Vertical control and elimination programs focused on specific neglected tropical diseases (NTDs) can achieve notable success by reducing the prevalence and intensity of infection. However, many NTD-endemic countries have not been able to launch or scale-up programs because they lack the necessary baseline data for planning and advocacy. Each NTD program has its own mapping guidelines to collect missing data. Where geographic overlap among NTDs exists, an integrated mapping approach could result in significant resource savings. We developed and field-tested an innovative integrated NTD mapping protocol (Integrated Threshold Mapping (ITM) Methodology) for lymphatic filariasis (LF), trachoma, schistosomiasis and soil-transmitted helminths (STH).The protocol is designed to be resource-efficient, and its specific purpose is to determine whether a threshold to trigger public health interventions in an implementation unit has been attained. The protocol relies on World Health Organization (WHO) recommended indicators in the disease-specific age groups. For each disease, the sampling frame was the district, but for schistosomiasis, the sub-district rather than the ecological zone was used. We tested the protocol by comparing it to current WHO mapping methodologies for each of the targeted diseases in one district each in Mali and Senegal. Results were compared in terms of public health intervention, and feasibility, including cost. In this study, the ITM methodology reached the same conclusions as the WHO methodologies regarding the initiation of public health interventions for trachoma, LF and STH, but resulted in more targeted intervention recommendations for schistosomiasis. ITM was practical, feasible and demonstrated an overall cost saving compared with the standard, non-integrated, WHO methodologies.This integrated mapping tool could facilitate the implementation of much-needed programs in endemic countries. Neglected tropical diseases (NTDs) cause significant physical debilitation, lowered economic productivity, and social ostracism for afflicted individuals. Five NTDs with available preventive chemotherapy: lymphatic filariasis (LF), trachoma, schistosomiasis, onchocerciasis and the three soil-transmitted helminths (STH); have been targeted for control or elimination, but resource constraints in endemic countries have impeded progress toward these goals. We have developed an integrated mapping protocol, Integrated Threshold Mapping (ITM) for use by Ministries of Health to decide where public health interventions for NTDs are needed. We compared this protocol to the World Health Organizations disease-specific mapping protocols in Mali and Senegal. Results from both methodologies indicated the same public health interventions for trachoma, LF and STH, while the ITM methodology resulted in a more targeted intervention for schistosomiasis. Our study suggests that the integrated methodology, which is also less expensive and logistically more feasible to implement, could replace disease-specific mapping protocols in resource-poor NTD-endemic countries. Neglected tropical diseases (NTDs) are parasitic and bacterial diseases that affect an estimated 2.7 billion of the world's poorest people, causing significant physical debilitation, lowered economic productivity, and social ostracism for afflicted individuals At the core of public health efforts to fight the five NTDs mentioned above is a strategy of mass drug administration (MDA) of at-risk populations with safe and effective drugs often donated by pharmaceutical companies This paper describes a novel methodology, the integrated threshold mapping (ITM) methodology, for an integrated mapping survey for LF, trachoma, schistosomiasis, and STH. Our methodology does not provide prevalence figures, its intended purpose is to determine whether a disease has attained the threshold for public health intervention by attempting to balance epidemiologic rigor and field practicality. The ITM protocol has been field tested in one district in each of two countries by comparing the ITM methodology to the standard disease-specific WHO mapping methodologies. Results from both methodologies were compared in terms of public health intervention based on the disease specific data and feasibility, including cost.The ITM methodology is derived from rapid mapping methodologies used by LF and schistosomiasis programs. It is designed to provide programmatically useful mapping data in a logistically practical and cost-efficient way.In Mali, the research site included nine sub-districts of the Banamba district (Koulikoro region), an area with an estimated population of 88,232 persons (2008). In Senegal, research was conducted in all 11 non-urban sub-districts of Diourbel district (Diourbel region), an area with an estimated population of 150,889 persons (2010). In both countries, the majority ethnic groups, Bambara and Wolof, respectively, are subsistence farmers living in established settlements; a minority Peuhl group in Mali is semi-nomadic and engages in cattle herding. The entirety of both the Banamba and Diourbel districts is located within the Soudanian ecological zone Wuchereria bancrofti antigen in persons aged ≥15 years and resident in the village for at least ten years Schistosoma haematobium, the presence of haematuria in urine samples from children aged 6–9 years was detected by urine reagent strips. Reagent strips were dipped in the urine samples and read after one minute by comparing them to a colorimetric scale by a trained laboratory technician. At the request of the Ministry of Health (MoH), urine samples were also tested by filtration in Senegal as part of the WHO methodology Schistosoma mansoni and STH, the prevalence and egg load (eggs per gram of feces) were calculated using the Kato-Katz method The standard indicators and target age groups currently recommended by the WHO for the targeted NTDs were employed for both the ITM and WHO methodologies, although some minor adaptations were made for trachoma S. haematobium prevalence by the district health officer or local dispensary staff, according to information on high haematuria prevalence or the presence of a nearby body of water The sampling, as shown in In the village, the team established a testing site at a school or other central location. A convenience sample of 25 school children aged 6–9 years was selected to be examined for TF, and 15 of these children were also asked to give urine and stool samples. An effort was made to achieve a gender balance. Females aged ≥15 years were asked to come to the central site with their children aged 1–5 years. A convenience sample of 50 of these females was examined for TT, and a convenience sample of 25 children aged 1–5 years was examined for TF, for a total of 50 children tested for TF in each village. In the two villages where LF was surveyed, a convenience sample of 100 persons ≥15 years was tested by ICT. This normally included the 50 females examined for trachoma as well as an additional 50 persons. All persons tested for LF had resided for at least ten years in the village.An integrated central team of five health workers from the national level of the MoH conducted the survey. The team included one laboratory technician for LF, two ophthalmic technicians for trachoma and two laboratory technicians for schistosomiasis and STH. Depending on the local situation, the team engaged health staff from the district laboratory to help performing Kato-Katz examinations. At the village level, village chiefs and community health workers were also involved in registration procedures and other logistics. The central team received a half-day training on study methodology, sampling, data collection tools, and the process of obtaining consent and assent. Because the team members were all active in the national programs, are engaged in laboratory work on a daily basis and had been involved in earlier prevalence surveys for these diseases, they were already trained in their respective diagnostic procedures. The CDC team supervised all data collection, laboratory preparations and slide readings for LF, schistosomiasis, and STH to ensure that all procedures were conducted according to the approved protocols. For trachoma, all ophthalmic technicians had been trained in the WHO grading system for trachoma and the examination of patients for trachoma was also part of their daily work.The team traveled together in one vehicle and visited two villages in one sub-district each day. Specimen collection, point-of-care testing and trachoma examinations were carried out during the day, and the Kato-Katz was performed each evening. In Diourbel, the team perfomed the laboratory testing at the district hospital; in Banamba, the team traveled with all necessary equipment, including miscroscopes and a generator, and a laboratory was set up in the dispensary. The CDC personnel travelling with the team kept records of the time it took to travel to a village, perform the survey, time taken to prepare and read the Kato-Katz and urine samples in the laboratory and time to travel to villages.For trachoma, the standard WHO 30-cluster population-based prevalence survey was conducted The standard WHO mapping protocols were conducted by separate teams for schistosomiasis/STH and trachoma. The teams worked independently. For trachoma, the number of teams was determined by the standard national trachoma program practices. In Mali, two trachoma teams, each composed of two ophthalmic technicians, conducted the trachoma cluster survey. In Senegal, three teams, each composed of one ophthalmic technician, conducted the trachoma cluster survey. A laboratory team, composed of the same two technicians who had conducted the ITM methodology, implemented the WHO methodology for schistosomiasis and STH. A half-day training was provided to all team members on the WHO sampling methodologies, data collection tools, and the process of obtaining consent and assent. No diagnostic training was given because the team members were all active in the national programs as mentioned above.The WHO standard methodologies were conducted immediately following the completion of the integrated methodology. Each of the three teams traveled in its own vehicle. Testing and examinations were carried out during the day, and the Kato-Katz was performed each evening in the district laboratory or in the dispensary.The study protocol received ethical approval from the Ethics Committee of the Faculty of Medicine, Pharmacy and Odontology-Stomatology, University of Bamako, Bamako, Mali; from the National Ethics Committee for Health Research (CNERS), Dakar, Senegal; and from CDC's Internal Review Board, Atlanta, GA, USA.All persons over the age