The SINERGIE  project is intended to set up a collaborative network comprising virologists, clinicians and public health officials dealing with patients affected by HCV disease in the Calabria Region. A prospective observational data-base of HCV infection will be developed and used for studies on HCV natural history, response to treatment, pharmaco-economics, disease complications, and HCV epidemiology . With this approach, we aim at improving the identification and care of patients, focusing on upcoming research questions. The final objective is to assist in improving care delivery and inform Public Health Authorities on how to optimize resource allocation in this area. The mission of the SINERGIE Study Group is to implement evidence-based research on Hepatitis C virus (HCV) into practice. We recognize that evidence from randomized clinical trials (RCT) is not fully informative in the clinical practice because patients are selected for inclusion into RCT based on strict criteria and study design is often not transferable to the diverse circumstances encountered in clinical practice. In fact, patients treated in clinical practice may be affected by bio-psycho-social co-morbidities that can affect treatment acceptability, retention into care, and outcome. Therefore, there is a need to ascertain treatment effectiveness in clinical practice, improve treatment algorithms based on clinical needs, and study their cost-effectiveness through pharmaco-economical analyses. Also, we will try to understand the transferability and the clinical outcomes of existing guidelines for treatment of HCV to guide future policy. In conclusion, we wish to improve the identification and care of patients infected with HCV in the Calabria Region , focusing on upcoming research questions that will most advance knowledge in this area and assist in improving care delivery and optimizing resource allocation.With this objective in mind, we have put together experts from different fields, following a patient-centered approach. In this framework, virologists, infectious disease specialists, gastroenterologists, and public health officials will be called to perform a coordinated effort to adapt the current international guidelines to the specificities and resources available to the Calabria Region’s Health System. Periodical audits will also be conducted and discussed during the annual meetings of the SINERGIE Study Group.1) Better disease identification, (2) Better disease management, and (3) Improved access and equity. Goal 1 recognizes that the benefit of better disease management depends first and foremost on identifying infected individuals and linking them to care. Through an improvement in the screening policy of the general population, we will obtain more reliable estimates of the HCV epidemics in order to provide public health officials with relevant information on the status and evolution of the epidemics as a basis for a targeted prevention policy. Phylogenetic analysis will help to understand HCV transmission routes within our population. Goal 2 acknowledges the need for patient-centered, comprehensive, coordinated care and treatment that not only addresses the viral infection but also the social environment, mental and physical complications that affect patients’ outcome. This will take advantage from involvement of specialist clinicians with complementary knowledge, skills and abilities. Goal 3 reaches out to infected patients at highest risk for impaired access, including migrants, the homeless, rural residents, and those with mental health and substance use disorders.To support our mission, we have developed three overarching goals:  is illustrated in Figure Amongst the open questions on the treatment of chronic HCV infection, the following merit to be answered: (i) What is the actual impact of metabolic co-morbidities and/or alcohol abuse on the efficacy of antiviral therapy ?; (ii) WTo try to answer these questions, the project aims at establishing a database of variables that can be analyzed for their association with or prediction of HCV treatment outcome. In particular: age; gender ; race/ehnicity ; previous or current substance abuse and types of substances used (substance abuse will be coded as present if an ICD-9 code for substance abuse/dependence is present); previous or current alcohol abuse ; HIV positivity (HIV will be coded as present for a positive antibody test confirmed by a western blot or positive HIV RNA); HBsAg positivity; current or previous sexually transmitted disease; stage of liver disease ; anthropometric parameters ; biochemical parameters . Ultrasonographic evaluation of the liver parenchyma, portal hemodynamic and spleen status, transient elastography and biochemical non invasive measures will also be monitored and reported at least in a sub-set of patients where these tools are available.Recently, different interleukins have been associated with HCV natural history, responses to pegIFN/RBV, and spontaneous clearance of acute HCV infection. In particular, IL28B single nucleotide polymorphisms are associated with spontaneous and treatment-induced clearance of HCV, so treatment guidelines recommend to perform a pharmacogenomic screening before prescribing HCV treatment . HoweverGenetic variability is a major hallmark of HCV biology. Currently available HCV sequences can be grouped into 6 genotypes, each further sub-divided into several subtypes . The cliGiven the unprecedented number of compounds being developed against different targets in HCV life cycle , monitorThe SINERGIE project aims at improving care of HCV infected patients through integration of clinical, epidemiological, virological and biostatistics expertise. Data collected from these domains into a dedicated on-line database will be analyzed and used to derive patient tailored treatment protocols. The individual HCV strain of each patient included in the database will be characterized for genotype , NS3 sequence  and NS5A sequence . Patients undergoing NS3/4A protease inhibitor therapy will be monitored for development of NS3/4A protease inhibitor resistance according to reference guidelines ,20. AlonAs for the epidemiological objective, storing HCV sequences in the SINERGIE database will allow phylogenetic and phylogeographic studies exploring the relationships among different clusters of specific HCV variants and patient population features such as transmission routes, origin of viral strains, time of acquisition of infection. This information can generate and periodically refresh a dynamic picture of the circulation of the different HCV strains in the area under analysis.The authors declare that they have no competing interests related to the contents of this paper.Publication of this supplement was partly supported by an unrestricted grant provided by Roche. The articles were independently prepared by the authors with no input from Roche. Roche were not involved in selecting the articles for the supplement. The pegylated IFN/pegIFN treatment mentioned in this article is produced by Roche.


