Misoprostol and vacuum aspiration are comparable in safety and effectiveness for treating incomplete abortion.Misoprostol, which can be provided by trained nurses and midwives, shows substantial promise for extending PAC services to secondary hospitals and primary health posts.Postabortion family planning uptake generally increases rapidly-and unintended pregnancies and repeat abortions can decline as a result-when a range of free contraceptives, including long-acting methods, are offered at the point of treatment; male involvement in counseling-always with the woman’s concurrence-can increase family planning uptake and support.Twenty years of postabortion care (PAC) studies yield strong evidence that: Misoprostol and vacuum aspiration are comparable in safety and effectiveness for treating incomplete abortion.Misoprostol, which can be provided by trained nurses and midwives, shows substantial promise for extending PAC services to secondary hospitals and primary health posts.Postabortion family planning uptake generally increases rapidly–and unintended pregnancies and repeat abortions can decline as a result–when a range of free contraceptives, including long-acting methods, are offered at the point of treatment; male involvement in counseling–always with the woman’s concurrence–can increase family planning uptake and support.Twenty years of postabortion care (PAC) studies yield strong evidence that: Worldwide 75 million women need postabortion care (PAC) services each year following safe or unsafe induced abortions and miscarriages. We reviewed more than 550 studies on PAC published between 1994 and 2013 in the peer-reviewed and gray literature, covering emergency treatment, postabortion family planning, organization of services, and related topics that impact practices and health outcomes, particularly in the Global South. In this article, we present findings from studies with strong evidence that have major implications for programs and practice. For example, vacuum aspiration reduced morbidity, costs, and time in comparison to sharp curettage. Misoprostol 400 mcg sublingually or 600 mcg orally achieved 89% to 99% complete evacuation rates within 2 weeks in multiple studies and was comparable in effectiveness, safety, and acceptability to manual vacuum aspiration. Misoprostol was safely introduced in several PAC programs through mid-level providers, extending services to secondary hospitals and primary health centers. In multiple studies, postabortion family planning uptake before discharge increased by 30–70 percentage points within 1–3 years of strengthening postabortion family planning services; in some cases, increases up to 60 percentage points in 4 months were achieved. Immediate postabortion contraceptive acceptance increased on average from 32% before the interventions to 69% post-intervention. Several studies found that women receiving immediate postabortion intrauterine devices and implants had fewer unintended pregnancies and repeat abortions than those who were offered delayed insertions. Postabortion family planning is endorsed by the professional organizations of obstetricians/gynecologists, midwives, and nurses as a standard of practice; major donors agree, and governments should be encouraged to provide universal access to postabortion family planning. Important program recommendations include offering all postabortion women family planning counseling and services before leaving the facility, especially because fertility returns rapidly (within 2 to 3 weeks); postabortion family planning services can be quickly replicated to multiple sites with high acceptance rates. Voluntary family planning uptake by method should always be monitored to document program and provider performance. In addition, vacuum aspiration and misoprostol should replace sharp curettage to treat incomplete abortion for women who meet eligibility criteria. Worldwide, 210 million women become pregnant annually; 135 million will have a live birth, and 75 million, or one-third, will have a spontaneous or induced abortion and need postabortion care (PAC). Of the 75 million abortions, 31 million are spontaneous (miscarriages) and 44 million are induced; half of the induced abortions are unsafe, performed by persons lacking the necessary skills or in an environment not in conformity with minimal medical standards.Since 1994, the United States Agency for International Development (USAID) has supported implementation of PAC programs in more than 40 countries to address complications related to miscarriage and incomplete abortion.The 3 components of USAID’s PAC model areEmergency treatmentFamily planning counseling and service delivery, and where financial and human resources exist, evaluation and treatment of sexually transmitted infections (STIs) as well as HIV counseling and/or referral for testingCommunity empowerment through community awareness and mobilizationUSAID’s PAC model contains 3 components: emergency treatment, family planning, and community empowerment.,PAC is an integral part of maternity care, and all components of PAC services are essential, as stated at the 1994 International Conference on Population and Development. All 3 components have been included in USAID programs since 1994.-In 2007, USAID published the first global PAC research compendium, “What Works, A Policy and Program Guide to the Evidence on Postabortion Care,” which reviewed the PAC literature from 1994 through 2003.The first and second editions of the USAID PAC research compendium reviewed in detail more than 550 articles and reports published between 1994 and 2013, representing 20 years of PAC research.,We searched Scopus, MEDLINE, and POPLINE for relevant PAC interventions that had been evaluated, using several search words relevant to PAC, such as postabortion care, postabortion contraception, incomplete abortion, abortion complications, dilation and curettage, misoprostol, and manual vacuum aspiration. If the article title indicated there might be an intervention that could be replicated, we reviewed the full-text article to determine if there was sufficient information to be included in the “What Works” compendium and that the intervention took place in low- or middle-income countries in Asia, Africa, Latin America, or the post-Soviet states.Key interventions that had taken place only in high-income countries  were included only if we determined that the interventions could be relevant for low-resource country contexts but had not yet been initiated in developing countries.,We also reviewed unpublished reports (gray literature) from key websites to supplement the studies published in peer-reviewed publications because of the limited amount of published literature on PAC. The websites reviewed comprised United Nations (UN) agencies, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), the Cochrane Collaboration, the Open Source Initiative (OSI), the International Center for Research on Women (ICRW), Futures Group, Population Services International (PSI), the Population Council, the International Council of Women (ICW), the World Bank, Family Health International (FHI) (renamed FHI 360 in 2011), Gynuity Health Projects, Ipas, and the Guttmacher Institute. Biomedical information was included insofar as it was relevant to programmatic considerations. The articles and reports included in our review covered the 3 components of the USAID PAC model as well as a fourth component that addressed policy, programs, and health systems in postabortion care. We adapted the Gray scale  with itsStudies with strong evidence for postabortion care are highlighted in this article and critical areas for future research are identified. Preference was given to studies from the Global South, but where evidence was scant from the South, studies from the Global North were included. Both editions of the compendium include a full description of the evidence statements along with complete references. In this article, we summarize the strong evidence we consider most applicable for extending PAC services, increasing access to family planning, improving cost-efficiency, and enhancing client satisfaction.Recent PAC studies (2004–2013) reinforce most of the strong evidence statements from the 2007 PAC research compendium; specifically, those related to access to services, quality of care, community awareness of PAC, and postabortion family planning. Recent research also highlights the continuing challenges of providing complete PAC services, including family planning, counseling, and client information. Treatment options for incomplete abortion, task shifting, and decentralizing services are rapidly evolving and well documented.In this section, we summarize key findings on the 4 main components covered in the scope of our literature review: (1) emergency treatment of incomplete abortion, (2) postabortion family planning counseling, including STI/HIV evaluation, (3) community empowerment, and (4) health systems and policies.Vacuum aspiration, either electric vacuum aspiration (EVA) or manual vacuum aspiration (MVA), is safer and less painful than sharp curettage, which is usually performed with general anesthesia in an operating theater.Women treated by vacuum aspiration  for incomplete abortion had shorter procedures and significantly less blood loss than those treated by sharp curettage. Pain is generally less than with sharp curettage.The use of general anesthesia with sharp curettage is associated with increased risk of blood loss, cervical injury, uterine perforation, and subsequent abdominal hemorrhage.,,Verbal support (“verbacaine”) to provide reassurance and diversion during the MVA procedure and/or paracervical block were generally inadequate for pain management with MVA.,Paracervical block with local anesthesia for incomplete abortion with an open cervix provided no discernible benefit over placebo in studies of MVA procedures.