Rupture of the anterior cruciate ligament (ACL) is common, especially in the active population. In defining the problem of ACL rehabilitation, this study draws from the knowledge that improved self-care, strength, and fitness are associated with better outcomes. Traditional rehabilitation involves regular physiotherapy, but it is not clear what the optimal way for delivering rehabilitation is, and it varies widely across the world. Evidence for treatments are discussed in the literature, however standard length of rehabilitation and frequency of appointments are unknown. Additionally, current rehabilitation models in the National Health Service (NHS) struggle with catering to large volumes of patients and the lengthy time span over which rehabilitation is delivered. The use of eHealth  has been successful at delivering behavior change to a number of diverse patient groups. In physiotherapy, problems such as exercise compliance, exercise technique, and managing a broad program of rehabilitation and advice can be challenging. An eHealth intervention called Taxonomy for the Rehabilitation of Knee Conditions (TRAK) to support self-management and behavior change has been developed by patients and clinicians, and acceptability studies have yielded positive results. TRAK is not an exercise rehabilitation protocol; it is a tool to support ACL rehabilitation with personalized plans, prompts, and logs to help adherence and videos and instructions to improve quality and address queries. The patients have their own log-ins and can email their physiotherapist through the website. This novel platform is directly in line with current NHS England, National Institute for Health and Care Excellence, and NHS Improvement agendas that call for rehabilitation initiatives using both technology and supported self-management for patients. This study forms part of a research platform to identify a best practice model of ACL care from the literature and opinions of key stakeholders. Patients’ exercise programs and duration of treatment are still based on individual needs, but use of the website may offer improved self-management and function and reduced health resource use.This is a feasibility study to establish recruitment, retention, sample size estimates, and practicality of collecting outcome measures to inform a future trial comparing the TRAK intervention, which has been rigorously designed to address the challenges of ACL rehabilitation, to usual care.This is a feasibility study comparing 2 groups: standard care and standard care plus eHealth. It will use convergent parallel mixed methods where both qualitative and quantitative data are sought for a more thorough understanding of the objectives. Primary outcomes relate to feasibility, including recruitment, retention, and usage. Secondary outcomes relate to health resource use and patient-rated outcome measures.This research expects to establish the feasibility of a full-scale randomized controlled trial to explore whether patients who use an eHealth intervention to support ACL rehabilitation have better outcomes plus improved self-efficacy and reduced health resource use than a usual care group.The study will provide essential information to support the development and powering of a future clinical trial of eHealth and physiotherapy for patients with ACL reconstruction in the NHS. Anterior cruciate ligament (ACL) rupture is a relatively common injury among those who are physically active -3. SurgeSome of the challenges of ACL rehabilitation include patient adherence, quality and type of exercises, motivation, and incomplete rehabilitation ,4,6-8. eTaxonomy for the Rehabilitation of Knee Conditions (TRAK) is a website that targets behavior change to support self-management. It provides an individualized exercise program, progress log for key exercises, information section for each stage of rehabilitation, prompts, and videos and instructions to support the quality of rehabilitation  see Mul. PatientThe TRAK intervention was developed at Cardiff University and has been the subject of a series of development studies to aid self-management in a cohort of patients with knee problems ,19,20. IA feasibility study is needed to establish recruitment, retention, sample size estimates and the practicality of collecting outcome measures. It will illuminate the mechanisms that may affect a future clinical trial comparing the TRAK intervention, which has been rigorously designed to address the behavioral challenges of ACL rehabilitation, to usual care.This study will use convergent parallel mixed methods where an embedded qualitative study will help expose the mechanisms influencing feasibility data such as recruitment, retention, and usage ,24. An oThe study will aim to recruit participants from the ACL rehabilitation pathway at a North London NHS Hospital. It will explore patient acceptance of the randomization process and of the burden of participation in a study such as submitting to demography profiling and outcome collection, attending training sessions and interviews, and committing to use the intervention -27.Collecting information for an economic evaluation as part of research is important for potentially informing policy . The stuA second part of the study will use semistructured interviews with patients and physiotherapists on their experiences of using TRAK. A schedule of questions will be used to provide an in-depth understanding of the user perspective of the intervention and the participation burden of the study that may have implications for a future trial. Conversations will be taped, transcribed verbatim, and analyzed using a thematic analysis discussed below.All adults immediately post ACL reconstruction who have been referred to the ACL rehabilitation program, are able to read and write English and give written informed consent, and have access to the Internet at home will be considered for this study. Individuals with complex comorbidities or surgeries such as multiligament reconstruction or fracture will be excluded from the study.Ethical approval will be sought from the Health Research Authority. There is a risk that using TRAK will not address an individual patient’s needs. The risk of this has been minimized by conducting a series of development research projects leading up to this study.There is a risk that the participant’s symptoms deteriorate but remote monitoring through email will not identify this quickly. Since face-to-face treatment still applies and the patient can be identified when attending the group, this risk will be minimized. Patients will also be encouraged to air concerns with their therapist via email through the website.There is a burden of time placed on the patient whereby they have to learn to use the website and take the time to log in daily. However, participants will have access to many aspects of TRAK beyond completion of the study through remote log-in, and using TRAK for some individuals will mean that rehabilitation can fit in better around their lifestyle.Treating clinicians will identify suitable participants when they attend the ACL group during their face-to-face consultation about their knee condition. If the individual is interested in finding out more about the study and gives verbal consent, the research team will be informed. All individuals will then speak to the lead applicant about the study and participation will be explained. The time of the lead applicant has been funded for this activity.Eligible and consenting patients will be recruited from a North London physiotherapy department. Patient recruitment will begin following completion of preliminary work packages on July 1, 2018. There are on average 2 new patients per week in the ACL group based on local audit data, which equates to 60 patients over 30 weeks who may be eligible for recruitment. There is potential for 15 further patients to be recruited from the first phase of rehabilitation bringing the potential recruits to 75 patients ,30. As tA sample size of 35 in each arm is recommended in feasibility studies in order to provide sufficient data and precision of means and variances to inform a future randomized controlled trial (RCT) . Once paRetention will be measured by follow-up outcomes at markers of 6 weeks, 3 months, 6 months, and end of care or the trial. Usage of the website to determine uptake will be measured by the frequency of log-ins, email contacts, and attendance at face-to-face sessions. This will inform the retention rate and the engagement of patients with the intervention.To assess the acceptability of the website as a self-management support tool, the patients in the TRAK arm of the study will not be obliged to attend weekly face-to-face sessions . Attendance becomes a key measure of self-efficacy, where less face time may indicate greater self-efficacy and therefore informs the possibility of reduced face time for eHealth users in a future RCT. Patient and public involvement (PPI) feedback that informed this application has indicated it is acceptable to randomize to either arm of the study. However, retention and usage data will show this more accurately and have significant implications on understanding of demand, implementation, and practicality of researching this new intervention in further studies.ACL rehabilitation is an exercise group using evidence-based milestones to progress through a mix of strength and neuromuscular control exercises. Stages 1 and 2 are weekly, and stages 3 and 4 are every 2 weeks. Those who consent and are randomized to the usual care group will have a usual induction to the ACL rehab program, includingRecommended amount of exerciseTypes of exercise Appropriate use of ice, crutches, or bracing as individually indicatedEducation on potential red flags, expected milestones, and challenges of each stagePatients will progress through the 4 phases of rehabilitation according to their ability. At each face-to-face session they will be assessed by their physiotherapist for quality of movement, strength, and neuromuscular control toward goal achievement.If randomized to the intervention arm, patients will have initial education on the use of TRAK to support their rehabilitation. They will be offered follow-up teaching sessions if required. Patients will have access to the 5 dimensions of TRAK:Contact with the physiotherapist via emailExpert knowledge base for each stage of the program detailing milestones, common problems, and a summary of the evidence baseIndividualized exercise program chosen by their physiotherapist, including videos and instructions of each session. There is a technique guide that advises the patient how to do the exercises correctlyExercise log to record exercise participation, progressions, and measures of leg strength and effort levelPrompt system to remind patients to adhereAt each face-to-face session patients will be assessed by their physiotherapist for quality of movement, strength, and neuromuscular control and appropriate progressions toward goal achievement. Their exercises will be modified on their TRAK interface to reflect progress. Use of behavior change tools like logs, goal reviews, and use of prompts are recorded with usage data.Patients will complete outcomes at 6 weeks, 3 months, 6 months, and final visit. This is in line with previous RCTs in the field -33.RecruitmentRetentionUsage such as log-ins, number of pages visited, response to prompts, and log use will inform influence of behavior change toolsCost analysisFace to face time with physiotherapistsNumber of appointmentsConsultant visitsGeneral practitioner visitsEmail contactsPhysiotherapist time outside of classPatient-rated outcome measures (PROMs) are chosen as the most likely outcome measures for use in a full RCT, depending on feasibility results.Knee Injury and Osteoarthritis Outcome Score Health Resource Use Questionnaire Stanford Self-Efficacy Questionnaire EQ-5D-5L Log-insPages visitedLog inputStrength progressions inputStrength gains Email contacts to physiotherapistsAdverse events such as infection, reinjury, or failure to progress are rare but will be monitored throughout at face-to-face sessions and via patient-clinician email. Patients will be alerted to these possibilities in their inductions, in the class, and on the TRAK website.With the help of the clinical trial unit, an online randomizing process will be used for this trial to help control against bias. A physiotherapist who is blinded to treatment allocation will collect PROMs from patients. PROMs by their nature are bias-limiting because they are filled in by patients and not clinicians.Standard procedures of data collection will be adhered to and guided by practices of the clinical trials unit. The qualitative and quantitative data strands are to be collected and analyzed simultaneously and with equal priority .Quantitative data will be analyzed as follows: binary and other categorical measures will be summarized using frequencies and percentages and continuous measures using means and standard deviations (or medians and interquartile ranges for very skewed distributions). All outcome measures will be summarized separately by study arm. Differences in outcomes between arms will be estimated using multilevel linear or logistic regression models with a random effect of person to account for the repeated measures on individuals over time. Potential therapist effects will be appropriately modelled. The precision of estimates will be assessed using 95% confidence intervals. Power analyses will be conducted to calculate the sample size necessary to detect an effect of the intervention in a future RCT. The qualitative analysis will be done using a thematic analysis approach. This sees the data itself, rather than the theory, driving the process. The themes emerging from the interviews are grouped stringently so all the interview data relating to a particular theme are recorded. An explicit process of analysis will be outlined and reported, especially with regard to how data are weighted and reported secondary to frequency of occurrence or explanatory value . The proExpected outputs:Determining the feasibility of an RCT by gathering sufficient data to power a trial as outlinedDetermining the acceptability of TRAK as a tool of behavior change to physiotherapists and patients and illuminating the mechanisms that influence feasibility measuresDetermining the feasibility of gathering costing data to inform an economic analysis alongside a potential RCTParticipant feedback will be sought from the patient steering group at quarterly meetings throughout the trial or by request. Patients were part of the design of TRAK, and they informed the content and filmed the exercise videos. They checked all lay project documents for the ethics process. A National Institute for Health Research PPI panel reviewed the study favorably, and changes were made based on feedback.Recruitment to this study will be pending successful funding of the study. Recruitment will aim to begin in July 2018 following completion of preliminary work packages. Ethical approval will be sought through the Health Research Authority in January 2017 pending successful funding of the study. The study will be overseen by a trial steering committee.Impact of the study will be the delivery of TRAK ready to test in an RCT at the end of the feasibility study. The feasibility of collecting data toward a phase 3 effectiveness and cost-effectiveness study and the future direction of eHealth interventions in the management of ACL patients in the NHS will be established.


