Africa’s strategies for pandemic influenza must also strengthen overall public health capacity. Global concerns about an impending influenza pandemic escalated when highly pathogenic influenza A subtype H5N1 appeared in Nigeria in January 2006. The potential devastation from emergence of a pandemic strain in Africa has led to a sudden shift of public health focus to pandemic preparedness. Preparedness and control activities must work within the already strained capacity of health infrastructure in Africa to respond to immense existing public health problems. Massive attention and resources directed toward influenza could distort priorities and damage critical public health programs. Responses to concerns about pandemic influenza should strengthen human and veterinary surveillance and laboratory capacity to help address a variety of health threats. Experiences in Asia should provide bases for reassessing strategies for Africa and elsewhere. Fowl depopulation strategies will need to be adapted for Africa. Additionally, the role of avian vaccines should be comprehensively evaluated and clearly defined. In January 2006, chickens in Kano and Kaduna States in northern Nigeria exhibited diarrhea and respiratory distress and died within a few days. The National Veterinary Research Laboratory in Plateau State isolated influenza viruses from these dying chickens. A Food and Agriculture Organization laboratory in Rome confirmed that the isolates were highly pathogenic influenza A subtype H5N1and genetically similar to influenza (H5N1) clade 2 viruses from China, Indonesia, Japan, South Korea, and other countries  infection in birds, and several hundred thousand additional birds were reported dead, including chickens, geese, and ducks. Niger and Cameroon had also confirmed influenza (H5N1) outbreaks near the Nigerian border.Despite continued spread of H5N1 subtype among poultry, human cases of avian influenza were not identified in Nigeria until January 2007, when 1 human case of infection with influenza virus subtype H5N1 was confirmed in a woman. However, weaknesses in existing disease surveillance systems limited capacity to detect transmission of avian influenza to humans. To rule out avian influenza, as of May 2007, specimens from 301 patients have been tested in Nigeria.. Egg and chicken sales declined by >80% within 2 weeks after the announcement of the outbreak; 4 months later, sales were still <50% of baseline. Poultry feed sales also dropped by >80%; 80% of workers on affected farms and 45% on unaffected farms lost their jobs  has been detected in fowl in 8 countries neighboring Nigeria and Egypt . OutbreaThe next influenza pandemic, if it plays out like the 1918 pandemic, would likely cause more deaths proportionately in sub-Saharan Africa than anywhere else in the world  of the World Health Organization (WHO) and its country offices have a clear mandate to address regional impending and ongoing health crises. Partners, including other United Nations agencies, development organizations, and allied nongovernment organizations, should line up with AFRO and national ministries of health and livestock to encourage and catalyze multisectoral government and nongovernment commitment and action.Streptococcus pneumoniae, Haemophilus influenzae type b, and rotavirus), but African countries lack the resources and infrastructure to take full advantage of these tools.The potential effects of pandemic influenza on human health and political stability in sub-Saharan Africa cannot be denied. Of paramount concern, however, is that this potential disaster emerges onto a backdrop of countries struggling to address epidemics of HIV, tuberculosis, and malaria; resurgence of paralytic poliomyelitis; and high childhood mortality rates due to pneumonia and diarrheal diseases. Many of the severe effects of these diseases could be prevented by use of proven public health tools . Similarly, when avian influenza was confirmed in poultry in Juba, Sudan, in September 2006, the newly formed Ministry of Health staff of the government of South Sudan had to balance already demanding commitments to battle HIV, tuberculosis, and an ongoing cholera epidemic with the need to prepare for potential influenza A virus (H5N1) infection of humans. The substantial effort required added more weight to a grossly overstressed public health system.Tension between existing disease concerns and the potential threat of a pandemic raises several questions: whose concern is avian influenza; and what are appropriate, balanced responses, particularly in countries with severely limited public health resources and overwhelming health problems? A pandemic strain emerging in Africa is a global concern as much as an African concern. Without rapid detection systems and effective control measures, a highly transmittable strain would quickly spread globally. Wealthier nations have recognized this and pledged nearly $2.5 billion to address the problem, although most is not specifically for use in Africa.In addition, an influx of massive resources from more developed nations, if not well coordinated and balanced in scope, could distort the sense of priorities and damage other critical public health and agricultural programs. How then can a balance be achieved and result in appropriate enhancements to address the threat of pandemic influenza while keeping focus on the existing major health priorities facing Africa? One approach, detailed below, would be to use new resources in a way that is broadly applicable to building public health capacity in recipient nations.The need and resources for rapid detection of potentially pandemic strains of influenza should be leveraged with support for surveillance  for otheFor IDSR to effectively function as an early warning system for influenza and other communicable diseases, a number of steps should be taken. First, additional resources should be made available for field training of national and local staff and subsequent site assessments. Second, this conventional public healthcare facility–based surveillance system should be expanded to cover private healthcare institutions and include community-level surveillance, through reporting by village chiefs, traditional healers, dispensaries, and primary schools. Finally, existing technology in Africa should be leveraged to make IDSR a user-friendly, more efficient surveillance system. The widespread use of mobile telephones and extensive mobile phone networks throughout Africa could be extremely helpful for reporting unusual health occurrences through inexpensive, potentially automated, text messaging to an identified, widely recognized, and toll-free number. Reports of disease clusters could then be immediately verified and investigated by public health personnel  was to ensure communication between Ministry of Health and Ministry of Agriculture staffs on the ground so that when poultry outbreaks occurred on farms, the Ministry of Health was alerted to look for human cases.Resources for improving infrastructure to address threats of avian influenza must be channeled to improve local laboratory capacity and strengthen laboratory networks. WHO and AFRO have a critical role to promote, select, develop, train, and sustain laboratory capacity for diagnosis of influenza within regional reference laboratories and national influenza centers. AFRO has already designated several existing laboratories in Africa as regional reference laboratories for testing seasonal and avian influenza in humans. With enhanced surveillance, these laboratories should be able to rapidly confirm or rule out influenza as the cause of a cluster of severe respiratory illness, which would allow for rapid epidemic responses. Already, laboratories in several countries in Africa have been upgraded, laboratorians have been trained, equipment  and appropriate reagents (primers and probes) have been procured, and quality control mechanisms have been put in place so that PCR can be used in a timely manner to reliably document the presence of highly pathogenic influenza A virus subtype H5N1. With additional reagents and training, these laboratories could have the capacity to rapidly detect causes for other outbreaks and assist with surveillance for routine and emerging diseases. As laboratory surveillance is initiated and strengthened, training, leveraging of equipment maintenance and service contracts, and resource sharing across animal and human facilities will be essential.Being prepared for an influenza pandemic will require having a well-trained corps of epidemiologists. Field epidemiology training programs and Public Health Schools without Walls are in place in several countries in Africa; these programs are successfully training medical doctors (and laboratorians in the case of Kenya’s Field Epidemiology and Laboratory Training Program) to become public health experts. To minimize out-migration, graduates should be rewarded through career advancement pathways within national public health systems.In a joint effort by WHO and the Centers for Disease Control and Prevention, rapid outbreak response teams are being trained in sub-Saharan African countries to recognize outbreaks, collect information and specimens, and implement quarantine measures, if indicated, while using and distributing personal protective equipment and antiviral drugs. Training rapid response teams in each country is a relatively new concept for Africa, but such teams in Asia have responded to dengue epidemics and, more recently, to avian influenza. If these teams are functional, they will strengthen responses in Africa to a wide array of epidemics, enabling timely implementation of interventions to prevent illness and death.Should a major health disaster such as an influenza pandemic occur, essentially no capacity exists to appropriately address the healthcare crisis while continuing to deal with other routine health problems, which themselves can at times overwhelmingly stress healthcare systems. Preparation for a pandemic must strengthen hospital capacity to optimally and safely manage severely ill patients with potentially highly contagious illnesses. Although aiming for parity with hospitals in industrialized nations on quality standards for infection control is excessively ambitious, simple, practical approaches to implement basic infection control measures developed by WHO can be used  epizootics have occurred. Without credible, adequate, and rapidly implemented compensation programs linked to depopulation efforts, farmers are not encouraged to report bird die-offs and may transport birds to unaffected areas, thereby spreading the virus (Vaccination of poultry may be a useful adjunct to depopulation in a defined area surrounding an affected farm (ring depopulation). Some available vaccines seem to provide immunity to infection without substantially prolonging viral shedding  would be helpful.Activities to address the threat of pandemic influenza should, whenever possible, build upon existing public health systems and enhance available health infrastructure rather than create new systems. In Vietnam, for instance, research organizations like Oxford University and The Wellcome-Trust, and partners they support, were able to refocus their efforts onto avian influenza and provide substantial new knowledge relevant for protecting health , which now compels countries to have more effective surveillance and reporting systems to improve the ability for early detection of global disease threats (An old expression says, “You can’t slide uphill.” The difficult work associated with preparedness for pandemic influenza will help bring Africa closer to the top of the hill, making it possible to efficiently respond to this and other threats and, when necessary, slide toward a beneficial outcome.