A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. In cancer, a biomarker refers to a substance or process that is indicative of the presence of cancer in the body. A biomarker might be either a molecule secreted by a tumor or it can be a specific response of the body to the presence of cancer. Genetic, epigenetic, proteomic, glycomic, and imaging biomarkers can be used for cancer diagnosis, prognosis and epidemiology. These markers can be assayed in non-invasively collected biofluids. However, few cancer biomarkers are highly sensitive and specific for cancer detection at the present time. Consequently, biomarkers are not yet ready for routine use due to challenges in their clinical validation for early disease detection, diagnosis and monitoring to improve long-term survival of patients. The NIH’s National Cancer Institute (NCI) (http://www.cancer.gov/dictionary/?CdrID=45618), describes biomarkers in its dictionary of cancer terms as “A biological molecule found in blood, other body fluids, or tissues that is a sign of a normal or abnormal process, or of a condition or disease. A biomarker may be used to see how well the body responds to a treatment for a disease or condition. Biomarkers are also called molecular marker and signature molecules.”According to the US National Institutes of Health’s (NIH) Working Group and the Biomarkers Consortium, a biomarker is a characteristic that is objectively measured as an indicator of normal biological processes, pathogenic processes, or a pharmacological response to a therapeutic intervention  defines a biomarker as any substance, structure or process that can be measured in the body or its products and influences or predicts the incidence of outcome or disease . In the following sections we discuss different classifications of cancer biomarkers and their clinical implications and current challenges in the field.Perhaps the earliest examples of cancer biomarkers are urinary Bence Jones protein and tumor specific antigen carcinoembryonic antigen (CEA) in colon carcinomas . Lander’i.e., biomarkers for cancer screening and prediction might also be useful for cancer grading or staging  and DCP (des- carboxy prothrombin) are the most utilized popular cancer biomarkers for liver cancer or hepatocellular carcinoma (HCC) known so far [Alphafaetoprotein [(AFP), AFLP , indicates that it is not associated with cancer in every patient. Therefore, many other potential cancer biomarkers for prostate cancer are being investigated. Different subtypes of PSA are known and percent of subtypes of PSA, fPSA, is also important to know the aggressiveness of lesion along with another subtype, tPSA . Many inp53 gene have been observed in saliva and surgical margin analysis in head and neck squamous cell carcinoma (HNSCC) [p16 gene [EGFR, cytokerin 14 and 15, TGF-α, STAT-1, HLA-C, and GST-2 have been reported in HNSCC samples. Expression patterns of E18Ag, Pemphigus vulgaris antigen (PVA), and many cytokeratins have been implicated in the metastatic gradation of HNSCC [Mutations in the tumor suppressor  (HNSCC) . Other op16 gene ,105. Dueof HNSCC ,107. Oveof HNSCC  proteinsof HNSCC .http://www.cancer.gov/cancertopics/factsheet/Detection/tumor-markers). ASCO, a nonprofit organization that represents more than 25,000 cancer professionals worldwide, has published clinical practice guidelines  on a variety of topics, including tumor markers for breast and colorectal cancer . The National Comprehensive Cancer Network® (NCCN), another nonprofit organization, is an alliance of cancer centers, and they also provide Patient Guidelines, which include tumor marker information for several types of cancers (http://www.nccn.org/patients/patient_gls.asp). The number of biomarkers which are currently used in clinical settings is small because (i) preparation and storage of sample is not uniform; (ii) analytical validation of equipments used has not been accomplished; (iii) few techniques, such as mass spectrometry, provide huge amount of data which has not been analyzed efficiently; (iv) cancer samples have heterogeneity and most of the samples have not been collected and analyzed by laser capture microdissection; and (v) proper validation of most of the cancer biomarkers has not yet been achieved, although policies and guidelines to validate biomarkers have been developed (http://edrn.nci.nih.gov/). It is a consortium of over 300 investigators from 40 private or academic institutions that represents divergent scientific disciplines including genomics, informatics, proteomics, and public health. Other Federal collaborators include additional NCI programs, the National Institute of Science and Technology (NIST), the Centers for Disease Control and Prevention (CDC), the Jet Propulsion Laboratory (JPL), and the FDA. The EDRN is at a junction of taking the discoveries made and determining if there are appropriate clinical applications for them. Discoveries lead to work that confirms and improves the accuracy of the biomarkers, which then moves quickly to early clinical validation. Before the EDRN was formed, each part of this process was separate from the next step, and this slowed scientific progress. Through the EDRN, investigator-initiated projects are combined with a strong administrative and data infrastructure that requires and supports information sharing and collaboration among individuals and organizations. A pathway or process to test biomarkers in human biospecimens and bringing the information to clinicians has also been developed [To overcome problems in cancer biomarker field and their implication in clinic a number of efforts are underway and we have discussed those in the following section. At the NCI, attempts are being made to identify and validate cancer biomarkers through a group of investigators who participate in the Early Detection Research Network (EDRN) , approaches such as direct sequencing and real-time quantitative PCR are being standardized and implicated so that methylation levels on both strands can be determined. Attempts are also being made to do methylation profiling, histone modifications, and miRNA profiling in same samples so that there is minimal variation due to samples. Furthermore, inclusion of multiple markers may increase the sensitivity and specificity of markers in diagnosing the disease. Factors that impact sensitivity and specificity include choice of clinicl specimen, e.g, urine or serum; specimen stability/degradation; processing of specimen, e.g., urine pellet (sediment) or supernatant; choice of target gene/primers; choice of technology for analysis; negative and no template control use to see whether reaction worked; efficacy of bisulfate treatment; and use of different areas of promoter of a gene for analysis. In proteomic markers, isotope coded affinity tag (ICAT) based markers have not been explored extensively in clinical samples.An example of a recent successful clinical trial to validate different markers in colon cancer used either tissue or formalin fixed paraffin-embedded tissues . SamplesIn closing, biomarkers offer great potential for improving management of cancer at every point from screening and detection, diagnosis, staging, prognosis, and assessment of treatment response.


AbstractGlauconycteris” superba Hayman, 1939 on the basis of cranial and external morphological comparisons. A review of the attributes of a newly collected specimen from South Sudan (a new country record) and other museum specimens of “Glauconycteris” superba suggests that “Glauconycteris” superba is markedly distinct ecomorphologically from other species classified in Glauconycteris and is likely the sister taxon to Glauconycteris sensu stricto. The recent capture of this rarely collected but widespread bat highlights the need for continued research in tropical sub-Saharan Africa and in particular, for more work in western South Sudan, which has received very little scientific attention. New country records for Glauconycteris cf. poensis (South Sudan) and Glauconycteris curryae (Gabon) are also reported.A new genus is proposed for the strikingly patterned African vespertilionid “PageBreak Glauconycteris Dobson, 1875, aptly erecting the specific name superba for its spectacularly bold black and white color pattern. Since that time, only a few specimens of this species have been collected. Our capture of a parous female in July 2012 in southwestern South Sudan represents a new country record for this poorly known bat, extending its range eastward. The only species of Glauconycteris previously reported from South Sudan is Glauconycteris variegata (In 1939 Hayman described a new vespertilionid bat from the Belgian Congo (now Democratic Republic of the Congo), noting that it was “one of the most striking discoveries of recent years’’ . He placariegata .Glauconycteris, originally described by Chalinolobus, is found in Africa south of the Sahara and is currently recognized as having 12 species  were collected and flash frozen in liquid PageBreaknitrogen. Specimens were either formalin fixed and then transferred to ethanol with skulls extracted or were prepared as skins, skulls, and skeletal material. Field work was approved by the Internal Animal Care and Use Committee of Bucknell University and by the South Sudanese Ministry for Wildlife Conservation and Tourism.Field work was conducted in Bangangai Game Reserve, Western Equatoria State in the new country of South Sudan in July 2012 . Bats, iGlauconycteris” superba and data from museum specimens as noted below. Measurements were taken with rulers (ears) or dial calipers . External and osteological characters examined are based largely upon