The community case management of malaria (CCMm) is now an established route for distribution of artemisinin-based combination therapy (ACT) in rural areas, but the feasibility and acceptability of the approach through community medicine distributors (CMD) in urban areas has not been explored. It is estimated that in 15 years time 50% of the African population will live in urban areas and transmission of the malaria parasite occurs in these densely populated areas.Pre- and post-implementation studies were conducted in five African cities: Ghana, Burkina Faso, Ethiopia and Malawi. CMDs were trained to educate caregivers, diagnose and treat malaria cases in < 5-year olds with ACT. Household surveys, focus group discussions and in-depth interviews were used to evaluate impact.Qualitative findings: In all sites, interviews revealed that caregivers' knowledge of malaria signs and symptoms improved after the intervention. Preference for CMDs as preferred providers for malaria increased in all sites.Quantitative findings: 9001 children with an episode of fever were treated by 199 CMDs in the five study sites. Results from the CHWs registers show that of these, 6974 were treated with an ACT and 6933 (99%) were prescribed the correct dose for their age. Fifty-four percent of the 3,025 children for which information about the promptness of treatment was available were treated within 24 hours from the onset of symptoms.From the household survey 3700 children were identified who had an episode of fever during the preceding two weeks. 1480 (40%) of them sought treatment from a CMD and 1213 of them (82%) had received an ACT. Of these, 1123 (92.6%) were administered the ACT for the correct number of doses and days; 773 of the 1118 (69.1%) children for which information about the promptness of treatment was available were treated within 24 hours from onset of symptoms, and 768 (68.7%) were treated promptly and correctly.The concept of CCMm in an urban environment was positive, and caregivers were generally satisfied with the services. Quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm. Urban CCMm is feasible, but it struggles against other sources of established healthcare providers. Innovation is required by everyone to make it viable. Urbanization in Africa is increasing at such a rate that the United Nations estimates that 50% of the African population will live in urban areas by 2025 .Since the launch of Primary Health Care (PHC) , the valIn general, the community providers are normally community volunteers, although shopkeepers have been used in Kenya ,9. Most "Community Case Management of Malaria (CCMm) is the strategy recommended by WHO to improve access to prompt and effective treatment of malaria episodes through trained community members living as close as possible to where the patients live. This strategy was previously known as the HMM (which is now considered to be an inaccurate description of the implementation) due to the misinterpretation of the concept to imply availability of drugs freely in the home without a system for regulating use."As originally developed, CCMm focused on rural, underserved areas with high malaria transmission in Africa. However, the on-going urbanization process and consequent epidemiological changes demand for an improvement of access to effective malaria treatment in urban settings , therefoHealth interventions delivered by community health workers are recognized as having the potential to accelerate progress in reaching the MDG in high mortality settings ,12. ConcTo evaluate the feasibility of CCMm in urban settings in sub-Saharan Africa, the UNICEF-UNDP-WORLD BANK-WHO Special Programme for Research and Training in Tropical Diseases (TDR) funded studies in urban areas in Ghana, Ethiopia, Burkina Faso and Malawi. This paper reports on the effectiveness of conducting CCMm  in a variety of urban settings, representing different health systems and socio-cultural environments.The studies were carried out in the African urban areas of Kumasi and Bolgatanga, Ghana; Jimma, Ethiopia; Lilongwe, Malawi, and Ouagadougou, Burkina Faso, selected by an advisory committee from those who responded to a call published by TDR in 2005.Variations in the methodologies were unavoidable, since in each case the specific national health framework was followed. The characteristics of each study site are summarized in Table kebeles (the lowest administrative unit in Ethiopia).Jimma has two public health centres and 13 private clinics, one Jimma University Specialized Hospital and 15 pharmacies. The peripheral area of the town is surrounded by swamps; lack of a proper drainage system, and two big streams containing sewerage water. The study participants were residents of 10 Kauma, a squatter settlement within Lilongwe, Malawi has one of the highest poverty levels in an urban setting; no health facilities, and transport costs to the nearest health facility posed serious barriers. The caregivers and children were residents of the 24,000 population of this settlement.In Ouagadougou, two adjacent districts were selected for the study: Wemtenga  is a built up area, which is serviced with all the urban amenities, and Taabtenga  is on the periphery of the city and has rural characteristics. Each district has socio-cultural differences and differing health care facilities.The design adopted was pre- and post-intervention (conducted between 2006 and 2009) and were carried out in three phases. Phase 1 involved the baseline behavioural survey and community sensitization and mobilization, the selection of CMDs, and the determination of key baseline indicators. Information, education and communication (IEC) materials were developed and staff recruited and trained by staff of MoH and the research teams. Phase 2 was the intervention phase which involved the training of the CMDs and the distribution of ACTs according to the criteria for diagnosis and treatment, i.e. CMDs examining the children with fever ; Kumasi had Community-based Agents or Community Medicine Distributors; Lilongwe had Health Surveillance Assistants (HSAs); Jimma had Community Health Volunteers (CHVs) and Ouagadougou had Agents de santé communautaire (ASCs). For the purpose of this paper all these are referred to as Community Medicine Distributors (CMDs).A summary of the characteristics of the CMDs, including the selection criteria, is provided in Table CMDs operating in the other sites were comparable as they were selected by the communities and had similar characteristics: they lived in the study communities; had at least a basic level of education; were volunteers; the majority were employed and did their CMD job as a secondary occupation; a few were unemployed, and they had varying occupational backgrounds  with children aged 6-59 months in the study communities. As the main outcome measure for each study was the proportion of fever episodes treated adequately within 24 hours, and as this parameter was not known, a prevalence figure of 50% with a power of 90% at the 5% significance level and a design effect of 2 was used to calculate the sample size, with the exceptions of Bolgatanga, which used 10% (obtained from the literature as there were no recent surveys) and Ouagadougou which used 56% (derived from a previous study of caregivers). For interview purposes, a caregiver was selected by simple random sampling from each household. Thus each household was represented by a caregiver or mother with a child aged 6 months to five years of age.The minimum number of households interviewed ranged from 794 to 956 per site.A household survey was conducted in all study areas at the beginning of the investigation, to gather baseline data on the perception and practice of caregivers on their knowledge of signs and symptoms of malaria, and on their treatment seeking behaviour. This was repeated in all areas at the end of the evaluation phase. During this latter survey only caregivers whose children were febrile within the preceding two weeks were interviewed. The decision to admit children who had been febrile within the preceding two weeks was to assess those who required the CMD services within a reasonable recall period. In addition, at the end of the evaluation phase, a CMD register survey was undertaken to assess the CMDs performances in delivering ACT.Focus Group Discussions (FGDs) (253) and In-depth Interviews (IDIs) (217) were used to assess the acceptability of the CMDs providing ACTs. The discussions involved policy makers, implementers and community members, including caregivers. These tools were also used to assess the progress and opinions on the interventions, challenges and contextual issues. Discussions and interviews were held with men and women's groups, and community health personnel. Interviews were held with private and public health personnel, drug sellers, traditional healers, chemists/pharmacists, and community leaders.®) (AL) was prescribed at the following regimes: 20 mg/120 mg twice daily for 3 days in children 6-35 months, and 40 mg/240 mg twice daily for 3 days in children 36-59 months.The national drug policies of the participating countries were adhered to. Thus, in Ghana artesunate and amodiaquine (AS/AQ) were prescribed, in combination, at the following dosage regimes: 25 mg/75 mg once daily for 3 days in children 6-11 months, and 50 mg/150 mg once daily for 3 days in children 12-59 months. In 2005, Burkina Faso adopted two ACTs (AL and AS/AQ) when the national policy for uncomplicated malaria treatment was changed. Both were considered "on an equal footing" and the policy decision to have two ACTs was made to prevent stock-outs should they have had only one ACT. Subsequently, the National Malaria Control Programme (NMCP) provided health facilities with AS/AQ more often than with AL. In the other countries artemether-lumefantrine  are given in Table CMDs were regularly supervised in all countries according to national policies. In Kumasi, the CMDs were supervised on a fortnightly basis by the research team members, whilst in Bolgatanga there was weekly supervision by members of the research team. During each visit the research sought to know from each CMD, when supplies of ACT were distributed and the numbers of malaria cases recorded. In addition, monthly CMD meetings were held. In Jimma there were monthly monitoring and supervisory meetings conducted by the research team. The supervisors were drawn from the Jimma Health Administration Bureau, Jimma Zone Health Bureau