The University at Albany School of Public Health has offered a Bachelor of Science in Public Health (BSPH) degree for the past 7 years. The final requirement of the BSPH degree is a capstone evidence-based public health class designed to culminate the degree program. This capstone course is framed by identifying a public health problem and creating a literature review based on this problem. The issues are selected through collaboration between the students and instructors. Developmental and analytical tools necessary to complete the literature review are provided throughout the semester. By the end of the course, students achieve the necessary competencies and skills to identify a public health problem, analyze information from peer-reviewed literature, and synthesize the relationship between a health issue and its correlated outcome. Successes were measured through achievement of core BSPH competencies, quality of final paper and presentation, and qualitative data gleaned from end of semester self-reported student surveys. Framing the Future: Second Hundred Years of Education in Public Health  School of Public Health’s Bachelor of Science in Public Health (BSPH) was launched in 2007. This program was designed to serve as a gateway to graduate public health education and culminates in a capstone course. Existing literature describes demand for undergraduate bachelor degrees in public health, although there remains uncertainty in what students can do with this degree . There ic Health .Within the ASPPH Undergraduate Public Health Learning Outcomes Model (2012), the capstone writing course is directly responsive to Domain 2: Intellectual and Practical Skills and Domain 4: Integrative and Applied Learning. The particular skill areas in focus are communications  and information literacy. A capstone evidence-based public health course that satisfies the accreditation criterion for a culminating experience to integrate, apply, and synthesize knowledge through cumulative and experiential activities is described here. The final product is a thoroughly researched literature review to confront a public health problem.The University at Albany BSPH degree program has four concentrations: policy and management, epidemiology, social behavior and community health, and biomedical and environmental. The degree sequence includes the objectives of nurturing critical thinking, analysis, and synthesis of information, while recognizing the historical and societal context of current trends in public health.Introduction to Public Health,Concepts in Epidemiology,Global Environmental Issues and their Effect on Human Health,Epidemiology and Biostatistics,Promoting Healthy People and Communities,How U.S. Health-Care Works: myths and realities, andCapstone: evidence-based public health.Students complete foundational classes before choosing a concentration. BSPH majors must successfully complete the following:Capstone: Evidence-Based Public Health.” This course is the culminating experience of the undergraduate program. The course teaches the graduating BSPH candidate how to use evidence-based decision-making to address a public health problem by providing practical guidance on how to find and assess the quality of available evidence and write a comprehensive literature review. These objectives are achieved through lectures, practical exercises, group learning, and class presentations. Learning how to analyze information from peer-reviewed literature is the main learning objective of this class.The course described here is “Introduction to the concept of exposure and outcome relationship,Topic assignments,Exposure and outcome articles for each topic,Library day,What is literature?Measurement,Cultural competence/ethics in research/engaging a community,Target population/stakeholders,Critical analysis and prevalence data,Review of statistics and study design, andData in the media.At course completion, students will have necessary competencies and skills to (1) identify public health problems, (2) analyze information from peer-reviewed literature, and (3) synthesize the relationship between an issue and its correlated outcome. The duration of each section has been largely variable and ultimately left to the discretion of the instructor. However, each section up to “measurement” (below) has been completed by midway through the semester, leaving the bulk of the writing to the second half. Every semester the class has followed a similar timeline:The course begins by introducing students to the concept of evidence-based public health.The BSPH program relies heavily on classroom-based knowledge, so the capstone is specifically designed to expose students to an evidence-based methodology. Typical class enrollment is 20–25 students. The course is offered annually; accommodating additional students would work best by offering additional sections.Evidence-based public health is the development, implementation, and evaluation of a public health topic intended to lead to effective interventions, programs, and policies . ThroughInstructors have used various methods to select public health issues that would stimulate interest and enthusiasm. These methods have included 1) students choose their issue, (2) issues are assigned, and (3) “umbrella topics” are assigned. For example, under the umbrella of “maternal and child health” a student might choose “mother to child transmission of HIV.” See Table  studentsEach method has successes and challenges. Letting students pick topics generates excitement; however, students who pick an association with which they are already familiar tend to assume a relationship between the issue and its correlated outcome that may not be evidence based. Student assessments showed allowing students to pick topics was preferred. A large component of the class involved teaching students to use literature to drive their decision-making processes, which becomes a challenge when students assume a relationship. Assigning student issues eliminates assumptions about relationships between the issue and its correlated outcome at the cost of potentially giving students topics in which they do not have interest. The class teaches skills that can be applied to any public health topic, so assigning a topic is more problematic in the beginning of the class. Furthermore, by either assigning a specific topic or letting a student choose a topic under a larger umbrella of topics exposes students to public health issues that they may not have previously encountered. Both methods have resulted in similar final products, however, assigning topics to students requires more work for the instructor and, as stated above, is the less preferred method of students.The class uses the epidemiological concept of exposure and outcome to simplify the relationship between a particular health problem and its associated outcome. The term risk factor is often used to describe an exposure variable, although this is not always accurate and often comes across as limiting. The term outcome is very broad and for the purposes of the class is defined as disease, state of health, health-related event, or death. In some studies, there may be multiple outcomes, although for the purposes of this course, students are limited to one outcome to simplify the concept.In the course’s original design, a primary objective of the first few classes was to develop a concise issue statement from the selected topic, after solidifying the concept of evidence-based public health. However, in later years, this timeline was changed, as it became apparent that students were developing an issue without utilizing the literature to define the issue. It was determined that demonstrating to students how to critically read and analyze peer-reviewed journals from the outset was the most effective way for them to comprehend evidence-based public health. This section demonstrated that students were able to develop intellectual skills of inquiry and analysis, and critical and creative thinking.Learning how to analyze information from peer-reviewed literature is the objective of this course. The final assignment requires demonstration of competence in synthesis and analysis of empirical information in the literature review and oral presentation. To introduce this topic, the instructor guides the class through easy to understand journal articles as a collective activity. The class is tasked with reading two journal articles and questioned about the exposure, outcome, research question, methodology, and conclusion.Guiding students through a literature search is also an essential component of the course. Each year, the class dedicates one full session to learning the university library system. The university’s science librarian presents on searching for journal articles, requesting articles, and general services. Students have responded very favorably to this every year it had been included. Student evaluations state that demonstrating a tangible way of finding primary literature was a highlight of the class.Several class sessions are designed to ensure that the students will have the quantitative and information literacy skills necessary to understand the data presented in the articles that they have found and incorporate these data into their assignments in a meaningful way. The intention of these sessions is to teach the students to apply mathematical and comprehension skills to problem solving. For example, students are instructed to compare data presented in the tables of each article to the author’s written conclusion. If there are discrepancies between the data and the conclusions, then students are instructed to pragmatically evaluate the information presented in each the article.What is the author’s primary research question?What is the exposure and how is it measured?What is the outcome and how is it measured?What is the author’s conclusion?What are the limitations within the study?To examine whether the students were able to understand the basics of a journal article, a take home exam was administered. The exam consisted of students finding one journal article and answering questions about that article. The article does not have to be about the students’ previously determined topic, although journal quality is mentioned as part of the introduction to literature section, the only requirements for the exam is that the article contain original research and is peer-reviewed journals. The questions for the exam are as follows:The results of this exam offer instructors an indication of how well students are grasping the concept of peer-reviewed literature and how able they are to dissect various components of journal articles. Teaching the fundamentals of the literature reviews is essential to a successful final project. Once the instructor feels comfortable with the class’s ability to understand the literature, he or she can confidently move forward with the course content. This section demonstrated