Germany has experienced different forms of immigration for many decades. At the end of and after the Second World War, refugees, displaced persons and German resettlers constituted the largest immigrant group. In the 1950s, labor migration started, followed by family reunification. There has been a constant migration of refugees and asylum seekers reaching peaks in the early 1990s as well as today. Epidemiological research has increasingly considered the health, and the access to health care, of immigrants and people with migration background. In this narrative review we discuss the current knowledge on health of immigrants in Germany. The paper is based on a selective literature research with a focus on studies using representative data from the health reporting system.Our review shows that immigrants in Germany do not suffer from different diseases than non-immigrants, but they differ in their risk for certain diseases, in the resources to cope with theses risk and regarding access to treatment. We also identified the need for differentiation within the immigrant population, considering among others social and legal status, country of origin and duration of stay. Though most of the studies acknowledge the need for differentiation, the lack of data currently rules out analyses accounting for the existing diversity and thus a full understanding of health inequalities related to migration to Germany. Vertriebene”) and ethnic German resettlers mainly from Eastern European countries fled or migrated to Germany. During the 1950s the migration of so called guest workers from southern Europe and Turkey started. Later their families followed as part of family reunification. The migration of ethnic German resettlers continued. The right of freedom of movement within the European Union led to an increase of migration to Germany from other EU member states. Since the 1980s, the migration of refugees and asylum seekers increased and now constitutes a large part of migration to Germany [Germany has been an immigration country for decades. At the end of and after World War II, expellees . In official data, nationality is available. Foreign nationals can acquire German nationality through naturalization after 8 years of “regular” residence in the country  and are then no longer identifiable as immigrants in most data bases . In 2005We use the current debates on health and healthcare of refuges migrating to Germany as an opportunity to look back at previous experiences with immigration to Germany and summarize what is known so far about the determinants of health and the health status of immigrants to Germany. Specifically, we summarize the history of immigration to Germany since the end of World War II and briefly elaborate on the different regulations applying to immigrant groups and their entitlement and access to social services, in particular the health system. We then present an overview of epidemiological research on the health situation of immigrants and point out important determinants of difference in health status between immigrants and non-immigrants in Germany. Finally, we discuss the challenges of tackling health inequalities on the one hand and avoiding the stigmatization of vulnerable groups on the other, with a special focus on the current in-migration of asylum seekers and refugees.Migration can be defined as “the movement of a person or a group of persons, either across an international border, or within a State” . The forAussiedler and Spätaussiedler) migrated to West Germany from Eastern Europe [At the end of and after World War II, refugees and displaced persons constituted the largest groups of immigrants to Germany. The two German states, the Federal Republic of Germany (West) and the German Democratic Republic  had to manage the settlement of these millions of persons. The Federal Republic alone received 9.5 million refugees, expellees and ethnic German resettlers until 1981. They were legally considered as Germans at arrival according to Article 116 of the German Basic Law. After 1981 , another 3.5 million so called “resettlers” , Greece (1960), Turkey (1961), Morocco 1963), Portugal (1964), Tunisia (1965), and Yugoslavia (1968) followed. Immigrant workers were supposed to stay in Germany only temporarily and be replaced by new workers regularly. The recruitment took place in the countries of origin and was based on specific selection criteria which considered age, sex, qualification, and also the health status of the workers. The recruitment agreements were just one form of labor migration. Workers from Eastern and Southern European countries also used other ways (such as tourist visa) to migrate to Germany and search for employment themselves . A total, PortugaSince the 1990s and still today, two thirds of all immigrants to Germany originate from European Countries of which many are EU member states – at present mainly from Poland, Romania and Bulgaria. Other, numerically smaller immigrant groups today are highly skilled professionals, students, Jewish immigrants from former Soviet Union countries, refugees and an unknown number of undocumented immigrants , 13. At ius sanguinis to ius soli). Finally, a new immigration act was introduced in 2005. It reorganized the immigration law and introduced integration and language courses [Germany has been receiving immigrants for many decades. Still, the German integration policy is generally considered to be exclusionist and as such distinguished from more multicultural, assimilatory or pluralist immigration policies . It has, courses , 18.Until 1980, less than 50,000 individuals claimed asylum in Germany every year. From the 1980s onwards, the migration of asylum seekers to West Germany (and later on to the reunified Germany) increased and reached its intermediate peak in 1992 during the Yugoslav Wars 1991–2001) with nearly 440,000 asylum claims (mainly by refugees from ex-Yugoslavia). Due to new legislation and the amendment of Article 16 of the German Basic Law in 1993 the number of asylum seekers decreased steadily. The new regulation defined “safe countries of origin” and “safe third countries” from where refugee migration to Germany became nearly legally impossible 01 with n. The asyThis brief overview of migration to Germany in the past 70 years shows the multitude of countries of origin and reasons for migration as well as the differences in duration of stay. An important conclusion is that immigrants are a heterogeneous population group in many respects. This basic fact is often overlooked when addressing immigrants’ health and health-related needs in epidemiological research.Gesundheitsberichterstattung). Data from official records, administrative records and dedicated surveys is collected and analyzed to picture the health status and the corresponding needs for prevention and care of the population as a whole. Ideally this system should also allow to identify the needs and risk exposures of sub-groups as well as existing health inequalities. Though people with migration background constitute a considerable share of the German population, many data sources used in the official health monitoring system do not routinely include information on the migration status, but only on nationality. So far, only few surveys and records are collecting information on the type of migration, duration of stay, residence status or language skill [The most reliable source of representative health data in Germany is the health monitoring system  is on average lower compared to non-immigrants . This isCultural differences as well as minority status and related experiences of discrimination have important health consequences. Whereas ethnic communities might be an important source of knowledge and social support, discrimination constitutes a risk for mental illnesses and psychosomatic conditions. In addition, language barriers, low health literacy and lack of diversity-sensitive health services constitute informal barriers to health care and are associated with a risk of inadequate or delayed treatment –44.Despite the exclusionism that characterized the German immigration policy over decades, regular immigrants and their families – irrespective of their nationality – were (and are) entitled to membership in the statutory health insurance when they are employed or recipients of social welfare. While they may face language and cultural barriers (see b), their entitlement to health care is equal to that of other citizens. This is not the case, however, for asylum seekers and other individuals without regular residence permit . For a certain period of time  their health expenditure is covered only in case of acute illnesses and pain as well as for pregnancy care and recommended vaccinations. In addition to the limited entitlement they face bureaucratic access barriers as they need to apply for health care vouchers at the local social welfare office before they can see a doctor in most of the federal states –47. IrreBesides the explanations related to exposures in the country of origin and the migration process as such (migration-stress-hypothesis), the post-migration context of immigrants living in Germany also differs from non-immigrants . Accordihealthy migrant effect and has become object of thorough analysis [Though these multi-dimensional differences suggest that immigrants’ health outcomes may be worse when compared to non-immigrants, empirical studies in Germany  frequently identified an on average lower mortality and morbidity of immigrants. This result also holds true after accounting for lower socio-economic status and adjusting for possible selective return migration , 50. Thianalysis , 51, 52.analysis . Thus, ianalysis . Secondlanalysis . Thirdlyanalysis , 55.The extend of the healthy migrant effect – and more generally of differences in health between immigrants and non-immigrants – varies according to health issue, quality of data, definition of “immigrant”, the selected reference group and the accuracy with which other social, demographic or migration-related determinants can be taken into account. Epidemiological research is slowly trying to account for this heterogeneity within the immigrant population, but the respective data is not always available as we show below.Epidemiological studies on mortality in Germany are usually based on cause-of-death records. These records allow for a comparison of mortality rates between German nationals and foreign nationals. Even after standardization for age, the excess mortality of Germans amounted to 37 % for men and 28 % for women . HoweverCancer risks differ between populations with and without migration background and depend on the type of cancer. Cancer risk among immigrants is related to previous infections which increase the risk of cancer e. g., of the stomach and the liver. Non-immigrants are at higher risk for lifestyle-related cancers such as colon and lung cancer . The cauWith regard to mental health only few representative studies have been published so far. A review on mental health of immigrants in Germany showed that the reported prevalence of depression, anxiety and posttraumatic stress disorders (PTSD) varies substantially between studies . Prevalence also varies between migration groups suggesting that refugees and asylum seekers are at higher risk for mental disorders compared to immigrant workers . AccordiRepresentative data on the health of children and adolescents with and without migration background have become available since the Robert Koch-Institute (RKI) has started the German Health Survey for