Until recently the Chittagong Hill tracts have been hyperendemic for malaria. A past cross-sectional RDT based survey in 2007 recorded rates of approximately 15%. This study was designed to understand the present epidemiology of malaria in this region, to monitor and facilitate the uptake of malaria intervention activities of the national malaria programme and to serve as an area for developing new and innovative control strategies for malaria.Plasmodium falciparum. The project included the following elements: a) a demographic surveillance system including an initial census with updates every four months, b) periodic surveys of knowledge attitude and practice, c) a geographic information system, d) weekly active and continuous passive surveillance for malaria infections using smears, rapid tests and PCR, f) monthly mosquito surveillance, and e) daily weather measures. The programme included both traditional and molecular methods for detecting malaria as well as lab methods for speciating mosquitoes and detecting mosquitoes infected with sporozoites.This research field area was established in two rural unions of Bandarban District of Bangladesh north of Bandarban city, which are known to be endemic for malaria due to Anopheles species, eight of which were positive by circumsporozoite ELISA. The annual rate of malaria was close to 1% with 85% of cases in the rainy months of May-October. Definitive clustering identified in the low transmission season persisted during the high transmission season.The demographic surveillance enumerated and mapped 20,563 people, 75% of which were tribal non-Bengali. The monthly mosquito surveys identified 22 This demographically and geographically defined area, near to the Myanmar border, which is also hypoendemic for malaria, will be useful for future studies of the epidemiology of malaria and for evaluation of strategies for malaria control including new drugs and vaccines. Bangladesh is one of the 109 countries listed by the World Health Organization as having endemic malaria. Within Bangladesh, 13 of the 64 districts are considered to have endemic malaria, with 26.9 million people living in these 13 districts, a population larger than many African countries, which illustrates the scope of the risk from malaria. The government of Bangladesh, with financial assistance from the Global Fund for AIDS, TB and Malaria, recently initiated programmes to control malaria in these districts. The primary interventions for the programme have focused on distribution of insecticide-treated bed nets, malaria diagnosis at the field level using rapid diagnostic tests (RDT), and artemisinin-based combination therapy (ACT) as the first-line of treatment. Reports from district hospitals in these endemic areas demonstrate a reduction in the numbers of cases detected since the programme started in 2008; however, it is not clear if this reduction is due to the programme activities, to climate related variability in rates from year to year, or differences in the ascertainment of cases. These reports are based on cases treated at health facilities, which may not reflect the true rates of malaria since many patients may not seek treatment or reach a facility. Thus, the true rate of malaria in the endemic districts is not well documented.Plasmodium falciparum, 5% by Plasmodium vivax, and the remaining by mixed infection. Asymptomatic prevalence in five southeastern districts was 40/1,000 versus 2/1,000 population in the eight northeastern districts. Such high rates of asymptomatic malaria infection suggested a need for further surveillance and control measures.A cross-sectional survey for malaria infection was conducted in 2007 by International Centre for Diarrhoeal Disease Research, Bangladesh  with BRAC to establish a baseline estimate of malaria prevalence in the population living in the 13 malaria endemic districts [While most control strategies, as well as surveillance methods, are focused on symptomatic malaria, transmission of malaria occurs because of circulating gametocytes often from asymptomatic individuals. Unfortunately, little is known about the epidemiology of gametocyte infection in Bangladesh, but reducing transmission will depend on an improved understanding of all phases of malaria infection in both humans and the insect vectors.Though the malaria burden among symptomatic patients is beginning to be understood for Bangladesh, there may be specific subgroups, which are especially vulnerable to increased mortality and morbidity from malaria, especially pregnant women. In other geographic areas, malaria increases the risk of mortality for the mother during pregnancy and increases the risk for low birth weight in the infant -4.P. falciparum, and their relative accessibility. Residents of these unions are predominantly tribal people who speak their own language and not Bengali. The study area is close to the border with Myanmar and thus provides information of relevance to the Southeast Asia "ecozone" for malaria. This ecozone has been the source for isolates of malaria, which are resistant to multiple drugs. Thus, the Bandarban study area was felt to be an appropriate site for monitoring for emergence of drug resistance in the future. Being hypoendemic, it seemed that the study site could be a potential site for future studies of innovative control measures. Such studies carried out in the Bandarban field area of Bangladesh may be relevant to other countries in the Southeast Asia ecozone and potentially to other areas which are becoming hypoendemic as control measures reduce rates of malaria in previously hyperendemic areas.In order to better define the epidemiology of malaria in an endemic area of Bangladesh, the ICDDR,B in collaboration with the Johns Hopkins Malaria Research Institute (JHMRI) established a surveillance system for malaria in an area of the Chittagong Hill Tracts in Southeast Bangladesh. The area selected for the surveillance was the two unions north of Bandarban town , each with a population of about 10,000 people. The selection of these unions was based on data from the initial survey showing relatively high rates of malaria due to Although the two unions selected for the surveillance activity are adjacent, they also have some contrasting features. Kuhalong is more forested and hilly, whereas Rajbila tends to have more rice fields. The earlier baseline survey conducted in a small number of subjects suggested that Kuhalong had higher rates of malaria ; however, based on these small numbers it was not possible to establish with certainty which union had a higher disease burden . KuhalonThe objectives for the project are shown in Table When the two unions were identified as areas which seemed to be ideal for the project, the Upazila (an Upazila is the name given for a sub-district in Bangladesh) Health and Family Planning (UHFP) office in the Bandarban district office was contacted to discuss the purpose of the investigation. Since malaria had already been identified as one of the high priority problems in this area, the officer was very cooperative in assisting with the project. UHFP had information about the population in the two unions; however, this information was several years old; thus, the need to carry out new data collection of the population was discussed. The UHFP office provided two experienced staff members to assist in planning the project. These staff members from the UHFP office were very familiar with the unions of Kuhalong and Rajbila, were from the same tribal communities, and were fluent in the tribal languages.Together with the UHFP staff, discussions were held with local community leaders, including all levels of leaders called Karbari, Headman, Union Parishad Chairman, and the Upazila Vice Chairman, to explain the purpose of the project and the proposed activities, including establishing a demographic surveillance system. Prior to actually starting the project, a meeting was held at the Bandarban Hill District Council Auditorium where most of the District & Upazila level Health & Family Planning Officers, NGO leaders, Upazila Chairman, Union Parishad Chairman & Members, Headmen and Karbaris participated. During the meeting, the project was described, and the participants had the opportunity to ask questions to the investigators. The general response was favorable since malaria was already known to be the major health problem of the area, and because the ICDDR,B has an excellent reputation in the country for its humanitarian services. The leaders were pleased that this effort was being made to help control malaria for their people.Baseline information on the populations of Kuhalong and Rajbila was collected during March and April, 2009 using locally hired surveillance workers. These workers recorded the numbers of persons as well as the global positioning system (GPS) coordinates of each household. The data was validated for consistency and completeness at the end of each day and problems were resolved the following day by revisiting the households. Random checks were carried out by a senior health assistant to ensure that data were properly noted on the forms.GPS coordinates were imported and mapped in a geographic information system (GIS) using ArcGIS9.2 . The map demonstrated that households were highly clustered within the unions. The clustering was likely the result of the terrain and hills, which is quite different from the plains of Bangladesh where people are spread more evenly throughout the countryside. These maps were then used to divide the unions into geographic clusters Figure . The uniUsing the baseline listing of the households, teams of surveillance workers visited each house to conduct the census, to administer a detailed survey and to confirm the GPS reading. A unique identifier or respondent ID (RID) was used to identify each person, which included a 1-digit union code, 3-digit cluster code, 3-digit para code, 3-digit household number and a 2-digit individual member number. The format is, therefore, as follows: RID: □-□□□-□□□-□□□-□□. A number was painted on the front door of each house corresponding to the first 10 digits of the RID number to be used by the field workers during subsequent visits. The initial visit included documenting the information on each member of the household, including age, sex, and relationships. Follow-up visits were then conducted every four months to update the census records by collecting vital events, which had occurred during these intervals.Information on pregnancy was collected by the DSS surveillance during each visit. Thus, the database includes information on pregnancy from a relatively early stage to ascertain pregnancy outcomes as well as any possible complications related to malaria. Pregnancy was documented only by history but not confirmed using pregnancy tests.The DSS system used certain definitions. A "resident" was