that students were able to develop intellectual and practical skills of inquiry and analysis, critical and creative thinking, quantitative literacy, information literacy, and problem solving.As stated previously, the capstone assignment of this class is a literature review. It is imperative that students understand the difference between a literature review and a research paper. Most undergraduates are accustomed to research papers where they simply report what they read. By contrast, the literature review involves critical thinking about methods and comparative analysis among various perspectives on the same topic. The final written product should be in the student’s own voice, backed by evidence, not simply a collection of published author conclusions. The purpose of the final written product is to offer an overview of significant literature published on a topic while addressing any gaps in current research. Instructors guide students regarding the organization of the paper by breaking down each major component.Background information on the topic, population, and region;Exposure background;Outcome background;Evidence of the association between the exposure/outcome; andLimitations.One suggested organizational framework is:Students are required to submit a spreadsheet of at least 10 articles related to their topics, organized by journal, authors, research question, exposure, outcome, conclusion, and limitations. This requirement ensures that the students are collecting appropriate articles in a timely manner. Next, a first draft is due and thoroughly edited to guide students toward a high quality final product. In the early years of the course, a draft was not required and lacking this element negatively impacted the quality of the final product. Proper citation is also addressed. Finally, the literature review is submitted and graded for content, grammar, and fulfillment of the assignment. In all student evaluations, it was reported that being taught to write a literature review is the most successful component of the class and develops a tangible skill. This section showed that students were able to demonstrate application of knowledge, skills, and responsibilities to new settings and complex problems.Overall assessment of student learning and analysis was achieved by the following.Dissection of Existing Peer-Reviewed LiteratureAssignments are given in which students identify a research question, exposures and outcomes under study, target population, inclusion and exclusion criteria, authors’ conclusions, and described limitations.Critical Analysis of Literature Themes SpreadsheetSegmented approach to clearly illustrate research themes and conclusion patterns among a variety of studies on a related topic from multiple publications.Literature ReviewThe comprehensive literature review is assigned and submitted in stages: outline with headings, introduction, full review with proper citations, and an edited revision. The final literature review is expected to contain: background, explanation of exposure, explanation of outcome, description of the association between the exposure and outcome, identification of at risk population, summary of literature themes, conclusions, limitations, and public health significance.Oral Presentation of Literature ReviewEmphasizes the importance of the ability to effectively communicate and disseminate scientific findings to a broad audience.Presentation of learning objectives in a tangible way has resulted in student understanding of secondary research and development of literature review writing skills. Successes are measured through achievement of core BSPH competencies and qualitative data gleaned from end of semester self-reported student surveys. Mastery of the core competencies is reflected through the quality of comprehensive literature reviews presented at the completion of the course. Progress was observable as students advanced through the stages of the literature review demonstrated by improved communication of concepts and comprehension of evidence-based topics and associations.Student success was evident to the instructors in the quality of the products created and in the majority of student attitudes and level of course satisfaction. Early in each semester, students communicated frustration and doubt regarding the learning goals. However, understanding of the material was demonstrated through increasingly high quality performance within semesters, as each competency and skill was learned. This success was most evident in the transformation of the draft literature reviews into the final product. The drafts consistently showed student challenges and opportunities for improvement. With individualized instructor feedback and completion of all the learning exercises, the final products showed comprehension and skill development. At the completion of the course, many students verbalized a fully realized sense of accomplishment and the acquisition of a new ability.Scientific writing ability,Familiarity with data presentation,Understanding of research tools,Clarification of exposure/outcome relationships,Differentiation between issue associations and singular topic descriptions,Knowledge of independent/dependent variable, andIdentification of appropriate peer-reviewed sources.Student surveys from 7 years of course delivery showed the following self-reported learning and skill development:Developing a curriculum to encompass developing all the tangible skills necessary to succeed in the public health workforce would be ideal. An effort to that effect was made in the early iterations of the course by including program planning and evaluation assignments. These assignments did not produce quality products from the students and did not consistently align with the evidence-based theme of the course. Student programmatic designs consistently included unfounded assumptions and anecdotal information, which are antithetical to the learning goals of the course. The results of the planning and evaluation assignments demonstrated the need to focus strictly on incorporating relevant evidence in public health decision-making and planning. A full semester is necessary to successfully achieve the described learning objectives of identifying and synthesizing peer-reviewed evidence, outlining and writing the literature review, and presenting a final product. Evidence-based program planning and evaluation should be considered for a corequisite course in the designs of BSPH curriculums.There were barriers to learning that was identified throughout the evolution of the course. As an example, non-native English speaking students demonstrated challenges in a class that relies heavily on scientific reading and writing in English. Arrangements were made for these students to visit the UA Writing Center in order alleviate any stresses associated with language barriers. Additional office hours were also made available in these instances. In addition, time management and an ability to synthesize large quantities of information presented barriers throughout the years the class has been available. These barriers were addressed by holding the class in a computer lab to allow for literature searches and writing to take place under the direct supervision of the instructors and with the development of Excel spreadsheet categorization tool.The UA BSPH degree program is designed to serve as a gateway to graduate public health education and public health careers; therefore, it was evident that an essential component of the course would be to develop skills through analytical thinking and evidence-based writing. Seven years of completed literature reviews and end of semester surveys have shown success is achieved through student empowerment and a stepwise approach to secondary data analysis. Students were able to achieve two ASPHH domains by the end of the class: (2) Intellectual and Practical Skills and (4) Integrative and Applied Learning, which are key components to successful public health graduate studies and careers. Additionally, development of research, writing, and oral presentation skills allowed students graduating with the BSPH degree to contribute to the public health field in relevant and meaningful ways.Given the limited time of an undergraduate semester, the resources of the class are concentrated on integration of a practical skill set. Considering the recent creation of the BSPH degree, students graduating with the BSPH will most benefit from preparation for successful transition into the workforce or further academic study. Successes from this learning modality should be applied to other undergraduate degree programs to ensure readiness for entrance into the academic arena or public health workforce.BS is the director of the capstone BSPH evidence-based course. BS has seen many iterations of this course and is able to offer suggestions and expertise as far as how it should be taught. VF and CM both taught this class for 3 years while going through their Doctor of Public Health degree programs and are able to offer insight into how a practice-based degree feeds into the teaching of an undergraduate practice-based course.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Poultry production cluster (PPC) programs are key strategies in many Asian countries to engage small commercial poultry producers in high-value production chains and to control infectious poultry diseases. This study assessed the multiple impacts of PPCs through a transdisciplinary ecohealth approach in four Asian countries, and drew the implications for small producers to improve their livelihoods and reduce the risk of spreading infectious diseases in the poultry sector.The data collection combined both quantitative and qualitative methods. It comprised: formal structured household survey questionnaires, measuring the biosecurity level of poultry farms with a biosecurity score card; and key informant interviews. Descriptive statistics were used to process the quantitative data and a content analysis was used to process the qualitative data.This research found that poultry farms in clusters do not necessarily have better economic performance than those outside PPCs. Many farmers in PPCs only consider them to be an advantage for expanding the scale of their poultry operations and improving household incomes, and they are less concerned about—and have limited capacities to—enhancing biosecurity and environmental management. We measured the biosecurity level of farms in PPCs through a 14-item checklist and found that biosecurity is generally very low across all sample sites. The increased flies, mosquitoes, rats, and smells in and around PPCs not only pollute the environment, but also cause social conflicts with the surrounding communities.This research concluded that a poultry cluster, mainly driven by economic objectives, is not necessarily a superior model for the control of infectious diseases. The level of biosecurity