Glauconycteris and “Glauconycteris” superba were determined with a t-test and both principal components analysis (PCA) and t-tests were performed on cranial and dental data. PCA was performed using the combination of cranial and dental measurements indicated in tables and in the text. All measurement values were transformed to natural logarithms prior to multivariate analysis. Principal components were extracted from a covariance matrix. Variables for multivariate analyses were selected judiciously to maximize sample sizes for comparison by allowing for inclusion of partially broken skulls in some cases. The software programs Statistica 8.0  and SPSS Statistics 19.0 @ 2010  were used for all analytical procedures.A comparative analysis included data from our 2012 specimens, a few South Sudan specimens from our earlier expeditions, data from the three previously collected specimens of “PageBreakPageBreakReeder et al.gen. n.urn:lsid:zoobank.org:act:EDF16BEE-0749-41BC-AE19-BAE130BE58F8http://species-id.net/wiki/Niumbahasuperba has also been collected (the holotype and another recent capture), and into southeastern Central African Republic. Gender: feminine.The name is the Zande word for ‘rare/unusual’. This name was chosen because of the rarity of capture for this genus, despite its wide distribution throughout West and Central Africa, and for the unusual and striking appearance of this bat. Zande is the language of the Azande people, who are the primary ethnic group in Western Equatoria State in South Sudan (where our recent specimen was collected). The homeland of the Azande extends westwards into Democratic Republic of the Congo, where Glauconycteris superba Hayman, 1939; by monotypy.Niumbaha bears closest comparison with species of Glauconycteris (the type species of which is Glauconycteris poensis), to which it is apparently closely related, but it has a considerably larger skull and is more strikingly patterned compared to any member of Glauconycteris (its patterning most closely approaching the Asian vespertilionid genus Scotomanes). It lacks various of the most exaggeratedly derived traits  that uniquely unite the species of Glauconycteris among African vespertilionids, including the excessively foreshortened rostrum, moderately to highly reduced relative canine size, and very elongate wing tips  of Glauconycteris ).Among vespertilionids, nycteris . Externak pelage :222 notenycteris . The muzthe side . The win 16.0 mm ; Fig. 5.he skull ), althouNiumbaha superba in South Sudan (USNM 586592) in July 2012 allowed for the examination of a live bat and for the preservation of an intact specimen in fluid. This bat was captured in a single-high ground-level mist net next to a stagnant pool of water on a rocky grasslands plateau. This plateau, located at 04°52.643'N, 027°40.557'E (elevation ~ 720 m) is surrounded by secondary thicket forest and is within the boundaries of Bangangai Game Reserve, Ezo County, Western Equatoria State. Data for previously collected specimens of Niumbaha superba were taken from The collection of a new specimen of Niumbaha superba were compared to those of various species of Glauconycteris, as summarized in Niumbaha superba (Scotophilus leucogaster and Scotophilus viridis) were made. Species/specimens examined: Glauconycteris alboguttata J. A. Allen, 1917 (2): Cameroon ; Glauconycteris argentata  (14): Cameroon , Democratic Republic of the Congo , Kenya (USNM 268759), Tanzania ; Glauconycteris beatrix Thomas, 1901 (4): Cameroon , Gabon (USNM 584723), Ghana (USNM 420078); Glauconycteris curryae Eger and Schlitter, 2001 (1): Gabon (USNM 584724); Glauconycteris humeralis J.A. Allen, 1917 (3): Democratic Republic of the Congo ; Glauconycteris poensis  (12): Ivory Coast , Ghana , Nigeria (AMNH 273244), Togo ; Glauconycteris cf. poensis (6): South Sudan (new country record) , Glauconycteris variegata  (27): Benin , Botswana , Democratic Republic of the Congo , Ghana , Kenya (AMNH 238490), Mozambique (USNM 304844), Nigeria , South Africa (AMNH 257397), South Sudan , Uganda (AMNH 184228); Niumbaha superba  (4): Democratic Republic of the Congo (RMCA 14.765), Ivory Coast (RMCA A9363), Ghana (BMNH 47.10), South Sudan (USNM 586592); Scotophilus leucogaster  (8): Benin , Burkina Faso , Sierra Leone (USNM 547030); Scotophilus viridis  (9): Ivory Coast , Mozambique . Museum abbreviations and information: USNM: National Museum of Natural History, Smithsonian Institution, ; AMNH: American Museum of Natural History ; BMNH: British Museum of Natural History ; RMCA: Royal Museum for Central Africa .Data for Glauconycteris are quickly recognized by a variety of distinctive traits, many of which are shared with the monotypic Niumbaha. Below we examine each of these traits, highlighting similarities and differences between Niumbaha and Glauconycteris.Species of Coloration, pattern, and body size: superba that he erected a new subspecies based upon it, Glauconycteris superba sheila. The patterning of this specimen differs in that (1) two white spots are found on each shoulder next to the base of the humerus, (2) the unpigmented areas on the upper surface of the elbow, knee and ankle joints are present, and (3) the ventral interfemoral membrane is a pale gray color. Our newly collected specimen more closely resembles the Ghana specimen, but has only one white spot on each shoulder next to the base of the humerus and lacks an unpigmented area at the base of the ankle (Niumbaha superba is from the Ivory Coast (RMCA A9363) and, while cited by Glauconycteris superba sheila . Thus, of the five specimens, four appear to have characteristics attributed to the subspecies sheila and only one to the nominate subspecies. However, given the variation seen within the specimens of the subspecies sheila and giventhat the single specimen attributed to the nominate subspecies was PageBreakcaptured in relatively close proximity to two specimens that match more closely the pelage patterning described for sheila,we do not recognize sheila as a valid subspecies  (BMNH 47.10). Hayman found the markings of this specimen sufficiently different from the holotype of he ankle . The reche ankle  resemblesee also . Within variable . In GlauNiumbaha superba . Indeed, our specimen, fixed in formalin and stored in ethanol, is now black and white, such that the yellow coloration of the paler fur ornamentation has leached from the fur, and only the images of the freshly collected bat indicate its true color.Notably, our specimen of Niumbaha superba is larger than all species of Glauconycteris, as noted by Glauconycteris variegata and Glauconycteris argentata, but that the skull is far bigger, with a total skull length greater than 16mm  on digit 3 (DIII) is longer than Ph1. Within Glauconycteris, Glauconycteris variegata is perhaps the PageBreakPageBreakbest studied species and Glauconycteris variegata suggest relatively maneuverable, low flight speed that might favor feeding in open areas around, but not within clutter .Facial features (including the ear): Glauconycteris is distinctive among African vespertilionids in possessing an extremely shortened but broad muzzle in which the nostrils open more or less to the side from a transverse, thick subcylindrical naked pad. On the underlip is found a thickened pair of pads and the lower lip near the corner of the mouth has a fleshy lappet or fold that can be made to extend horizontally  noted that the skull was longer and less broad with marked flattening of the rostrum PageBreakPageBreak“so that the profile shows an angle at the junction of the brain-case and the rostrum” and (1947:549) and so that there is “considerable lengthening of the infraorbital foramen”; he also noted the presence of proportionally deeper basisphenoid pits  species, we do not find this to be the case in our South Sudan specimen. The canines, and especially the upper canine, are considerably more robust (unreduced) in Niumbaha than in Glauconycteris. The size difference between Niumbaha and Glauconycteris presumably allows Niumbaha to take larger, more hard-bodied prey than Glauconycteris, an apparent lepidopteran (moth) specialist  clearly indicates that the skulls of Niumbaha separate from skulls of species of Glauconycteris, suggesting greater overall ecomorphological resemblance of Niumbaha with medium-sized, less specialized African vespertilionids such as Scotophilus  the proportionally narrower interorbital dimensions, less dramatic postorbital constricPageBreaktion, longer toothrows, narrowed skull, but widened anterior rostrum in Niumbaha relative to Glauconycteris.tophilus . The fireris see . Beyond Niumbaha superba has been rarely captured (only five times) but is apparently widely distributed  is believed to be a high flier . Very few reviewers of Glauconycteris have mentioned first-hand examination of specimens of superba or their attributes. Obviously, it is not only on the basis of its ecomorphological distinction from other species of Glauconycteris, but especially in its lack of several of the most characteristic morphological properties of Glauconycteris (which we take to be synapomorphic for the species of Glauconycteris sensu stricto), that we erect a new genus, Niumbaha, to house superba, one of the most beautiful and rarely collected of Africa’s vespertilionids. In lacking the reduced body size, extremely blunt face, characteristic nostril configuration, and extreme wingtip lengthening of Glauconycteris, Niumbaha superficially reminds us of other medium-sized and less specialized vespertilionid genera, such as Scotophilus  some emballonurids, such as Saccopteryx bilineata. Niumbaha superba] … may appear very conspicuous in the hand it doubtless acts as a concealing pattern in nature in a similar way to that well-established for many other animals with disruptive markings…” Such disruptive coloration may, in part, explain the lack of local and scientific knowledge regarding this bat. In each collection location it was unknown to indigenous peoples, and early scientific collecting of bats was often focused on areas where they could be most obviously located, such as buildings or other conspicuous roost locations. Niumbaha superba might be a tent-making bat is intriguing. Another possibility is that the striking pelage pattern of Niumbaha superba is not disruptive or camouflaging, but rather serves in social signaling. However, the use of pelage markings (outside of epaulettes) as social signals in bats is not well studied , but we did not detect a strong scent in our specimen. Regarding its common name, Niumbaha superba was originally described by Spilogale and has had several common names over the years, including the Magpie bat . Given that several species of the Australo-Papuan genus Chalinolobus are referred to as ‘pied bats’, we think it best to avoid that name, and propose the use PageBreakof ‘badger bat’ in reference to its tenacious appearance and its bold black and white/cream coloration, both reminiscent of badgers.Our naming of a new genus for one of the most extraordinary and rarest-collected bats in Africa highlights a number of issues.  