Foreign direct investments (FDIs) have been widely recognized as a crucial feature of the Chinese industrial development process. Over the past decades, China has been attracting huge amounts of inward FDIs as a consequence of both spontaneous market dynamics and place-based preferential policies at the sub-national level. However, the Chinese market exhibits large dissimilarities in terms of FDI localization across territories that are worth investigating at a more disaggregated level. In this regards, our study explores the determinants of attraction of inward FDIs in China, at the county level. It focuses on the pharmaceutical industry and attempts to assess whether factors related to location advantages, agglomeration dynamics, information cost effects and environmental regulation costs affect foreign firms’ localization choices as well as invested amounts in that location. By means of discrete choice models, our paper confirms the findings of the prevalent literature about the positive effects of location advantages on pharmaceutical FDI attraction. Different from our expectations, a higher proportion of foreign enterprises do not stimulate significant effects on FDI localization, while preferential policies and sectoral agglomeration are positively correlated with the localization of pharmaceutical foreign firms. Finally, our results suggest that investing firms tend to avoid areas with strict environment regulation. In the course of the past few decades, China has been experiencing rapid economic development. Foreign direct investment as a source of capital, knowledge transfer and export competitiveness has been playing an important role in the Chinese industrialization process . Since tThe total amount of Foreign Direct Investment (FDIs) tripled during the past 15 years in China, increasing from 46.9 billion U.S. dollars in 2001 to 126.2 billion U.S. dollars in 2013, with the largest proportion based in the manufacturing sector .In this research, we investigate the dynamics of FDI inflows in the Chinese pharmaceutical industry. From an economic perspective, the pharmaceutical industry in China has experienced a rapid growth, mainly from the mid 2000s , and an In this regards, taking into account the heterogeneity of the Chinese market in terms of territorial assets and policies, our paper intends to assess the determinants of pharmaceutical FDI localization ,11. SpecWe intend to contribute to the literature on FDI localization in China  by proviIn terms of policy implication, a more precise understanding of the key factors affecting FDI localization is crucial for the government’s formulation of relevant place-based specialization policies directed at enhancing international competitiveness as well as at mitigating territorial differences. Besides, our analysis provides some insights on FDI localization dynamics and on possible attraction policies with respect to other emerging countries in the East Asian region.The paper is structured as follows. Over the last few decades, the academic literature has devoted significant attention to the issue of FDI location determinants. In particular, the regional determinants of inward FDI distribution have been developed and explained from different perspectives, considering the territorial differences in terms of tangible and intangible assets, policy incentives and investment opportunities as well as focusing on enterprises’ motivations and the business strategy ,15,16,17In the OLI paradigm, Dunning ,19,20 emFollowing a similar approach, in the presence of location advantages, a foreign firm would be more likely to relocate its production abroad, as directly investing in the host country would result in more cost-saving than exporting overseas. Dunning  categoriStarting from this framework, some of the latest research has integrated the original Dunning’s paradigm including further determinants of FDI location, such as the agglomeration effect, the information cost effect and the environment regulation effect.With the rise of new economic geography, the agglomeration effect has received increasing attention as a source of FDI location. The economic rationale for agglomeration dynamics derives from Marshall who argued that the spatial concentration of enterprises from the same industry generates positive externalities by means of a cost reduction provided by shared labor markets, professional services and fundamental infrastructure . Porter According to the conclusions of a series of empirical studies, foreign enterprises will obtain a wide range of benefits when entering an industrial agglomerated area. Firstly, as implied by He and Liu , and KinIn addition to location advantages and agglomeration effects, FDI location choices also seem to be influenced by a series of political and institutional factors. Indeed, compared with domestic enterprises, foreign firms are not familiar with the local business environment, thus facing potential transaction costs linked to the unpredictability of the host country institutional systems that lead them to take on the burden of higher information costs . In theiA last aspect is related to regulation effects on the selection of FDI location, in terms of administrative, labor and environmental standards. The literature has devoted much attention to the environmental rules in China: since the 1980s, the impact of environmental control on the location choice of enterprise has become a central issue in the academic research even though they have not reached a unified conclusion. On one side, there are those who consider the influence of environment regulation intensity as less significant than the agglomeration and the information cost effects . On the Our study makes use of several databases . In ordeFocusing on the changes that occurred in pharmaceutical FDI total assets over the period from 2004–2013, From this perspective, this descriptive analysis of the spatial distribution of pharmaceutical FDI demonstrates that the counties located in the eastern side of the country are likely to be characterized by a higher degree of attractiveness. This may be partially due to their higher performance in terms of Gross Domestic Product (GDP) growth, industrial development and market competitiveness. However, there are many other factors that are likely to influence FDI localization trends. From this perspective, in the following sessions we develop a model to explore the determinants of pharmaceutical FDI localization across Chinese counties.Our study is aimed at determining the impact of location advantages, agglomeration, information cost and environmental cost effects on the localization choice of foreign pharmaceutical firms’ in China.As explanatory variables we have used sixteen different variables related to the categorization previously discussed . The anagdpgrowth is the growth rate of GDP at the province level and it is used to estimate the effects of local economic performances on FDI attraction. In order to control for the potential distortions on the coefficients due to the faster growth rates of the backward provinces, we combine the previous variable with gdppc, i.e., the GDP per capita at provincial level. As wealthier and highly performing economies are generally associated with higher returns, we expect that the impact of the two variables on the location selection should be positive. market_ind consists of the Marketization index value—an indicator, firstly proposed by Fan, Wang and Zhang [For the location advantage, we selected seven variables to measure its effects on the localization and investment decisions of foreign pharmaceutical enterprises. Firstly, we use four variables to estimate market factors. nd Zhang , intendesrdexp corresponds to the amount of R&D expenditure at the provincial level that indicates the local degree of support for science and technology. Dunning [HHI, i.e., the Herfindahl index that is commonly used as an indicator of the regional market concentration and competitiveness at the industrial level. From this perspective, a high HHI value is associated with a monopolistic structure of the local market and to a lower degree of industrial competitiveness. According to Audretsch and Keilbach [In our paper, we expect that the counties located in provinces characterized by a higher marketization index will be more likely to be selected as a destination for a foreign investment.  Dunning  implies Keilbach , market HWAY, i.e., the length of the highway and flightcargo, i.e., the freight volume by air at the provincial level. As widely stressed in the literature, the configuration of an extended and efficient transport system is one of the most important preconditions for doing business activities and for FDI attraction [In order to estimate the effects of transportation costs, we introduce traction ,43,44. Ogini, i.e., the Gini coefficient of industrial location intended to measure the degree of agglomeration of the pharmaceutical sector at the provincial level. The Gini coefficient as an indicator of industrial agglomeration was first introduced by Krugman [ratio_phar, i.e., the pharmaceutical industry output share out of the total provincial manufacturing output to measure the local degree of sectoral specialization. We predict that the provinces with higher degrees of pharmaceutical sector value added tend to positively benefit from pharmaceutical FDI inflows.In our study, we use two variables to measure the agglomeration effect. Specifically, we adopt  Krugman . In our  Krugman . We assuratio_forind measures the share of FDI on output at the provincial level. According to Mariotti and Piscitello [city_lvl is a dummy variable that informs whether the city is one of the municipalities directly under the central government, or is a city under separate state planning at the city level, thus being characterized by more direct decision-making processes, as well as well-developed fundamental infrastructure and business services. From this perspective, valuable business information is more easily collected by foreign investors. coastcity is a dummy variable measuring whether the city is located in the East coastal areas of the country. According to Wei et al. [city_dev is a dummy variable informing on whether the city has benefitted from place-based preferential policies aimed at attracting foreign investments. Several