in PPCs was found to be low. Given the intensity of poultry operations in PPCs (farms are densely packed into clusters), and the close proximity to residential areas of some PPCs, the risk of spreading infectious diseases, in fact, increases. Good management and collective action for implementing biosecurity measures are key for small producers in PPCs to address common challenges and pursue health-based animal production practices.The online version of this article (doi:10.1186/2049-9957-4-6) contains supplementary material, which is available to authorized users. Please see Additional file The poultry industry in Asia is a vital source of livelihood for many of the continent’s rural communities. However, the large-scale industrial producers are squeezing out the small operators from the expanding market .Since 2003, the unprecedented highly pathogenic avian influenza (HPAI) outbreaks in Asia have stalled the development of the poultry sector . GovernmIn general, a cluster is defined as a geographical concentration of interconnected companies and institutions which gain advantages through co-location , 10. CluAlthough there are many initiatives to develop PPCs in Asian countries, there is very limited empirical evidence on the social, economic, human health, and environmental consequences of production clusters and their implications for the control of emerging infectious diseases. Specifically lacking is an ecohealth approach to assess this production mode from a multidisciplinary perspective.Many key issues remain debatable. It is not clear if the economic returns of producers in a PPC are better than those of traditional producers. The rapid industrialization of poultry for the wrong reasons could harm the mechanism of income generation for the poor . Some stControl of HPAI is not only a biosecurity issue, but also a challenge for development . Some reThis research applied an ecohealth approach, which perceives human health, animal health, and environmental components as an integrated system, and gathers insights from different scientific disciplines to develop sustainable solutions that transcend the health sector. Ecohealth approaches also help translate research findings into policy and action .This study involved four Asian countries: China, Indonesia, Vietnam, and Thailand. In each country, one to three provinces with PPCs were selected . In addition, the PPCs in each country have different social and economic contexts, natural resource endowments, management modes, and poultry species, which constrained the use of uniform sampling procedures across the research sites.Formal structured household survey questionnaires were used to collect quantitative information on the social and economic situation of small-scale poultry farmers: farmer household profiles, poultry species and scales of operation, poultry management mode, costs, and benefits of poultry raising. Two targeted groups were selected: small producers located inside the PPCs, and typical small producers located locally, but outside of the PPCs. The information on the location and numbers of PPC and non-PPC farms were acquired from local government agencies and village committees. The selection of PPCs was based upon the representativeness of the PPCs in the local area and the ease of access to the site for the researchers. From the selected PPCs, the producers were selected by random sampling based on the sample size needs, and taking time and financial constraints into account. The non-PPC farms were selected from the farms that were located in the same village or nearby to the PPC farms, and had similar poultry species and operational scales as them. Table Altogether, 10–15 key informant interviews were conducted in each research site. These interviews were mainly conducted with the representative poultry farmers, village committee members, village health and veterinary workers, representatives from the contract companies, and government officials. Semi-structured interview guides were used to collect the respondent perceptions and concerns relating to the PPCs.A biosecurity score card was developed to meaures the level of application of biosecurity measures in the surveyed farms. This score card, in accordance with the Food and Agriculture Organization of the United Nation’s (FAO’s) concept of biosecurity, was developed by a professional consultant. There are 14 indicators in total, which include different control measures: (1) Attractiveness to wild birds; (2) Wild bird protection; (3) Measures related to staff on the farm; (4) Measures for incoming poultry; (5) Measures for visitors; (6) Measures for traders; (7) Measures for equipment and vehicles; (8) Source and treatment of water; (9) Source of feed; (10) Local environment: distance from the road and other farms; (11) Types of poultry on the farm; (12) Capacity to clean and disinfect the farm; (13) Measures taken at the entrance to poultry sheds; and (14) Availability of biosecurity plans. For each indicator, a grading scale was established of 0, 1, 2, or 3, with zero as the lowest score (poor condition) and 3 as the highest level of security measure, totaling a possible score of 42. The main method for the scoring consisted of observations during farm visits and questions posed to farm owners/managers. The data were collected from sample farms in PPCs and non-PPCs whenever possible, and the samples were the same as those in the formal structured household interviews, as indicated in Table In each country, the data collection combined both quantitative and qualitative methods:The four country teams (researchers together with trained research assistants) collected data from January to December in 2012.The data from the quantitative surveys and the biosecurity scores were entered into the SPSS software package. Descriptive statistics were used to compare the differences in terms of economic and biosecurity aspects between PPC farms and non-PPC farms. Content analysis was used to analyze information collected from key informant interviews. The research teams analyzed the presence, meanings, and relationships of qualitative information, and then made inferences about the findings and their meanings in a local context. The onsite observation results, collected through field visits, were documented and the key issues were identified, described, and discussed.The first observation regarding the PPCs derives from a geographical description of the location—that is, location differences between PPCs and non-PPCs, and between PPCs and the village communities nearby, as well as differences across countries. In general, a number of small-scale commercial poultry farms that are located near each other form a PPC. In comparison, non-PPC farms are located more sparsely in and around villages. The number of farms within surveyed PPCs varied in different countries, from five to 60, and the distance from one farm to the next in the same cluster varied from a couple of meters to about 100 meters.The surveyed clusters in the four countries are located from 500–3,000 meters away from the residential areas, or in the residential areas, depending on the history of the PPCs and the availability of land .The first is government policies and programs to support small commercial producers to build up PPCs outside of residential areas, with the following rationales:The second is the large commercial companies that supply inputs and purchase outputs. They select a number of contract farmers in a concentrated area so that they can supervise and manage them more efficiently. For example, in Dawuan PPC, Indonesia, three poultry farmers established a partnership with a company in 1989. Over 20 years, 55 nearby farmers joined the contract group and formed a big cluster.The third is farmers’ social networks, consisting of extended families, relatives, neighbors, friends, or cooperatives who build poultry farms near each other to facilitate mutual social support and connections, and to learn from each other. For example, one successful poultry farmer in Nong Khai, Thailand helped his family members and relatives move in and build poultry farms near him since the 1990s, which eventually formed a PPC with 50 farms.Three management modes were observed in the surveyed PPCs: (i) independent, which means that the producers in the PPCs are independent of each other for their production activities and lack of collective action in PPCs; (ii) cooperatives (the producers build up a cooperative to coordinate some of the collective action such as the procurement of inputs); and (iii) contract farming (the producers are under contract farming arrangements with big companies). Usually, the companies provide production inputs and technical services and buy the harvested chicken at pre-fixed prices.The average poultry scale per production cycle per farm and the species in PPCs and non-PPCs differ in different countries :However, by locating together, the farmers in PPCs are more likely to engage in contract farming with large companies. For example, in Hanoi, Vietnam, 69% of the surveyed farms in PPCs are under contract farming arrangements, while only 36% of surveyed farms outside PPCs are contracted. In Indonesia, all three surveyed PPCs (each with 50–60 farms) are under the contract farming system. Contract farming has helped small commercial producers to cope with the financial, technical, and market barriers to operate their poultry businesses, and brought them a more reliable, though not necessarily higher, income than that of the non-PPC producers.In all four countries, it was observed that income from poultry production was used to build new houses and renovate old houses, buy new vehicles, and support children’s education. The meat and eggs from the available poultry also improved the nutrition status of most families. Women also played active roles in PPCs since their husbands alone cannot do all the work given the commercial scale of a poultry operation. In Baregbeg PPC, Indonesia, women mainly operate the PPC farms as the men migrate out of the district for non-farm jobs. The income from poultry contributed to 47% of the household income.In comparison with poultry farmers outside PPCs, the farmers within PPCs have more frequent social exchanges, due to their close proximity, such as exchanging information related to markets and disease control. However, some social exchanges may bring the risk of infectious diseases. For example, it is common for PPC farmers to exchange labor, such as helping each other apply vaccinations, remove poultry manure, and catch chickens during harvest. One benefit of doing this is saving costs of hired labor. In Dawuan PPC, Indonesia, 90% of PPC farmers and 55% of non-PPC farmers exchanged labor.The PPC farms do not show better results in terms of environmental protection. Most of the farms inside PPCs in the four countries, as their counterparts in non-PPCs, do not have wastewater and manure