In the coming 5 years, what types of residence should be organized for people with mental health problems? The purpose of this article is to provide mental health care providers, public housing corporations, and local government with guidelines for planning organizational strategy concerning types of residence for people with mental health problems.Despite large-scale investments in mental health care in the community since the 1990 s, a trend towards reinstitutionalization has been visible since 2002. Since many mental health care providers regard this as an undesirable trend, the question arises: A scenario analysis was performed in four steps: 1) an exploration of the external environment; 2) the identification of key uncertainties; 3) the development of scenarios; 4) the translation of scenarios into guidelines for planning organizational strategy. To explore the external environment a document study was performed, and 15 semi-structured interviews were conducted. During a workshop, a panel of experts identified two key uncertainties in the external environment, and formulated four scenarios.The study resulted in four scenarios: 1) Integrated and independent living in the community with professional care; 2) Responsible healthcare supported by society; 3) Differentiated provision within the walls of the institution; 4) Residence in large-scale institutions but unmet need for care. From the range of aspects within the different scenarios, the panel was able to work out concrete guidelines for planning organizational strategy.In the context of residence for people with mental health problems, the focus should be on investment in community care and their re-integration into society. A joint effort is needed to achieve this goal. This study shows that scenario analysis leads to useful guidelines for planning organizational strategy in mental health care. In the field of specialized mental health care in the Netherlands there are two main types of care for people with (complex) mental health problems. There is inpatient care, where patients stay in a psychiatric hospital unit , or in a small-scale residential unit in the community with supervision and support from a mental health care provider. There is also outpatient care, where patients live independently and receive ambulatory treatment or care  inpatient care, and the tendency of health insurance companies to move healthcare costs for complex groups away from private insurance to the social care sector  .In the coming 5 years, what types of residence should be organized for people with mental health problems? This question also arose at Stichting Geestelijke Gezondheidszorg Eindhoven en de Kempen (GGzE), a mental health care provider in Eindhoven. With a population of 212,000, Eindhoven is the fifth largest city in the Netherlands. Because of the regional function of GGzE, it has a working area of 525,000 people (Eindhoven and surrounding towns and villages), in which institutional care increased by almost 6% between 2006 and 2008.This reinstitutionalization is an undesirable trend in relation to the policy vision that mental health care in the community should be stimulated . Therefouncertainty about the characteristics of future residences for mental health care, an additional qualitative study was needed to explore the influence of these developments.Initially, a projection was made to estimate the number of patients that could be expected in 5 to 10 years. However, this demographic projection did not provide a reliable basis. Apart from demographic changes, the mental health care sector is also faced with socio-economic changes and developments in society. These developments can have considerable impact on people with mental health problems, and consequently on the options of mental health care providers regarding the types of residence for their patients. Because this leads to much scenario analysis. The essence of scenario analysis is to acquire a better understanding of the external environment, to create pictures of possible futures, and to enhance policy planning based on these pictures [macro-level studies on scenarios in healthcare. In the profit sector, several organizations use scenario analysis on a smaller scale as a tool for planning organizational strategy. Since the successful use of the scenario approach by Shell at the time of the oil crisis, various other organizations (e.g. the car industry) have adopted the method [A method for exploring the many aspects of future developments, in which uncertainty plays an essential role, is offered by pictures . In the pictures , the 'Pupictures , the Netpictures , and, inpictures . All thee method -12. ThisThe main questions are:What are realistic scenarios concerning different types of residence in mental health care in Eindhoven?1. What are the implications of these scenarios for GGzE, public housing corporations, and local government?2. What guidelines does the scenario analysis offer for planning organizational strategy?3. Unlike in the past, when strategy planning was based primarily on quantitative extrapolations, qualitative explorations (resulting in scenarios) regarding future developments have nowadays become more common. Although mathematical elaboration can be part of scenario analysis , exploraScenarios: the art of strategic conversation' the author describes both an inductive and a deductive approach to scenario development. The deductive method is described as working from the general to the more specific, whereas the inductive method uses a bottom-up approach. The deductive method, more than the inductive method, aims at thinking beyond what can be reasoned, and is more likely to identify uncertainties [Over the years, there have been several authors who describe scenario analysis as a method for strategic planning, e.g. Van der Heijden ,17, Posttainties . The dedtainties . Differetainties , van Asstainties , Postma tainties . Dammerstainties  and Schotainties .The first step is to explore the external environment and identify which certain and uncertain developments confront the organization. This exploration can include a document study of relevant reports and websites, an interview with stakeholders, or both. Exploring the external environment should result in a set of uncertainties concerning future policy of the organization ,17,18. TThe aim of this scenario analysis was to provide guidelines for strategic planning for GGzE and its cooperating partners concerning residence for people with mental health problems in Eindhoven. To perform the study, we used the steps of the deductive scenario analysis method described by Van der Heijden .In the scenario analysis in Eindhoven, the external environment was mapped by a document analysis, followed by 15 interviews with a total of 20 participants. Both the document analysis and the interviews were guided by a framework of themes. These themes were selected on the basis of the notion that future scenarios are a collection of events that all have a certain degree of probability of occurring ,14. In t• demographics• socio-economics• society• policyNetherlands Institute for Social Research, Statistics Netherlands, the Netherlands Bureau for Economic Policy Analysis, and the National Institute for Public Health and the Environment. These organizations are appointed by law to advise the Dutch Ministry of Health, Welfare, and Sport on national healthcare and welfare issues. We therefore chose to analyze reports from these associations in order to arrange our picture of the most recent developments concerning society as a whole. We then gathered more specific information on mental health care from the Dutch Association of Health and Addiction Care (the umbrella organization for the sector), and the Netherlands Institute of Mental Health and Addiction, . To complete the document analysis, we also looked at reports by Aedes-Actiz, a branch organization concerned with residence and care for special groups in society.In the Netherlands, the national associations that engage in uncovering developments in society and future scenarios are the We coded the information on the basis of the themes we selected before starting our exploration (step 1). The information found in the document analysis, using the themes as search criteria, led to a further specification of our framework.The interviews were held with representatives from mental health care providers (7), public housing corporations (5), local government (2), financiers (2), patients' representatives (2), and patients' family organizations (2). A semi-structured interview was conducted, guided by our framework. The interviews were recorded and transcribed. The information was coded on the basis of the framework, and worked out in more detail using the data that was obtained from the interviews. In a workshop, a panel of experts further discussed the interview results. The panel, consisting of experts who were also involved in the study as interviewees, were given the interview data and asked to agree which themes were significant for further scenario building.In the interviews we focused on people's views of the present situation and developments they expected in relation to the position of people with mental health problems in society and the consequences for the provision of residences. The result of step 1 is a list of uncertainties deduced from the document study and interviews. These uncertainties were used in a workshop with a panel of 11 experts. These were in policy or management functions with: mental health care providers (6), public housing corporations (3), and local government (2) in Eindhoven. We specifically approached these organizations to participate in the workshop because of their shared responsibility for residence provision and policy for mentally vulnerable people in Eindhoven. The dominance of the mental health care providers' discipline within the group was controlled by using a facilitator who ensured that every member of the panel was given the opportunity to participate in the discussion, and by dividing people from different disciplines equally within the subgroups that worked on the scenarios during the session.By means of a two-axis system Figure , two keyThis scenario outline was further defined using the plenary discussion that followed the initial compiling by the subgroups in the workshop. The different aspects of the scenarios were discussed, which led to the recognition that several actions needed to be taken in strategy planning in order to anticipate future developments. The scenario analysis and discussion about the impact and consequences of the scenarios provided the panel with guidelines for strategic planning. The actual drawing up of strategic plans, and the testing and development of these plans for each of the scenarios , did notThe external environment was explored using the framework as described in the Methods section. It can be characterized by demographic, socio-economic, social, and policy topics.Demographic topics that were found in the document study were aging, immigration, and family composition . During Due to new market forces, the  healthcare sector has major concerns about the financial resources that will be available in the near future for adequate residence, care, and treatment for patients with mental health disorders. This implies that a larger demand may be made on society. At the same time, society is changing rapidly: in the coming years individualism in society will increase further, which will diminish social cohesion . In addiThe interviews showed that, in general, experts believe that this means that people with mental health problems will be easily stigmatized and excluded from society, which places more pressure on intramural facilities. The reinstitutionalization trend is already visible in the Netherlands: from 2002-2006 there was a 6% increase in the number of psychiatric hospital beds [availability of financial resources for mental health care and the possibilities for successful integration