studied  and the  in bats . Strong gpie bat , Mrs. Cagpie bat , and PieNiumbaha superba is difficult to assess. Until 2004, the International Union for the Conservation of Nature (IUCN) listed Niumbaha superba as “Vulnerable”. In 2008, it changed the listing to “Least Concern” “in view of its wide distribution, presumed large population, and because it is unlikely to be declining fast enough to qualify for listing in a more threatened category”  highlights the need to expand biodiversity surveys and studies in this new nation. These bats were captured in the Bangangai Game Reserve in Western Equatoria State, which resides within a ‘tropical belt’ along the border with the Democratic Republic of the Congo. It is largely composed of dense tropical/subtropical forest, the type of which is highly restricted in South Sudan. Its placement near the Congo Basin ecoregion sets it apart from the rest of South Sudan and elements of the faunas and floras of West Africa and East Africa overlap here (The capture of this bat in South Sudan (as well as the collection of lap here , creatinNiumbaha superba, In his original description of


Awareness of the importance of strengthening investments in child health and monitoring the quality of services in the pediatric field is increasing. The Pediatric Quality Indicators developed by the US Agency for Healthcare Research and Quality (AHRQ), use hospital administrative data to identify admissions that could be avoided through high-quality outpatient care. Building on this approach, the purpose of this study is to perform an empirical examination of the ‘pediatric gastroenteritis admission rate’ indicator in Italy, under the assumption that lower admission rates are associated with better management at the primary care level and with overall better quality of care for children.Following the AHRQ process for evaluating quality indicators, we examined age exclusion/inclusion criteria, selection of diagnostic codes, hospitalization type, and methodological issues for the ‘pediatric gastroenteritis admission rate’. The regional variability of hospitalizations was analyzed for Italian children aged 0–17 years discharged between January 1, 2009 and December 31, 2011. We considered hospitalizations for the following diagnoses: non-bacterial gastroenteritis, bacterial gastroenteritis and dehydration . The data source was the hospital discharge records database. All rates were stratified by age.In the study period, there were 61,130 pediatric hospitalizations for non-bacterial gastroenteritis, 5,940 for bacterial gastroenteritis, and 38,820 for dehydration. In <1-year group, the relative risk of hospitalization for non-bacterial gastroenteritis was 24 times higher than in adolescents, then it dropped to 14.5 in 1- to 4-year-olds and to 3.2 in 5- to 9-year-olds. At the national level, the percentage of admissions for bacterial gastroenteritis was small compared with non-bacterial, while including admissions for dehydration revealed a significant variability in diagnostic coding among regions that affected the regional performance of the indicator.For broadest application, we propose a ‘pediatric gastroenteritis admission rate’ that consists of including bacterial gastroenteritis and dehydration diagnoses in the numerator, as well as infants aged <3 months. We also suggest adjusting for age and including day hospital admissions. Future evaluation by a clinical panel at the national level might be helpful to determine appropriate application for such measures, and make recommendations to policy makers. Thorough understanding and international comparisons of the health needs of children and the ways in which health systems address these needs require appropriate data. MoreoveSimply applying indicators to younger age ranges is insufficient because specific characteristics distinguish children from being simply ‘little adults’,3. OptimAlthough some European projects have provided sets of indicators for children for primary and secondary care evaluation , few resA systematic attempt to measure the quality of child health services has been made in the US with the Pediatric Quality Indicators (PDIs) developed by the Agency of Healthcare Research and Quality (AHRQ) in collaboration with Stanford University and the University of California. The PDIThe underlying concept is that timely and effective ambulatory care ensured by an integrated comprehensive system of providers and services with a preventive orientation, may avoid hospitalizations due to the mentioned conditions. According to the AHRQ, the development process of such indicators requires an empirical analysis in order to establish their validity and reliability, detect bias and design appropriate risk adjustment models before submitting candidate indicators to clinical panelists.Programma Nazionale Esiti) and 298 [symptoms concerning nutrition and metabolism <18 years]) have very similar national relative weights (0.30 and 0.27) , thus exclusion of the newborns aged <3 months does not affect the indicator. The indicator proposed by the PNE considers the pediatric population aged 0 to 17 years.Our empirical analysis confirms the need for age-adjustment when comparative evaluations are performed. In fact, the risk of hospital admission is significantly higher in younger age groups; noteworthy, it is not necessary to stratify by age group, as age is not an effect modifier of regional performance.Lastly, we found a very low proportion of day hospital admissions for gastroenteritis and dehydration at the national level, but some variability among regions. Thus, we argue that including day hospital admissions in the numerator would be worthwhile, so as to capture all potentially avoidable hospital admissions for gastroenteritis and dehydration, even shorter ones.As for another ACSC indicator for the pediatric age , it is recommended to adapt the ‘pediatric gastroenteritis admission rate’ to the Italian healthcare setting. Our empirical analysis highlights some key points to be discussed by a structured clinical panel review involving specialists from the pediatric field at the national level.Acute gastroenteritis hospitalizations might be particularly important also to evaluate the impact of rotavirus vaccination campaigns. As already mentioned, since pediatric acute gastroenteritis in industrialized countries is mainly caused by rotavirus, rotavirus vaccines will be introduced in upcoming infant vaccination plans to reduce avoidable hospitalizations and complications due to this common acute pediatric condition. Following the example of a recent US vaccination campaign introduction, where RV5 vaccine proved to dramatically reduce the hospitalization rates due to pediatric gastroenteritis, we submaIn Italy, daytime hospital care  consists in a planned one-day admission to the hospital without overnight stay, to perform diagnostic procedures and/or surgical, therapeutic or rehabilitative care. These diagnostic and therapeutic procedures require specific instrumental techniques, are carried out by multidisciplinary staff and are more complex than those run on an outpatient basis.bBacterial gastroenteritis diagnoses were included in the analysis because we assume that they are potentially preventable in Italy, where family pediatricians are trained specialists who work at the primary-care level providing ambulatory and home care.CHILD: Child Health Indicators of Life and Development; OECD: Organization for Economic Co-operation and Development; US: United States; AHRQ: Agency for Healthcare Research and Quality; PDI: Pediatric Quality Indicator; CDC: Center for Disease Control and Prevention; ACSC: Ambulatory Care Sensitive Condition; PNE: Programma Nazionale Esiti [National Outcomes Program]; HDR: Hospital Discharge Records; ICD-9-CM: International Classification of Diseases ; RR: Relative Risk; AP: Autonomous province; VG: Venezia Giulia; PIE: Piedmont; AOS: Aosta Valley; LOM: Lombardy; APB: Autonomous province of Bolzano; APT: Autonomous province of Trento; VEN: Veneto; FVG: Friuli-Venezia Giulia; LIG: Liguria; EMR: Emilia-Romagna; TUS: Tuscany; UMB: Umbria; MAR: Marche; LAZ: Lazio; ABR: Abruzzo; MOL: Molise; CAM: Campania; APU: Apulia; BAS: Basilicata; CAL: Calabria; SIC: Sicily; SAR: Sardinia.The authors declare that they have no competing interests.JL conceived the statistical methodology, performed the statistical analysis and drafted the manuscript; LL contributed to the conception of this paper, conceived the study design and drafted the manuscript; KMM participated in the study design and helped to draft the manuscript; SR took responsibility for the integrity of the data and performed the statistical analysis; GD provided data sources and participated in the study design; GC critically revised the draft and contributed to the final writing of the paper; MPF contributed to the conception of this paper, conceived the study design and drafted the manuscript. All authors read and approved the final version of the manuscript.List of ICD-9-CM diagnosis codes for non-bacterial gastroenteritis, bacterial gastroenteritis, and dehydration.Click here for fileNote: Gastroenteritis comprises both non-bacterial and bacterial diagnoses. Data source: Ministry of Health.Percentages of hospital admissions for gastroenteritis and dehydration by region (<3 months). Click here for fileNote: Gastroenteritis comprises both non-bacterial and bacterial diagnoses. Data source: Ministry of Health.Percentages of hospital admissions for gastroenteritis and dehydration by region (3–11 months). Click here for file