management systems. For example, in Vietnam, about 64% of the surveyed PPC farms and 66% of the non-PPC farms let wastewater go directly into the ground or to nearby ponds, rivers, or streams. In China, the farmers in PPCs in Heishan just let the wastewater go along the canals/ditches used for drainage of rain water and simply leave the poultry manure outside the poultry pens before the manure is sold. When it rains, the manure and the wastewater will flow freely over the PPC land and into nearby farm fields.It is evident from onsite observations and key informant interviews that there are higher concentrations of flies, mosquitoes, rats, and various smells in and around PPCs, especially during rainy seasons. These not only increase the risk of disease transmission to animals and humans, but also disturb community neighbors and sometimes cause serious social conflicts. For example, the Dawuan PPC (with 55 farms) in Indonesia was originally located in a residential area and later moved to a paddy field two to three kilometers away because of complaints from community members. However, the smells and flies still spread to the communities at harvest time when transportation vehicles pass through the residential areas, causing a protest on the presence of PPCs by 500 people in 2010.To reduce complains from the community neighbors, PPC farmers donated money to community affairs and provided chickens for religious events, gave several chickens as gifts to their neighbors during harvest time, gave away poultry manure to neighbors for free, and hired laborers from the communities for temporary jobs. In these ways, the PPC farmers attempted to keep harmony with the surrounding community.Overall, the biosecurity scores for poultry farms in PPCs were not high  and lower than the contract farming PPC in Maha Sarakham (34.86).Overall, the field surveys showed that governments tended to play limited roles in supervising biosecurity and human health issues. For example, there is a lack of technical services provided by governments for small poultry farmers. Governments tend to think that poultry farm operation is a private sector issue and consequently leave the farmers and the companies to take the main responsibilities for biosecurity.Although there is a wealth of research and initiatives relating to clusters in general, remarkably little attention has been paid to clusters in developing countries, and even less information is available on agricultural clusters . This stFirst, we observe that, in general, the cluster is the main form of production for small commercial poultry producers as it enables them to survive and compete with large commercial companies. However, this study shows that the poultry farms in clusters do not necessarily have better economic performances than those outside PPCs, though the existence of PPCs does give farmers a better chance of engaging in contract farming. It enables them to cope with the technical, health, and market barriers of poultry production, and have a more reliable, though not necessarily higher, income. But it is also evident that entrepreneurial non-PPC farmers can reach these goals as well. One of the reasons for this is that companies will take a big share of the profits away and thus reduce the income of the contract farmers in PPCs.Poultry production clusters were not only driven by government policies and private sector trends, but also by farmers’ social networks. This study found that there is active social exchange and interaction within PPCs (such as the exchange of labor), and between PPCs and surrounding communities (such as giving manure and poultry to neighbors as gifts). These enhanced social exchange activities take advantage of the proximity in cluster settings, but also pose a higher risk of spreading diseases. For example, moving labor between different farms may spread diseases from one farm to another.The research also characterized a discrepancy between government policy intentions and farmers’ priorities. Governments expected to use the PPCs as a model to reach the scale of economies and also enhance farm biosecurity through standardizing disease control measures in the PPCs. However, many poultry farmers only considered PPCs as an advantage to expand the scale of their poultry operations and improve their household incomes. Farmers were less concerned about biosecurity and environmental management.The level of biosecurity in PPCs was found to be low due to socioeconomic factors and poor incentives for farmers to apply strict biosecurity measures. The high impact of a disease does not guarantee high benefits from its control . Given tPoultry production clusters also pose negative impacts on the environment. Most of the farms do not install equipment to process wastewater and poultry manure, which pollutes the environment, especially during rainy seasons. It is evident that the number of flies, mosquitoes, rats, and smells increase in PPCs, which not only disturbs the local people, but also increases the risk of disease transmission. The poultry farmers in PPCs also underestimate the risk of disease transmission between poultry and humans, as they do not always take protective measures. This may increase their exposure to risks with the intensity of poultry farming in clusters.Governments tended to play a weak role in supervising and enhancing the biosecurity measures in PPCs. There is a lack of technical services and regular supervision provided to small farmers in PPCs by the local livestock officials. Government roles could be greatly enhanced to improve the biosecurity status of farm units and thereby improve the livelihoods of farmers in PPCs.This research demonstrated that the cluster model by itself is not a superior model for disease control compared to the traditional poultry production mode, unless the producers in PPCs take concerted collective action for biosecurity measures. Therefore, collective action is the milestone for clusters , which iIncreasingly, agricultural cluster initiatives are seen as a key approach to help promote the agricultural sector of developing countries . The resGovernments can place more emphasis on using the “cluster” as a unit of surveillance and intervention, as it is the main form of existence of small commercial producers in the Asian countries surveyed. Therefore, governments can include the clusters in their regular supervision and monitoring activities for animal disease control. The cluster initiatives should emphasize on organizational development of the producers in PPCs, and strengthen the linkage between the clusters and the private sector in the high production value chain. For example, governments can help small producers in the clusters set up farmers’ cooperatives, and provide support and seed funding for the operation of these cooperatives. Governments can also help farmers contact poultry companies so that the farmers and companies can make contract arrangements. Governments should also regulate companies’ behaviors, and urge them to enhance the environment management in PPC areas. Governments should also monitor the environment status in PPC areas regularly. Governments can also consider improving public services for farmers to enhance their technical capacities and increase their economic benefits, thus increasing their incentives for disease control. For example, governments can provide technical training and services to farmers; provide the farmers with information on the market; issue farmers certificates for biosecure farms and safe products; and develop and introduce low cost biosecurity and environment protection measures which suit farmers’ capacities and interests. Government awareness programs should also target the social exchange activities that may generate risks.The private sector should enhance the technical training of small producers and increase the awareness of small producers on biosecurity in poultry production. Companies should also take measures to reduce the negative impacts on the environment which will thus reduce social conflicts with the communities surrounding the PPCs.The PPC model, which concentrates on different poultry farms in one area, is mainly driven by economic motives to achieve a new scale of economy and reduce transaction costs, however, it contradicts biosecurity requirements to prevent disease transmission by reducing poultry densities and isolating farms. Though PPCs are crucial for small producers to stay in the poultry business and maintain their livelihoods, small producers are more interested in expanding their poultry business and generating more income through PPCs, and are less concerned about enhancing biosecurity and environmental management. Given the intensity of poultry operations in PPCs (farms are densely packed into clusters) and the close proximity to residential areas in some PPCs, the risk of spreading infectious diseases increases. This is a paradox that can at least be partly resolved with good support services—from both the private and public sector—to ensure that farmers in all arrangements are better able to improve their livelihoods, while exercising good practices in biosecurity and environmental control. This research shows that good management and collective action in PPCs are the keys to reducing biosecurity risks.Each research team involved in this study received ethical clearance from the related authorities in each country before the study began.Multilingual abstracts in the six official working languages of the United Nations.(PDF 229 KB)Additional file 1:


Nonsuicidal self-injury (NSSI) and suicidal behaviors, both important issues in adolescent health care, are frequently associated and possibly clinically related. Our objective was to explore the views of relations between nonsuicidal self-injury and suicidal behaviors during adolescence and young adulthood (11–25 years) expressed in the scientific  literature. We adopted a textual approach to the process of synthesis to tell the story of the findings from the included studies. Our narrative systematic review of 64 articles found that they share the same risk factors. Integrated models envision nonsuicidal self-injury as a gateway enabling teens to acquire the capability for suicide. Because suicidal behavior short-circuits thought, it is difficult to conceive an intention to die during adolescents' acts of self-injury. Intention is constructed by the narrative of the act, influenced by numerous elements from the psychopathologic, cultural, religious, and philosophic context. Techniques of mentalizing-based treatments and work on the meaning that adolescents attribute to their behaviors might improve care. Nonsuicidal self-injurious behavior (NSSI), also referred to as self-mutilation  is a relatively frequent behavior in adolescents and young adults (jointly described hereafter as young people ) and is In the United States, the mean prevalence of NSSI in the clinical population of hospitalized adolescents is around 35% ,12–14, wSuicide is also an important concern in adolescent health: it is the second leading cause of death among those aged 15–29 years , and 4 tThe risk of both suicide attempts and suicide is significantly higher in those who have engaged in NSSI. Among those with a history of NSSI, 70% have attempted suicide at least once and 55% several times ,30. The NSSI and suicidal behavior also raise problems in terms of their management: access to care is often difficult for adolescents  , and thiself-injury, deliberate self-harm and nonsuicidal self-injury (NSSI). One such term is self-injury which includes NSSI but also behavior such as exposing oneself to violent situations, trichotillomania, ingesting drugs, etc. Another is deliberate self-harm which comprises all NSSI behavior and intentional drug overdoses. The term we use here, nonsuicidal self-injury (NSSI) [The distinction between NSSI and suicidal behavior is not always clear in the terminology used–a lack of clarity that illustrates their conceptual proximity : numerouy (NSSI) , was choy (NSSI) –40. Despy (NSSI) . In viewy (NSSI)  organizey (NSSI) , on the y (NSSI)  resembleThese and other attempts at definition and classification share a concern for clarity and the particularity of being simultaneously descriptive and atheoretical . The exiIn our daily clinical practice, NSSI and suicidal behaviors appear to be closely linked. We thus decided to survey what the literature says about their associations and to examine how research and theory envision them. Accordingly, the objective of our narrative systematic review is to examine the association between NSSI and suicide in young people (age 11–25 years) in the scientific  literature, focusing on papers that study the intentions underlying these acts. Specifically, we seek to refine the nosographic classification of these phenomena. The issue is to pinpoint these behaviors and their reciprocal interactions to improve their assessment and their management and thus to limit their often serious complications. We present the different integrated models that have attempted to establish an association between NSSI and suicide and discuss their limitations. This requires a better characterization of NSSI, which can be simultaneously seen as a symptom of various psychiatric disorders, an individualized syndrome, or part of a spectrum of self-injurious behavior that includes suicide. We have chosen to apply a textual approach to the process of synthesis in order to tell the story of the findings from the studies included here.This is thus a narrative systematic review of the topic of the associations between suicidal and NSSI behaviors in adolescents. Narrative systematic review makes it possible to synthesize findings from multiple studies when statistical meta-analysis is not feasible  S1 PRIS.This inductive systematic work includes six steps:Definition of the research question and the objectivesManual literature review to select the principal papers on the topic and to construct key words and inclusion and exclusion criteriaSystematic review and identification and selection of studiesAnalyzing the papers, extracting their data and identifying their themesGenerating a thematic analysis and structuring the synthesisWriting the paperOur clinical experience with adolescents presenting self-injurious behaviors has led us to question the heterogeneity of their profiles and the apparent associations between NSSI and suicide (step 1). An initial literature search ,48 allowPublished in EnglishBetween January 1990 and January 2014Considered the association between NSSI and suicideAdolescent and young adulthood population (11 to 25 years when specified)All methodologies were included .Finally, the following studies were excluded:Studies focusing on specific medical conditions such as psychosis, autism, mental disabilities, or chronic somatic suffering (diabetes or chronic pain for example)After elimination of duplicates, we obtained 1355 references . Two autThe data extraction was performed after reading carefully the complete articles. Three researchers  independently extracted and analyzed the data and developed categories inductively from the themes identified in these studies (step 4). The data were then reported descriptively, cross-classified, shared, and distributed throughout the various subthemes, in a narrative synthesis. As our objective was to explore the views of the relations between NSSI and suicidal behaviors in literature, we have chosen to focus on words and narrative results instead of statistical results per se. Results were nonetheless extracted according to their level of relevance and regrouped according to their common themes. Finally we ordered these results into a framework containing two themes (step 5). The last step consisted in expressing the synthesis in a useful form (step 6). This process led not to a summary of the different studies included, but to an interpretation of the papers, described in the discussion.This review consists of a thematic construction in an analytic framework of data from this research, intended to present a narrative report of the existing literature on the nosographic questions concerning self-injurious behaviors.shared risk factors, the contribution of intergroup comparisons, whether NSSI is a risk factor for suicide or not, and intentions underlying NSSI and suicidal behaviors. The integrated models are the second theme and include three subthemes: the gateway theory, the third variable theory’ and Joiner's theory: pain tolerance and capability for suicide.In all, we examined 64 studies that questioned relations between NSSI and suicidal behaviors in adolescence and young adulthood. S2 Table details the characteristics of each study. The thematic analysis of scientific literature clearly showed two themes. The first is an exploration of the association between suicidal behaviors and NSSI and comprises four subthemes: The association between NSSI and suicidal behavior is expressed in different ways. Here we describe some different aspects of this relation, organized in four subthemes.First, NSSI and suicidal behavior share some risk factors ,49:among the psychiatric comorbidities: depression, borderline personality disorder ,20, subsamong the contextual, relational and traumatic factors: history of sexual abuse or physical violence , family Some authors have suggested the potential value of intergroup comparisons ,26,54–56Young people with both types of behavior (NSSI+SB) are at higher risk of psychiatric symptoms or at least of psychological vulnerability than the other two groups (NSSI group and SB group). For example, the adolescents in the NSSI+SB group are diagnosed more frequently than the others with major depressive episodes or posttraumatic stress. They more often present symptoms of self-denigration, anhedonia, and impulsivity. They also report more suicidal ideation and fewer reasons to live. This suggests that the multiplicity of means of self-injury forms a group of patients with more clinically severe disease . MoreoveFrom another perspective, numerous works have studied the correlations between NSSI and suicidal behaviors. Some authors treat NSSI as an important risk factor predictive of concomitant or subsequent suicidal behavior or ideation ,44,57,58Nonetheless, there are numerous methods of self-injury , and somOther authors argue that NSSI should be envisioned as protective against suicidal behavior. This is the anti-suicide model . NSSI isWhat elements distinguish NSSI from suicidal behavior? The central difference is that suicide attempts involve a conscious intention to die, through the abolition of consciousness ,64. AccoNonetheless, intentionality appears to be a theoretical difference, difficult to clarify clinically: it complicates the question. It is difficult for mental health professionals to assess clinically what adolescents think and say about death, especially their (the adolescents') own, for these thoughts and accounts depend on their character, education, and culture. Young people most often mix together their seeking of relief and their ideas of death ,69. DiffSeeking a more thorough theoretical comprehension of this topic, several authors have set themselves the task of understanding why and how NSSI is a predictive factor for suicidal behavior for some patients but not for others. Integrated models have proposed several readings of the link between NSSI and suicide.Some began by envisioning the concept of a continuum or spectrum ,70,71, cA second model assumes the existence of a third variable, the presence of which links NSSI and suicidal behavior (the Third Variable theory). It is based on the sharing of risk factors and on the high prevalence of similar psychiatric diseases in young people who have died by suicide and those with NSSI (90% vs 87%) ,75. The The two models presented above envision the association between NSSI and suicidal behavior restrictively, with NSSI considered either as a risk factor (Gateway Theory), or as a comorbidity (Third Variable Theory). They have major theoretical and clinical limitations and have been undermined by some recent studies ,26,54; nTowards this end, Joiner  developeJoiner  conserveReinforcing this theory, Muehlenkamp and Gutierrez  show thaSeveral authors see NSSI as a strategy of emotional adaptation and regulation ,65. If tThe variable of capability for suicide has direct clinical interest for both primary and secondary prevention. Identifying a subtype of patients at higher risk would make it possible to provide graduated management and more supportive care to the patients at the greatest risk of suicidal acts .Our literature review has allowed us to explore diverse aspects of the relation between NSSI and suicidal behavior. All of these behaviors directed against the self share the same terrain of fragility and risk factors; they are also statistically correlated. NSSI thus appears to be a risk factor predictive of subsequent suicidal behavior. This result has been used in the development of several integrated models, the most recent of which includes the concept of acquiring the capability for suicide through NSSI. Most of the studies on this subject begin by distinguishing NSSI and suicidal behaviors according to the intention to die. This intention appears to us to be central but also very difficult to assess in clinical situations. The definition of behaviors with and without death as their intention has made it possible to set up groups of patients accessible to research. Nonetheless, the assessment of adolescents with such different profiles and clinical histories seems close to impossible to us. In our view, this question cannot be resolved completely, both because adolescents cannot imagine death at the moment they are acting out these behaviors and because of the act’s communicative value. NSSI and suicide attempts