into society. Figure Using the list of uncertainties Table , two keyTo find four scenarios that are realistic (but still uncertain), the two key uncertainties were used as scales in a system of axes that was used to develop scenarios. Based on a discussion of the implications of the different possible combinations of key uncertainties on types of residence needed for people with mental health problems, the panel compiled four scenarios Figure :1. Integrated and independent living in the community with professional care 2. Responsible healthcare supported by society 3. Differentiated provision within the walls of the institution 4. Residence in large-scale institutions but unmet need for care. A high level of integration into society of people with mental health problems is an important policy goal of mental health care providers, public housing corporations, and local government. Successful integration of people with mental health problems enhances the wellbeing of these people, and may lead to a lower need for professional care. Integration also advances people's possibilities of being self-reliant and of living independently or in a group. In this scenario financial resources can provide for highly differentiated and specialized outpatient treatment by a mental health care provider.In a scenario where integration is high and financial resources in the mental health care sector are low, the demand for professional mental health care could decrease. This would be due to voluntary care from a patient's direct environment, which 'takes over' certain aspects of care that would otherwise need to be delivered by (costly) professional facilities. Furthermore, mental health problems may be partly prevented, symptoms may be reduced because of the individual's integration into society, and negative influences on wellbeing and functioning may be reduced through integration into society. This scenario would mean that there is limited need for professional care. Obviously, there is also a group of people with mental health problems with complex psychiatric disorders who  require professional treatment and  care. Nevertheless, should this scenario become a reality, there would be a large increase in demand for independent housing facilities and small living facilities among those requiring mental health care.In scenario 3, integration has failed, which will further stimulate the pressure on intramural facilities within mental health care institutions. People with mental health problems will be dependent on the 'safe' environment of the institution. Concentrated within the institution, a large range of differentiated customized care is available, with separate facilities for each group. There will probably be a reduced need for independent housing facilities outside the institution, since society does not accept their use. In summary, in this scenario there will be an increase in demand for professional care in an intramural setting, and the mental health care sector will have the financial resources to amply provide it.In this feared scenario of both a low integration level and a low availability of financial resources in mental health care, patients' needs and quality of life are no longer central in planning supply. The lack of social integration of people with mental health problems will stimulate the need for residential facilities in a safe and protected environment. In these facilities there will be too few staff to deliver adequate care. Customized care will become a rarity. Independent and normalized living for people who cannot manage on their own will have no place in this scenario. The availability of professional support, care, and treatment will be limited and only in large-scale institutions.In the final step, the panel translated the results into guidelines for organizational strategy. Examining the four scenarios, the panel formulated two key strategies: investing in financial and social security, which means institutional, predominantly inpatient care facilities, or taking some acceptable risks and investing in the integration into society of people with mental health problems.Differentiated provision of healthcare within the walls of the institution). With current budget cuts in the healthcare sector scenario 1 seems a risk. Also, financiers - under the pressure of a limited budget - tend to invest in the financially more solid intramural facilities [Responsible healthcare supported by society) [Market forces have increasingly been driving healthcare providers to focus on financial resources. In the Netherlands, since 2006, the healthcare financing system has changed from budget-based costing towards performance-based costing. The limited budget compels mental health care providers in the Netherlands to negotiate every year with financiers about healthcare procurement. Consequently, a scenario in which financial resources are high and integration into society is successful (scenario 1), initially seemed the most positive scenario to the panel. In this scenario the financial resources are abundant, making it possible to offer broad and differentiated care programs, including specialized mental health care and a wide range of options for residential facilities. However, after careful consideration of the consequences and implications of this scenario, the panel found that several negative outcomes can be expected. When there is an abundance of financial resources this can lead to a substantial supply of professional care, which can have negative consequences at the integration level. Excessive professionalization of healthcare for people with mental health problems living in the community can lead to further stigmatization which, as a result, would again isolate them from society. The panel concluded that that would lead to scenario 3 (cilities . This desociety) .In this case study, the panel unanimously considered 'integration' to be the basis for their future strategy planning. Without the scenarios, policy would probably be primarily aimed at gaining substantial financial resources. Although the latter is important, the scenarios were an eye-opener, and showed the panel that more focus on integration and participation in society of people with mental health problems is probably better realized under the pressure of a limited budget. This does not imply the need for new policy plans for the mental health care branch, because it has been a point of discussion for the last few decades. Paradoxically, care in the community has been the vision of the sector for several years, but it has not yet been successfully taken up in all of the sector's policy. To achieve this, there should be more cooperation between public housing corporations, local government, and collaborating partners. The study also shows the difficulty of achieving integration, especially in view of the current financial pressure. Besides financial uncertainty, there is the question of a changing society. Because of individualism, changing lifestyles, and the falling tolerance level, much effort is needed to achieve a situation in which people take responsibility for each other. Mental health care providers, public housing corporations, and local government in Eindhoven concluded that they have to consider these developments in relation to their policy goals.social support systems, separation of residence and care (e.g. by using home automation facilities), effective spending on daycare, reaching closely involved people, and investing in chain care". There should be pressure against further extension of residential care. This does not imply that inpatient care has no benefits or should gradually disappear because a large group of people will not be able to live in the community on their own. For this latter group, inpatient care is needed and should be available in an agreeable and safe environment. Nevertheless, the vision in Eindhoven is that the goal should be to treat people as much as possible with ambulatory care, and to institutionalize only if there is no possibility for the patient in the community. This changes the way of thinking about inpatient care from "yes, if..." to "no, unless...".Achieving integration is, to a large extent, one of the primary policy goals of care providers, local government, and public housing corporations. Successful integration into society advances the wellbeing of people with mental health problems, and should decrease the need for professional healthcare. This enhances the possibility of achieving independent or group living in a normal community environment as the dominant type of residence. Conversely, reduced financial resources, should act as an incentive for society to take responsibility. Healthcare providers, together with public housing corporations and local government, aim to invest in making people aware of this responsibility. When achieved, this could mean that participation of mentally vulnerable people in society is enhanced with less financial expenditure. However, this demands considerable action, which is represented in the 4-year policy plans of GGzE: investing in "Scenario analysis has proved to be a useful tool for providing guidelines for organizational decision making in healthcare. That has been shown in this case study in Eindhoven. First, it helped to achieve a shared mindset on the central issue of residence for people with mental health problems. Second, it provided a structure in which uncertain developments concerning this topic were easily exposed by considering a broad range of uncertainties that were systematically narrowed down to two key uncertainties. Third, by means of deducing the key uncertainties and then compiling scenarios, the participants in the workshop achieved a better understanding of the alternative future possibilities. Fourth, this scenario analysis resulted in guidelines for future policy plans. These plans have a good potential for success, since their foundation was established by various stakeholders in a shared setting. Finally, this scenario analysis provided a method for identifying the essence of the central theme, which in this case led to four scenarios with guidelines for future policy on residence in mental health care. Drawing on the jointly established view on possible futures for people with mental health problems in Eindhoven, GGzE was able to make strategic plans in the specific area of residence in mental health care. The managing director of GGzE Psychiatry (adults) and Geriatrics division has used this scenario analysis in the division's policy plan for the next 4 years. The key message in this policy plan is recovery and equal citizenship.This study in Eindhoven has shown that it is possible to translate macro-level developments to organizational policy planning using systematic scenario analysis. While current scenario studies are mainly performed at a national level, the method has proved useful at a regional level. Uncertainties can be made transparent at different levels and for specific themes using a uniform method. It is essential to include all necessary stakeholders in the scenario analysis, and to translate macro-level developments to the appropriate level of discussion.By focusing on two key uncertainties, the range of topics that have to be taken into account is reduced considerably, and this may involve the risk of ignoring important policy topics. It is therefore essential to involve both certain and uncertain developments in the scenarios. Furthermore, identifying the uncertainties does not mean we have a complete view of all possible futures. Besides the uncertainties, there are the 'unknowables' that are naturally missing from our scenarios . This means that there will always be a certain number of unexpected and unanticipated events affecting an organization's business strategies, even when based on scenario analysis. Also, rapid changes in society may imply that the scenario analysis is easily outdated. Therefore, scenario analysis should not be a single operation, but an iterative process