and the Jimma University Specialized Hospital. In Lilongwe there was regular supervision (three times a week) by the District Malaria Coordinator, plus monthly joint meetings with community members, the District Malaria Coordinator and the research team. In Ouagadougou supervision was carried out weekly by the chief nursing officer of the health facility to which the CMD was attached and monthly by the research team.Epi Info version 6.02, SPSS version 11.0 and STATA version 9.2 were used by the study groups for entering and analysing the data. A set of indicators (apply to corresponding author for a copy) and quantitative analyses to be performed were agreed in discussion between the study teams and the TDR facilitators in a meeting held in Nairobi in 2005. Each research team then undertook the analyses of their own data.The FGDs and the IDI information was tape-recorded, transcribed, categorized and analysed according to study themes at each country level by the research teams. The analyses were conducted manually.Ethical approval for all these studies was granted by the WHO Ethics Review Committee and by the appropriate national and Institutional Ethical Review Boards of each participating country. Informed consent was obtained from community leaders, household heads and the caregivers who participated in the studies.The ratio of female to male CMDs varied from 1:1 (Kumasi) to 5:1 (Ouagadougou). The average number of children that each CMD had under his/her care varied from 55 in Ouagadougou to 570 in Lilongwe. The differences are mainly due to different population densities and how scattered the settlements were in the various areas. In several cases, CMDs had commercial outlets not related to health (e.g. barber or video shops) or were teachers.Housewives/unemployed were the most common CMDs followed by traders. Interestingly, in Bolgatanga drug shop owners were the most common CMDs along with traders. Artisans, labourers, farmers and students made up the bulk of the rest of CMD occupations in each of the study areas. Overall, it is interesting to note the much greater variety of cadres on which urban CCMm programmes can draw compared to rural CCMm ones. They were available to serve as CMDs because this did not interfere with their main job, and sometimes it would even bring them a commercial benefit. In rural CCMm programmes, on the contrary, where the majority of CMDs are subsistence farmers, serving as a CMD at times interferes heavily with their personal commitments.Overall, the use of services by CMDs was high. A total of 9001 children with an episode of fever were treated by 199 CMDs in the five study sites during the study period, with the average number of children seen by each CMD varying between 27 and 266 average 45) , followed by Kumasi (24.3% change), Lilongwe (15.8% change) and then Jimma (8%) and Ouagadougou (3%). The use of modern medicines for self-treatment increased in four of five sites, while the use of public health facilities decreased, and the use of traditional healers either declined or remained static.No use of informal medicine vendors was made in Jimma. The preferred use of chemists/pharmacists declined in Bolgatanga and Kumasi, and increased in Lilongwe. Their use was not recorded in Jimma or Ouagadougou.The performance of CMDs was evaluated on the quality of their delivery of ACTs Table . In all As an indicator of treatment coverage by the CMDs a household survey was conducted. The recall period for this survey was two weeks Table . The totA total of 253 FGDs and 217 IDIs were carried out during the baseline and evaluation phases. The majority of FGDs (187) were conducted with mothers and 79 IDI were conducted with community leaders. Overall, all sectors of the communities were addressed: health workers, public health service providers, health managers, pharmacists, NGOs, community health workers and practitioners. Most of the FGDs were conducted in Ouagadougou and the majority of IDIs were conducted in Jimma. There was considerable variation between the five study sites in the number of qualitative investigations carried out, and there was no consistency between the groups.The findings were discussed during the report production workshop, and were interpreted and presented in the form of narratives comparing the results across the sites. The thematic narrative findings of the FGDs and the IDIs are presented below.The qualitative data indicated that many respondents knew about the signs and symptoms of severe malaria. The most commonly cited symptoms were vomiting, high body temperature and inability to feed.A participant in Kumasi noted that:Affected children may be convulsive, have high body temperature, refuse to accept and eat any food, sometimes vomit virtually all food and water out, vomit is sometimes yellowish .Most participants, through the FGDs, mentioned that the major sources of information were the CMDs, radios, local community health providers, hospitals and friends.In Malawi, most participants indicated that they used the HSA centres. This was mainly due to the fact that there were no other formal health providers in Kauma before the introduction of the Centres. In Bolgatanga, a participant in a female FGD stated that:There are some women in our community who have been chosen and trained. If you are near one of them you can send your child there. They have something with which they test the children before they give them the medicine. If the child has malaria they will give the medicine .The following sequence in health seeking was reported more generally, with some minor variations in the five sites:(i) caregivers seek the opinion of spouses, in-laws and/or elderly relatives;(ii) children are sponged and/or given available medication ;(iii) medicines are bought from chemists/shops;and (iv) that care is sought subject to affordability, recommendations of friends or relatives and prior experience of the caregiver.The majority of the participants, in both the FGDs and IDIs, indicated that the severity of the illness determined the choice of the provider.A caregiver in Lilongwe observed that:If the child is serious we do not wait for anything, we just take the child to the health centre, regardless of time .The pre-packs were generally accepted and described as very effective for treating fever, available all the time, cheaper and affordable. In addition they considered the pre-packs a helpful strategy. In Ghana, it was notable that most participants were happy with the intervention and they wished it could cover everyone in the community not just children. A participant in Bolgatanga stated thatIt is a malaria drug, if you are going to give this drug to a child like this, you will break the yellow tablet into two and then break it into two again. You do the same thing to the white one. Then you dissolve the drugs on a spoon with water and give to your child to drink .There was an indication that the caregivers had acquired adequate knowledge on the drug regimen. Some remembered the colours of the drugs but were not certain about the dosage and the number of days for drug administration. Although the mothers were expected to return to the CMDs, it was noted that this was difficult due to their engagement in income generating activities. Some of those who failed to comply stated that it was due to the immediate recovery of the child after taking the first dose.The positive view across the countries on CMD as a channel of distribution was mainly due to proximity. The terms used to describe CMDs included: appropriate, comparatively stress-free, convenient and preferable source. The participants in Ghana expressed the view that complaints and the need for further explanation were addressed promptly by CMDs, and CMDs occasionally visited the mothers in their homes.There were, however, some community members who did not appreciate the work of the CMDs. This was mainly related to perceptions towards their low skill levels. A CMD in Bolgatanga reported the following:They say they don't know where we have gone for training that has given us the knowledge to treat children. That person told me he does not like our medicine. He said he would rather take his child to hospital. He does not know the school I attended and the training to enable me sell medicines in the community .In Ethiopia, although the CMDs were known to mothers in Hirmata Markato, their services did not attract the attention of most households. Thus, during malaria illness, mothers often took their children to the health centre than seek the help of CMDs. The reasons include the fact that mothers were already conditioned to the health centre or they lacked confidence with the CMDs. Reasons for preference for private facilities included: to get prompt diagnosis and hence timely treatment; private clinics were nearby in the community; and private clinics felt more responsibile and were more accountable than public health care settings.The study highlighted some challenges experienced in the delivery of treatment to children. In Malawi, the main issue was the availability of the CMDs at all times. This was mainly due to the fact that most of them were not resident in the area and, therefore, their hours of operation were limited from 10.00 to 16.00 hours.A major problem in the study sites was poverty given that the selected communities were in urban poor areas. In Ethiopia, a participant noted:We are living in abject poverty. Thus, financial insecurity has curtailed our ability to buy drugs, food items and meet other extra costs when our children are ill .In Ouagadougou, staff at health facilities thought stocks of Coartem were exhausted very quickly because of competition between CMDs and health centres:There was no regulation which required us to keep some stocks especially for CMDs. Now, people come to the HC from everywhere and not just Taabtenga and Wemtenga. When we diagnosed malaria we prescribed Coartem, which they could find cheaper here . If there was a stock-out of ACs in the pharmacies, then the public attended the HCs where they were provided with anti-malarials.Until relatively recently malaria has always been considered a rural disease in Africa mainly because of the perception that suitable malaria vector breeding sites in towns and cities were rare. This may explain why the transmission of malaria is generally lower in the urban environments, when compared to that of rural areas; and together with a greater availability of health