thus appear to be behaviors on a single continuum of self-injury. We think that a distinction based on the intentionality of the action does not justify the conclusion that a desire for death was not present during NSSI nor does it differentiate NSSI from suicidal behavior.The question is what a desire to die can mean to young people. Behind intentionality lies the question of the representation of one's own death at this age. Adolescence is not only a period of construction and transition, but also the stage when awareness of death develops. Adolescents are confronted with the need to grieve for the immortality of their childhood. The concept of death appears to follow a developmental progression , as founIt is thus both frequent and normal for adolescents to think about death. Adolescents regularly develop interests in symbols of death and in music groups that convey these symbols. These thoughts can be considered to be a necessary psychological development: with puberty, the feeling of death, anxiety about death, and ideas of death, seen as irreversible, universal and inevitable, fuse to approach knowledge of death –89. The Nonetheless, one's own death is unthinkable: according to some authors, death is an ontological impasse . It makeSeeking to assess the intentionality underlying the act thus appears contradictory. In NSSI as in suicide attempts, the act short-circuits the thought. Before the act, death is thought, symbolized: it may appear fascinating, attractive, or not. After the act, it becomes urgent to create a narrative of the event. This is the moment when intentionality appears to be constructed, in an attempt to give a meaning to the act. At this stage, adolescents may or may not allow themselves to talk about suicidal behavior.Numerous elements can interfere with this process (of meanings). In the first place, the reaction of family and friends and the relational value they give to the act appear central. We know the communicative value given to self-injury, which is sometimes interpreted as aggression or rejection ,92. But Additional studies thus appear necessary to examine this question in greater detail, to take into account the complexity of the context, and to explore further the subjective experience reported by patients. Qualitative studies are perfectly adapted for the in-depth study and detailed understanding of these complex questions of behaviors .It is possible to associate the difficulties presented by adolescents who self-harm with defective mentalization . MentaliS1 File(DOC)Click here for additional data file.S1 PRISMA(DOC)Click here for additional data file.S2 PRISMA(DOC)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Bacillus anthracis, a Gram-positive spore-forming bacterium, is initiated by the entry of spores into the host body. There are three types of human infection: cutaneous, inhalational, and gastrointestinal. For each form, B. anthracis spores need to cross the cutaneous, respiratory or digestive epithelial barriers, respectively, as a first obligate step to establish infection. Anthrax is a toxi-infection: an association of toxemia and rapidly spreading infection progressing to septicemia. The pathogenicity of Bacillus anthracis mainly depends on two toxins and a capsule. The capsule protects bacilli from the immune system, thus promoting systemic dissemination. The toxins alter host cell signaling, thereby paralyzing the immune response of the host and perturbing the endocrine and endothelial systems. In this review, we will mainly focus on the events and mechanisms leading to crossing of the respiratory epithelial barrier, as the majority of studies have addressed inhalational infection. We will discuss the critical gaps of knowledge that need to be addressed to gain a comprehensive view of the initial steps of inhalational anthrax. We will then discuss the few data available on B. anthracis crossing the cutaneous and digestive epithelia.Anthrax, caused by  Bacillus anthracis, the etiological agent of anthrax, is a Gram-positive, spore-forming bacillus. Dormant spores are highly resistant to adverse environmental conditions and they are able to survive for long periods in contaminated soils , anchored to the cell wall  without needing to be transported to the draining lymph nodes , 2008. SB. anthracis crossing the cutaneous and digestive epithelia.In this review, as the majority of studies have addressed inhalational infection, we will focus mainly on the crossing of the respiratory epithelial barrier Figure ; subsequB. anthracis with lung-derived cells, the majority of studies having been performed with cells originating from other sources .As will be apparent, relatively limited data are available on the interactions of This section is divided in two parts. We will first examine the available data on binding, capture of the spores and subsequent immune cell activation. Then, the data on subversion of the immune response by the toxins will be detailed separately. It is in fact still unclear whether toxins affect crossing the epithelial barrier, though some evidence indicates that they might. We will conclude by considerations upon the critical gaps of knowledge that will need to be addressed to gain a comprehensive view of the initial steps of inhalational anthrax, and envision more targeted therapeutics.Bacillus anthracis enters the host as spores. Spores are a dormant form of the bacteria. They do not present any detectable metabolic activity. They thus depend on host signals to trigger germination. During germination, spores rehydrate, resume metabolic activity, shed the external crystalline layers forming the coat and exosporium, and differentiate into bacilli, the active form of the bacteria. Bacilli produce the virulence factors that enable successful colonization of the infected host. As spores are dormant, they cannot actively cross the epithelial barrier and thus need to be captured by host cells. However, some reports have shown that B. anthracis spores can undergo germination in the respiratory tract , enhancing phagocytosis by human monocyte-derived macrophages . Absencein situ, probably through the presence of germinants at this location, which could originate from the inflammatory response and danger signals produced in response to the aggression. Bacterial growth and expression of virulence factors (capsule and toxins) then occur, enabling the bacteria to survive and colonize the host locally at the site of entry, and then to migrate via the lymphatics to the draining lymph node, before entering the blood through the thoracic duct and disseminating systemically , DC, and, more recently, the epithelial cells lining the respiratory tract.Alveolar macrophages are a population of resident macrophages that are present in the alveolar spaces . They orneg or low in mouse , a highly efficient endogenous antibiotic, CXCL-8 and the inflammatory mediator prostaglandin PGE2  suggest that AM are an efficient first line of defense, able to capture spores and contain bacilli outgrowth.Evidence for germination of urine AM  confirmeinea pig . As sporinea pig . This ininea pig . FurtherAlong with the resident AM population, recruitment of monocytes in the alveolar space occurs rapidly—the size of the population increases as soon as 6 h after instillation in a murine model . These cInterestingly, what is now considered is not the crossing of the epithelial barrier by the bacteria, but by the AM  carrying the bacteria. The mechanisms involved are thus those of eukaryotic cell–cell interactions. The mechanisms of trans-epithelial migration (paracellular versus transcellular) of the AM, or more generally of leukocytes, are still under debate . This po+ intra-epithelial DC that extend cytoplasmic processes between epithelial cells directly into the airway lumen; they perform sampling of the airway luminal surface. They can capture antigens, with an increased sampling after bacterial stimulation  lies beneath the epithelium of many mucosal surfaces. Microfold (M) cells are specialized epithelial cells that actively capture and transport soluble and particulate compounds across the epithelial barrier. They have been extensively studied and described in Peyer’s patch in the gut. The presence of a specialized epithelial cell type with similar functions has been observed in the respiratory tract in the rabbit and the mouse . Their rB. anthracis virulence factors.Clearly, owing to the paucity of data on the role of lung epithelial cells in inhalational anthrax, further studies should focus on this cell type to ascertain its contribution in infection control, and its subversion by NeutrophilsB. anthracis inhalational infection, few studies have addressed the potential role of neutrophils. Neutrophils are highly microbicidal cells that belong to the first wave of cell recruitment in an infected site and participate in host innate defenses and adaptive immunity  also referred to “patrolling” monocytes thought to patrol and maintain endothelial cells; and on the other hand “non-classical” monocytes , sometimes referred to as “inflammatory” monocytes, as they can serve of precursor of macrophages and DCs under inflammatory conditions  in rabbits , probably non-physiologically encountered locally in the epithelium  and the mechanisms triggered will be different whether in the nasopharynx, along the bronchial surface or in the alveolar space. A better understanding of the relative importance of these different locations will lead to an increase in knowledge of the mechanisms involved and could lead to better targeted therapeutics.Finally, it should be remembered that a non-exclusive additional portal of entry could be at the site of a concomitant inflammatory and infectious lesion where the integrity of the epithelial barrier is affected. Indeed, when a lesion of the respiratory epithelium exists, infection initiates at the immediate site of the lesion .B. anthracis life cycle, as it will produce its virulence factors and subvert the host innate defenses. Defining the site of germination is thus critical to understanding whether crossing the epithelial barrier is influenced by toxin production.One main point of contention is the location of spore germination, and, by way of consequence, of toxin secretion, after entry into the respiratory tract. Germination is a key step for the Significant germination in the lung tissue has rarely been reported and was usually related to inadequate sampling procedures. For example, spore germination is triggered by homogenisation and physical pressure, especially when the sample temperature increases . From bain situ. Through histologic analysis, Ross observed early germination of spores of a wild-type B. anthracis in the guinea pig lung aerial space . We have detailed above the effects of the toxins on the different cell types encountered by B. anthracis in the respiratory tract. Depending on the portal of entry and the first cells