus prompt. During a facilitated discussion in which we used key word groupings for the statements, the group merged similar statements and eliminated statements that were not directly related to the original focus prompt. They reduced the original 193 statements to 70 statements, which were then used for the second phase of the research project. Other concept-mapping projects have used this synthesis-and-reduction process to generate a final statement set that is manageable for sorting and rating ,11.The second phase of the study required both sorting the statements into conceptual groups, or clusters, and rating statements on importance and feasibility. The average number of participants involved in sorting and rating statements for Web-based concept-mapping ranges from 28 to 113 . SortingI used Concept Systems GlobalMAX software  to conduct the analyses. The software uses multidimensional scaling and hierarchical cluster analysis to interpret sorting and rating data and create maps and graphs ,13. SeveIn cluster mapping, the position of the individual clusters in relationship to each other is significant as is the placement within the cluster of the number for each statement included in each cluster. The Multidimensional scaling translated the sorting from all participants in the project and placed each concept as a separate point on a 2-dimensional map . The locIn analyzing the results of this study, it is important to address the issue of internal validity. Internal validity is primarily concerned with the ability to draw conclusions about cause and effect of a treatment or intervention. Since this research was not looking at a cause-and-effect relationship, a different focus on internal validity is necessary. For concept mapping projects, internal representational validity looks at the degree of fit of the final concept map to how individuals originally organized and rated statements . InternaMembers of the Federal Virtual Communities of Practice workgroup reviewed the different cluster maps. They agreed that individual statements grouped in the 9-cluster map created the best conceptual framework for this study . The com1. Standardization and best practices. Statements in this cluster focus on developing guidelines and standards for dissemination and implementation of research results and the need for agreed-upon terms and methods for dissemination and implementation. Specific statements speak to the need for developing measures that will support dissemination and implementation as well the ability to compare data across systems .2. External validity. Statements in cluster 2 focus on issues related to translation or transferability. This cluster acts as the bridge between the standardization and best practices cluster and the funding and resources cluster and focuses on the need for real-world experience that can be used to justify the use of a research-tested program in clinical practice. Whereas the standardization and best practices cluster speaks about guidelines for dissemination and implementation and the funding and resources cluster focuses on tools and resources for dissemination and implementation, the external validity cluster asks for case studies.3. Funding and resources. Statements in this cluster focus on grant funding mechanisms and creation of resources to support the translation of research into practice. An overall theme of the statements in cluster 3 is creating funding mechanisms that allow for community involvement as well as involvement of multidisciplinary teams. A secondary theme is the need to create or organize tools, education materials, and other resources designed to assist with the translation of research into practice.4. Social learning and collaboration. Cluster 4 is located in the middle at the bottom of the figure. It is bordered by cluster 3, funding and resources; cluster 5, cooperation; and cluster 9, preparing the environment. The positioning of these 3 clusters illustrates the relationships among research, practice, and collaboration. The theme for this cluster is providing space and opportunities to permit shared learning. For shared learning to occur, participants in the community of practice must have the ability and desire to collaborate. Furthermore, participants need to be able to share information about their work and need their organizations’ support to allow this sharing to happen in a virtual setting. This cluster speaks not only to the need for sharing among public health practitioners, but also to the need for government and other funding officials to participate in the virtual communities. Trust is an overarching issue when considering willingness to share and collaborate.5. Cooperation. The cooperation cluster is on the lower right side of the figure, the side diagonally opposite the standardization and best practices cluster. The cooperation cluster focuses on engaging broad and diverse expertise and organizations in government-sponsored virtual communities of practice. Some statements in cluster 5 seem directly related to the social learning and collaboration cluster . However, the majority of statements in this cluster focus on having broad representation for addressing the issues of translating cancer control research into practice.6. Partnerships. The partnership cluster is on the right side of the figure above the cooperation cluster and is closely related to that cluster. Some of the proposed cluster labels were the same for both clusters. This cluster is differentiated from the cooperation cluster by focusing on inclusion of partners at the beginning of research and the beginning of the creation of the virtual community of practice. Several statements specify the types of participants that should be included such as health care providers, office managers, community organizations, health departments, federally qualified health centers, survivors, and family members. Statements in this cluster have a very different focus than the standardization and best practices cluster on the opposite side of the map.7. Inclusiveness. The inclusiveness cluster falls between the social determinants and partnerships clusters because its focus is on making sure a variety of populations, including patients, tribal nations, and health care practices, are represented in the communities.8. Social determinants and cultural competency. This cluster is located at the top of the map between the standardization and best practices and inclusiveness