Children and Adolescents (KiGGS) in 2003. The baseline study enrolled 17,000 children with a representative share of children with migration background. The study identified some differences in health status and health behavior between children and adolescents with two-sided migration background  compared to children with one-sided migration background and children without migration background. This includes for example the risks for mental illnesses which is higher for children with migration background than for children without migration background. However, this result is partly explainable by the disadvantaged socio-economic status of the families. The analyses also show differences within the group of children with migration background depending on the country of birth (of the parents and the child), the duration of stay and the reason for migration , 62.Data on the prevalence among immigrants of many other non-communicable diseases  is scarce and, where available, possibly not representative . EstimatData are also lacking regarding the prevalence and incidence of infectious diseases. Only for tuberculosis and HIV/AIDS data stratified by country of origin is available.p < 0.001). Of the German nationals with tuberculosis, only 37.6 % were born in Germany. The data suggest that immigrants are at higher risk for tuberculosis as they have been living in in high-risk countries before migration [As part of the registration of notifiable diseases at the RKI, information about the nationality and the country of birth of individuals with tuberculosis are collected. According to the report on tuberculosis in Germany of 2014, the incidence of tuberculosis among foreign nationals was 33.6 per 100,000 which was 13 times higher than among German nationals  people living with HIV/AIDS. Of these, 10,400 (12.5 %) had a foreign nationality and have been infected abroad. The majority of HIV-positive persons (87.5 %) had a German nationality and have been infected either in Germany or abroad , 67.Higher prevalence of infectious disease among people with migration background might also be due to an increased risk of infection during visits to their or their parents’ country of origin, as has been shown for Hepatitis A .From the KiGGS study on health of minors we know that the 12-month prevalence of acute ailments  as reported by the parents is lower among children with than without migration background. By contrast, children with migration background are more often only incompletely vaccinated, especially those who were born outside of Germany, and thus at higher risk of vaccine-preventable diseases .According to the Socio-economic Panel (SOEP) – a longitudinal survey with a representative sample size of around 30,000 participants – the subjective health status of immigrants (from Turkey and other recruitment countries of immigrant workers) is worse compared to non-immigrants of the same age and sex . The subIn the absence of solid data on the prevalence of chronic diseases like diabetes and coronary heart disease, the distribution of risk factors and risk behavior might provide us with hints at their prevalence. According to the DEGS study, the proportion of smokers among men (first and second generation) and women (only second generation) with migration background is higher than among persons without migration background. For men this difference is mainly due to differences in socio-economic status and does not persist after adjustment . More deMicrocensus data from 2013 also allows for a comparison of obesity among persons with and without migration background based on self-reported height and weight. For men, no differences in the prevalence of obesity was found whereas the prevalence of obesity was higher in the group of elderly women with migration background than in that without . Again, Regular physical activity and alcohol consumption do not differ substantially between population groups with and without migration background. Only elderly women (most of whom immigrated long ago) are considerably less likely to be physically active and to show a risky alcohol consumption .With regard to children, a two-sided migration background is associated with a higher prevalence of overweight or obesity (measured) with important differences according to country of origin of the parents. Children with migration background are less physically active and watch television more often. Again this association is largely explained by differences in socio-economic status. On the contrary, the alcohol and tobacco consumption of children with two-sided migration background is lower – especially among children with Turkish or Arabic-Islamic migration background – compared to children without migration background .Health systems research has compared the access to, and the utilization as well as the outcome of, health care services between immigrants and non-immigrants in Germany. Entitlements are similar for regular immigrants and the majority population. Restrictions exist for asylum seekers and refugees as well as for the group of irregular immigrants (c.f. section 3.2). There is increasing evidence that these restrictions may contribute to the aggravation of diseases and to an overuse of emergency services , 62, 76.Regular immigrants do not face restrictions in legal entitlements, but there are other access barriers leading to lower utilization and worse outcomes of healthcare. This has been shown for the use of rehabilitative care offered e.g., after cardiovascular disease, cancer treatment, or accidents. Given the growing number of older people with migration background and their often unfavorable working conditions this service is of increasing importance. The analysis showed that foreign nationals use medical rehabilitation less often than the majority population. For those who take part, the objective  as well as subjective (expressed satisfaction with rehabilitation) outcomes are less satisfactory – even after adjustment for socio-economic, health and demographic characteristics , 77. FinThese observations point at the existence of barriers that immigrants face when accessing health care. In the terminology of Anderson , the effHowever, care needs to be taken not to generalize findings. For example, uptake of mammography screening is as high (or even higher) among immigrant women of Turkish origin as in the majority population . MoreovePeople with migration background – including people with insecure or irregular residence status – will constitute a growing share of the population of Germany in the future , 21, 86.First, the quality and availability of social and health data for all immigrant groups needs to be improved. The underrepresentation of immigrants in health reporting and epidemiological studies makes it difficult to identify existing heath inequality and health care needs of immigrants. In epidemiological research, the lack of data precludes attempts to picture the diversity of the German population and the heterogeneity within the group of people with migration background , 22. ResSecond, there is a need to develop and implement concepts of diversity management in the health care system. Two extremes can be conceptualized when adapting health services to this group – a migrant-specific (“exclusive”) and a migrant-sensitive (“inclusive”) approach. Proponents of a migrant-specific approach argue that health services and prevention programs need to be tailored to the specific needs of immigrants as they differ substantially from those of the majority population. For example, there should be rehabilitation services specifically for immigrants of Turkish origin, with Turkish-speaking staff and Turkish food. A migrant-sensitive approach, however, would consider migration background as one of many dimensions of difference between individuals. Health services should try to cater for the differing needs of all clients, as far as is possible. As a consequence, there is no need for specially tailored programs or services, but rather of a need for openness towards diversity and the increasing heterogeneity of populations . AcknowlThird, research on immigrant health has to be self-reflexive and aware of the stigmatizing effects of research results. The example of refugee health highlights the risk of epidemiological studies in minority populations. Research that does not carefully consider the social, structural, and global context of migration and flight might contribute to the stigmatization of immigrants as importers of diseases, burden on the destination country’s health system, and being entirely different in their health risks, needs, and behavior. Epidemiological and public health concerns may thus inadvertently contribute to the social construction of immigrants as being ‘the others’ and as not belonging to society . Such a Migration has shaped, and is still shaping, the demographic, social and health situation of the population in Germany. Broadly speaking, immigrants suffer from the same types of diseases as non-immigrants do, but individual disease entities may be more or less frequent, the onset may be earlier or the course more severe. Immigrants may have fewer resources to cope with illness and face barriers towards accessing the required treatment. Differences in prevalence and risk factors or behavior are to a considerable extent the results of social inequalities and the demographic structures of both groups. Thus, migration background is only one dimension of diversity and inequality that interacts with other dimension like socio-economic status or sex/gender. Due to these other social determinants of health, the variance of health status and health literacy within the groups of immigrants is probably just as high as within the population of Germany as a whole, or maybe even higher given the different countries of births and the sustained influence of pre- and peri-migration contexts. In public health research and practice, this diversity as well as the existing migration-related inequalities need to be addressed. Preconditions are the availability of data, the development of diversity-sensitive concepts or services and the avoidance of discriminatory or stigmatizing practices.DEGS, German health interview and examination survey for adults; KiGGS, German health survey for children and adolescents; PTSD, posttraumatic stress disorders; RKI, Robert Koch-Institute; SOEP, socio-economic panel