-Costs can be substantially reduced by introducing MVA to replace sharp curettage when accompanied by changes in protocols for admission, place of procedure (often a simple procedure room), and an improved service delivery model that gives priority to PAC clients. Direct costs are reduced by avoiding use of the operating theater, general anesthesia, blood transfusions, and prolonged hospital stays.,Prophylactic antibiotics to prevent postoperative infection have not shown effectiveness in the relatively underpowered studies from the Global South.Electric and manual vacuum aspiration are safe, effective, and preferable to sharp curettage for uterine evacuation.The past decade has seen major advances in medical evacuation using misoprostol for treatment of incomplete abortion. Misoprostol is rapidly gaining acceptance as a safe, effective treatment for incomplete abortion in primary and secondary outpatient settings and can be provided by trained nurses and midwives. It should be an available option for women needing postabortion care.Misoprostol is safe and effective for treatment of incomplete abortion and can be provided by trained nurses and midwives. Evidence from at least 16 studies of misoprostol points to an optimal dose and route of administration of 400 mcg sublingually or 600 mcg orally; both are equally effective for treating uncomplicated first-trimester incomplete abortion, either spontaneous or induced. No advantage was seen with higher or multiple doses, or when given by other routes of administration.Study criteria for misoprostol treatment typically included first-trimester incomplete abortion without complications and an open cervix. Other selection criteria in clinical trials usually included women residing within one hour’s travel distance of a hospital. Back-up surgical evacuation and ultrasound were available on site or by ready referral to another regional or tertiary hospital.,-Successful evacuation rates with misoprostol ranged 89%–99% at 1–2 weeks post-treatment.Success rates were lower in studies with shorter time frames for judging completion and more frequent follow-up visits. For example, one study scheduled the first follow-up visit at day 2; if evacuation was not complete, women could opt to return at day 7, but not later. Success rates were lower and also different between the 2 study sites, 44% vs. 85%, suggesting major provider and institutional variations. The authors of the study acknowledged that providers’ lack of confidence in using misoprostol may partly explain the large differences between sites.-Surgical evacuation is still needed for the 2% to 8% of women with incomplete evacuation following misoprostol; women presenting with complications ; women with advanced gestational age; and women who prefer surgical management.,,,,,,-Recent programmatic expansions in Senegal document favorable client and clinical outcomes when misoprostol is given at lower-level health facilities farther from hospitals.Major findings with misoprostol for PAC are as follows:Success rates were comparable with MVA in most studies using doses of 400 mcg sublingually or 600 mcg orally with optional follow-up extended to 2 weeks . Surgica,Complications were low and comparable to MVA. Most studies reported less pain with misoprostol than with MVA.,,,,High client satisfaction and complete evacuation rates were also achieved when misoprostol was expanded to secondary and district hospitals and health posts that had no previous capability to treat incomplete abortion.-Pain management with ibuprofen, 800 mg to 1000 mg, was generally adequate and clearly superior to paracetamol (acetaminophen).,,Routine ultrasound was not necessary to diagnose incomplete abortion or confirm complete uterine evacuation when misoprostol was used at less than 12 weeks gestation; clinical judgment was adequate for the large majority of cases.,,Two studies noted that ultrasound available through referral was helpful for establishing ectopic pregnancy, determining gestational age, and confirming complete evacuation for a few cases.,,,,Mid-level clinicians can correctly diagnose and treat incomplete abortion with misoprostol and accurately determine complete evacuation.,Although emergency treatment for incomplete abortion often receives greater attention than postabortion family planning, the family planning component to reduce preventable child and maternal deaths in both the postpartum and postabortion periods is a growing focus for maternal, neonatal, and child health programs.,The Family Planning High Impact Practices brief on postabortion care summarized the results of 15 studies to strengthen postabortion family planning in 14 countries.Postabortion family planning uptake before discharge increased by 30–70 percentage points in 1–3 years when family planning services included a wide range of methods provided at the same time and location as treatment.,,-,,Multiple studies (published between 1998 and 2010) from 9 countries show that training providers in family planning counseling, service delivery, and MVA increases family planning uptake.-After women gave permission for including their husbands in counseling, family planning use increased. Counseling covered follow-up care, rapid return to fertility, and family planning methods. Men also provided physical, emotional, and material support for PAC clients during recovery. Husbands who were counseled were 60% more likely to provide a high level of support for family planning use; 30% were also more likely to provide a high level of emotional support.,,,,Providing all contraceptive methods free to PAC clients greatly contributed to the increased uptake of postabortion family planning prior to discharge from the facility.Couples counseling, with approval from the woman, improved family planning uptake and support.Providing all contraceptive methods free greatly increased uptake of postabortion family planning because many women cannot pay at the time of treatment.Delaying the next pregnancy for at least 6 months after miscarriage or abortion reduces the incidence of preterm delivery, low birth weight, premature rupture of membranes, and maternal anemia.,Insertion of an intrauterine device (IUD) immediately after a first-trimester abortion yielded few expulsions and carried no increased risk of perforation or infection. There was only a minimal increase in expulsion rates over delayed insertion.,,Several studies found that women receiving immediate postabortion LARCs had fewer subsequent unintended pregnancies and repeat abortions than those who were offered delayed insertions (3 to 6 weeks post-procedure).-Women with HIV who are symptomatic are at an increased risk for spontaneous abortion.We did not find documentation that PAC services routinely included counseling on STI and HIV risk factors and provided condoms for prevention. One study identified this as an unmet need.-,,,,Women who have undergone induced or spontaneous abortion may require special counseling considerations. Increased risk of spontaneous abortion is associated with several common conditions, including malaria, HIV/AIDS, STIs, gender-based violence, smoking, excess alcohol use, exposure to pesticides, and previous spontaneous abortion.About one-third of women seeking abortion have been victims of abuse sometime during their lifetime.,A substantial percentage (40%) of PAC clients are under the age of 25, yet they account for almost half of the deaths from unsafe abortion.,The Community Action Cycle—a participatory problem-solving approach involving community diagnosis, planning, implementation, participatory evaluation, and scale-up—can increase awareness of PAC services, especially through training of CHWs to provide postabortion family planning counseling and services, including referral to facilities.In several countrywide PAC programs, postabortion family planning is emerging as a strong program component.Nepal was one of the first countries to widely replicate PAC programming and document valuable lessons learned during the expansion phase. The lessons are especially relevant as the challenges are similar throughout most PAC programs. In 1995, Nepal first initiated PAC services at the Maternity Hospital in Kathmandu. It then expanded services to 78 sites in 50 districts mainly in public-sector health facilities.In Nepal, technical support service centers were crucial for institutionalizing comprehensive PAC services. Resistance by doctors and hospital management to nurses providing MVA was partly overcome through formal and informal orientations for doctors. Structured on-the-job training was cost-effective for maintaining PAC skills and strengthening services. PAC program data were difficult to collect as they were not included in the Ministry of Health and Population’s regular health management information system. Challenges included the frequent transfer of trained PAC service providers; unavailability of family planning services to women having sharp curettage procedures; insufficient caseload at some sites to support group-based training; and irregular supply and replacement of MVA equipment.Guatemala expanded its PAC program to 22 of the 33 public district hospitals. The 22 district hospitals increased postabortion family planning counseling from 31% to 78% over 18 months; postabortion family planning acceptance before discharge rose from 20% to 49%; and vacuum aspiration increased from 38% to 68%.Tanzania achieved high performance when initiating PAC with MVA, expanding from 11 to 229 sites between 2005 and 2010. In 2010, the