which has a fixed place in the policy cycle of a healthcare provider and its associates.Van der Heijden  explicitResponsible healthcare supported by society) as the best basis. However, in scenario analysis it is important to assess all aspects in the different scenarios before developing strategy plans. It is therefore essential to scenario analysis to prevent focusing on a single scenario during the process.After developing the scenarios, a discussion took place to work out tangible guidelines for the planning of future strategy for the residence and care of people with mental health problems in Eindhoven. This resulted in the panel focusing on scenario 2 .Furthermore, we did not double code our interview transcripts. However, the interview results were presented to the panel in the workshop, before work on scenarios started.Organizations can take a practical approach to the method, and use as many elements as they have time for. However, they should be aware that a solid scenario analysis will eventually save time in developing policy plans of higher quality.The scenario study discussed here shows that, in connection with the future provision of residence types for people with mental health problems in Eindhoven, there should be a focus on investing in a socially supportive and responsible society and community-based care. This implies that more effort should be made to create social support systems and normalized living possibilities. It also means that cooperation between specialized mental health care providers, social care, public housing corporations, and local government is essential.The scenario study has shown that working with scenarios provides policymakers of healthcare providers, public housing corporations, and local government with concrete guidelines for creating a shared vision of developments concerning a specific issue , and with tools for understanding their implications for future strategy plans. Because the scenarios were constructed jointly by representatives from healthcare providers, public housing corporations, and local government, there is a strong possibility of regional support for strategy planning, of residence and care for mentally vulnerable people in the community by any of the organizations.The authors declare that they have no competing interests.All authors participated in the design of the study. JB carried out the document analysis and interviews. The workshop was organized and facilitated by JB and IB. The manuscript was initially composed by JB. IB and HvO contributed to the discussion and further improvement of the manuscript. All authors read and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/11/1/prepub


Mycobacterium leprae and manifests as damage to the skin and peripheral nerves. The disease is dreaded because it causes deformities, blindness and disfigurement. Worldwide, 2 million people are estimated to be disabled by leprosy. Multidrug therapy is highly effective in curing leprosy, but treating the nerve damage is much more difficult. The World Health Assembly targeted to eliminate leprosy as a public health problem from the world by 2000. The objective of the review was to assess the successes of the leprosy elimination strategy, elimination hurdles and the way forward for leprosy eradication.Leprosy is caused by A structured search was used to identify publications on the elimination strategy. The keywords used were leprosy, elimination and 2000. To identify potential publications, we included papers on leprosy elimination monitoring, special action projects for the elimination of leprosy, modified leprosy elimination campaigns, and the Global Alliance to eliminate leprosy from the following principal data bases: Cochrane data base of systematic reviews, PubMed, Medline, EMBASE, and the Leprosy data base. We also scanned reference lists for important citations. Key leprosy journals including WHO publications were also reviewed.Mycobacterium leprae, the relationship between leprosy and poverty, prevention of disabilities, lack of a reliable laboratory test to detect subclinical infection and a vaccine are also challenging issues.The search identified 63 journal publications on leprosy-related terms that included a form of elimination of which 19 comprehensively tackled the keywords including a book on leprosy elimination. In 1991, the 44th World Health Assembly called for the elimination of leprosy as a public health problem in the world by 2000. Elimination was defined as less than one case of leprosy per 10000-population. Elimination has been made possible by a confluence of several orders of opportunities: the scientific , technological (multi-drug therapy and the blister pack); political (commitment of governments) and financial (support from NGOs for example the Nippon Foundation that supplies free multi-drug therapy) opportunities. Elimination created the unrealistic expectation that the leprosy problem could be solved by 2000. First, the elimination goal was not feasible in several areas which had high incidence of leprosy. Even if elimination was to be attained, significant numbers of new cases of leprosy would continue to occur and many people with physical imperfections, severe psychological, economic and social problems caused by leprosy would need continuous assistance. Extra-human reservoirs of The evidence base available to inform on leprosy elimination is highly positive with the availability of multi-drug therapy blister packs. There are concerns that leprosy was not the right disease to be targeted for elimination as there are no reliable diagnostic tests to detect subclinical infection including the lack of a vaccine, extra-human reservoirs (monkeys and armadillos), increase in the burden of child cases, no good epidemiological indicator as prevalence instead of incidence is used to measure elimination. Multi-drug therapy treats leprosy very well but there is no proof that it concurrently interrupts transmission. The high social stigma, prevention of disabilities, and the relationship between leprosy and poverty are still major concerns. Mycobacterium leprae and manifests as damage to the skin and peripheral nerves. The disease is dreaded because of the damage that occurs in weak and anaesthetic hands and feet, as well as in blindness and facial disfigurement [Leprosy is caused by gurement . Worldwigurement . In 1991gurement . EliminaBy the end of 2000, 108 of the 122 countries originally listed as leprosy endemic by the WHO, attained the elimination goal at the national level. By the end of 2005, 116 of the 122 leprosy endemic countries had attained the goal. Extra efforts were still needed to achieve the elimination goal at the national level in the remaining six countries. The elimination strategy is based on detecting and treating all leprosy cases with MDT and thereby reducing the disease burden to a very low level. The key is to ensure that all new cases continue to have access to MDT services . MDT is Mycobacterium leprae) that causes it throughout the world. At present, we lack the tools both to protect people from developing leprosy and to diagnose and treat the disease in its sub-clinical form. Significant resources would be required to develop and deploy the necessary tools, and hence, it was decided to aim at elimination of the disease as a public health problem, as the first step [Eradication would mean the complete absence of leprosy and the organism  to eliminate leprosy, many partners supported the elimination struggle including the WHO, the World Bank, the International Leprosy Federation (ILEP), the Nippon Foundation and the Sasakawa Memorial Health Foundation (SMHF), Novartis, the Danish International Development Agency (DANIDA) and many more . Even wiWe used a structured search to identify publications on the elimination strategy. The keywords used were leprosy, elimination and 2000. The search identified 63 journal publications on leprosy-related terms that included a form of elimination of which 19 comprehensively tackled the keywords including a book on leprosy elimination. To identify potential elimination publications, we included papers on leprosy elimination monitoring, special action projects for the elimination of leprosy, modified leprosy elimination campaigns, and the Global Alliance to Eliminate Leprosy from all countries of the world. We searched the following principal data bases: Cochrane data base of systematic reviews, PubMed, Medline, EMBASE, and the Leprosy data base.The following key journals were reviewed: International Journal of Leprosy and other Mycobacteria Diseases, Leprosy Review, The Lancet, PLOS Medicine, WHO publications, International Journal of Epidemiology, World Health Forum, American Journal of Public Health and Hygiene, Indian Journal of Dermatology, venerology and leprology, Journal of Public Health in Africa, Nigerian Quarterly Journal of Hospital Medicine, ILEP publications, Bulletin of the WHO, and Epidemiology and Infection. Data from books, reports from ministries of health and conference/workshop proceedings were also reviewed. We also accessed and retrieved data from websites such as http://www.who.int/lep, http://www.searo.who.int, http://www.paho.org, http://www.Ilep.org.uk. Reference lists for important publications were also scanned.The search identified 63 journal publications on leprosy-related terms that included a form of elimination of which 19 comprehensively tackled the keywords including a book on leprosy elimination. The use of MDT, first recommended by the WHO in 1982 led to significant reductions in leprosy prevalence in several countries . In 1991As a result of the new strategy, the estimated number of leprosy cases in the world dropped to 3.1 million in 1993  and 2.4 million in 1994 . Reductions were observed in all endemic regions including Africa despite political upheavals and economic difficulties .In mid-1998, more than 8.5 million people had been cured of leprosy using MDT, the dosage and duration of treatment being tailored to the severity of the infection. While in 1985 there were 122 countries with a prevalence of more than one case per 10.000 population, in 1988 there were 55 countries striving to reach the target of elimination . EliminaBy the end of 2000, the WHO stated that leprosy had been eliminated in 98 countries of the world and announced the creation of a Global Alliance to eliminate leprosy as a public health problem from every country in the world by 2005 .In 1999, the GAEL was formed to inject new energy into the elimination campaign, bringing together WHO, the governments of major endemic countries, the Japanese Nippon Foundation, the Novartis Foundation for Sustainable Development, DANIDA, and ILEP. Quite soon, major contrasts emerged between some of the GAEL partners, namely between WHO and ILEP, who always remained critical of the elimination -focused strategy. The clash was so strong that ILEP was expelled from the alliance at the end of 2001 . Later oThe Nippon Foundation and SMHF have been active worldwide since 1975 in combating leprosy, having spent more than US$ 200 million in this period. The SMHF does not directly implement any leprosy programme but funds projects through the WHO or other ILEP members. From 1995 to 1999, the Foundation provided MDT drugs free of charge to anybody who needed it anywhere on the planet [Leprosy Elimination Campaigns (LEC) were recommended by the WHO for detecting serious leprosy cases- referred to as “cases of consequence”. The proposal was to identify these cases and treat them with MDT. LEC was a combination of three elements: capacity building measures for local health workers to improve MDT services; increased community participation to strengthen elimination activities at peripheral levels; and diagnosing and curing patients, particularly “cases of consequence”. LEC aimed at case detection through passive methods, with individuals coming forward for diagnosis . In IndiHowever, there have been challenges to MLEC in countries like India. Since leprosy programmes