As a disaster prone country, Bangladesh is regularly hit by natural hazards, including devastating cyclones, such as in 1970, 1991 and 2007. Although the number of cyclones’ fatalities reduced from 0.3 million in 1970 to a few thousand or fewer in recent events, loss of lives and impact on livelihoods remains a concern. It depends on the meteorological characteristics of cyclone and the general vulnerability and capacity of the exposed population. In that perspective, a spatially explicit risk assessment is an essential step towards targeted disaster risk reduction. This study aims at analyzing the spatial variation of the different factors contributing to the risk for coastal communities at regional scale, including the distribution of the hazards, exposure, vulnerability and capacity. An exploratory factor analysis method is used to map vulnerability contrasts between local administrative units. Indexing and ranking using geospatial techniques are used to produce maps of exposure, hazard, vulnerability, capacities and risk. Results show that vulnerable populations and exposed areas are distributed along the land sea boundary, islands and major inland rivers. The hazard, assessed from the density of historical cyclone paths, is highest in the southwestern part of the coast. Whereas cyclones shelters are shown to properly serve the most vulnerable populations as priority evacuation centers, the overall pattern of capacity accounting for building quality and road network shows a more complex pattern. Resultant risk maps also provide a reasonable basis from which to take further structural measures to minimize loss of lives in the upcoming cyclones. Cyclones are one of the most destructive natural hazards along highly populated coastlines all over the world. This is especially true for low-lying delta environments such as Bangladesh. A cyclone hits the coast of Bangladesh almost every year. Among these, at least one severe cyclone every three years causes significant damage along part of the coast . The majHuman deaths and injuries due to cyclones, often associated with storm surges, are one of the major concerns to the national, regional and local policy makers in Bangladesh. Although the number of casualties caused by recent major cyclones  decreased compared to those in 1970 and 1991, the probability of human loss due to future cyclones remains significant . UnderstRisk is the probability that an extreme natural hazard cause adverse impacts on vulnerable elements exposed to it, including loss of lives, properties or other economic assets ,6,7. It Vulnerability, usually considered as two components namely physical and social vulnerability, refers to the susceptibility of people, sector of society or economy to death, injury or damage by natural hazard ,13,14,15Exposure is defined as the degree to which a place is exposed to natural hazards . PotentiThis paper presents a first effort to assess regional risk to cyclone casualties and damage at the scale of the lowermost administrative level of Bangladesh. The main objective of the research is to identify the spatial distribution of cyclone risk for the communities living in coastal areas of Bangladesh. The specific objectives include the mapping of the spatial distribution of the exposed population, the main vulnerability, hazard and capacity factors and their integration into a risk map.Using available socio-economic statistics for unions’ administrative level , historical cyclone paths and geospatial analysis, we propose regional maps of cyclone hazards as well as exposure, vulnerability and capacity indices of the coastal population. These indices are derived using principle component analysis (PCA), weighted indexing and ranking with the help of geospatial techniques. Vulnerability with its contributing dimensions; and capacity, exposure and hazard with their contributing components are mapped to understand how they are spatially distributed. As vulnerability, capacity, exposure and hazard contribute to the risk of natural hazard ,32,36,393 km2, with 710 km of coastline [Bangladesh is a land of natural hazards. Cyclones form in the Bay of Bengal  and reguoastline , many isSince 1797, 70 cyclones of different intensities caused the death of ca. 1.5 million people in Bangladesh according to the compilation of different sources ,51,52. AGorky) and 3000 in 2007 (Cyclone Sidr). The number of casualties decreased as government took measures at policy level  and implementation level . The number of casualties from cyclone depends on multiple conditions such as landfall time (day or night), synchronization with high tides, wind speed and proper dissemination of accurate warnings before landfall. Similar warning signals produce different cyclone impacts as assigned danger levels do not consider the variation among the characteristics of the people living along the coast, their exposure and ability to respond. Assessment of population exposure, socio-economic vulnerability, and capacity to find shelter are important to understand the differential impacts of the cyclones based on the spatial variations.Poverty, poor structure of housing, lack of adaptive capacity and nature-dependent livelihood of coastal people increase their vulnerability to cyclone and wind-driven storm surges ,53. The As the coastal unions are poorly connected to district and division headquarters, elected local representatives and government officials of the lowest administrative level (unions) should act promptly in the phases before, during, and after a disaster. Many risk reduction and management decisions are taken at union’s level, including the selection of beneficiaries of the social safety budget, as well as structural and non-structural risk reduction actions such as repairing polders or dissemination of warning messages . Union dBuilding a vulnerability index requires the selection of meaningful variables as well as a method to aggregate these data into a single index. The choice of variables is more important than methods followed in index building ,54.In this study, we applied data driven inductive approaches to assess the vulnerability of the population to cyclone casualties and damage at union level ,44,54. Wz values.These 41 indicators have heterogeneous units. To make them comparable they were converted to standardized For further reducing the number of variables and analyzing multicollinearity, we applied a data reduction technique, Principle Component Analysis (PCA), using a varimax rotation option. The necessary preconditions for PCA application  ≥ 0.5 were checked and met. The factors with eigen values greater than one were retained for calculating vulnerability indices. Each factor was attributed a directional sign based on the interpretation of the contribution of the dominant variables’ loading on the factor to increase or decrease vulnerability .Finally, the social vulnerability index was calculated for each coastal union based on a weighted additive model using the retained PCA factors. The weight used in the additive model is calculated based on the relative variance explained by each factor . The spaCyclone shelters have been argued to be the most important elements contributing to save human lives from the impact of cyclones . The locThe ability of the cyclone shelters to save human lives has been assessed by four indicators: (1) the average distance of cyclone shelters to nearest roads; (2) the density of shelters; (3) the unserved space; and (4) unserved people by cyclone shelters.The distance of each cyclone shelter to the nearest usable road was calculated using Euclidian distance. For each union, the average distance of the different shelters to the road was calculated. Unions having no shelters were attributed the largest distance values obtained for unions with at least one shelter. A negative value was attributed to this indicator, as the lower the average distance of shelter to the road, the more accessible they are to provide capacity against cyclone risks.The density of cyclone shelter is calculated from the number of cyclone shelters per union divided by the area of respective unions. The service area of a cyclone shelter has been shown to be limited to 1.5 km radius due to accessibility constraints during cyclones . Based oEach shelter is characterized by a certain capacity, i.e., the number of people that can find shelter in it. The population of each union and the standard capacity of cyclone shelter  have been collected from national population census and cyclone shelter database, respectively. The proportion of the union’s population that can be accommodated in available shelters was then calculated as a ratio of total population.This indicator was attributed a positive sign as a high number of people served by cyclone shelters indicate that higher capacity of the union to protect lives from cyclone threat.The four shelters’ indicators were averaged using equal weight to calculate the “cyclone shelter competency index”.z-value to give the “housing strength indicator”. This indicator contributed positively in increasing the capacity of a union to face the impact of a cyclone.Houses that are constructed with reinforced cement concrete (RCC) and bricks can withstand strong wind forces and storm surges. These houses are considered as strong houses in this study. Percent of strong houses per union has been collected from national population census data of 2011. This parameter was converted into The mobility of population during cyclones is quite essential, to evacuate inland or reach cyclone shelters. Shape file of roads has been collected from WFP (The World Food Programme) dataset. The road density within each union has been calculated by dividing the total length of roads, considering all types of construction material , by the union area.z-value. A final capacity index was calculated by averaging the cyclone shelter competency index, the housing strength indicator and the road density.All of the above indicators were converted to In the literature, a confusion exists between the concepts of exposure and vulnerability: some previously proposed coastal vulnerability Indices ,58,59,60Land elevation is extracted from the SRTM DEM at 30 m resolution. Elevation is considered to contribute negatively to exposure, assuming higher elevation induces lower exposure to tidal surge and flooding ,58,59.We used a global land cover dataset prepared from Landsat satellite images at 30 m resolution . We updaDistance of each point of the study area to the closest river and coastline were calculated separately and added together later. Distance to coast and river were assigned a negative sign—meaning that they contribute negatively to exposure—assuming the places closest to water are the most exposed to flooding and tidal surges.We converted all the four indicators to z factor. As these factors are poorly correlated with each other and the relative importance of each of them is ill-defined, we aggregated these indicators using an arithmetic average, with equal weight to each indicator, to construct the exposure index. The unions were mapped using exposure indices and ranked into five categories based on quantiles as cut points.The cyclone tracks of historical cyclones in Bangladesh have been collected from NOAA global cyclone dataset and updated with the cyclone tracks provided by Bangladesh meteorological department. The kernel method of linear features, with a radius of approximately 2.5 km i.e., equivalent to 1/30 of the north–south dimension of the study area, was used to derive a probability density function of all the cyclone tracks . This siSeveral methods can be used to assess the risk to natural hazards as different combinations of Vulnerability, Capacity, Exposure and Hazard. We applied four of these approaches. As the variables, indicators, indices and dimensions, used in assessment of risk to natural hazards, vary based on availability of the data in different parts of the world, there is always uncertainty of the produced risk map. To minimize those, we used several possible combinations of risk components to prepare risk maps of different alternative scenarios. Although individual risk indices exist as theoretical definitions in the literature ,64 and aSidr that hit Bangladesh in 2007 have been collected from the needs assessment report produced by the Disaster Management and Relief Department of Bangladesh [z-values of human death, injury, livestock and property damage data at a district scale to use as a proxy for cyclone impact. As the scale of these damage statistics is rougher and as it concerns a single cyclone event, only semi-quantitative comparison with the produced risk map is conducted.The damage