PAC program served 9,563 PAC clients, with 84% of women being counseled on family planning and 82% accepting a method.In replicating PAC services, Rwanda engaged lower-level health facilities to provide PAC, including misoprostol, and increased use of family planning services. Before the pilot program, only 2 of 50 health centers were providing PAC services; all other health centers referred PAC clients to hospitals. Within a year, 91% of PAC clients were treated at health centers and only 9% were referred to hospitals. Overall, misoprostol was used to treat 83% of PAC clients, and 59% of women were discharged with a contraceptive method.,,,An expanded scope of practice for mid-level providers was assessed in a number of studies providing PAC service delivery. These studies confirm the safety, effectiveness, and acceptability of trained nurses and midwives as providers of MVA, affirming their ability to accurately determine complete evacuation.,,Twelve studies compared costs for PAC services using MVA versus sharp curettage. There was strong evidence that using MVA for PAC instead of sharp curettage along with changes in protocols and an improved service delivery model can significantly reduce costs of care in most cases.Changes in protocol to the standard use of MVA with local anesthesia if the uterus was smaller than 12 weeks’ sizeProviding PAC as an ambulatory outpatient procedureProvider training on information and counseling Refresher training and supportive supervisionUsing MVA instead of sharp curettage can significantly reduce costs of care in most cases.-A number of cost studies document the high cost of treating abortion complications, the value of expanding PAC services with a robust family planning component, and the substantial savings that could be achieved by preventing unintended pregnancies and abortion through improved contraceptive services.One study also made the case that greater use of misoprostol for PAC could free surgical resources to be used for more complicated cases.The implications for practice flow from PAC research documenting practices that impact health outcomes and that are practical and cost-efficient to implement. These include emergency treatment of incomplete abortion and postabortion family planning.,,,Medical (misoprostol) and surgical management  have been proven to offer safer options over sharp curettage for treatment of incomplete abortion. In countries where both misoprostol and vacuum aspiration are authorized, women should be informed of appropriate treatment options. Programs should ensure that both are available, staff are trained, and communities are informed, including CHWs. New protocols and training curricula for vacuum aspiration and medical evacuation, for example, from USAID and Ipas, incorporate the findings of recent research and will facilitate revised practices.The voluntary informed choice of whether to use contraception must always be solely that of the woman. Asking the woman about her reproductive intentions and providing counseling for all methods  will promote informed and voluntary choice for her; her health and that of her next pregnancy will benefit. Several studies have found an urgent need to improve content and quality of client counseling. The most important recommendations emerging from PAC studies are to offer all women family planning counseling and services before they leave the facility regardless of the method of uterine evacuation, and to complement counseling with written instructions on:Her chosen contraceptive method—including how to use the method, what to expect, and how to resupplyThe rapid return of fertility after the abortion (within 2 to 3 weeks)The signs and symptoms of postabortion complications  that would need medical attentionAll postabortion women should receive family planning counseling and services before they leave the facility.These actions are endorsed by a joint consensus statement by the professional organizations of obstetricians/gynecologists, midwives, and nurses along with major donors.The International Confederation of Midwives (ICM) recently included PAC and postabortion family planning as basic skills in their “Essential Competencies for Basic Midwifery Practices”.Health management information systems need to universally report postabortion contraceptive services as an essential measure of program and provider performance. Documentation should include the percentage of postabortion clients receiving contraceptives by method before leaving the facility and at return visits.Documentation of method-specific uptake in the postabortion period needs a special focus when using misoprostol. Many of the misoprostol studies failed to report on this key component of PAC. LARCs deserve special emphasis, given that postabortion IUD insertion must be delayed until complete evacuation after misoprostol.Among the many topics for future research, two especially stand out. Cost studies are needed to better assess the potential benefits of misoprostol in comparison with both vacuum aspiration and sharp curettage, especially given that sharp curettage is still widely used. Better evaluation is needed on the effects of misoprostol on expanding the scope of practice for nurses and midwives, frequency of surgical procedures, use of lower-level facilities, and community engagement.For women wanting to use the IUD postabortion, there may be benefits to offering immediate postabortion insertion with vacuum aspiration as an alternative to delayed insertion with misoprostol and the lost-to-follow-up that inherently occurs—an opportunity for research.Advocacy for universal access to postabortion family planning is supported by health professional organizations, major donors, and maternal health networks.


Kiran Jobanputra and colleagues argue that better evidence, guidance, and tools are needed to improve the effectiveness and feasibility of noncommunicable disease care in humanitarian settings. Treatment of noncommunicable diseases (NCDs) is particularly challenging in settings affected by humanitarian crises, where insecurity and damaged health systems reduce access to treatment. While a United Nations (UN) Political Declaration and a World Health Organization (WHO) Global Action Plan recognise the significant contribution of NCDs to global morbidity and mortality , 2, the The diversity of the epidemiology of NCDs and health system characteristics in humanitarian crises preclude a simple “one size fits all” approach. The demographics of crisis-affected populations also vary. For example, among Syrian refugees in Jordan, Médecins sans Frontières (MSF) have observed a higher proportion of older people, females, and more frail individuals than among displaced populations in transit within Syria and in neighbouring Lebanon. The Syrian conflict has also displaced populations that have high levels of obesity, diabetes, and cardiovascular disease linked to urbanisation and lifestyle factors . In contThe UN Interagency Task Force on NCDs (UNIATF) has recently published brief guidance on NCDs in emergencies . AlthougThere is a lack of informative NCD-related epidemiology in emergency settings, such that in many cases, NCD care provision is based on immediately identified and sometimes presumptive needs, with little data to inform health care priorities or approach. Population-level surveys and digital surveillance systems are starting to provide some understanding of NCD epidemiology amongst displaced populations in the Middle East . HoweverThe setup of NCD services in humanitarian settings will vary with resources and geography, preexisting health systems, and the availability and experience of medical staff. For example, MSF’s NCD clinic in Irbid in Jordan is structured along the lines of a European-style chronic care clinic in a primary care centre, with multidisciplinary care, integrated mental health and social work services, and Short Message Service (SMS) text message appointment reminders. By contrast, the MSF diabetes clinic in North Kivu takes the HIV service as its blueprint, in terms of the organisation of patient flow, expert patient counselling, nurse-led care, and use of family members as treatment supporters. Rigorous monitoring and evaluation with cohort analysis will help target interventions to address the weak points in NCD services. Clinical audit is helping us to simplify and streamline these models of care; for example, in a refugee health programme in Jordan, an audit of statin prescribing for prevention of cardiovascular disease found that cholesterol quantification did not increase coverage of appropriate statin prescribing and instead resulted in many patients not having a risk score calculated . The disTo fill a gap in appropriate clinical guidelines, MSF have developed draft NCD Clinical Guidelines for humanitarian settings, influenced by guidelines from WHO, the National Institute for Health and Care Excellence (NICE) and the European Society for Cardiology (ESC) guidelines Better evidence, guidance, and tools will improve the effectiveness and feasibility of NCD care in humanitarian settings. Evidence on minimum viable packages for NCD care in different settings will also help inform advocacy efforts, showing donors that good quality care for NCDs is feasible and effective and demonstrating the costs involved. Since NCD care is complex and comorbidity is particularly common in humanitarian settings, health care actors will need to work in a coordinated fashion to ensure relevant services are integrated and patient centred. Partnerships between operational and academic agencies will be critical to ensure that high-quality evidence can be generated to support NCD programming in these difficult settings.