Aedes pupae, interventions ranged from mechanical lid covers for containers to biological control. Where small discarded containers presented the main problem, groups experimented with solid waste management, composting and recycling schemes. Many intervention tools were locally produced and all tools were implemented through community partnership strategies. All sites developed socially and culturally appropriate health education materials. The study also mobilised and empowered women’s, students’ and community groups and at several sites organized new volunteer groups for environmental health. The initiative’s programmes showed significant impact on vector densities in some sites. Other sites showed varying effect — partially attributable to the ‘contamination’ of control groups — yet led to significant outcomes at the community level where local groups united around broad interests in environmental hygiene and sanitation. The programme’s findings are relevant for defining efficient, effective and ecologically sound vector control interventions based on local evidence and in accordance with WHO’s strategy for integrated vector management.This article provides an overview of methods and cross-site insights of a 5-year research and capacity building initiative conducted between 2006 and 2011 in six countries of South Asia  and South-East Asia .The initiative managed an interdisciplinary investigation of ecological, biological, and social  dimensions of dengue in urban and peri-urban areas, and developed community-based interventions aimed at reducing dengue vector breeding and viral transmission. The multicountry study comprised interdisciplinary research groups from six leading Asian research institutions. The groups conducted a detailed situation analysis to identify and characterize local eco-bio-social conditions, and formed a community-of-practice for EcoHealth research where group partners disseminated results and collaboratively developed site-specific intervention tools for vector-borne diseases. In sites where water containers produced more than 70% of  Aedes aegypti — water containers of different types present in domestic and peridomestic environments — are closely related to environmental factors linked to and maintained by human behavior. Recrudescent dengue is a particular public health concern in Asian cities and peri-urban areas where the disease is now widely endemic and where epidemic outbreaks occur with increasing frequency and intensity. Dengue emergence and resurgence is widely associated with rapid and uncontrolled urbanization.Dengue is the fastest advancing vector-borne arboviral disease in terms of geographical expansion and number of cases and is a significant economic and social burden in many countries worldwide.Dengue prevention relies on vector control and will likely continue to do so even when an effective dengue vaccine becomes available. In the past 10 years, significant progress was made in developing innovative biological, chemical, and mechanical vector control technologies.7Vector control tools, regardless of their technological basis, must be feasible and practical to apply in real-life situations. Community engagement and intersectoral partnerships are particularly important elements of integrated public health strategies for vector control. In Asia, government services routinely conduct vector control using the characteristically ‘top-down approach’ of vertical programmes that consist of larviciding water containers and space spraying of insecticides in neighborhoods with reported dengue cases. Novel approaches to dengue vector management successfully tested in recent years include targeted interventions in key productive container types 9Existing research on the complexity of eco-bio-social contexts repeatedly argues that dengue control necessitates sound intersectoral approaches that combine environmental management practices with community mobilization.The research presented in this special issue results from a multicountry research initiative in Asia, carried out between 2006 and 2011, supported by a research and capacity building partnership between the Special Programme for Research and Training in Tropical Diseases (TDR) and the Ecosystem and Human Health Program of Canada’s International Development Research Centre (IDRC).The overall objective of the research programme was to strategize and contribute to improved dengue prevention using interdisciplinary analysis to better understand ecosystem-related, biological, and social determinants of dengue, as well as to develop and evaluate intersectoral and community-centered ecosystem management interventions directed at reducing dengue vector habitats. This multicountry research initiative complements earlier research programmes facilitated by TDR that substantiated the cost-effectiveness of targeted dengue vector interventions.8Upon development of a core protocol based on established multimethod approaches to public health research, and following an international call for letters-of-intent and a review of submissions by an external expert committee, multidisciplinary teams in six research institutions of South Asia  and South-East Asia  joined the initiative. The study design encouraged mutual complementarity among different research disciplines  by combining eco-logical, bio-logical  and social  assessment of various dimensions affecting dengue in urban and peri-urban Asia.All six sites first undertook a situation analysis to characterize and map the urban ecosystem, vector ecology in relation to rainfall, and social and cultural context, including stakeholder environment, community dynamics and gender implications. The situation analysis identified productive container types , social and environmental risk factors favoring vector breeding, variation of vector ecology in the dry and wet season and in public and private spaces, and developed recommendations for locally adapted interventions. All six teams conducted a spatial analysis of randomly selected area clusters (urban neighborhoods determined by Geographic Information Systems grid sampling), with 20 clusters at three sites and 12 clusters at three other sites. The teams subsequently administered the following standardized research instruments that were based on methods in entomology, epidemiology, environmental sciences — including ecology — and social sciences:household survey to assess basic demographic information (household composition), characteristics of housing and basic services, and knowledge of dengue and vector-related knowledge, attitudes and practices;larval/pupal survey for use in households and public spaces, measuring water volume, water type, relative shading, location, usage, coverage, larval density, and pupae counts by container type;cluster background information instrument to assess and describe the overall environmental situation of research clusters, including housing conditions and public spaces;social research toolkit with modules that predominately utilize qualitative methods to assess: (1) social context and gender, (2) vector control policy and programme functioning, and (3) stakeholder environment;Aedes dengue vectors to facilitate the basic description of the ecosystem under study;standard guide for ecosystem characterization with reference to manual for applying Geographic Information Systems to dengue research to geo-reference clusters, households and open spaces.The cross-site analysisAn important cross-site finding helped explain why rainfall is associated with increased dengue incidence by showing that uncovered outdoor water containers left unused for more than one week and usually positioned beneath vegetation were the most productive breeding sites of dengue vectors. Public spaces — except for schools and religious facilities — and commercial areas were much less important for pupal production than the peridomestic and intradomestic environment, particularly in densely populated neighborhoods. A complex yet non-significant association between water supply and pupal counts revealed that irregular supply with piped water, as well as the absence of piped water, may lead to increased water storage and vector infestation. Lack of waste disposal services was associated with vector abundance in