data of cyclone ngladesh . A cycloUsing the PCA and the 41 initial statistical indicators, thirteen vulnerability factors have been extracted to differentiate the coastal unions of Bangladesh by relative vulnerability . The 13 Aila in 2009 [This vulnerability dimension regroups 6 components of the PCA explaining 51.6% of the total dataset variations. It is related to the demographic structure, education level and opportunities in different job sectors. Coastal unions along the south east coastline, all unions bordering main rivers in the central coastal region  are highly vulnerable areas b. The po in 2009 . High anThe first PCA component contributing to this vulnerability dimension is composed of indicators related to social security and citizen’s socio-economic opportunity that decrease vulnerability to natural hazards. People who have better jobs, better access to safe drinking water, better housing can recover earlier from cyclone impact than those that do not have such opportunities ,67,68. HUnemployment and education indicators are loading on the third component of this socio-demographic vulnerability dimension. Unemployed people have no formal income. Inaccessibility to formal education results in poor understanding of hazard forecasting and risk misperception. Both indicators increase vulnerability. Natural hazards are discussed at school from primary to higher secondary level in Bangladesh . People The sex ratio of the unions and percentage of male child aged over seven that are not enrolled in school are the indicators loading on the 5th component which is assumed to increase vulnerability. Higher sex ratio  means gender imbalance that encourage early marriage of poor rural girls that eventually increase vulnerability [The seventh component, accounting for 4.7% of the variance, concern industrial jobs. Industry workers are better paid compared to agriculture wages and other informal sectors ,71 and cMales and females of the unions who are looking for jobs are financially not capable to support their family in post cyclone recovery. These indicators are summarized in the 8th component that accounts for 4.5% of the total variance.Aila in 2009 in southwestern coastal districts. This second dimension of vulnerability is composed of the 6th (access to water) and 9th (access to toilets) components of the PCA, which account together for 8.8% of the total variance. Part of the southwestern coast area, surrounding the Sundarban mangrove reserve, is the most vulnerable in terms of limited access to these basic facilities , as well as the spatial variations of height of storm surge water. The only available parameter for historical cyclones of Bangladesh is the tracks, without information on the wind speed distribution, radius, etc. As we have low level of confidence on the hazard map, as it is produced based only on cyclone tracks, we formulated cyclone risk applying four kinds of mathematical combination of the vulnerability, exposure, hazard and capacity components. Standardized values of vulnerability, exposure, hazard and capacity are −1.13 to 1.13; −7.39 to 0.71; −2.17 to 3.39 and −1.1 to 2.13 respectively . We usedThis risk map takes into account the differential social indicators that cause certain populations to be more vulnerable to natural hazards as well as the physical factors that make the place differentially exposed to water surge and cyclone wind. Multiplying the map of “equal hazard risk” with the mapped distribution of cyclone hazard enable to generate the map of potential cyclone risk b. It shoAssuming equal socio-economic status of the coastal population, physical risk is the measurement of risk by taking into account the spatial distribution of hazard and exposure. The distribution of risk in the map of natural risk c is dispBuilt capacity to face cyclones is partially balancing the vulnerability of the exposed population. The map of mitigated risk, incorporating capacity index with vulnerability, exposure and hazard index, shows a more complex spatial pattern than the non-mitigated risk. Most sea facing unions or islands in the central coast remain in the very high cyclone risk, together with a majority of riverine islands and unions along the banks of Meghna River. However, comparison of the maps shows that the high capacity of some unions in delta of Meghna River and in Cox’s Bazar district contribute in reducing their risk.Sidr as a proxy to compare our vulnerability and risk maps. Impact of cyclone Sidr is highly visible along its track in all component of direct loss  and inductive methods (aggregating many available indicators) to select the social indicators that influence hazard impacts ,79. We cSidr and Aila in 2007 and 2009, respectively [High to very high vulnerable unions in central coast are characterized by the riverine and offshore island geographies. It is interesting to note that those islands are not only exposed to more severe natural processes, due to their low elevation and proximity to water, but they also concentrate vulnerable populations. Indeed, those islands have poor access to modern facilities, basic education, strong housing structures . As an eectively ,85.The use of census data in vulnerability assessment involves some limitations. It includes the absence of meaningful vulnerability indicators such as income, language, knowledge on disaster etc. Using an inductive approach, the data reduction and aggregation technique is driven by the available data and its structure, more than a priori knowledge on factors controlling the vulnerability of local communities in the studied areas. Although the derived factors and their respective controlling variables are interpretable and consistent with the literature, it is difficult to know if the factors explaining the largest variance have indeed more relevance for the vulnerability index or if it is a mere consequence of the availability of redundant variables in the dataset. Direct validation of this vulnerability indicator is not possible at national scale, even if detailed disaster impact would be available, as impacts would be strongly influenced by spatial variation of hazard intensity and exposure as well.The pattern of physical capacity, assessed in our method does not match the pattern of vulnerability in the coast of Bangladesh. There is even a weak negative correlation between the map of vulnerability and capacity , meaningWe are aware that the capacity to face cyclone disasters does not rely exclusively on physical infrastructures. The social and economic capitals of the exposed population are partially taken into account in the vulnerability assessment. The aspects related to the scientific forecasting and risk management, including evacuation order, are not considered in this study as no data enable to grasp these processes at the Union scale, but these are not expected to vary at a local spatial scale. Contrast in the socio-political context, i.e., local decision process, corruption, community support, that might affect the outcome of a disaster at local level can however not be grasped in our geo-statistical approach .Although spatial contrast in cyclone impact on human lives and livelihoods can partly be attributed to differential socio-economic vulnerability of people living along the coast, the role of exposure and hazard, controlling the local intensity of the hazardous process  is also important in controlling the impacts. Selection of variables, defining exposure and hazard, in this study is in agreement with Dwarakish et al. (2009) . He usedWe used the density of cyclone tracks to roughly assess the spatial distribution of cyclone hazard across the coastal region. This approach is affected by significant limitation inherent to the limited available data. Buffer with arbitrary distance from historical cyclone tracks is used in hazard assessment in Esnard et al. (2011) . All theAccurate risk assessment is important to support the development of effective cyclone mitigation policies and implementation of specific measures. The produced maps might contribute to improve three kinds of mitigation measures in Bangladesh, namely expand coverage of CPP (Cyclone Preparedness Programme) service areas, building new coastal embankments and construction of new cyclone shelters. The construction of embankments and cyclone shelters should be in the places with high and very high risk. Although successful early warning of some previous cyclones has been claimed to have saved many human lives, there is still controversy about false warning . IncorpoAs Bangladesh is one of the most disaster prone countries, it is hit regularly by severe to very severe cyclones. Assessing the spatial distribution of risk is crucial to develop target risk management strategies and reduce impacts in term of casualties and property loss. This study aimed for the first time to identify the spatial variations and contributing components of risk for human lives and livelihood from cyclone and associated tidal surge. This integrated risk assessment incorporated a wide range of variables under the component of vulnerability, exposure, hazard and capacity. The method developed included exploratory inductive technique in vulnerability assessment, deductive technique in hazard, exposure and capacity assessment. Risk was assessed by simple equation considering the product of vulnerability minus the capacity, exposure and hazard.Bangladesh being a developing country, the coastal inhabitants do not get the opportunity to subscribe life or property insurances. The government has no special allocation in its annual budget targeting the cyclone losses. To ensure an efficient use of the rehabilitation funds provided after each disaster by international donors, it is essential to assess the long term spatial distribution of casualty and livelihood risk of the coastal people to cyclones and not only invest all risk reduction actions in the areas that were most affected by the last cyclone. This research could therefore serve as a baseline document both at pre and post disaster phase for local and national disaster managers to adopt and efficiently implement structural and non-structural disaster risk reduction measures. The produced cyclone risk maps give a picture of the risk across the whole coast of Bangladesh based on the available data at the most detailed spatial scale. They enable highlighting the complex interplay of geographic, socio-demographic and physical infrastructure factors that contributes to the accumulation of risk in certain areas. The spatial pattern of vulnerability, capacity, exposure, hazard and risk may be the basis of the formulation of specific risk reduction strategies to face cyclone hazard. The method used in this study may be used with the best available similar types of data in risk assessment of other natural hazards in Bangladesh and other parts of the world. The use of four formulations of the risk in the same case study is useful to calculate different risk scenarios. It enables users to compare risk maps of different alternative scenarios, identify the major components controlling the risk gradients and take proper actions to improve the effectiveness of mitigation measures. Future works may include validation of risk maps using impact dataset of more historical cyclones. Development of the method should include more detailed studies on the factors controlling the spatial distribution of the experienced hazard intensity and the recorded direct and long term cyclone impacts on communities of the coastal regions of Bangladesh.