New data from the Global Burden of Disease (GBD) Study 2016 indicate substantial declines in the prevalence and disease burden (as measured in disability-adjusted life years [DALYs]) of six of the seven neglected tropical diseases (NTDs) targeted by integrated mass drug administration (MDA) over the previous decade.During the early 2000s, a concept was proposed for linking or integrating MDA in order to simultaneously target trachoma and six helminth infections—ascariasis, trichuriasis, hookworm, schistosomiasis, lymphatic filariasis (LF), and onchocerciasis , 2. CentFor such African populations, a package of drugs, initially called “rapid impact,” could be delivered . The druIt was further predicted that gains could be achieved in terms of efficiencies and cost-effectiveness. Indeed, because of the drug company donations, it was estimated that integrating NTD control through the rapid-impact package of essential medicines could reduce DALYs roughly approximating those of HIV/AIDS, tuberculosis, or malaria , but at In addition, collateral benefits could also be achieved because of the impact of ivermectin on scabies and other ectoparasitic infections, as well as strongyloidiasis; albendazole on oesophagostomiasis; praziquantel on cestodes; and azithromycin’s ability to treat other bacterial infections, including yaws, and possibly adult mortality rates , 6, 7, 8The concept of rapid impact helped to drive new pro-poor policies. By 2006, a new Department of NTDs was established at the World Health Organization (WHO) with Dr. Lorenzo Savioli as its inaugural director, and funds were appropriated by the United States Congress via USAID and the British Parliament through the UK Department for International Development to support implementation of integrated NTD control. Shortly thereafter, this approach expanded from Africa to Asia and the Americas. In 2012, the commitment of the major multinational pharmaceutical companies—which now also included donations for praziquantel (Merck KgaA); triclabendazole for fascioliasis (Novartis); and diethylcarbamazine citrate for LF , among others —was reaffirmed through a London Declaration for NTDs in 2012. New NGDOs entered into the NTD space under umbrella organizations such as the Global Network for NTDs and Uniting to Combat for NTDs. These latter activities also reflected renewed interest by the Bill & Melinda Gates Foundation. The scale-up of MDA proceeded rapidly such that WHO reported that in 2016, an estimated 1.024 billion people had received at least one essential NTD medicine from the rapid-impact package, representing 62.3% of the world’s population requiring treatment .The newest information released by the GBD Study 2016 reveals critical progress in reducing the global disease burden resulting from NTDs, both globally and within sub-Saharan Africa , 12. OveThe reduction in DALYs likely reflects both the reduction in disease prevalence and intensity due to either the direct impact of MDA on worm burdens or, in some cases, to the interruption of disease transmission. In addition, there may be added effects due to reductions in disability that result from patient care. The data sources we report here do not enable a distinction between these pathways. Thus, while such information does not prove that MDA and other pro-poor policies produced these results, it presents a plausible hypothesis for future investigations given that there has been limited expansion of other determinants of infection such as specific health education, clean water provision, and improved sanitation.It is also interesting to note that the least impact was for human hookworm infection—both globally and in sub-Saharan Africa, the age-standardized DALYs decreased only 13% . This fiFor trachoma, the GBD prevalence estimates number of individuals living with visual impairments from blinding trachoma rather than those with active infection. As such, reductions in trachoma prevalence may directly reflect improvements in population health and access to eye care services but will not necessarily correlate with the impact of MDA over the last decade, which aims to reduce the transmission of infection, together with simple surgeries, face washing, and environmental control (known by the acronym of SAFE).In addition, and as shown in GBD 2016 is providing important information in order to assess the global impact of MDA and other NTD interventions, and there appear to be substantial health gains as reflected in reductions in disease burden and prevalence since 2006. With respect to disease burden assessments, de Vlas and colleagues recently estimated that NTD programs will avert some 600 million DALYs in the period 2011–2030 for ten NTDs targeted by the London Declaration . ApproxiWe must urgently and more effectively assess the true impact of integrated MDA and whether this approach was indeed the driver for the disease burden and prevalence reductions reported here. Implicating such associations might require individual country-level data in order to examine the effects in real time and whether they coincide with the timing of national control programs. We initially projected that the unit costs of programs would be around US$0.40 annually ,2, and tFinally, while our original call to integrate MDA also included efforts to link this approach with HIV/AIDS and malaria control , 9, 17, The last decade has witnessed extraordinary progress towards global NTD control and elimination. It will be critical for this new generation of global leaders to continue their NTD commitments , 19.


Chris Beyrer and colleagues reflect on an underappreciated trend in multiple African, Asian, and Caribbean settings, in which the provision of HIV and other essential health services for sexual and gender minorities is expanding despite challenging legal and social environments. At the 21st International AIDS Conference in July, 2016, in Durban, South Africa, The Elton John AIDS Foundation (EJAF) and the United States President's Emergency Plan for AIDS Relief (PEPFAR) program announced the inaugural awardees of the new US$10 million initiative to increase access to HIV services for lesbian, gay, bisexual, and transgender (LGBT) individuals and communities in Africa and the Caribbean. The awardees of the fund were the International HIV/AIDS Alliance (IHAA) and the Global Forum on Men Who Have Sex with Men (MSM) and HIV (MSMGF), both community-based organizations with track records in providing support at the grassroots to LGBT populations, including in many countries where sexual and gender minorities remain stigmatized and, too often, criminalized for their behaviors, identities, or gender expression [This extraordinarily welcome step speaks to a larger and little-appreciated trend underway in multiple African, Asian, and Caribbean settings, in which the provision of HIV and other essential health services for sexual and gender minorities are expanding despite challenging legal and social environments. Although in some high HIV burden countries there is strong opposition to such efforts, in others—Kenya is an example—coverage and quality of service provision continue to improve despite legal obstacles. The government of Kenya recently approved pre-exposure prophylaxis (PrEP) for gay and other MSM without first decriminalizing same-sex sexual acts . South AMe and My Health Care Provider—to celebrate physicians, nurses, and other providers offering culturally competent HIV and other sexually transmitted infections (STI) prevention, treatment, and care services for key population patient groups, including gay men, other MSM, and transgender clients [Also, at AIDS 2016, the International AIDS Society and EJAF launched a new initiative— clients . Provide clients . CamerooThese efforts are encouraging and are forging new paths in difficult environments. At the same time, evidence that anti-gay laws negatively affect HIV outcomes continues to mount. For example, the TRUST cohort, a large prospective cohort study of Nigerian MSM living with or at risk for HIV, provided the context for a natural experiment of sorts when, in 2014, Nigeria imposed a harsh anti-gay law, the “Same-Sex Marriage Prohibition Act,” which extended Nigeria’s existing sodomy laws . In addiOther studies from Malawi, Namibia, and Botswana—all countries that criminalize same-sex behavior—have also demonstrated that fear of seeking health care because of sexual minority status is a potent barrier to seeking HIV services, including HIV testing, the first critical step in engaging in either the prevention or treatment continuums of care .Therefore, although improving health services in the face of repressive laws is admirable and beneficial, legal reform—often a slow and contentious process—is necessary in the long term. In his dissent from the 2003 US Supreme Court decision overturning sodomy laws across the US, Justice Antonin Scalia objected that decriminalizing homosexuality and same-sex practices more broadly would constitute significant steps towards full citizenship rights (notably marriage) for LGBT persons . AlthougCriminalization and stigmatization not only perpetuate systematic discrimination and violence that limit the study of HIV risks for MSM; they also restrict the extent to which health care providers can effectively offer and MSM can safely access health care services that would reduce HIV transmission and treat HIV infection  . CriminaWhile the legal, human rights, and LGBT advocacy communities work to advance structural reforms such as overturning sodomy statutes, community-based clinical and service providers have vital roles to play in the realization of more immediate rights and benefits, including the right to dignity, safety, and equitable access to services in health care settings. The progress that they are making is essential, because the sustained high rates of incident HIV infections among young gay, bisexual, and other MSM, globally as in the US, remain a critical challenge to controlling the HIV epidemic.