care providers and a generally higher socio-economic status in the urban situation  results The studies described in this paper are implementation research studies, which (by definition) have to follow national policies and be embedded in 'real life' local ways and cultures. This accounts for the diverse type of CMDs operating in different countries  and may explain either the diversity of the effects observed on health seeking behaviour and some of the differences in performance or impact between studies.Notwithstanding differences between sites, the results show that CCMm in African urban environments is a feasible option, which is well accepted by the populations. In line with findings in rural areas, the overall quality of care provided by CMDs is quite satisfactory (99.2% of correct prescriptions), as well as adherence by caregivers to the correct treatment schedule (92.6%) and the promptness of administering the first dose (68.3%). However, the coverage obtained by urban CCMm is generally more modest than in rural environments, with "only" 40% of caregivers consulting CMDs for the treatment of their febrile children compared to the overall figure of 59% noted by Ajayi .In Jimma, about 80% of caregivers reported that their preferred provider for childhood malaria treatment was the CMDs because services were available in the neighbourhood and were quickly performed, however only 7.3% of caregivers used the services as they preferred to utilize the 'established' health services. In fact, this apparent disconnect between perceptions and practice was also evident in Bolgatanga and Ouagadougou, although the differences were not as great as in Jimma. In Kumasi, only 31% said that they would prefer to use the services of the CMDs, but actually 41% used them. These differences between perceptions and practice can generally be accounted for by caregivers' preference for the existing systems (which they know); the proximity of established pharmacies, clinics, etc.; lacking confidence in their CMD; not finding the CMD at the first attempt; professing to be unaware of the quality of their training; stock-outs, and inability to pay. Of interest is the situation in Lilongwe, where 64% of respondents said they would prefer the CMDs, and the same proportion actually used them. The point about the study area in Lilongwe (Kauma) is that the CMDs were the only health service providers, and as has been stated previously, the eight CMDs had a much wider role than those in the other sites under investigation. The fact that the Lilongwe CMDs had, in addition to their normal duties, malaria diagnosis and treatment, meant that they were filling a void in the area. Thus it is not surprising that more people sought their services than going elsewhere.The main reason that CMDs were used was because of proximity; they were trained, and they provided quick treatment.It would appear that the effectiveness of the CCMm is directly linked to the efforts of the CMDs to become familiar with the caregivers in their areas, and to engender trust in their ability to diagnose and treat childhood malaria quickly, safely and effectively.A comparison of those parameters that were measured by both the household survey and the CMDs registers shows a close agreement between what the CMDs recorded and that which the caregivers recalled in the last two weeks of the implementation phase in terms of quality of care and utilization of services.The CMD registers showed that 99.4% of the children were treated with the correct dose for their age, and the household survey showed that 92.6% were treated with the correct dose and for the correct number of days.The CMDs recorded that 54.2% of the children were treated within 24 hours of being ill, whereas the household survey recorded 67.6%. We acknowledge that the data are not strictly comparable, as CMD registers were maintained over a period of one year (the intervention phase) and the household survey was conducted at the end of the intervention phase with a recall period of two weeks. In a similar study carried out in rural areas of sub-Saharan Africa  adherencIs CCMm affordable in the urban setting, or would caregivers find it cheaper to seek care in the private sector?" Self-treatment continues to be common, and in urban areas it is commonly due to the large numbers of medicine vendors  that exist. Various reasons why people patronize drug shops, pharmacies, and even illegal drug sellers instead of health centres and hospitals, indicate that it is the ease of buying and obtaining immediate treatment that encourages them. In a study in Maiduguri in Nigeria, it was reported that immediate attention for both consultations and treatment was the most important reason why pharmacies and drug shops were frequently patronized, rather than the health centres [in the home might not be appropriate for large urban areas or settings with fairly low malaria transmission, the findings of our study show that when drugs are distributed by appropriately trained CMDs, the quality of prescription and adherence to treatment schedules by caregivers are as high as in rural areas with high malaria transmission.The unit dosed pre-packed anti-malarial medication for the CCMm is widely accepted amongst mothers  and this centres . Thus, i centres . While wQualitative research findings of the study indicate that the acceptability of pre-packed ACTs for treating malaria in children under 5 was very high. Compliance with the recommended dosage, as well as treating children with malaria or fever within 24 hours by caregivers was said to have improved significantly across sites. These data indicate that the use of the CCMm in urban settings is feasible and acceptable to caregivers, and contributes to an improvement of malaria case management.It is vital for the success of CCMm in urban situations to implement an effective and sustained health educational programme aimed at caregivers, coupled with an equally important educational and training programme specifically for health personnel. It was extremely difficult to mobilize urban communities for health education programmes. In Kumasi, only about 25% of caregivers sought care for their children either from clinics or hospitals depending on distance and recommendations from relatives and friends (Kumasi interviewed respondents).The main challenge to urban CCMm is the motivation of CMDs in order to sustain the pre-packed ACTs . At thisConsidering that the IEC campaigns were not as successful as anticipated, did the caregivers gain any knowledge about malaria signs and symptoms during the period of the intervention? In Kumasi, Lilongwe and Ouagadougou there were marked improvements Table . In LiloCMDs will not always work as volunteers. They need remuneration or incentives in order for them to make an intervention sustainable and effective, e.g. in the Sudan the volunteer Malaria Control Assistants worked on a consultation fee of US$0.50  and in tBy using collaborative approaches that include the community, the private sector and existing health, urban planning, agricultural and governance structures, urban malaria is uniquely amenable to prevention and control .Most of the FGD participants appreciated the project and acknowledged the approach adopted. They observed that being served or getting malaria treatment closer to their homes was highly valued and something that everyone required to effectively manage childhood malaria.The concept of CCMm in the urban environment was positive, and those caregivers who used the system were generally satisfied. Overall, 40% of caregivers opted for their children with fever to be treated by CMDs, and the vast majority of them were treated promptly and correctly. This shows that CCMm has an important role to play as a public health strategy for malaria case management in urban as well as in rural settings. However, it is obvious that as a new system, it was not universally utilized, and there are several reasons for this. For example, it was generally considered that the IEC system was not nearly good enough, and the systems used in rural areas did not work in the cities. It also seems probable that some of the CMDs did not integrate well with the communities they served, thus jeopardizing the overall uptake of the system. In part, this may have been due to the fact that some form of incentive was a necessity to maintain the activities of the CMDs. The main reason for not using the system more was because there were traditional conflicting sources of health care, and the introduction of a novel system requires considerable input from the initiators as well as the community incumbents. It is probable that the need for incentives is higher in urban areas given that access to food and all services is cash based.Incentives for CMDs are an important aspect of the development of this system of delivering malaria diagnosis and treatment. It is recommended that RDTs be provided to CMDs for improved diagnosis of malaria, in keeping with WHOs latest edict .Urban CCMm is feasible, but faces an uphill battle compared to its rural counterpart. Within the urban context there are many competing health outlets, all of which have been serving the communities for many years. The introduction of a new system requires time and patience for the community to evaluate it, and to accept it as an improved system to that which currently supplies their needs. Since there are many conflicting sources of medicines in urban centres it may also be possible to integrate CCMm with private health care providers, as long as the advantages of cost, good advice and CMDs being "friends of the households" are maintained. The programmes must, therefore, invest in community mobilization to market the intervention.The authors declare that they have no competing interests.All the authors except GB conceived the study; MS, ATK, PC, PA-B and PA were principal investigators for their respective country's study site and together with PA, AT, BS and ELNB participated in the research design and supervised data collection from the field. Apart from the PIs, Samuel Boateng (Ghana), AT (Jimma) and BS  performed most of the quantitative data analysis and analysed the qualitative data. FP, the WHO/TDR CCMm research programme manager supervised all the field sites. FP, MA-N and GB facilitated the data analysis workshop. GB co-ordinated all the final reports and developed the final manuscript. All authors read and approved the final manuscript.