encountered, the effects can be different and complex. In this case, a short time window will exist during which a delicate balance between subversion by the toxins secreted by the nascent bacilli and the killing mechanisms of the resident lung cells takes place.The corollary is that toxins may play a role in impairing the local immune response, as their expression is rapid upon germination  still inside the cells that helped them cross the barrier, or are they free on the basolateral side of these polarized cells? The classical view uses the concept of Trojan horse, or even “galloping” Trojan horse , where AAnother unknown is the number of spores needed to successfully cross the epithelial barrier and initiate infection. A very low number could possibly be sufficient, once the bacteria has protected itself in its capsule and paralyzed the immune defenses through secretion of its toxins. If this number is low, then epithelial cells, micro-lesions of the epithelium or a few lung DCs having successfully sampled the respiratory lumen, could play a significant role in establishing disease. Recent data on a model of A/J mice infected intra-nasally by spores of an encapsulated strain has identified two independent bottlenecks depending on the port of entry  is necessary (http://www.who.int/csr/resources/publications/AnthraxGuidelines2008/en/index.html). Cutaneous anthrax in humans is, in the great majority of cases, associated with a lesion. Germination is rapidly triggered upon access to the subepidermal tissue  anthrax has not been developed extensively, and ivestock . The rolivestock . Russellbacteria . More inbacteria . The ATRbacteria . In a mobacteria , while smmensals .B. anthracis, its host and its microbiota, and the way each reacts and adapts to the encounter. Specific intestinal microbiota may protect or favor the GI anthrax by competition or synergy. Among the factors that most probably play a significant role are bacterial competition with the endogenous intestinal flora, the relative levels of O2 and CO2 and the presence of anaerobiotic zones and their consequences on germination triggering and virulence factor production. Another intrinsic characteristic of the digestive tract is that its content is subjected to a constant transit, as it is an “open tube” in contrast to the respiratory tract, which is a “dead-end tube.”Clearly, further studies are required to understand the physiology of intestinal anthrax. The ecology of the intestinal tract is very different from that of the respiratory tract, in the sense that a third player –the microbiota- is affected along the infection. This will most probably influence the interactions between Digestive anthrax is usually considered as the main cause of infection in animals. The physiology of infection in polygastric ruminants certainly presents specificities. As the main origin of natural infection in humans is through handling of animals having died from anthrax or of their derived products, a better understanding of veterinary infection may help devise better epidemiologic control both in animals and in humans.The last decade of intensive funding on bioterrorism after the 2001 bioterrorist attacks has yielded a number of advances in knowledge on anthrax pathogenesis and some novel therapeutics, but important gaps of knowledge remain.in vivo and have helped unravel key steps in the interactions between B. anthracis and its host, such as detection of new portals of spore entry . New dynamic imaging technologies from the animal down to the microscopic level have improved our knowledge on this insidious and dreadful disease. Emerging “omics”  technologies will further help to elucidate additional avenues to control the infection. This integrative approach may lead to a better understanding of dynamic biological processes in the context of intact organ systems.Non-invasive imaging technologies have recently enabled real time tracking of the infection B. anthracis infection require these technologies to be available in BSL3 (or at least in BSL2) confinement, thus requiring financial commitment and investment, together with a political will to dedicate costly equipment to infectious studies. In the meantime, data gained with the available models and tools help shape an interpretative model of what occurs in human infection. Each animal model has its limits that one should be aware of, and the intrinsic value of the data obtained in each model should be recognized, as they may help focus on key steps/events when translation to larger animals will be possible  regulation in France. If these microbial threat lists have afforded some benefits for the society in term of biosecurity and biosafety, their drawbacks have also affected the scientific community, by limiting the access to the pathogen to well-funded labs and increasing the costs for the institutions housing laboratories working on biodefense. The reactions of the scientific community to the implementation of these new regulations have been very limited so far (An unexpected consequence of the anthrax letter attack has been the implementation of very restrictive laws and regulations to control the access to and the use of microorganisms and toxins known as the Select Agents and Toxins List (SATL) in the USA , and Micd so far , but theB. anthracis spores, the epithelial cells and all the residing and recruited immune cells. The pathogens are confronted with “intelligent gateways” that react and adapt to the incoming danger, raising the defense machinery of the host. B. anthracis, in response, has either to remain silent during the crossing and exploit the natural sampling mechanisms of the host, or attempt to subvert these defenses with its toxins and maybe sacrifice itself while enabling other spores to cross the barrier more easily.Crossing the epithelial barrier is not a passive phenomenon, nor is it a simple mechanical transfer of particles across a barrier. It represents a complex network of interactions between the pathogen, even for inert particles as The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This paper introduces the reader to the characteristics of methamphetamine. Explored within are the drug's effects on those who consume it as well as the history and prevalence of its use. The highly addictive nature of methamphetamine is compounded by its affordability and the ease with which it is produced, with North America and East Asia having become established as heartlands for both consumption and manufacture. The paper discusses recent cultural depictions of the drug and also the role that mental health professionals may take in designing and delivering interventions to treat methamphetamine addiction. Unlike cocaine though, a single dose of methamphetamine sustains these effects for many hours. Methamphetamine can be smoked, snorted, injected or swallowed. The psychological effects of long-term use include hallucinations and delusions, depression, suicidality and aggression.5 Withdrawal may exacerbate these symptoms, while also leading to fatigue and intense craving.6 Long-term health effects are considerable, and include neural damage and associated cognitive impairment,7 cardiovascular damage,8 dental disease9 and stroke.10 The drug is also associated with risky sexual behaviour, resulting in a high prevalence of sexually transmitted disease.11 Methamphetamine is also noted for its addictiveness. Evidence shows that addiction occurs more rapidly than with cocaine12 and that unlike with amphetamine, methamphetamine-seeking behaviour may persist even when tolerance is reached.13 The trajectory of methamphetamine use over a 10-year period has been found to resemble that of heroin more so than that of cocaine.14 Methamphetamine is also associated with criminality15 and social decline.16 It therefore represents a major public health, social and political dilemma.Methamphetamine (‘meth’) is a stimulant which increases levels of monoamines  in the central nervous system. Its pharmacological effects occur via a number of neurochemical processes, including disruption of vesicular17 In the USA during the 1960s and 1970s, methamphetamine was produced and trafficked mainly by motorcycle gangs, mostly in California.18 Patrons were typically White, male, blue-collar workers, but the drug has since become popular among white-collar workers, students, ethnic minorities and women,19 and manufacturing has spread to Midwestern states.20 One of the principal factors in its rise is the ease with which it can be manufactured. The chemicals necessary for its production  are relatively easy to obtain, as is the equipment required for the ‘cooking’ process. This has led to a cottage industry in methamphetamine production, with home-based laboratories being commonly uncovered by law enforcement agencies in the USA21 and in other parts of the world, particularly in Asia.22 In addition to the home lab phenomenon, there exist industrial producers of methamphetamine, who manufacture and transport large quantities of the drug.23 In North America, large-scale production occurs in both Mexico and Canada and the product is then brought across the border for sale within the USA. In the USA itself, 4.7% of respondents to a national survey admit to lifetime use of methamphetamine.24Across the world, methamphetamine use as a recreational drug has increased significantly since the 1990s, and it is reported as the second most widely misused substance, exceeded only by cannabis.23 when military stocks of methamphetamine flooded the market, giving rise to high incidence of misuse among young people. A second epidemic occurred in the 1970s, when use soared among blue-collar workers. This crisis has now stabilised and Japan's methamphetamine users now represent an aging population. Since the 1990s, the popularity of methamphetamine has spread to other East Asian countries. By 2007, 63% of worldwide methamphetamine seizures occurred within the Southeast Asian region, and it is estimated that half of the world's methamphetamine users are found there.25 The Mekong region of Myanmar, close to the border of Thailand and China, is identified as Asia's most prolific production centre for methamphetamine. From there the drug is transported across the borders for sale in neighbouring countries.25 In Myanmar, it is usually pressed into pill form, known colloquially as yaba (‘crazy medicine’). Thailand has suffered its own epidemic, with methamphetamine treatment admissions rising dramatically in the late 1990s,26 but evidence of increasing methamphetamine use is also found in Brunei, Laos, the Philippines22 and Cambodia.27Data from Asia also indicate high levels of use. Japan has a long history of misuse, dating back to the 1940s,28 In Australia, use has increased in recent years but not dramatically.29 In South Africa, the past decade has seen a significant increase in treatment admissions for methamphetamine.30 This increase in methamphetamine