The advent of farming was associated with thousands of years of manual labor for women that exceeded that of living athletes. The intensification of agriculture is often associated with declining mobility and bone strength through time, although women often exhibit less pronounced trends than men. For example, previous studies of prehistoric Central European agriculturalists  demonstrated a significant reduction in tibial rigidity among men, whereas women were characterized by low tibial rigidity, little temporal change, and high variability. Because of the potential for sex-specific skeletal responses to mechanical loading and a lack of modern comparative data, women’s activity in prehistory remains difficult to interpret. This study compares humeral and tibial cross-sectional rigidity, shape, and interlimb loading among prehistoric Central European women agriculturalists and living European women of known behavior (athletes and controls). Prehistoric female tibial rigidity at all time periods was highly variable, but differed little from living sedentary women on average, and was significantly lower than that of living runners and football players. However, humeral rigidity exceeded that of living athletes for the first ~5500 years of farming, with loading intensity biased heavily toward the upper limb. Interlimb strength proportions among Neolithic, Bronze Age, and Iron Age women were most similar to those of living semi-elite rowers. These results suggest that, in contrast to men, rigorous manual labor was a more important component of prehistoric women’s behavior than was terrestrial mobility through thousands of years of European agriculture, at levels far exceeding those of modern women. BC to 100 AD], on average, male tibial diaphyses became significantly straighter and, in cross section, smaller in area, less rigid, and more circular  loading through time, where Medieval women had significantly straighter tibial diaphyses that were more circular in cross section than their earliest farming counterparts in the Neolithic period  properties and interlimb strength proportions among prehistoric women spanning the first ~6150 years of agriculture in Central Europe  in relation to a comparative group of living European women of known behavior. Interlimb strength proportions between the humerus and the tibia were used to characterize the relative importance of manual labor versus terrestrial mobility among agricultural women. Although tibio-humeral strength proportions have never been used in the analysis of behavioral differences among human populations, femoro-humeral structural proportions have proven useful in this regard (J), cross-sectional shape (Imax/Imin), and interlimb strength proportions are compared between Neolithic, Bronze Age, Iron Age, and Medieval women and living female athletes, as well as recreationally active control subjects as a reference group of low-impact loading. Athletes were included from three sports that load the limbs with differing intensity and directionality: (i) endurance running, high lower limb loading based on ground reaction force and unidirectional loading trajectories; (ii) football (soccer), high lower limb loading based on ground reaction force and multidirectional loading trajectories; and (iii) rowing, higher repetitive upper limb loading based primarily on joint contact forces and unidirectional loading trajectories. This comparative data set was used to explore the following questions: (i) To what extent can the apparent homogeneity in interpopulation variation in female tibial morphology among early agricultural women be explained by high internal variability? (ii) Were Central European prehistoric farming women more mobile than living sedentary women? (iii) Among prehistoric Central European females, was manual labor a more rigorous behavioral component of agricultural intensification than terrestrial mobility?Size-standardized humeral and tibial polar second moments of area (J) was significantly higher among Neolithic, Bronze Age, and Iron Age women than rowers, football players, and controls. In the right humerus, mean J was significantly higher among Neolithic, Bronze Age, and Iron Age women than football players and control subjects. Iron Age women also had significantly higher mean humeral rigidity than Medieval women. In contrast, mean midshaft tibial J . Mean tibial J among football players also significantly exceeded the particularly low values among Bronze Age and Medieval women.Summary statistics for all female solid-section CSG properties by group are presented in tibial J  was signJ than endurance runners, Neolithic women did not differ significantly from them in tibial Imax/Imin  significantly exceeded those of Medieval women and living control subjects. Bronze Age, Iron Age, and Medieval women and living control subjects all had significantly lower mean Imax/Imin (more circular cross sections) than did endurance runners.Despite having significantly lower mean tibial J  between the Early Neolithic and Early Medieval periods remained very similar to that of living recreationally active control subjects (low impact) and varsity rowers (no ground impact but high muscle magnitudes) when adjusted for body size. However, there was substantial overlap in tibial rigidity between prehistoric and living women, even endurance runners: Some women within all time periods exhibit size-standardized tibial Many of the Neolithic LBK cemeteries included in the analyses here have been well studied, providing substantial evidence of female behavioral variation across many aspects of life. Analyses of strontium isotope residues from sites including Vedrovice, Schwetzingen, and Nitra provide evidence of a patrilocal kinship system, with women being more likely than men either to have originated from or obtained their subsistence from areas outside of the preferred LBK loess soil areas  is biased heavily onto the upper limb. The distribution of loading between the upper and lower limbs among Early Neolithic LBK women most closely matched the pattern documented among rowers see ; there iBronze Age women exhibited lower average tibial rigidity than control subjects but higher average humeral rigidity than all living female groups. This pattern of interlimb loading, heavily biased toward the upper limb, differs most substantially from that of football players, where loading is heavily biased toward the lower limb see . FootbalThese results suggest that the behaviors of Central European women in the Bronze Age were dominated by intensive and repetitive manual labor, such as grain grinding, combined with the lowest tibial loading of the prehistoric groups examined. It is likely that food processing remained largely a female activity in the Bronze Age, and saddle querns were still the dominant technology for grinding grain in the Early Bronze Age of Central Europe . Substantial social stratification at this time, the changing importance of women’s domestic and farming activities with the intensification of agriculture, the shift from hoes and digging sticks to the plow  to generate a comparative data set of CSG properties from living women of known behavior with which to interpret prehistoric female CSG and (ii) to use these comparative data to better understand the sex differences in mobility patterns and temporal change that accompanied the intensification of agriculture in Central Europe. We hypothesized that the observed lower mean bone strength and less pronounced trends through time among prehistoric agricultural women relative to men in this region were an oversimplification of female behavior resulting from an inadequate understanding of biological differences in the bony response to loading. Thus, we aimed to address this through comparison to living women to better elucidate female behavioral complexity through agricultural intensification in Central Europe.Sports for inclusion in the study were selected on the basis of the specific patterns of limb loading generated: (i) endurance running, low upper limb loading and high, unidirectional lower limb loading; (ii) football (soccer), low upper limb loading and high, multidirectional lower limb loading; and (iii) rowing, moderate unidirectional upper and lower limb loading. Athletes from these sports as well as an additional group of healthy, recreationally active control subjects were recruited (see details below). All participants were healthy adults, predominantly of European descent living in the United Kingdom, and all were between the ages of 19 and 43 years. The following exclusion criteria were established prior to recruitment and were applied to both athletes and control subjects: any medical condition or medication known to interfere with bone metabolism, any current pregnancy, 18 years of age or younger, or peri- or postmenopausal status. Additional exclusion criteria for athletes were participation in the sport of interest for fewer than 3 years, any significant injury within the past year that rendered them inactive for over 1 month, or any current intensive participation in another sport other than the one for which they were recruited. Additional exclusion criteria for control subjects were any current or past participation in competitive sport and any current or past participation of more than 3 hours a week of weight-bearing intensive physical activity.All participants were recruited through the Cambridge University Women’s Boat Club, Women’s Association Football Club, Athletics Club, Hare and Hounds, and Triathlon Club, as well as the Cambridge and Coleridge Athletics Club, the Cambridge Triathlon Club, the Beyond the Ultimate Jungle Ultra 2016, the Everest Trail Race 2016, several University of Cambridge colleges, and the Graduate Union. Participants filled out a health and activity history questionnaire to determine their athletic training history, recreational physical activity, medical and injury history, and menstrual history . The studies of varsity female athletes and ultramarathon runners were approved by the Cambridge University Human Biology Research Ethics Board (HBREC.2015.25 and HBREC.2016.14), and ethical approval for the use of pQCT was obtained from the National Health Service (NHS) Health Research Authority National Research Ethics Service (NRES) Committee East of England–Cambridge East (15/EE/0017). All living participants provided written informed consent prior to their participation in the study. Descriptive