Here, we briefly describe only new or changed recommendations.Since the publication of the American Association for the Study of Liver Diseases (AASLD) practice guidelines on the management of hepatocellular carcinoma (HCC) in 2005, new information has emerged that requires that the guidelines be updated. The full version of the new guidelines is available on the AASLD Web site at In the previous guideline, groups were specified for which surveillance was likely to be cost-effective because the hepatocellular carcinoma (HCC) incidence was high enough. New data on defining HCC risk have emerged for hepatitis B virus,10de facto staging system that is used.The BCLC staging system Fig. 11 has coThe recommendations for liver transplantation have not changed. No new data have emerged that can be used to define a new limit for expanding the patient selection criteria. The usefulness of portal pressure measurement to predict the outcome of patients and define optimal candidates for resection has been validated in Japan.The recommendations regarding patient selection and method of administration of chemoembolization are unchanged. Radioembolization, i.e., the intra-arterial injection of yttrium-90 bound to glass beads or to resin, has been shown to induce tumor necrosis, but there are no data comparing its efficacy to transarterial chemoembolization or to sorafenib treatment for those with portal vein invasion. However, for patients who have either failed transarterial chemoembolization or who present with more advanced HCC, new data indicates the efficacy of sorafenib  in prolonging life.In summary, in the past decade HCC has gone from being an almost universal death sentence to a cancer that can be prevented, detected at an early stage, and effectively treated. Physicians caring for patients at risk need to provide high-quality screening, proper management of screen-detected lesions, and provision of therapy that is most appropriate for the stage of disease.


Antiretroviral therapy (ART), for those who have access, has revolutionised the morbidity and mortality consequences of HIV infection. By the end of 2010, 6.6 million people living with HIV in low- and middle-income countries were receiving ART, a dramatic 20-fold increase since 2001, saving millions of lives. In addition to the impact of ART on the health of those living with HIV, recent randomised controlled trials demonstrate the additional impact of ART in reducing HIV transmission. With this double effect, ART is a game changer in the response to AIDS. With other advances over the past year, we now have a set of effective tools to stop the transmission of the virus and to keep people living with HIV healthy and productive. It is now the collective responsibility of researchers and implementers, of governments, the private sector and civil society, to identify and overcome the challenges and translate the science into real results for people. At the recent United Nations High Level Meeting on AIDS, Member States endorsed ambitious targets including to reach 15 million people living with HIV with ART and to cut sexual transmission of HIV by half by 2015. The declaration also calls for additional resources of 22 to 24 billion dollars by 2015 as an investment that will yield returns in multiples. However, it wasn’t until 1996 that combination antiretroviral therapy (ART) truly changed the treatment landscape and produced the “Lazarus effect”However, the first drug combinations were extremely expensive, required frequent doses, often caused severe side effects, and resistance developed quickly due to imperfect adherence. These drawbacks, and a reluctance to provide the requisite finances, kept these medicines from broad international use.Ten years ago, at the 2001 United Nations General Assembly Special Session on HIV/AIDS, consensus was not able to be achieved among world leaders to include treatment targets in the final Declaration of Commitment. At that time, only about 30,000 people in Africa had access to treatment [—thanks to the work of activists and competition from generic manufacturers — costs have fallen dramatically.Now, after years of intensive research and clinical experience, the quality, simplicity and tolerability of ART regimens have radically improved, andAt the end of 2010, more than 6.6 million people living with HIV in low- and middle-income countries were receiving HIV treatment, and at the 2011 United Nations General Assembly High Level Meeting on AIDS, leaders agreed to the target of increasing this number to 15 million by 2015.— making the step from averting illness in individuals to drastically slowing the epidemic in populations.Today, we stand at the brink of a new way of thinking about the role of treatment, not just to save the lives of people who are infected, but to prevent infection in the first place HIV Prevention Trials Network (HPTN) 052 randomised controlled trial demonstrated that early treatment for people living with HIV in serodiscordant couples can be 96% effective in preventing sexual transmission [Partners Pre-exposure Prophylaxis (PrEP) study findings demonstrated that pre-exposure prophylaxis, taken by an HIV-negative partner, can reduce sexual transmission by up to 73% [Clear and unequivocal science has driven the agenda forward. Adding to prior observational and cohort studies, the smission . The Parp to 73% .These breakthroughs carry the promise of changing the context of HIV: tipping us from endemic HIV in perpetuity to an epidemic in decisive decline.However, treatment for prevention is not a magic bullet. ART for prevention is an investment that needs careful nurturing so it can flourish as part of the portfolio of effective HIV prevention and care responses.The challenge is to realise the potential of ART to help shift the dynamics of the global epidemic by adding its impact to other HIV prevention efforts and overcoming the global inequities that currently stand between impoverished people and their health, happiness and development.The critical steps to tipping the HIV epidemic into decline revolve around simpler treatment, resolving the cost conundrum, placing communities at the centre of programme delivery and putting the whole prevention toolbox to use.With the drugs we currently have, there are strong and often serious side effects. Programmatic challenges continue, and in some countries, up to 40% of people on treatment are lost to follow-up within three years . If HIV-Treatment 2.0 agenda: it calls for new pharmaceutical compounds that will lead to a “smarter, better pill” — less toxic, longer-acting, less expensive and easier to use. Combined with dose optimisation and improved sequencing of first- and second-line regimens, this will simplify treatment protocols, and—in concert with new models of service delivery, point of care testing and community mobilisation—will improve efficacy.The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) have developed a  Treatment 2.0 will not come to fruition unless we can reduce the time from research findings to policy implementation. The virus does not move slowly, and neither should we. To close the gap between science and implementation, we must be driven by a sense of urgency—the same sense of urgency felt by the millions who wait every day for discoveries to reach them.The overall costs of providing HIV treatment are growing as countries scale up treatment, adopt the WHO guidelines for expanding early diagnosis and access to earlier treatment initiation, provide safer (but currently more expensive) first-line regimens and respond to the growing need for second- and third-line treatment.Reducing the prices of antiretrovirals must continue to be given high priority. One effective route has been competition from generic drug producers, but this strategy has limited impact on the current prices for second-line treatment, as there are fewer second-line generic drugs available today. Another route to control costs is the Medicines Patent Pool, established in 2010, which aims to increase access to newer antiretrovirals by creating a pool of patents and intelligence on antiretroviral production donated by the originator companies.The global consensus on trade regulation asserts the prior obligation of states to protect the public health, and accordingly as trade agreements are negotiated, we must challenge any components that seek to limit trade-related aspects of intellectual property rights (TRIPS) flexibilities. Countries must not succumb to pressure to amend intellectual property rights flexibilities or allow patent linkage, data exclusivity or patent term extension, or to form alliances that pre-empt countries’ use of compulsory licensing.These measures to break the cost trajectory of treatment are among the answers to the skeptics who say that implementing treatment for prevention in this fiscal climate will be too costly, too risky and unsustainable. But what is truly costly, risky and unsustainable is inaction. If we want to turn scientific successes into progress for the poor, we must overcome the fiscal threats to HIV treatment and prevention access and the programmatic challenges to treatment adherence.Another critical pillar of sustainable treatment is ensuring that people and communities are at the centre of any approach. We need to go back to the community level to increase treatment literacy, increase demand for services and improve delivery on the ground. To make this possible, we must tap into unconventional capacity and introduce new alternative delivery systems. In that vein, UNAIDS is working closely with partners to mobilise more community health workers in Africa by 2015 .— particularly marginalised groups such as sex workers and their clients, men who have sex with men, people who inject drugs, and people in prison or other closed settings—can and will access integrated services that address their needs and protect their human rights. There is good evidence that effective outreach and engagement of affected communities will increase access, adherence and health outcomes.Funders and policy makers must make sure that all people living with HIV and those most affected by the epidemic We have already seen HIV prevalence among young people fall by more than 25% in 15 of the highest burden countries because of changes in sexual behaviour . The strBut there are still critical gaps in the “how” agenda, in terms of ensuring efforts are sensitive to national and local context, and that the most vulnerable and stigmatised groups do not miss out.Currently, too much of the AIDS effort comes too late: many people are still only tested after they have been diagnosed with an opportunistic infection. While it may never be possible to eliminate acute stage infection as a driver of onward transmission, the gap between infection and HIV care can certainly be shortened, especially by eradicating the stigma and human rights violations that still deter health-seeking behaviour among key populations.Extending treatment access is at the centre of a new agenda of hope in the global AIDS response. Realising the full potential of antiretrovirals for prevention is a challenge for the scientific community, civil society and leaders everywhere.Treatment 2.0, could avert an additional 10 million deaths by 2025 [But the prize is great. Modelling suggests that, compared with current treatment approaches, full implementation of smart HIV interventions, including  by 2025 . The queLet us celebrate these scientific breakthroughs, and carefully nurture the investments that will maximise their full potential.