studies have analysed the positive effects of place-based policies on FDI attraction and economic performances at city and sub-regional levels [We deal with the estimation of information cost effects by taking into account four different variables. scitello , locatini et al. , the coai et al. . city_del levels ,50.ratio_envinvest measures the amount of investment in environmental pollution control over the GDP at the provincial level. It is worth emphasizing that environmental regulation may consist of either qualitative policies or quantitative investment and fees. From this perspective, environmental regulation intensity has to be considered not only as a constraint but also as a factor that is likely to foster desirable outcomes, such as an improvement in environmental conditions, which in principle may address the demands of the foreign pharmaceutical firms. However, following a standard profit-maximizing firm approach, we assume that places with higher investment in environmental pollution control will be less attractive to pharmaceutical industries due to the possibility of increased costs. river_dist measures how distant from the nearest river is the county in which the pharmaceutical enterprises are located. lake_dist assesses how distant the county in which the pharmaceutical enterprises are located is from the nearest lake. According to the Guidelines for Environmental Information Disclosure of Listed Companies published by the Ministry of Environmental Protection in 14 September 2010, the pharmaceutical industry is categorized as one of the 16 heavy polluting industries. Within such a normative framework, enterprises should consider their own obligations to environmental protection and to meeting environmental standards, and this may influence their localization choices. Following this logic, if enterprises locate in well-regulated areas, it is more likely that they will have enough space and channels for treating waste, so they do not have an incentive to place their operations close to rivers and lakes in order to discharge sewage at a lower cost. Conversely, in the absence of environmental regulation constraints, they would be more likely to locate in proximity to rivers and lakes to exploit the advantages of cheap waste disposal. Therefore, we use these distances to proxy the stringency of environmental regulation.Finally, in our research we use three variables to estimate the influences of environmental regulation on FDI localization choices. On the basis of the set of determinants identified above, we investigate pharmaceutical FDI localization, adopting two different specifications. Firstly, by using a binary probit model we estimate whether, and to what extent, the values of the explanatory variables in 2004 are likely to have influenced the FDI decision to locate in a county in 2013. Secondly, we examine whether, and to what extent, the same covariates are likely to have affected the FDI expansion in terms of total assets at the county level in the interval between 2004 and 2013.x and 0 otherwise.Focusing on the location decisions of foreign pharmaceutical enterprises, we define the variable Then, we estimated the model 1 as follows:Similarly, to examine the effects of the covariates on the changes in location, we define the variable Therefore, we estimate the following model:After analyzing the determinants of pharmaceutical FDI location decision across Chinese counties, we want to discover whether, and to what extent, our set of covariates is likely to affect the total amount of assets invested in a county, thus exploring the degree of FDI localization. As we can see from the graph in As before, we use two different specifications. In model 3 we estimate the effects of the covariates in 2004 on the amount of FDI total assets in the year 2013. The equation is as follows:In model 4, we test the same covariates on a new dependent variable, i.e., As we can see from the graph in In this section, we display and interpret the results of the four specifications that we derived previously.In model 1  the dataFocusing on the agglomeration advantage effects, it is possible to notice that the Gini coefficient of industrial location, although positive, is not significant. At the same time, the data provide evidence suggesting that a higher share of pharmaceutical enterprises in the provincial industrial structure is likely to attract more FDI operating in the same sector.Analysing the effects of the variables linked to the information cost, it is worth mentioning that, in contrast with our expectations, a local foreign presence is likely to negatively affect pharmaceutical FDI localization decisions. This may be due to saturation and over-competition dynamics that generally discourage new entrants, pushing them towards less competitive markets. In addition, coastal areas also report negative coefficients suggesting the negative effect on FDI attraction caused by the progressive reduction of local support policies based on a FDI-led model of industrialization and the simultaneous promotion of FDI attraction policies in the internal areas. Conversely, the presence of municipalities under separate state-planning as well as of cities implementing preferential policies tends to generate positive effects on FDI localization.Finally, with respect to the cost of environmental regulation, it is interesting to find that those provinces investing more money in environmental protection are less likely to be attractive for pharmaceutical FDI location.Considering model 2 , relatinAnalysing the results from model 3, related to the Tobit regression on the amounts invested by the foreign enterprises at the county level, the data still report similar evidence . In thisDirect investments have been widely recognized as a crucial feature of the Chinese industrial development process. However, the Chinese market exhibits large dissimilarities in terms of FDI localization across territories. We choose to analyze the pharmaceutical industry as one of the key priority sectors selected by the Chinese government both to support the industrial enhancement of China towards a more R&D oriented country, and to feed the internal booming demand for healthcare services and products. Our study examines the determinants of pharmaceutical FDI localization across Chinese counties. It focuses both on the firms’ localization decisions and their invested amounts in a specific location. To draw out a more systematic framework about the pharmaceutical FDI localization dynamics, we build an augmented version of Dunning’s OLI model that takes into account four different categories of determinants such as location advantages, agglomeration cost, information cost and environmental cost effects.We find that pharmaceutical FDI localization is positively affected by factors related to the location advantage such as GDP level and the degree of local marketization, while it is negatively associated with lower degrees of competition in the market structure. As for the agglomeration advantages, the data do exhibit significant effects related to the positive impact of local industrial specialization in the pharmaceuticals on FDI localization trends.Focusing on information cost effects, in contrast with conclusions drawn in the prevalent literature, our findings suggest that a higher presence of FDI at the local level is likely to discourage foreign pharmaceutical firms’ from deciding to locate there. This may be due to over-competition and market congestion dynamics affecting the operation of new entrants in the pharmaceutical sector and pushing them towards less competitive markets. At the same time, the promotion of preferential policies and other place-based measures seems to stimulate a positive impact on FDI localization at the county level, while the geographical variable related to location in coastal areas does not provide explanatory power.Finally, examining the effect of environmental costs, it is worth highlighting that those counties located in provinces investing more money in environmental control are less likely to be attractive for pharmaceutical FDI location. This suggests an adverse inclination of the investing firms towards environmental protection issues. The aforementioned results are confirmed even considering total pharmaceutical FDI assets as a dependent variable, with the only exception of local R&D expenditure, which becomes significant and positively associated with the amount invested.Such findings are quite relevant for policymakers. The study demonstrates the heterogeneity of China in terms of its capacity to attract foreign firms, based not only on local resources and endowments but also on differentiated local systems of incentives, which might influence location choice and affect the decisions of the international ventures. From this perspective, it is clear that location choices are significantly affected by selective policies promoted at territorial level.The availability of incentives is a key determinant in the location choice of foreign investors. The same logic also applies to the possibility of avoiding the stringent environmental regulation experienced in their home countries. The last one is a central issue in the light of orientation, from the Chinese side, of future policies to continue attracting foreign investors and promoting learning spillovers. Considering that China is strongly committed to a green environment and is at the front line in fighting against climate change, it is hard to imagine that relaxed environmental standards will be used as a way to attract foreign investments.From a Western perspective it appears clear that, given the vast heterogeneity of the Chinese market, the promotion policies to invest abroad should not be tailored at the country-level, and should focus instead on a differentiation of the targets based on local specificities.Despite the novelty of our study, we can identify some limitations and further avenues for research. There is the need to improve the quantitative model by including more variables for detecting determinants of FDI at a more disaggregated level than Chinese provinces, including more proxies of R&D capacity and industry specificity. Also, firm-level qualitative analysis via questionnaire or direct interview could help in better understanding the determinants of location choice.