clusters. The social determinants and cultural competency cluster addresses the need to include a focus in the virtual community on issues related to health disparities, social determinants of health, and cultural competency, specifically, how these issues affect an person’s lifetime risk of cancer and also how research is translated into practice in disparate populations.9. Preparing the environment. This cluster is located in the center of the map, indicating by its position that its statements can be related to all the surrounding clusters. Statements in this cluster focus on preparation for moving research into practice.The results from the concept mapping study provide insight into similarities and differences among researchers, practitioners, and intermediaries. Sixty participants completed the sorting and all the ratings, but only 50 answered questions concerning their organizational backgrounds . The conThe ratings from the pattern match provide insight into how researchers, practitioners, and intermediaries view these issues, which can be helpful when trying to engage these groups to participate and contribute to the virtual communities. Similarities and differences exist among the 3 groups  around the importance of creating virtual communities of practice designed to move cancer control research into practice. There is a strong correlation between how intermediaries and practitioners (r = 0.71) and how practitioners and researchers (r = 0.83) rated importance of statements included in clusters. This indicates that the 3 groups are in general agreement about what issues need to be addressed during the creation of the virtual community. Researchers and practitioners rated partnership and cooperation as the most important issues that need to be addressed when creating virtual communities of practice. However, intermediaries rated preparing the environment as the most important issue that should be addressed, followed by partnerships. Researchers and practitioners rated issues related to funding and resources similarly toward the middle on importance while intermediaries rated funding and resources as the lowest in importance. Issues related to social determinants and cultural competency were the least important for researchers, and issues related to external validity were the least important for practitioners.Researchers derive the greatest benefit from the types of partnerships that occur in a virtual community of practice. The ability to partner and learn from other researchers and having the opportunity to develop partnerships with health care practitioners and intermediaries may be key to engaging researchers in a virtual community. Health care practitioners are more likely to be engaged if the virtual community is patient- or client-centered. They will also be more involved if guidelines and resources for translating research into practice are available in an easy-to-use format at little or no cost. Because intermediaries are the people who link researchers and practitioners, promoting the virtual communities as a mechanism for collaboration and partnership may increase intermediaries’ participation.Trust is a recurring theme throughout the literature on virtual communities of practice and is reflected in my concept mapping study. The literature shows that for individuals to engage actively in a community they must develop trust with other members of the community –16. TrusThe findings from this concept-mapping study not only provide guidance for federally sponsored virtual communities of practice focused on translating cancer control research into practice. Many of the recommendations are relevant for other federal agencies that may be considering to the development such communities on other topics. Other government and nongovernment agencies that are involved in developing virtual communities of practice to translate science into practice can benefit from understanding the different perspectives of researchers, practitioners, and intermediaries when developing strategies to engage these key groups.


The issue of sustainability is at the top of the political and societal agenda, being considered of extreme importance and urgency. Human individual action impacts the environment both locally  and globally . Urban environments represent a crucial example, with an increasing realization that the most effective way of producing a change is involving the citizens themselves in monitoring campaigns (a citizen science bottom-up approach). This is possible by developing novel technologies and IT infrastructures enabling large citizen participation. Here, in the wider framework of one of the first such projects, we show results from an international competition where citizens were involved in mobile air pollution monitoring using low cost sensing devices, combined with a web-based game to monitor perceived levels of pollution. Measures of shift in perceptions over the course of the campaign are provided, together with insights into participatory patterns emerging from this study. Interesting effects related to inertia and to direct involvement in measurement activities rather than indirect information exposure are also highlighted, indicating that direct involvement can enhance learning and environmental awareness. In the future, this could result in better adoption of policies towards decreasing pollution. Air pollution has an important effect on our health, with an increasing number of studies showing higher risk of respiratory and cardiovascular diseases for people exposed to higher pollution levels , 2. In tParticipatory sensing, involving citizens in environmental monitoring, can have multiple potential benefits. Firstly, it can increase coverage of monitored areas, both in time and space, due to the ability to distribute the monitoring activities to multiple individuals . Secondl2 and CO sensors.One element to foster large scale participation in participatory monitoring campaigns is the availability of low-cost wearable sensing devices. These will give intrinsically lower quality data, since low cost implies decreased sensor accuracy, so at the moment the tradeoff is between the additional social benefits stemming from large participation and data quality . As techHowever, many of these projects focus mainly on the electronics and systems integration, power issues, wireless data transfer, data storage and visualization and pay little attention to the limitations and quality issues