Recent studies show that the prevalence of tobacco use among teens and students is increasing, and the initiation age of tobacco use has decreased.The current research aimed to signify the role of schools in the process in which student teenage boys became smokers in 2012 in Mashhad.The current study was part of a qualitative research conducted by content analysis method and purposive sampling, performing 35 in-depth interviews, and 2 focused group discussions. The participants in this research included teenagers, teachers, students` parents , psychologists, and experts in the field of fighting against tobacco use, those who either had the experience of exposure to cigarettes at school, or were well-informed persons about tobacco use.After performing each interview, the interview was transcribed, and analyzed before the next interview. The data were under continuous consideration and comparative analysis in order to achieve data saturation.After analysis and codification of data, four concept categories were achieved to clarify the role of schools in student smoking: 1) School purity or impurity to high-risk behaviors; 2) Directive or nondirective schools for controlling tobacco; 3) Preventive or predisposing schools for smoking behavior, and 4) Perceived positive outcomes from smoking at school. Each main category was divided into three subordinate themes.With regard to decrease of cigarette use initiation age and the great influence of schools on teenagers’ behavior, it is recommended to perform special screening programs based on the achieved themes in this research to reduce tobacco use. It is also suggested that school staff pay more attention to students’ communication networks and pressures that are imposed on a student for smoking cigarettes during the school time. Smoking is the most important cause of preventable death in the world , 2. EverConsidering the Global Youth Tobacco Survey (GYTS), findings in the current decade indicate the decrease of smoking initiation age, and the increase of cigarette use prevalence among teens . AccordiMany experts have considered cigarette use as an introduction to tendency to use other substances, and mention it as the gate to narcotics use . With reThe current research aimed to signify the role of schools in the process in which student teenage boys became smokers in 2012 in Mashhad.The current study was part of a qualitative research conducted by content analysis method, and purposive sampling in 2012. The content analysis is beyond extraction of visible content taken from textual data. By this method, in the current study we could obtain contents and hidden patterns from the participant’s data .All the The participants in this research included teenagers, teachers, students’ parents, psychologists, and experts in the field of fighting against tobacco use. Participants were selected based on their experiences and the research objectives. Inclusion Criteria of this study were age 10-35 years, and either cigarette use background in teenage, or having experience about teenagers smoking. For a better understanding of smoking behavior, both teenagers (10-19 years) and adults (20-35 years) were interviewed. Teenagers were two groups including smoking teenagers and non-smoking teenagers. The non-smoking teenagers were selected because by comparison of their conditions and reactions in similar situations, we could achieve a better understanding of the process in which these teenagers became smokers.Adults included persons who had started to smoke from their teenage years (10-19 years). Adult smokers were selected because by keeping aloof from teenage experience, they possessed a deeper understanding of their experience, and could provide in-depth information in comparison with teenagers, about how they became smokers, and their information was complementary to the information received from the teenagers. In order to create maximum variety in the samples and perceive broader dimensions of this subject, the experts of the field and the students’ parents were involved in this research. Lack of tendency toward continuing the cooperation, presenting dishonest answers and revoking conscious satisfaction, were considered as the exclusion criteria.Purposive sampling through Maximum variation sampling was initially used for data collection. In this sampling method, the basis of selecting participants was having special information about the considered phenomenon, and the aim of their selection was to collect these data. In this section, the persons who had the experience regarding smoking behavior and were close to this group in terms of age, or had experience and skill in the field of working with teenagers participated in this research. Samples were selected from different places like Parks, extracurricular classes of the municipality, training associations, schools, universities, drug stop clinics, and Nicotine Anonymous (NicA). Because of the authors` background in working with centers of drug abuse treatment and smoking cessation clinics, the first samples were selected from these centers, and other samples were selected using snowball method. Some of these samples were also selected using accessible samples and direct observation of teenager smoking by the researcher.The data in this section was collected using in-depth interviews and Focus Group Discussion (FGD). All of the interviews were recorded and transcribed. The interviews were conducted by the first author who was identical with the studied group in the light of gender and regarding the age was also closer to them. He had also activity background in the field of tobacco studies and studies about students and teenagers as well. He had good communication skills and specialty about interview. Interviewees’ written consent was obtained prior to recording their voices, and the research aims were explained to them. In addition, they were assured that all of their information will remain confidential, and only the researcher will have access to their information and sound file. All of the participants studied and signed the form of conscious satisfaction designed by the research team. This conscious satisfaction form had been prepared on the basis of ethical codes regarding work with human cases and approved by Ethics Committee of Tehran University of Medical Sciences (registered under 17878-73530Dated27/2/91).The places of interview were determined based on agreement of both parties . The interviews were conducted in face-to-face approach and in an open and semi-structuralized method. The interviews were carried out just with the presence of researcher and the interviewee and not anyone else. The interviews commenced by questions regarding age, education, and leading questions to enter discussion. The key question for smokers was their story about smoking the first cigarette, which they were asked to talk about. The key questions were: “Let us talk about the story of your first smoke. Why did you choose to smoke for the first time? Why made you continue smoking?”The other questions were related to cases that the interviewee did not mention school conditions, smoking at school, and so on. Moreover, in the new and supplementary interviews, the information of the previous interviews was used, and the new questions were added to the new interview. The new questions were added based on the obtained memos. In addition, the comments made by smoking teenager, parents, experts of teenage behavioral training, teachers, and health trainers of schools were obtained through group discussion .The time of interviews was different ranging from 20 minutes up to 90 minutes. Totally 40 samples were selected for interview that five persons were left out according to lack of interest to continue cooperation , and by interviewers’ discretion. In the focus groups, nobody was left out of this study.In the 35th interview, we reached data saturation. The researchers did not feel any necessity to repeat any of the interviews. Thirty-five people participated in the interviews, and 15 people took part in two group discussions. The time of each group discussion session was 180 minutes.The analysis was carried out by means of Graneheim & Lundman approach  Table 1Table 1. Data collection and analysis were done simultaneously . After eDuring this study, to make sure of credibility, dependability, fittingness, and conformability methods were used for exactitude in qualitative scientific researches . The wriThe analyses were carried out in two groups, the Encounter Group, and the Informed persons Group. The encounter group included teenagers either smoking, exposed to cigarette offers, or had experiences about their friends who had became smokers, and also adults who had started smoking from their teenage and education period. The total number of these persons was 35 people . The informed persons group included four persons from teenagers’ parents, three persons were teachers active in training matters, three persons were health trainers of schools, two persons were psychologists in the field of drug abuse, and three persons were experts of health education and health promotion who worked on the field of tobacco use. The number of these persons was 15.After analysis and codification, the manner of school effect on students’ smoking behavior was determined as follows:•Purity or impurity of school in terms of high-risk behaviors;•Directive or nondirective schools for controlling tobacco; •Preventive or predisposing schools for smoking behavior, and•Perceived positive outcomes from smoking at school  Then, each main category and subordinate themes