This study assessed the book collection of five selected medical libraries in the Philippines, based on Doodys’ Essential Purchase List for basic sciences and clinical medicine, to compare the match and non-match titles among libraries, to determine the strong and weak disciplines of each library, and to explore the factors that contributed to the percentage of match and non-match titles.List checking was employed as the method of research.Among the medical libraries, De La Salle Health Sciences Institute and University of Santo Tomas had the highest percentage of match titles, whereas Ateneo School of Medicine and Public Health had the lowest percentage of match titles. University of the Philippines Manila had the highest percentage of near-match titles.De La Salle Health Sciences Institute and University of Santo Tomas had sound medical collections based on Doody’s Core Titles. Collectively, the medical libraries shared common collection development priorities, as evidenced by similarities in strong areas. Library budget and the role of the library director in book selection were among the factors that could contribute to a high percentage of match titles. Libraries typically aim to keep their collections fresh and updated based on client needs and professional standards. Aside from quantity, the quality of collections is constantly improved and maintained, because this is one of the fundamental services of libraries. High-quality collections also demonstrate the relevance and importance of libraries to the communities they serve. Thus, collection analysis is a significant aspect of library management.List-checking is a method of collection analysis that librarians use to ensure the quality of resources. It establishes the authoritativeness and relevance of a collection. Faigel noted that it is the most popular method used to qualitatively evaluate collections . CrawleyShedlock and Walton described Doody’s Core Titles (DCT) in the health sciences as a guide to selecting core titles in health sciences literature that was established in 2004 in response to the cessation of the Brandon/Hill list , which pDCT identifies certain titles as “Essential Purchases” that are important for a small library collection . These tThe author assessed the book collection of selected medical libraries in the Philippines based on DCT 2014 Essential Purchase Titles for basic sciences and clinical medicine. I compared the percentages of match and non-match titles among libraries and determined the strong and weak disciplines of each library. Furthermore, I explored the factors that can contribute to differences in the percentage of match and non-match among libraries.This study was descriptive and employed list-checking against DCT 2014 Essential Purchase Titles for basic sciences and clinical medicine. The monograph collections of five medical libraries in the Philippines were included: Ateneo School of Medicine and Public Health Library (ASMPH), De La Salle Health Sciences Institute Romeo P. Ariniego MD Library (DLSHSI), University of East Ramon Magsaysay Memorial Medical Center Library (UERMM), University of the Philippines Manila Dr. Floerentino Herrera Medical Library (UPM), and University of Santo Tomas Health Sciences Library (UST). The libraries were chosen based on geography, the availability of an online public access catalog (OPAC), and their consent to answer the questionnaire on library profile.DCT titles were exported to Microsoft Excel and searched against the OPAC of the five libraries. To check updates in their collections, I searched against their respective OPACs in intervals from June to September 2014. The same methodology of checking via OPAC was previously used by Smith , NissongIn the assessment of strong and weak subject areas, subjects consisting of less than three titles were excluded from the list. These subjects were: anatomy/embryology, biochemistry, immunology, microbiology, and neuroscience for the basic sciences; critical care, endocrinology, gastroenterology, health care administration, laboratory medicine, nephrology, ophthalmology, rheumatology, and urology for clinical medicine.I found that UST and DLSHSI had sound and good-quality collections with the highest percentages of matches in basic sciences, clinical medicine, and combined titles. UPM and UERMM had high percentages of near-matches, reflecting the obsolescence of their collections. ASMPH had the highest number of non-match titles, which suggests deficiencies in its collection.All five libraries had comparable strong subjects in basic sciences and clinical medicine, which shows similarities in their collection priorities. However, the libraries had different weak areas. Due to budget limitations, it may difficult to develop all weak areas at once. Thus, one library might choose to develop one area, while other libraries might strengthen another area. These differences in weak areas could be considered a driving force for forming consortiums for collection sharing.The age of a medical school can be either beneficial or detrimental to its library collection. Ideally, an older medical school has a head start in developing its collection, compared with a younger school that is still building its collection. UST, the oldest medical library, exhibited this effect and had a high percentage of match titles compared with other libraries. However, this may not always be the case, as age does not guarantee a high percentage of match titles. UPM and UERMM are older medical schools but had high percentages of non-match titles, compared with other libraries. On the contrary, DLSHSI had a high percentage of match titles compared with other libraries but is one of the youngest libraries. Thus, age can be a disadvantage when it leads to a high percentage of near-match titles and hence obsolescence. Older libraries have a tendency to keep superseded editions in their collections, as illustrated in the case of UPM, which had more near-match than exact match titles. On the other hand, younger libraries tend to only acquire the latest editions in their collections, as in the case of DLSHSI and ASMPH, which are younger libraries and had more exact matches.Budget appears to be among the factors that contribute to a high percentage of match titles, as higher budgets give a library spending power to purchase books and keep its collection current. DLSHSI and UST had the highest percentage of match titles and had the largest budgets among the medical libraries. On the other hand, ASMPH and UERMM had more non-match than match titles and had smaller budgets than the other libraries.The size of a collection can also contribute to a high percentage of match titles, because it increases the chance of having an exact or near-match title. However, similar to the age of a medical school, collection size could also contribute to the prevalence of more near-match than exact match titles, reflecting an obsolete collection. This was seen for UPM, which had a high percentage of match titles, although near-matches accounted for most of these titles. By contrast, ASMPH had the lowest percentage of match titles, but most of these were exact matches, making its collection relatively current.The use of DCT as a selection tool as well as the library director’s role as a book selector may be additional factors that contribute to the percentage of match titles. DLSHSI and UPM shared these characteristics and had more match titles than UERMM, which did not employ DCT as a selection tool and whose library director was not involved in the selection process. Although UST did not subscribe to or use DCT, its age, budget, collection size, and the library director’s role in the selection process may have afforded it the opportunity to acquire more DCT-listed titles. It should also be noted that libraries that were aware of DCT might not necessarily have used it as a selection tool, as in the case of UST and UERMM. Furthermore, a library might subscribe to DCT but not use it as a selection tool, as observed for UERMM, or a library might use DCT as a selection tool but opt to partially follow the list, as observed for ASMPH.This study has limitations that should be acknowledged. Even if a title was owned, it might not have been available during the period of evaluation. My findings represent a snapshot of a moment in time, thus holdings could be different if checked at a later date. Differences in library mission and financial or space limitations may be other factors influencing their collections, but these are beyond the scope of the study. For instance, the library or medical program might not be among the high-priority departments or academic programs of a university, which could result in a lower budget and minimal management support, thereby lowering the quality of the library collection. Space limitations may drive some libraries to acquire e-books and not catalog them in their OPACs, and thus these titles might not be accounted for when the OPAC is searched for match titles. Use of a larger checklist might have been desirable, especially since some of the subject areas were exceptionally small. Further studies could include checking the libraries’ collections against the entire DCT core titles list. A user-centered collection assessment technique could also be employed to provide useful feedback on the actual use and relevance of the collection.The findings demonstrate that medical libraries in the Philippines vary in terms of the quality of their collections. Some libraries have a sound collection, as evidenced by a high percentage of match titles. Other libraries lean toward obsolescence due to a high percentage of near-match titles. Still other libraries have poor collections with a high percentage of non-match titles. Many factors contribute to the percentage of match and non-match titles such as budget, the role of the library director as a selector, and the use of DCT as a selection tool. Libraries may consider reviewing their policies and practices to improve the quality of their collections, such as increasing the budget, involving the library director in the selection process, and using DCT as a benchmark for their collections. Medical libraries may share common collection development priorities but differ in areas that need to be improved. They are encouraged to consider their collection priorities to build their weak areas to achieve a balanced collection with all medical subjects and specialties fairly represented in their collections. A consortium for resource sharing or cooperative acquisition may help address gaps in library collections while managing costs.