a person who resided in the study area continuously for at least three months during the past 12 months. A "visitor" was a person who remained in the study area for at least one week at a time, but stayed in the area less than three months during the past 12 months. The category of "visitor" was needed since the malaria surveillance intended to include all persons present in the surveillance area during the study period regardless of permanence residency. A "visitor" however could become a "resident" during the study if he/she met the defined criteria.Information was collected from each household to determine the socio economic status and to identify the knowledge, attitudes, and practices (KAP) of the families in the area with regard to malaria, malaria treatment, health seeking behaviour, and use of bed nets. The first round of KAP surveys was administered at the same time as the initial DSS survey and subsequent KAP surveys are scheduled to be carried out periodically to observe changes over time.The field work was conducted by locally hired surveillance workers (SW). The SWs were hired through a competitive process , with nearly all being tribal people. Thus, the SWs spoke the local languages and were familiar with the customs and geographical features of the area. Most of them had worked in other non-government organizations and had some experience with data collection.The workers were trained in the specific research methods to be undertaken, including approaching and communicating with persons in the community, obtaining informed consent, obtaining the relevant survey information and filling in the forms properly, weighing subjects, obtaining finger prick blood, preparation of blood slides, collection of blood using the rapid diagnostic kits, interpreting the results of the rapid test, obtaining blood on filter paper for PCR, and mosquito trapping procedures. They were also trained in the appropriate use of anti-malarial drugs according to the national guidelines as well as the guidelines for referral of severe cases. Figure Hiring of SWs was initiated in June 2009 and their field work in Kuhalong began in October 2009. Field work in Rajbila began in April 2010. The SWs in each union were divided into five teams with two persons in each team. One team was designated to carry out the DSS survey, three teams were designated for the active malaria surveillance and one team was designated to conduct mosquito surveillance. The teams were supervised at the first level by a Field Assistant (FA), and at the second level by the Field Research Manager (FRM) and a medical officer (MO). The FA was selected from among the SWs eight months after initiation of the project based on his/her performance in the field. The MO was a local, qualified, physician who had completed post-graduate studies in Public Health from Australia.Before initiating the field activities, an experienced Field Research Manager (FRM) was transferred from another project to help with communications with the community. Being a tribal person with more than 20 years experience working in field projects with the ICDDRB, he was familiar with the local customs and language as well as with field epidemiologic methods. Together with other project staff, he visited the communities and discussed the project with local leaders and administrative officials. When the teams went to the households to request their participation in the study, they obtained the informed consent of the head of each household or his/her representative. This consent allowed for the collection of information for the Family Visit Register (FVR), which included the names of all the household members, the relationship with the household head, age and sex. A copy of consent form and completed FVR were given to the head of the household.In addition, for those households or persons who were included in the active and passive surveillance or the mosquito surveillance, written informed consent was obtained from each household or subject . Copies of the consent documents were given to the individuals who were enrolled.Weather information was obtained from Bandarban from the Ministry of Agriculture, Soil Resources Development Institute which had been measuring the following parameters daily for over ten years: temperature , dew point, humidity, soil temperature at 5, 10, 30 and 50 cm, wind direction and speed, span of sunshine, evaporation and daily rainfall.Active surveillance was conducted on a random sample of persons throughout the year. Each of the 12 clusters had roughly equal numbers of households. The sampling design was based on clusters stratified into 3 groups . Sampling was also stratified by age: 6m- < 5y, 5y- < 15y and > 15 yrs. Information and blood samples were obtained every week from four individuals from each age group in each cluster group . Two of the 12 subjects were followed for one year as part of a longitudinal surveillance process. These two persons were selected at random from the DSS listing for the union. Using this sampling procedure, a total of 624 samples, equally divided between the three age groups, were collected over the course of one year. Additionally, all pregnant women were invited to participate in both active and longitudinal surveillance.P. falciparum and P. vivax. Persons with a positive malaria smear or rapid test were provided with Coartem®, according to the national guidelines [During visits for the active surveillance, information related to symptoms of malaria were obtained, and a blood sample was obtained for a malaria smear for microscopic examination, a rapid diagnostic test , and a filter paper sample for PCR. The blood sample was obtained regardless of symptoms. This rapid test identifies antigens for both idelines .Information from symptomatic cases of malaria was obtained by field workers during their visits to the community. These were detected either directly from family members who alerted a SW about a person with fever or from another group of health workers from a nongovernmental organization (BRAC) which were providing services for malaria as part of the national programme. In either case, when a person with fever became known to an SW, the patient was visited, a blood sample was obtained for a malaria smear, a RDT , and a sample was taken for PCR using filter paper. If the rapid test or the smear was positive, the patient was provided with Coartem, according to the national guidelines. The resPersons with malaria, regardless of whether detected during active or passive surveillance were visited on days 2, 7 and 28 to inquire about the persistence of symptoms and to obtain additional samples for microscopy, rapid test and PCR.Anopheles mosquitoes were preserved in a separate vial (1.5 ml) according to house and species, labelled and caped with silica gel and cotton inside before sending to the ICDDR,B Parasitology Laboratory in Dhaka to reconfirm species designations and assess the presence of sporozoites by ELISA.For the entomological investigation, five houses were selected to include houses at both high and low altitude from each of the 12 clusters . Entomological collection was done using a CDC light trap. Each trap was placed in the house for at least 12 hours (6-7 PM to 6-7 AM) close to persons sleeping under a bed net. Collections were made from the same five houses in each cluster for five nights, one week per month, throughout the year. After each collection, traps were returned to the field laboratory and the mosquitoes were killed. Mosquitoes were then counted, sorted and identified up to species level. Laboratory facilities were available in Bandarban at the field office, at the ICDDR,B in Dhaka and at the Malaria Research Institute at Johns Hopkins. In Bandarban, the laboratory facility included a microscope and staining resources for the malaria smears, and a dissecting microscope for examining mosquitoes. In addition, the laboratory had facilities for processing, labelling and organizing the specimens collected in the field.At the ICDDR,B laboratory in Dhaka, facilities were available to carry out PCR testing on filter paper blood spots using real time PCR, and to carry out PCR testing for mosquito species. Because of interest in both blood stage malaria as well as the presence of gametocytes, the molecular tests for malaria included a real time PCR multiplex DNA as well All data from the field was entered onto pre-coded forms, which were designed for direct data entry using a scanner. Field workers were trained on using the forms so the information could be read easily using this system. The system used ABBYY FlexiCapture 8.0 software for electronic data capturing and processing. After entry, the data was exported to Microsoft Office Access 2007 database. The data files were maintained at the data center in Dhaka and copies of the data were also sent to Johns Hopkins. Images of the scanned data forms were maintained in digital format in case there was a need to inspect the primary data source. The data forms used are described on Table The field area, consisting of two unions, had an area of 179 square kilometers located in southern Bangladesh, near the border with Myanmar. The maps of the two unions are shown in Figure The study area is hilly with elevations ranging from 80 to 152 meters. Vegetation consists of mixed thicket or dense forest with mixed evergreen and deciduous trees. The forested area is interspersed with some rice paddies. The average annual maximum temperature is 35.9°C; the average minimum is 13.2°C. The average total rainfall is 1780 mm, with most of the precipitation occurring from May through September. Photographs of the area are shown in Figure Anopheles mosquitoes were found to be common throughout the year and a total of 22 different species of Anopheles were detected during the year. Eight of these species were found to be positive by CsELISA for sporozoites. Full details of these findings and of their relationship with the transmission of malaria in the area will be published elsewhere. Figure P. falciparum, six were P. vivax and two were mixed infections. The distribution of the cases from active and passive surveillance in the two unions is shown in Table A total of 150 infections with malaria were detected from the field area by microscopy and RDT from the start of the surveillance through October 2010. Of these, 142 were The malaria studies were found to be welcomed by the residents of the area and in fact 100% of the households agreed to participate in collection of the demographic, SES and KAP surveys, and 97% agreed to participate in the active surveillance which included blood draws. Furthermore, 100% of the households that were approached for mosquito trapping inside the house agreed.The ICDDRB-JHU collaboration has established a population-based malaria research study area in the Hill Tracts