Monoclonal antibodies (MAbs) such as trastuzumab and bevacizumab have become important yet expensive components of systemic cancer therapy across a variety of disease sites. We assessed the potential cost implications of adopting trastuzumab and bevacizumab therapy in the context of their potential utilization in breast, lung, and colorectal cancers.We first estimated MAb costs per patient and treatment indication and then included the MAb acquisition cost and the costs of medical resource utilizations required for therapy delivery. Drug costs were based on 2005 average Canadian wholesale prices, assuming full drug delivery and uncomplicated cycles. A direct-payer perspective was undertaken, and results are reported in Canadian dollars. Potential lifetime costs were then derived according to constructed schema, which account for absolute numbers of target patients and systemic therapy utilization. We subsequently estimated costs of MAb therapy relative to total costs of conventional management without MAb therapy.Trastuzumab costs $49,915 and $28,350 per patient treated in the adjuvant and metastatic breast cancer settings, respectively; bevacizumab costs $48,490 and $39,614 per patient treated in the metastatic lung and colorectal cancer settings, respectively. Potential lifetime absolute costs to Canada’s health care system were approximately $127 million and $299 million for trastuzumab and bevacizumab respectively, corresponding to an average increase in health care expenditure of approximately 19% for breast cancer and 21% for lung and colorectal cancer over conventional management without MAbs.Novel Mab-based therapies such as trastuzumab and bevacizumab will likely add a significant cost burden to Canada’s publicly funded health care system. Cancer treatment costs have increased dramatically since the late 1990s, escalating particularly since 2000 her2/neu)–positive breast cancer, but bevacizumab is funded in only a few provinces for the palliative treatment of metastatic colorectal cancer. This discrepancy highlights provincial differences in funding and has become an important issue in discussions regarding a national strategy for equitable drug funding in cancer care (Canadian Partnership Against Cancer) proposed by the current federal government The introduction of targeted therapeutic agents such as monoclonal antibodies for solid tumours has revolutionized cancer care and is rapidly changing treatment approaches across common cancer disease sites. Trastuzumab and bevacizumab are two such agents that have been shown to improve disease-free, progression-free, or overall survival in breast, colorectal, and lung cancer Because of high acquisition costs, trastuzumab and bevacizumab could add significant economic burdens to all provincial health budgets in Canada. However, the estimated cost potentially incurred with their use across cancer-specific disease sites is not currently known. We undertook an economic analysis to estimate the incremental costs potentially associated with the use of trastuzumab and bevacizumab for breast, colorectal, and lung cancers in Canada.nsclc) cancers in Canada were estimated according to the schema outlined in Costs potentially associated with the use of trastuzumab and bevacizumab in breast, colorectal, and non-small-cell lung  was multiplied by the 2005 average wholesale price in Canada for the relevant monoclonal antibody  to calculate the monoclonal antibody cost per patient per indication .We also estimated the additional cost of medical resource utilizations required for treatment delivery, including costs associated with necessary supportive medications, diagnostic investigations, and human resources required during clinic and chemotherapy suite visits to administer the monoclonal antibody. Unit costs were derived from local resources at the QEII Health Sciences Centre in Halifax, Canada . Resourcher2/neu-positive meta-static breast cancer The estimated costs of trastuzumab therapy for metastatic breast cancer were validated by reviewing pharmacy utilization records at the QEII Health Sciences Centre for patients with Canadian Cancer Statistics and the literature as described in Lifetime costs associated with potential trastuzumab and bevacizumab treatment for patients diagnosed with breast, lung, and colorectal cancers over a 1-year period in Canada were estimated. Potential repeat utilizations upon relapse  after treatment initially given as adjuvant therapy were included. The stage distribution and disease course, including potential relapses, were derived from Absolute and relative costs were both examined . Absoluti–iii and iv disease were derived from the literature with adjustments: $29,868 and $42,532 for breast cancer, $26,980 and $28,790 for nsclc, and $39,925 and $65,390 for colorectal cancer respectively Relative lifetime cost was defined as a ratio of this absolute lifetime cost to the absolute lifetime cost for conventional management without monoclonal antibodies. The time horizon of this budget impact analysis was that of a lifetime horizon for the study cohort, ranging from several years in metastatic cancer to decades in patients who are potentially cured with adjuvant treatment. Lifetime costs of conventional management per patient with stages A stepwise approach with multiple calculations was used . The numnsclc in 2005 in Canada the number of patients diagnosed with breast cancer, colorectal cancer, and  the respective stage-specific disease distribution at diagnosis and predicted lifetime relapse rates ; and the proportion of incident cases potentially eligible for each monoclonal antibody therapy per indication  accordinher2/neu-positive disease As an example, the proportion of breast cancer patients eligible for treatment with adjuvant trastuzumab  was deriAbsolute lifetime cost of monoclonal antibody therapy in Canada was calculated as the product of the monoclonal antibody cost per patient per indication  and the i–iii disease, plus the costs of palliative trastuzumab therapy for patients with relapsed disease after adjuvant trastuzumab who remained candidates for re-treatment, plus the costs of palliative trastuzumab therapy for eligible patients diagnosed with metastatic disease at first presentation  per patient for the relevant tumour type was estimated according to disease incidence rates, stage distribution, and estimated rates of relapsed disease after potentially curative primary therapy . Costs were derived from the literature her2/neu-positive breast cancer was estimated to be $49,915 and $28,350 respectively per patient. The incremental cost of bevacizumab was estimated to be $48,490 and $39,614 for the treatment of metastatic nsclc and metastatic colorectal cancer respectively per patient. These costs reflect primarily the acquisition costs of monoclonal antibodies, which accounted for 94%–97% of estimated total costs  would increase the overall lifetime cost of breast cancer management by 19%, and treatment with bevacizumab ($299 million) could potentially increase the overall lifetime costs of colorectal cancer and nsclc management by 21% relative to the estimated costs of conventional management without monoclonal antibodies for these cancers.Nationally, the absolute lifetime cost associated with trastuzumab for the treatment of The estimated total drug acquisition cost for palliative trastuzumab per patient based on the assumptions in the present study  was approximately 10% higher than the actual average total drug cost per patient previously derived through local pharmacy records  nsclc and metastatic colorectal cancer respectively. These costs could amount to an additional $426 million in lifetime costs across all patients diagnosed with breast, colorectal, and lung cancers in 1 year, corresponding to an approximate 21% increase in the relative lifetime costs of treatment for these diseases. Of these total estimates, the additional $127 million expected with trastuzumab therapy for her2/neu-positive breast cancer likely reflects a current effect, because this agent is currently funded in all Canadian provinces; the $299 million estimate for bevacizumab represents a potential rather than an actual effect, because funding for bevacizumab is currently limited to colorectal cancer and is supported by only a few Canadian provinces.Monoclonal antibody therapy for breast, colorectal, and lung cancer in Canada is expected to have significant budgetary implications for Canada’s publicly funded health care system. We estimate that, for each patient treated with adjuvant and palliative trastuzumab, an additional cost of $49,915 and $28,350 respectively will be incurred. Bevacizumab could also add an additional cost per patient of $48,490 and $39,614 for the treatment of metastatic her2/neu-positive metastatic breast cancer. Second, the conventional management costs used to estimate relative lifetime costs were derived from older studies and were themselves estimates. Since those estimates were first reported, clinical practice has evolved across the three disease sites examined. We attempted to address that evolution by incorporating the costs of newer interventions whenever possible and by adjusting older costs to current costs through the Consumer Price Index Although our study corroborates the high costs of trastuzumab and bevacizumab, its limitations include the number of assumptions that had to be made and the derivation of the conventional management costs on which we relied. First, in regard to the assumptions made, we did not conduct sensitivity analyses, because such analyses would have required the definition of arbitrary distributions around the point estimates examined and because the input parameters and the resulting cost estimates had a simple linear relationship in our schema. We attempted, however, to validate our estimated costs for trastuzumab based on these assumptions. The validation revealed our estimates to be within 10% of the actual cost of national trastuzumab sales for 2006 and also within 10% of the observed local cost of incorporating trastuzumab for the palliative treatment of Given limited health care resources, the results of our economic evaluation reinforce concerns of drug affordability on an individual and a population basis. The implication of rising costs of anticancer drugs within relatively fixed provincial health care budgets is that inequity in access to novel anticancer therapies is beginning to arise in Canada. Currently, newer interventions that are not within an acceptable cost-effectiveness threshold


Animal studies have described the development of adverse health effects such as tumors and developmental delays with exposure to the PFCs perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid (PFOS). A new study now suggests these and other PFCs may affect serum cholesterol levels in humans Elevated cholesterol levels are associated with an increased risk of cardiovascular disease, and are one of the conditions that define metabolic syndrome. Risk factors for high cholesterol include diet, low physical activity, and a family history of the condition, but increasing evidence indicates some environmental chemicals also may contribute. With estimated half-lives of up to 8.5 years, PFCs are classified as persistent organic pollutants (POPs). However, unlike most POPs, which are stored primarily in fat tissue, PFCs persist by forming chemical bonds to proteins in the liver and serum.Previous studies in humans have reported positive associations between PFOS and PFOA exposures and higher cholesterol levels. The research team in the current study investigated the relationship between insulin resistance, cholesterol levels, body size, and exposure to two less studied PFCs, perfluorononanoic acid (PFNA), and perfluorohexane sulfonic acid (PFHxS) in addition to PFOS and PFOA. The study used data from the 2003–2004 National Health and Nutrition Examination Survey.The authors found a positive association between total cholesterol (TC) and serum concentrations of PFOS, PFOA, and PFNA. TC is the sum of low-density and very low-density lipoproteins (“bad” cholesterol) and high-density lipoproteins (“good” cholesterol). The findings appeared driven by an increase in the non–high-density lipoprotein fraction of TC, and the association was most pronounced for PFNA. In contrast, PFHxS concentrations were inversely related to TC: samples reflecting the highest PFHxS exposure had the lowest TC levels.The authors observed little evidence of associations between body size, insulin resistance, and PFC concentrations. They note several limitations in this study, including the fact they could not rule out the possibility of reverse causality—that is, that having higher cholesterol levels could lead to increased PFC concentrations in the blood. Nevertheless, the results support previous epidemiologic research indicating that environmentally relevant exposures to PFCs may affect human cholesterol metabolism or homeostasis.