The proper handling of samples to be analyzed by mass spectrometry (MS) can guarantee excellent results and a greater depth of analysis when working in quantitative proteomics. This is critical when trying to assess non-traditional sources such as ear wax, saliva, vitreous humor, aqueous humor, tears, nipple aspirate fluid, breast milk/colostrum, cervical-vaginal fluid, nasal secretions, bronco-alveolar lavage fluid, and stools. We intend to provide the investigator with relevant aspects of quantitative proteomics and to recognize the most recent clinical research work conducted with atypical samples and analyzed by quantitative proteomics. Having as reference the most recent and different approaches used with non-traditional sources allows us to compare new strategies in the development of novel experimental models. On the other hand, these references help us to contribute significantly to the understanding of the proportions of proteins in different proteomes of clinical interest and may lead to potential advances in the emerging field of precision medicine. The study of molecules responsible for the mechanisms behind body function, better known as omics, has revolutionized the study of the human body. After the conclusion of the human genome project 2001), efforts have shifted into the study and understanding of the human proteome. The increased sensibility and specificity of the available technology has led to the discovery of an increased number of proteins, making possible the creation of databases for proteomes of different organs as in the case of the Human Eye Proteome Project (HEPP) [, effortsTechnological advances in the field of quantitative proteomics have allowed for their use in the study of the mechanisms and treatment of disease. With the new techniques, an increased number and types of biological samples can be analyzed. Each biological sample presents a possible place to discover biomarkers in the study for certain diseases. This review focuses in the uses of quantitative proteomics methodology in the diagnosis and treatment of disease. It centers on research done in human biological samples to serve as a guide for future research. Although there are a large number of biological samples that are currently being used in research, our discussion is limited to research done with mass spectrometry technology in the following samples: cerumen, saliva, vitreous humor, aqueous humor, tears, nipple aspirate fluid, breast milk, cervicovaginal fluid, nasal secretions, and stools. Before addressing the theme of non-conventional body fluids in quantitative proteomics, it is of utmost importance to acknowledge two professionals who revolutionized the study of proteins with their application of mass spectrometry in the field. John B. Fenn and Koichi Tanaka shared a Nobel prize in chemistry (2002) for the development of electrospray ionization (ESI) and matrix-assisted laser desorption/ionization (MALDI), respectively . Their cResearch in proteomics requires profound understanding of each phase of the sample preparation and analysis. Some of the most important steps are sample collection, sample conditioning, mass spectrometry processing, comparison of theoretical data with experimental data, and finally, the use of specialized software that can generate lists and tables with the analyzed data. There are also a number of variables that need to be considered as they can often affect the results. One of them is the denaturing of the sample caused by errors in collection or mishandling. Others include poorly performed digestions, desalting errors, and loss of relevant data due to failure to perform depletions. The mass spectrometry and label method selected for the quantitative proteomics assays can also affect the results. It is for this reason that before developing a study design with this type of technology, it is fundamental to understand what method works best for the desired analysis. This can be achieved by the study of previous research, especially of studies using clinical samples. The acquisition of clinical samples is a delicate process as it often involves permits and is limited by its availability. When collecting a sample, it is important to follow previously specified conditions of temperature and storage in order for them not to be contaminated or altered. To achieve a good digestion, it is essential to know the initial concentration of the sample. Reaction salts in each phase must be removed before mass spectrometry analysis so it does not interfere with the sample analysis . One of m/z) ratio [m/z of the sample [As previously mentioned, there are two main technologies available for sample processing in mass spectrometry quantitative proteomics analysis. These are electrospray ionization (ESI) and matrix-assisted laser desorption/ionization (MALDI). Both of these techniques can be used with a variety of mass spectrometers. ESI technology uses electric energy to change ions from a solution into gas phase. Neutral compounds can also be processed with ESI MS by being ionized . After tz) ratio . The sigz) ratio . In the e sample . A majore sample .16O/18O and stable isotope labeling with amino acids in cell culture (SILAC). There is also the label free method in which, as the name suggests, the sample is not labeled [An important step in MS quantitative proteomics is the process of sample labelling. Labelling enables the identification and quantification of the samples by different methods. There are two main types of quantification methods: absolute and relative. These are based on the absolute or relative abundance of the samples. Most of the techniques available are part of relative quantification. With stable isotype labelling methods, the quantitative analysis is achieved by calculating the amount of protein with the ratio of peak intensity of isotope ions. The principle behind it is to have samples tagged with stable isotopes so they can be differentiated by their mass. Some of the better known relative quantification isotope strategies are isotope-coded affinity tag (ICAT) isobaric tags for relative and absolute quantification (iTRAQ), dimethyl labeling,  labeled . In this labeled . Another labeled . Each me labeled ,10,11,12At present, the technology for protein identification and quantification is being constantly studied and modified to address the problems encountered in their use. Their use will depend on the availability of the instruments for spectrometry and how well the experimenter knows the labels to be used. It is also important to understand that different variables such as the type of sample and quantity can determine what method is best suited for each experiment. These technologies will hopefully keep advancing and their limitations will continue to be addressed. Other virtues and uses of them will also be discovered as they are used in relatively unexplored samples.As previously mentioned, the use of cerumen as a biomarker of disease has not been widely studied in the field of quantitative proteomics. In 2013, the first in depth characterization of the proteins present in cerumen in healthy samples was reported [Saliva is one of the most accessible body fluids. It has been studied in the search of biomarkers for a number of diseases, including oral cancer ,14. In oImmune diseases such as chronic graft vs host disease (CGVH) have also been studied using saliva. CGVH is a complication of allogenic hematopoietic stem cell transplantation that can lead to impaired organ function . It commFor years, a large amount research into the mechanism and treatment of human immunodeficiency virus (HIV) infection has been reported. Studies based on the quantitative analysis of saliva have been done to search for new ways to monitor the progression of the disease and to understand the mechanism of infection . HIV neuThe human vitreous humor is an aqueous solution that fills the posterior compartment of the eye . AlthougAside from its many advantages, a major setback to the use of vitreous humor is the invasive techniques for removal of the fluid. This also poses a problem in acquiring samples for study purposes since ethically healthy eyes cannot be subjected to the procedures for the sole purpose of extracting the fluid . To addrThe pathways associated with PDR have also been studied with quantitative proteomic techniques . Among tExudative or wet age related macular degeneration (AMD) is commonly associated with alteration of the retinal pigment epithelium and its basal membrane and can lead to blindness . Using bAs with vitreous humor, aqueous humor (AH) collection cannot be performed in adults that do not suffer from ocular diseases or that are not subjected to eye surgery . Still, Tear fluid has been used to study a diverse array of diseases. Unlike vitreous humor and aqueous humor, it is readily accessible and the methods for acquiring it are noninvasive. Dry eyes (DE) is a multifactorial ocular surface disease. The search for understanding more of this pathology has prompted the study of differences in expression of proteins in tear fluid ,41. In oAnother approach to the study of DE was done by focusing on the different clinical phenotypes of patients with DE and how they could affect the tear proteome . This reThe association of dry eye syndrome with type 2 diabetes was studied using Two-Dimensional Strong Cation-Exchange/Reversed-Phase Nano-Scale LC MS . They foAs previously mentioned, tears have been used to study a variety of disease, including some that are not ocular in nature. The search for non-invasive biomarkers for Alzheimer’s disease has led quantitative proteomics research in tear fluid. Using LC-MS/MS and Selected Reaction Monitoring (SRM) based targeted proteomics, they found that a combination of lipocalin-1, dermicin, lysozyme C, and lacritin as biomarkers showed 81% sensitivity and 77% specificity . QuantitNipple aspirate fluid (NAF) is a ductal fluid that can be extracted from the breast through the nipple with a non-invasive technique . NAF hasIn the early 2000s, several studies in the field of proteomics explored the use of NAF as a source of breast cancer biomarkers ,55,56. MBreast milk as a source of biomarkers for disease has been relatively unexplored in the field of quantitative proteomics. Several research studies have assessed the contents of the fluid ,59,60,61Cervicovaginal fluid (CVF) originates from the vagina, cervix, endometrium, and oviducts . Over thCVF has also been studied for its potential use in cervical cancer screening. Using label free quantitative analysis as well as qualitative identification a study found alpha-actinin-4 as a potential biomarker in CVF for cervical cancer . CVF is The protein content of nasal secretions has been analyzed in a number of research studies ,69. A chBroncho alveolar lavage fluid (BALF) has been used in the study of pulmonary diseases. Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive interstitial pneumonia with poor prognosis. To understand more about the underlying mechanism of the pathology and differentiate between other fibrocystic pneumonia candidate, biomarkers in BALF have been investigated . The firChronic obstructive pulmonary disease (COPD) is a complex and heterogeneous disease with major public health importance. A study using nano-reverse phase liquid chromatography mass spectrometer (RPLC/MS) found 423 proteins, 76 of which displayed altered expression. They also observe upregulated expression of alcohol metabolism enzymes, including ADH1B, ALDH2, and ALDH3A1. This was the first report of the association between alcohol metabolism and COPD and its possible implications . AnotherThe use of BALF has also been explored to help with the understanding of some inflammatory and immune diseases. Acute respiratory distress syndrome (ARDS) is caused by a response to infection or other inflammatory triggers and has a high mortality rate. Currently, there are no biomarkers for ARDS that can provide prognostic information for clinical management. To investigate new possible biomarkers, a study used iTRAQ and LC-MS/MS to compare BALF protein content in different stages from the disease . Their fChronic graft dysfunction is a complication of lung transplantation and is the major cause of morbidity and mortality in transplant patients. The search for non-invasive biomarkers has led to the investigation of BALF with the use of quantitative proteomic techniques. Lung cancer is another area of interest for BALF research. Primary lung cancer adenocarcinoma has a poor prognosis. A study using liquid chromatography mass spectrometry found 33 overexpressed proteins in samples taken from patients that are potential biomarkers in the future . The search for biomarkers for different diseases that affect the gastrointestinal (GI) tract has led to the study and characterization of proteins from human stools. There is a special interest in the host-microbe interaction as it can provide insight into pathophysiological mechanisms of GI disease ,78. TherQuantitative proteomics has provided the tools necessary to explore the mechanisms of the human body and their changes in disease. Biological samples can lead to the creation of better and less invasive screening methods. Still, the quantitative proteomic analysis of the samples previously discussed is constantly evolving, with new technologies and approaches to address the problems that are encountered in their use. In the search for future analysis methods it will be important to first understand how the technology could be used for studying the mechanisms of disease and discovering biomarkers for their identification. In this manner, effort will be aimed at specific goals that will help us achieve faster and better results.