use is positively associated with risk-taking sexual behaviour,31 which if unchecked may in turn exacerbate an already urgent HIV epidemic.In Europe, the meth epidemic has not yet arrived, perhaps because there is already a congested market for stimulant drugs, although the Czech Republic and to a lesser extent Slovakia have a history of high methamphetamine use.Breaking Bad. This drama describes the exploits of a terminally ill chemistry teacher who chooses to become a manufacturer and then seller of methamphetamine, initially to guarantee financial security for his family after his death. The series focuses on the corruption of the main character and the erosion of his relationships with those close to him. What is notable about the series though is that the problem of devastating effects of methamphetamine on individuals and communities occupies only a minor part in the story. The series has done much to publicise the existence of methamphetamine to households across the world, but in not fully exploring its sinister effects , the series runs the risk of sanitising or normalising this destructive drug to the wider society.The emergence of methamphetamine as one of the most widely used recreational drugs is associated with its rise in the media. Methamphetamine has become a cultural phenomenon, in much the same way that heroin, MDMA  and cannabis had become popularised already. The most obvious cultural reference to methamphetamine is in the hugely successful American drama series 32 exposes police custody photographs of users, showing images of the same individual at different points in time, so as to longitudinally chronicle the ravages of the drug on physical appearance. These before and after photos – which reveal apparently common features of long-term methamphetamine use: skin damage (caused by obsessive picking) and dental ill health 33 – are designed to shock and appal observers. The effectiveness of the scheme is difficult to assess due to the absence of trials, however, the use of fear and shock is not always an effective deterrent in health campaigns and is generally regarded as inferior to positive reinforcement approaches.34At the other extreme, also in the USA, there has been a widely publicised campaign to highlight the unpleasant physical effects of methamphetamine addiction. The ‘Faces of Meth’ project35 who argues that its focus on the visual effects of methamphetamine, mostly in White methamphetamine users, represents a type of social panic. Murakawa argues that historically, drug panics in the USA have been constructed in line with racial prejudices . Methamphetamine addiction is often described along racial lines as a ‘White trash’ phenomenon. Murakawa claims that decayed or missing teeth mark prevailing fears over the decline in White social status, as traditional representations of American so-called ‘White trash’ typically depict poor dental health as a visual indicator of lower class.The Faces of Meth-type approach has come under criticism from Naomi Murakawa,36 Psychosocial interventions have proved effective in the short term, but more evidence is needed to demonstrate long-term benefits.37 Community-based prevention schemes have also shown evidence of benefit.38 The promise shown by such interventions is encouraging, given the addictiveness of methamphetamine, the intensity and duration of cravings experienced by those who go through withdrawal6 and also the psychological comorbidity. Interestingly for mental health professionals, there is evidence that the cost-effectiveness of treatment39 and prevention38 approaches may compare favourably with alternatives, such as, for example, interventions by law enforcement to disrupt the supply of the precursor chemicals needed for methamphetamine production.40 Furthermore, given the advance of this drug across Asia and North America and its potential for expansion across thus far untapped markets (e.g. Europe and Africa), the further development of robust treatment programmes for the future is urgently needed.Given the prevalence of methamphetamine use across the globe, considerable effort has been put into designing effective treatment programmes for its users. Broadly speaking, these interventions are pharmacological, psychosocial or community-based prevention approaches. The evidence in favour of pharmacological treatments is mixed, although some promising findings with modafinil, bupropion and naltrexone have been reported.


A case of conjoined twins with monocephalus, thoracopagus, partial abdominopagus, tetrabrachius and tetrascelus in lambs complicated with several defects of skeletal, cardiovascular, gastrointestinal, and urogenital systems is reported. The twins were dead and delivered by cesarean section. This case report highlights the detailed anatomical study of defects in different systems due to an abnormal birth defect. Sometimes the separation is not complete and the twins remain conjoined to various degrees and at almost any site of their bodies , and more commonly in cattle than in other ruminants . In sheep, the failure of separation most commonly involves the cranial region, whereas in cattle, the defect is most typically confined to the caudal region .Conjoined twinning has been reported in most domestic animal species. It occurs rarely in horses, occasionally in dogs and cats . As a result, only one umbilicus and one mixed umbilical cord with a tendency toward the left one was formed . There wConsequently a detailed dissection was done as an anatomical survey. The dam and lambs were not examined for congenital anomalies caused by viruses.The conjoined twins had a single normal head with normal structures; the occipital bone also had a single foramen magnum. In the cervical region, there was one atlas with two vertebral foramens, and paired axes articulated with each other medially .The rest of the vertebral column was bifurcated at the C3 and extended caudally to include 2 distinct tails, whereas bifurcation of the spinal cord was just caudal to the foramen magnum .There were 8 limbs: 4 brachial (Tetrabrachius) and 4 pelvic (Tetrascelus). One forelimb of each twin was situated on the normal site, but the other one located along the vertebral column and attached to its counterpart, belonging to the other twin by a common brachiocephalic muscle.There were also 2 sets of ribs and 2 sterna but only a single thoracic cavity was formed, which widened craniocaudally.The cavity was bound ventrally by a seemingly normal sternum, laterally by the 13 pairs of ribs, caudally by a broad diaphragm, separating the thoracic cavity from the abdomen, and dorsally by vertebral columns, smaller ribs, and the tip of the second sternum. The latter which passed caudad and laterad, was located between the diverging vertebral columns, deviated to the left side, and articulated with some additional ribs from the other twin. The xiphoid cartilage was attached to the hypoplastic diaphragm.There was one esophagus, 1 heart, 1 trachea, 2 lungs and 2 vagus nerves in the thoracic cavity. The esophagus after passing of a seemingly normal pathway was terminated at the cardiac orifice, situated at the fusion site of the double proventriculi, a little to the left side of the median plane .The lungs were smaller than usual, but their lobations were normal. Regarding the heart structure, except for a slightly dilated aortic orifice, no other defects were observed. Also, the cardiac septation was fully and normally developed. The left and right ascending aortae were fused together from their origins and formed a common stout trunk and continued cranially as a single brachiocephalic trunk and the right subclavian artery.The left subclavian artery was branched separately from the convexity of the left aortic arch. Interestingly, two subclavian arteries, the left and right, were arised caudally from the origins of the corresponding descending aortae. Only one pulmonary trunk was observed in the left side and that was connected to the left aortic arch by a single ductus arteriosus .In the left twin there was one pair of the umbilical arteries, but in the right twin only one single umbilical artery was observed  and 9.In the abdominal cavity, a complete duplication of spleen and liver was found which the right liver was larger than the left one.Double reticuli and rumens externally were fused together in the midline, the omasi were under grown and a complete fusion of the two abomasi had resulted in formation of a single abomasum .Two spleens were separately attached on either side of the fused rumens. The intestines from the pyloric portion to midway of the jejunum were single, but afterwards a complete duplication of the ileum, colon, rectum and anus was seen .The jejunum had numerous close coils around the border of the common mesentery and was irregularly positioned between the two colons in the center of the common abdomen . No atreet al., 2010).The frequency of congenital malformations varies with species, breed, geographical locations and due to many other factors. Various studies indicate that approximately 1.5% to 6% of all live-born domestic mammals show at least one recognizable congenital malformation . The genesis of congenital malformations is best regarded as an interaction between the genetic constitution of an embryo and the environment in which it develops.Such malformations are comparatively infrequent in cats but occur to an upper limit of 3–4% in sheep, cattle and horses and up to 6% in newborn dogs and pigs  twins.et al., 2007).Conjoined or fused symmetric twins are classified according to the nature and degree of union as thoracopagus ; pygopagus; craniopagus and ischiopagus . When these twins have a single head, it is called monocephalus. In this case, the failure of separation involved most structures cranial to C3, leading to the appearance of duplication of both the axial and ab-axial portions of the skeleton and associated organs. This particular combination has only been reported in a dog , but there are some differences and new additional findings. The causality of birth defects is not necessarily genetic in origin and various aetiological categories can be recognized: Chromosomal anomalies, Polygenic disorders, Single gene mutations, Environmental/teratogenic factors, Multifactorial aetiology and Unknown aetiology.Our case is similar to the conjoined twin lambs reported in 2010 (Spiers The embryo does not occupy a completely protected and privileged environment and, in some respects, is as open to effects from its environment as the neonate or adult. Also, teratogenic materials in one species do not necessarily cause malformation in other species.The present case has been under intensive care during the pregnancy based on the owner’s statements. Hence, the anomaly does not seem to be caused by grazing freely.The reason for this anomaly in this sheep could not be ascertained, as no further tests or assays were carried out.