were shifted from the hands of specially trained vertical leprosy staff and long time associated NGOs to the general health services staff, some degree of slowness in picking up requiring level of efficiency was observed . This caCrucial to any public health programme is access to treatment for those who need it most. The WHO suggested SAPEL as an initiative to provide MDT services to patients living in difficult-to-reach areas and neglected population groups. By definition, SAPEL had to be flexible in its implementation strategy and adapted to the needs of the individual community and target audience . For exaIn Madagascar, the highlight of SAPEL activities included updating of registers and the development of plans to intensity leprosy elimination efforts. The SAPEL constraints in Madagascar were poor geographical accessibility to many health facilities especially in the rainy season and the restructuring of the national leprosy programme .This is a component of case validation that was added to the leprosy elimination strategy. The WHO document: Leprosy Elimination Monitoring Guidelines for Monitors-2000 was used as reference , 23. TheTaking into account the epidemiological characteristics of leprosy, and the large number of grey areas in our understanding of the disease, it was important to select carefully the outcome indicators that would be monitored-incidence is the most relevant indicator, but may be the most difficult one. Prevalence, as a composite indicator varies considerably, depending on the operational components of interventions. Incidences of disability and of MB cases in the community could be very useful to evaluate the leprosy situation. The uneven distribution of leprosy, as well as the role of various local factors, calls for caution when extrapolating the results from one place to another. There was a clear need to collect a set of indicators to enable programme managers in endemic countries to analyse the results of their work, increase their motivation and convince the decision-makers .LEM was meant to complement existing information systems and methods for reviewing elimination programmes. The main purpose of LEM was to collect a limited number of indicators that describe the performance of MDT services at the national, sub-national and peripheral levels in endemic countries. The term ‘MDT services’ refers to comprehensive health activities, including: diagnosis, classification, prescription of treatment, delivery of MDT, case-holding and cure of leprosy patients. In some situations, these indicators could help in identifying areas where special campaigns or projects could be implemented .In India, for example, the child proportion, which had decreased in 2003, marginally increased in 2004 . The treIn 1974, Cameroon demonstrated its political will to fight against leprosy by putting in place a national system of co-ordination. The first survey was made in 1975. It recorded 43,816 people with leprosy at a time when the population numbered 5,856,863-that is 75 cases of leprosy per 10,000 inhabitants. Eleven years later, when Aide aux Lépreux Emmaüs-Suisse established a regional office in Yaoundé, there was a need to find ways to develop structures and resources that could ensure greater follow-up of the National Programme .By 1996, the number of people with leprosy had fallen considerably to 1850 among a population of 12,121,002; the equivalent of 1.51 cases per 10,000 inhabitants. This drop reflected the efficiency of the strategies that had been implemented and the introduction of MDT as the means of treating people with leprosy in 1985. Initially only 14.3% of people needing treatment for leprosy received MDT. Today all those who are diagnosed with leprosy in Cameroon are treated with MDT. In 1998, there was less than one person per ten thousand with leprosy .In Essimbiland of North Western Cameroon, leprosy prevalence is high , 27. BoyThe WHO dubbed the ambitious project “the final push to eliminate leprosy”. The strategy behind the slogan involved expanding MDT services to all health facilities and making leprosy diagnosis available, training health workers to diagnose and treat leprosy, promoting leprosy awareness and encouraging people to seek and continue treatment . HoweverElimination created the unrealistic expectation that the leprosy problem could be solved by the year 2000. In the first place, the elimination goal was not feasible in several areas which had high incidence of leprosy . Even ifLeprologists and people involved in disease control feared that once leprosy is declared eliminated as a public health problem, the future of anti-leprosy services and of leprosy workers and researchers will be at high risk , 52. EliMycobacterium leprae [The International Leprosy Association′s Technical Forum has also noted that the expectation that reduction of prevalence to very low levels would lead to a reduction of the incidence within a few years was overoptimistic, as there was little evidence to support this hypothesis . Since pm leprae . There im leprae . The polm leprae . The prem leprae . Furtherm leprae . The prem leprae . The WHOm leprae . Prevalem leprae , 56. Dism leprae . Using Wm leprae . Preventm leprae .The evidence base available to inform whether leprosy is being eliminated is highly positive based on the availability of MDT blister packs. There are concerns that leprosy was not the right disease to be targeted for elimination as there are no reliable diagnostic tests to detect subclinical infection including the lack of a vaccine. Social stigma to leprosy is still very high for both new cases and those discharged from treatments that are deformed. The high social stigma affects rehabilitation of patients because their original communities are not willing to accept them. Furthermore, in some communities, people are not willing to buy goods produced by lepers from their rehabilitation trades. Leprosy affects mostly the poor but the relationship between poverty and the disease needs to be established. The use of prevalence as an indicator to assess elimination instead of incidence rate is misleading and needs to be revisited. Leprosy relapses and the prevention of disabilities among patients on treatment and discharged cases are still major problems. Humans are not the only reservoirs of M. leprae as extra-human reservoirs have been identified in monkeys and armadillos. There is an increase in the burden of child cases indicating that transmission is ongoing. MDT treats leprosy very well but there is no proof that it concurrently interrupts transmission and this relationship can be investigated further through more research. There is need for more research in the areas that are hurdles to the elimination strategy in order to better understand the epidemiology of leprosy and eradicate it from the world.In order to ensure that leprosy does not go underground, the elimination strategy must be swiftly converted to a post-elimination strategy . This neData for evaluating the impact of MDT on transmission are not readily available because leprosy has a long incubation period . Mathema


Computational Modeling in Biology Network (COMBINE), is an initiative to coordinate the development of the various community standards and formats in computational systems biology and related fields. This report summarizes the activities pursued at the first annual COMBINE meeting held in Edinburgh on October 6-9 2010 and the first HARMONY hackathon, held in New York on April 18-22 2011. The first of those meetings hosted 81 attendees. Discussions covered both official COMBINE standards-, as well as emerging efforts and interoperability between different formats. The second meeting, oriented towards software developers, welcomed 59 participants and witnessed many technical discussions, development of improved standards support in community software systems and conversion between the standards. Both meetings were resounding successes and showed that the field is now mature enough to develop representation formats and related standards in a coordinated manner.The  At the beginning of the 21st century, the life sciences have witnessed a tremendous change in the way research is performed, characterized by the acquisition and analysis of large amounts of quantitative data, as well as the integration of these data within computational models used to understand and investigate living systems. In systems biology, structured representations of information, coupled with rich metadata frameworks and the exchange of knowledge, are fundamental enablers of research. The enormous size of biological data sets and the computational models involved favor exchange and collaboration rather than independent redevelopment.In computational systems biology, three major efforts to standardize data formats for different knowledge domains stand out by their development models. Each is community-based, with community consultations and democratic processes for choosing the individuals who comprise the editorial boards as well as for making technical decisions during the development of the standards. The Systems Biology Markup Language (SBML) , covers Computational Modeling in Biology Network , an initiative whose goal is to coordinate the development of the various community standards and formats in computational systems biology and related fields. By doing so, the federated projects can develop a set of interoperable and non-overlapping standards covering all aspects of computational modeling, at every scale, in every field of biology, in a manner that is similar to how the World Wide Web Consortium (W3C) develops standards for the Web.These various standardization efforts were originally developed in independent and largely uncoordinated ways. This has resulted, in some unfortunate redundancy in topical coverage, human effort, and funding. In response to this, many of the individuals involved in the different efforts created the , an iOne of the first goals of COMBINE has been to coordinate the organization of common meetings. Two different annual meetings are currently being organized. The COMBINE annual meeting replaces the SBML and SBGN fora. COMBINE is an open event targeting not only developers, but end users, it offers the opportunity to hear and make presentations about implementations of standard support, scientific investigations made possible by their use, and exploration of new approaches. The second annual meeting, the Hackathon on Resources for Modeling in Biology (HARMONY), is a hackathon-type gathering primarily targeted at software developers, with a focus on continued evolution of the standards, their interoperability, and supporting software infrastructure.th International Conference on Systems Biology (ICSB). The agenda, presentation materials, audio recordings, video recordings of presentations are available on the COMBINE 2010 website. A total of 81 people attended the 14 plenary sessions and breakouts, collectively presenting 42 talks and 30 posters. Most of the presentations and posters have been made part of a special Nature Precedings collection for COMBINE 2010  a a7] and Three sessions were dedicated to the visual representation of models. The first was on the current status of the languages forming the Systems Biology Graphical Notation ,23; the Nicolas Le Novère, from the EMBL-EBI (UK), reported on the status of SBGN Entity Relationships and proposed extensions, in particular for the representation of nested entities (domains) . Stuart Bernard de Bono, ( EMBL-EBI), closed the session by discussing the representation of anatomy and an attempt to use SBGN Entity Relationships to represent physiological mechanisms. The SBGN issues outlined during this session were the topic of dedicated breakout sessions during the evenings of days 2 and 3. These breakouts were deemed very productive.Best SBGN software support - Completeness, exactitude, validation”. The category “Best SBGN software support - Layout and rendering” resulted in a tie, between Arcadia [Best SBGN map: Breadth, accuracy, aesthetics” was awarded to the central metabolism diagram of Falk Schreiber and his collaborators from the Leibniz Institute of Plant Genetics and Crop Plant Research (IPK), Gatersleben (Germany). The “Best SBGN outreach: lecture, training, publication, book, website” prize was awarded to a tutorial given by Anatoly Sorokin from the University of Edinburgh.The SBGN session closed with the announcement of the winners of the first annual SBGN competition. The software system SBGN-ED  was awar Arcadia  and VISI Arcadia . The priThe SBGN software support session was opened by Alice Villéger, from the University of Manchester (UK), who presented the status of LibSBGN, a Java API for manipulating SBGN  ,31. TobiDiscussions of graphical visualization continued on day 2 of COMBINE 2010. Ralph Gauges, from the University of Heidelberg (Germany), presented the SBML Level 3 package to encode graph layout and rendering . Huaiyu A common source of discussions, misunderstandings and disagreements in the COMBINE community is the relationships between interactions and reactions (or processes). This session covered related efforts in the field and was aimed at providing material for more informed discussions. Henning Hermjakob, from the EMBL-EBI presented the efforts of the Human Proteome Organization's (HUPO) Proteomics Standards Initiative (PSI ) towardsThe afternoon of the second day was devoted to the topic of semantics in computational models. It began with a session on the resources available to annotate models. Nick Juty, from the EMBL-EBI, presented an update on the Systems Biology Ontology , describA second session of the day was dedicated to the use of the resources presented above. Neil Swainston, from the University of Manchester, described the SBML Level 3 package dedicated to annotation . This paThe morning of the third day centered on conversion among standard representations and software supporting several COMBINE standards.Martijn van Iersel, from Maastricht University (the Netherlands), presented the PathVision 9 pathway vizualization tool  ,57 and tLucian Smith, from the University of Washington, discussed the problems of modularity and model composition in relation to CellML and SBML encoding . CamilleThe afternoon of the third day started with a session devoted to BioPAX. Emek Demir, from the Memorial Sloan-Kettering Cancer Center , presented new features in  BioPAX Level 3 and compared it to the former widely-used BioPAX Level 2. Nadia Anwar, also from the MSKCC, detailed the new community and governance structure of BioPAX. Gary Bader, from the University of Toronto (Canada), presented his views for the future of the standard. Martijn van Iersel summarized ongoing discussions in the layout workgroup. Emek Demir closed the session with a discussion on generic physical entities and interactions, extending the debate to SBML and SBGN, which face the same problems.3D, a 3-dimensional graph viewer.The third day closed with a session centered on the problems that are not yet covered by the current standardization efforts involved in COMBINE. Nicolas Le Novère presented his vision of what the COMBINE mission is, working towards a comprehensive set of descriptive standards for modeling biology . Robert The last part of the COMBINE meeting focused on SBML . The firMichael Hucka, from the California Institute of Technology (USA), presented the current status of SBML Level 3  and the Sarah Keating, from the SBML Team working at EMBL-EBI, presented the current status of libSBML ,80, and th anniversary of SBML. The first draft of the SBML specification was released in August 2000 by what would later become the SBML Team. Ten years later, a whole ecosystem of tools, teams and research projects has blossomed around SBML, and significant participants of this adventure were invited to give presentations on this occasion.The COMBINE meeting proper was followed on the last day by a symposium and celebration to mark the 10The symposium was opened by Hiroaki Kitano, from the Systems Biology Institute of Tokyo (Japan), who, a decade earlier and with funding from the Japan Science and Technology Corporation (JST), initiated the project from which SBML eventually emerged. At this anniversary event, Kitano presented his thoughts on the conditions that made possible the emergence of SBML as a successful worldwide standard. He then described his Garuda project to expand the community software development approach to the entire spectrum of computational modeling activities. After Kitano’s presentation, Pedro Mendes, from the University of Manchester, gave an overview of the earliest attempts to develop quantitative models in biochemistry, encode them, and simulate them using computers. Mendes  was one of the earliest contributors to SBML. and Prior to SBML, he contributed to the design of a portable file format for metabolic network models (known as PMB). Hamid Bolouri, from the Fred Hutchinson Cancer Research Center (USA), was the head of the initial SBML Team at the California Institute of Technology beginning in 1999. His presentation focused on CRdata, a software platform for computational systems biology using R and the Amazon cloud . HerbertThe symposium resumed after a short break with John Doyle, from the California Institute of Technology. Doyle was the Principal Investigator on a subcontract of the JST grant of Kitano awarded to Caltech and hosted the SBML team from late 1999 into the early 2000s. He presented a summary of his ongoing work in applying control theory to physiological modeling, and expressed the need for better theory and tools to connect physiological measurements to an understanding of the functioning of the human body. After Doyle's presentation, Andrew Finney, now at Ansys (UK), another early member of the SBML team. described some of the ways in which SBML development worked, or sometimes did not work, and what could learn for the future development of standards. Michael Hucka, the third member of the original SBML Team and program lead and global co-ordinator since 2004 recapitulated the history of SBML development, some of its successes, and reminded the audience of many important contributors to the evolution and success of SBML. Finally, Nicolas Le Novère, who was one of the earliest contributors to SBML and a developer and contributor since 2004, closed the symposium. . He placed SBML within a broader constellation of emerging standards in systems biology, and called for continued and expanded collaboration within COMBINE.quiet hacking, because experience from previous meetings has shown that hackathon attendees can neither contain their vocal enthusiasm nor their desire to continue pushing on technical problems regardless of the schedule. The fifth and final day of HARMONY was shared between presentations on SED-ML [The first HARMONY meeting was hosted by the Computational Biology group of the Memorial Sloan-Kettering Cancer Center  and heldn SED-ML  and issuThe meeting opened with an introduction to the day from Michael Hucka, followed by overview presentations about SBML, BioPAX and SBGN given by principal developers involved in the development of each standard. The rest of the day was structured into short introductory tutorials on five topics, with materials made available on the meeting website. The first tutorial was on PaxTools; Emek Demir gave an overview presentation of the Java API library supporting BioPAX. This was followed by Nadia Anwar who gave an introduction to the RDF and OWL technologies used by BioPAX, along with a hands-on session using the W3C SPARQL query language to access data from BioPAX files. Tutorials continued in the afternoon,, beginning with a LibSBGN session given by Martijn van Iersel and Tobias Czauderna and served as an update of the current progress and future plans for LibSBGN. It also provided an opportunity to present the initial milestone release of SBGN-ML. this was followed by a libSBML tutorial by Sarah M. Keating and Frank T. Bergmann. Like other sessions in the day, it included illustrative hands-on exercises for attendees to try on their laptops. The day was closed with a tutorial by Nicolas Rodriguez on JSBML.Following the tutorial sessions, the HARMONY meeting officially opened with a simultaneous buffet reception and evening poster session. In all, 15 posters were presented. They covered a wide variety of topics—everything from databases that can export data in the various formats discussed at HARMONY, to new software tools and emerging standards, including BioPAX and CellML.The first plenary session focused on SBGN. It was chaired by Falk Schreiber and focused on unresolved issues in the 3 SBGN sublanguages: Process Description (SBGN-PD), Entity Relationship (SBGN-ER) and Activity Flow (SBGN-AF). The session started with an overview and history of the SBGN standard from Nicolas Le Novère. This was followed by a report on the status of SBGN-PD by Stuart Moodie and discussion of items that were scheduled to be included in the Level 1 Version 2.0 release of SBGN-PD, but which still remained contentious. These problematic topics included the rules of subunit naming, the exact semantics of the “Empty Set” glyph, resolution of the community vote about reversible arcs, and the use of the SBGN Unit of Information to describe the cardinality of multimers and the material type of EPNs. A record of these SBGN-PD issues is available online at .The next session of the morning concerned SBGN-ER and was led by Nicolas Le Novère. Discussions focused on several issues, particularly the semantics of an “entity” and whether different outcome glyphs were required to describe occurrent (e.g. an interaction itself) and continuant (e.g. a complex resulting from the interaction). Huayu Mi then presented the status of SBGN-AF, which was nearing a maintenance release (Level 1 Version 1.1). The major topic of discussion was whether a separate phenotype and perturbing agent activity were required, and whether SBGN-AF needed different glyphs. In addition, the outcome of the vote on how the type of activity  was indicated in AF .The plenary session of the third day was devoted to BioPAX. Gary Bader began with an overview of the planned activities, then introduced the projects and issues that were of interest within the community. The goal was nucleation of interested parties to begin discussions and work. This was followed by the session on specification and data. It was chaired by Emek Demir, who gave an overview of data integration and normalization and discussed progress since his last presentation on the topic during COMBINE 2010. Arman Aksoy then introduced the Patch algorithm and outlined the goal to test data integration at the meeting. He reported that several data providers tested integration with specific data sets. Peter D’Eustachio followed with an introduction to current issues in data exchange, including provenance, use of pathwayOrder and nextStep classes, and multiple organism pathways. He also sought to gather end users of BioPAX to highlight known issues and collect additional issue reports from the community. The ultimate goal was coordinated creation of a list for proposal and specification changes and best practices to be co-ordinated into a working group. This followed with a discussion about future development and ideas for BioPAX level 4.The specification/data session was followed by presentations about works in progress from various BioPAX working groups which were introduced to the community by the  BioPAX editors. Proposals from the SemWeb working group and the layout co-ordinate exchange group were announced as ready for community feedback. Several working groups met in the afternoon to organize and prioritize their activities.A session about software tools followed. Software developers discussed current developments in BioPAX Software Tools, specifically the BioPAX validator, the PaxTools API, the PathwayCommons resource and the Chibe Visualization tool . In thisThe day closed with lecture by Chris Sander  on the analysis of pathways to characterize cancers, predict outcomes and suggest therapeutic avenues.The morning of the fourth day was devoted to SBML. Michael Hucka began with a review of SBML Level 3 and an update on the statuses of various Level 3 package development efforts.  