region of Southern Bangladesh. This is an area which is close to the border with Myanmar and is considered hypoendemic for malaria. Unlike other areas with malaria in South Asian countries, this region is part of the same ecozone with Southeast Asia where malaria resistance has been described. Malaria is often considered to be primarily a problem of Africa and Southeast Asia, but the large number of cases observed highlights the importance of malaria in South Asia as well.This paper describes the methodology used to establish this research field area; future reports will provide details of the specific studies being carried out.P. falciparum, though P. vivax and Plasmodium malariae were also detected by PCR. Plasmodium ovale has also been found in this area [During the first year of surveillance 150 cases of malaria were detected; mostly due to his area , but thiAnopheles mosquito species found in Africa, the studies here have documented at least 22 such species in this area and eight of them were found to be positive for sporozoite antigen. In a previous study in Matiranga in the same eco-zone of Chittagong Hill Tracts 15 anopheline species were reported in the peak transmission season of 2009 of which seven were infected with sporozoite antigen [In contrast to limited number of  antigen . With thP. falciparum. This study will document the relative importance of the different species and this data will help to guide future interventions toward controlling malaria caused by all species of malaria.There has also been concern that the rapid test being used in the national programme detects only In contrast to most malaria projects, this demographic surveillance system and malaria surveillance system includes all age groups, not only the groups who are thought to be at highest risk. Inclusion of all ages will facilitate epidemiological studies of age specific disease rates as well as studies of malaria transmission during the high and low seasons.The inclusion of several ethnic groups who reside in the field area makes it possible for future studies to also identify specific risk factors for malaria among the different groups, depending on possible behavioural or genetic factors. A majority of the population belongs to Indian subcontinent tribal hill groups, which are known to have high rates of haemoglobinopathies  as well Combining the surveillance with a GIS and weather pattern database will allow for studies of geographic and climate risks. By studying patterns of malaria during the year, relationships between rainfall, temperature and other weather variable can be described. Differing rates of malaria from year to year may be the result of the interventions, or they may be more related to climate conditions which vary. These studies will help analyze these environmental factors.Anopheline mosquitoes.This project includes molecular studies of malaria. PCR assays using filter paper blood spots increase the sensitivity of this surveillance for blood stage malaria and also allows for detection of infections due to non-falciparum malaria. RT-PCR is able to detect gametocytes from blood specimens; thus, detecting persons who transmit the infection. Identification of genes associated with resistance will allow for detection of resistant strains. PCR will also be used to confirm species identification of Looking ahead, this field area will be an important resource for the national programme to evaluate strategies for malaria control, as well as for research on the epidemiology of malaria, the transmission of malaria in a hypoendemic area, studies of genetic and behavioural risk factors, intervention studies to reduce transmission and for vaccine trials of promising new vaccines. The data can be shared with the Malaria Atlas Project . In certICDDR,B: International Center for Diarrhoeal Disease Research, Bangladesh; JHMRI: Johns Hopkins Malaria Research Institute; UHFP: Upazila Health and Family Planning; RDT: Rapid Diagnostic Tests; ACT: Artemesinin based Combination Therapy; GPS:Global Positioning System; GIS: Geographic Information System;The authors declare that they have no competing interests.WK, DSa, RH, GG, MN, DN, SA, AC, DSu conceived and designed the study. ZH supervised GIS mapping with Assistance of SA, JK, MR, WK. WK, DSa, SA, CP, MSA, RH, JK, MR, JA, MMN, DN, GG, TS, ZH, DS analyzed the data. WK, DSa, SA, CP, MSA, RH, JK, MR, MMN, DN, GG, TS, ZH, AC, DS wrote the paper.


Malnutrition affects 50% of hospitalized children and 25–70% of the critically ill children. It increases the incidence of complications and mortality. Malnutrition is associated with an altered metabolism of certain substrates, increased metabolism and catabolism depending on the severity of the lesion, and reduced nutrient delivery. The objective should be to administer individualized nutrition to the critically ill child and to be able to adjust the nutrition continuously according to the metabolic changes and evolving nutritional status. It would appear reasonable to start enteral nutrition within the first 24 to 48 hours after admission, when oral feeding is not possible. Parenteral nutrition should only be used when enteral nutrition is contraindicated or is not tolerated. Energy delivery must be individually adjusted to energy expenditure  with a protein delivery of 2.5–3 g/kg/day. Frequent monitoring of nutritional and metabolic parameters should be performed. Malnutrition affects millions of children throughout the World. Recently, the humanitarian organization Save the Children warned that “chronic malnutrition affects 178 million children in the World and is the third cause of all childhood deaths worldwide” [Children under 5 years of age in developing countries are particularly vulnerable to malnutrition. However, malnutrition also exists in children in developed countries, in families with few resources or due to disturbances of feeding behavior or diseases that affect eating or the absorption of nutrients.Infants and children are very susceptible to problems of nutrition. In comparison with adults, children have lower percentages of muscle mass and fat and therefore have fewer reserves and higher resting energy expenditure. For this reason, children have a poorer tolerance to fasting than adults, they are particularly susceptible to protein depletion, and they have an increased risk of developing malnutrition when they suffer serious illness . It mustIn the ill child, malnutrition is usually of multifactorial origin. It is associated with an altered metabolism of certain substrates, increased or decreased metabolism and catabolism depending on the severity and kind of the lesion, and reduced nutrient delivery. The presence of malnutrition prior to admission worsens the prognosis in the critically ill child and, furthermore, severe illness has marked repercussions on the nutritional status of these patients .Malnutrition interferes with the appropriate response of the body to disease and predisposes to infection and to the onset of multiorgan failure, increasing morbidity and mortality, the mean length of hospital stay, and health costs ,4–7.Malnutrition is common at the time of hospital admission and tends to increase during the hospital stay. In Europe and North America, 40% to 50% of hospitalized patients can be at risk of malnutrition. A number of studies have demonstrated that malnutrition affects 50% of children and adolescents during their hospital admission. The incidence of malnutrition in the critically ill child varies between 25% and 70% depending on the series –11.Improvements in the evaluation and monitoring of the nutritional status in the critically ill or chronically ill child, and individualization of nutritional treatment in these patients, appears to have reduced the prevalence of malnutrition in paediatric intensive care units (PICU) to some extent. However, the figures continue to be very high –13.Strictly speaking, the term malnutrition refers to any type of alteration of the nutritional status and includes nutritional deficiencies, obesity, and the use of inappropriate diets. However, the term is typically used to refer to nutritional deficiencies.Nutritional deficiency has traditionally been defined in two ways, depending on the underlying deficit: calorie malnutrition or marasmus and protein malnutrition or kwashiorkor.Marasmus is caused mainly by a deficit in energy provision and is characterized by a pronounced loss of fat and muscle, leading to emaciation, with the child acquiring a cachectic appearance. Apart from their low weight and height for age, children with energy malnutrition present marked weakness and suffer frequent infections. Other symptoms include dry and wrinkled skin, bradycardia, and bradypnoea.Kwashiorkor is caused by protein deficiency and is characterized by a loss of appetite, apathy, fluid retention and oedema, alterations of the skin, changes in hair colour, anaemia, and diarrhoea.However, this clinical classification is subjective and it must also be taken into account that combined clinical states of protein and energy malnutrition are very common. Protein-energy malnutrition, in which there is a combination of energy deficit and, to a lesser degree, protein deficit, is the most important and common form of malnutrition.Malnutrition can be classified according to its origin as primary, when the cause is a deficit in delivery , and secondary, when there is an underlying chronic disease or disorder that causes the malnutrition.Malnutrition can also be classified as acute or chronic according to the time of onset and duration of the condition. Acute malnutrition occurs when there are recent deficits of supply or the sudden onset of an extensive lesion that leads to high levels of catabolism, whereas chronic malnutrition or growth delay is due to a persistent deficit in nutrient delivery, chronic disease, or acute disorders with a prolonged clinical course . Acute mOther forms of malnutrition arise due to specific deficiencies of certain micronutrients, such as the vitamins or minerals. The most common deficiencies in the community are of vitamin A, iron, and iodine, although alterations of magnesium, zinc, and copper are also common in the critically ill child.There are numerous factors that contribute to the onset of malnutrition in children admitted to intensive care. The incidence of malnutrition is higher in children under two years of age, in those with a prolonged hospital stay, and in those who require mechanical ventilation. Children with congenital heart disease and extensive burn injuries are also at increased risk of malnutrition .An additional factor is that critically ill children frequently receive an insufficient calorie and protein delivery because enteral or parenteral nutrition cannot be initiated due to gastrointestinal intolerance or the need to restrict fluid intake, initiation