Proactive changes are needed to protect the public from myriad serious diseases. Bacillus anthracis (57), Mycobacterium tuberculosis complex (48), Echinococcus spp. (41), and Leptospira spp. (35). Genera capable of harboring the greatest number of risk zoonoses were Canis and Felis (14 each), Rattus (13), Equus (11), and Macaca and Lepus (10 each). These findings demonstrate the myriad opportunities for zoonotic pathogens to be imported and suggest that, to ensure public safety, immediate proactive changes are needed at multiple levels.The United States is the world’s largest wildlife importer, and imported wild animals represent a potential source of zoonotic pathogens. Using data on mammals imported during 2000–2005, we assessed their potential to host 27 selected risk zoonoses and created a risk assessment that could inform policy making for wildlife importation and zoonotic disease surveillance. A total of 246,772 mammals in 190 genera (68 families) were imported. The most widespread agents of risk zoonoses were rabies virus ,  Most emerging infectious diseases are caused by zoonotic pathogens . We then assessed the zoonotic diseases that imported mammals are known to host. Our results may be used to inform policy decisions about wildlife importation and zoonotic disease surveillance and may alert clinicians to the broad range of possible zoonoses that may be encountered in patients who have been exposed to imported animals.http://animaldiversity.ummz.umich.edu/site/index.html).We used Freedom of Information Act requests to obtain records from the database of the US Fish and Wildlife Service Law Enforcement Management Information System. We obtained records for all wildlife shipments into the United States during 2000–2005 through 14 of the 18 designated animal importation ports . Data were not available for Houston, Texas; Louisville, Kentucky; Memphis, Tennessee; and Newark, New Jersey. For each importation, we acquired information on the taxonomy, quantity, source , country of origin, intermediate port of call, port of entry, and declared purpose of all live specimens. Descriptive analyses were performed to determine the volume of trade from various regions of the world and the types of mammals imported. Individual importation events were then grouped into genera to determine the diversity of taxa imported. The phylogenetic relationships and geographic ranges of host mammals were determined by using the Animal Diversity Web at the University of Michigan Museum of Zoology  and importations for which the genus was known were retained for analysis. Statistical analyses were performed by using Intercooled Stata 9 . In our final risk assessment, we did not account for the origin of each specific importation because of limitations in the database, likely caused by a complicated system of exportation and reimportation.www.cdc.gov) and the World Health Organization website (www.who.int), reviewing the list of Select Agents  of the US Department of Health and Human Services ; and 5) if the pathogen uses an intermediate vector, competent vectors must exist in the United States. The resulting list comprised 30 risk zoonoses ; no fungal, protozoal, or prion diseases were on the list, and thus they were not analyzed.We created a list of relevant zoonotic diseases at risk for importation (hereafter referred to as risk zoonoses) by searching the Centers for Disease Control and Prevention website (www.pubmed.gov), the Google search engine (www.google.com), and references within published works. Confirmed presence was defined as either isolation of the pathogen from an animal or serologic evidence of past infection. For all animals identified in the literature as carrying a risk zoonosis, genus and family were recorded. The host ranges of all of the risk zoonoses were then cross-referenced against the imported genera to generate tables showing diseases found in each imported genus (affected genera). If the disease was found in a different genus within the same family, this was also noted . The justification for this expanded risk assessment is the host nonspecificity of many infectious diseases; lack of evidence for the presence of a given disease in a given host should not be construed as evidence against its presence.Determination of the host range of the risk zoonoses was accomplished through systematic genus-driven and pathogen-driven searches of PubMed databases (Macaca fascicularis), 30,058 small desert hamsters (Phodopus sungorus), 19,724 rhesus macaques (Macaca mulatta), 19,537 raccoons (Procyon lotor), and 7,112 chinchillas (Chinchilla lanigera). Together, these 5 species accounted for 82% of all imported individuals. By number of shipment fractions, the most common animals were 1,343 M. fascicularis macaques, 332 Callithrix jacchus marmosets, 229 M. mulatta macaques, 165 C. lanigera chinchillas, and 107 Potos flavus kinkajous.During 2000–2005, a total of 4,067 shipment fractions of mammals were imported , totaling 246,772 individual mammals and representing 190 genera and 68 families. The average number of animals per shipment fraction was 61 . The most common declared purpose for importation was commercial use , accounting for 66%  of the total. The second most common declared purpose was biomedical research, accounting for 28%  of the total. Only a small number of individuals were imported for breeding, educational, zoo, personal, and other uses. Numbers of the most commonly imported animals were 126,014  long-tailed macaques ; Guyana (635), United Kingdom (359), Vietnam (314), and Indonesia (305). These values must be interpreted cautiously, however, because many animals are imported and then reexported; thus, their true origin may become obscured. For example, a “wild-caught” chinchilla with a “country of origin” of Czech Republic must have originated elsewhere because chinchillas are native to Chile. A comparison between the natural geographic range of all wild-caught animals and their stated countries of origin showed that >25% of the pairings were impossible . This limitation is inherent in the way US Fish and Wildlife Service Law Enforcement Management Information System data are collected, and we were unable to correct these data.The source of the animals was largely uninterpretable because 49% of all individuals were declared as being sourced from “animal derivatives and parts,” despite the fact that we had selected only live animals for our analysis, and despite the fact that “animal derivatives and parts” is not one of the permitted responses to this question. Another 29% were declared as “captive-bred” and 15% as “wild-caught.”Rickettsia prowazekii) were removed because few, if any, genera were found to harbor these infections; the final tables therefore include 27 diseases , the number of genera potentially capable of harboring rabies viruses rises to 155 ; potential carriers of Canis (dogs) and Felis (cats), 14 risk zoonoses each; Rattus (rats), 13; Equus (horses), 11; Macaca (macaques), 10; Lepus (rabbits and hares), 10; and Ovis (sheep) and Vulpes (foxes), 9 each  were Muridae , 21 risk zoonoses; Cricetidae , 20; Canidae , 16; and Bovidae  and Felidae (cats), 15 each.Our data demonstrate that myriad opportunities exist for key zoonotic pathogens to be imported into the United States or, if already present, to be introduced in a new context . Imported animals of a large number of taxa were found to be capable of carrying risk zoonoses; these diseases include such serious public health threats as rabies, the filovirus hemorrhagic fevers, tuberculosis, and highly pathogenic avian influenza.Spizaetus nipalensis) smuggled from Thailand and recently confiscated in Belgium were infected with highly pathogenic avian influenza (H5N1) , if not higher. Furthermore, we included only live animals in this analysis; recent outbreaks associated with animal products  attest to the risks associated even with dead animals (Peromyscus for certain hantaviruses), whereas proof of the permissiveness of other genera to certain pathogens is limited to isolated case reports . Perhaps the greatest unknown associated with quantifying risks for each of the zoonoses is a pathogen’s infectivity in various hosts. Some pathogens may increase to a high enough load in their hosts to be infectious; others may cause nothing more than a measurable serologic response in what is otherwise a dead-end host .We did not quantitatively assess the risk for transmission of each pathogen at each importation event. Rather, we attempted to demonstrate the breadth of risk associated with importations of wild animals in general. Quantitative prevalence of the various pathogens in each wildlife host is highly variable, and determining it is beyond the scope of our analysis. Some genera represent the primary reservoirs of certain pathogens  but also their actual origin. Accurate recording of the source of the animals  is also needed. Our results showed that half of all individuals had a declared source that was not one of the allowed choices . The source of an animal affects not only the likely level of risk  but also mitigation strategies when zoonotic diseases are identified .The potential for importation of zoonoses that would pose a major public health threat suggests that increased surveillance should be applied to imported wildlife in the United States. One opportunity to reduce this threat is restriction of importation of key high-risk species, as was done when the Centers for Disease Control and Prevention used emergency powers to restrict importation of Gambian pouched rats during the monkeypox outbreak . Notably, the numbers of shipments of mammals is low relative to other wildlife groups . Lawmakers’ interests in protecting our borders from external bioterrorism threats intersect with the need to protect ourselves from zoonotic diseases; many Category A bioterrorism threats   trade, thereby eliminating the possibility of screening shipments for potential hazards. A more effective and acceptable strategy would be enhancing surveillance for the specific pathogens noted for the key risk genera , a greater proportion (even among the high-risk genera) are destined for commercial use and therefore could expose a wider group of persons to zoonotic diseases. Education of professionals likely to come in close contact with imported animals , as well as the general public, should emphasize the risks for contracting zoonotic diseases from wildlife and pets (The recommendations above mirror others that exist in policy documents by the Defenders of Wildlife (Risk zoonoses capable of infecting mammals imported into the United States, 2000-2005