of the gas sensors adopted. Very few tests or validation results have been published in publicly available reports or peer reviewed literature. Examples are Hasenfratz et al. and Mead et al.. Hasenfratz et al.  introducAnother issue is the collection of a representative data set using mobile air quality sensing technologies. To be representative and useful for personal or community decision making, mobile measurements have to be repeated regularly, data have to be aggregated over relevant time frames and locations, and carefully interpreted using data handling and expert knowledge to filter out inaccuracies , 17. TheAn important issue concerns the technological versus social aspect of such projects. Most of the existing projects concentrate mainly on the sensor side of participatory air quality sensing, i.e., how to build the sensing devices and map pollution. However, participant engagement, participatory patterns, learning and awareness are equally important aspects, and feed back into the quality of the data collection, as we have also shown in a parallel project concerned with noise pollution . By collIn this paper, we discuss the behavior and perceptions of citizens involved in monitoring, during a large scale international test case: the AirProbe International Challenge (APIC) . This waobjective data. The second activity was playing a web game (AirProbe), where volunteers were asked to estimate the pollution level in their cities by placing flags  on a map and tagging them with estimated black carbon (BC) concentrations on a scale from 0 to 10 μg/m3, resulting in subjective data on air pollution (perception). Volunteers involved in the measuring activities were encouraged to play the game and bring other players as well (create a team).During this test case, volunteer participants were asked to get involved in two activity types. The first one consisted in using a sensing device (Sensor Box), to measure air pollution (black carbon (BC) concentrations) in their daily life, generating what we call AirSquares). At the same time, measurements were continued, this time without a restriction of the area to be mapped. Incentives in the form of prizes were given at the end of each phase to the best teams/players , with the web game running in parallel. Phase 3 introduced a change in the game, so that players could acquire limited information about the real pollution in their cities in the form of sensor box measurements averaged over small areas . An additional 3,326,956 data points were uploaded to our servers in the same period, but were missing complete GPS information, and were not included in the analysis. Some of these measurements contained labels (tags), with 742 geo-localized overall tags coming mostly from one location of the challenge (London).Additional information on perception of pollution has been extracted from the online game. The platform had 288 users in total, over six weeks, 97 of which played the game at least ten times. Their activity resulted in 70,758 AirPins at the end of the test case, which we will use to assess perceived pollution levels.The web game activity follows similar heterogeneous patterns. coverage, both in space and time. As we have seen before, measurements have been performed at all hours of the day and days of the week. However, usually not all areas are covered equally. Here we show general information about overall coverage achieved . However, when computing coverage we selected larger areas that cover most of the surface of the 4 cities and encompass most measurements. Thus, the resulting number of squares considered was of 14,150,070. One square was considered covered if at least one measurement was performed within it. 2, which is three times more than the mapping areas. If compared to the total surface of the cities considered, coverage is 1.7% only, but this depends a lot on the fact that some of the locations are very large, while the number of teams was comparable across the cities.In order to compute the coverage, the area of each of the four participating cities was divided into 10 by 10 meter squares (tiles). Phase 2 mapping areas were selected to be around 2 kmfi of measurements in each category i as the ratio between measurements falling into that category and the overall number of measurements in that square. Then the entropy for that square is Since pollution levels vary both in time and space, it is important to have more measurements in the same location. So, for each tile, we also look at how measurements are spread in time, i.e., time coverage. We divided the measurements into 8 categories based on the time of measurement. First we separated the working days (Monday to Friday) from the weekends (Saturday and Sunday). Each of the two groups were divided into 4 further categories, by setting time thresholds at hours 08:00, 14:00, 18:00 and 23:00. The entropy of the resulting sets was computed. For each square, we obtained the fraction The curves display jumps and it appears that squares can be divided into sets based on time coverage. One first set (rightmost) includes those squares that have measurements only at one time of the day (entropy 0), which is followed by those covered in 2 time slots, ending with those that are covered at all times of the day (leftmost). Within each set, coverage decays differently. While for the highly covered squares decay appears to be exponential (as plotted in the inset), this becomes slower as the coverage decreases, with curves resembling polynomial decay.When comparing the two phases, time coverage in phase 2 is much better overall than in phase 3. This indicates that volunteers not only explored more in space, but also in time, during phase 2, while in phase 3 they followed their daily schedule which allowed for poor time coverage as well. This underlines again the importance of giving volunteers a specific mapping area in order to obtain better measurement spread.The overall coverage results are also displayed as spatial heat maps in The measured BC levels can also provide useful insight into the aims and strategies of the volunteers during the challenge. To this end, we can examine how these change from phase 2 to phase 3. Thus, The analysis of the structure and location of the collected objective data gives some insight into volunteer behavior and interests when measuring air pollution. Subjective data, on the other hand, can provide a stronger indication of changes in perception. For