of each category were explained.We considered the pure school as a school in which the students were not exposed to high-risk behaviors. This category had three themes explained as follows.One of the causes emphasized by participants in this study was the influence of school environment on increasing the smoking possibility of teenagers. The presence of smoking students was one of the cases that the participants mentioned as a persuasive factor for cigarette consumption. Participant number 14 in this case said: “Before the beginning of the class or at breaks, the guys who had experienced cigarette consumption described it to us in detail, in a way that you wished to experience it right away” .All of the participants in this research confirmed that the presence of smoking students at school creates more pressure on teenagers for smoking. With regard to the effect of peers on teenagers in this period of life, the pressure will be applied through temptation, and offer in the presence of other students by smoking students.Most of the participants expressed that easy access to cigarettes at school, and sales of cigarettes around the school increase the students` possibility of smoking. Some of the interviewees mentioned the presence of smoking students at school, and possessing several cigarettes as one of the factors that leads to easy access to cigarettes. Participant number 17 said: “I smoked my first cigarette at school. One day, we did not have a teacher, and gathered with some guys behind the playground. One of the guys was talking about his smoking. I said: if there is a cigarette right now, I will smoke, too. I hoped that there would not be any cigarettes. He went into the class and brought the cigarette and matches that were inside his bag. It was disgraceful if I did not smoke” .Generally the participants` comments emphasized the point that easy access to cigarettes at school, could complete the chain of pressure, temptation, and offer, that consequently places the students in an irreversible situation for smoking their first cigarette.Presence of students with other high-risk behaviors like drug abuse or drinking alcohol also creates a collection of high-risk actions including smoking among other students. One of the interviewees who was currently giving up his addiction told us his story:“Once, one of the guys said: “My father drank wine last night, a little wine has remained at the bottom of his bottle.” He had brought it to school, and we drank it together. During the break, we went behind the school trees, drank the wine, and then smoked a cigarette” .Comments of experts and students’ parents confirm the matter that the presence of students with high-risk behaviors can increase the possibility of smoking among other teenagers. From the view point of the experts who participated in this research, presence of students with high-risk behaviors like drug abuse or drinking alcohol has an effective role on increasing the possibility of the other students’ smoking. This can take place through different ways such as normalization, influence of the high-risk group, and coherence of high-risk behaviors.Research participants have considered a school as “Directive” when the school staff and the students’ parents effectively participated in the enforcement of anti-tobacco programs. “Nondirective school” consisted of three subordinate themes as follows:Presence of compiled and purposive educational programs at schools to prevent and control smoking behavior are some of the factors that greatly affect tobacco use control, the teenagers and the experts who participated in this study believed that lack of the enforcement of these programs can make the students vulnerable to smoking behavior. The participants expressed that in Nondirective schools, anti-tobacco educational programs are not priorities. One of the school health trainers explained the subject in this way:“The authorities of these schools do not consider any priority for anti-tobacco programs.” Ineffective enforcement of available programs is also another reason mentioned by experts in this regard. Participant number 45, an expert of health education, expressed:“The selected educational methods are not proportionate to educational aims.”Irrelevancy of educational methods with educational goals, and the low quality of education are the cases that all experts mentioned as a failure cause of anti-tobacco instructional programs at schools. It seems that lack of benefiting from experts and educational planners in designing and executing instructional programs has great influence on the failure of such programs.According to the participants` statements, another considerable subject is the teachers` important role in prevention of tendency toward cigarettes. Participant number 30 mentioned: “None of the teachers preached or said what to do in cases of cigarette offerings” .Lack of appropriate participation of head masters and school authorities in such programs is another problem that makes a school “nondirective”. In addition, a health trainer states, “You cannot do anything at school if the head master does not want you to”. In this case, everything will fail” .The participants confirmed that if the students’ parents do not cooperate with schools appropriately, playing a directive role by schools is impossible. One of the teachers said in this regard:“Many families do not agree to send their teenagers to schools for extracurricular non-educational training workshops” .Lack of cooperation and participation of families in anti-tobacco instructional programs was the concern of all the experts participating in this research. According to these comments, enforcement of anti-tobacco instructional programs will face failure or achieve low output, without appropriate cooperation of the students’ families.”Preventive schools are those that do not create grounds for cigarette use among students and eliminate or control the conditions that reinforce the behavior, and tend to remove the use opportunities and temptations, or minimize them.This category has three subordinate themes as follows:Interview with persons that have had a chance to smoke at school, shows that, schools can provide chances for teenagers to smoke. Availability of the out of sight unsupervised places inside the school, or undefined class hours without teachers are some of the opportunities provided for students to engage in high risk actions. Participant number 16 said:“Behind the precinct of our school, there was a back yard that teachers parked their cars. One day I went there and saw that my friends were smoking. They asked, “Do you smoke?” I replied, “Yes, I do” .With regard to the fact that the influence of peer groups on teenagers is very high, being exposed to the situation increases the possibility of cigarette use by the teenager. One of psychologists participating in this discussion expressed: “The teenagers’ informal groups at school have a great influence on their behaviors. Now, if the conditions of smoking at school are available, saying no to cigarettes will be more difficult for the teenager” .The unsupervised places of school like teachers’ parking, under maintenance classes, behind playgrounds and places like this where students can commit irregular acts without the fear of being seen by school authorities, can provide extremely effective opportunities to experience cigarettes.Most interviewees believed that absence of protective programs for Weak students  are considered as effective causes of cigarette smoking among teenagers. One of the parents expressed his opinion in this regard:“When the older students annoy my child and put pressure on him, I can’t be with him to defend him, he can’t cope with them” .Teachers as the students’ role models are considered as another effective factor on students` smoking behavior.Participant number 29 expressed that “During the break, our teachers would go behind the pantry and smoke” .Both teenagers and experts expressed that openly smoking inside the school environment, or even out of it by smoking teachers is one of the effective factors on the students’ tendency toward cigarette use. It seems that teachers’ behavior as one of the important role models of the teenage period for students, beyond the instructional programs of anti-tobacco, is effective on students` tendency or lack of tendency toward cigarette use.The majority of participants in this study expressed that one of the most important reasons of tendency toward cigarette use among students is the expectation of positive consequences against smoking behavior. The subordinates of this category are three themes explained as follows:Students who had experienced cigarettes believed that at their schools, smoking was a superiority factor among students, and was somehow considered as a value among many groups of students. Participant number 23 mentioned that:“As we wanted the other classmates to think that we are superior to them, we smoked in front of them” .According to the participants, lack of supervision by headmasters and teachers on forming valuation systems at schools will make smoking and doing high-risk behaviors a value among informal groups of teenagers at school.According to the participants receiving protection of the group and obtaining permission of entrance to informal groups are mentioned as some other effective reasons in tendency toward cigarette use among teenagers. A teenager who has become a smoker at school mentioned:One of the cases that lead teenagers to smoking is entry to forbidden groups, increasing the sense of belonging to the group, and receiving