statistics for all living women included in the study are available in table S1. See the Supplementary Materials for further details on recruitment and sport groups. Target sample sizes for living women were based on the sample sizes of prehistoric women (see below) to ensure comparability and range from 11 among football players to 37 among controls. Sample sizes among athletes were limited most by the availability of women who fit the appropriate criteria for study inclusion, particularly with regard to sport and loading history. Three rounds of recruitment were performed to maximize the athlete sample sizes.The prehistoric skeletal sample consisted of females from Central/Southeast European agricultural populations (see fig. S1), spanning portions of four time periods: the Neolithic , Bronze Age , Iron Age , and Medieval . Details on all prehistoric cemeteries included in the analyses are available in table S2. Age and sex estimates were determined according to the methods outlined by Buikstra and Ubelaker (J), a measure of torsional and twice average bending rigidity in two perpendicular planes , and the shape ratio Imax/Imin, a measure of the distribution of bone about these major and minor axes  or silicone molding (humeri). For tibiae, a 3D model of the complete bone was obtained with a portable a NextEngine desktop laser scanner. Only the best-preserved tibia for each individual was included, but if both elements were equally well preserved, then preference was given to the right side. In addition to individual scan surfaces of the proximal and distal joints, 3D models were composed of 10 individual scan surfaces taken during a 360° rotation. Scans were taken using the HD quality setting in ScanStudio HD Pro (version 1.3.2). The 3D models were trimmed, aligned, and fused using ScanStudio HD Pro and Rapidform XOR. Tibiae were oriented through the alignment of the x axis mediolaterally and the y axis anteroposteriorly. The resulting mold images were imported into Adobe Photoshop, where the periosteal contour was traced, resulting in a solid cross-sectional image. The cross-sectional images were then imported into ImageJ (http://rsbweb.nih.gov/ij/), and the solid CSG properties were quantified from them using BoneJ, a bone image analysis plug-in . All testing took place at the Phenotypic Adaptability, Variation and Evolution Imaging and Performance Laboratory in the Department of Archaeology at the University of Cambridge. Body weight was recorded in kilograms with a SECA electronic scale. Maximum humeral and tibial lengths were obtained from participants using sliding calipers. Cross-sectional images were obtained using pQCT at the 35% section location of the left and right humeri and the 50% section location of the right tibia. Cross-sectional pQCT images were imported into ImageJ, and the soft tissue was cropped out prior to the image being thresholded using the Optimise Threshold function. The medullary cavity was then artificially filled using the Fill Holes option. This resulted in solid cross sections from the living women to generate periosteally derived solid CSG property estimates that would be directly comparable to those from the prehistoric women. CSG properties were then quantified from these solid sections using BoneJ.J were standardized to appropriate measures of body size following the method of Ruff (J/[estimated or true body mass × (maximum bone length2)]. For prehistoric skeletal remains, body mass was estimated using the equations for European Holocene populations derived by Ruff and colleagues  unless otherwise stated. The relative distribution of upper and lower limb loading was assessed using linear regression of mean raw humeral J of the upper limbs combined and raw tibial J to produce standardized residuals, which were tested for group differences using ANOVA. All statistical analyses were conducted in SPSS version 23. Variability in humeral and tibial CSG properties was evaluated through the calculation of coefficients of variation [(SD/mean) × 100].All data distributions were checked for normality using the Kolmogorov-Smirnov test, and outliers exceeding three SDs from the mean were removed from analyses. All data were normally distributed with the exception of left humeral


During the past decade, African swine fever (ASF) has spread from the Caucasus region to eastern European Union countries affecting domestic pig and wild boar populations. In order to avert ASF spread, mitigation measures targeting both populations have been established. However, despite these efforts, ASF has been reported in thirteen different countries . In the absence of an effective vaccine or treatment to ASF, introduction and spread of ASF onto domestic pig farms can only be prevented by strict compliance to control measures. This study systematically reviewed available measures to prevent the spread of ASF in the EU domestic pig sector distinguishing between commercial, non-commercial, and outdoor farms. The search was performed in PubMed and using a common browser. A total of 52 documents were selected for the final review process, which included scientific articles, reports, EU documents and official recommendations, among others. From this literature review, 37 measures were identified as preventive measures for the introduction and spread of ASF. Subsequently, these measures were assessed by ASF experts for their relevance in the mitigation of ASF spread on the three mentioned types of farms. All experts agreed that some of the important preventive measures for all three types of farms were: the identification of animals and farm records; strict enforcement of the ban on swill feeding; and containment of pigs, so as to not allow direct or indirect pig–pig and/or pig–wild boar contacts. Other important preventive measures for all farms were education of farmers, workers, and operators; no contact between farmers and farm staff and external pigs; appropriate removal of carcasses, slaughter residues, and food waste; proper disposal of manure and dead animals, and abstaining from hunting activities during the previous 48 h . Finally, all experts identified that the important preventive measures for non-commercial and outdoor farms is to improve access of those farms to veterinarians and health services. Ornithodoros genus (African swine fever (ASF) is an infectious disease of swine notifiable in the European Union (EU) and to the World Organization for Animal Health (OIE). Susceptible pigs can be infected by direct or indirect contact with infectious animals or their fluids, ingestion of contaminated animal feed, pork, or pig products, or contact with contaminated surfaces or fomites  acting as mechanical vectors . In the os genus . No vaccos genus –4. Adequos genus .Since 1978 and until recently, the Italian island of Sardinia has been the only European ASF-infected area . HoweverThe main piece of legislation providing the tools for the control of ASF in the EU is the Council Directive 2002/60/EC , which eMoreover, specific regionalization measures are laid down in Commission Implementing Decision 2014/709/EU . This DeBearing in mind all of the above, the aim of this study is to review described measures to prevent the introduction and further spread of ASF in the domestic pig sector focused on the EU scenario. An additional aim of this review was to assess the importance of these identified measures depending on the different pig farming systems see  section.Following an approach similar to Rodríguez-Prieto et al. , the sysControl measures” are defined as the best/safest options to eliminate or reduce specific risks, while “preventive measures” are actions taken to avoid specific risks  “outdoor pig farms” which refers to farms in which pigs are kept temporarily or permanently outdoor, and (iii) “non-commercial farms” which refers to farms where pigs are kept only for fattening for own consumption and neither pigs nor any of their products leave the holding. Elsewhere, this last type of farm is referred as “family farms” : (i) published before 1978; (ii) not related to the theme of this review; (iii) not related to the European scenario; and (iv) repeated document . If abstract were not available, the piece of literature would be kept for the next stage. Then, the full text of each selected piece of literature was screened. As a second exclusion criteria, documents (v) which full text was not available; (vi) no preventive measures were described; (vii) described preventive measures were not focused on ASF; or (viii) information on the theme was insufficient, were excluded. The explained process was individually performed by three reviewers following the mentioned exclusion criteria in order to cross-check selected literature and resolve any disagreement.A group of experts was invited to participate in an expert opinion session to assess the preventive measures identified in this review.Participants belonging to the COST (European Cooperation in Science and Technology) action: “Understanding and combating African swine fever in Europe” (ASF-STOP) supported by COST (COST Action 15116)Before starting the assessment, the list of measures were reviewed by authors to ensure measures were accurate and clear, as well as no measures were omitted. In total, 20 experts were invited to participate and contacted by email, 12 of them returned their responses.Experts were asked to assess the relevance of each described preventive measure by answering yes or no to the closed question: “Is this measure important for commercial, non-commercial, and outdoor-farms?” “Importance” was defined as the perceived need for each measure. Experts were asked to perform this assessment within the EU context. Moreover, experts were encouraged to suggest additional measures if they thought they were missing. Results were recorded in an Excel datasheet .Figure After applying the second exclusion criteria and completion of the screening rounds, 34 articles (25 retrieved from PubMed and 9 retrieved from the browser search), 4 official recommendations , 4 reports, 5 scientific opinions, and 5 technical guidelines were included in the review. The rest of the documents including reports, recommendations, and guidelines were retrieved from the browser search.Preventive measures described hereinafter were obtained from the 52 pieces of literature selected during the systematic review. These measures were classified in four different groups: general prevented measures