is delayed, or there are interruptions in enteral nutrition in order to administer medication or to perform interventions requiring sedation .The diagnosis of malnutrition in the ill child must be based on an objective evaluation of the nutritional status; this includes an adequate history of recent food intake and weight loss, anthropometric measurements, analysis of biochemical parameters and cellular immunity, and calculation of the body composition ,15. An aAnthropometric evaluation is the simplest method for evaluating the nutritional status of a child. It has the advantages of being applicable to all patients, it is non-invasive, and it is not an expensive technique . AnthropThe weight and height of the patient at the time of hospital admission allow us to perform a simple evaluation of the nutritional status and to calculate a number of nutritional indices. Weight is a good parameter for evaluating the effectiveness of nutrition in the child, though it is difficult to measure in the critically ill child on mechanical ventilation and with numerous catheters. Furthermore, it has a low sensitivity in the short term, and can be affected by variations in body composition (oedema or dehydration) without indicating changes in the nutritional status ,18.Measurement of the skinfolds is a cheap and relatively easy technique for studying the protein and fat components of the body; this is useful for the evaluation and monitoring of nutritional status . The mosHaematological parameters are of very little value in the nutritional evaluation of the critically ill child as other factors such as haemorrhage, recent surgery, blood extractions, chronic infection or inflammation, and blood transfusions will alter their values to a much greater degree than the nutritional status .cholesterol and lipoproteins have been found in critically ill adults; these changes are due to an interruption of the enterohepatic circulation secondary to fasting or parenteral nutrition, infection, the administration of antibiotics, intestinal bacterial overgrowth, and multiorgan failure [In contrast, biochemical parameters are useful for evaluating and monitoring a patient’s metabolism during hospital admission. Very low plasma concentrations of  failure . Some st failure . In chil failure ,20–22. I failure .Hyperglycaemia is a common finding in critically ill children in the first 48 hours of their admission and is usually due to resistance or a decreased sensitivity of the tissues to insulin [ insulin ,21,22,24 insulin ,21,22. BCreatinine/Height Index measures global muscle catabolism and its values are affected by the quantity and type of proteins in the diet. In the critically ill patient, the creatinine/height index is able to detect malnutrition on admission, but its value as a variable for monitoring patients is an unresolved issue and also is not useful in renal failure [The  failure ,23. Some failure .Nitrogen Balance is not a valid parameter for the diagnosis of malnutrition, although it can be used to control nutritional treatment and as a nutritional prognostic indicator (4). However, it must be taken into account that the critically ill patient presents acute phases of catabolism during which there is a negative nitrogen balance. Although the aim of nutrition is to achieve a positive or neutral nitrogen balance through an adequate energy and protein delivery, the hypercatabolic state that develops in the critically ill child as a response mechanism to the aggression cannot be initially blocked despite adequate protein delivery. At later stages a positive nitrogen balance can be reached with an adequate nutrition delivery [The delivery ,16,21,23Certain serum proteins  can be good nutritional indicators in the critically ill patient. They reflect the ability of the liver to incorporate amino acids into protein synthesis, their half-life is not very long, and their concentrations fall rapidly in acute disease and recover in a relatively short time ,16. HoweAlbumin is a parameter that is widely used in nutritional evaluation due to its high specificity. However it has a low sensitivity as a nutritional marker as it has a long plasma half-life (20 days) and therefore is not a good parameter for monitoring nutritional status due to its low sensitivity to acute changes [ changes . Other bPre-albumin, with a short half-life of two days and a small volume of distribution, is very sensitive and specific to changes in the nutritional status. Variations in its concentration can be observed in less than seven days after changes in the diet, and some studies report a good correlation between the levels of this protein and the nitrogen balance [ balance ,21,25–27 balance .Transferrin, the iron transport protein, has a short half-life of eight to ten days, and a small volume of distribution. However, its value as a nutritional indicator is lower than that of pre-albumin due to its low sensitivity and specificity when analyzed individually. Its levels are altered in liver disease, iron deficiency anaemia, nephrotic syndrome, and by multiple transfusions or the administration of aminoglycosides and cephalosporins. Even so, in the absence of alterations of iron metabolism, the transferrin concentration is a parameter that provides an adequate evaluation of the protein nutritional status. The rapid increase in transferrin and pre-albumin on starting enteral nutrition supports the hypothesis that when the energy and protein delivery is adequate in the critically ill child, hepatic synthesis of body proteins is rapidly stimulated, leading to a rise in their serum concentrations [trations ,21,27.Retinol binding protein has a very short half-life of 12 hours, and its levels fall with malnutrition; however, levels also fall with liver disease, infection, and with intense stress. Retinol binding protein is a good marker of the nutritional status evolution and re-nutrition, but is not of value in patients with renal failure [ failure .Fibronectin is synthesized in endothelial cells, hepatocytes, macrophages, and fibroblasts and it has a short half-life of between four and 24 hours. During fasting and in patients with malnutrition, fibronectin levels fall earlier than those of other proteins synthesized in the liver, and increase rapidly after restoration of an adequate energy delivery. It is considered to be a good marker of the nutritional status, although its concentration also falls in numerous acute diseases, such as sepsis and burns, and also in the postoperative period [e period ,25.electrolyte and mineral levels are common in the critically ill patient, but these changes are not generally secondary to problems of nutrition.Alterations in The incidence of hypocalcaemia, hypophosphataemia, and hypomagnesaemia is high in the critically ill child . The mosIn the critically ill child, complex metabolic changes occur in order to mobilize the substrates necessary for defense of the body against aggression. Two different phases can be identified in this response of the body to disease: an initial phase of a few hours during which there is a rapid fall in the metabolic rate, with a decrease in oxygen consumption and in energy production; and a second phase, regulated by hormonal changes, during which there is hypercatabolism with a negative nitrogen balance, loss of weight and muscle mass, and altered dynamics of carbohydrate metabolism ,9,16,21.These changes lead to protein-energy malnutrition, characterized by a loss of body protein and fat deposits and a fall in the serum protein levels. They are more common in children under two years of age and in more severely ill patients and are associated with an increase in mortality and morbidity –29.One of the fundamental roles of nutrition in the healthy child is to enable growth and development. In contrast, the critically ill child uses nutrients principally to defend the body against disease and, even if a high energy delivery is provided, the body is not able to use this for growth . In thesAlthough nutrition is receiving ever more attention as a part of the treatment of the critically ill child, there are few studies that have systematically analyzed its efficacy ,31, and A number of studies have analyzed the methods for administering nutrition to the critically ill child. A recent publication reported the results of a survey undertaken in 24 PICUs in 14 Latin-American countries and offers a vision of the way in which nutrition is provided to the critically ill child in Latin-America .It should be noticed the importance of the refeeding syndrome in the critically ill children who can be moved from the starved state to the fed state rapidly via enteral or parenteral nutrition. This syndrome causes severe complications such as electrolyte abnormalities, heart failure, respiratory failure, and death .The critically ill child typically has a lower energy expenditure than the healthy child due to the reduced motor activity and work of breathing, in addition to the sedation, relaxation, and hypothermia; however these patients have different requirements for certain nutrients ,6. Only The ideal energy delivery that a critically ill child should receive is not known. An insufficient calorie delivery leads to a loss of organ reserves and of the response capacity of the body to aggression. In contrast, an excessive energy delivery can lead to metabolic overload without stimulating anabolism, with increased carbon dioxide production and prolongation of mechanical ventilation.2 greater than 60%, if there are leaks of greater than 10% from the endotracheal tube, or during extracorporeal membrane oxygenation or venovenous continual renal replacement therapy [Numerous formulae have been used to calculate the energy delivery that the critically ill child requires, though none has been found to be useful . Indirec therapy . Recentl therapy .For a long time it was thought that severely ill patients could not tolerate enteral nutrition because there would be marked alterations of gastrointestinal motility, digestion, and absorption; parenteral nutrition was therefore considered to be the initial method of feeding.The principal advantages of parenteral nutrition are that nutrient delivery is independent of the state of the digestive tract, an exact energy delivery can be ensured, and it does not have the risk of digestive tract complications or pulmonary aspiration.However, numerous studies in the past decade have demonstrated that the majority of critically ill children tolerate enteral nutrition well ,16,17,35Parenteral nutrition should be reserved for those children in whom enteral nutrition is contraindicated or is not tolerated. The contraindications to enteral nutrition have decreased, and now include the following: patients with intestinal obstruction or severe gastrointestinal damage, ischaemia or inflammation; gastrointestinal