In 2007, WHO established the Guidelines Review Committee (GRC) to ensure that WHO guidelines adhere to the highest international standards. The GRC reviews guideline proposals and final guidelines. The objectives of this study were to examine the rates of and reasons for conditional approval and non-approval of documents submitted for the first time to the GRC, and calculate the time intervals and numbers of submissions to achieve approval for documents conditionally approved or not approved at first submission.All initial submissions to the GRC between 2014 and 2017 were examined. Data were extracted from the GRC’s records of written comments and discussions.Of a total of 85 proposals and 88 final guidelines, 32 (37.6%) proposals and 37 (42.0%) final guidelines were conditionally approved, and 15 (17.6%) proposals and 28 (31.8%) final guidelines were not. For both conditionally approved and not approved proposals, the most frequent reasons were suboptimal composition or inadequate description of the guideline contributor groups , followed by inadequate formulation of key questions . For both conditionally approved and not approved final guidelines, the most frequent reasons were problems with recommendations , followed by inappropriate methods for evidence retrieval or an inadequate description thereof . The median time to achieve approval was 2 months for proposals and 1–2 months for final guidelines. The median number of submissions was 2 for proposals and 2–2.5 for final guidelines.The GRC implements a rigorous quality assurance process and identifies problems with a significant percentage of initial submissions. WHO needs to continuously evaluate its guideline development processes to inform effective quality improvement measures and optimise the quality of its guidelines. WHO guidelines are documents, whatever their title, that contain one or more recommendation(s) regarding health interventions or policies . RecommeWHO Handbook for Guideline Development, 2nd edition [In 2007, the WHO Director-General established the Guidelines Review Committee (GRC)  to ensur edition , and forAt monthly, closed meetings, the GRC makes its decisions via consensus, based only on information in the submitted documents. The assessment is one of approval, conditional approval or non-approval. Conditionally approved documents usually require revisions that can be addressed by the authors with oversight by the GRC Secretariat and the Chair, but without the need for another full GRC review. Documents that are not approved require significant revisions and the revised documents must be discussed at a subsequent GRC meeting. For both conditionally approved and not approved documents, authors must submit a revised document and provide point-by-point responses to the GRC’s comments.The objectives of this study were to examine the rates of and reasons for conditional approval and non-approval of documents submitted for the first time to the GRC, and calculate the time intervals and numbers of submissions to achieve approval for documents conditionally approved or not approved at first submission.All proposals and final guidelines that were submitted for the first time for review at a GRC meeting between 1 January 2014 and 31 December 2017 were eligible for this study. All included documents were related to standard guidelines, and none was developed using abbreviated processes and methods in response to a public health emergency.Data for this study were extracted from the GRC’s records of written comments from reviewers and from discussions during GRC meetings.P < 0.05.We examined trends in initial conditional approval and non-approval of proposals and final guidelines across the years using Cochran–Armitage trend tests for proportions, using the Statistical Analysis System . Differences were considered significant at Reasons for conditional approval and non-approval were categorised according to their primary focus, namely introduction and guideline scope; key questions underpinning the recommendations  format); guideline contributor group composition, roles and responsibilities; declarations of interest, management of conflict of interest and funding sources; methods for literature reviews; assessment of the certainty of the evidence; and formulation of recommendations.The time interval and number of submissions to achieve approval were calculated for documents that had been approved as of January 15, 2018. The time interval to achieve approval for documents conditionally or not approved at first submission was calculated using the period between the GRC meeting date when a document was first reviewed and the date when the GRC approved the document. The decisions of the GRC are consistently provided 2 days after monthly meetings, and between-meeting approval of conditionally approved documents occurs within 2 to 3 days of submission. The number of submissions to achieve approval was calculated by counting the initial submission plus the number of subsequent submissions until approval was granted.Between 2014 and 2017, 85 new proposals and 88 new final guidelines were submitted to the GRC  and not approved documents .The rate of conditional approval was between 27.6%  and 52.6%  and that for non-approval was between 8.0%  and 36.8% . We did not observe a significant association between time and the rates of conditionally approved documents  proposals and 58 (89.2%) final guidelines had been approved by January 15, 2018. The median time to achieve approval was 2 months for proposals and 1–2 months for final guidelines  questions. All final guidelines had concerns regarding the recommendations, which included an unclear rationale for the strength of recommendation, and more than three-quarters were submitted with issues regarding the reporting of methods for evidence retrieval. The majority of proposals and final guidelines also had issues with declarations of interest, management of conflicts of interest or funding sources. Half of the documents that were initially conditionally approved or not approved were subsequently approved after a second submission, and within 1 or 2 months. However, some documents required additional revisions over lengthy periods before approval was granted.Planning proposals are generally short, concise documents that must comply with a reporting checklist provided by the GRC Secretariat. The Secretariat also provides a detailed, structured template for proposals since 2014. The GRC expects the proposal to convey that the guideline developers have clear, achievable objectives and know how to approach the guideline development steps, even if all the details are not provided. The high rate of concerns with the scope and key (‘PICO’) questions may be explained by the fact that some proposals are submitted at an early stage when the WHO steering group and the guideline development group have not finalised these decisions. Getting the scope and key questions right is critical as they represent the health issues that guidelines aim to address and form the basis of the evidence searches which underpin the recommendations. Consequently, key questions must be finalised early in the guideline development process and the GRC Secretariat is working with WHO staff to help ensure that key questions are clear, answerable and acceptable to a wide range of stakeholders.Furthermore, other problems, such as suboptimal composition of the guideline contributor groups and concerns regarding funding sources, declarations of interest or management of conflicts of interest, also need to be addressed at the planning stage since they are irremediable at the final guideline stage. To better address this issue, the GRC instituted a policy in 2017 that requires GRC Secretariat review of proposed guideline development group members, their declarations of interest and the management plans for any conflicts of interest before the meeting at which recommendations are formulated.With regard to final guidelines, the GRC noted particular problems with the rationale statement for recommendations. Rationale statements should be clear, concise and cogent statements that articulate the basis for the recommendation, encompassing the balance of benefits and harms as well as considerations of equity, human rights, acceptability, resource use, and feasibility, among others, as relevant. These statements are essential for a high-quality and transparent guideline. Potential solutions include more engagement of the guideline methodologist, whose main role is to assist the guideline development group in formulating recommendations based on evidence. The methodologist may have additional roles, including helping to develop key questions, reviewing the systematic review team’s assessments of the certainty of evidence, helping to draft the methods section of the final guideline, and reviewing the draft final guideline . AdditioWHO’s quality assurance process is rigorous and self-evaluation efforts such as this study feed back into quality improvement efforts. The high rate of conditional approval and non-approval of both planning proposals and final guidelines is concerning, but presents clear opportunities for quality improvement such as targeted training of guideline developers, dissemination of best practice examples, question-and-answer sessions, and more individual and group consultations with the GRC Secretariat, among other possible strategies.WHO Handbook for Guideline Development, 2nd edition, was published in December 2014 [An important strength of this study is that