only one site where, in the absence of large water containers, vectors bred in discarded containers . Peoples’ knowledge of dengue transmitting mosquitoes was associated with reduced mosquito breeding and production, attributed to increased self-protection with domestic insecticides. Vector control measures (mainly larviciding in one site) substantially reduced the larval/pupal indices and ‘pushed’ mosquito breeding to alternative containers.The comparative analysis of vector control services indicated that most vector control interventions are limited to space spraying and selective larviciding during local outbreaks and periods of increased case incidence, despite extensive dengue-related national or local guidelines and a significant formal organization of public surveillance and control services.All sites conducted a participatory problem analysis involving communities and other stakeholder groups, based on the situation analysis with important multisectoral stakeholder groups aiming at building consensus on potential intervention approaches. This process led to the design of site-specific intervention packages using innovative biological, chemical, mechanical and/or environmental vector control technologies and/or a combination of these tools. The intervention tools were selected according to the site-specific productive container types  and rangAll sites developed socially and culturally appropriate health education materials. Various community groups  were mobilized and empowered at different levels. The teams applied the process indicator framework for assessing degrees and intensities of community participation to their interventionsThe impact on vector densities compared to control neighborhoods was significant in some sites  and was as strong as in neighborhoods with enhanced public vector control but more sustainable in two sites .The common denominator in the six study sites was: (1) to design, conduct and evaluate multipartnership interventions with emphasis on community involvement; (2) to identify productive container types for adult dengue vectors  and to apply a targeted approach in the productive containers; (3) to use as much as possible an ‘eco-health approach’ with judicious use or no use of insecticides according to IVM principles (integrated vector management)Based on the cross-site process evaluation, a process model for eco-bio-social research on vector-borne diseases emerged and contains five basic elements necessary for locally relevant and community-based vector control :local situation analysis leading to better understanding of transmission dynamics through research on vector ecology, social context, stakeholder environment, gender analysis, community dynamics and ecosystem characterization;dissemination of early and formative results leading to collaborative problem analysis and consensus building;design of site-specific and locally-relevant intervention packages with combination of tools and clear delivery strategies;implementation of partnership-driven interventions through the mobilization, participation and empowerment of local communities and stakeholders at different levels, with clear definitions for supply and delivery mechanisms, as well as adequate management and organization;ongoing monitoring and evaluation of process, uptake, outcomes, impact and sustainability.The prospects of a forthcoming dengue vaccine and — if ethically sound and acceptable by society — the use of genetically modified vectors will provide additional tools for achieving more comprehensive prevention of dengue virus transmission. Yet even with the future availability of such technical approaches, dengue prevention will continue to depend largely on innovative and robust intersectoral vector control strategies that are both cost-effective and sustainable. This study was unable to undertake a proper economic analysis of the cost-effectiveness and effect on dengue transmission dynamics of the intervention packages developed by the programmes in the initiative. However, evidence generated through this multicountry study suggests that vector management would be more sustainable when it complements or replaces other interventions by: (1) involving diverse partners — including local communities, (2) targeting water container interventions that achieve a significant reduction of dengue vectors , and (3) utilizing novel non-insecticidal intervention tools . The findings are relevant for defining efficient, effective and ecologically sound vector control interventions that are based on local evidence and are in accordance with WHO’s strategy for IVM. Within this strategy, eco-bio-social research can be considered an important research framework for the systematic assessment of vector control needs and the development of partnership strategies at the local level.


Cancer is a leading cause of death in Latin America but there have been few assessments of the cancer burden for the 10% of the population who are indigenous. Evidence from other world regions suggests cancer survival is poorer for indigenous people than for others due to a greater incidence of case-fatal cancers, later stage at diagnosis, and less cancer treatment. A status report on the cancer profile of indigenous people in Latin America and the Caribbean (LAC) is therefore clearly warranted. We undertook a systematic review of the peer-reviewed literature in academic databases, and considered evidence from cancer registries from 1980, to assess cancer epidemiology among indigenous people in LAC. We identified 35 peer-reviewed articles pertaining to cancer in indigenous people. Rates of cervical cancer in parts of Brazil, Ecuador, and Guyana, stomach cancer rates in regions of Chile and gallbladder rates in Chile and Bolivia, were higher for indigenous compared to others. Breast cancer rates were lower in Ecuador, Brazil, and Chile. Six cancer registries in Brazil provided incidence data but no other reports of incidence, mortality, or survival were identified. There was a paucity of data surrounding the cancer burden of indigenous people in LAC. In view of predicted increases in cancer rates in ensuing decades, and the disparities in burden already experienced by indigenous people in the region, it is imperative that cancer profiles are obtained and cancer control measures identified and prioritized. Cancer is a leading cause of death in Latin America and the Caribbean (LAC) A recent comprehensive review of cancer care in Latin America by The Lancet Oncology Commission highlighted the lack of data on cancer outcomes among indigenous populations A formal definition of indigenous peoples has not been adopted by the United Nations, the diversity of indigenous populations rendering definitions problematic Literature searches were undertaken using PubMed and databases pertinent to the region, including LILACS, SciElo, Biblioteca-CEPAL. Key terms used were “indigenous,” “Indian,” “Amerindian,” together with “neoplasm” and “cancer,” with specific searches carried out on the basis of identified names of indigenous populations. English, Portuguese, and Spanish language publications, after 1980, were included. Electronic searches for/of cancer registry or government reports, as well as scrutiny of hard copy reports, were conducted. Where information on indigenous status was lacking, but data were available for regions with a predominantly indigenous population, we utilized available cancer rates.Age-adjusted incidence rates per 100,000, available for indigenous people from six population-based cancer registries (PBCR) in Brazil, were compared with corresponding rates for the whole population. Rates were calculated by age, sex, and cancer to the world population. Population data were obtained from the 2010 Brazilian Census The literature review yielded 1794 articles, 35 of which were included. No cancer rates for indigenous people were found in cancer registry reports, and contacts at registries in Argentina, Bolivia, Colombia, Guatemala, Ecuador, Mexico, and Peru confirmed either that these data were not routinely collected or that reports did not exist; incidence data were made available from six registries in Brazil.There are over 400 indigenous groups in LAC, encompassing 45–48 million people “Indigeneity” is determined variously throughout the region  and not All Latin American countries are classified by the World Bank as low or middle income countries In Central and South America, 13% of the population is covered by population-based cancer registration and 95% of the population by a national mortality scheme n = 11) and nine additional articles report cancer risk factors. Below, we describe the limited information on rates and cancer profile among indigenous peoples within LAC.To date there has been no regional overview of cancer among indigenous people in LAC. Country-specific searches identified 26 articles with reference to cancer among indigenous people, the majority relating to cervical cancer  detected differences in people whose name indicated Mapuche descent There are no rates available for indigenous people in Colombia, however, estimates in the La Guajira region, where 45% are indigenous, found lower cancer rates than Colombia overall  Standardized breast and cervical cancer rates, primarily among indigenous women in four regions of the Amazon Basin of Ecuador, were 5.08 and 21.58 per 100,000, respectively, for the period 1985–1998. Rates of breast cancer were less than those of the whole of Ecuador  and more developed countries  but cervical cancer rates were similar to those of all women in Ecuador  and considerably higher than those of women in developed