of eighteen years were asked to provide written consent to participate in the study. The school director or a member of the team explained the study to the school-aged children (5–14 years) using a verbal assent script describing the study, and the children who participated in the study were asked to give their verbal assent. Written consent to participate in the study was also obtained from parents or custodians of children between the ages of 1–18 years.W. bancrofti antigen and children who were found to be infected with S.haematobium, S.mansoni or STH were referred to the district health center in case an MDA was not planned in the district.Children who were found to have active trachoma received two tubes of tetracycline ointment, to be applied twice daily for a period of six weeks. Females found to have trichiasis were referred to the nearest health center that provides trichiasis surgery. Persons who tested positive for To determine feasibility, we took into consideration time and resources needed to conduct field activities and overall costs. All receipts were collected, and actual expenditures were recorded. The cost data were compiled into four categories: training, per diems , travel to the field  and supplies . Any costs of inputs that were used for multiple activities were distributed evenly among the activities. Although LF testing was only conducted once, costs for conducting the testing were included for both methodologies. The training of health personnel on diagnostic methods, salaries and data entry and analysis conducted by CDC were not included in the cost analysis.Results for trachoma, STH and LF were analyzed at the district level for both methodologies In Banamba District, Mali, 1,898 persons, including 900 children (1–9 years), in 18 villages were surveyed for the ITM methodology, and 4,479 persons, including 2,738 children (1–9 years) in 35 villages were surveyed for the WHO methodology. For trachoma, eight villages already tested for the integrated method were also sampled for the WHO method. As shown in Because the ITM method had as its purpose to refine the schistosomiasis mapping, the two methods differed, in indicating a need for schistosomiasis treatment: the WHO methodology indicated a need for MDA for schistosomiasis among only school-aged children in the entire area. The ITM methodology indicated that four sub-districts were in need of MDA for schistosomiasis among school-aged children only, and that five sub-districts were in need of MDA for schistosomiasis for the whole population. Treating the whole population in the sub-districts where this was indicated by the integrated mapping protocol would result in nearly 33,500 additional at-risk persons being treated than if only school-aged children in these sub-districts were treated (as indicated by the WHO protocol).In Diourbel District, Senegal, 2,734 persons, including 1,100 children (1–9 years), in 22 villages were surveyed for the ITM methodology, and 4,614 persons, including 2,914 children (1–9 years) in 34 villages for the WHO methodology. For trachoma, one village already selected for the ITM method was also sampled for the WHO method. Both methodologies indicated the need for MDA for trachoma in the surveyed district  and both methodologies indicated that there was no need for intervention for STH: 0%, 0%.Both ITM and WHO methodologies were also concordant regarding the need for TT surgeries . As mentioned above, the LF mapping was added to validate the feasibility of the integrated mapping and not to validate the results.In Mali, however, the public health interventions differed with regards to schistosomiasis treatment because the ITM method had as its purpose to refine the schistosomiasis mapping. The WHO methodology indicated a need for MDA for schistosomiasis treatment among only school-aged children in the entire area, while the ITM methodology indicated six sub-districts in need of MDA for schistosomiasis among school-aged children only, four sub-districts in need of MDA for schistosomiasis for the whole population and one sub-district which did not pass the threshold for treatment. Compared to the district based WHO protocol, the ITM methodology targeted nearly 46,000 extra at-risk individuals for treatment.In the ITM methodology, we compared the public health intervention decisions for schistosomiasis that would result from using only the randomly or only the targeted selected village To compare the feasibility of the two protocols, we compared the time it took to conduct each survey. For the ITM methodology, the total number of days on the field was 46 person-days in Mali and 56 persons days in Senegal. It took approximately two hours to survey one village; in a village where LF testing was done, four hours were needed. The schistosomiasis and STH team spent an additional three hours each day preparing and reading the Kato-Katz slides. The time to travel to the villages from the health center of the sub-district varied according to geography from approximately 15 minutes to 1 hour. For the WHO methodology, the total number of days on the field was 56 person-days for Mali and 58 person-days for Senegal. Each trachoma team took approximately 4–5 hours to survey one village. The schistosomiasis and STH team surveyed one village a day with approximately two hours to collect the samples and an additional five hours to prepare and read the 50 Kato-Katz and urine samples in the district laboratory. The time to travel to the villages varied according to geography from approximately 15 minutes to over 2 hours.The results of the cost data analysis We describe an integrated NTD mapping methodology (Integrated Threshold Mapping) that can be used as an operational tool by Ministries of Health in NTD-endemic countries to determine if the threshold needed to launch disease-specific public health intervenions has been reached. With the recent increased interest in NTDs, there is a real need for an integrated mapping approach that can provide district level data in a timely manner The first step in making a NTD action plan is to evaluate the existing data, including the methodology and time of the data collection, and to determine whether any factors that could influence the prevalence of the disease have changed since the data were collected. The second step is to collect data where existing data are missing or out of date; our ITM mapping protocol was designed for this purpose. Because it will be rare that all four NTDs will need mapping in any one district, the methodology consists of disease-specific modules. For each specific situation, modules can be combined to create the situation-specific NTD integrated protocol To understand the value and limitations of this protocol, it is critical to understand that this protocol is not claiming to provide epidemiologically correct prevalence data because both the villages and the individuals tested were not randomly selected. First, this implies that we cannot recommend using findings from this methodology as a baseline for measuring impact at the district level. This is also not possible for the WHO recommended mapping protocols for schistosomiasis, STH and LF, but it is the case for the trachoma WHO methodology. A possible second implication could be that the WHO recommended threshold could not be used when using this methodology; but here again, this would only be an issue for trachoma, bearing that the WHO methodology does not provide epdemiological correct prevalence figures for schistosomiasis, STH and LF.One barrier to integrated mapping of NTDs is the misconception that mapping can only be integrated if all testing is done using the same age groups. In our ITM mapping protocol, we insisted on using the program-specific age groups as indicated by WHO with the exception of some adaptation for trachoma. The advantage of using these established age groups was that the WHO thresholds were applicable and that few people had to undergo multiple tests and examinations; only in a limited number of cases were people asked to undergo more than one test or examination. In each village, we chose to use a convenience sample for reasons of field practicality. Asking people of different ages to come to a central location in each village facilitated data collection and was much more time-efficient than house-to-house visits, such as those used in the WHO trachoma protocol. As the field testing in both countries showed, the data of both methodologies resulted in the same public health recommendations.The ITM protocol maintains the WHO-recommended disease indicators and thresholds for LF, schistosomiasis and STH, but we used a novel sampling frame for more practical field implementation. To improve the representativeness for the TF indicator, we selected a pre-determined number of children between the ages of 1–5 and 6–9. This was intended to prevent biased estimates in case the 6–9 year age group made up the majority of children being graded for trachoma because prevalence rates are highest in 1–5 year olds. Although current WHO guidelines measure trichiasis in adults of both sexes as a standard indicator, literature shows that different adult age groups have been used to determine TT prevalence Because the ITM methodology is focused on public health action, the sampling frame is directly linked to the implementation unit for MDA for each of the NTDs. Based on field experience, we decided to slightly modify those MDA implementation units to make public health interventions more feasible in the field, as shown in The integrated approach proved to be more efficient in cost, transport, time in the field and the use of human resources. Because transportation and per diems are variables that significantly increase the cost of mapping, we created one small team of experienced technicians already active in the national MoH program instead of using multiple disease-specific teams. We decided to limit the number of team members to five by capitalizing on their laboratory expertise in parasitic diagnostic techniques mastered during their lab technician training. Each member of the team performed multiple tasks, which increased time and energy efficiencies and also made planning and field organization easier. We also counted on the strong engagement of local staff as we saw this as capacity building of district, dispensary, and village health staff. Although the team members from the different NTD programs were initially reluctant to work as one team, because it was a new concept, this hesitancy evaporated over the course of the survey. The team members also noticed that resources were used more efficiently compared to the WHO methodologies: the ITM methodology used one vehicle to