In 2000, annual mass administration of diethlycarbamazine and albendazole began in Leogane Commune, Haiti, to interrupt transmission of lymphatic filariasis (LF). After 5 years of treatment, microfilaremia, antigenemia, and mosquito infection rates were significantly reduced, but LF transmission was not interrupted. These finding have implications for other LF elimination programs. Globally, more than 1 billion persons are at risk for lymphatic filariasis (LF), a mosquito-transmitted parasitic infection that causes lymphedema and hydrocele. Transmission of LF can be interrupted by annual mass treatment with drugs that target microfilariae, the stage of the parasite that circulates in the blood  and albendazole. We discuss how sentinel site data were used to determine whether to continue mass MDA after 5 rounds and how our experience may be relevant to other LF programs.Culex quinquefasciatus, began in these sites 3 months before the first MDA, using CDC gravid traps   were co-administered at stationary posts to persons >2 years of age, excluding pregnant women and persons too ill to receive the drugs. Adverse events were monitored each year by recording the number of persons who returned to distribution posts with complaints. Cluster surveys were conducted after the first and third MDA to assess coverage and the effect of health messages on compliance  and albendazole ; however, after 2 rounds of MDA, infection was reduced significantly at all sites (p<0.007) except Mapou . After MThese data were collected to monitor progress and to provide a basis for programmatic decisions. In January 2005, 3 months after MDA 5, a meeting was convened in Leogane with program and ministry staff to discuss the need for further MDA. Sustained reductions in LF infection in both humans and mosquitoes demonstrated the substantial effects of the intervention through 4 MDA rounds. However, persistent antigenemia and sporadic parasitemia were detected at all sentinel sites. Project leaders adopted a conservative approach and planned for MDA 6 on the basis of the evidence of continued transmission in the sentinel sites.Several factors supported this decision, including detection of infections in both humans and mosquitoes and concerns about systematic noncompliance , and the sensitivity of both tests decreases as LF intensity and prevalence decline.Entomologic monitoring provides an alternative method of measuring the impact of MDA on transmission. Although it circumvents the human cost of repeated blood collection and provides a direct, real-time measure of potential transmission, continuous mosquito collection and dissection were more costly and labor-intensive than other monitoring methods that we used. Conducting intermittent rather than continuous collections may be an alternative approach.The limitations of these monitoring tools highlight the need for more sensitive, standardized tools to help programs define MDA endpoints and to conduct surveillance. Antibody responses may develop before patent infection and serve as a cumulative measure of filarial exposure and a proxy for transmission (In summary, MDA-based LF programs, including that in Leogane, lead to dramatic declines in filarial infection in humans and mosquitoes after several annual rounds of MDA (


The comorbidity of chronic pain and depression has been consistently associated with a poor prognosis and greater disability in patients as compared to those suffering from each illness alone. This further has implications on significant financial costs to the patients and to our society. The biological underpinnings of major depression and chronic pain have considerable overlap in the areas of genetic, structural, functional, neuroendocrine and neurotransmitter functionality. Although the field has evolved in the past decade, more efforts should now focus on understanding the biological underpinnings of this shared comorbidity, while shedding light on treatment implications for these two devastating conditions. There is a burgeoning interest in the mind-body connection in mental illness over the recent years. This is further substantiated by a growing body of evidence on the neurobiology of pain and depression given the cross talk between pain and affective pathways, outlining the interactions between affective, executive, cognitive processes and pain experiences. Depressed patients have a four times greater risk, than non-depressed patients, of a chronic painful physical condition (CPPC) while 69% of patients in primary care clinics present with somatic symptoms leaving depression unrecognized and undertreated.2th Edition, Text Revision (DSM-IV-TR), enumerates the presence of symptoms that occur across the physical, psychological and cognitive domains.[et al. the most common symptoms in patients with a mood disorder were back pain, musculoskeletal complaints like muscle, joint or limb aches and pains, sleep disturbances (insomnia), chest pain, dizziness and fatigue.[Current diagnostic criteria for major depressive disorder (MDD), established in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4 domains. DepressiChronic painful physical conditions (CPPC) are common in subjects with MDD and a recent international study has shown that the presence of a CPPC increased the frequency and severity of seven depressive symptoms including depressed mood, lack of interest, psychomotor agitation/retardation, weight gain, insomnia, fatigue, and impaired concentration. Some phyThere is a bidirectional complex relationship between pain and depression with chronic pain as a predictor of subsequent major depression, and vice versa. Co morbi7This article is an attempt to review current scientific understanding of overlapping pathophysiological processes and circuitry of pain and depression that would help shed some light on the neurobiology and treatment implications that could potentially have significant relevance on clinical outcomes for our patients.The co morbidity of chronic pain and depression has been consistently associated with a poorer prognosis and greater disability in patients as compared to those suffering from each illness alone.10 The fi910The biological mechanisms underlying the link between pain and depression are heterogeneous.–17 AreasThe complexity of genetic determinants for chronic pain and depression involves the multiple polymorphic nature and varying contribution of the genes which may contribute to these disorders. Although many genes have been implicated in major depression, the genes regulating serotonergic function such as the serotonin-transporter-linked promoter region 5HTTPR or the serotonin 2A (5-HT2A) are consistently identified.18 Other 21At the cellular level, inflammatory signals from distress or pain are conveyed primarily from the periphery to microglia.24 In majNeuroimaging studies have allowed for examination of the areas of the brain which are structurally or functionally aberrant in both pain and depressive syndromes. The dorsolateral prefrontal cortex (DLPFC) is the area of the brain which regulates influence over limbic structures and is a crucial part of the executive function network. Studies 30Neuroendocrine abnormalities such as dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis have been recognized in both depression and chronic pain disorders, such as the inability to suppress cortisol as seen in patients with fibromyalgia. Physical34The role of neurotransmitters, peptides and endogenous opioids continues to be a focus of research in chronic pain syndromes and depression. Serotonin, a neurotransmitter well known for its usefulness in antidepressants, has been shown to have antinociceptive and pronociceptive effects depending on the receptor subtype and region of the central nervous system.15 Descen111141The biological underpinnings of major depression and chronic pain have considerable overlap in the areas of genetic, structural, functional, neuroendocrine and neurotransmitter functionality. The pathology that is similar between these illnesses therefore results in similar phenomenology that is seen in clinical practice.There is sufficient evidence to suggest that nearly 30-60% of patients with depression also suffer from pain syndromes. More oftStress seems to play a role as a precipitant and a perpetuator in both pain and depression. In addition, both of these syndromes seem to share neurobiological underpinnings including the rubric of genes, brain circuitry, dysregulation of neurochemistry , inflammatory processes, neuroendocrine and neurotrophic signaling. Neuroanatomic regions that play a role in both these syndromes include the limbic and paralimbic prefrontal cortical areas – amygdala, hippocampus, insula, anterior cingulate cortex (ACC), ventromedial prefrontal cortex (vmPFC) as well as more "cognitive" and integrative brain areas.There is a bidirectional relationship between pain and depression with the symptoms of one worsening the other. These co morbid conditions also complicate treatment response and increase risk for relapse, thereby warranting the need to address both of these problems concurrently.4344 Cons431


Dear Sir,With the advent of the Internet, communication and teaching are gradually shifting from the print to the electronic media. The website of the Indian Journal of Radiology and Imaging (IJRI) receives 4000 hits daily. In a stuhttp://groups.google.com/group/iriadelhi?lnk=gschg [We have started a webgroup of the Indian Radiology and Imaging Association (IRIA) - Delhi state branch at the uniform resource locator (URL) nk=gschg . Two of Google groups is a free webgroup hosting service provided by Google Inc. Disseminating information through a webgroup is fast, entails lower costs than traditional postage, saves stationary, and is eco-friendly. The finances thus saved can be channelized into more productive avenues. Some disadvantages of using a group instead of a regular website include the inability to offer advanced functions such as payment gateways or an online voting system for state body elections.Future directions include posting of interesting cases, online registration for conferences and CMEs, and uploading scientific sessions of CME programs.