haemorrhage; peritonitis; and paralytic ileus. In theory, recent gastrointestinal surgery should not be considered a contraindication to enteral nutrition. When it is not possible to achieve an adequate nutrient delivery with enteral nutrition, mixed enteral and parenteral nutrition may be administered .The majority of critically ill children receive gastric enteral nutrition as it is more physiological, simpler, and can be started more quickly ,32. In mGastric nutrition is occasionally poorly tolerated, particularly by children with more serious illness and on mechanical ventilation with deep sedation. This leads to a situation in which a high percentage of critically ill children with gastric nutrition do not receive the prescribed intake.Transpyloric duodeno-jejunal nutrition, also known as transpyloric post-pyloric enteral nutrition, reduces the volume of gastric residue and the number of interruptions, enabling the nutrition to be increased more rapidly in order to reach the prescribed volume ,39. In aThere are no studies that have analyzed the ideal diet in the critically ill child and there are no new products specifically designed for these patients. For patients of one to two years of age, many authors administer maternal milk or infant formula due to their availability, digestibility, excellent tolerance, and low osmolarity; complete enteral diets are used in older children. An enteral diet for ill infants has recently come onto the market, though studies are necessary to analyze its efficacy in critically ill children and to compare it with infant formula. Nor are there any studies that have demonstrated the advantages of hydrolyzed proteins over complete diets .There is a pronounced increase in catabolism in critically ill patients, which makes it difficult to achieve a positive nitrogen balance. The protein delivery typically recommended in the critically ill child is of 2.5–3 g/kg/day. Some studies have found that a hyperproteic diet increases protein synthesis and improves the nitrogen balance, although it does not reduce catabolism or improve the prognosis ,21.The terms immunonutrition and pharmaconutrition have become widespread in recent years. These terms refer to the concept that nutrition serves not only for the administration of energy substrates but also of other substances that are deficient in the critically ill patient and/or that modify the inflammatory and immune responses. Immunomodulating diets supplemented with glutamine, arginine, ribonucleic acid, antioxidants, and omega-3 fatty acids have been used in critically ill adults, with very variable clinical results; some authors have reported a reduction in the incidence of nosocomial infection and even in mortality, whereas others have reported negative effects . AlthougCritically ill children are particularly vulnerable to the effects of fasting and of prolonged stress, as they have lower percentages of muscle and fat and higher basal energy requirements than adults. A number of studies have demonstrated that the majority of critically ill children tolerate early enteral nutrition well, with no increase in the incidence of complications ,39. It wThe greatest advances in parenteral nutrition in recent years concern the lipids. The lipid content of parenteral nutrition reduces gluconeogenesis and fat deposition and stimulates lipid oxidation and protein retention. It is interesting that, although many studies have demonstrated the compatibility of lipids with the other substrates of parenteral nutrition, and that combined administration reduces the number of intravenous catheters and manipulations required, reducing the risk of infection, there are still many PICUs that administer lipids separately . New lipA recent retrospective study showed that parenteral nutrition with commercial solutions in critically ill children reduced the cost with respect to preparation of the solutions in the pharmacy department; however, that study did not compare safety, contamination and adverse effects of the preparations .The objectives of monitoring nutrition in the critically ill child must be to evaluate its effect on the nutritional status and to detect adverse effects. Nutritional evaluation in the critically ill child is complicated because, as has been stated above, anthropometric methods (weight and skinfold thickness), which are the simplest, are relatively insensitive to short-term changes and can be affected by variations in body composition (oedema or dehydration). Some serum proteins with a short half-life, such as pre-albumin and retinol binding protein, are relatively sensitive and specific indicators of the nutritional status, although there is still little experience with their use in critically ill children. Indirect calorimetry is the best method for measuring energy expenditure and, together with the nitrogen balance, which is easy to calculate and allows protein catabolism to be determined, and analysis of the nutrition administered, the balance between the delivery and utilization of energy and immediate substrates can be calculated.The greatest limitation to achieving adequate enteral nutrition in critically ill children is the onset of gastrointestinal complications 38). The most common gastrointestinal complications are abdominal distension, excessive gastric residues, vomiting, diarrhoea, and constipation ,38. In o. The mosMalnutrition is very common in the critically ill child and has a negative effect on prognosis, increasing the incidence of complications and the morbidity and mortality. Although scientific evidence is still scarce, it would appear reasonable to start enteral nutrition early in the critically ill child, within the first 24 to 48 hours after admission, when oral feeding is not possible. Energy delivery must be adjusted to energy expenditure and, if this is not possible, a delivery of 40–65 kcal/100calories metabolized/day should be administered, with a protein delivery of 2.5–3 g/kg/day, reaching the prescribed energy delivery within the first 48 to 72 hours. Gastric feeding can be the initial method of nutrition in the majority of critically ill children, keeping transpyloric feeding for more seriously ill patients on mechanical ventilation and who are receiving high doses of sedatives and muscle relaxants, those who have a higher risk of pulmonary aspiration, and those who do not tolerate gastric feeding or in whom an adequate energy delivery cannot be achieved. Parental nutrition should only be used when enteral nutrition is contraindicated or is not tolerated. Frequent monitoring of nutritional and metabolic parameters should be performed, together with vigilance for complications.versus intermittent gastric feeding, and to analyze the usefulness of the diet guided by calorimetry and hyperproteic, hydrolyzed, and immunomodulating diets, and the effectiveness of prokinetics and laxatives for the prevention and treatment of the increased incidence of constipation.The objectives in the future should be to administer individualized nutrition in accordance with the specific characteristics of each critically ill child and to be able to adjust the nutrition continuously according to the metabolic changes and nutritional status. For this, it is important to conduct studies to identify sensitive methods for the evaluation of nutrition that can be applied in the majority of critically ill children. In addition, prospective clinical trials are needed to compare continuous


The objective of this study was to establish a regional profile of the indigenous knowledge system (IKS) for medicinal plant use and cultural practices associated with the healing process of these plants by traditional healers in the Oshikoto region, Namibia.An ethnobotanical survey was undertaken to collect information from traditional healers during September and October 2008. Data was collected through the use of questionnaires and personal interviews during field trips in the ten constituencies of the Oshikoto region. A total of 47 respondents were interviewed with most of them aged 66 and above.IC) value for all ailment categories was 0.75. High FIC values were obtained for Pergularia daemia, and Tragia okanyua, which were reported to treat weakness and dizziness problems, snake bite, swelling and cardiovascular problems indicating that these species traditionally used to treat these ailments are worth examining for bioactive compounds.The traditional healers in Oshikoto region use 61 medicinal plant species that belong to 25 families for the treatment of various diseases and disorders with the highest number of species being used for mental diseases followed by skin infection and external injuries. Trees (28 species) were found to be the most used plants followed by herbs (15 species), shrubs (10 species) and climbers (4 species). The average of the informant consensus factor (FThe traditional healers in Oshikoto possess rich ethno-pharmacological knowledge. This study allows for identifying many high value medicinal plant species, indicating high potential for economic development through sustainable collection of these medicinal plants. Traditional healers are found in most societies. They are often part of a local community, culture and tradition, and continue to have high social standing in many places, exerting influence on local health practices; it is therefore worthwhile to explore the possibilities of engaging them in primary health care and training them accordingly . Most Afhttp://www.kew.org/sepasalweb/sepaweb) revealed that 274 (36.4%) of these plants are used for medicinal purposes [There are about 2400 traditional medical practitioners in Namibia who are registered with the National Eagle Traditional Healers Association (NETHA), but the actual number practicing could be higher . Approxipurposes .The documentation of the traditional medicinal plants used by the traditional healers in Oshikoto region is limited compared to the extent of the variety of cultures and the diversity of plants of the region. Furthermore, the majority of these studies are focused only on interviewing traditional healers  and listThe Oshikoto region was selected on the basis that it is inhabited by people from different ethnic groups: the San, Owambo, Damara/Nama, and Ova Herero. It was chosen as a pilot site because it could provide data useful for design of proper data collection instruments for a country-wide baseline study Figure .Ethnobotanical knowledge and practice within any culture vary by geographical origin, residence, ethnicity, religion, age, and gender . The bioIC) was calculated to estimate user variability of medicinal plants [IC values range from 0.00 to 1.00. High FIC values are obtained when only one or a few plant species are reported to be used by a high proportion of informants to treat a particular ailment, whereas low FIC values indicate that