transport the team, versus 3 used in the WHO methodologies, employed a 5-member team instead of a 7-member team, and took about half as much time to implement as the WHO methodologies.It is also important to mention that certain cost savings from integrated mapping such as time saved by only having to plan one survey compared with several different protocol meetings and logistic preparations is priceless for overburdened health staff. In addition, the workload for all the preparations and supervision can be shared among different program coordinators.It is worth mentioning that cost savings are just a single variable that justifies conducting integrated surveys: mapping is often the first field activity of an integrated NTD program, and the creation of the team demonstrated the concept of integrating vertical programs to all levels of the MoH and this first activity can help with further collaboration for implementing integrated public health interventions.Although the ITM methodology resulted in substantial cost savings compared to the WHO methodology, the cost depends on the number of sub-units in a district. This means, for example, that the sampling size for schistosomiasis could be much higher using the ITM methodology than using the WHO methodology. However, this would result in a more targeted MDA for schistosomiasis, which is important because there is limited availability of donated praziquantel.The results from both the ITM and WHO methologies indicate that health workers are not always well-informed about where schistosomiasis is most prevalent. The results show that treatment decisions, based on the purposely-selected villages, did not systematically result in more treatments than those based on the randomly-selected villages.We encountered some limitations in conducting the integrated mapping. We are comparing a convenience sampling for schistosomiasis and STH mapping with an accepted WHO convenience sampling. Ideally, we would have compared both methods to an independent, “gold standard” survey methodology. The main limitation for the trachoma mapping is that a total of nine of the 60 trachoma villages sampled were selected for both methodologies. To decrease the burden of the inhabitants by not having the same children examined twice, we included the data collected in the integrated mapping for the WHO method and added only 30 children by visiting the households. For three villages, the selection bias was limited because the villages were so small that the likelihood that all the children in the integrated method would have also been included by visiting the houses was very high, but for the other six villages, a selection bias was likely introduced because up to 62% of the sample was selected by convenience only and those persons would maybe not have been included if the sample was collected randomly.This study shows a novel integrated mapping protocol to determine whether thresholds for public health interventions have been reached. The approach is logistically practical, cost-efficient and flexible. For schistosomiasis, our approach also results in more targeted MDAs compared with the district level implementation currently adapted by most integrated NTD program. The protocol uses mainly the age-specific disease indicators as recommended by WHO. Further, it sets the stage for all of the following integrated program activities essential for NTD elimination and control. Based on the lessons learned from the implementation in the first two countries and feedback we received form NTD colleagues, we do recognize that this novel mapping approach requires some modification to ensure that the most useful data are collected. For this reason, we are currently field testing an adapted protocol with all villages selected randomly among other minor changes.


The Cancer Fast-track Programme's aim was to reduce the time that elapsed between well-founded suspicion of breast, colorectal and lung cancer and the start of initial treatment in Catalonia (Spain). We sought to analyse its implementation and overall effectiveness.A quantitative analysis of the programme was performed using data generated by the hospitals on the basis of seven fast-track monitoring indicators for the period 2006–2009. In addition, we conducted a qualitative study, based on 83 semistructured interviews with primary and specialised health professionals and health administrators, to obtain their perception of the programme's implementation.About half of all new patients with breast, lung or colorectal cancer were diagnosed via the fast track, though the cancer detection rate declined across the period. Mean time from detection of suspected cancer in primary care to start of initial treatment was 32 days for breast, 30 for colorectal and 37 for lung cancer (2009). Professionals associated with the implementation of the programme showed that general practitioners faced with suspicion of cancer had changed their conduct with the aim of preventing lags. Furthermore, hospitals were found to have pursued three specific implementation strategies , which made for the cohesion and sustainability of the circuits.The programme has contributed to speeding up diagnostic assessment and treatment of patients with suspicion of cancer, and to clarifying the patient pathway between primary and specialised care. Concern about the delay in diagnosis of cancer and its clinical and psychosocial implications for patients has led a number of European health systems to develop fast-track referral mechanisms for patients with suspicion of cancer. In Catalonia, the Cancer Fast-track Programme (CFP) was launched in 2005 for neoplasms registering the highest incidence and mortality rates. The incidence of breast, colorectal and lung cancer accounts for 43% of all cancer incidence in women  and 30% in men  in Catalonia  is a universal health-care system organised on the basis of the separation between public funding/sponsorship and a mix of private- and publicly-owned health facilities . It was this context that led the Department of Health to permit circuits to be freely organised, subject in all cases to the use of the referral guidelines agreed by experts from both care levels, and the setting-up of a system of monitoring indicators.This study analysed the overall effectiveness of the system, using data sets that focused on the implementation of the colorectal, breast and lung cancer fast tracks in Catalonia. It was considered necessary to combine a quantitative assessment of programme-monitoring data with a qualitative assessment of health professionals’ and administrators’ perception of the organisational change entailed by the programme's implementation. The policy knowledge yielded by this analysis is expected to improve the second phase of implementation, during which bladder and prostate cancers are scheduled to be added to the programme. Quantitative and qualitative methods stress the holistic and wide-ranging approach needed to understand an innovative programme, thanks to which health-service delivery has changed.The CFP was proposed as a means of reducing the lag (time elapsed) between well-founded suspicion, diagnosis and treatment of cancer, by designing circuits that would foster the rapid coordination of the process circuit see . SimilarWith regard to quantitative data sources, the following seven fast-track monitoring indicators were laid down: number of patients included in the CFP; cancer patients diagnosed through the CFP route; patients referred from general practitioners (GPs); compliance with referral guidelines; cancer detection rate; mean time between detection of suspected cancer and start of treatment; and distribution of the wait among different categories . Our analysis covered the period 2006–2009. The hospitals were tasked with recording and sharing these data with the primary-care level. Hospitals have reported quantitative data to the CHS on an annual basis since 2006, with the health regions having the obligation of ensuring the validity of the data. Some clarifications must be made with regard to data registration criteria. All new cancer diagnoses were included but cases of relapse were excluded. Date of entry into the circuit coincided with the referral date, and date of start of ‘treatment’ with the first treatment applied to the patient instead.Qualitative study consisted of semistructured interviews conducted from January to March 2009, with health professionals drawn from primary and specialised care, and planning staff from the health regions.A total of 83 health professionals were recruited from 18 fast tracks. Professionals were deemed eligible if they participated in fast-track management as stakeholders or data managers. For selection of informants and composition of the purposive sample, three inclusion criteria were established. To ensure that the views of different health regions could be explored, the first criterion ensured the presence of at least one fast track  per health region. The second criterion reinforced a systematic approach to the phenomenon under study, by insisting on the presence of informants from each fast track reflecting professional views, whether institutional, technical or process-related see . A finalA semistructured interview ensured that all critical points were addressed. To elicit beliefs and experiences, participants were given the necessary flexibility to enable them to volunteer information on topics of relevance to them. The health professionals selected were interviewed on a one-to-one basis for 45–75 min at the hospital or primary-care offices. Interviews started with a general question on fast-track development and ended with a question on how to introduce future changes to improve the programme. No notes were taken by the researcher during the interview; instead, all interviews were audiotaped and transcribed in full. These data were then compiled into a documentary record and rendered anonymous to protect confidentiality. Every transcription was checked against its corresponding sound recording, and accuracy was found to be good. A preliminary analysis was conducted after each interview. All the professionals selected for study purposes consented to the interviews being recorded.Interview data were examined inductively. This process allowed for data references to be labelled and developed for subsequent analysis. Grounded theory methodology was considered appropriate for describing fast-track implementation and organisation according to the professionals’ points of view. As our study was theoretical and aimed at incorporating the organisational context in which fast tracks had been implemented, we used axial coding, as described by A total of 56 020 persons were