Many of the Level 3 packages have been highly anticipated by the SBML community and Hucka announced that software implementations of several were available for libSBML. Sarah Keating presented a status update on libSBML version 5, a modular version of libSBML that supports extensions for SBML Level 3 package implementations. Nicolas Rodriguez gave a status update on his ongoing work with Andreas Dräger on JSBML. Following that, Andreas Dräger described his own work on a new software system, KEGGtranslator that is designed to convert KEGG pathways to SBML . Martin Marco Antoniotti summarized the area of multicellular modeling, which is actively pursued by many research groups worldwide yet remains an area that is not well supported by SBML at present. He was followed by Michel Dumontier, who presented exciting work on advanced search and reasoning over SBML model annotations using semantic web technologies. The final session of the morning provided updates on the development of two SBML Level 3 packages. James Schaff discussed the spatial geometry package for SBML, which supports the representation of models and processes that have non-homogeneous spatial qualities. Brett Olivier discussed his collaboration with Frank Bergmann on a package to support the representation of flux balance constraint models  in SBML.The remainder of the fourth day was devoted to parallel discussions on SBML and BioPAX topics.The final day began with a session about SED-ML. Frank Bergmann discussed the SED-ML specification, some pending issues about SED-ML, and libSEDML, an API library for developing software support for SED-ML. Frank was followed by Richard Adams, who presented several SED-ML developments: JlibSEDML, a Java-based complement to libSEDML; a new SED-ML Editor; and a SED-ML web service which includes a validator. These presentations were then followed by David Nickerson, who described the work of the CellML group with SED-ML, and the status of CellML software simulators and model repositories. This was followed by presentation by Nicolas Le Novère about recent developments in KiSAO, the Kinetic Simulation Algorithm Ontology , in partThe following session explored efforts to foster greater coordination between the governance and outreach activities of the main standards involved in COMBINE today. Robin Haw opened the session with a presentation about community outreach activities. He was followed by overview presentations by the principal organizers of the SBGN, SBML and BioPAX efforts, covering the current governance structures of those organizations. The audience was then engaged in a general discussion about the possibility of creating common governance guidelines that could be shared among the various COMBINE efforts as well as used as templates for other, future standardization efforts that aimed to follow in the footsteps of BioPAX, SBML and SBGN.The rest of the day consisted of various meetings of scientific advisory boards, editorial committees, additional hacking sessions and ad hoc get-togethers organized by HARMONY attendees.Immediately following both the COMBINE 2010 meeting in October, 2010, and HARMONY in April, 2011, we conducted exit surveys of the participants. We used a commercial electronic survey tool and made the questions anonymous, in order to maximize the chances of getting unfettered and honest feedback. We asked similar questions on both occasions. The number of responses to the exit survey for each meeting was approximately 40%. The feedback from the COMBINE survey was available prior to the HARMONY meeting, and we took the results into consideration when organizing HARMONY.The feedback from the surveys showed that attendees found breakout sessions very useful; however, the organization of such sessions needs to be improved in future COMBINE and HARMONY meetings. COMBINE and HARMONY were purposefully structured with a combination of formal talks and focused breakouts, though with fewer breakouts during COMBINE. Nevertheless, the organization, management and communication of breakout schedules was deemed suboptimal in the end—respondents complained not only when interesting breakouts clashed with the main session, but also that participants were not always made clearly aware of which sessions were being held, leaving people unsure about how best to split their time. While we attempted to consider this and improve how breakouts were organized in HARMONY, the fact that the same issues were raised again in the HARMONY exit survey shows that we need to revisit this problem in future meetings.COMBINE respondents raised the suggestion of using parallel sessions in order to help provide more time to the different major efforts, and we implemented this idea in HARMONY 2011, where each main standard was given a specific day and other standards had optional parallel sessions. There was no specific agenda for the parallel sessions from the meeting organizers; instead, the communities were left to organize themselves. This appeared to work well and made the meeting both informative and productive for participants. However, the feedback in the exit survey suggested that a more explicit agenda, such as that provided at COMBINE, would actually have been useful. In the future, we can improve this aspect of the meetings through better coordination between the people organizing the different main topics.The HARMONY exit survey also highlighted the need to improve the communication about activities at the meeting. HARMONY was intended to be relatively free-form, with little scheduled time, to allow each standard group to self-organize based on the participants and skills actually present on the days in question. For the most part, the feedback suggests that this worked well for people who could organize themselves, but less well for others—especially newcomers—who were not intimately involved in the different communities. Better communication of the schedule and breakouts by the organizers was proposed in the feedback, and this should help in the future to encourage more cross-community collaboration at these meetings.Generally, the feedback suggested that the concept of the two different meetings worked well. Most participants understood the structure and what was expected of them at each of the meetings. Feedback suggested that the initial meetings had a different dynamic from the individual standard meetings, and that this also worked well, as it promoted interaction among the standards groups. Given the freestyle organization of a hackathon, participants commented that this helped them focus and make excellent progress on tasks that would otherwise have taken months to achieve.The tutorials were deemed a good idea, though with some mixed reviews. Some attendees, particularly those actively involved with the different standards, did not find the tutorials useful, while others found the tutorials extremely informative, enabling less active users of the standards and newcomers to “catch up”. To newcomers, the tutorials also were meant to introduce the main individuals involved in each of the standardization efforts but respondents indicated that this could have been achieved in introductions instead. We conclude that tutorials should be kept, and the best improvement to make for future tutorials is to clarify the target audience as well as provide the tutorial contents in advance so that people can determine for themselves whether attending those sessions would be useful.Attendees reported having made progress in specific areas and the availability of dedicated time for particular topics with specific individuals enables progress and resolution of outstanding issues faster than usual. More generally, participants found the meeting  helped them become more familiar with other standards and could see how they could participate more actively. Respondents commented on their ability to discuss and get feedback on issues so they could be be implemented/resolved immediately, and having focused time to do this saved considerable time overall. Thus, the meeting accelerated progress that would otherwise have taken much longer, through e-mail and conference calls.,. Participants overwhelmingly agreed that the COMBINE and HARMONY meetings are informative and productive.th ICSB [Combining the meetings of the various standardization efforts in computational systems biology was a gamble and could have been a challenge. Indeed, while the communities largely overlap at the level of tool development, the end-users are often different, as are their expectations. Contrary to our worries, the meetings were resounding successes with an attendance and an enthusiasm exceeding our most optimistic hopes. The outcomes were numerous. COMBINE 2010 allowed members of the different communities to become acquainted with the  efforts of others. The extent of the overlap and potential for synergy was very clear for all attendees. In addition to a better coordination of the development of standards, this led to discussions and collaborations that further unfolded at HARMONY 2011. These meetings have been defining moments and hopefully launched an irreversible process. The benefits of coordination and synergy are such that stopping the movement would be a significant blow to the various participating projects. However, there is a downside. The scale of the meetings is different (two to three times larger than the separate fora used to be). At that level, the organizational and financial aspects become very significant and require greater commitment on the part of organizers and attendees alike. Nevertheless, combining these meetings also brings an economy of scale that we believe should be recognized by funding bodies who used to support the efforts separately. The next round of meetings. COMBINE 2011 took  place in Heidelberg from September 3 to 7 2011, after the 12th ICSB  at the H


The Swedish salmonella control programme covers the entire production chain, from feed to food. All salmonella serotypes are notifiable. On average, less than 20 cases of salmonella in food-producing animals are reported every year. In some situations, the cases would be expected to cluster geographically. The aim of this study was to illustrate the geographic distribution of the salmonella cases detected in pigs, cattle and sheep.Data on all herds with pigs, cattle and sheep found to be infected with salmonella during the time period from 1993 to 2010 were obtained from the Swedish Board of Agriculture. Using the ArcGIS software, various maps were produced of infected herds, stratified on animal species as well as salmonella serotype. Based on ocular inspection of all maps, some were collapsed and some used separately. Data were also examined for temporal trends.No geographical clustering was observed for ovine or porcine cases. Cattle herds infected with Salmonella Dublin were mainly located in the southeast region and cattle herds infected with Salmonella Typhimurium in the most southern part of the country. Some seasonal variation was seen in cattle, but available data was not sufficient for further analyses.Analyses of data on salmonella infected herds revealed some spatial and temporal patterns for salmonella in cattle. However, despite using 18 years' of data, the number of infected herds was too low for any useful statistical analyses. Salmonella spp. in feed, animals or food of animal origin are notifiable and action is always taken to eliminate the infection. Whenever salmonella is isolated, restrictions on animal movements and manure are immediately put on the farm and a prompt investigation and trace-back of the infection is performed. An eradication plan is instituted by an official veterinarian and approved by the Swedish Board of Agriculture. The herd