this, we look at the data collected by the web game, which consists of perceived levels of pollution in the mapping area, the AirPin values. In particular, to inspect awareness improvement and the learning process, we are interested in the relation between these annotations and the ‘true’ pollution values available in the web game during phase 3 in the form of AirSquares. Thus we define the APD (AirPin difference) as the difference between the AirPin value (perception of the volunteer) and the relative AirSquare value . In other words, the APD is the amount of ‘error’ in the annotation intended as distance from the measurement. μg/m3. This is likely to be caused by a scale misunderstanding: players, which were not accustomed to the BC concentration scale, almost ignored completely which values were to be considered reasonable and thus used the middle of the scale  as a ‘normal’ value. This results in the observed overestimation since the real average BC concentration measured lies between 1 and 2 μg/m3.In phase 1, when no volunteer had been exposed to real measurements, we observe three different opinion structures in the three cities, representing the initial perception of volunteers. A systematic overestimation of pollution is present, i.e., the APD has peaks at ∼ 4 Air Ambassadors) were given the sensor boxes to start performing measurements. The web game players consisted of these volunteers plus a set of other players recruited by them . No data, except for the direct feedback from the boxes, was shown to the volunteers. Even so, a change is visible in the distribution of APD reported in the left part of In phase 2 things began to change. Some volunteers  in form of average pollution levels within the respective square measured by the sensor boxes. There is a corresponding radical change in the subjective air pollution estimation emerging clearly in the left part of In order to describe this phenomenon we defined a stochastic transformation to reproduce the APD distribution for phase 3 starting from the APD distribution of phase 1. This transformation should reproduce the effect of the hints received by our volunteers on the initial distribution of their errors. Based on the empiric observation, the transformation takes into account two main effects: the possibility of complete trust in the hint, so that the opinion is reset near the hint, and the possibility of incomplete trust, so that the opinion is just shifted closer to the hint. The mathematical definition can be found in . The lefVolunteer participation is crucial for the success of bottom-up monitoring campaigns, however most projects concerned with air pollution monitoring concentrate only on the development of the technical tools necessary. Here, we give a different user-centric perspective, using the experience from the EveryAware project, through its large scale international challenge, APIC. The tools developed by the project are described in more detail in Objective measurements allowed for analysis of user interests during the challenge and activity patterns. A large number of measurements was obtained, however, coverage varied from location to location, with higher values when monitoring areas were restricted. Both coverage and pollution levels measured indicated a volunteer tendency to monitor familiar areas when there was no restriction, with a search for highly polluted spots.Subjective data, on the other hand, allowed for analysis of perceived pollution levels and learning mechanisms. We observed, by analyzing differences between perceived and real pollution levels, that users are able to reduce the ‘errors’ in the annotations, by learning the true values. However, some inertia in changing the old opinion structure was also observed, since asymmetric tails and slow shifts of old peaks are present. We also looked at differences between AirAmbassadors (volunteers with sensor boxes that played the web game) and AirGuardians (only web game players). In phase 1 there is no clear distinction between them, as it is expected. In phase 2 Ambassadors, who begin to learn real pollution levels from the sensor boxes, start to shift their opinions, reducing the errors, while Guardians change less. Finally, in phase 3 we observe Ambassadors continuing to shift their opinions in a smooth way, with a certain inertia, while Guardians change radically showing a prominent primary peak at zero estimation error with a secondary peak in the position of the old peak. We can argue that the personal experience of the Ambassadors produces a smoother transition (which begins in phase 2), while the in-game information produces radical changes. But still both approaches shows the inertia we described earlier, even if in different forms.In general, we can conclude that all our evidence shows that involving volunteers in monitoring campaigns can result in large amounts of data collected. These data show that participation can help learning, to create a more accurate perception of air quality. Thanks to our case study, it has also been possible to outline some of the mechanisms behind the resistance of subjective opinions to objective results.Based on our experience, we can also propose a set of recommendations for future similar studies. First, the delineation of a mapping area is important, otherwise coverage is not uniform and becomes difficult to control. A second factor affecting uniformity of measurements is the length in time of the test cases. These should be at least a few weeks long, and ideally even spanning a few months, since at the beginning users tend to actively look for highly polluted spots. This is also important if behaviour shifts are expected, since just a few weeks are not enough to observe behaviour change. In terms of recruiting, our experience shows that upfront talks and events are most effective in attracting volunteers. While for enhancing awareness, we found that encouraging volunteers to recruit, among their friends, participants for some of the activities (the web game in our case) allowed for information from the sensors to spread also to volunteers not involved in the measuring activity. So, when the number of sensors is restricted, these other activities can facilitate the spread of awareness also outside the measuring group.The study presented here is based on data collected by volunteers during a large scale test case  organized in four European cities  in from October 2013 to November 2013. It required volunteers