included in the CFP during the period 2006–2009. The results of the monitoring indicators regarding circuit performance are presented in P<0.001).The proportion of patients referred by GPs across the entire study period was ∼60% for colorectal versus 40–50% for breast and lung cancer. There is less variability among neoplasms in the case of adherence to the clinical criteria for inclusion of possible patients in the circuits, with the proportions being >70% in all three cases. The cancer detection rate showed a statistically significant moderate decreasing trend  surrounding the length of the course of care for a potential cancer process. Indeed, the existence of these circuits has altered and standardised such physicians’ conduct in the face of suspicion of cancer. A total of 3 out of 12 GPs interviewed stated that, before the programme's introduction, it was a routine procedure to request a mammogram in any case where there was suspicion of breast cancer. Now, however, such a case would be referred immediately so as to prevent the processes being delayed any further by the health-care services.In contrast, the feedback of clinical information from fast-tracked patients at the primary-care level, during or on conclusion of the diagnostic–therapeutic process, was viewed as deficient. Feedback showed itself to be extremely unsystematic and subject to the individual work practices of each hospital department. Indeed, it was very usual for GPs to call the hospitals to enquire about their patients’ progress. Furthermore, only 25% of the 18 fast tracks assessed had a software programme in place that allowed for the recording and multilateral consultation of clinical information based on suspicion of cancer, which would normally make for the smooth running of the interface at an operational level.The intrahospital stage of the circuit encompasses notification of suspected-cancer cases, organisation of the patient pathway until final diagnosis, first treatment and feedback to primary care. Among the changes implemented , mentionn=5), where hospital management designed a flow chart and implementation programme in the territory, which was then transferred to the clinical teams.Top-down (n=10), where the clinicians responsible led the process of change, with the institutional support of hospital management.Consensus-based (n=3), where a leader was appointed and an implementation committee was set up, on which all the clinical departments were represented. The committee then proceeded to act on a horizontal, cross-department basis.Participatory .This assessment seeks to give an account of the implementation process of the fast-track cancer diagnosis and treatment programme, which was initiated in 2006 and has been positively assessed by health-care system stakeholders and policymakers as a whole. Half of all colorectal, lung and breast cancer patients are diagnosed today within periods of ∼30 days (longer in lung cancer) via a fast-track route created among care levels, which has made a considerable contribution to clarifying and accelerating cancer diagnosis and treatment. There will always be patients who cannot be diagnosed within the CFP but, on being incorporated once diagnosis has been made, they will nevertheless be able to take advantage of the enhanced speed to treatment and the greater degree of integration achieved by the entire patient pathway, with an implicit goal being to prevent the creation of a two-tier system in which routine referrals might be adversely affected in terms of waiting time  referral, namely, the English National Health Service's Two Week Rule (TWR) , differeThis study has some limitations. Insofar as the quality of the quantitative data is concerned, the statistical analyses were performed using the overall data available. Progressive implementation did not allow for an analysis of the data with a breakdown by hospital . A further limitation was the lack of a procedure for validating the data generated by the hospitals. Similarly, there is no regulation requiring hospitals to generate data on patients not included in the circuits, information that would enable one to ascertain whether such patients undergo a far longer diagnostic or therapeutic delay or are diagnosed at a more advanced stage of the disease. This also hinders comparison between the CFP and the performance of other fast-track processes. A clear limitation of the qualitative study lay in the selection process, which was based on proposals put forward by hospital managers and programme coordinators, and could have biased the choice of professionals towards those sensitive to the programme's effective implementation. The selection criteria specifically designed to target different profiles were intended to minimise this limitation. Our research focused on the views of professionals from 18 fast-track routes, thereby implicitly ruling out the possibility of capturing all the experiences and best practices that might exist in the health system as a whole.Several important lessons were learned from this experience. The distinctive feature recognisable in the best hospital implementation strategies is their horizontal, cross-department mode of operation. From these hospitals’ experience, we know that it is essential not only to ensure a vertical approach to the process , but also to make provision for horizontal integration, especially among treatment hospital departments. At all events, caution must be exercised in establishing a causal relationship between implementation strategy in hospitals and quantitative results, as health-care organisation culture – which is hierarchical to a greater or lesser degree and guides individual behaviour within such organisations – tends to intervene in this relationship. Lastly, the implementation of the CFP involves an exercise in prioritisation for health administrators, that is, on the one hand, the inclusion of the first treatment within the 30-day reference period places a certain degree of stress on the management of operating-theatre schedules and the availability of certain health professionals, something that is also borne out by a qualitative study (Prompt diagnosis and treatment of patients with suspicion of cancer has, in essence, amounted to a commitment to the generalisation of process-based management among care levels. This change was in contrast to the initial scepticism of health professionals, who saw it as simply formalising something that had already existed informally. However, this has led to a marked qualitative leap in their opinion, though no data are available on delay times before programme implementation. Despite the implementation problems outlined here, the circuits have succeeded in impacting positively on health service delivery, something that needs to be weighed on the basis of improving monitoring indicators and providing data on patients not included in the circuits. This would give us a valuable knowledge in terms of potential delays in other cancer patients. At all events, unnecessary or unexplained delays are now being perceived as a matter of concern by all cancer patients (


Background. Rheumatoid arthritis is a progressive inflammatory disease that affects greatly patients' quality of life and demands for aggressive management early on during the course of the disease. The discovery of biologics has equipped rheumatologists with evolutionary treatment tools but has also impacted greatly management costs. Objectives. To conduct a systematic review in order to evaluate the cost effectiveness of abatacept in the treatment of moderate to severe rheumatoid arthritis. Methods. Pubmed, the International Society for Pharmacoeconomics and Outcomes Research Outcomes Research Digest, the National Health System Economic Evaluation Database, and the Database of Abstracts of Reviews of Effects were searched. Results. In total 301 studies were identified and 42 met the inclusion criteria. Half of the selected studies evaluated abatacept in the treatment of rheumatoid arthritis, after failure of or intolerance to tumor necrosis factor alpha inhibitors. Of those, 82% were in favor of abatacept as a cost-effective or dominant strategy versus varying alternatives, whereas 18% favored other treatments. Conclusion. The majority of evidence from the published literature supports that abatacept can be a cost-effective alternative in the treatment of moderate to severe rheumatoid arthritis, especially in patients that have demonstrated inadequate response or intolerance to anti-TNF agents or conventional disease modifying antirheumatic drugs. Rheumatoid arthritis (RA) is a systemic inflammatory disease that presents itself in multiple joints of the musculoskeletal system. Symptoms include joint swelling, redness, and pain with gradual joint deformity in some cases. Due to its pathophysiology, RA causes not only significant morbidity and progressive loss of quality of life, but also carries a substantial economic burden, both for the individuals as well as for the society as a whole, since it is associated with high intense short- and long-term healthcare resource utilizations due to its increased prevalence and disability potential .Over the last two decades, researchers have equipped rheumatologists with revolutionary therapeutic options. However, these changes have not been fully brought into effect in many European countries and other parts of the world , 3. DiseAbatacept is a selective modulator that blocks T-cell activation. It has a marketing authorisation for use in combination with MTX for the treatment of moderate to severe active rheumatoid arthritis in adults whose disease has responded inadequately to previous therapy with one or more DMARDs, including MTX or a tumour necrosis factor (TNF) inhibitor . Its uniThe plethora of therapeutic options available and the variability of patient subgroups that represent target populations for each medication have led to the publication of a number of guidelines and treatment algorithms internationally. Among the agencies that have published such guidance, the National Institute of Clinical Excellence (NICE) has issued several guidelines on the use of biologics in RA , produciIn light of the aforementioned, the purpose of the present study was to conduct a systematic review of cost-effectiveness studies of abatacept in order to evaluate the role of this agent in the treatment of moderate to severe rheumatoid arthritis, specializing to treatment algorithms after previous inadequate response or intolerance to disease modifying antirheumatic drugs (DMARDs) and/or TNF inhibitors. The literature search was extended to a wide range of databases, in order to include as much and as recent information as possible. The