After a decade of analyzing environmental influences on substance use and its consequences among youth in the United States, the Robert Wood Johnson Foundation's Bridging the Gap program has begun studying the effect of environmental factors on youth physical activity, diet, and weight outcomes. Much of this research has focused on access to food, as reflected by availability and price. Program researchers have documented disparities in access to healthy foods and opportunities for physical activity; healthier food outlets and opportunities for physical activity are relatively less available in communities with lower income and larger proportions of racial/ethnic minority populations. They also have found that healthier environments are associated with more fruit and vegetable consumption, more physical activity, lower body mass index, and reduced likelihood of obesity among youth. The Robert Wood Johnson Foundation's Bridging the Gap program (BTG), created in 1997, has studied the effect of policies, programs, and other environmental influences on adolescent alcohol, tobacco, and illicit drug use and related outcomes in the United States . BTG is As recognition of the obesity epidemic has increased, researchers, policy makers, and public health professionals have focused more attention on the role of environmental factors as determinants of healthy and unhealthy eating, physical activity and inactivity, and weight outcomes. BTG's research focus has turned to applying the approach it successfully used for a decade to looking at the effect of relevant environmental factors on youth physical activity, diet, and weight outcomes. The conceptual framework for BTG's research on adolescent obesity  draws onBTG's earliest research on the contextual factors that contribute to overweight and obesity concentrated on documenting differences in the availability of food and physical activity-related outlets across communities -9. Most Measures for the density of food-related outlets based on standard industry classification codes were developed for chain supermarkets, independent supermarkets, convenience stores, grocery stores, fast-food restaurants, and full-service restaurants. Comparable measures for the density of physical activity-related outlets were developed for membership and nonmembership health clubs, spas, and other fitness facilities; membership sports and recreation clubs; and dance studios, schools, and public dance halls. One study used measures of publicly available opportunities for physical activity, including sports areas, parks and green spaces, playgrounds, public pools and beaches, and bike paths collected around nationally representative samples of US secondary schools in 2002 and 2003 as part of BTG's extensive original data collection efforts .This research consistently documented racial/ethnic and income-related disparities in the availability of healthy food and opportunities for physical activity across communities. For example, availability of free opportunities for physical activity was lower in communities with lower income levels and in those where a greater percentage of the local population was African American . SimilarFewer chain supermarkets were in lower-income communities; predominantly African American communities had approximately half as many chain supermarkets as predominantly white communities, and predominantly Latino communities had approximately one-third as many as did largely non-Latino communities . In contGiven the evidence that overweight and obesity are more prevalent among lower-income and minority populations, including adolescents ,16, BTG'BTG's research assessing the effect of availability of food and physical activity-related outlets on adolescents' eating, physical activity, and weight outcomes links the business list data to outcomes from the annual Monitoring the Future (MTF) surveys of US secondary school students. These are nationally representative surveys of approximately 45,000-50,000 8th-, 10th-, and 12th-grade students conducted each spring in approximately 420 schools by the University of Michigan's Institute for Social Research . These sSince 1986, the MTF surveys have also collected information on self-reported height and weight, which can be used to calculate body mass index (BMI) and indicators for youth obesity. These surveys also collect information on dietary habits , physical activity , sedentary behavior , and other behaviors potentially related to weight outcomes . Consistent with available data from other nationally representative surveys such as the National Health and Nutrition Examination Survey ,19 and tData from 1997 through 2003 on the availability of commercial physical activity-related outlets  have been linked to 8th-, 10th-, and 12th-grade student self-reports of physical activity (frequency of participation in sports/athletics and exercise) . Outlet Using 8th- and 10th-grade students' self-reported height and weight to calculate BMI and an indicator for obesity, researchers  examinedIn contrast, researchers found little association between fast-food and full-service restaurant availability and adolescent diet or weight outcomes . Using sBTG researchers have similarly examined the associations between food prices and adolescent diet and weight outcomes by using data from the American Chamber of Commerce Research Association (ACCRA) quarterly cost-of-living index reports matched to the MTF survey data. The ACCRA reports include prices for goods and services, including 3 fast foods  and 7 fruits and vegetables . BTG researchers used these price data to create 2 price indices, 1 for fast-food prices (a simple average of the 3 prices) and 1 for fruits and vegetables (a weighted average based on household expenditure shares). ACCRA (now the Council for Community and Economic Research) collects prices for about 300 metropolitan statistical areas each quarter; prices were matched to MTF schools based on the prices in the metropolitan statistical area nearest each school.Researchers used MTF 1997-2003 data on 8th- and 10th-grade students to analyze the effect of prices on frequency of fruit and vegetable consumption, BMI, and an indicator for obesity . As expeA subsequent BTG study  looked aBTG researchers have documented that healthier food outlets and opportunities for physical activity are less available in communities with lower incomes and larger proportions of racial/ethnic minorities. These findings for youth across the nation are consistent with observations in studies that focused on 1 or a few communities. Likewise, BTG researchers have begun to demonstrate that healthier environments are associated with more fruit and vegetable consumption, more activity, lower BMI, and reduced likelihood of obesity.These studies, however, have several limitations. For example, some studies have focused on food and physical activity environments only and have not taken into account the variety and range of environments to which a person is exposed. Moreover, because people of different ages have different interactions with their environments, these studies of youth have produced findings that do not translate to all age groups. In addition, these studies are cross-sectional, demonstrating associations and not causation. Also, the business list data and price data used to assess physical and economic availability may be subject to some measurement errors. Finally, these studies used BMI and obesity measures based on self-reported height and weight, which may be inaccurately reported ,28.The empirical findings presented here (based on US data) and similar study findings (based on data from other countries) have several implications for policies that could be used to curb the rising obesity epidemic. Governments can use a variety of policies to promote healthier environments, from zoning and land use regulations to fiscal policies. One of the fiscal tools that governments can use to promote development of new supermarkets, fitness facilities, and others is to provide tax incentives to businesses that are considering opening facilities in underserved communities; several have begun to do this to attract supermarkets to "food deserts" — areas with little or no ready access to relatively healthy foods. Similarly, governments can directly provide opportunities for physical activity by investing in local recreation centers, parks, and other resources in underserved areas.Governments also can use taxes and subsidies to alter the relative prices of foods and beverages. Most food subsidy programs to date aim to improve food security by subsidizing food purchases by low-income households  and have few restrictions on what products can be purchased. Subsidies that target healthy foods would reduce prices for these products relative to those of less healthy foods and likely result in healthier eating. Similarly, governments could tax less healthy foods and beverages to raise the relative prices of these products and discourage their consumption. Forty states already impose modest sales taxes on at least 1 soft drink, candy, or snack item . Higher As governments adopt policies such as taxes on less healthy products and subsidies for healthier products, investments in food and physical activity outlets, research on the effect of these policies will be needed to support future, evidence-based efforts to curb the obesity epidemic. Particularly useful will be longitudinal studies that assess the effect of these policy changes on people's behavior and on changes in weight outcomes.


Approximately 10% of the 7.9 million annual fracture patients in the United States experience nonunion and/or delayed unions, which have a substantial economic and quality of life impact. A variety of devices are being marketed under the name of “bone growth stimulators.” This article provides an overview of electrical and electromagnetic stimulation, ultrasound, and extracorporeal shock waves. More research is needed for knowledge of appropriate device configurations, advancement in the field, and encouragement in the initiation of new trials, particularly large multicenter trials and randomized control trials that have standardized device and protocol methods. The economic and health burden of fractures is large. Fortunately, most fractures heal without any complications. However, out of the estimated 7.9 million fractures that occur annually in the United States, 5–10% of them develop nonunions and/or delayed unions, which are major sources of complications in the treatment of bone fractures.2The cause of nonunions and delayed healings of fractures is usually unknown. The known reasons of delayed or impaired unions include problems with operative and nonoperative interventions, comprising inadequate mobilization of the fracture, distraction of fracture fragments by fixation devices or traction, repeated manipulations or excessive early motion of a fracture, excessive periosteal stripping, and damage to other soft tissues during operative exposure. Other risks for impaired fracture healing include contamination at the time of injury or operation, smoking, diabetes, and the skeletal location of the injury.3Bone healing may be manipulated by external  and internal  stimuli. The ability for fracture healing to be enhanced in the percentage of patients with impaired fracture healing would have a great economic impact, as well as enhance the physical and mental well-being of these patients. A variety of biological, mechanical, and physical interventions have been developed to enhance fracture healing. This article focuses on the range of physical methods to stimulate bone healing including electrical stimulators, low-intensity pulsed ultrasound, and extracorporeal shock waves. These modalities are less invasive to patients and the cost or complications related to harvesting an autograft are eliminated.3There have been case reports of success using electrical stimulation as early as 1841,Another physical stimulus that is of newer use in the enhancement of bone healing is sound. The benefits of ultrasound are determined by intensity. Diagnostic use of ultrasound requires very low intensities (milliwatts per square centimeter) to avoid excessive heating of the tissues. Nevertheless, ultrasonic intensities of one to three watts per square centimeter have been reported