we had access to all documents submitted to the GRC during the time period examined, as well as to all comments provided by the GRC and its Secretariat during the review process. Nonetheless, several limitations should be noted. First, there are many factors that influence the number and nature of the comments on documents and the decisions made by the GRC. Like any peer-review process, comments vary across reviewers and over time within each reviewer, and GRC members generally serve 3-year terms. Second, the experience and training of WHO technical units, staff and the GRC Secretariat increased over time and an updated, more detailed The processes, methods and standards that are implemented by the GRC are exemplary and relevant to every organisation that develops guidelines. WHO has implemented and executed a transparent, efficient and sustainable quality assurance process for all of its guidelines consisting of structured peer review, actionable constructive feedback, and technical and process support and training. Guideline development groups might consider whether the model of WHO’s GRC might be adapted to their settings and needs. The reasons for non-approval of guideline proposals and final guidelines that we identified are likely relevant to documents developed by other organisations since WHO’s procedures and methods are consistent with those of the international guideline community, and WHO uses existing high-quality systematic reviews and commissions new reviews from external teams. Thus, the weaknesses identified at first review of WHO documents are also likely relevant to many other organisations.The WHO GRC implements a rigorous quality assurance process and identifies problems with a significant percentage of documents submitted for the first time. The reasons for conditional approval and non-approval of proposals were related to fundamental steps in the guideline development process that must be remedied early. For final guidelines, the reasons pertained most commonly to the recommendations and the lack of a clear linkage to the evidence and other considerations. WHO needs to continuously evaluate its guideline development processes and outputs, and use that information to inform effective quality improvement measures. This will help to ensure that WHO’s normative guidance to United Nations Member States will optimally impact global public health.


Tuberculosis has been declared to be a global epidemic. Despite all the effort, only less than half the annual estimated cases are reported by health authorities to the WHO. This could be due to poor reporting from the private sector. In Ethiopia, tuberculosis has also been a major public health problem. The aim of this study was to assess the role of the private health sector in tuberculosis control in Debre Markos.  An institution based cross-sectional descriptive study was carried out in private health facilities. A total of 260 tuberculosis suspects attending the private clinics were interviewed. Focus group discussion, checklist, and structured questionnaire were used.  Majority of the private clinics were less equipped, poorly regulated, and owned by health workers who were self-employed on a part-time basis. Provider delay of 4 and more months was significantly associated higher likelihood of turning to a private provider ).  There is significant delay among tuberculosis patients. Moreover, there is poor regulation of the private health sector by public health authorities. The involvement of the private sector in tuberculosis control should be limited to identification and refer to tuberculosis cases and suspects. Tuberculosis remains one of the top 10 causes of death worldwide in 2015. The global plan, to achieve The End TB Strategy by 2020, set 4-5% per year decline rate of tuberculosis (TB) incidence, but 2015 report shows 1.5% between 2014 and 2015 [Tuberculosis has been considered a major public health problem as far back as 40 years ago and still remains so in Ethiopia, and a functional effort to control tuberculosis was started in the early 1990s by opening the central office of the national TB control program. The program gives free access to TB screening and anti-TB drugs, which were not provided in private sector .According to WHO 2016 report estimates, Ethiopia stands 7th in the list of high burden countries for TB .Most of the few available health institutions are underequipped, and there is generally an insufficient spending on cost-effective health care. Failure by the underresourced public health care services to fulfill their responsibility to deliver health care to all parts of the population led to passive privatization –5.If the private health sector persists and grows as an alternative and unregulated source of care, National Tuberculosis Program (NTP) will be hampered in reaching their case detection targets. The epidemiological impact of the DOTS programs could be diluted in the private health sector by poor case management practice. Such practices, if unchecked, could contribute to the evolution and spread of multidrug-resistant tuberculosis (MDR-TB) .Studies which are conducted in India , VietnamIn the context of increasing privatization of health care, countries should introduce innovative methods for optimal cooperation and coordination between the two sectors to improve the quality of health care delivery in general and for the betterment of tuberculosis control in particular , and thiInstitutional based cross-sectional study was conducted to assess the role of private health sectors in TB control from February to March 2017. Around 378 participants  were selected by using purposive sampling technique .p values < 0.05 were considered significant.First structured questionnaire and checklists were designed  visited public health facilities while 34.6% visited private clinics and pharmacies (private providers) .There was no statistically significant association between sex, ethnicity, religion, marital status, and residence of the study subjects and the type of provider visited.In the univariate analysis, age less than 45 years, family size less than five, being literate, and being merchant were significantly associated with higher likelihood of turning to a private provider. However, these associations were nullified in the logistic regression.Average monthly income of more than 500 Birr and being student were significantly associated with higher likelihood of turning to a private provider both in the univariate analysis and in the logistic regression model  .Out of the 260 study subjects, 40% were not screened for tuberculosis on their visit to private clinics or public health facility who were supposed to be screened. There was no statistically significant association between sex, residence, ethnicity, occupation, duration of illness of the study subjects, and being screened for tuberculosis.Age less than 45 years, being orthodox, and being literate were found to be positively associated with not being screened in the univariate analysis. Nevertheless, these associations were not significant in the binary logistic regression model. Turning to a private provider was found to be positively associated with not being screened for tuberculosis . On the other hand, compared to those with income of 500 Birr and more, those with income of less than 500 Birr were more likely to be screened .It is shown that there were no statistically significant associations between duration of illness, traveling time, patient satisfaction, and the type of provider opted for by the study subjects.There was a significant patient delay with 50.1% of the patients having a delay of four or more months before their first contact with a provider. The mean patient delay was 5.3 months with the standard deviation of 5.6 months, while the median patient delay was four months. But when it comes to provider delay, the majority (78%) was delayed for less than 4 months before starting anti-TB chemotherapy. The mean provider delay was 2.3 months with the standard deviation of 4.9 months. It was found that provider delay of more than four months was strongly associated with turning to the private provider on the first visit among tuberculosis patients ).On the other hand, there was no statistically significant association between duration of illness before the first visit (patient delay) and the type of provider opted.Paying service charge of 100.00 Birr and more was significantly associated with higher likelihood of a visit to a private provider both in the univariate analysis and in the logistic regression model .Likewise, waiting time of three hours and less was significantly associated with higher likelihood of a visit to a private provider with increasing association as waiting for time decreases ) .For the second part of the quantitative study, the necessary data were collected from 13 out of 14 clinics in Debre Markos Town; only one of the owner clinics refused to participate in the study. Private clinics in Debre Markos were staffed by high-level professionals like eight specialists, nine general practitioners, and 14 laboratory technicians to list some. Surprisingly, minority of the respondents responded that, tuberculosis can be treated in the private sector, and only 2 out of 13 said that they want to treat TB patients in their clinics. The majority responded that tuberculosis treatment is affordable for few patients. TB control program manual is available only in 4 out of 13 clinics, and only one clinic had a separate register for tuberculosis patients. Only 3 out of 13 (23%) of the clinics had the necessary reagents and facility for AFB microscopy.All the respondents agreed that both sectors could collaborate in tuberculosis control. When it comes to possible areas for collaboration between the two sectors, 53.8% responded that the collaboration should be in multiple areas like diagnosis and treatment of tuberculosis, patient referral, reporting, and common training and workshops .There was one group consisted of eight participants. Participants were selected with purposive sampling to include opinionated and articulate individuals.Qualitative data were elaborated and summarized immediately after the sessions by the moderator.The following principal topics were covered in these focus groups.Absence of bacteriological follow-up, lack of trained staff, high cost of drugs, lack of diagnostic facilities, inadequate health education, and lack of mechanisms for defaulter tracing were mentioned as the main problems faced by tuberculosis patients in the private for-profit sector. It was said that these problems could lead to a delay in diagnosis. On the other hand, overcrowding, long waiting time, lack of confidentiality, poor patient-doctor relationship, and poor handling of patients sent from the private sector including requesting reexamination of the sputum of patients who had their sputum already examined in the private sector were mentioned as some of the problems in the public sector. It was said that these problems could lead to a delay of diagnosis or default from diagnostic process especially for patients from rural area due to high cost of accommodation.The private health providers can actively participate mainly in screening TB suspects, reporting, and referral of tuberculosis patients for treatment to public facility. The discussants stressed that it is very difficult to provide anti-TB drugs to the private providers due to difficulty of monitoring them. Moreover, it was indicated that the private sector may not be well motivated to supervise treatment and follow patients throughout the long treatment period; instead it would be more interested in new patients who would be able and willing to pay. Therefore, it was said that, unless there is strong monitoring system in place, it is better to limit the responsibility of the private clinics to diagnosis and referral of patients.The participants stated that there should be better communication and collaboration between private and public facilities than the prevailing condition. Diagnosis and referral of patients and using available diagnostic facilities in common were mentioned as some of the important areas for collaboration between the two sectors. It was said that the government should create conducive environment for private sector development based on legal framework and enforce both the private and the public sectors to comply with state-of-art tuberculosis control strategy by regular supervision, monitoring, regulation, and capacity building. They also stressed that the public sector should build its own capacity to be able to take the ultimate responsibility of monitoring and supervising itself and the private sector.They indicated that there is a better opportunity of getting treatment for the poor in the public sector than that in private sector, though they also indicated that it is more difficult for the poor with the increasing hierarchy in the public health facilities. For instance, it was stated that there was better equity in Debre Markos Health Center than that in DMRH. The participants mentioned that the quality of patient doctor relationship was better in the private sector than that in public facilities. Confidentiality and privacy of patients were said to be well guaranteed by the private providers compared to the public providers. Nevertheless, the discussants stated that they doubt if the private sector was providing appropriate and quality drugs.This study revealed that a considerable proportion (34.6%) of the patients with TB or symptoms of TB in Debre Markos town had been in contact with a private health care provider either for screening or for anti-TB treatment initiation. There was also similar finding from a study conducted in Bahir Dar on health-seeking behavior of TB patients, which reported that 32.4% of TB suspects turned to the private sector during their first visit . HoweverThere was no statistically significant association between different sociodemographic factors and visit to the private provider except income and being student. The positive association between higher income and higher likelihood of a visit to the private provider in this study could be due to the fact that the service charge in the private sector was higher than that of the public sector. Hence, this difference in the service charge could be one of the reasons why people with higher income opted for the private sector possibly for better courtesy, less waiting time, and privacy as it was indicated in focus group discussions.Early detection of TB patients by sputum smear microscopy among symptomatic patients reporting to health services is one of the strategies in TB control. The policy is that all patients with cough of more than two weeks are supposed to give two consecutive sputum samples to be the screen for possible tuberculosis . In thisHaving a waiting time of three hours and less is also positively associated with visit to private provider, with higher strength of association with decreasing waiting time . Less ovThe positive association between not knowing someone with tuberculosis and higher likelihood of a visit to a private provider  could be due to the fact that those who do not know someone with TB would be less likely to know the TB program and the availability of free treatment and might still opt for the private provider. On the other hand, those who knew someone with TB would be more informed about the TB program, especially taking into consideration the fact that the overwhelming majority of them responded that they knew someone from the family member. This might create more awareness for the patient and the patient's family about the presence of the program in the public sector and might lead them to opt for the public provider.The delay between the onset of tuberculosis symptoms, diagnosis, and initiation of anti-TB chemotherapy is an important factor in tuberculosis control program. Especially, due emphasis should be given to smear-positive patients delay since they are the most infectious.A study done in Sidama on delay in treatment of pulmonary tuberculosis revealed that patients with longer duration of illness had a greater number of bacilli on direct microscopy in their sputum. This might lead to increased excretion of bacilli from these patients, which would further aggravate transmission. One of the important strategies in tuberculosis control is early detection of smear-positive tuberculosis cases and treating them with an appropriate combination of chemotherapy to render them noninfectious .Two types of delays were assessed in this study. The first type of delay was a patient delay.This was defined by the duration of illness from the date of onset till the first visit to a health facility.Delay of any type should be seriously seen among smear-positive pulmonary TB cases due to its public health impact resulting from its infectiousness. Among smear-positive TB patients starting anti-TB treatment, mean patient delay was 5.3 months with a standard deviation of 5.6 months. This is significantly longer than the mean patient delays reported by other studies. For instance, Lonnroth et al. reported the mean patient delay of 3.1 weeks among smear-positive patients in Ho Chi Minih City, Vietnam . There wConsiderable numbers of tuberculosis patients visit the private health sector. There is significant provider delay before initiating treatment for TB patients especially for those patients who first visited the private provider. Underscreening of tuberculosis suspects that is more significant in the private sector compared to the public sector. There is a lack of appropriate coordination and collaboration between the private and public sectors in tuberculosis control. The majority of the private clinics in Debre Markos are unregulated and unsupervised and lack the necessary requirements for effective tuberculosis control like sputum microscopy, NTP manual, TB register, trained staff, and regular working hour.There is a need to establish better communication, coordination, and referral of patients between private and public sectors and also to monitor, supervise, and regulate the private health sector, in order to achieve the objectives of tuberculosis control program in the study area. The health workers in the private sector should be trained to be able to early screen or refer tuberculosis patients in case there is no screening facility in the private sector. To reduce repeating sputum examination for patients who had their sputum did in the private sector, the tuberculosis control program should better establish quality control and close supervision to the private clinics to ensure the validity of the result from the private sector. Health education about tuberculosis should be conveyed to patients and the communities by different media like radio, billboards, and brochures to create awareness about tuberculosis so that they report early when they have symptoms of tuberculosis. Operational research in possible involvement of the private sector in service delivery in TB control  in the study area should be conducted.