databases that were searched included Pubmed, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Outcomes Research Digest, the National Health System Economic Evaluation Database (NHS EED), and the Database of Abstracts of Reviews of Effects (DARE). Overlapping hits were included once. The literature search was not limited by study type or publication year; however, study selection was limited to articles written in English (inclusion and exclusion criteria are listed in detail later). For economic evaluation data, the outcomes included cost effectiveness and related types of analyses .A preliminary database search was conducted in order to challenge the systematic review strategy, focusing on the keywords to be used and the need for limiting the main literature search. Furthermore, it provided an estimate of the size of the literature available on the specific topic.The main search was carried out in August 2012. Slightly different strategies were employed for each database searched due to inherent limitations pertaining to the type and classification of information. An initial search using the keywords “abatacept, cost effectiveness, and rheumatoid arthritis” was carried out in Pubmed. The Pubmed search was enriched by selecting the “related citations” option to each one of the initial results. The study that was selected as the basis for related citations was one containing all keywords in the title and was deemed the most relevant to the objective . The ISPTwo members of the review team assessed the titles of the identified results independently. All relevant hits were then cross-checked against the inclusion and exclusion criteria. Studies that were identified by only one of the reviewers were examined in a separate meeting, in order for an inclusion decision to be reached. studies comparing abatacept to other biologics or conventional therapies in rheumatoid arthritis;studies included both systematic reviews as well as stand-alone economic evaluation studies;types of costs included direct and indirect costs—effectiveness measures included all life expectancy and quality of life outcome measures;studies focusing on adult patients.The criteria which all initial results were examined against are listed as follows:studies comparing abatacept to other treatments in different indications than rheumatoid arthritis;studies not reporting cost data—comparisons to other treatment options only on clinical effectiveness grounds were excluded;studies not specifying a time horizon for costs or results ;studies comparing treatments in juvenile rheumatoid arthritis;studies with no research abstract and/or author details available;articles commenting on previous research studies;studies that did not meet the quality assessment criteria.Exclusion criteria were as follows:All relevant study information was extracted into predesigned tables. Fields included study information and origin, study type, type of economic evaluation, comparing treatments, results, and comments. Studies that were identified in multiple databases were reported once. The quality of independent economic evaluation studies was evaluated in accordance to the Centre for Reviews and Dissemination set of guidelines .All relevant studies are presented and analyzed according to the line of therapy or treatment algorithm in rheumatoid arthritis. The main analyses focused on (a) abatacept use after failure of traditional DMARD therapies and (b) abatacept use after an inadequate response (IR) to TNF-a inhibitor therapy. All other relevant pharmacoeconomic studies which met the inclusion criteria but could not be accurately classified in one of the previous approaches are presented and analyzed in a separate section (c).In total, 301 studies were identified. The initial Pubmed search produced 19 hits and the secondary search produced another 197 results. The CRD database produced 8 hits and finally the ISPOR database revealed 50, 24, and 3 matches for “rheumatoid arthritis,” “arthritis,” and “Muscular-skeletal Disorders (including Tunnel Syndrome)” disease sections, respectively. After the inclusion and exclusion criteria were applied, 42 studies were finally selected. The majority of rejected studies were due to lack of cost data, failure to include abatacept as a comparator to other biologic agents, and failure to include RA as a treatment indication. Other reasons for exclusion included failure to meet the quality assessment criteria (1 study) and comparison of different biologic sequences, where results were presented for single agents (other than abatacept) and not the entire sequencing strategy containing abatacept (2 studies).In total 9 studies on the cost effectiveness of abatacept in the treatment of rheumatoid arthritis after failure of or intolerance to conventional DMARDs were identified. All retrieved publications followed the cost-effectiveness analysis. Two of the previous also presented budget impact data for the agents under comparison. The results are presented in detail in In total 21 studies on the cost effectiveness of abatacept in the treatment of rheumatoid arthritis after failure of or intolerance to TNF-a inhibitors were identified. Apart from the “classic” economic evaluations in the form of cost-effectiveness analysis, the results under this section included other approaches, such as cost of therapy and budget impact analysis. The results are presented in detail in An additional 12 pharmacoeconomic studies relevant to the role of abatacept in the treatment of rheumatoid arthritis were identified but could not be included into one of the two major treatment pathways mentioned earlier. Those studies mainly included abatacept use after conventional DMARD therapy and anti-TNF replacement or studies that failed to specify the line or sequence of treatment and simply compared the cost effectiveness of abatacept against other modes of therapy. Those results are presented in A wide range of economic evaluation and cost-analysis studies were identified with several comparators under investigation. Abatacept mainly appears to have been studied after failure of a TNF inhibitor. In regards to the economic evaluation studies, abatacept's cost effectiveness appears to range within the acceptable cost-effectiveness thresholds according to the authors in the majority of studies. In general, abatacept versus comparators after conventional DMARDS appear to have a higher cost effect ratio when compared to abatacept versus comparators after TNF failure. Other cost analyses are highly dependent on the country of origin and the comparator treatments used. The disease and economic burden of RA remains substantial for the patients and health systems of developed economies worldwide. The continuously increasing therapeutic armamentarium provides clinicians with numerous options for the treatment of RA. Even when adopting the health economics point of view, it is safe to emphasize on the need for mutual patient-clinician agreement on the treatment options and strategy to be followed throughout the course of the disease, as recommended by an international task force on RA . HoweverPlaced in the previous line of thought, the present study aimed to review the existing economic evaluation evidence for abatacept, a recently approved agent for the treatment of RA . For thaThe criteria to initiate a biologic agent after failure of conventional DMARDs have been analyzed by several rheumatology bodies  . UsuallyIn all 9 studies that were retrieved, abatacept was a cost-effective strategy against comparators after failure of methotrexate, although in varying degrees. This ranged from abatacept being a dominant strategy , versus etanercept, adalimumab, infliximab, and tocilizumab  by gains in Quality Adjusted Life Expectancy, thus leading to favorable economic evaluation results. £27,657. The indirect comparison to other biologic therapies, such as etanercept and adalimumab [Specifically, when compared to infliximab, abatacept proved to be associated with higher treatment costs, especially during the initiation phase , 16, 17.alimumab , 16, demalimumab . RegardiN = 21). Most studies focus on the comparison between abatacept and rituximab, either “head to head” or with the inclusion of other alternatives. This comparison is in favor of abatacept, since 10 studies report that abatacept is more cost effective or dominant versus rituximab and 4 state the opposite. However, it needs to be noted that 2 of the 4 studies in favor of rituximab are based on the (rather bold) hypothesis of equal efficacy across all agents under evaluation, thus selecting the cheapest one as the dominant option  the cost utility analysis by Wong et al.   costs, mainly productivity losses and costs of informal care, which in the case of RA is important, given the disabling nature of the disease.Another issue that should be taken into account when interpreting the results of the present analysis lies within an inherent problem of economic evaluations, that is, the transferability of cost-effectiveness data among varying healthcare settings. Although guidelines on the best practices for economic evaluation and the uniformity of calculations do exist, variability in the organization, administration of care, and, thus, costs, between health systems, renders the caution on the interpretation of the results a necessity.Other important limitations that specifically apply to this study are the exclusion of research presented in languages other than English and the lack of full paper articles for some of the research presented. Specifically, for the majority of the ISPOR studies, only abstracts were retrievable. So, there remains a  degree of uncertainty as to whether all the information available internationally regarding the value of abatacept has been in fact included in the present review and therefore, the findings have to be treated with caution. Future similar reviews will be able to identify full-text availability of the included research in abstract format. Finally, it has to be noted that one of the included studies  is a heaRheumatoid arthritis is a disease with high prevalence and a significant social burden. Interventions with proven efficacy, such as abatacept, are an important addition to the clinician's armament. However, fiscal realities and scarce resources make cost-effectiveness data essential for decisions about treatment in the micro- (patient) as well as the macro-  level. The majority of data from the international research shows that abatacept is both clinically efficient and highly cost effective in the treatment of moderate to severe rheumatoid arthritis, especially in patients that have demonstrated inadequate response or intolerance to anti-TNF agents or DMARDs.