is not declared free from infection until all animals in the herd are negative in two consecutive faecal samplings one month apart, and adequate cleaning and disinfection have been completed. Culture is the detection method of choice for most samples from animals, as this is independent of serotype and has a high specificity, both important features for the Swedish situation. However, culture from faecal material has a low sensitivity [The Swedish National salmonella control programme covers the entire production chain, from feed to food . The salsitivity  and may Regular sampling of pig and cattle carcasses is performed at slaughterhouses. Furthermore, random lymph node samples are taken at slaughter. No regular sampling is performed in herds with pigs or ruminants, but a voluntary surveillance programme is in place for breeding pigs. Due to the pyramidal structure of the commercial pig production, about 60-65% of all slaughtered pigs descend directly from these breeding herds. Clinical or post-mortem suspicion of salmonella infection is notifiable for all veterinarians, who must take relevant samples in case of such suspicions. Salmonella samples are also taken at most post-mortem investigations of cattle and pigs.Only a few cases of salmonella in food-producing animals are reported every year . In someData on all herds with pigs, cattle and sheep found to be infected with salmonella during the time period from 1993 to 2010 were obtained from the Swedish Board of Agriculture (SJV).A herd was considered a case if salmonella was isolated from at least one faecal sample in the herd. Each holding was only included once even if investigations revealed that several animal species were infected. The case species was set to the animal species from which Salmonella was first identified, and thus regarded as the species of the herd. In the studied period there were a total of 267 holdings where salmonella was isolated from the animals. One large feed-borne outbreak involving 31infected pig herds occurred during the study period and only the first case of this outbreak was kept in the dataset (i.e. 30 of these herds were excluded) [Salmonella spp. as well as separately for the most common serotypes. Furthermore serotypes were grouped into cattle-, pig- and sheep-adapted types  and "other" representing mainly feed-associated serotypes, and summarised by animal species. Finally, analyses were also done for serotypes associated with small passerine birds (S. Typhimurium DT U277 and DT40) [Analysis of the data was done for all nd DT40) ,9.Because the exact coordinates of each farm from the earlier years were not available, and such detailed resolution was not deemed necessary, postal codes were used for geographical reference. A few of the postal codes had been changed since the data was first collected. Based on the address or if that was not possible, the municipality, new postal codes were obtained.Using various techniques in the software ArcGIS 10 , each case has been attributed with geographical coordinates representing the corresponding geometric centres, centroids, of the 5 digit postal code areas. Information for all cases has been stored in a geodatabase. From this geodatabase separate animated map series were generated for all serotypes or groups of serotypes isolated from pigs, cattle and sheep respectively. The maps were generated for each year and for each salmonella serotype, and subsequently amalgamated into versions conveying relevant information.Ocular inspection of the maps was made before deciding what maps would be used separately and what maps could be collapsed into one.In order to relate the distribution of cases to the geographical distribution of the animal populations, maps illustrating the animal density per 3 digit postal code area were created. For cattle, this was based on the average number of animals > 1 year of age on each holding in Sweden in 2008, as registered in the national database of individual cattle (Swedish Board of Agriculture). For pigs, the number of animals on each holding was based on data retrieved from the Swedish Board of Agriculture and the Swedish Animal Health Service in a previous study .Salmonella Typhimurium phage type 40 are shown in figure The total numbers of infected herds identified during 1993-2010 in different animal species are shown in figure Salmonella Dublin in cattle were located mainly in the southeast region of Sweden (Figure Salmonella Typhimurium cases were in the very south (Figure The cases of n Figure , while th Figure  and the h Figure . The oveh Figure .The cases in sheep herds were too few to observe any geographical clustering Figure .Seasonal variation was not investigated for sheep due to the low number of infected herds, and there was neither indication nor reason to suspect seasonal variation in pigs. Some seasonal variation was seen in cattle Figure , but avaThe species where Salmonella was first identified determined the species assigned to the herd. This may not be the same as the species that was first infected and cattle herds may be overrepresented. Complete data on how many herds that had more than one animal species infected was however not available.By establishing a geodatabase for all case data it has been possible to generate map series from almost any point of view. This facilitated the analysis. The data and the map documents generated can easily be published on a web map server giving access for others to share the results, but also for alternative analysis. The software allows for spatial statistical analysis of the gathered data. In this case, visual inspection of the generated maps proved to be enough to make the conclusions above. How GIS can add new dimensions to epidemiological work has clearly been demonstrated in other studies ,12.As the salmonella prevalence in Sweden is low, spatial and temporal analyses of data on infected herds might reveal insights not detectable in endemic regions. However, the low prevalence situation meant that full spatio-temporal analyses were not useful due to the number of herds being too low. Ocular inspection of the resulting maps and diagrams still indicate the presence of some spatial and temporal patterns. For instance, the detection of salmonella infected cattle herds appears to peak in September. The majority of cattle herds are detected through tracing form other infected herds, at necropsy or due to clinical symptoms . It coulS. Dublin or S. Typhimurium may be a reflection of the clustering of cattle movements in Sweden [S. Dublin, which is almost exclusively associated with cattle. The geographical clustering is also more pronounced for S. Dublin than for S. Typhimurium (figures The geographical clustering of cattle herds infected with n Sweden , where tn Sweden  and the  figures  and 6, tAnalyses of data on salmonella infected herds revealed some spatial and temporal patterns for salmonella in cattle. However, despite using 18 years' of data, the number of infected herds was too low for any useful statistical analyses and no patterns could be observed in pigs or sheep.Lars Skog is employed by ESRI, the company that produces the GIS software used in the study. He is conducting his PhD studies in the Royal Institute of Technology, Geoinformatics in Stockholm, on the use of GIS. Except for this, the authors have no competing interests.All authors participated in the design of the study. HW and SSL performed the data collection and data cleaning. LS produced the maps of infected herds and JF produced the population density maps. SSL wrote the manuscript and produced the graphs and table. All authors read and approved the final manuscript.


Due to fragmentation of care, continuity of care is often limited in the care provided to frail older people. Further, frail older people are not always enabled to become involved in their own care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals. This article describes the process evaluation of its implementation, and aims to establish (1) the outcomes of the implementation process, (2) which implementation strategies and barriers and facilitators contributed to these outcomes, and (3) how its future implementation could be improved.Mixed methods study, consisting of (1) a survey among professionals (n = 118) and monitoring the use of the ZWIP by frail older people and professionals, followed by (2) semi-structured interviews with purposively selected professionals (n = 12).290 frail older people and 169 professionals participated in the ZWIP. At the end of the implementation period, 55% of frail older people and informal caregivers, and 84% of professionals had logged on to their ZWIP at least once. For professionals, the exposure to the implementation strategies was generally as planned, they considered the interprofessional educational program and the helpdesk very important strategies. However, frail older people’s exposure to the implementation strategies was less than intended. Facilitators for the ZWIP were the perceived need to enhance interprofessional collaboration and the ZWIP application being user-friendly. Barriers included the low computer-literacy of frail older people, a preference for personal communication and limited use of the ZWIP by other professionals and frail older people. Interviewees recommended using the ZWIP for other target populations as well and adding further strategies that may help frail older people to feel more comfortable with computers and the ZWIP.This study describes the implementation process of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals. As e-health is an important medium for overcoming fragmentation of healthcare and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the positive results of this implementation are promising. Our current healthcare system is not well equipped to meet the needs of the growing population of frail older people . Due to Information Technology has the potential to diminish these problems, by means of a multidisciplinary shared Electronic Health Record that is accessible to patients as well ,8. ThereAs the program consisted of a number of interacting components and was delivered to several different general practices, conducting a process evaluation to study its implementation was considered critical . First, We evaluated the implementation of the ZWIP with a mixed methods study, consisting of (1) a quantitative evaluation by means of a survey and data collected during the implementation and use of the ZWIP, followed by (2) a qualitative evaluation by means of semi-structured interviews with purposively selected participants. The local ethics committee, the Committee on Research involving Human Subjects Arnhem-Nijmegen, reviewed the study and stated that no formal approval was required.Participants of the study were community-dwelling frail older people, who were patients of participating general practices in the province of Gelderland or Noord-Brabant, the Netherlands; their informal caregivers; and healthcare and welfare professionals involved in their care. They participated in the ZWIP during its implementation phase, which started in September 2010 and ended on the first of July 2011. We monitored the use of the ZWIP and its implementation strategies for both frail older people and professionals. Further, professionals were surveyed and interviewed. We chose not to survey or interview frail older people and informal caregivers as the project had already been time-consuming for them, and they would be surveyed and interviewed as part of the project’s future effect evaluation as well.The ZWIP was developed by means of Intervention Mapping , a methoThe ZWIP can be considered a combination of an Electronic Health Record accessible to the frail older person, informal caregiver and all professionals involved, with a tool for interprofessional and patient-professional communication. The ZWIP consists of (1) information about the frail older person’s health, functioning and social situation, contact information about professionals