In Uganda, a low-income country in east Africa, African swine fever (ASF) is endemic with yearly outbreaks. In the prevailing smallholder subsistence farming systems, farm biosecurity is largely non-existent. Outbreaks of ASF, particularly in smallholder farms, often go unreported, creating significant epidemiological knowledge gaps. The continuous circulation of ASF in smallholder settings also creates biosecurity challenges for larger farms. In this study, an on-going outbreak of ASF in an endemic area was investigated on farm level, including analyses of on-farm environmental virus contamination. The study was carried out on a medium-sized pig farm with 35 adult pigs and 103 piglets or growers at the onset of the outbreak. Within 3 months, all pigs had died or were slaughtered. The study included interviews with farm representatives as well as biological and environmental sampling. ASF was confirmed by the presence of ASF virus (ASFV) genomic material in biological  and environmental  samples by real-time PCR. The ASFV-positive biological samples confirmed the clinical assessment and were consistent with known virus characteristics. Most environmental samples were found to be positive. Assessment of farm biosecurity, interviews, and the results from the biological and environmental samples revealed that breaches and non-compliance with biosecurity protocols most likely led to the introduction and within-farm spread of the virus. The information derived from this study provides valuable insight regarding the implementation of biosecurity measures, particularly in endemic areas. Sus scrofa) in Kenya in the beginning of the twentieth century  was first observed and described in pigs of European settlers  and established to financially support the organization’s humanitarian activities. The objective of the farm was to produce piglets and pork and in addition to offer training in pig husbandry for local pig farmers. As such, the farm represented a larger-scale farming operation located in an area with typical smallholder family farms, thus vulnerable to the various challenges, including biosecurity, facing a pig farm in an ASF-endemic setting.The farm started breeding pigs in 2013. In January 2014, the farm had 35 adult pigs and 103 piglets and growers, all of exotic  breed. The pigs were kept in a purpose-built, fenced compound with two stables. One stable was made entirely of concrete with a tin roof (“concrete stable”), and one had concrete floors, tinned roof, and pen walls of wooden planks with gaps between the planks allowing nose-to-nose contact (“wood fence stable”). The compound also contained additional buildings for office, storage, and guards and an unfinished construction with a cement slab  comprising interviews with farm representatives, site assessment, and the collection of biological and environmental samples. Interviews were informal, with simultaneous note-taking. Photographs were taken as part of the assessment, and feedback in the form of investigation reports were provided to farm representatives following each visit. Information regarding biosecurity was extracted from the interview data and from observations made during the farm visits.Biological samples were collected on the 11th of March and 10th of April 2014  (samples from the 11th of March) or by a MagMAX kit  (samples from the 10th of April), according to the instructions of the manufacturers. All organ material was pooled before DNA extraction. The extractions from the 11th of March were analyzed for the presence of ASFV nucleic acids using a commercially available real-time PCR assay  according to the instructions of the manufacturer. The extractions from the 10th of April were analyzed for the presence of ASFV nucleic acids with a Universal Probe Library (UPL) probe (5′-FAM-GGCCAGGA-dark quencher-3′)  as previously described  in accordance with instructions of the manufacturer.The outbreak became apparent on the 7th of March 2014 with an adult boar presenting with shivering, fever (40.8 °C), and anorexia Table . The boaA DNA extraction of the pooled organ samples from one dead pig from the 11th of March was positive for the presence of ASFV. All 18 DNA extractions of blood samples from the 11th of March were negative for the presence of ASFV. Five DNA extractions of blood samples from the 10th of April were positive for ASFV. One of these ASFV-positive samples was also positive for the presence of ASF antibodies, as was one of the ASFV-negative samples. See Table The first impression of the farm setup was that the farm seemed to comply with rather high biosecurity standards and to be fit for pig farming in an ASF-endemic area. The fenced and guarded compound, staff wearing overalls and rubber boots, and pigs confined in pens and fed only concentrate feed contributed to this impression. However, the interviews and more in-depth assessment of the farm site revealed that biosecurity standards were lacking, including routines as well as the layout and location of specific activities. Specific biosecurity risks are described in more detail below.The slaughter took place inside the compound, less than 3 m from the wood fence stable, with no drainage and on an unpaved surface see Fig. . During At the visit on the 11th of March, four different staff members tended to the pigs, including the guards. There had been a high turnover of staff with four farm workers leaving in the previous 6 months, causing biosecurity routines to be lost in the transition process. During the course of the outbreak, the manager quit his position, leaving only less experienced personnel behind. According to the routines, rubber boots and overalls were provided for the staff and overalls were washed daily. Despite the stated routines, it was apparent that procedures were not being followed, as some personnel were not using overalls at the visit on the 23rd of March.Pig pens were cleaned with a water hose and the cleaning water tunneled towards the manure tank. Part of the water from cleaning of the wood-fence stable was flowing on the ground along the side of the stables. The manure tank was overflowing, creating a manure-filled ditch close to the fence at one side of the compound see Fig. .Pigs were not individually marked, and prior to the outbreak, no records were kept. Pigs that fell sick during the outbreak were in general not euthanized or slaughtered immediately but left in the pen, or moved to pens with other sick pigs. Dead pigs were buried within the compound, and while awaiting burial, they were left on the ground for several hours. During cleaning of the pens, pigs sometimes escaped into the yard where they had access to the slaughter site and the overflow from the manure tank.When the outbreak started, disinfectant boot baths were placed at both entrances to the concrete stable and at the gate to the compound. After the visit on the 11th of March, a commercial disinfectant with ammonium chloride as the active ingredient was used. However, the boot baths were placed on an unpaved surface and used without prior cleaning of the boots, causing contamination of the water by organic material. In both sites, the boot baths were placed without any demarcation of the “clean” and the “dirty” side. General cleaning of the pens seemed to be insufficient as material from an abortion was found in a pen at the visit on the 23rd of March.Offal from slaughter and dead pigs was buried in a rather limited area of the compound. As the number of deaths and the related slaughter of sick pigs increased, the risk from these burials  increased. In January 2014, 2 months prior to the outbreak, the closest neighbors of the farm, just adjacent to the fence, opened a pork joint  with on-site slaughter. Offal from slaughter at the pork joint was left in the open.Before the outbreak, the farm employed two farm workers, two guards, and a farm manager. At the visits on the 23rd of March and the 2nd of April, the farm manager expressed feelings of deep stress and depression from seeing the pigs getting sick and die and not being able to control the outbreak. At the visit on the 10th of April, the farm manager had left his position without giving notice to the employer. On the visit of the 21st of September, the farm representative reported that he had considered leaving his position because of similar feelings of stress and depression connected to the outbreak. Apart from the farm manager who left his post voluntarily, two staff members lost their job due to the outbreak as no farm labor was needed once all pigs had died. The staff at the NGO’s main office also expressed worries that they might lose their employment due to the financial impacts of the outbreak.In total, 35 adult pigs and more than a hundred piglets or growers died or were slaughtered with clinical symptoms of ASF during the outbreak. The farm estimated the market value of a pig at slaughter to 90 USD. The full value of all pigs were not lost as some were slaughtered. Further, the planned income was reduced by more than the slaughter value of the herd pre-outbreak, as a fourth of the original herd was breeding stock not meant for slaughter and representing a higher value. The farm estimated the total loss  at approximately 20,000 USD.The results from the outbreak investigations correspond to the pathogenesis and survival features of ASFV. The virus can be found in a wide range of tissues and secretions, including feces and urine, from clinically affected pigs  to the clean (meat) side Skaarup . No equiIn the described outbreak, most pigs had died within a month and all pigs had died or been slaughtered within three months. Farm records did not allow full distinction between pigs that died by themselves from the disease, those slaughtered upon showing clinical signs, or those slaughtered as a preventive action to avoid losses. The time to clearance of the outbreak , however, matched recent simulations on the spread of ASF on farm level for pig herds of the same size, based on the ASFV strain from Georgia  is not extremely high; Guinat et al. (The farm manager’s expressed feelings of stress and depression during the outbreak could have been one of the reasons behind the habit of not immediately euthanizing or slaughtering pigs that fell ill. The farm manager stated that he did not euthanize sick pigs “because they might recover.” Healthy pigs were further put together in pens called “isolation units” and sick pigs put together in other pens. As pigs were not individually marked, this routine made the tracking of cases more difficult and, in addition, probably contributed to disease transmission. It is worth mentioning that standard disease control advice such as isolating sick pigs will be useless, or even counterproductive, if implemented when disease transmission has already started. In order for managers to make correct decisions in outbreak situations, they need knowledge about disease transmission and infection. The case fatality rate after infection with highly virulent ASFV, such as the genotype IX circulating in Uganda, is very high (Plowright et al. t et al.  describeThe continuous circulation and frequent outbreaks of ASF in the smallholder pig sector in Uganda impact negatively on the livelihoods of poor smallholders (Fasina et al. In order to achieve ASF control globally, nationally, and locally, many different aspects of the epidemiology need to be considered (Costard et al. In conclusion, at first, the study farm appeared to have the biosecurity measures in place to prevent an ASF outbreak on the farm, despite being located in an endemic region. However, the study shows that in-depth, practical knowledge in many areas is required in order to succeed with pig farming in this setting without introducing ASF. More specifically, a high level of awareness about the surrounding circumstances and the required biosecurity is fundamental. In addition, emphasis must be put on effective, feasible, and vigilant maintenance of biosecurity routines.