informants disagree over which plant to use [IC values can thus be used to pinpoint particularly interesting species for the search of bioactive compounds [IC is calculated using the following formula [The informant or respondent consensus factor , the percentage of informants claiming the use of a certain plant for the same major purpose, was calculated for the most frequently reported diseases or ailments as following:Np is the number of informants that claim a use of a plant species to treat a particular disease, and N is the number of informants that use the plants as a medicine to treat any given disease [Where  disease ,18,19. P disease . General disease .Generally, traditional healing is a gender-based practice; although in some communities both men and women perform this practice . It was Indigenous knowledge (IK) is acquired through time in which it takes for the traditional healers to acquire the indigenous knowledge . Most ofThe traditional healing is widely acknowledged as an occupation in Namibia. This study indicates that 58% of the respondents regarded themselves as subsistence farmers. Although these particular respondents use medicinal plants to treat ailments, they do not necessarily see themselves as practitioners of a profession/occupation. Twenty eight percent confirmed that they are traditional medicinal practitioners, while four and two percent reported to be pensioners and headman, respectively. It is evident that 37% and 34% of the respondents indicated that farming and pension, respectively; are their main sources of income. However, slightly more than 20% indicated that use of medicinal plants is their main source of income  before they became traditional healers. This is a sign that signifies the importance of indigenous knowledge in the sense that the community tends to believe that once someone goes through that ritual she or he can be trusted as someone who knows his or her work well. Some applications noted in some areas of Namibia were not compatible with western medical tradition, as local traditional healers have a different understanding of how certain diseases are caused. This is largely because traditional healing is a very complex issue involving rituals and spiritual aspects, far more than simply the use of plants [It is generally believed that to become an acclaimed healer one has to go through the traditional ritual that will allow you to practice as a qualified healer. This process is called language . The surf plants ,26.In cases where people indicated that they were mentored, the study sought to establish whether the respondents knew the whereabouts of their mentors. The findings in Figure The traditional healing system in Oshikoto region is well established. Forty seven respondents reported 61 medicinal plants that are used to treat 43 types of ailments and diseases in both human and animal  of used medicinal plants Figure ; it was Rhamnaceae, Combretaceae and Ebenaceae (3 species). Other families with low number are listed below: Olacaceae, Plumbaginaceae, Asteraceae, Rubiaceae, Apocynaceae, Asparagaceae and Pedaliaceae (2 species), other families which represented with only one species are represented in Figure Regarding to the life form of the reported medicinal plants by the respondents; the study showed that trees (28 species) were found to be the most used plants Figure  followedPterocarpus angolensis, Ximenia americanum, Ximenia caffra and Combretum imberbe. The total number of plant species used by the traditional healers normally will be diminishing in supply. Some plant species that are becoming more difficult to obtain include Albizia brevifolia, Commiphora mollis, Commiphora glaucescens, Commiphora pyracanthoides, Elephantorhiza elephantina, Fockea angustifolia, Gardenia spatulifolia, Momordica balsamina, and Protea gaguedi. Protea gaguedi, which occurred naturally along the Okavango River in Namibia, is practically extinct [In this study; 47 respondents reported 61 medicinal plants species that belonged to 25 families. The most cited plants mentioned by the respondents are:  extinct  due to fIC) for the different ailments treated by the traditional healers in Oshikoto region. The level of informants agreement was high for most ailment categories (mean FIC = 0.75) and total consensus (FIC = 1.00) was even obtained for weakness and dizziness problems, snake bite, swelling and Cardiovascular problems  which cover areas such as bio-trade of medicinal plants, plant genetic resources, access and benefit sharing (ABS) need harmonization. However, Namibia is a Signatory to Cites, which also lists a number of fauna and flora species to be protected, FAO Treaty on exchange of agricultural research. There exists a Patent Office under the Ministry of Trade and Industry, but the absence of a policy regarding IPR as well as limited capacity to deal with IPR issues is a concern. Namibia is a Signatory to the Convention on Biological Diversity (CBD) which includes among other the ABS Protocol, and this protocol was adopted in 2010 in Nagoya, Japan. In Namibia, the Ministry of Environment and Tourism is responsible for this protocol and they are also working on a draft policy for ABS in Namibia. According to Du Plessis; Namibia has had a draft bill on ABS since 2007, but because of technical reasons, the bill has not been finalized and enacted into law . To condResolving of these issues is still at a primary phase because of the lack for national legislation relating to indigenous knowledge on indigenous plants. A Research, Science and Technology Act on this protocol was passed in 2004 to govern research activities and institutions in Namibia.This study showed that the study area has plenty of medicinal plants to treat a wide spectrum of human ailments. Many people in the study areas of the Oshikoto region are still depending on medicinal plants, at least for the treatment of some simple diseases such as, cold, cough, fever, headache, poison bites, skin diseases and tooth infections. It is necessary to acquire and preserve this traditional system of medicine by proper documentation and identification of specimens. A nationwide database is in the process of being established by collecting all conceivable IKS plant-based nationwide medicinal therapeutic data as currently applied by traditional healers. This traditional knowledge on the indigenous uses of the medicinal plants could boost new innovations in the pharmaceutical industry and have many beneficial applications such as new medicinal trails for some diseases like: malaria, Tuberculosis and AIDS, of which will develop the health care sector in Namibia.The authors declare that they have no competing interests.MS had interviewed the traditional healers in Oshikoto region; he has analyzed and drafted the report on the medicinal plant use by traditional healers. KM designed the questionnaire, and reviewed the manuscript. HMA led the research project and also reviewed the manuscript. AC has written the article, organized the compiled research data and carried out the statistical analysis. All authors read and approved the final manuscript.


Systematic Reviews. During this first year we have been delighted by the journal’s growth and rate of development. At the time of writing we have published 84 articles. Of these, 42 were protocols, 17 were completed systematic reviews, 9 were methods papers, and 16 were other types of articles including two overviews. Twenty articles have been highly accessed, meaning that within a short period of time of being published they were frequently accessed, ranging from 2,000 to 9,000 times. Topics cover a wide spectrum of health issues, such as male participation in prevention programs of mother to child transmission of HIV; psychosocial interventions to reduce alcohol consumption; the use of intravascular ultrasound during bare-metal coronary stent insertion; to the effectiveness of certain antibiotics for preventing traveler’s diarrhea. We have also published a number of articles about evidence synthesis methods: a systematic review of guidelines for clinical trial protocol content, sample size and power consideration in network meta-analysis, and the evolution of approaches to rapid reviews. Corresponding authors have come from many parts of the globe, including Australia, Cameroon, Finland, Germany, and the United Kingdom.About a year ago we launched Our launch issue included a series of nine articles about the importance of registering systematic reviews and the development of PROSPERO, an international prospective register of systematic reviews, and we are pleased to stream titles of latest protocols registered in PROSPERO on the journal home page. We are now indexed on Medline, PubMed, and Scopus and will apply to Thomson Reuters ISI for a journal impact factor (JIF) in the near future. Other relevant metrics, such as the number of accesses and citations, as well as an Altmetric score, can be found when accessing any journal article.Based on data from the journal’s website the journal is gaining momentum and attracting interest from readers. When we launched we had about 3,000 visits per month which has grown more than fivefold to more than 17,000 visits per month. We are very gratified with our early progress and thank all of our authors who took a risk and submitted their research to the journal.Research Synthesis Methods recently published a special series on the more technical aspects of NMA [et al. paper [Looking ahead, we see a number of interesting developments happening within the systematic review community that we are interested in featuring in the Journal. Based on the number and trajectory of published network meta-analyses (NMA) and associated methods papers, this type article has gained considerable interest within the systematic review and decision-making communities. s of NMA , and we l. paper  on theirWe are delighted to be part of the Cochrane Collaboration’s 20th year anniversary. Later this year we will publish a series of articles celebrating the collaboration’s contributions to the science of systematic reviews over the last 20 years. Recently the journal made a call for papers in two areas - the latest developments in comparative effectiveness treatments for obesity and in treatments for dementia; and new developments in the conduct and reporting of diagnostic and prognostic systematic reviews. We hope to publish a series of papers on each topic later this year.We hope authors will consider the journal to disseminate their research. We remain committed to innovation and to open access, including helping to ensure the widest possible readership for all articles published in the journal.Other than being co-editors in chief we have not other competing interests.DM drafted the initial paper and PS and LS provided critical revisions. All authors read and approved the final manuscript.