to measure air quality as well as provide their opinion on air pollution, using the EveryAware platform. This consists of a sensing device (Sensor Box), measuring air pollution, a mobile application (AirProbe), allowing for data visualization and upload to servers, a set of web services and websites, handling data storage and visualization and a web game developed on the XTribe platform , allowinThis work is part of the European project Every Aware, contract number IST-265432. The European Commission finances only those projects that comply to its ethics and privacy regulations. Citing from the regulations of the Seventh Framework Programme, Decision No 1982/2006/EC, Article 6: “All the research activities carried out under the Seventh Framework Programme shall be carried out in compliance with fundamental ethical principles.” At the same time, the official rules for participation, Article 15, mention: “A proposal which contravenes fundamental ethical principles shall not be selected. Such a proposal may be excluded from the evaluation and selection procedures at any time”. Hence, acceptance and funding of this work by the European Commission implies approval of the ethics statement made in the proposal. This is why no further formal ethics approval was required for this research to be performed.All participants to our study had to participate in training for using the sensor box and install our mobile application. Before admission to the test case, all volunteers were required to sign our Terms and conditions, which represents the user’s consent to use the measurements made. These clearly state that the data will be used for research purposes only and no personal information will be made public or used for other purposes. This includes sensitive information such as location data, names and contact information, that were collected during the test case.Volunteers were recruited using a range of approaches in each city. These included a designated Facebook page, the EveryAware project website, posters, newspaper articles and either university mailing lists or those of local interests groups and environmental agencies . The gas sensor array consists of low-cost continuous sensors of CO, NOx, OThe sensor box electronic system has been designed with the purpose of being a low-cost, open and scalable platform. It is composed of two main boards . The firAirProbe is an Android application designed to connect to the sensor box via Bluetooth, acquire sensor readings and transit them to the EveryAware servers as soon as a working connection to the Internet becomes available. In addition, the application allows users to visualize the data they collect. Specifically, they can see their tracks on a map, calculate an estimated black carbon exposure and follow sensor output in real time plots. While collecting data, users can make free annotations (tags) that will be attached to the recordings and sent to the servers.The case study web platform  is desigA collection of statistics pages provides overall information about the data, such as graphs showing currently active sensor boxes, the overall black carbon average per day, or the overall number of collected measurements per day. Also, information on separate sessions corresponding to different tracks (defined both by the Sensor Box and by the user) is available. This allows users to compare routes and locations. A world map gives a visual overview on the collected data. This includes cluster and grid views as well as a heatmap representation of the collected data on a personal as well as a global level providing visual information about areas with good measurement coverage and their average pollution levels. Users also have the possibility of downloading their own data, in case they want to compile any further personal statistics.During the APIC challenge, the platform was specifically tuned for the needs of the game. Even though the platform supports several statistics and visualization of the data, most of this functionality has been disabled during the second stage of the challenge, in order to make opinions on air quality during the web game as unbiased as possible. The goal was for the AirAmbassadors and their sensor boxes to be the sole source of information regarding real measurements in order to limit information flow and facilitate a more controlled environment for the experiment. All visualisations were back online in the third phase of the challenge.The web platform has been also providing a ranking page for the AirAmbassadors to be motivated throughout the challenge. Points were issued for space and time coverage during each collection phase. The ranking page showed which city and which team was ranked first globally as well as per city. In addition, the AirAmbassadors and their teams were able to access several statistics about their measurement behavior and the data collection process, including a coverage heatmap, the amount of covered squares and their points.AirPins: geo-localized flags tagged with an estimated or perceived pollution level . The game area of each city is divided into tiles. At the beginning of the game, users are asked to create a profile (by choosing an avatar and a name) and to choose a city and a team. Then the volunteer starts from a given tile of the map of the chosen city. Users can interact by placing (or editing or removing) AirPins or by expanding their territory, i.e., buying more tiles. Each day, the AirPins placed generate a revenue based on the precision of the annotation (precision depends on what other users think of the same area). In order to collect the revenue generated every day by each AirPin, the user has to access the game daily, otherwise the revenue will be lost. The collected revenue will be added to the user balance, allowing them to buy more AirPins and more tiles. In this way, players can build their air pollution perception map. At the beginning of phase 3, a new feature was made available in the web game: the AirSquare map. This consisted in an alternative map on which players could buy AirSquares, i.e., information about measured pollution levels aggregated on a small area. This data spreading stimulated the learning process described earlier.The AirProbe web game is a simplified map management game. Players are called to fulfil their role of Air Guardians by annotating the map with so-called In order to set up the APIC study, volunteers were recruited in each of the four cities and they comprised two types of participants: Air Ambassadors, who were tasked with collecting air quality measurements with the sensor box, playing the online game, and recruiting Air Guardians, and Air Guardians, whose central focus was to play the online game and who were linked to a team of Air Ambassadors. Volunteers were recruited using a range of approaches in each city. These included a designated Facebook page, the EveryAware project website, posters, newspaper articles and either university mailing lists or those of local interests groups and environmental agencies Click here for additional data file.