countries Cervical cancer was more common among Indian women than other groups, and significantly associated with higher prevalence of human papillomavirus (HPV) infection, earlier age at first intercourse, greater number of births, and lower socioeconomic status Two case studies in Peru reported Kaposi's sarcoma in three HIV-negative Quechua men The most commonly occurring cancers in Latin America overall are prostate, lung, stomach, colorectal, and bladder in men and breast, cervix, colorectal, stomach, and lung in women Prevalence of cancer risk factors among indigenous people was reported in nine articles. Higher smoking rates were reported among indigenous people in the Southern Andes of Argentina than those of European descent Human T-cell lymphotrophic virus (HTLV), an oncogenic virus that is prevalent in indigenous women in the Peruvian Amazon, has been associated with HPV, suggesting the need for HTLV-positive women to be screened for HPV and cervical neoplasia Cancer was associated with exposure to contaminants from oil drilling in the Amazon Basin of Ecuador, in a predominantly indigenous population Two papers have reported protective factors for breast cancer, including breast feeding and a greater number of births, and less hormone replacement therapy and alcohol consumption, among selected communities of Indian women in Brazil n = 2050), reported a high frequency of cervical cancer (without providing rates) and that 20% of women tested positive for HPV Seven articles related to cancer screening and cytological programs among indigenous women in LAC were identified. Since 2005, a cervical screening program has been carried out among indigenous women in Xingu Indian Park, Brazil, with a reported coverage of 93%, and a decreased incidence in high-grade cervical lesions and invasive cancer reported in that population Indigenous women reportedly have limited access to cervical screening services; 70% of indigenous women in Ecuador and 58% in a Guatemala report never having had a Pap smear An appraisal of the peer-reviewed literature, cancer reports, and other sources revealed a paucity of data concerning cancer among indigenous people in LAC. Indeed, a 2006 comprehensive report on indigenous health in LAC makes no mention of cancer To the best of our knowledge, indigenous status is recorded in cancer registries of only four LAC countries and therefore there is no definitive way of quantifying and comprehending the cancer burden among indigenous peoples. In all, nine of the 35 papers identified for review were from Brazil, where less than 1% of the population are indigenous. With the exception of Bolivia (1983), no publication contained population-based cancer rates for indigenous people, and a number of reports highlight the lack of available data on cancer profiles of indigenous people The paucity of data aside, results point to cancer as an emerging public health problem among indigenous peoples in LAC over the next decades. Cervical cancer is the leading cause of death among women and, if current incidence rates remain unchanged, the burden of this cancer is predicted to increase by 75% in the region by 2025 Empirical evidence suggests that improvements in social and economic status have led to an overall increase in life expectancy in Latin America Indigenous communities are thus exposed to a double burden of cancer, one set of neoplasms related to westernized diet and lifestyle as communities transit from more traditional and isolated lifestyles, and a residual cancer burden linked with infections, pertaining more to poverty. This, coupled with a lack of access to health care services, including cancer screening and treatment, lower levels of education, and lower social status, contribute to poorer cancer survival among indigenous people. High-resource countries such as Australia A barrier to a critical assessment of cancer burden in indigenous populations is the lack of a universal definition of “indigenous” or “indigeneity,” although a generally accepted premise is that such peoples are the first inhabitants of a region or country and for whom existence predates colonization. The mechanism of identification used by countries and regions also varies, and may include self-identification, geographical concentration It is well recognized that robust cancer surveillance frameworks are necessary in order to develop, implement, and evaluate adequate cancer control programs Helicobacter pylori) Poverty has been inextricably linked with poorer overall health Health beliefs and systems for indigenous people in LAC range from traditional medicine practices Beliefs about cancer among some indigenous populations reportedly vary considerably from the biomedical model http://gicr.iarc.fr/) and roll-out of Regional Hubs for Cancer Registration in Latin America (as well as Africa and Asia), is well placed to assist countries in these efforts.Goss and colleagues rightly state that cancer registration in all countries in LAC must underpin cancer control measures, including prevention, screening, diagnosis, and treatment. The International Agency for Research on Cancer, through its Global Initiative (


The use of highly hazardous pesticides by smallholder farmers constitutes a classic trans-sectoral ‘wicked problem’. We share our program of research in potato and vegetable farming communities in the Andean highlands, working with partners from multiple sectors to confront this problem over several projects.We engaged in iterative cycles of mixed methods research around particular questions, actions relevant to stakeholders, new proposal formulation and implementation followed by evaluation of impacts. Capacity building occurred among farmers, technical personnel, and students from multiple disciplines. Involvement of research users occurred throughout: women and men farmers, non-governmental development organizations, Ministries of Health and Agriculture, and, in Ecuador, the National Council on Social Participation.Pesticide poisonings were more widespread than existing passive surveillance systems would suggest. More diversified, moderately developed agricultural systems had lower pesticide use and better child nutrition. Greater understanding among women of crop management options and more equal household gender relations were associated with reduced farm pesticide use and household pesticide exposure. Involvement in more organic agriculture was associated with greater household food security and food sovereignty. Markets for safer produce supported efforts by smallholder farmers to reduce hazardous pesticide use.Participatory interventions included: promoting greater access to alternative methods and inputs in a store co-sponsored by the municipality; producing less harmful inputs such as compost by women farmers; strengthening farmer organizations around healthier and more sustainable agriculture; marketing safer produce among social sectors; empowering farmers to act as social monitors; and using social monitoring results to inform decision makers. Uptake by policy makers has included: the Ecuadorian Ministry of Health rolling out pesticide poisoning surveillance modeled on our system; the Ecuadorian Association of Municipalities holding a national virtual forum on healthier agriculture; and the Ecuadorian Ministry of Agriculture promulgating restrictions on highly hazardous pesticides in June 2010.Work with multiple actors is needed to shift agriculture towards greater sustainability and human health, particularly for vulnerable smallholders. The use of highly hazardous pesticides by smallholder farmers, especially in lower and middle income countries (LMICs) constitutes a classic trans-sectoral ‘wicked problem’. Wicked problems are those where good social solutions are difficult to achieve because of differences among stakeholders in framing, understanding and responding to the problem . SmallhoPesticides most commonly used by smallholder farmers in Ecuador are those categorized by the WHO  as extreAgricultural sector investment in LMICs has been strongly oriented towards medium to large scale commercial agriculture . GovernmEcosalud [EcoHealth] II (2005-2008), Hortisana [Healthy Horticulture] (2007-2010), and Gobernanza con Capital Social [Social Capital and Accountability] (2008-2011). Partnerships underpinning these projects involved core Andean-based organizations  linked with both external collaborators - primarily with the University of Toronto and affiliated institutions- and internal, within-country collaborators. The latter have included nongovernmental development organizations, provincial ministries of health and agriculture, organizations of independent smallholder family farmers, agricultural marketing organizations, research institutes and municipalities . Our ovThe development of our research program has been an iterative process: starting with particular questions, and working with stakeholders to obtain results in an assessment phase. Research teams included health , bio-physical/natural , social  scientists and practitioners. Young professionals-researchers in training have joined us in a trans-disciplinary approach . Mixed mThe geographic areas of our research program were highly diverse, with a wide variety of production systems and education, poverty, ethnicity and gender relations. In keeping with the observations of rural sociologists , we founIn the Ecosalud II project, knowledge of pesticide-related hazards and practices to reduce exposure was limited and varied by gender. At baseline, women’s greater participation in farm decision-making and a more equal allocation of production and household roles