suggested for all types of farms , and three groups of suggested measures for each of the identified types of farms.The risk of introduction and exposure to ASF depends on the epidemiological characteristics of the country, area, and type of farm , 74–80. The EU Commission has established minimum biosecurity requirements for commercial, non-commercial, and outdoor farms . Health Regarding physical barriers on farms, animals should be kept in a way that ensures that no direct, nor indirect contact occurs with wild boar, feral pigs, or domestic pigs coming from other premises , 63. AddIn addition, as part of good farming practices, carcasses, discarded parts from slaughtered pigs and food waste should be disposed in accordance with Regulation (EC) No. 1069/2009 , 63, 67.Stomoxys calcitrans flies. Therefore, given this potential role of stable flies as mechanical vectors, it has been suggested that sanitation, biological, and chemical controls should be applied to suppress stable flies. As an example, commercial and non-commercial farms could eliminate fly breeding sites in combination with placing insecticide-treated nets to reduce the potential risk posed by flies  , 48, 53.by flies , 69.Specific preventive measures based on biosecurity have been proposed depending on the type of farm: commercial, outdoor, or non-commercial .Commercial farms are significantly larger in size and number of animals  and so, Key measures to prevent the introduction of ASF on commercial farms are to establish clear clean/dirty areas for personnel including changing rooms and shower , 49, 55 Several steps should be included when preparing a protocol for animal transport. First, farms should be designed to allow deliveries without entering the farm , 45, 63.Furthermore, animals should be identified and all animal movements recorded , 45, 86;Finally, proper disposal of manure as well as dead animals and other removable material should be ensured , 58, 65.Backyard farms are characterized by limited farming management practices and nearly absent biosecurity levels , 6, 55. Specific measures focusing on these farms have been proposed, swill feeding practices are not allowed , 52, 57,Moreover, the use of fresh fodder harvested in areas at risk for ASFV exposure should be avoided , 28, 53,The number of outdoor farms is increasing in Europe due to a growing interest in organic farming systems , particuOrnithodoros ticks in the surroundings , in good repair, otherwise it is recommended to fence them or destroy them if ticks are present  were categorized as “not applicable” preventive measure.There was 100% agreement among experts (12 experts out of 12) that the identification of animals and farm records including animal movements; enforcement of the ban on swill feeding; and containment of pigs to not allow contact with pigs from other farms, feral pigs, or wild boar or their products, were important preventive measures for the three types of farms . Other important preventive measures identified for all farms were education of farmers, workers, and operators; no contact between farmers and farm staff and external pigs; appropriate removal of carcasses, slaughter residues and food waste; proper disposal of manure and dead animals; and a 48 h (minimum) interval between hunting and being in contact with domestic pigs for all farm staff, particularly those who work in an infected wild boar area.Moreover, all experts identified as important preventive measures for non-commercial and outdoor farms, to improve access of those farms to veterinarians and health services. Between eight and nine of experts considered that logistical arrangement for the entry and exit of animals including protocols regarding entrance of vehicles, loading areas and role of pig transporters; quarantine period for purchased animals and quarantine rooms; and internal audits and evaluations to enforce biosecurity measures, were not important preventive measures for non-commercial farms. In addition, 10 experts concluded that control measures against flies were not an important preventive measure on outdoor farms.Ornithodoros ticks and change of boots before entering the farm and units. Furthermore, several respondents wanted to emphasize the importance of measures already included in the questionnaire. For instance, establishment of double fencing perimeter on outdoor farms; education of swine veterinarians and farmers paying especial attention to clinical signs and transmission routes; and discouragement of using the same injection syringes and instruments on different farms unless thoroughly disinfected sterilized.Additional preventive measures were suggested by some experts such as the use of nets on animal facilities; establishment of pest control programs on farms; use of carbonic dioxide traps to check the presence of Figure In the absence of an effective vaccine, prevention is the main tool to avoid further spread of ASF or an endemic situation. Both the systematic literature review as well as the expert opinion elicitation, highlighted three main areas where preventive measures would be very relevant to halt ASF spread in the domestic pig population: (1) control of entries into the farm, (2) control of pigs’ feed, and (3) improvement of health services and education.The first main area of prevention encompasses both the movements associated to production as well as the potential spill-over from infected wild boar in the surrounding areas. Both have been major drivers of spread in the current ASF epidemic in Eastern EU, where the majority of ASF notifications in domestic pigs have occurred in backyard or small commercial farms with limited biosecurity . The ideThe Eastern EU scenario presents the additional challenge of spill-over from wild boar, where 95% of the ASF notifications have taken place  and whicMost experts (11 out of 12) recognized the importance of allowing a 48 h interval between hunting and being in contact with domestic pigs if farmers and farm staff worked in an infected wild boar area. Although it is not the scope of this article to cover the control measures in wild boar, the management of wild boar populations and hunting practices in affected areas has an undeniable effect over the prevention of ASF at the interface with domestic pigs located in the same area. Such measures have included the reduction of wild boar densities , 59 and The second main area of prevention deals with avoiding ASF transmission through the ingestion of contaminated food. Even if swill feeding is banned in the EU, all experts agreed that it was an important measure to prevent ASF spread. Other measures identified in this sense are rules on food entry for farm workers in commercial farms; proper disposal of manure and dead animals; avoiding the use of fresh fodder from areas at risk of ASF unless a treatment to inactivate potential ASF virus, has been applied; or avoid sharing feed between farms. Long distance ASF transmission has been associated to the disposal of infected waste, meat or meat products in wild boar habitat, for example, in the Czech Republic, where the closest ASF cases were about 400–500 km away. Moreover, evidences of domestic pigs and/or pig sub-products as source of infection are scarce but they have been suspected in a few cases, like in Romania. On July 31, 2017, Romania’s Veterinary Authority confirmed the first detection of ASF in a backyard herd of domestic pigs. Romania’s Veterinary Authority suspects that contaminated Ukrainian products are the likely source of the Romanian detection . Human mBetter access to veterinary health services and educational programmes, with specific training on ASF identification and biosecurity measures, are essential tools to improve human-mediated prevention measures. More than 11 experts agreed with this idea, considering both measures important for non-commercial farms but also, for commercial and outdoor facilities. In the end, effectiveness of prevention depends on awareness, compliance and diligence of people dealing with disease control and good timing of implemented measures . The effFrom the research side, efforts have been made to fill in gaps that make disease control and eradication difficult. A recent publication identified current gaps in ASF and prioritized them into high importance, medium importance, and low importance . HighestAfrican swine fever is currently one of the major threats to the pig production in the EU. As there is no a vaccine against ASF, biosecurity is key to prevent its spread between and within domestic pig farms. This study identified thirty-seven preventive measures aimed at reducing the spread of ASF among domestic pigs. These measures were also assessed by ASF experts within the framework of the EU scenario. According to this expert panel, the most important preventive measures for commercial, non-commercial, and outdoor farms were the identification of animals and farm records; enforcement of the ban on swill feeding; and containment of pigs to not allow contact with pigs from other farms, feral pigs, or wild boar or their products. In addition to this, other measures were considered relevant in preventing ASF introduction, namely education of farmers, workers, and operators; no contact between farmers, farm staff and external pigs; appropriate removal of carcasses, slaughter residues and food waste; proper disposal of manure and dead animals, and abstention from hunting activities for a period of 48 h prior to any contact with domestic pigs. Finally, all experts considered important to facilitate and promote the access of veterinarians and health services to non-commercial and outdoor farms. Adequate implementation of these measures can lead to significant advances in ASF prevention and control, and possibility contributing to the eradication of ASF from the EU pig sector.All authors contributed to the literature review performed to build this review. CJ compiled the whole information and wrote the manuscript. CJ, JS-V, and SB designed the questionnaire for the assessment of preventive measures. CJ analyzed results from the expert opinion. CJ, SB, JS-V, MM-A, and AT participated in the creation of the argument line of this the text. All authors contributed to the critical review of the manuscript and approved the final version.HF was employed by company GD Animal Health Research Institute. All other authors declare no competing interests. The reviewer AB and handling Editor declared their shared affiliation.