to reduce joint stiffness, pain, muscle spasm, improve muscular mobility, and more recently enhance the growth and healing of bones.7An even more recent method, now being studied for the treatment of bone fractures, is extracorporeal shock waves (ESWT). This method requires higher frequencies and energies and has been used as a standard for the treatment of ureter stones. In recent years, investigators have become interested in ESWT absorption through bone structures. Only a few studies have been published so far on the mechanisms and effectiveness of this therapy.8At this time, the various bone stimulation devices are being produced and marketed—under the common names, “external bone growth stimulators” and “implantable bone growth stimulators.” Some of the common companies include Biomet Incorporated, Smith and Nephew Incorporated, DJO Incorporated, Depuy Spine, Orthofix Incorporated, and VQ OrthoCare.Electrical and electromagnetic (EM) fields are assumed to play a role in bone healing through the same principles as mechanical stress applications. When mechanical load is applied to bone, a strain gradient develops.A variety of instruments have been developed to be delivered to electrical and EM fields to fracture sites, each being categorized into one of three types: invasive direct-current (DC) stimulators, noninvasive capacitive coupling (CC) stimulators, and noninvasive inductive coupling (IC) stimulators—produced by pulsed electromagnetic fields (PEMF).et al.,in vitro and in vivo, have demonstrated that EM stimulates the synthesis of structural extracellular matrix (ECM) proteins and initiates cascade events in the production of proteins that have a role in gene regulation and signal transduction of electrical potentials.2A).10However, the effects of EM on cellular processes are not well understood.Direct-current stimulators deliver EM though either implanted or percutaneously applied insulated electrodes.3Stimulation via CC devices usually applies potentials of 1–10 V at frequencies of 20–200 kHz. The resulting electrical fields in the tissue are around 1–100 mV/cm. These devices are noninvasive and the electrodes are placed on the skin on opposite sides of the fracture site.9The third technique that has become quite popular is IC stimulation, which is also applied externally (as the CC technique), and it produces electrical fields in bone with varying or pulsed electromagnetic fields .9The advantages of electrical stimulation may be the low complication rates as compared to other invasive methods. Implantable forms of the DC stimulators have the advantage of providing constant stimulation of bone directly at the fracture site as well as increased patient compliance. However, the invasive DC method may cause more infection rates, have the potential for a painful implant, and the common stress associated with operative procedures.In vitro studies suggest that ultrasonic stimulation enhances bone healing by increasing the incorporation of calcium ions in cultures of cartilage and bone cells and stimulate the expression of numerous genes  involved in the healing process.2) than that currently used by physiotherapists . Although ultrasound has been used for healing purposes, many textbooks, including reviews on fracture management, but specifically occupational therapy and physiotherapy texts, continue to “misclassify” the use of ultrasound for the treatment of fractures as a contraindication. These notions are largely based on much higher intensity ultrasound (100 W/cm2) using the physiotherapy literature; damage to tissues has been demonstrated by the use of high intensity ultrasonography.12The ultrasonic intensity required to heal fractures is lower  have very recently started being investigated, and the mechanisms of action are not well known or researched. The therapy is not currently used as a standard treatment for bone fractures.8The effect of electrical stimulators on the enhancement of fresh fracture healing remains inconclusive. Researchers have had mixed results in answering whether the use of electrical stimulators enhances the healing of slow-to-heal fractures.A recent meta-analysis of electrical stimulation for long-bone fracturesLow-intensity pulsed ultrasound, on the other hand, has a fairly extensive evidence base derived from randomized trials. In particular, one meta-analysis of 3 studies was conducted to explore the effect of low-intensity pulsed ultrasound therapy on time to fracture healing.The most commonly used bone stimulators are the low-intensity pulsed ultrasounds and electrical stimulation devices. Frost and Sullivan market research specialists report that sales of these devices, especially noninvasive spinal fusion stimulators, are climbing.et al.,et al.,In North America, there is a rather wide use of bone stimulation therapies for tibial shaft fractures, the most common of all long-bone fractures. Busse Busse and BhandariAlthough multiple randomized trials exist to support the variety of bone stimulation modalities, all are small and limited to primarily radiologic endpoints. There remains a need to conduct, large, and definitive trials that use patient-important outcomes before widespread  acceptance of such modalities will occur.


The source of information has been annual reports, notification and the approved 11th five-year plan of GOI, articles published with key words like rehabilitation, disability, assistive devices, low vision aids, and/or blind person through the mode of Internet. Annexure provides a list of selected institutions in the country offering Low Vision services compiled from various sources through personal communication and an approved list of training institutes under NPCB, GOI offering Low Vision training.India, the largest democratic country in the world, is marching ahead strongly on the growth and developmental front and is poised to be the leader in the market economy. This role creates and increases far greater responsibilities on us in ensuring that the benefit of the developmental cycle reaches each and every citizen of this country, including the able and the disabled ones. It has been enshrined in the Constitution of India to ensure equality, freedom, justice, and dignity of all individuals and implicitly mandates an inclusive society. With increase in consideration of quality parameters in all spheres of life including availability, access, and provision of comprehensive services to the disabled, it is pertinent to have a look on the contribution of government in keeping the aspiration and commitment towards common people. The article attempts to review the concept of rehabilitation for the disabled keeping a focus on the blind person, and list out the activities, programs/schemes, institutional structure and initiatives taken by the Government of India (GOI) for the same and the incentives/benefits extended to blind persons. The article concludes by reiterating the importance of individual need assessment and mentioning new initiatives proposed on Low Vision services in the approved 11 The source of information has been annual reports, notification and approved 11th five-year plan (2007-12) of the GOI, articles published with key words like rehabilitation, disability, assistive devices, low vision aids, and/or blind person through the mode of Internet. Annexure provides a list of selected institutions in the country offering Low Vision services compiled from various sources through personal communication and/or an approved list of training institutes under NPCB, GOI offering Low Vision training.There has been an evolutionary process in changing attitudes regarding the disabled and blindness around the globe. About 1,000 years back the attitude was of disregard, rejection, isolation, and abuse, however, 100 years back the attitude changed to pity and benevolence. Currently, there is a positive attitude towards the disabled including the blind to inland/foreign destination if sent by surface route weighing upto 7 kg only. If packets are to be sent by air, prescribed airmail charges needs to be paid.th or middle schools pass for rural areas and matriculation or high school for urban areas is eligible for allotment of STD/PCO on priority basis.The blind person is entitled for rental rebate of 50% on telephone facility on Non-OYT [s] category only. An educated unemployed handicap person with atleast VIIISelected goods when imported into India by a disable person for their personal use are exempted from customs duty if a certificate from a government medical officer/institution certifies that import of goods is essential to overcome the said disability.All central government employees who are in a regular establishment and who are blind or orthopaedically handicap are to be granted conveyance allowance at 5% of the basic pay subject to a maximum of Rs. 100/month.Grant of children educational allowances, reimbursement of tuition fees to central government employees are governed by central civil services orders.This is centrally sponsored scheme and was launched in 1974 by the then department of Social welfare. This scheme has however been transferred to the department of Education since 1982. Under the scheme, handicapped children are sought to be integrated in the normal school system. Financial assistance to the tune of 100% is provided to States/UTs for education of children suffering from certain mild handicaps in common schools with the help of necessary aids, incentives and specially trained teachers. The following types of disabled children are covered under this scheme: (a) children with locomotor handicaps; (b) mildly and moderately hearing impaired; (c) partially sighted children; (d) mentally handicapped educable group (IQ 50-70); (e) children with multiple handicap; (f) children with learning disabilities.Section 80 DD provides for a deduction in respect of the expenditure incurred by an individual or Hindu Undivided Family (HUF) resident in India on the medical treatment [including nursing], training and rehabilitation of handicapped dependants. Section 88 B provides for an additional rebate from net tax payable by a resident individual who has attained the age of 65 years.3% of vacancies in government employment in Grade C and D post are reserved for people with disabilities, 1% each for persons suffering from blindness or low vision, hearing impairment and locomotor disability and cerebral palsy. The GOI has set up 47 special employment exchanges in different states for the visually handicapped. As per the decision of the GOI, it has been instructed that recaning of chairs in government offices should be done by a visually impaired person as far as possible when the volume of work requires a full time chair caner.Under the scheme of public sector banks for orphanages, women's homes and physically handicapped persons including blind the benefits of the differential rate of interest are available to physically handicapped persons as well as institutions working for the welfare of the handicapped. Under the integrated rural development programme (IRDP), 3% quota is earmarked for physically handicapped persons.In India, different definitions of disability are introduced for various purposes and as such, they have been based on various criteria. No single standard exists in India in order to evaluate disability. In common parlance, different terms such as disabled, handicapped, crippled, physically challenged are used interchangeably. Visual aA person who after treatment of standard refraction has a visual acuity in better eye of <20/60 to light perception; or a visual field of <10° from the point of fixation, however, and is potentially able to use vision for planning or execution of a task [WHO].Effect of light and glareExtent of recognition and naming of colorsExtent to which contrast affects their activitiesExtent of use of vision for different activities and purpose in the environmentExtent to which a person sees and recognizes an object depends, amongst other on: Familiarity of the object; light; size; distance; contrast; color; detail or simplicity of the objectAge, socioeconomic conditions, literacy status, and level of motivationAssistive devices for the visually impaired can be broadly divided into the following categories: Education, mobility, vocational, daily living devices, low vision devices, and psychological test for vocational assessment and training.23Braille duplicators and writers, for example, Brailler and thermoform machine to convert material into Braille; Writing devices: Braille slates, Taylor postcard frame, pocket Braille frame; Braille paper; talking books and tape recorders: Material recorded on cassettes has emerged as the most popular mode of imparting education; Reading machines: Kurzweil reading machine, which reads typeset or typewritten text and turns it into speech; Braille computers: Braille Windows, Index Braille, Braille'n speak helps individual while working with personal computers; Mathematical devices: The Taylor arithmetic frame, abacus, talking calculator, spur wheel helps in learning mathematics; Geography and science devices: Sensory quill and three-dimensional raised maps help in learning geography, human physiology, zoology, and botany.Canes , mobility show-card, mini beeper.Goniometer, attachment to lathe, spot welding, continuity tester, Braille micrometer.Daily living devices can be further classified into five broad categories namely, clocks and watches, games and puzzles, sports, kitchen equipment and personnel devices.Low Vision devices can be further divided into two types: Optical devices, which use lenses to magnify objects and non-optical devices and techniques, which make objects easier to use. A third category is electronic magnifier which is sometimes subsumed under non-optical devices. These devices include telescopes , visualtek, schmidt reader, magnifying lenses , microscopic spectacles, visolett, fluorescent reading lamps, tinted lenses. Electronic magnifier/adaptive technology in the form of closed circuit television (CCTV), computer software , speech synthesizer, talking books, overhead projector.