The renewed interest in community participation in health research is linked to its potential for bridging gaps between research and practice. Its main attributes are the generation of knowledge that can lead to socially robust, long-lasting solutions and the creation of a co-learner relationship between researchers and research users. Following this philosophy, Ecohealth has evolved into a specialized framework for participatory research on the impact of pollution on ecosystems and human health. However, its principles pose considerable challenges. Its outcomes are strongly influenced by contextual factors that are impossible to control for ahead of time.This paper describes how the Ecohealth principles were applied to an epidemiological study of heavy metals exposure among indigenous communities of the Peruvian Amazon. It illustrates how knowledge generated from participatory research does not necessarily imply solving a public health problem. This study aimed to contribute to the understanding of the benefits and barriers of following the basic principles of the Ecohealth approach, and assist researchers working in similar contexts.Based upon their personal experience as participant observers, the authors describe the research process; then, they discuss the most important challenges faced, their implications, and the attempted strategies for resolution.Challenges were grouped into four themes: (1) building trust; (2) one partnership, many stakeholders, multiple agendas; (3) being a researcher; and (4) communicating complex and unexpected findings.Integrating the principles of transdisciplinarity and participation posed a series of challenges to the research process that were difficult, and sometimes impossible to overcome. However, positive outcomes from this experience were the lessons learned by the different actors. Despite the lack of immediate action, it is expected that useful interventions to prevent and control lead exposure in the Corrientes population will be implemented in the medium term. The world’s increasing demand for oil has in the last decade led to unprecedented exploration and development of oil activity in the Amazon region . In PeruThe Corrientes river basin is an area populated by 36 indigenous communities, who for many years have protested about the negative impact of oil activity. In 2006 a governmental study reported elevated levels of blood lead and cadmium in a group of indigenous people from this river basin ,5. DisseThe epidemiological study took place in specific conditions, including the intricate reality of a marginalized indigenous population, an environmental health problem related to industrial pollution, and a social movement’s struggle for the recognition of potential health hazards. These combined conditions defined the participatory nature of the study and posed the need for a holistic approach to inform the research process. In this regard, the Ecohealth framework was chosen. Ecohealth has evolved from the school of approaches that share a community participation philosophy  into a specialized framework that addresses the impact of pollution on ecosystems and human health. In addition, it has common ground with other fields based on reconnecting people and place and recognizing social-ecological changes as determinants of health, such as environmental justice .The Ecohealth framework consists of two main principles: (1) transdisciplinarity, which looks for the integration of different views, types of knowledge and research methodologies through the involvement of academicians, communities, and decision makers in research partnerships; and (2) participation, which seeks the involvement of the affected population throughout the research process and the formulation and implementation of actions .Globally there is renewed interest in community participation in health, both in the health care system  and in tThe attributes of participatory research include (1) the generation of accessible, understandable, and relevant knowledge of the participants’ needs that (2) can lead to “socially robust”, long-lasting solutions . Yet, paMany of these challenges have been described in relation to applying the Ecohealth principles. In most cases, key strategies such as changing the research question to account for stakeholders’ concerns, conducting workshops to generate dialogue, and implementing education programmes to engage the population, seem to allow partnerships to achieve successful outcomes. In a few cases the influence of structural factors seem to prevent the translation of knowledge into positive actions -16.This paper describes how the Ecohealth principles were applied to an epidemiological study of heavy metals exposure in the indigenous communities of the Corrientes river basin. It illustrates how knowledge generated from a participatory research process does not necessarily imply solving a public health problem. This study aimed to contribute to the understanding of the benefits and difficulties of using the Ecohealth principles, and assist other researchers working in similar contexts.The content of this paper is based upon the authors’ personal experience in their role as researchers and participant observers over the course of the study. Their perceptions and understanding of the phenomena and the process are based on field notes, official documents and written communications, informal interviews, and a continued process of collective reflection . In thisThe Ecohealth framework proposes a sequence of two main phases for the research process: (1) participatory design , and (2) knowledge development . This section starts by describing the context and actors in the study before summarizing the research process.The territory of the Corrientes River was first explored for oil in 1969. In 1971, the territory’s concession was sold to the American company Oxy and 30 years later, it was transferred to the company now called Pluspetrol Norte S.A. . During However, the health and social impacts on the Corrientes population have not been studied, although there is evidence of adverse effects including spontaneous abortion and cancer in communities exposed to oil activity in a similar context such as the Ecuadorian Amazon . For manFECONACO’s first attempts to document the health impacts were manifested in 2004. One year later, the indigenous organization and government officials jointly defined and agreed upon a plan for an environmental assessment and a toxicological study to determine the presence of lead and cadmium in the population .These results, combined with authorities’ indifference to FECONACO’s demands, triggered a series of protests, culminating in a two-week blockage of Pluspetrol facilities in October 2006. As a result, the indigenous organization achieved a new agreement that consisted primarily of a comprehensive health care plan to be implemented by the regional bureau of the Ministry of Health (DIRESA Loreto) and paid for by Pluspetrol [Activists and scholars have associated the heavy metals exposure with pollution related to oil activity ,5. HowevAccording to Ecohealth, all parties should contribute equally and share control of the research process . NeverthA key initial task for researchers based in Umeå was to develop trust with partners based in Loreto. The main researcher (university delegate) spent a considerable time in Loreto to achieve the following objectives: (1) to become aware of the study’s historical context, the partnership members and, other stakeholders, (2) to cultivate a common understanding of the problem among all the ORC delegates, (3) to achieve agreement on the rules of participation, and (4) to establish preliminary contact with the affected communities.The overall study objective was to identify environmental sources, pathways, and factors associated with lead and cadmium exposure in the population. Under the hypothesis that oil-related pollution was the main source, the study was designed in a way that compared exposed and unexposed communities. Initially, the study included two components: (1) the determination of lead and cadmium levels in the total population and the environment of three communities, two of them exposed and one non-exposed to oil pollution; and (2) the assessment of risk factors for lead and cadmium by a parental questionnaire.Field work took place in February 2009. The results showed elevated blood lead levels (BLLs) and urinary cadmium (UCd) levels (compared to the reference limits of 10 μg/dL and 1 μg/g creatinin respectively) in both the exposed and non-exposed communities, with no significant difference between them. The analysis of water and soil samples showed concentrations below international standards. The limitations of the analytical process did not permit the assessment of samples of dust, fish, and other food stuff .The researchers shared these findings with DIRESA and FECONACO before completing the final report. FECONACO and NGO representatives appeared surprised and suspicious of the results. They believed that the oil contamination should not be completely disregarded from the causes of the heavy metals exposure.Later on, the researchers made a public presentation of the results to all the stakeholders. They proposed conducting a new study that would include a broader environmental analysis and a complete examination of young male practices as potential risk factors for elevated BLLs. Although contradictory opinions flowed within FECONACO, the leaders supported the researchers’ proposal, as did the DIRESA authorities.it is likely the oil company is contaminating us with lead and cadmium”. Apparently, such a message was necessary to provoke the communities’ reaction. Finally, the communities agreed to participate in the new study.The researchers also shared the findings with participating indigenous communities. They explained that sources other than oil pollution might be behind the heavy metals exposure and that further research was required to clarify the real source(s). But, FECONACO delegates added their own message that “The new study had similar objectives and procedures to the first one. However, the sample size was increased to six communities and the questionnaire focused on fishing and hunting-related practices, which were identified as involving the manipulation of metal lead. This time, the environmental analyses were more comprehensive  and were performed in Sweden to ensure high quality analysis. The results showed that the activities of manipulating and chewing lead scraps to construct fishing sinkers were the most important risk factors for lead exposure in children. An important connection to oil activity still remained: communities near oil facilities had greater access to lead cables and other industrial wastes from which to extract lead. Regarding the cadmium exposure, UCd levels reflected an overall low exposure, therefore, the main concern was the lead.The final report recommended three strategies: (1) improved control of industrial waste disposal by the oil company, (2) a public awareness programme on preventing lead exposure and changing lead-handling practices, and (3) the replacement of lead by other materials in the construction of fishing weights .avoid spreading misleading information”, which resulted in the latter’s time consuming review of the study report before it could be officially submitted. Meanwhile, FECONACO leaders rejected the results, arguing that the manipulation of lead for fish sinkers was a harmless practice common among many communities of the Amazon region, who “were not contaminated with heavy metals as they were”. However, no other native communities in the Peruvian Amazon have been tested for heavy metals exposure. The main researcher disseminated the findings in the communities with FECONACO’s assistance. The communities’ reactions varied from a hostile rejection to calm queries regarding feasible solutions. With regard to the latter, the researcher asked the community leaders to demand actions (suggested in the study report) from DIRESA. However, it is likely that the profound disappointment discouraged the community leaders from taking any action in the short term.For the researchers, presenting the final report to the stakeholders was a difficult task. The FECONACO and DIRESA delegates, with whom researchers had previously worked, had been removed from their positions and the new ones knew little about the study. Moreover, Pluspetrol pressured DIRESA delegates to “We have grouped the most relevant challenges in four cross-cutting themes that underlie the three phases above: (1) building trust; (2) one partnership, many stakeholders, multiple agendas; (3) being a researcher; and (4) communicating complex and unexpected