The opportunity to integrate vector management across multiple vector-borne diseases is particularly plausible for malaria and lymphatic filariasis (LF) control where both diseases are transmitted by the same vector. To date most examples of integrated control targeting these diseases have been unanticipated consequences of malaria vector control, rather than planned strategies that aim to maximize the efficacy and take the complex ecological and biological interactions between the two diseases into account.0) for each disease. Transmission of both diseases was most sensitive to vector mortality and biting rate. Simulating different levels of coverage of long lasting-insecticidal nets (LLINs) and larval control confirms the effectiveness of these interventions for the control of both diseases. When LF was maintained near the critical density of mosquitoes, minor levels of vector control  were sufficient to eliminate the disease. Malaria had a far greater R0 and required a 90% population coverage of LLINs in order to eliminate it. When the mosquito density was doubled, 36% and 58% coverage of LLINs and larval control, respectively, were required for LF elimination; and malaria elimination was possible with a combined coverage of 78% of LLINs and larval control.We developed a general model of malaria and LF transmission and derived expressions for the basic reproductive number  interventions required for malaria with the long duration predicted to be required for filariasis elimination. Integrated vector management aims to optimize efficacy and make better use of available funds, including targeting multiple diseases, using one or more interventions. However, we have relatively poor understanding of the programmatic demands that arise when controlling two diseases. For instance, does the intensity, duration of deployment, or type of intervention most suitable for each disease overlap or clash? We developed a mathematical model to explore these issues for the example of the vector-borne diseases malaria and lymphatic filariasis. Since the causative agents of these diseases are transmitted by the same mosquito species in certain areas, there is clear potential for an integrated approach using long-lasting insecticidal nets (LLINs) or larval source management. We found that the transmission potential of both malaria and LF is most sensitive to changes in mosquito survivorship and the duration of the feeding cycle, supporting the usefulness of LLINs. In areas where both diseases occur, malaria elimination was predicted to require high levels of both LLINs and larval source management, whereas either intervention at a low intensity was sufficient to eliminate LF, if maintained for a longer period. This highlights that integrated control programs should be flexible and dynamic in order to accommodate these demands. Vector control continues to play a major role in ameliorating the burden of vector-borne diseases, such as malaria, for instance through the use of long lasting insecticidal nets (LLINs) Loa loa co-occurs, mass drug administration programmes to clear Wuchereria bancrofti microfilariae from the human population face the challenge that the most effective anti-helminthics are contraindicated and vector control may have to be relied on more heavily Plasmodium falciparum infections, and especially in rural areas where malaria is spread by the efficient and anthropophilic vectors Anopheles gambiae s.l. and An. funestus, that are also primary vectors of W. bancroftiMalaria and lymphatic filariasis (LF), both transmitted by the same vectors in rural Africa, serve as an examplar of the potential benefits and complications of IVM. The potential for integrating control across both diseases stems from their broad geographic overlap, shared vectors across much of this range, and susceptibility to the same interventions An. farauti and An. koliensisAn. gambiae s.l. and An. funestus and reduced the human blood index of Culex quinquefasciatiusAn. punctulatus decreased from 1.8% to 0.4% after the distribution of LLINs in Papua New Guinea, and, importantly, no infective larvae were found To date, synergy between malaria and LF control programmes has been mostly in the form of almost accidental side-effects of malaria control on filariasis transmission. A notable example being the Solomon Islands malaria eradication initiative commenced in 1960, where both parasites were transmitted by Cx. quinquefasciatus is the primary vector, it was estimated that an average of 15, 500 infective bites resulted in one microfilaraemic case Anopheles spp. are the vectors could be enhanced further by the process of facilitation, which is a density-dependent parasite-vector interaction resulting in an increasing yield of infective larvae as the number of microfilariae ingested increases. It has been suggested that this introduces an additional unstable equilibrium point above that associated with worm mating probabilities gambiae, funestus, or punctulatus complex) without developing species-specific behavioural characteristics such as the degree of anthropophily or response to interventions. We derive expressions of the basic reproductive numbers, R0, of both diseases in the presence and absence of the other disease and calculate the local sensitivity of R0 to the transmission parameters it encapsulates in order to gain insight in which parameters contribute most strongly to transmission and therefore make attractive targets for interventions. Additionally, we perform simulations of the impact of LLINs and larval source management to gain insight in the relative efficacy of each for both diseases in the presence and absence of the other. LLINs are used on a massive scale for the control of malaria, particularly in sub-Saharan Africa The evidence suggests that interventions directed against malaria vectors may be more