Climatic changes have increased the world-wide frequency of extreme weather events such as heat waves, cold spells, floods, storms and droughts. These extreme events potentially affect the health status of millions of people, increasing disease and death. Since mitigation of climate change is a long and complex process, emphasis has recently been placed on the measures required for adaptation. Although the principles underlying these measures are universal, preparedness plans and policies need to be tailored to local conditions. In this paper, we conducted a review of the literature on the possible health consequences of extreme weather events in Israel, where the conditions are characteristic of the Mediterranean region. Strong evidence indicates that the frequency and duration of several types of extreme weather events are increasing in the Mediterranean Basin, including Israel. We examined the public health policy implications for adaptation to climate change in the region, and proposed public health adaptation policy options. Preparedness for the public health impact of increased extreme weather events is still relatively limited and clear public health policies are urgently needed. These include improved early warning and monitoring systems, preparedness of the health system, educational programs and the living environment. Regional collaboration should be a priority. Human-induced emission of greenhouse gases into the lower atmosphere is increasingly contributing to the warming of the earth's surface. There is now strong evidence for recent climatic changes. There have been significant temperature increase, more extreme weather events, sea level rise and shrinkage of most glaciers and snow cover ,2. AccorIn 2007, the Intergovernmental Program on Climate Change (IPCC) produced the fourth report on the potential health effects of climate change . The finInternational efforts are being made to mitigate the effects of climate change by reducing the production of greenhouse gases. Despite these efforts, it is clear that climate change is already happening and cannot be prevented. Thus, comprehensive plans are necessary to ensure effective adaptation to different scenarios. The term "adaptation" refers to the process of adjustment to actual or expected climate and its effects in human systems, to moderate harm or exploit beneficial opportunities .Due to the many uncertainties, a so-called "low-regrets" approach has been proposed. Low-regrets measures provide benefits under current climate conditions and a range of future climate change scenarios. They are useful and readily available starting points for addressing projected trends in exposure, vulnerability and climate extremes. They have the potential to offer benefits now and lay the foundation for addressing projected changes . These mSince the 1960s, the Mediterranean region has become warmer with a significant increase in the frequency, intensity and duration of heat waves . In addiAll of these trends have been detected in the Eastern Mediterranean Basin in general, and most, if not all, have been detected in Israel. According to the IPCC (2012), an increase in warm days and nights has been observed, in parallel with a reduction in cold days and nights. During the last few decades, the summers in Israel have become significantly warmer , with anAlthough Israel's climatological community agrees that the region is experiencing a warming trend , less coThe Israel Climate Change Information Center (ICCIC) report (2011)  summarizIn this paper, we review the potential health consequences of extreme weather events resulting from climate change in Israel as a case study of the Mediterranean region, and propose adaptation measures that need to be incorporated in public health policy.The consequences of extreme weather on human health can be divided into two categories; direct and indirect. Direct impacts are deaths, disease and injury due to heat waves, floods and storms  and mental stress, poor air quality, increased pollen, reduced food safety due to higher temperatures and greater exposure to ultraviolet radiation. The indirect effects are widening health and social inequality due to rising global food prices, and food insecurity, causing population displacement and migrations. In the Eastern Mediterranean region, the most common extreme weather events are heat waves.The National Oceanic and Atmospheric Administration (NOAA) (2009) defines a heat wave as: "a period of abnormally and uncomfortably hot and unusually humid weather…typically, a heat wave lasts two or more days" . In factHeat-related illnesses  can occur when high ambient temperatures overcome the body's natural ability to dissipate heat. Older adults, young children and persons with chronic medical conditions are particularly susceptible to these illnesses and are at high risk for heat-related mortality . Heat stThe health impact of the increasing frequency of heat waves is already being felt in countries such as Germany , China , Russia No studies in Israel have reported an increase in cardiovascular disease during heat waves. However during the summer months, more hospital admissions due to cardiovascular disease were reported during warmer days than colder days . In one The lack of reports of increased cardiovascular morbidity during heat waves in Israel may represent the reality or, alternatively, may be a result of the incomplete analyses of the available data. Excess mortality from heat waves may have occurred, but has not been documented. This may be due to the relatively small size of the population, where small-scale effects are difficult to detect, or to inadequate analysis of available data. Furthermore, the lack of reporting on the health impacts of heat waves in Israel may be due to the structure of the monitoring system of deaths and causes of death, which may lack the sensitivity required to detect the direct effects of heat waves on mortality. It is also possible that behavioral adaptation of the Israeli population has mitigated the health impact of heat waves.Nevertheless, based on the experience in Europe in 2003, it is possible that Israel will face significant mortality as a result of a prolonged extreme heat wave in the future. Due to the Mediterranean climate, Israel’s existing infrastructures for dealing with heat waves,  are probably better than those that were available in Europe in 2003. Nonetheless, special attention to the preparedness for protecting vulnerable groups, including low socioeconomic persons, is still essential. Without proper adaptive planning that takes into consideration both the population growth and the possible increase in extreme heat waves in Israel, climate change will result in significant adverse health effects and additional costs for the Israeli public health sector in future decades .Exposure to pollutants, such as airborne particulate matter, has been shown to be associated with a rise in hospital admissions because of respiratory diseases . Interacvector-borne diseases. These include Dengue and West Nile virus [In general, infectious diseases are not related to extreme heat events. However, in recent years, increasing attention has been paid to the linkage between extreme heat conditions and some le virus -55. In ale virus  due to iThe elderly and the chronically ill are vulnerable groups at high risk of heat stress ,57. A nuExcess mortality among the elderly during heat waves has been reported in Australia . It has In Israel, the risk of heat waves is not dissimilar from the risk in Australia, which also has regions with Mediterranean climate type. Thus, without an adaptation plan that will take into account the expected increase in heat waves and the aging of the population, the predictions for Israel might well be similar to the predictions for Australia.Among the elderly and the chronically ill in Israel, excess morbidity and mortality from heat stress might have occurred, but has not been documented. The actual monitoring of the condition of those groups is complex on account of the lack of an adequate monitoring system for heat-related morbidity and mortality and the failure to mention heat stress on death certificates. In addition, older and chronically ill people may be treated mainly in the community where the data from monitoring are often less specific. Thus, the lack of data might conceal the true extent of the effects of heat stress on morbidity and mortality among the elderly and the chronically ill. In Israel, these populations are included in the Ministry of Health risk groups to be monitored in cases of extreme weather events -65.Poor people often lack well-designed, adequately insulated housing and air conditioning. They will be more affected by heat waves if they lack the means to protect themselves ,66. No rInformal evidence shows that well-being, morale and mental health are affected by changes in the environment and the perceptions of it ,67. HeatIn Israel, several studies have found a seasonal variation in the admission rates of patients with mental illness suffering from different conditions, as well as a linear correlation between admission rates and the mean maximal monthly temperature ,71. EvenIn addition to the possible effects of heat waves on acute psychiatric episodes, extensive and frequent heat waves may also affect the health of people with special needs. For example, extreme heat could severely limit outdoor activities for people with serious physical disabilities due to the extra effort this requires.As far as we know, little research has been performed concerning the health effects of heat waves on the different minorities living in Israel. Different ethnic and cultural minority groups in Israel have traditional customs that may cause difficulties in coping with heat waves. For example, many Bedouin in the Negev desert live in tents and are poorly protected against heat waves. There is evidence of some behavioral adaptation which could limit the adverse effects of heat . Heat waAlthough