L. donovani in Sri Lanka may also complicate the issue. Lack of knowledge among local communities also reduces the effectiveness of vector and reservoir host control programs. Immediate actions need to be taken in order to increase scientific knowledge about the disease and a higher effectiveness of the patient management and control programs must be achieved through increased awareness about the disease among general public and active participation of local community in control activities.The present works reviewed the existing information on leishmaniasis in Sri Lanka and in other countries, focusing on challenges of controlling leishmaniasis in the country, in an outbreak. Evidence from recent studies suggests that there is a possibility of a leishmaniasis outbreak in Sri Lanka in the near future. Difficulty of early diagnosis due to lack of awareness and unavailability or inadequacy of sensitive tests are two of the main challenges for effective case management. Furthermore, the absence of a proper drug for treatment and lack of knowledge about vector biology, distribution, taxonomy and bionomics, and reservoir hosts make the problem serious. The evident potential for visceralization in the cutaneous variant of Leishmania. The disease has several different forms including three main forms, namely, visceral leishmaniasis (VL), cutaneous leishmaniasis (CL), and mucocutaneous leishmaniasis (MCL), where VL is considered to be the most virulent form of the disease. Although several case reports provide evidences for sexual or vertical transmission [Leishmaniasis is a worldwide vector borne zoonotic disease caused by several heteroxenous intracellular parasitic organisms of genussmission –4, the mLeishmaniasis has been listed as one of the eight major neglected tropical parasitic diseases with a prevalence in more than 90 countries where 88 of them are endemic to the disease. The zoonotic nature and the large genetic diversity of the both parasites and vectors make the control of this disease very difficult , 6.In the control of leishmaniasis, early diagnosis and effective patient management, vector control, effective disease surveillance, control of reservoir hosts and social mobilization, and strengthening partnerships are the key strategies . Early d Leishmania donovani. However, the potential for visceralization in the cutaneous variant of L. donovani in Sri Lanka is not known.The first report of leishmaniasis from Sri Lanka was found in the 1990s. However, those were not due to local transmission, but reported mainly among overseas employees returning to the country . First eAfter 2001, an outbreak of CL in the island became evident, but still relatively an unknown disease . HoweverWhen considering the progress of the disease during last sixteen years, with increasing encroachment in to forests and ever-changing environmental conditions due to climate changes, occurrence of a serious outbreak of leishmaniasis in Sri Lanka is very likely. Hence, this review article emphasizes the potential challenges of controlling leishmaniasis in Sri Lanka at a probable outbreak and the steps that need to be taken in order to minimize adverse impact.Early diagnosis is a very important factor for an effective management of any disease. Currently, several parasitological, molecular biological, and serological tests are used for the diagnosis. However, the diagnosis of leishmaniasis is still controversial as none of the available tests provide 100% specificity and sensitivity. Also the symptoms may vary from one form to another and also can be similar to some other diseases . The simAdvanced costly techniques such as Polymerase Chain Reaction (PCR) are more sensitive than microscopic observations –22. ImmuIn Sri Lanka, the detection of the disease is passive and only the patients seeking medical attention for their symptoms are screened for the presence of parasites. No programs are conducted to detect patients at early stages of infection . DetectiMicroscopic detection of parasites in VL requires some techniques that are very difficult to perform. For an example spleen aspiration which has a relatively higher sensitivity may be very dangerous since it can cause fatal damage to spleen and thus requires well trained personnel to perform , 27, 28.Other tests used in Sri Lanka, specially rK39 test, are inexpensive and rapid and can be performed by untrained person , 27, 30 Immunization for the disease is not yet established since the unavailability of a vaccine, although it appears to be very effective in controlling the disease . As in aSystemic treatments include the administration of drugs through oral, intravenous (IV), intramuscular (IM), or intralymphatic (IL) routes . AdminisIn local or topical treatments for CL, both drugs and nonpharmaceutical agents are used. The drug that is mostly used in topical treatments is paromomycin, while some other drugs such as imidazole and methylbenzethonium chloride –47. Use  Leishmania parasites are heat sensitive [When considering nonpharmaceutical topical treatments, cauterization or the application of heat to the site of the lesion is the simplest treatment. This can be very effective sinceensitive , 53. Howensitive .In Sri Lanka, intralesional administration of Sodium stibogluconate is used as the main method of treatment for CL, which is more common and known to have relatively less side effects . HoweverOther disadvantages of currently available drugs are the requirement of long term treatments, variation of efficacy from region to region, and the possibility of the recurrence of the disease , 34. On Vector control is currently the most effective control strategy for leishmaniasis. Chemical, biological, and environmental methods are used to control leishmaniasis. When considering chemical control, indoor residual spraying is used worldwide. In Morocco, indoor residual spray has resulted in reducing disease incidence . HoweverHowever, controlling methods in many of the countries have been proposed and tested after thorough investigations on vector, for instance, exact vector species, behavior, breeding habits and places, resting places, distribution, and other bionomic characteristics such as population fluctuations. In Sri Lanka very few studies have been conducted on these aspects which is not sufficient to support for such control programs. Phlebotomus, Lutzomyia, and Sergentomyia, are known to feed on vertebrate blood [ Phlebotomus and Lutzomyia are known to be responsible for the transmission of the disease to humans [ Sergentomyia also have the ability to harbor Leishmania parasites suggesting a high likelihood of transmitting the disease by the species of the genus Sergentomyia [ Culicoides also act as a host for the transmission of leishmaniasis [ P. argentipes, is the proven vector of L. donovani which causes visceral leishmaniasis in the Indian subcontinent [The most common vectors, Phlebotomine sand flies have a wide distribution in tropics and other warm mainland areas, and extend up to southern parts of the northern hemisphere . There ate blood . Howevero humans , 69, butentomyia , 71. Thimaniasis . Howeverontinent . P. argentipes, the vector of L. donovani vector in other countries, has been reported from Sri Lanka in early 1940s [ P. argentipes is the vector of leishmaniasis in Sri Lanka. Interestingly, in 2009 studies revealed that all three members of Phlebotomus complex including, P. glaucus, P. argentipes, and P. annandalei are prevalent in Sri Lanka [ Leishmania DNA in blood fed and unfed female sand flies confirming the possibility of P. argentipes to act as vectors of leishmaniasis [Presence ofly 1940s . Therefori Lanka . Moleculmaniasis . Phlebotomus was known to act as vectors for Leishmania parasites, but as mentioned earlier, recent studies have proven the presence of Leishmania parasites in sand flies of the genus Sergentomyia. In Sri Lanka, 8 species from the genus Sergentomyia have been recorded [However, exact number of species that transmit the disease in Sri Lanka is yet poorly understood. Vector species range especially has been found to be broader than predicted earlier. For an instance, earlier only the genusrecorded –79. TherWith the increasing complication of the issue, Sri Lanka has a huge challenge as the exact species that are transmitting the disease is yet unknown. On the other hand only a little knowledge is available on the species proven to be vectors in Sri Lanka, about their behavior, especially, breeding places, resting places, and the distribution which are essential in designing vector control strategies, and also there are no information on population dynamics of these sand flies which can be very useful in a sudden environmental change which may lead to an outbreak of sand flies and in turn of the disease, leishmaniasis.In addition to control of sand fly populations, the prevention of sand fly bite is also important for effective control of the disease, for that also the information on biting times of sand flies and their habitat preferences which are very scanty for Sri Lankan species are needed.The infective agents of leishmaniasis are heteroxenous unicellular organisms where a single species of parasite can survive within several different hosts. Thus, the disease is a zoonosis with a range of sylvatic mammals, such as forest rodents, hyraxes, and wild canids and also domesticated animals mainly, dogs acting as reservoir hosts –85. ReseHence, the control and management of reservoir hosts is an effective control measure for leishmaniasis. For that the identification of exact species that act as reservoir hosts is essential. On the other hand their behavior, habitats, and specific habitat conditions are also needed to be understood in order to prevent the contact with humans. Screening of animal species individually for parasites is very difficult and time consuming. Hence, more effective methods such as screening blood fed sand flies for reservoir host DNA may give more reliable results in the identification of reservoir hosts , 88.In Sri Lanka, few studies have been conducted to find out possible reservoir hosts for the disease and dogs have been identified as possible reservoir hosts , 89. HowWith the end of the civil war for 30 years, people have started to move in to previously uninhabited areas. The recent increase of the prevalence of the disease may have been partly influenced by these population movements. In these parasites which may have maintained their transmission cycle with a help of a reservoir host will infect humans when they are exposed to these. If the dogs are the only reservoir host for the disease, the control of stray dogs, screening and treatment of domestic dogs may provide a significant contribution to the control of leishmaniasis. The real problem arises if the reservoir host is a forest living animal as the control of this animal is difficult. The increasing deforestation and establishment of human habitations in recent past may also have a significant impact on the increased prevalence of the disease as this may take humans closer to reservoir hosts. Further, increase in these activities may cause a significant health issue as in the case of Iran during 1999–2001 where an outbreak resulted due to increased construction buildings near rodent colonies . Leishmania of family Trypanosomatidae are the parasites of this disease. So far, about 21 species of this genus have been identified as causative agents of the disease including L. donovani complex with 2 species, L. donovani and L. infantum (or L. chagasi); L. mexicana complex with 3 main species, L. mexicana, L. amazonensis, and L. venezuelensis; L. tropica; L. major; L. braziliensis; L. guyanensis; L. panamensis; and L. peruviana [ Leishmania donovani complex is mainly responsible for the visceral form of the disease [ L. donovani and L. tropica are the sources of anthroponotic infections, while most other species which cause cutaneous leishmaniasis act as sources of zoonotic infections. However, species of this complex also cause other types of the disease [Intracellular parasites of the genuseruviana . Leishma disease . Out of  disease , 12. L. donovani is the species that causes the cutaneous leishmaniasis [ Leishmania donovani MON-37, a zymodeme differing by only one nucleotide substitution in the glucose-6-phosphate dehydrogenase gene from L. donovani MON-2, the strain most commonly isolated from VL cases in India [ L. donovani [ L. donovani in Sri Lanka beginning to appear.In Sri Lankamaniasis . The onlin India , 90. TheAwareness about the disease in local community is one of the main factors that determines the success of a control program. It is essential to have the knowledge on symptoms for effective case management. In order to prevent infection by following preventive measures such as reducing the contact with potential reservoir animals, preventing the bite of sand flies by reducing the exposed parts of the body during outdoor works, use of insecticide impregnated mosquito nets, and managing household environment to reduce the sand fly populations, people must know about how the disease get transmitted (reservoir hosts and vectors), the peak biting time of the vector, and