effective at controlling LF if their use is sustained at least as long as the average lifespan of adult worms in humans, with estimates ranging from 4–10 years We model both malaria and LF as a system of ordinary differential equations, representing mean filarial worm and microfilariae burdens in humans based on parasite burden helminth models We use a susceptible, exposed, infective, resistant and susceptible (SEIRS) compartmental model for malaria, following Chitnis et al h,R to model immunity to malaria in humans, where people harbour low levels of parasite in their blood that are often undetectable but still allow a lower probability of transmission to mosquitoes. Although in reality, humans frequently move between patent and sub-patent parasitaemia, and the duration of infection may be dependent on past exposure, we make the simplifying assumption here that the recovered stage has a fixed duration. Equations and further details are provided in the We use the recovered class, An. gambiae, An. arabiensis and An. melasThe number of microfilariae ingested by mosquitoes depends on the density of microfilariae in the blood meal G reflects the mean microfilariae burden among infected humans,P(F) is the prevalence of infection depending on the mean microfilariae burden. We approximate a negative binomial relation between microfilariae burden and prevalence of infection as in Where a is the number of bites per mosquito per day and m is the proportion of ingested microfilariae that passes the midgut barrier . The force of infection for malaria of human to mosquito, mλ, is:b is the likelihood of a mosquito becoming infected when feeding on an infective human, and The force of infection on mosquitoes is:Anopheles spp. and W. bancrofti infection and a meta-analysis did not support the notion of density-dependent mortality for this pairing An. farauti density-dependent mortality due to filarial infection was observed An. gambiae s.l. and An. funestusPlasmodium on Anopheles survival is likewise equivocal, with evidence suggesting it occurs mostly based on experimental systems consisting of mosquito-Plasmodium species combinations that do not occur in nature, such as An. stephensi infected with P. bergheiPlasmodium in vectors Interactions between parasites and vectors are multi-faceted and likely depend on the co-evolutionary history of the association. Filarial larvae can exert a number of costs on the mosquito, including damage inflicted while crossing the midgut, while developing in the thoracic musculature, or due to breakage of the labium To investigate the robustness of our baseline analyses we performed simulations allowing for model parameter uncertainty, environmental variation in the form of seasonality, and density-dependent larval mosquito survivorship.P. falciparum and W. bancrofti prevalence we ran a series of 500 simulations. The parameter sets used were drawn using Latin hypercube sampling from uniform distributions of parameter values with ranges as specified in To explore the impact of vector control methods on Here, mosquito immatures were assumed to be subject to density-dependent mortality, based on the formula of Dye 0 is the baseline value of f(t) and ε regulates the strength of seasonal variation.The effect of seasonality on mosquito population dynamics was assumed to operate through the effect of rainfall patterns on the number and size of available larval development sites. We approximated this effect by making the strength of density-dependent mortality, f(t) vary following a sinusoidal pattern:0, estimates the number of secondary infections that result from the infectious duration of a single case in a fully susceptible population and thus it provides a basis for judging whether a disease will thrive or be eliminated. When R0 is less than or equal to 1 the disease will be eliminated, whilst if it is greater than 1, the disease will survive. We derive expressions for the basic reproductive numbers of malaria and LF  in the absence and in the presence of the other pathogen, using a next-generation matrix approach The basic reproductive number, or ratio, RWhere the first term represents the probability of a person in the latent stage progressing to the infective stage rather than leaving the compartment through dying, multiplied by the average amount of time spent in the infective stage, multiplied by the number of mosquito bites on that person per day that result in infection of a vector. The second term stands for the probability that a latent human passes to the immune stage (through the infective stage), the average amount of time spent in the immune or recovered stage, multiplied by the number of bites received per day that result in vector infection. The third term is then the probability of an infected vector progressing to the infective stage times the bites per day that result in infection in humans, multiplied by the average amount of time spent in the infective stage.While for LF in the absence of malaria we obtain:Which, following a similar logic, consists of terms representing the fecundity of an adult worm and the mean lifespan of adult worms and microfilariae, multiplied by the number of mosquito bites on the population that result in establisment of infection in the vector, and terms for the probability that an infected mosquito progresses to the infective stage, the average duration of the infective stage, and the number of infective larvae that are delivered per day per human that reach maturity. Here For malaria in the presence of filariasis and for filariasis in the presence of malaria the basic reproductive numbers are given by large expressions (see the supplement), but we note that these reduce to the expressions similar to the equations above when parasite-induced mortality due to the other parasite is ignored.Plasmodium-induced mosquito mortality. Over a much longer period this is balanced by the adjustment in human population size following the removal of malaria-induced human deaths. The implications or removing LF on malaria transmission, based on our model, are more straightforward as transmission will increase in intensity due to the absence of filarial-induced vector mortality.Potential positive or negative side effects associated with disease control methods that target a single parasite only  can be investigated by simulating the artificial removal of either parasite from the co-endemic equilibrium state. The effects on the proportion of infectious