global temperatures are rising, extreme cold weather events are increasing in frequency . DiffereOverall mortality increases in winter in Israel Figure , and casIt is, of course, possible that generally warmer weather may reduce the extent of winter peaks in mortality in Israel. Since the climate is generally warm, the general population is often unaware of the potential dangers related to exposure to extremely cold weather, especially to newborns, premature babies and the elderly.The elderly and the chronically ill are especially susceptible to the adverse effects of extreme cold, because of their lower resistance to illness as well as the chronic use of medications. A study in Moscow, which examined the health effects of two cold spells that occurred during 2006, found that their cumulative effects on mortality were significant only in the 75+ age group, in which 370 extra deaths occurred . AlthougChildren represent a particularly vulnerable group that is likely to suffer disproportionately from both direct and indirect adverse health effects of extreme cold . An incrPoor and indigent people are more susceptible to the effects of extreme cold, as they are less equipped to deal with them than people in higher socioeconomic strata. It might be expected that during extremely cold days and nights, poor and homeless people would seek shelter in public places such as hospitals. According to a study in the United Kingdom, attendance of homeless people in emergency rooms was more frequent during evenings and nights when the temperature dropped, and a relatively high proportion (17.4%) of them left without being seen by a doctor. The same research found a small positive correlation between daily attendances of homeless people in emergency rooms and minimum daily temperature . Those wGrowing evidence shows that climate change is increasing the frequency and intensity of climate-related natural disasters ,86. The Droughts are likely to increase as a consequence of climate change . AccordiRecurrent floods occur in Israel, mostly in the arid southern regions. During January 2013, severe floods occurred in many areas of the country as a result of extreme storm conditions. In fact many hydrological systems reported the highest ever recorded water flows . This tyThe acute stress caused by natural disasters might adversely affect the elderly and chronically ill populations, who have fewer coping mechanisms and are highly sensitive to the health effects of stress. Children are at highest risk of malnutrition, with long-term implications for their overall development ,58. ExtrThe health dimension of vulnerability to extreme events includes differential physical, physiological and mental health effects in different regions and on different social groups. It also includes the possible impact of extreme weather events on the provision of health services . Vulnerability can also be understood in terms of functionality related to communication, medical care, maintaining independence, supervision and transportation . The pubIn particular, health policies that address the special needs of vulnerable groups must be identified, and where necessary, given special attention. In general, policy recommendations should address at least five areas: early detection of extreme weather events, preparedness of the health systems, monitoring of morbidity and mortality, public education and the living environment. These recommendations are grounded in the review of the literature presented in previous sections of this paper, along with our own insights into Israeli society and its policy development processes. In light of the space constraints of a journal article, these recommendations are perforce presented in general terms and could easily be elaborated in appropriate forums.The meteorological services are responsible for the updated alerts on the possibility of extreme weather events. Thus, a prerequisite for any monitoring system for the early detection of extreme weather events is productive collaboration between the meteorological service and the health authorities. An action plan should be developed, containing definitions of "changes in the level of alertness and action" for the preparedness for heat waves and cold spells. Exercises on an annual basis should be carried out to evaluate the functioning and quality of the alert system.Policy recommendations should address the emergency services’ delivery, governance and regulations, the health workforce, medical products, financing and assisting other countries in addressing the health effects of climate change. Special attention should be given to people with limited ability and who are unable to leave their homes independently. During heat waves and cold spells, all individuals in the high risk groups should be contacted personally by employees of the Ministry of Welfare, either by telephone or a home visit. In case of need, those individuals should be evacuated to hospitals or to air-conditioned public places. This should be done in addition to, and not instead of, the current recommendation that family members should visit individuals in risk groups, such as older persons, on hot days.Moreover, the Israel Ministry of Health defined heat wave as sequentially three days or more with at least 32.2°C. According to their report, extreme heat wave occurs when the temperature is 30°C and the relative humidity is at least 70%, or when the relative humidity is lower but the temperatures are higher . Since tThere is a need for a monitoring system for the health effects of climate change, including indices of total and cause-specific morbidity and mortality. As soon as a heat/cold wave begins, causes of morbidity and mortality should be reported to a central department in the Ministry of Health within 48 hours Figure . The datThere is a need for improved educational programs for the public and for health professionals on how to adapt to the changes in the climate. Guidelines for behavior in case of heat waves and cold spells for the general public, as well as guidelines for the proper treatment of heat and cold injuries in hospitals, have been published by the Israel Ministry of Health ,64,97. TThe potential impact of climate change requires a conceptual adjustment in the way buildings and cities can be adapted . Currently, health aspects are not given sufficient consideration in existing compulsory building regulations. It is important that the building codes will require new buildings to be designed to comply with green standards  considerSpecial consideration should be given to existing buildings, offering incentives to perform green retrofit and to adapt them to updated green standards, improving the building envelope to reduce energy consumption and improve thermal comfort. The use of energy-efficient heating, ventilation and air-conditioning (HVAC) systems to achieve thermal comfort during extreme events should be encouraged.Open areas, parks and streets can provide a vital space for public urban life throughout the entire year. The public’s successful use and enjoyment of this space depends heavily on microclimatic conditions that affect thermal comfort. Appropriate comprehensive planning should consider ways of bringing together the different urban components to make use of renewable energy sources for passive heating and cooling of buildings, to reduce the heat island effect  and to create open spaces that can provide enjoyment and sustain a healthy urban lifestyle.The Israeli government has started taking steps toward the achievement of this goal, but has reduced its investment in the plan due to budgetary considerations . This plst century [Based on predictive modeling, the average temperature might increase globally by between 2-5°C during the 21 century . Indeed,The authors declare that they have no competing interests.MG conceptualized the idea of the manuscript and was involved in all steps of the writing of the paper. SP was involved in all aspects of the writing of the paper including its conceptualization. NGP was involved in data collection and analysis and assisted with writing the article. GC assisted with writing the section of the article concerning the living environment. YE assisted with writing the section of the article concerning heat conditions. All authors helped in reviewing drafts of the article. All authors read and approved the final manuscript.Manfred Green MD,PhD is an epidemiologist and professor and head of the School of Public Health at the University of Haifa. Until 2008, he was director of the Israel Center for Disease Control and a professor in the Sackler Faculty of Medicine at Tel Aviv University. He is board certified in public health, health administration and occupational medicine.Noemie Groag Pri-or is a research assistant at the School of Public Health, University of Haifa. She has a MPH degree in health promotion. Her main interest lies in understanding the effects of environmental and policy factors on the health of the population as a whole and the health of women and children in particular. Guedi Capeluto DSc is an architect and Associate Professor at the Faculty of Architecture and Town Planning, Technion, Israel Institute of Technology. His research is focused on sustainable design, green architecture, intelligent buildings, daylighting, daylight access and solar rights in urban design. Yoram Epstein PhD, FACSM specializes in environmental physiology and ergonomics, with special interest in thermoregulation. Presently, an associate professor of environmental physiology in the Sackler Faculty of Medicine, Tel Aviv University and a senior investigator and consultant at the Heller Institute of Medical Research in the Sheba Medical Center, Tel Hashomer. Shlomit Paz PhD is a senior lecturer at the Department of Geography and Environmental Studies, University of Haifa. She is a climatologist, who investigates the impacts of climate change on the public health, with a main focus on the effects of the global warming on vector-borne diseases.