–28Psychological assessment tests and training program is designed to develop a person's skill potential to the extent possible. These include Minnesota rate of manipulation test; Pennsylvania bi-manual work sample; Purdue pegboard; Crawford small parts dexterity test; Stanford-kolhs block design test for the blind; Blind learning aptitude test.th five-year plan under NPCB in addition to ongoing activities. Regional Institutes of Ophthalmology (RIO) and government medical colleges are being developed as Low Vision units in a phased manner. Financial assistance for Low Vision devices like high plus spectacles, hand held magnifiers, stand magnifiers, telescope, video magnifiers [closed circuit television], absorptive lenses; field expanding devices are being provided by NPCB especially for poor patients. Eye surgeons working in public sector are being provided seven days orientation training on Low Vision services and financial support is borne by the GOI. Technical guidelines and comprehensive resource on Low Vision services is being developed involving all stakeholders for reference and dissemination. Improving quality of life of persons suffering from visual impairment involve patience, perseverance, multi-disciplinary approach with efficient coordination amongst stakeholders including medical, paramedical, social/psychological and educational professional. The gap between need and availability of Low Vision services is known globally, however, a beginning has been made by the GOI to address this issue and fruitful results will be evident in times to come.Strengthening Low Vision service is one of the thrust areas under 11


In response to the human health threats stemming from Hurricanes Katrina and Rita, inter-disciplinary working groups representing P30-funded Centers of the National Institute Environmental Health Sciences were created to assess threats posed by mold, harmful alga blooms, chemical toxicants, and various infectious agents at selected sites throughout the hurricane impact zone. Because of proximity to impacted areas, UTMB NIEHS Center in Environmental Toxicology was charged with coordinating direct community outreach efforts, primarily in south Louisiana. In early October 2005, UTMB/NIEHS Center Community Outreach and Education Core, in collaboration with outreach counterparts at The University of Texas MD Anderson Cancer Center @ Smithville TX/Center for Research in Environmental Disease sent two groups into southern Louisiana. One group used Lafourche Parish as a base to deliver humanitarian aid and assess local needs for additional supplies during local recovery/reclamation. A second group, ranging through New Iberia, New Orleans, Chalmette, rural Terrebonne, Lafourche and Jefferson Parishes and Baton Rouge met with community environmental leaders, emergency personnel and local citizens to 1) sample public risk perceptions, 2) evaluate the scope and reach of ongoing risk communication efforts, and 3) determine how the NIEHS could best collaborate with local groups in environmental health research and local capacity building efforts. This scoping survey identified specific information gaps limiting efficacy of risk communication, produced a community “wish list” of potential collaborative research projects. The project provided useful heuristics for disaster response and management planning and a platform for future collaborative efforts in environmental health assessment and risk communication with local advocacy groups in south Terrebonne-Lafourche parishes. When Hurricane Katrina—a strong category 3 tropical cyclone with sustained 125 mph winds and a storm surge range of 12–15 feet—made landfall near Buras-Triumph LA in southern Plaquemines Parish, the environmental community was acutely aware of the potential for catastrophic damage to the regional ecosystem and the huge negative implications for public health. Impacted areas in coastal Louisiana and Mississippi “hosted” no fewer than 65 National Priority List (Superfund), Toxic Release Inventory (TRI) reporting and hazardous materials (HAZMAT) storage sites, and the bayous are literally festooned with hundreds of natural gas and petroleum exploration, production and transmission operations. The high density of offshore drilling rigs and active wells closely proximate to the Louisiana and Mississippi coasts compounded the risk of widespread destruction to community water supplies and the regional fishery from massive oil spills.Hurricane Rita’s impact on the coasts of east Texas and southwestern Louisiana three weeks later, amplified these concerns and galvanized action from the scientific community. In mid-September 2005, a consortium of National Institute Environmental Health Sciences (NIEHS) centers nation-wide formed to focus on human health threats stemming from the impacts of Hurricanes Katrina and Rita. These groups assessed environmental threats posed by mold, water-borne pathogens, harmful algal blooms, chemical toxicants, and various infectious agents at selected sites throughout the hurricane impact zone. Because of its proximity to the impacted areas, the University of Texas Medical Branch NIEHS Center in Environmental Toxicology was charged with coordinating direct community outreach efforts in Louisiana and East Texas.In early October, UTMB/NIEHS Center Community Outreach and Education Core and counterparts at The University of Texas MD Anderson Cancer Center at Smithville TX/Center for Research in Environmental Disease sent two groups into Southern Louisiana. One group, based in Larose LA (Lafourche Parish) delivered humanitarian aid and assessed local needs for additional supplies during the recovery/reclamation stages of the local disaster response. A second group, ranging through New Iberia, New Orleans, Chalmette, rural Terrebonne, Lafourche and Jefferson Parishes, and Baton Rouge sampled public risk perceptions, evaluated the scope and reach of existing risk communication efforts, and attempted to determine how NIEHS could best collaborate in environmental health research and local capacity building efforts. Using open-ended interview questions, outreach personnel identified information gaps and areas of unresolved concern which limited the efficacy of risk communication, produced a community “wish list” of collaborative research, and developed a base for future efforts in environmental health and risk communication. Survey responses were compiled and presented at the NIEHS Center Directors meeting . Results informed the design, content and structure of Project CEHRO , a follow-up intervention based on a site-specific coastal parish model addressing disaster preparedness, and environmental health and safety risks from future storms.How may environmental health research institutions collaborate with local/regional stakeholders to comprehensively address environmental threats from Hurricanes Katrina, Rita and future storms?The NIEHS COEC scoping project assessed 1) perceptions of physical and social damage, 2) perceptions of environmental risk, 3) efficacy of risk communication efforts, 4) scope of immediate to long-term recovery needs, 5) range of suggestions for collaborative environmental health research. The interviews consisted of five items organized around the following central principle: The method underpinning this research derives from the rubric of community-based participatory technique; Rutgers University political scientist, Frank Fischer, describes this practice as “a collaborative orientation that requires an inquiry process which informs the goals and purposes of the research, and the design of necessary interventions”.5This strategy—informed by CBPR models of population health research—inverts the normal paradigm of experts assessing risk and communicating prescriptions to affected populations.10Core questions were informed by environmental justice/social epidemiology concepts central to community health practice: race, political marginalization, economic/social opportunities, types of work and work hazards, access to quality health care, cumulative burdens of stress, specific community vulnerabilities, and ability to recover from adverse stressors.16Our interview instrument consisted of four general queries, and a fifth question reserved for directors or active members of public or environmental health organizations in Louisiana. Item #4 was designed to elicit specific information on possible foci and structures for environmental health collaborations. Items #1, #2 and #3 covered the general domains of damage/risk assessment, risk perception, reactions to official attempts at risk communication, and comments on social outcomes. see Many respondents (9/15) in our purposive sample were selected on the basis of involvement in hurricane relief efforts, environmental credibility and/or direct prior connection with NIEHS Public Forum and Toxics Assistance division programs or presentations. 