findings.Trust between native communities and researchers is crucial to the success of intervention studies. Previous experiences where native communities have been analysed, stereotyped, and exploited by outside groups, have generated a suspicious attitude towards researchers . In thisFrom the beginning, the greater interest of FECONACO and the NGOs in the study, compared to DIRESA, facilitated a good relationship between them and the researchers. The university delegate was stationed at the FECONACO’s office and integrated as a technical advisor. This close relationship had positive and negative consequences. It helped to gain the communities’ trust, but it also led to strong criticism from Pluspetrol, who alleged that the researchers were taking sides. In fact, Pluspetrol representatives argued that their own participation in the second study was needed to create a balanced partnership and to prevent the research from favouring FECONACO’s interests. By contrast, the researchers considered that taking a totally neutral position with all the stakeholders was problematic for their interaction with the communities, given the indigenous population’s scepticism about governmental institutions and the conflictive relationship with Pluspetrol. At the same time, not building a sufficiently strong trust-based relationship with DIRESA was problematic, given its responsibility for health polices and interventions. Thus, defining the most appropriate position between these competing forces was a major challenge.The interaction of people with so many differences in their backgrounds, in terms of gender, ethnicity, education, and residence, added to the complexity. According to Christopher et al. , interacOther barriers included the lack of funding, time constraints, and the distance that impeded the research committee from being seen in the communities.Lastly, the priorities of each party and the community needed to be acknowledged and appreciated to build trust -25, but Collaborative partnerships may include community, academic, government and other stakeholders, who interact and contribute with their knowledge towards the achievement of a common objective .Yet, these partnerships are usually complex. They embody relationships that can fluctuate and even fade away for uncontrollable reasons. Since the parties do not usually comprise single individuals but are collective dynamic bodies, issues of power/control, leadership, and representation can affect their roles -28.Many of those issues emerged in the present study. Firstly, the ORC delegates had limited power and a low degree of authority. This implied that the delegates’ decisions had to be approved by their superiors, who knew little about the study. Thus, decisions were delayed. As a strategy, the researchers tried to reach agreement directly with the main authorities, which was positive at the beginning, but eventually this generated conflict because it undermined the role of the delegates.Secondly, instability among leadership positions, especially within FECONACO, weakened partners’ support for the research project. On the one hand, lack of an official organizational commitment can allow incoming leaders to refuse to continue a project. On the other hand, reliable non-leaders within an organization can ensure continuity of support for the project through encouraging changes within the leadership . In thisThirdly, working with FECONACO leaders also raised problems of representation. It was efficient in terms of time and resources to consider them as the communities’ representatives, but that also ensured certain negative conditions were embedded in the participatory process, such as the historical tensions between the communities’ leaders and the mistrust of the study’s financing. Despite these potential risks, Ecohealth projects continue to work primarily with the communities’ representatives for practical reasons, limiting the study population’s involvement .Fourthly, placing community leaders’ perspectives and knowledge on an equal footing in a research partnership (transdisciplinarity) was problematic. For example, in the selection of the study communities, FECONACO leaders insisted that their own communities be included. Also, in the funding distribution, FECONACO leaders opposed costly components of the study, even though these could have improved the study quality in the researchers’ view. In order to deal with these challenges, it is necessary to develop non-academic skills including consensus building, negotiation, communication, and financial and strategic planning.Finally, the parties had unclear, dual dimensions and changing agendas that incorporated unanticipated facts and eventually affected the research process and outcomes.For instance, the FECONACO leaders had a tangled agenda. At first, their interest in the study denoted their priority of finding the source(s) of the heavy metals exposure. However, several times they manifested that their real expectation was to find scientific evidence that oil activity was endangering their health . In addition, FECONACO had a public discourse which highlighted their ancestral lifestyle. But at the same time, they knew that the communities’ younger generations did not necessarily follow their ancestral healthy lifestyle and adopted “modern” practices involving the manipulation of harmful elements such as industrial waste. In fact, some scholars have pointed out that the currently perceived identity of indigenous groups as living in a harmonious relationship with nature is embedded in stereotypes, and that the introduction of commercial practices and adoption of foreign products and lifestyles over the last decades have destroyed this harmonious relationship .The communities’ agenda also had contrasting sides. They showed concern about the fact of being exposed to heavy metals and wanted solutions. But they also believed that such circumstances would allow them to obtain an economic compensation from the oil company. Many non-affected participants showed discontent and refused to believe they were not “contaminated”.The researcher’s agenda might be wrongly perceived as a solely altruistic gesture in the service of communities and decision makers . In thisIn the context of a participatory study, researchers should be aware of the paradigms that might emerge, and how they can guide their work. Often, those paradigms are presented as dichotomies, suggesting an either or choice. For instance, between exerting authority or promoting equal participation, recognizing the layperson’s knowledge or putting the scientific evidence first, and becoming an activist/advocate or remaining a passive agent.An important dilemma, especially when documenting environmental hazards, is the researcher’s decision about whether to assume an activist or advocate role. According to Savitz , the epiIn this regard, there is a substantial debate. For some, epidemiologists can best contribute to public health by striving for objectivity. From that perspective, impassioned scholars who mix scientific and activist roles, promoting a specific public health agenda, will be likely to threaten their research’s validity/scientific rigour and reduce its benefit to public health . For othOf particular interest are the competencies that researchers need to manage the interpersonal and political dynamics of a participatory process. Among the competencies, the most relevant are skills that foster dialogue and create a reflection space  . In thisSpeaking about evidence of individuals’ environmental exposure and health risks can be a daunting challenge for researchers . In thisOne challenge was the complex content of the message: (1) the exposure to chemicals of an uncertain origin; (2) the elevated levels of these chemicals in their bodies, and the issue of what are considered tolerable levels; (3) a set of potential health effects that had to be explained carefully, without underestimating the problem or causing unnecessary alarm; and (4) the absence of a curative treatment. All these topics involved technical concepts that are difficult for any person to understand. To overcome such issues, messages need to be clear and comprehensive, and they should anticipate probable questions and reactions. Trusted individuals and institutions are also required to communicate the information in the original language of the communities . Howevera medicine that would remove the metals from their bodies” could never be addressed. The solution was to reduce the exposure but since the sources and pathways of the exposure were still unknown (the first study was unable to determine them), it was difficult to implement any preventive strategy. Nevertheless, when the source of exposure was revealed by the second study, the researcher could not offer a concrete solution either. Any intervention had to be commanded by DIRESA, which was absent.A second challenge was the lack of clear potential solutions for the affected people. Some ethical streams argue that study participants deserve to know their results, no matter the lack of potential solutions . On the Dealing with the unexpected results was another challenge. In the authors’ view, had the study results supported FECONACO and the NGOs expectations, these actors would have maintained their support for the study. Instead, there was a general scepticism about the study and there were unfriendly responses from FECONACO and the communities to the researchers. The pre-understanding of the risk associated with oil activity, the lack of material benefits such as a curative treatment, and the refusal to accept that a change in certain practices could substantially reduce the heavy metals exposure more rapidly than any environmental remediation, were major factors that impeded the receptiveness of the evidence . The EcoThis paper illustrates the application of the Ecohealth principles to the study of heavy metals exposure in the Corrientes native communities, a public health problem embedded in long-standing, unresolved conflict concerning oil activity in the territory of the indigenous populations.The research question emerged from an affected population in a complex context where multiple stakeholders, including the government, the oil company, the indigenous organizations, and environmental NGOs all played important roles. These conditions determined the participatory nature of the study and the application of the Ecohealth principles in the research process. Yet, integrating the transdisciplinarity and participation principles posed a series of difficult challenges, and it was sometimes impossible to overcome them. However, this experience generated positive outcomes too, and they can be understood as the lessons learned by the different actors. Many in the communities learned that the elevated blood lead levels among their children were mainly produced by the manipulation of this metal and that only a change in this practice could help to reduce the exposure. DIRESA delegates, who held managing positions in different sectors, publicly recognized that their institution had to promote a comprehensive participatory framework  to tackle the problem of heavy metals exposure and ensure long term solutions. Likewise, FECONACO leaders gained knowledge of various health topics as well as skills to participate in research projects. Hopefully, they will disseminate that learning and carry it forward into their future occupations. Finally, the researchers learned that (1) it is important to clearly discuss potential unexpected results with the stakeholders, in order to avert and prevent major conflicts of interest; (2) non-academic skills in negotiating, dialogue, and promoting participation and consensus are as relevant as scientific skills in conducting a participatory project; (3) conducting a participatory research project is difficult and the researchers’ influence in shaping the forces involved in the process and outcomes are limited. Other relevant influencing factors included the context in which the project is developed, the history of the issue, the level of conflict involved, the nature of the evidence, and the existing power dynamics.Despite the numerous challenges, applying the Ecohealth principles might be relevant for this type of complex research. Although there was a lack of immediate action, we hope that useful interventions to prevent and control lead exposure in the Corrientes population will be implemented in the medium term.The authors declare that they have no competing interestsAll authors provided their own experiences in the research process. CA synthesized the information and drafted the manuscript with the help of MSS and ABC. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/437/prepub