Substantive equity-focused policy changes in Ontario, Canada have yet to be realized and may be limited by a lack of widespread public support. An understanding of how the public attributes inequalities can be informative for developing widespread support. Therefore, the objectives of this study were to examine how Ontarians attribute income-related health inequalities.We conducted a telephone survey of 2,006 Ontarians using random digit dialing. The survey included thirteen questions relevant to the theme of attributions of income-related health inequalities, with each statement linked to a known social determinant of health. The statements were further categorized depending on whether the statement was framed around blaming the poor for health inequalities, the plight of the poor as a cause of health inequalities, or the privilege of the rich as a cause of health inequalities.There was high agreement for statements that attributed inequalities to differences between the rich and the poor in terms of employment, social status, income and food security, and conversely, the least agreement for statements that attributed inequalities to differences in terms of early childhood development, social exclusion, the social gradient and personal health practices and coping skills. Mean agreement was lower for the two statements that suggested blame for income-related health inequalities lies with the poor (43.1%) than for the three statements that attributed inequalities to the plight of the poor (58.3%) or the eight statements that attributed inequalities to the privilege of the rich (58.7%).A majority of this sample of Ontarians were willing to attribute inequalities to the social determinants of health, and were willing to accept messages that framed inequalities around the privilege of the rich or the plight of the poor. These findings will inform education campaigns, campaigns aimed at increasing public support for equity-focused public policy, and knowledge translation strategies. Income-related health inequalities in Canada are well recognized by the health, policy, and research communities, as is the role of the social determinants of health (SDOH), such as education, housing, and job security, in producing and maintaining these inequalities Our previous research suggests that only a small majority of Ontarians are aware of income-related health inequalities in the province, with 53% agreeing that ‘the rich are much healthier than the poor’ An understanding of how Ontarians attribute income-related health inequalities can be used to inform effective framing of messages aimed at increasing public awareness of inequalities and support for policy change to promote health equity. Effective messages should include emphasis on the importance of external factors, but we must also ascertain what messages the general public, and population subgroups, are willing to accept. For example, Niederdeppe et al.'s Message Design Strategy Framework for Raising Awareness of SDOH and Population Health Disparities states that messaging can frame inequalities as being within the control of the disadvantaged individual, being beyond the control of that individual, or some combination of the two, with the most effective messaging emphasizing external factors but acknowledging the role of the individualWith these considerations in mind, this paper reports on survey results of how Ontarians attribute differences in health between the rich and poor. The data presented here are part of a larger body of work where the overarching aim is to better understand how to increase public support for health equity by exploring Ontarians' awareness of income-related health inequalities, their attributions of these inequalities, and their opinions about solutions to inequalities. Specifically, this paper examines Ontarians' attributions of income-related health inequalities relative to the SDOH, their attributions relative to the framing of messages, and how various sociodemographic factors influence these attributions.The study, and its consent procedures, received approval by the University of Toronto's Office of Research Ethics. Individuals were asked if they would participate in the survey, and when they verbally agreed, this was taken to imply consent. This is common practice in telephone interview surveys that are deemed to present little or no risk to participants, so no written consent is generally obtained. As well, it was not feasible to obtain written consent due to the nature of the survey . All telephone surveys were recorded for quality control purposes, and all responses were entered real-time using computer-assisted telephone interview technology. The process, as documented by the market-based research firm, indicated that of 69,906 numbers called, there were a total of 33,530 individuals asked to participate with 9.24% of persons asked to complete the survey doing so.Details of the study methods have been previously published The survey included questions pertaining to three broad themes: (1) awareness of income-related health inequalities, (2) attributions of income-related health inequalities, and (3) possible solutions to income-related health inequalities. Results related to the first theme have been previously published We analyzed responses to thirteen Likert items, with each attribution statement linked to a particular SDOH . As manyFor all statements, participants were given the options of strongly agreeing, agreeing, disagreeing, strongly disagreeing, providing a neutral response, or refusing to answer. The proportion refusing to answer ranged from 0.2% to 2.8%. To investigate participant characteristics that may influence how one attributes health inequalities, political affiliation and demographic information were also collected. Demographic characteristics used in this analysis include sex, age group , area of residence , immigration status , visible minority status, total annual household income , highest attained education (high school diploma or lower versus higher than high school), and whether participants were employed at the time of the survey. Political affiliation was gauged in response to the question, “If the election were being held today, do you think you would vote for the Progressive Conservative, Liberal, New Democratic Party (NDP), Green, or some other candidate?” The former three parties are the parties currently represented in the Ontario legislative assembly, and can very generally be defined as right to left wing, respectively. Participants who indicated affiliation with the Green Party or another candidate were classified as ‘Other’. We also examined a fifth category of political affiliation that comprised participants who either didn’t know who they would vote for or who refused to answer the question.We tabulated the proportion of survey responses to each of the thirteen statements. We then classified responses as a binary measure indicating some level of agreement, versus some level of disagreement or a neutral response. To determine the association of sociodemographic characteristics with survey responses, we conducted multivariable logistic regression. For this analysis, all characteristics that were associated with agreement, based on a significance level of 0.2, were eligible for inclusion in the model. Spearman correlation coefficients between all significant subgroup characteristics were examined to identify collinearity between predictors. We then used a manual backward stepwise approach to identify a parsimonious list of characteristics that independently predicted agreement with the attribution statements.For all analyses, data were weighted to provide estimates that were representative of the provincial population. Weights were based on provincial age and sex distributions according to the 2006 Canadian Census. SAS Version 9.3 was used for all analyses .The participation rate and demographic profile of study participants are described elsewhere Almost 85% strongly agreed or agreed that income-related health inequalities could be attributed to the poor having greater job insecurity, or to the rich having more choices and control over their lives than the poor . There wIn this survey of Ontarians, we found that respondents were most willing to attribute income-related health inequalities to differences between the rich and poor in terms of employment, social status, income and food security, and least willing to attribute inequalities to differences in terms of early childhood development, social exclusion, the social gradient and personal health practices and coping skills. These distinctions may reflect a better understanding of some social determinants by the public than others, and are important for health equity advocates to consider when working to create widespread support for health equity-focused public policy in Ontario. These findings identify policy solutions that the general public may be more willing to support at present, as well as issues where more education is needed to improve popular understanding and support. We also found that respondents were generally more likely to agree with statements that were framed around the plight of the poor or the privilege of the rich and less likely to agree with statements that implied the poor were to blame for income-related health inequalities. This finding suggests a willingness on the part of Ontarians to accept a more macro-social understanding of the determinants of health. While there was no noticeable preference for the “plight” frame over the “privilege” frame, it must be noted that mean agreement for neither exceeded 59%, signifying room for improvement in the public's understanding of social responsibility.Attribution theory suggests that certain SDOH may have resonated more with certain respondents because of the role of lived experience Attributions are influenced not just by personal experience, but also by one's socialization  We found a number of other Canadian studies that corroborate several of our findings. For example, Ruetter et al. have explored attributions of poverty and health, and similarly have shown that Canadians generally have a good understanding of the effects of poverty on health and quality of life Our findings will be informative for the process of devising effective knowledge translation activities and messaging. We have shown that this sample of Ontarians was generally willing to accept messages framed around the plight of the poor or the privilege of the rich, with no strong preference for either. Messages that lay responsibility on the poor for inequalities seem likely to be less appealing to the public. Our results also suggest that, to be most effective, messages may need to be framed differently for different sociodemographic groups, such as older Ontarians, men or visible minorities This study has several limitations. First, we used telephone sampling to obtain respondents. Telephone surveys exclude those without conventional landlines and accordingly, might under-sample people of lower socioeconomic position Although a majority of this sample of Ontarians were aware of income-related health inequalities