how to prevent the bite and reduce the sand fly populations. Surveys have shown that the presence of adequate knowledge has significant contribution to the success of control programs through changes in behavior and more widespread participation , 92.However, according to a recent survey conducted in an endemic area for the disease in Anuradhapura District of Sri Lanka shows that the level of awareness on this disease among local population is very low. For an instance, 37% of the study population have had never heard of the disease even they were living in a endemic region for the disease and nearly half of the study population had no clue about any advanced diagnostic and treatment facilities . On the Leishmaniasis can be considered as a significant health issue at global level. Therefore, institutions such as World Health Organization are now focusing on development of advanced diagnostic tests, drugs, and vaccines . An incrImmunization for the disease is not available since there is no proper vaccine available in the market for leishmaniasis. On the other hand, none of the existing treatment methods are ideal as each method has any complication such as high toxicity, resistance by the parasite, or low efficacy.Lack of adequate scientific knowledge and literature based on the research work is one of the main problems for the prevention and control of the disease in Sri Lanka. However, considerable improvement of research interest about leishmaniasis can be seen in recent years. But, the problem comes when applying these scientific knowledge effectively in the control processes. First of all steps must be taken to increase the awareness among local communities. In this case it can be very effective if these awareness programs can be integrated to the general health care programs.In South Asian countries, despite the fact that these are male dominant societies, mothers can be considered as the Centre of the family; therefore, the target personnel must be mothers of families. School students are the next most important target group as it is easier to educate them. Provision of knowledge and getting the community participation in control efforts will increase their success effectively. Sergentomyia which was known to be harmless and are proven to be potential vectors. Sexual transmission is also possible for this disease.On the other hand, extended researches on the identification of vectors and reservoir hosts, their biology, distribution, bionomics, and other important factors must be encouraged. Use of advanced techniques in researches may improve the effectiveness of these researches. For an instance, in the identification of reservoir hosts, screening each potential species is less effective and highly impractical; therefore, advanced and more reliable methods such as sand fly blood meal identification where blood meals of blood fed sand flies are screened for the presence of host DNA use molecular biological techniques . As mentTherefore, studies must be focused more and more on these subjects for proper identification of exact vectors and other means of transmission in order to take preventive and control measures. In both vector and reservoir control activities much higher attention must be given to environmental management and biological control strategies other than the use of chemicals. Studies on environmental requirements of vectors and reservoir animals will provide information needed for control of vectors and reservoirs by reducing preferable conditions through environmental management. Several biological control strategies have been suggested by studies in other countries. These methods can be adopted to suit our country after feasibility studies.Geographical Information System (GIS) is an effective tool that can create distribution maps of diseases. These maps can be used to understand geographical distribution patterns of the disease and associated risk factors. Although, use of GIS mapping has been shown to be very effective in disease control by the studies in other countries , 96, 97,Leishmaniasis also has some serious complications such as post-kala-azar dermal leishmaniasis (PKDL) which is a complication of VL that results in nodular rashes in patients recovered from VL , 98 and Psychological studies suggest that depression and anxiety are significantly higher in leishmaniasis patients . Therefo Leishmania parasites in Sri Lanka, such as screening dogs and some other rodent species while there is a large range of mammals which may have the ability to act as probable reservoir hosts that exist in Sri Lanka. Complexity of the action of parasite is also a challengeable aspect. Lack of awareness among local communities is also another drawback for the success of the control of the disease. On the other hand, not having the access to advanced diagnostic techniques may affect negatively on the effectiveness of case management. However, studies must be carried out to reveal the biology, distribution, bionomics, and other important characters of vectors and reservoir hosts. Awareness programs must be conducted to improve the advocacy of the general public on the disease in order to enhance community participation in control activities while promoting the use of advanced technologies and techniques for diagnosis and continuous surveillance of the disease.Unavailability of immunization due to the absence of a proper vaccine and the absence of a completely safe and effective treatment method indicates the importance of the control of the disease through prevention of the infection. Major challenge for this is the lack of knowledge about disease. Sufficient information especially on vectors, reservoir hosts, and vector behavior in terms of biting time, resting preferences, breeding, oviposition behavior, and host range is not adequately documented. In addition, only few studies have been conducted to find out the exact reservoir host for the


Mental health is the greatest challenges for the current and future generations. Worldwide, out of the 66 million people suffering from depression; majority (85%) were from low and middle income countries. The prevalence was more common among the prisons population than the community. However, a worldwide consideration given to the problems is very low, particularly for prisoners.To assess level of depression and associated factors among prisoners in prisons of Northwest Amhara Regional State, Ethiopia, Institutional based cross sectional study was employed on 727 prisoners selected by multistage random sampling from three prisons of northwest Amhara. Patient Health Questionnaire (PHQ-9) was used to assess an individuals’ depression level. The reliability of the tool was checked by Cronbach’s Alpha . Multivariable logistic regression was done to identify factors associated with depression after Hosmer and lemeshow goodness of fit test was used for model fitness.Of the total prisoners participated (649), 284  had symptoms of depression. Detainees’ satisfaction level about life before imprisonment, belief about their life after imprisonment, plan to commit suicide, social support and types of prisons were significantly associated with depression.Depression level among detainees was found to be high. Thus, providing training to scale up satisfaction of prisoners, on how to cope up with environment just before imprisonment and release, and treating prisoners will improve the problem. Worldwide, there are about 10 million people in prisons. Worldwide, prison population is being raised by around one million per decade. The majority of the world prison population were observed at low- and middle-income countries .Estimated 450 million people worldwide suffered from mental or behavioral disorders . The proWorld Health Organization (WHO) forecasted, in 2001, that by 2020 depression will be the second leading contributor to the global burden of disease . AdditioThere were many factors in prisons that have contribution on mental health, particularly on depression including; overcrowding, various forms of violence, enforced solitude or conversely, lack of privacy, lack of meaningful activity, isolation from social networks, insecurity about future prospects , inadequate health services, especially mental health services in prisons, luck of social support, dissatisfaction before and after imprisonment, older ages and status of prison. The increased risk of suicide in prisons (often related to depression) was, unfortunately, one common manifestation of the cumulative effects of these factors , 24–28.In Ethiopia, approximately 1.7% of the national health expenditure was spent on mental health in 2004. So, in order to tackle mental health problem the Government of Ethiopia launched a National based Mental Health Strategy that can enable the government to deliver comprehensive and integrated service to mental health needs of Ethiopians , 30.Majority of the population in the prison was found in the productive age category that will be returned to their community after they complete the time at jail. The government gives high attention to the prisoners to create productive mentality through implementation of different strategies that lead to the production of entrepreneur prisoners of the future country. However, the emphasis given to mental health was very low across the globe in general and for prisoners in particular. This is even more in countries with limited resource and still there is no accurate magnitude of prisoners with mental disorder who were incarcerated in Ethiopia, particularly in Northwest of Amhara Regional state and information about prisoners’ health conditions is scarce. Even though health care service for mental disorder was designed in the national health policy of Ethiopia, interventions against the problem were very limited, which might be due to limited information about the problem. Thus, establishing the prevalence rates of mental disorders, particularly depression, is of great importance . As a re2 with a total population of 19,602,512. There were 30 prisons in the region of which 10 found in the North West part of Amhara region. The numbers of prisoners found in 30 prisons were 22,590 while 7564 prison inmates were detained in the selected prisons.Institution based cross sectional study was conducted to determine the magnitude of depression and associated factors among prison inmates found in the prisons of North West Amhara regional state, Ethiopia, from January to February 2015. The region is one of the 11 regions found in the Democratic Republic of Ethiopia. The region covers a total area of 20,650,420 Kma/2)2*P (1-P)]/d2] by assuming 95% confidence level, 5% margin of error (d), design effect of two, 61.9% proportion (p) among Kality prisoners . In line with this study, many studies among different population suggested that satisfaction had strong association with depression; which stated strong positive association between low satisfaction and depression . AlignedOn the other way, the odds of developing depression among prisoners who had plan to commit suicide were more than four times more likely when compared with prisoners who hadn’t plan to commit suicide . This finding in lined with earlier reports of world health organization and American Psychiatric Association which showed that mental health disorders  were related with more than 90% of all cases of suicide  and majoThe study showed that prisoners in the Gondar and Debre Tabor prisons were more likely to be imitated by depression when compared to Bahir Dar prison with  and  respectively. This finding was strengthened by the result from Jos maximum Security Prison, Plateau State which indicated a strong association between depression and status of prison , 49–55. Even though the study indicated very important factors associated with depression, the study is not free of the limitations of cross sectional study design like lack of indicating the strong cause and effect relationship. Additionally, the study is not still free of social desirability bias because subjects were systematically more likely to provide a socially acceptable response since data was collected through self report. Furthermore, the study did not collect information on the injury and trauma as they might be other factors associated with depression.In conclusion, depression level among detainees in the region was significantly high. Prisoners who had satisfaction with their day to day life before being imprisoned and social support were less likely to have depression while those who had a plan to commit suicide and who thought that they will have impossibility to run life as before if released from the prison were more likely to have depression. Additionally, place of prisons also associated with depression.It would have been better if the government as well as the administrators of each prison strengthen social support within each prison and support of relatives, peers, and families for the prisoners. In addition, providing training to scale up satisfaction of prisoners, on how to cop up with new environment just before imprisonment and release, on suicide reduction and treating prisons with psychological distress and depression improve depression level.