mosquitoes of either disease (i.e. harbouring sporozoites or third-stage larvae) after setting all human and mosquito infections to zero for the other disease are shown . When ma0 was performed by calculating the normalized forward sensitivity indices ip is any parameter of the model. Such an analysis can help identify which parameters influence R0 most strongly and therefore make appealing targets for disease management 0 for malaria at the malaria-free endemic equilibrium point for LF, and vice versa. The values for each of the parameters that constitute the expressions of R0 are given in a, followed by the base mosquito mortality, μm. Notable is that the parasite-induced mortality  has only a weak impact, while parameters related to transmission of the other parasite, including parasite-induced mortality, have a relatively minimal impact. This suggests that although removal of one parasite could (temporarily) increase transmission of the other parasite, such an effect should be overshadowed if interventions simultaneously target a shared parameter, such as the biting rate, vector mortality or density.To determine the key variables that drive transmission of LF and malaria in the presence of the other disease a local sensitivity analysis of Rm. We note here that in certain settings such as urban areas, high coverage of larval breeding sites may be possible, but in many areas it may be difficult to achieve such high coverage.We investigate the impact of vector control by calculating the basic reproductive number of malaria and LF over a range of coverage levels (indicated by φ), and by numerical simulations. Both LLINs and larval control are considered due to their targeting of different vector-related parameters: the mosquito biting rate and feeding-related mortality, and the emergence rate and resulting mosquito density. Larval control is here modelled in a simplified manner and assumed to have a linear effect on the daily emergence of mosquitoes, Λ, so that a 90% coverage of breeding sites is assumed to reduce emergence of adults by 90% (but note that a recent paper suggests that treating 50% of breeding sites was associated with a 90% reduction in adult mosquitoes 0 (further details provided in the supplement). We make the simplifying assumption that mosquitoes are fully anthropophilic, but this can be relaxed if species-specific differences in feeding behaviour are of interest.LLINs are investigated using the formulae derived by Le Menach et al 0 are equivalent. This is the case because our model, evaluated at the parameter values specified, predicts a very low R0 of filariasis even in the absence of interventions, and a very low level of vector control  is sufficient to reduce this below one. The R0 for malaria is greater and requires coverage of 90% of bed nets, 100% of larval control by itself, or 70% coverage of both ITNs and larval control. At a higher mosquito density , 36% coverage of LLINs, 58% of larval control, or 26% of the interventions applied together, are sufficient to reduce the basic reproductive rate of LF to below one, while 78% of LLINs combined with larval control is now required for malaria, while 100% coverage of either on its own is required to eliminate malaria transmission.The impact of LLINs and larval control over a range of 0–100% coverage on the basic reproductive number of malaria in the absence and presence of LF, and of LF in the presence and absence of malaria, is presented . In both0, simulated by varying the mosquito density between 80000 and 330000 on the prevalence of infection over time when LLINs and larval control are both employed at 80% coverage, is shown , or, more likely with the (in-)efficiency of establishment of  adult worms from infective bites (ψ1). A central criticism of our work is that this inefficiency of LF transmission stems from only one field study in Myanmar (formerly Burma) and an estimate from one prior modelling study 1, represents an amalgamation of a number of factors, such as the probability that an infective filarial larva egresses from the labium during a blood meal, the probability that the larva successfully enters the puncture wound created by the blood-feeding mosquito, and the probability that the larvae survives, develops and mates within the human. The second, the probability that an infective larvae exposed on the human skin in a drop of haemolymph survives and enters the blood stream has been shown to depend on the relative humidity and rate of evaporation The main difference in the values of R1) 3.4-fold, but if increased 18-fold (as in certain models where immunity is assumed to negatively affect worm establishment) then at higher mosquito densities, 80% coverage of both LLINs and larval source management are predicted to lead to a lower equilibrium prevalence of LF rather than elimination, as is also the case for malaria , as well as a mating function for filarial worms, would be more suitable for accurately determining the duration of programs needed for elimination. In our simulations, the RPlasmodium and Wuchereria parasites may have adverse effects on the survival of their vectors, agrees with previous investigations that interventions that target only one of the parasites may have negative, unintended consequences on transmission of the other parasite Our combined malaria and LF model takes into account that both This analysis confirms that the massive roll-out of LLINs for malaria control will have additional impact on the transmission and control of LF. Elimination of LF via vector control only is plausible, but likely only feasible in the form of mosquito abatement sustained over many years. The synergies that come from attacking two diseases with the same interventions should be exploited to a greater extent in elimination programmes. This is particularly relevant in West Africa where drug treatment against LF cannot be administered in areas endemic for loaiasis. LLINs and, where applicable, larval source management should be used for the control of malaria and LF in areas where both diseases are transmitted by the same vector.S1 Supporting InformationWuchereria-Anopheles interactions included in the model (section II); the formulae used to represent the effects of long-lasting insecticidal nets (section III); and the basic reproductive numbers for malaria and lymphatic filariasis (section IV).Detailed descriptions of the model equations (section I); (DOCX)Click here for additional data file.