A diagnosis of asbestosis, which is a long-latency, fibrotic lung disease, has implications for the patient in terms of prognosis, treatment and compensation. Identifying and quantifying asbestos exposure is difficult without a detailed occupational history, and the threshold dose of asbestos required to cause asbestosis is not well understood. We reviewed all cases of asbestosis diagnosed between 2001 and 2016 at the Birmingham Regional NHS Occupational Lung Disease Service to determine the industries and occupations most frequently implicated in causation, in order to help clinicians identify where asbestosis might enter the differential diagnosis for a patient with chronic respiratory symptoms. A variety of construction trades were frequently reported including carpenters and joiners, pipe fitters, laggers, labourers, painters and shop fitters. Traditionally heavily exposed occupations such as shipbuilding were not commonly seen. Of 160 patients, 158 (99%) were males and median age at diagnosis was 74 (IQR = 69–79) with age distribution as follows: 51–60 years (3%), 61–70 years (33%), 71–80 years (43%) and 81–90 years (21%). At diagnosis 41 patients (26%) had asbestosis only, 117 (73%) had additional benign asbestos pleural disease (BAPD), 2 (1%) had mesothelioma (one with BAPD), and 2 (1%) had bronchial cancer (one with BAPD).Commonly encountered industries and occupations are shown in Table A variety of trades within the construction industry were commonly responsible for exposure sufficient to cause asbestosis: particularly carpenters and joiners, laggers, painters and shop fitters. Pipe fitters, labourers, steel workers and welders were also frequently implicated, seen in a number industries (including construction). Work in naval engineering, train carriage manufacture and in power stations were also regularly encountered, but other traditionally heavily exposed UK occupations such as shipbuilding were not seen commonly.8 Although further health risks of asbestos subsequently emerged, UK asbestos consumption increased throughout the twentieth century.9 Its properties of low cost, strength, flexibility and resistance to chemical corrosion, heat and fire made it desirable, particularly during World War II and the construction boom that followed. Consumption in the UK reached a peak in the 1960s, though the highest risk of asbestosis is observed 40–60 years after first exposure;10 thus annual deaths and compensated cases have continued to increase year on year since 1978.11 In the UK, insulation workers followed by asbestos stripping/removal workers have the highest risk of asbestosis, followed by shipbuilders and construction workers.10Asbestosis was first described in the UK in 1924 in a 33-year-old female asbestos factory worker.11 suggesting different levels of exposure by region.In this study, it is not possible to infer and quantify risk from employment without knowing when and how much exposure occurred or without population figures for the number of exposed workers at the time. Moreover, an increase in reported cases does not necessarily imply an increase in incidence of asbestosis, and other factors such as better and more frequent CT imaging, and the evolution of multi-disciplinary team decision making  may contribute to this. This is the experience of one regional UK centre and employment characteristics in other regions may vary, for example, one might expect to see more shipbuilders in Scotland and the North-East, where UK shipyards were concentrated, but not in the West Midlands. Indeed historically the West Midlands has seen lower rates of asbestosis than average for England, and significantly less than the North-West and North-East,13 thought to be due to the use of asbestos insulation board, and an increased risk in other construction trades  elsewhere.14 A small number of workers in this study had co-existing thoracic malignancy at the time of diagnosis, though future risk of bronchial cancer and mesothelioma cannot be extrapolated from this data.These results are broadly supported by studies which have shown heavy exposure and increased risk of lung cancer and mesothelioma in UK carpenters,16 The current trend of increasing incidence of asbestosis reflects the latency from previous heavy exposures. If, as the Health and Safety Executive (HSE) maintains, heavy asbestos exposures are required to cause clinically significant asbestosis during an exposed worker’s lifetime, one would predict a decline in incidence during the next decade.10 However, there is a strong association between asbestos imports and mortality from IPF, a disease whose incidence is rising. This is similar in magnitude to the association between asbestos imports and mesothelioma and this has raised an as yet unanswered question, about whether a proportion of IPF is actually asbestosis, caused by ‘hidden’ or low-dose asbestos exposures.17The advent of UK asbestos control legislation during the 1970s and beyond has resulted in lower workplace exposures to asbestos.Asbestosis is an important diagnosis to suspect since the natural history may be different to IPF; there is an increased risk of mesothelioma when asbestos exposure has been recognized, and workers are eligible for state compensation. It is worthwhile considering asbestosis and referral for a full occupational history in patients who have worked in construction trades, presenting with chronic respiratory symptoms.18 Diagnosis of asbestosis is based on exposure history and expert opinion on whether dose is sufficient to cause asbestosis, CT appearance and exclusion of other causes of usual interstitial pneumonia. From the database the following data were gathered, without recourse to individual patients’ medical records: age at diagnosis, gender, presence of additional asbestos-related diseases at diagnosis of asbestosis, and industry and occupation where exposure occurred. Descriptive analyses were performed; non-normally distributed data were displayed using median and IQR, and categorical data with percentages. Chi-squared testing at the 95% confidence level was used to look for significant differences between categories. The study was considered to be a service evaluation by UK Health Research Authority and Heart of England NHS Foundation Trust, and as such no ethical approval was sought.All cases of asbestosis diagnosed at the regional NHS Occupational Lung Disease Service in Birmingham, UK between 1 January 2001 and 31 December 2016 have been retained on a Microsoft Excel clinical database containing pseudo-anonymized data . These local data are used for monthly notifications to the UK Health and Safety Executive (HSE) national “Surveillance of Work-related Respiratory Disease (SWORD)” voluntary surveillance scheme for occupational lung disease.The data that support the findings of this study are available from the corresponding author upon reasonable request.