Nanotechnology is a cutting-edge field of science with the potential to revolutionize today’s technological advances including industrial applications. It is being utilized for the welfare of mankind; but at the same time, the unprecedented use and uncontrolled release of nanomaterials into the environment poses enormous threat to living organisms. Silver nanoparticles (AgNPs) are used in several industries and its continuous release may hamper many physiological and biochemical processes in the living organisms including autotrophs and heterotrophs. The present review gives a concentric know-how of the effects of AgNPs on the lower and higher autotrophic plants as well as on heterotrophic microbes so as to have better understanding of the differences in effects among these two groups. It also focuses on the mechanism of uptake, translocation, accumulation in the plants and microbes, and resulting toxicity as well as tolerance mechanisms by which these microorganisms are able to survive and reduce the effects of AgNPs. This review differentiates the impact of silver nanoparticles at various levels between autotrophs and heterotrophs and signifies the prevailing tolerance mechanisms. With this background, a comprehensive idea can be made with respect to the influence of AgNPs on lower and higher autotrophic plants together with heterotrophic microbes and new insights can be generated for the researchers to understand the toxicity and tolerance mechanisms of AgNPs in plants and microbes. The ever-increasing indiscriminate anthropogenic activities worldwide together with the technological advances have led to the creation of huge waste material contaminating our biosphere and causing many ecological risks. Due to this, environmental stability is gradually diminishing thereby resulting in the damage to ecosystem facilities. In addition, the uncontrolled rise in human population will continue to intensify the ecosystem degradation in the near future . Due to -1 and in sludge up to 2.9 mg kg-1. Despite its beneficial applications, numerous harmful effects of AgNPs have also been reported in plants and animals . Synthesis of the NPs in laboratory or industry is one of the important sources of its release in the environment . The nanosilver species such as Ag0, AgCl, and Ag2S are frequently observed in various environmental compartments . AgNPs generated from anthropogenic activities are of greater concern as they are most widely incorporated in multidisciplinary applications. AgNPs are released in soil either from point sources that are suspended in surrounding environment after the application of NPs or organic matters in the forms of nano-fertilizers, sludge recycling, etc. in agricultural fields or from non-point sources such as products that contain AgNPs in themselves and directly contaminate the system  is an element of group 11 and period 5 with atomic number 47 and standard atomic weight 107.862. It has high electrical and thermal conductivity and also the reflectivity. This is considered as one of the main property of any metal. Silver belongs to the ‘d’ block in periodic table and its electronic configuration is [Kr]4The range of AgNPs lies between 1 and 100 nm  that conHowever, Silver nanoparticles are intensively used in our daily life. AgNPs along with various other engineered NPs have wider application in many commercial and industrial sectors. It has also been used in the field of bioremediation and biomedicine because of its characteristic physiochemical properties . NotablyAspergillus fumigatus, Mucor, Saccharomyces cerevisiae, and Candida tropicalis  from simple substances present in the surrounding by using energy from sunlight via photosynthesis. They are plants on land or algae in water. Autotrophs can reduce COr growth . The redr growth . Hence, Algae are considered as polyphyletic eukaryotic autotrophs which include many unicellular as well as multicellular forms and most of them are aquatic in nature and instead of lacking different tissues and cells like xylem and phloem, they make their own food. As most of the AgNP traces are released into the water after being used and are also employed for waste water treatment, it affects aquatic organisms in which algae are prime . The toxThe uptake, translocation, and accumulation of the AgNPs in the cells depend on the cellular structure, its permeability, size of the particles and other cell properties . The celIt has been reported that due to the influence of AgNPs on algal cell, newly formed pores are larger than the prior ones and this may led to instigate the increase in uptake of the nanosilver in the cells of algae . The sizTable 1). AgNP shows toxic effects as it releases silver ions and poses adverse effects on algal community at varied concentrations. The structural and functional properties of the algal cell could be affected by severe alterations induced by these NPs. The toxicity is induced through decrease in chlorophyll content, viable cell counts, increased ROS generation and lipids peroxidation (MDA)  . It was on (MDA) . There aon (MDA) . The negon (MDA) .+ ion  have differing impacts on algae (Table 1). Thalassiosira pseudonana and cyanobacterium Synechococcus. Various algal species have been tested for the toxicity of AgNPs at various concentrations (Table 1) such as, Dunaliella tertiolecta and Chlorella vulgaris  in order to inactivate AgNPs toxicity . Hence, cis-epoxycarotenoid dioxygenase)  declines the expression of aminocyclopropane- 1-carboxylic acid synthase 7 and aminocyclopropane- 1-carboxylic acid oxidase 2, that ultimately inhibits biosynthesis of ethylene under the effect of AgNPs uptake in roots  . In Arabin roots . AgNPs ain roots .Figure 2). After entering into the plant, they penetrate the cell wall and plasma membranes of epidermal layer of roots, and then enter inside the vascular tissues . The AgNPs come in the plant together with the plant’s uptake of water and other solutes. The cell wall consists of pores which are smaller than the NPs . They damage the cell membranes; interrupt ATP production as well as DNA replication . The enhanced production of ROS and subsequent generation of oxidative stress lead to various toxic impacts and may also affect the gene expressions and the demolition of DNA due to enhanced generation of ROS. Toxicity of AgNPs can be seen from seedling growth stage up to a full developed stage of the plants  in the plants cells is also an important toxic effect to be considered which affect the growth and development of the plants and kill the cells . Escherichia coli) and Gram-positive (Staphylococcus aureus) types of the bacteria are found to be affected by the silver ions . From many studies and researches, it is proved that AgNPs or silver ions may be toxic to some species of bacteria like E. coli  depend on their size. The most preferable size they observed was in between 1 and 10 nm. The proteomic analysis in E. coli revealed the change in expression of HSPs (heat shock proteins) due to the impact of AgNPs  has been recorded (E. coli) and Gram-positive (S. aureus) bacteria accumulate dense electron light particles or granules as a defense strategy in the center of the cell. This region actually consists of thicker DNA (deoxyribonucleic acid) molecules and this thickness provides them security against the attack of silver ions.Bacterial cells also adopt some defense mechanisms to save themselves from the harmful effects of AgNPs. It has been reported that the peptidoglycan membrane thickness and their component (phospholipids) participate in the defense mechanism against AgNPs as their first line of defense . In ordeehind it . Accordirecorded . AccordiE. coli (E. coli . BacteriE. coli . After tE. coli . HoweverIt is quite evident that the technological interventions related to the nanotechnology have immense use and importance in modern times; however, somehow they are leading to the destruction or imbalance in ecosystem with their unregulated release posing toxic impacts on plants, algae and micro-organisms. Although researches are being carried on the beneficial as well as harmful impacts of AgNPs, there is a need to work in order to understand the toxicity of AgNPs at the cellular level of these organisms and their further impacts. Studies have yet not been able to fix any conclusive results on the effective/lethal/sub-lethal/optimum concentrations of NPs/AgNPs as a whole or/and the organism wise on which some regulatory framework can be made. The data regarding this are inadequate and researches must be carried on looking these things into consideration. The toxicity of AgNPs is translocated from plants to other communities through food chain and leads to the disruption of balanced ecosystem. However, the food chain analysis and health effects on trophic structure on this regard is sporadic and must be considered in the studies. The differences existing among experimental results of toxicity are thus creating problems in interpretation of the toxicological data. The studies on the toxicity and tolerance in plants, algae and microbes on molecular level are yielding some good results though, studies regarding fungi, yeasts, and viruses are very few on these aspects.There must be some microcosm studies involving ecosystem based studies on this regard. The molecular marker approach, the evaluation of the tolerance mechanism and their use to develop artificial tolerance in the organisms may pave the significant pathways in this research field not only for developing new nanomaterials of use but also for formulating some regulatory concentration in various components of the environment. There is a strong need for the appropriate association between analytical techniques and toxicological studies through which more understanding towards this subject may be developed for the future research projects. Studies are generating good amount of data to be interpreted. A common research platform is needed to agglomerate all the data and to reach out to a logical conclusion to safeguard the ecosystem functioning and humankind as well.DKT, AT, S, ShS, KV, GY, RM, and YS designed the manuscript. DKT, AT, S, KV, and SwS wrote the manuscript. DKT, DC, ShS, VKS, YL, RU, and ND critically evaluated the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.