27% of respondents (4/15) were considered significant leaders in the Louisiana environmental community with national profiles, direct grass-roots connections and regional credibility. One respondent has achieved national prominence as an expert in levee design and construction, and the management of levee districts in flood prone areas. Difficulties establishing phone connections or physically finding identified respondents who evacuated high impact areas limited the scope of our contact base. Respondents represented 7 parishes, and the following communities: Baton Rouge (three respondents), Chalmette/Donaldsonville (one), New Orleans (two), New Iberia (one), Mathews (four), Dos Gris (one), Larose (one), Grand Boise (one), Golden Meadow (one). Additional information was gathered informally from residents of Galliano, Isle de Jean Charles, Port Fourchon, Grande Isle, Leeville, Chauvin, Dulac, Pointe-aux-Chenes and Montegut.Time limitations, disaster logistics and the need for swift response restricted scope and universality of the study. Sporadic phone and internet service made contact more difficult; extensive damage to infrastructure complicated physical access in some cases. It was often difficult for potential respondents to find time for the interview  during day-to-day recovery operations.We chose a small purposive sample (N = 15) for our qualitative interview process, adapting our need for accurate information to the circumstances of disaster recovery. While our sample size (N = 15) would be considered woefully inadequate in a traditional probabilistic survey focused on statistical power and significant confidence levels, small samples are often sufficient in providing accurate qualitative information within a particular context (or domain of knowledge/experience), provided respondents “possess a certain degree of expertise about the domain of inquiry.” Guest, Bunce and Johnson posit that 4–12 interviews are sufficient to achieve agreement on basic facts and a representative spectrum of perceptions and judgments—they term this, “data saturation”—provided the respondents share some degree of expertise in the “domain of inquiry”.We maintained a consistent interview structure  through out the process. Direct experience with the content of our interview questions was widely distributed throughout our pool of respondents. Our respondent pool was homogenous, insofar as all interviewees lived in severely impacted areas and worked actively in community/personal recovery efforts.There were some variances in respondent credibility/reliability. This correlated closely with respondent levels of engagement with community-based environmental issues prior to the disaster.While “lay expert” respondents represented a wide spectrum of the Louisiana environmental community—Southern Mutual Self-Help Association, Louisiana Environmental Action Network, New Orleans National Bucket Brigade Coalition, MacArthur and Heinz award-winning community-based environmental scientists, and Principal Chief of the United Houma Nation—it is always problematic to accept the opinions and agenda of any individual or organization as the surrogate “voice” of a community.Respondent interviews showed variability in environmental health knowledge and personal concern baselines. Respondents from our original purposive sampleSeveral features of our methodology-design and the circumstances under which we deployed our interviews affect the nature of our results:Survey responses fell into three general categories of information: general conclusions, environmental health risk perceptions/risk communication gaps, and possible formats for community research and intervention projects. Categories overlap and responses to the same survey item yielded information that could often be used verbatim, or as the basis for inferences and generalizations across categories.Survey items #1, #2 and #3 were most useful in eliciting these broad stroke characterizations: 1) Interviews and commentary showed a wide variation in risk perceptions and degree of acceptable risk, 2) within this basically nonscientist population, the degree of risk anxiety and skepticism toward official risk assessments appears directly correlated with level of environmental health awareness and scientific literacy, 3) risk perceptions continue to evolve as monitoring yields credible data and, conversely, 4) credibility issues influence risk perception and mediate risk communication. see While most of these findings are fairly straightforward, 2) requires further explanation of the seeming relationships among scientific backgrounds of individual respondents, their perceptions of risk, and their willingness to accept official risk assessments. Respondents with a comprehensive overview of the scope of storm damage, a working knowledge of National Priority List sites in the impacted areas, and a grasp of the extent of multi-media pollution in the petrochemical belt of coastal Louisiana and Mississippi prior to Hurricanes Katrina and Rita were most concerned that accurate risk assessments and citizen safety were lower priorities for local and state governments than jump-starting a severely damaged regional economy.These beliefs were reinforced for respondents participating in community-based toxicity monitoring projects, even when community results roughly approximated data generated by Louisiana Department of Environmental Quality and EPA. One survey respondent, also a renowned environmental scientist managing community level monitoring projects in Louisiana and Mississippi, corroborated much of the agency data with her own results but diverged from official interpretations of how much risk these data implied, saying:“… if it was a Superfund site, and the concentrations were at the levels we’re finding, they wouldn’t allow people to go back in there. They would require that the material be removed, treated and detoxified”.18Other respondents with environmental health backgrounds independently echoed this sentiment and stressed the need for continuous and comprehensive monitoring, and a careful program of reentry and redevelopment. Conversely, respondents with less science background or community involvement were more focused on the practicalities of debris removal and rebuilding, and the speed and smoothness of the recovery.damage to coastal marshlands, mold exposure, respiratory effects of desiccated storm sludge, possible transport of metal residues and petrochemical waste, water quality and short-term/chronic mental health issues were mentioned by 13 of 15 respondents.19Responses to items #2 and #3 provided most of our specific data on perceived health risks, gaps, ambiguities or inconsistencies in interpretation of data or formal communication of environmental health risks. Respondents covered a wide spectrum of possible toxic point sources, exposure pathways, and opinions on linkages with short and long term health effects. Many responses were in some sense linked to local geography and economics but environmental health-oriented symptoms or biomarker surveys, monitoring toxic residue levels, and comprehensive hazard assessment and preparation. Respondents who favored monitoring of toxicity and health effects expressed a strong preference for direct community involvement in all aspects of these processes, including formal risk assessments, and transparent, timely access to all results.20Responses to item #4 addressed the possibilities for collaborative responses to immediate damage, health and environmental monitoring, and preparation for the future. This query prompted a variety of elaborations including: All agreed that their missions and energies were redirected from long-term environmental projects to the immediate rescue/recovery response, and would be for the foreseeable future.Item #5 was incorporated into interviews with eight individuals involved with environmental and other community-based organizations including: Two Executive Directors of community-based environmental organizations, one Tribal Executive, one former Biology Professor/environmentalist at Southern University, Baton Rouge, one group practice community M.D., one private sector environmental scientist, one retired community/state Attorney General’s liaison specialist, one director of a private community health research non-profit. 1) Based on assessments of environmental risk and community needs identified in responses to items #1, #2 and #3, the Sealy Center for Environmental Health and Medicine at UTMB agreed to assist the Louisiana Environmental Action Network with funding for production of additional reentry safety kits for citizens returning to homes inside the storm impact zones. The LEAN kits consist of disposable N-95 mask/respirators, safety goggles, disposable nitrile gloves, heavy-duty work gloves, a Tyvek suit and booties, and Clorox ultra. This kit was “co-authored” by Wilma Subra  and Mary Lee Orr  and thousands of kits have been distributed to returning home owners and volunteers who traveled to Louisiana from other regions to assist in recovery efforts.2) Relevant responses to survey item #4 were analyzed, and compiled as a community “wish list” of necessary and urgent collaborative environmental health research projects. This compilation was presented in a special Katrina outreach panel convened at the NIEHS Center Director’s meeting . see The panel consisted of representatives from NIEHS teams monitoring water borne pathogens, metals and petrochemical pollutants, and mold spores, as well as the director of the NIEHS Center Community Outreach and Education Core at UTMB who supervised outreach efforts, on location.Project CEHRO—Community Environmental Health and Risk Outreach. This outreach was inspired by a survey recommendation by Willie Fontenot (Baton Rouge) that called for “development of a disaster management plan and precautionary procedures that incorporate environmental health, risk communication and community hazards assessment.”3) UTMB-NIEHS pilot funding was approved to produce Wetlands Loss and Hurricane Evacuation Safety– Disasters and Children: a Developmental Approach– Handling Disaster News– Post-Traumatic Stress and Disaster Anxiety– Vulnerable GroupsMental Health IssuesToxic Exposures and Medical Issues: an Epidemiology of HurricanesAssessing Community Hazards, Understanding Risk Perceptions, Communicating RiskProject CEHRO sparked collaboration among various local and regional agencies including: Les Reflections du Bayou, the United Houma Nation, Terrebonne-Lafourche Levee Districts, South Lafourche Unified School District, Bayou Inter-Faith Shared Community Organizing, Bayou Grace, Louisiana Spirit, Inner-Works, Inc. and more. The project offered 18 hours of training to a cadre of community volunteers using materials and techniques drawn from the ATSDR Toxicology Curriculum for Communities, the UTMB/NIEHS Center “Tox and Risk” Community Environmental Forum Project, the EPA NEJAC Cumulative Risk/Multiple Stressor Interaction Matrix, and the Louisiana Department of Health and Hospitals. UTMB/NIEHS community outreach personnel created a site-specific handbook for the training that incorporated themes and topics developed consensually by community project partners; major themes included:This instructional program, geared toward site-specific treatment of a range of consequences stemming from severe storms, prepared volunteers to serve as peer educators and risk communicators in their respective communities.21Tox and Risk segment of the workshop; local mental health and group leadership practitioners co-facilitated sections on Community Development and Advocacy/Risk Communication. South Lafourche Levee District and EPA personnel covered effects of previous flood management and channel engineering interventions on coastal marshland, and gave an overview of coastal reclamation plans promoted by various governmental agencies and nonprofits. Private sector and university environmental health scientists clarified results of soil and water monitoring, CDC tracking of epidemiological trends, and community hazard assessments. This curriculum developed through a consultative process involving major project partners: UTMB NIEHS Center, South Lafourche School District, United Houma Nation, Bayou Interfaith Shared Community Organizing.UTMB-NIEHS Public Forum and Toxics Assistance Division conducted the Risk uncertainty, ambiguities in risk assessment and lack of access to reliable information on risks and precautions contribute to risk anxiety and complicate regional, local and individual reentry strategies. Complications in mapping storm surge exposure pathways compound this dilemma.The preexisting “trust dynamic” among citizens and regulatory entities charged with protecting population health and the environment certainly mediates the reception of official risk communication.“… sediment sludge carried onto the land by the storm surge is contaminated by heavy metals and a host of microorganisms, all of which are known to cause acute and chronic impacts on public health. There is a need to determine the extent of that contamination and establish a plan to remove the contaminants in order to prevent residents and workers from being harmfully exposed.”24Gentilly) or landfills closely proximate to minority neighborhoods (Chef Menteur) was heated and sharp.Contention over issues such as the storm surge enabling effect of the Mississippi River Gulf Outlet (MR. GO), the significance of Murphy Oil spill data for citizens of Chalmette LAIn some degree, all respondents were acutely aware that levee systems, industrial channels, and the Mississippi River diversion adversely affect the capacity of native marshland to dampen hurricane force winds and absorb storm surge? This was a serious issue throughout all coastal areas: Plaquemines, Jefferson, St. Bernard, and Orleans parishes (Katrina), and Cameron, Vermillion, Terrebonne and Lafourche parishes LA, as well as Jefferson, Orange and Chambers counties in east Texas (Rita).