supports of the group. In fact, the teenager stabilizes his membership in the forbidden groups formed at school, by cigarette use.The intense educational competition, and using different methods to obtain higher marks, is one of the causes that persuade a teenager to use cigarettes. Participant number 18 expressed:“Some guys smoke to stay awake or to reinforce their memory”.Another participant said: “It had really affected my studies and my marks improved dramatically.” The comments of experts participating in this research confirmed the students’ opinions about this matter. It seems that intense educational competitions, excessive evaluation of grades, assigning special privileges to elite students, and the discrimination imposed by teachers and school authorities on students in terms of grades are some of the reasons and motivations of students for using abnormal methods like smoking in order to obtain higher scores.In the current study, some of the participants stated that the presence of high-risk students could increase the possibility of smoking among other students, and cigarettes may persuade them to try other high-risk behaviors. The study of Ziaoddiny et al. also showed that the total prevalence of narcotic substances among boy students is 26.5%, which is statistically high . It alsoLack of appropriate educational programs and ineffective performance of the available ones require reconsideration of programs, and benefiting from health education experts. The study of Ziaoddiny showed that most of the instructions have been given by the principal and the least training has been done by the health instruction teacher , consequMany studies confirm the role of smoking teachers in unwantedly promoting cigarette use among students. Poulsen et al. based on a study in Denmark showed that teachers’ smoking during school hours plays an important role in urging students to smoke . HeydariThe participants expressed that family partnership is obligatory for success of preventive programs at schools. Other studies confirm this matter. The studies carried out in Iran indicate passivity of Iranian families in the case of educating their children about the harmful effects of tobacco use . ZareianMany other studies confirm the results of this research about the fact that schools are currently a place for using high risk substances, prohibitions, and anti-smoking rules at school, access to cigarette around the school, prevention of predisposing backgrounds, educational status, and effect of other factors related to schools on the situation of teenage smoking , 30-32.Finally, the researcher suggests that in order to reduce cigarette use in the society, screening programs should be conducted at schools, they should be specifically catered to identifying high-risk schools regarding existence or non-existence of these types of programs, smoking teachers, susceptible students to tobacco use, vulnerable students, high-risk students, and physical predisposing status. These screening programs aid in conducting effective anti-tobacco programs and reducing the possibility of smoking behavior among teenagers, and consequently tobacco use in the society.The main strong point of this study was to focus on the role of school in initiation of cigarette use among teenagers. The most important limitation of this study was the use of Non-probability Sampling methods and also not to have studied girl groups that limits the generalization of its results.


The conference received an overwhelming response from three hundred participants including scientists, medical professionals, academicians, industrialists and students from all quarters of the country. Participation from the Clinical and Laboratory Standards Institute, USA also made a remarkable contribution to the event.The three day conference on Antimicrobial Resistance: A Cause for Global Concern was organized from 6-8Elaborating on the focal area of the event, Organizing Secretary and Convener Prof. (Dr.) Rubina Lawrence, spoke on the significance of miracle drugs in the treatment of infectious diseases. She emphasised the chemical repercussions of the chemical warfare waged against microbes through therapeutic and non-therapeutic uses of antimicrobial agents. She highlighted the global problem of antimicrobial resistance (AR) which is particularly pressing in developing countries where the infectious disease burden is high, there are cost constraints on testing to identify resistant infections and using newer and more expensive agents to treat them. In her address she illustrated the recent survey which emphasized that “Antibiotic resistance is a burgeoning problem in India”. Due to availability of over-the-counter antibiotics and their improper and rampant use, antibiotic resistance in the Indian population has skyrocketed. The future is however not entirely gloomy. The global strategy of WHO for the containment of antimicrobial resistance was underlined in her talk. However significant gaps in knowledge, research and development (R & D), funding and policy remain, particularly in developing countries. Prof. Lawrence, stated that the Second National Conference on Antimicrobial Resistance: A Cause for Global Concern is a follow-up to the first national conference organized in the year 2009 that was organized to further re-assess, consolidate the latest picture of the issue and the challenges faced thereof through the years. Concluding her talk she said that the conference is ventured to address this peril and to formulate strategies to combat it.The popular consensus was that the conference succeeded effectively in attaining the various interlinked fields in contributing to analyse the problem of antimicrobial resistance. Presentations made under the five major subthemes are described below.Dr. K. Venkatesan, Scientist F/Deputy Director, National JALMA Institute of Leprosy and Other Mycobacterial diseases, Agra focused his talk on tuberculosis by stating it as one of the leading causes of mortality in India, killing two people every three minutes i.e., nearly 1,000 per day as reported by the Directorate of Health Services, India in 2009 while an estimated 2 billion people are infected with the pathogen worldwide. He quoted a study conducted on a cohort of patients from urban population in Mumbai reporting a high incidence of MDR-MTB (51%) . The same compound has been isolated in their laboratory from one of the isolates. The MIC of ECO-2301 was not at par with amphotericin-B. Further, there was evidence of cytotoxicity which hindered its further consideration for development. He also said that genomic approaches may take longer time as a way to identify the novelty in the final bioactive compound.By quoting “Bad bugs need new drugs” Amycolata autrophica. The organism was initially rejected because of lack of antimicrobial activity. However, treatment of inactive wild strains then discarded in the screening program was subject to intercalating agents ethidium bromide or daunorubicin. This induced the culture with very high frequency progeny which exhibited antibacterial activity. Antibacterial antibiotics 167-A and 167-B were isolated from the fermentation broth of mutant EB5 derived from an inactive wild strain of Amycolata autrophica 167 by treatment with EB. The antibiotic 167 B was identified as cervinomycin A2, component 167-A being a new representative of the cervinomycin group. A large number of mutants had to be screened with the mutation process, which according to Dr. Mahajan was the limitation of the method. The next approach found to be more fruitful as addressed by Dr. Mahajan was isolation of novel compounds from microbes in the marine environment. Salinispora sp., a Gram positive aerobic non-acid fast bacteria isolated from marine sediments, was reported with potential of compounds with anticancer, anti-inflammatory, antibiotic and antiviral activities. He exemplified the same by reporting the discovery of potent novel antibiotics (PM181104 and PM181108) from marine resources by his organization. Dr. Mahajan concluded his talk by saying that India is a rich source of diverse microbes owing to its large variations in climatic conditions and geographical extremes. This asset has to be used especially by collaborative research work with universities and industrial research organizations towards getting novel compounds. The active synthetic derivatives or microbial compounds should be tested on panels of hundreds of test cultures to strengthen their true trait; a strategy which may put us in the frontiers of global drug research.The second approach discussed by him on antimicrobial drug discovery was mutation. For this he showed an example of Mr. Suchir Arora, Senior Consultant, Business and Decision, Gurgaon in order to model Homo sapiens biological systems against antimicrobial resistance through homeopathy. He said that drug interactions of allopathic drugs are well known, however for homeopathic drugs it has to be developed since the molecules are not characterized. He explained that conventional medications have options for personalized medicines through the help of pharmacogenomics. But in the case of the homeopathic approach the genetic, physical, emotional and personal health history etc. are followed. Hence more emphasis on individualized medicine is given. For the homeopathic approach, there is evidence from in vitro and in vivo streams facilitating our knowledge but much less work is done at in silico level. So effort will be made to establish a new stream, “homeoinformatics”, which will be a combination of bioinformatics and computer aided