involved in their care, and care-related goals formulated by or with the frail older person, (2) a secure messaging system for communication between the frail older person and one or more professionals or between professionals, and (3) tailored educational materials for the frail older person and informal caregiver. The frail older persons hold the key to the ZWIP, as they decide which professionals are granted access to their personal ZWIP. The ZWIP can be entered by logging on to a website which conforms to Dutch security regulations. This website, which runs in Dutch, can be accessed from any computer. Frail older persons and their informal caregivers can log on by means of a shared user name and password, while professionals need a security token for logging on. The ZWIP implementation team consisted of the project manager, physicians, a nurse, a nurse scientist experienced with implementation, and research assistants working for the department of Geriatric Medicine of the Radboud University Nijmegen Medical Centre. They implemented the ZWIP using tailored implementation strategies for each target population, i.e. frail older people and informal caregivers, professionals and the employing organizations of professionals. An overview of the implementation strategies used is provided in Table We invited general practices affiliated with this University Hospital or involved in the program’s development to participate in the ZWIP, which was made available to them at no charge for the duration of the study. The participating practices invited local primary care professionals from all relevant disciplines involved in the care of frail older people, such as physiotherapists, district nurses and social workers, to take part in the programs’ interprofessional educational program. This program, for which continuing medical education credits were available, addressed screening for frailty, self-management support, interprofessional collaboration, and use of the ZWIP during three three-hour workshop meetings. In addition, professionals received coaching in specific components of the program, and were supported by a telephonic helpdesk. Further, financial compensation was provided for the time invested in the program.The general practices screened their populations of ≥70 years for frailty using a two-step screening questionnaire (Easycare-TOS). In the first step, the general practitioner (GP) selected patients which were considered (possibly) frail. In the second step, the thus selected patients were screened for frailty on the physical, psychological and social domain during a home visit by a nurse or gerontological social worker. During a second home visit, all people who were frail were invited to participate in the ZWIP. If they gave informed consent, a ZWIP was installed for them.We supported frail older people and informal caregivers in using the ZWIP by a number of strategies, such as offering a visit by a volunteer who could demonstrate the ZWIP, having a telephonic helpdesk available, and making the ZWIP available in print when this was preferred.The quantitative evaluation of the implementation of the ZWIP consisted of a survey for professionals, and an evaluation of the data collected about the use of the implementation strategies and the data from the ZWIP itself. Data collected included the numbers of older people screened, the number of participants, the number of messages sent, the number of professionals participating in a frail older person’s ZWIP, the number of participants who logged on to the ZWIP, the number of calls to the telephonic helpdesk and the number of visits to frail older people by volunteers.The survey for professionals was sent out at the beginning of July 2011. The survey was developed building on existing questionnaires used previously to evaluate the implementation of complex interventions and on previous experience of the authors. The survey included questions concerning demographics, time spent on using the ZWIP, perceived value of the implementation strategies, and barriers and facilitators for the use of the ZWIP. We used separate questionnaires for GPs, for nurses and gerontological social workers conducting the screening, and for other professionals. Participants were asked to fill out the survey online, those who did not respond were sent a paper version.The qualitative evaluation consisted of semi-structured interviews about experiences with the implementation process and perceived barriers and facilitators for the use of the ZWIP. A topic list for these interviews was developed by members of the research group and was adjusted until consensus was reached. We conducted these interviews with 12 purposively selected professionals, who had a variety of experiences with the implementation process of the ZWIP. This was arranged by selecting professionals from several disciplines and with different roles in the implementation process, who came from three general practices with varying levels of adoption of the ZWIP. In addition, we interviewed members of the implementation team, who were not involved in conducting its evaluation. Interviews were conducted by members of the research group  and were transcribed verbatim by a research assistant.We used descriptive statistics to describe baseline characteristics of participants, data collected about the implementation and the actual use of the ZWIP, and data derived from the survey for professionals. The qualitative data gathered in the semi-structured interviews were analyzed by two members of the research group  using content analysis . InterviFourteen general practices were invited to participate in the study, seven of these (50%) agreed to participate. The characteristics of these practices are shown in Table A total of 158 professionals received a survey, i.e. 39 GPs, 26 nurses and gerontological social workers conducting the screening, and 93 other professionals. Eleven professionals could not be reached. Hundred-eighteen professionals (75%) returned the questionnaire, 34 were GP’s, 22 were nurses and social workers who conducted the screening and connected frail older persons to the ZWIP, and 62 were other professionals, such as physiotherapists, pharmacists, nurses and social workers.Twelve purposively selected professionals participated in the semi-structured interviews. Three of them were GPs, three were nurses and gerontological social workers conducting the screening at the homes of participants, three were other professionals, i.e. pharmacists (n = 2) or physiotherapist (n = 1) and three were members of the implementation team, i.e. project manager, nurse providing coaching, or research assistant.The 290 frail older people who had a ZWIP account installed constituted 49% of all frail older people invited. The percentage of frail older people agreeing to participate varied over the separate general practices. Interviewees suggested that this may have been caused by variation in local professionals’ attitudes towards the ZWIP, as well as by variation in computer literacy due to social-economic differences between the general practices. An overview of the outcomes of the implementation process is provided in Table Most interviewees described being involved in the ZWIP of at least some frail older people, varying from one to tens of people. Some used the ZWIP quite often for a limited number of frail older people, whereas others rarely used it. Interviewees described that most frail older people and their informal caregivers made limited use of the ZWIP. On the other hand, they also gave examples of frequent users of the ZWIP. One interviewee described that the use of the ZWIP was limited when the frail older person was in good health, but that its use increased when the frail older person became ill. Table All but one of the planned implementation strategies targeting professionals Table  had beenExposure of professionals and frail older people and informal caregivers to the separate implementation strategies varied over the participating general practices Table . For insOf the surveyed professionals who had participated in the educational program, 70% 63 of 89) considered it (very) necessary for being able to work with the ZWIP. Interviewees confirmed this, as they felt that meeting each other and gaining knowledge about each others’ expertise during the educational program facilitated collaboration, and they appreciated the opportunity to ask questions and to practice working with the ZWIP. However, they did feel that the educational program could have been shorter, and that too much time had elapsed between the educational program and the first frail older persons having a ZWIP. As for the coaching, only 26% 14 of 53) of surveyed professionals who had received coaching felt they would not be able to work with the ZWIP without it. However, interviewees did consider coaching necessary, as they appreciated the assistance of someone experienced in conducting the screening and entering data in the ZWIP. The helpdesk was considered (very) necessary by 77% (41 of 53) of surveyed professionals who had contacted it, and interviewees agreed that it was useful  of surveyed professionals considered the time spent on using the ZWIP (very) limited. Further, limited use of the ZWIP by both professionals and frail older people presented a barrier to respectively 52% (50 of 94) and 60% (56 of 94) of surveyed professionals  had not been involved in the development process themselves, the use of a mixed-methods design which combined multiple data sources, and the ZWIP being implemented directly in everyday practice for use in regular care.This study has described the implementation of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals, which had positive results. The implementation strategies for professionals, especially the involvement of the target populations in its development, the educational program which resulted in professionals getting to know each other personally and the helpdesk, as well as the experienced need for improving care for frail older people contributed to this. However, the strategies intended to improve frail older people’s computer literacy did not always succeed as exposure to these strategies was limited. Therefore, both additional strategies targeting frail older people’s computer literacy and reviewing the ZWIP to optimise its user-friendliness are needed. Nevertheless, as e-health is an important medium for overcoming healthcare fragmentation and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the results of this implementation are promising.Based on the current study, several recommendations can be made for the implementation of comparable e-health interventions. First, when e-health innovations are directed at populations who currently have limited computer literacy, such as frail older people, implementation efforts should focus on improving this by e.g. a comprehensive training program . PilotinThe authors declare that they have no competing interests.SR was involved in the design of the study, conducted the interviews, conducted the data analysis and drafted the manuscript; MP was involved in the design of the study, conducted the interviews, conducted the data analysis and critically reviewed the manuscript; MH was involved in the design of the study and critically reviewed the manuscript; LvN conducted the interviews and critically reviewed the manuscript; HS was involved in the design of the study and critically reviewed the manuscript; CvW critically reviewed the manuscript; MOR critically reviewed the manuscript; TvA was involved in the design of the study and critically reviewed the manuscript; MMH was involved on the design of the study and critically reviewed the manuscript; RM was involved in the design of the study and critically reviewed the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/251/prepubMovie demonstrating the use of the Health and Welfare Information Portal by a frail older person and her informal caregiver. (WMV 16069 kb)Click here for file