modelling. Application of bioinformatics such as effective data mining, network biology, systems biology etc. will be effective in understanding the principles of homeopathy for more effective treatment. He concluded by stating that in the primary steps computational modelling of homeopathic drugs is required to combat disease with a special focus on antimicrobial resistance. Later, we can exploit the possibility of establishing new principles, algorithms, strategies in providing evidence based support to the principles of homeopathy.The term homeoinformatics was introduced by Dr. Shabir Simjee delivered the first keynote lecture of this session on harmonization in the generation, presentation and application of antimicrobial susceptibility test data for bacteria of animal origin: the X08 report. He highlighted on risk assessment, risk management and government legislation. He explained that the data generated from the surveillance programs are used for registration purposes, as an indicator for the emergence of resistance and, for national risk assessment and subsequent risk management guidelines. Dr. Simjee said that it is important to ensure that the data being generated is of uniform quality and is interpreted using single interpretive criteria. Pharmaceutical products should have risk assessment prior to registration or post-registration. He concluded that India does not have a risk assessment process for drug companies to submit presently but that could change. It is not possible to compare resistance rates from different surveillance schemes  as they are not measuring the same parameter. Within national surveillance schemes  methods of analysis have changed overtime such that percentage resistance values need to be viewed with caution. Further he demonstrated that bacterial resistance showed varied antimicrobial susceptibility with respect to the source from where they are isolated e.g., Escherichia coli of humans will show a different antimicrobial susceptibility profile as compared to birds and so on.The Co-Chair of the CLSI Sub-Committee on Veterinary Antibiotic Susceptibility Testing and Microbiology Technical Advisor at Elanco Animal Health, UK viz., standard, guidelines and report. For interpretation using the standard method the details are to be strictly followed, with the guidelines some modifications can be made in methodology, while the report is a technical document that is intended for informational use only and which offers guidelines on how it should be done. He emphasized that the need for development of X08 – R is driven by the needs of the VAST  group, confusion in use of common terms such as susceptible and resistance and use of wild type or epidemiological cut-off values for reporting results of national surveillance program. The benefits of using ECV as outlined by him were: early detection of resistance development in a given microbial population, it is easier to develop than clinical breakpoint, can be developed for any agent regardless of clinical usage and can be incorporated into all clinical breakpoints. However it may not be predictive of clinical outcomes and methods for setting ECVs are not yet standardized.Resistance interpretation is done on the basis of the clinical break point and epidemiological cut-off value (ECV). Because of discrepancies in interpretation of data, the CLSI initiative on harmonization was undertaken. CLSI publishes three types of documents Dr. Simjee said that the clinicians look for clinical breakpoint without caring for the wild and non-wild type population. However, when the data on surveillance is observed over a period of time clinical breakpoint is of no value. Further to observe the trends, long term surveillance programs are needed. So he recommended from the X08 report the use of ECV rather than clinical break point value. He further explained the need to have universal adaptation of terminologies, and differentiation of ECV and clinical break points. Further, data obtained from Europe and the United States should not to be taken at face value, as it can be challenged, because the resistance and susceptibility standards of these countries vary.Dr. K. K. Tripathi, Advisor, and Member, Review Committee on Genetic Manipulation, Department of Biotechnology, Govt. of India, New Delhi presented the second keynote address of this session. He spoke on the regulation of genetically modified plants and use of antibiotic resistance markers. He said that the various genetically modified organisms and r-DNA products are governed by the Environmental Protection Act 1986, Industries Development and Regulation Act 1951, Drugs and Cosmetics Act 1940 and Pharmaceutical Policy 2002. He also talked about the various biosafety frameworks in India which control the rules for manufacture, use, import, export and storage of hazardous microorganisms/genetically engineered organisms or cells (1989) under the EPA 1986  was discovered as an antibiotic adjuvant. This compound was reported to have the potential to inhibit efflux pump, stop biofilm formation, act as a catalyst and provide synergy to antibiotic combinations. It also makes the drug effective against ESBL producing strains, prevents mutagenesis by preventing conjugation, prevents resistance development and decreases infection induced hepatotoxicity with its antioxidant effect.viz., TEM, SHV, CTX-M and metallo-betalactamase, effectively. Expression of outer membrane protein was found to decrease with VRP 1034. The efficacy of Renisil was found to be at par with meropenem in E. coli and K. pneumoniae and superior with meropenem in Pseudomonas aeruginosa. The expression of Mex AB protein (OMP) in P. aeruginosa was much diminished with VRP 1034 adjuvant with antibiotic combination drug. It also found to break bacterial biofilm, prevent conjugational transfer of F-plasmid, alter cell membrane porosity and was considered safe as per the clinical studies conducted. Dr. Sayeed further stated that national and international clinical trials are still in progress. It is also known to reduce hospitalization time from 14 days to an average of 7 days and the pharmacokinetics of individual drugs are unaltered after adding VRP 1034. Improved safety and tolerability has been established by pre-clinical, Phase-III and Phase-IV studies. It further has the potential to replace Piperacillin, Tazobactum and save Meropenem as a reserve drug which is also manufactured in EU GMP approved facility.Dr. Sayeed said that regulatory measures have to evolve for guidelines to make adjuvants work. They are also reported to work better than –penams. He said that with the help of adjuvants, much of the effectiveness of antibiotics would be rejuvenated. He illustrated that novel combinations with VRP 1034 (Renisil) were found to increase the efficacy of antibiotics. As per the experiments conducted at Venus Research Centre, Renisil caters to all ESBL types The conference on antimicrobial resistance grabbed the attention of academicians, clinicians, microbiologists, scientists, biotechnologists, agriculturalists, environmentalist, R&D personnel and industrialists to share a common platform to combat the menace. The event helped the understanding of the issues related to emergence and spread of antimicrobial resistance in a better way. National level data pertaining to the recent surveillance studies of various microorganisms was compared and analyzed. Specific intervention measures to harness the problem were discussed. It helped in uniting the network of people working on antimicrobial resistance to monitor the antibiotic susceptibility pattern among the clinical and environmental isolates. The event facilitated in identifying latest technologies that could help in understanding the mechanism of drug resistance and drug discovery.The National Conference on Antimicrobial Resistance organized consecutively within a gap of three years gave us a clear picture on the present status and progress attained in this field at national level. As we are in pursuit of tackling this menace with those who work on the issue, we would like to further initiate network projects to generate surveillance data which will support in developing appropriate guidelines. As we have identified the key personnel and centres involved in the research on antimicrobial resistance, we expect the national bodies and funding agencies to support our projects on antimicrobial resistance so that we may effectively contribute in the future endeavours.Prof. (Dr.) Rubina Lawrence, Organizing Secretary and Convenor NCAR 2012 in her concluding remarks of the conference stated that from the deliberations made during these three days, four basic steps are needed in order to achieve the interrelated goals of antimicrobial stewardship and development—strategies that were discussed throughout the conference—and that have long been advocated to address the threat of AR. These are: limit the use of antimicrobials, discourage their misuse, reduce infection through disease prevention measures and create incentives for improved treatment and innovation. She further hoped that the initiative of this conference strengthens federal antimicrobial resistance surveillance, prevention, control and research efforts as well as enhances the collection of critical information on the use and misuse of antimicrobial agents. The Hon’ble Vice Chancellor Most Rev. (Prof.) Rajendra B. Lal during his concluding remarks appreciated the efforts taken by the organizing committee to unite national leaders and scientists in this field to find a plausible solution.The authors declare that there are no competing interests.