between genders was associated with less use of highly hazardous pesticides on the farm, particularly those farms with less of a commercial orientation . InformeThe Ecosalud II team addressed this challenge through a health promotion intervention guided by socio-ecological conceptual frameworks which encompass a range of theories on behaviour change at multiple levels . Our objsana) products was increasing as was interest in indigenous foods. Direct-marketing arrangements like a local organic market (Bioferia) in Peru or an Agricultural Association-sponsored store in Ecuador facilitated the formation of relationships of trust between producers and consumers . The arrangements provided greater financial returns to farmers and quality assurance to consumers. Feedback up the value chain from consumers indicated that they sought better quality, greater variety of vegetables, more consistent availability and larger volumes .The Ecosalud II team found that farmers did not have access to inputs such as insect traps or less hazardous pesticides. We worked with a farmers’ organization and a local municipality in co-sponsoring a store to provide such inputs, along with advice on how best to use them. In the HortiSana project, a women’s agricultural association expanded their composting facility to provide both themselves and others with a key input for vegetable production. In Peru, farmers expressed concerns about climate change affecting the diversity of agricultural products they produced. However, they thought that the threats to their food security were due primarily to fluctuating returns for their crops while purchased food prices were increasing. In both Ecuador and Peru, the HortiSana team found that consumer demand for organic or “healthy” , our partnerships have inevitably been complex and dynamic ,19. ThouResearch partnership has been facilitated by a longstanding Associate Scientist position held by the key Canadian researcher (DCC) with CIP, where the lead social scientist is located (GP). In Ecuador, a formal relationship of the key Ecuadorian health scientist (FOT) with INIAP and a mentoring relationship between the Canadian and Ecuadorian leads has helped immensely. Each lead contributes to joint conceptualization, design, and obtaining funding for the research, oversee its implementation and takes primary responsibility for analysis and reporting to the broader scientific community. These core research collaborations have been complemented through multi-disciplinary agricultural research alliances with national and international scientists in CIP and other Ecuadorian and Peruvian organizations. Decisions have been primarily made in country by collaborative research-action teams, complemented by supporting virtual dialogue  among Canadian and Andean colleagues.Implementation partnerships involved dynamic shifts in the core collaborations among organizations strongly linked with Andean institutions. Foremost among these were farmers' organizations. The common role of the project teams has been to strengthen existing organizations, though the HortiSana team has also worked with farmer innovators to facilitate organization of groups of organic farmers in municipalities where no such organizations existed. Representatives of nongovernmental organizations (NGOs) which regularly work with farmers and municipal technicians, and who increasingly perform development roles in their jurisdictions, played key roles during implementation. To formalize links between, for example CIP or INIAP and NGOs, memoranda of understanding have been elaborated, specifying in detail the nature of the collaboration, resource flows, counterpart support and mutual objectives. NGOs have also worked with a wide range of stakeholders, often bringing them together in “platforms”, and social spaces where discussion, coordination, project development and learning from research results could occur. An example is the “Platform for Inter institutional Dialogue to Work towards Sustainable Production in the Mantaro Valley” in Peru, in which the idea of a “bioferia” in Chupuro, Peru was developed into a successful marketing and health education event .A third kind of partnerships has involved knowledge use by mainly policy actors, usually at higher levels of government, who can position the activities and results of the intervention-research process. Relationships with these political actors have been more complex, often taking the form of shifting alliances among a wider range of social actors. For example, in policy and regulatory initiatives, such as the prohibition of extremely and highly hazardous pesticides in Ecuador , much woThe fundamental challenge of persistent and deepening inequities in determinants of health in the Andes  has bothTrans-disciplinary research for development also offered multiple challenges  as did iCIP: International Potato Center; IIN: Institute for Research in Nutrition, Peru; INIAP: National Institute for Agriculture and Livestock Research in Ecuador; LMIC: lower and middle income countries; NGO: non-governmental organization; WHO: World Health Organization.The authors declare that they have no competing interests, other than those identifiable through their institutional affiliations.DCC conceived the article, co-designed the research for two projects and participated in their analysis and interpretation, co- wrote the initial draft and revised the manuscript.FO is co-researcher and coordinator for Ecosalud II project; conceived, designed, and is the main researcher of the Gobernanza Project, is co-writer of the article and revised the manuscript.WP was involved in the coordination and evaluation of the initial draft of the HortiSana project and revised the manuscript.JS, AC, XM and SW all were involved in implementation of different projects.GP co-conceived one project, has co-lead implementation of the same and made revisions to the manuscript.JL analyzed and interpreted data for the HortiSana project; and revised the manuscript.All authors read and approved the final manuscript.


Rift Valley fever (RVF) is a neglected, emerging, mosquito-borne disease with severe negative impact on human and animal health and economy. RVF is caused by RVF virus (RVFV) affecting humans and a wide range of animals. The virus is transmitted through bites from mosquitoes and exposure to viremic blood, body fluids, or tissues of infected animals. During 2007 a large RVF outbreak occurred in Sudan with a total of 747 confirmed human cases including 230 deaths ; although it has been estimated 75,000 were infected. It was most severe in White Nile, El Gezira, and Sennar states near to the White Nile and the Blue Nile Rivers. Notably, RVF was not demonstrated in livestock until after the human cases appeared and unfortunately, there are no records or reports of the number of affected animals or deaths. Ideally, animals should serve as sentinels to prevent loss of human life, but the situation here was reversed. Animal contact seemed to be the most dominant risk factor followed by animal products and mosquito bites. The Sudan outbreak followed an unusually heavy rainfall in the country with severe flooding and previous studies on RVF in Sudan suggest that RVFV is endemic in parts of Sudan. An RVF outbreak results in human disease, but also large economic loss with an impact beyond the immediate influence on the directly affected agricultural producers. The outbreak emphasizes the need for collaboration between veterinary and health authorities, entomologists, environmental specialists, and biologists, as the best strategy towards the prevention and control of RVF. Bunyaviridae family, genus Phlebovirus affecting humans and a wide range of animals Globally, vector-borne diseases are responsible for almost 20% of the infectious diseases affecting humanity, and developing countries in Africa suffer most from the vector-borne disease burden and its socioeconomic consequences http://www.ncbi.nlm.nih.gov/sites/entrez/) and by using “Rift Valley fever” alone, 1,010 articles were found. Additional articles were obtained by citation tracking of review and original articles. The books, reports, and fact sheets that include information about the disease were searched through the following sources:Using the terms “Sudan” and “Rift Valley fever” 26 articles were identified by searching Medline through PubMed (http://www.who.int/); World Organization of Animal Health (OIE) (http://www.oie.int/); Food and Agriculture Organization of United Nation (FAO) (http://www.fao.org/); Google scholar (http://scholar.google.com/); United States Center for Emerging Issues (http://www.aphis.usda.gov/).World Health Organization (WHO)  Sudan asked the WHO to assist in the investigation and control of a suspected hemorrhagic fever outbreak  [10]. ThAt the end of the outbreak in January 2008, a total of 747 laboratory confirmed cases had been recorded with 230 deaths Sentinel animals had been surveyed during 2005–2006 in Kosti with no evidence of RVF Disabilities associated with the disease and the cost of treatment is a burden for the health system during an epidemic. In a recent publication the number of human cases estimated in the Sudan outbreak was 75,000 Bunyaviridae such as the Hantaviruses that cause hemorrhagic fever with renal syndrome Clinical symptoms reported during the Sudan outbreak were fever, hemorrhagic symptoms, hepato-renal failure, and ocular complications Mosquitoes play a crucial role in transmission to animals and humans, but the most important risk factor for severe infection is contact with RVFV-infected animals such as consuming or handling products from sick animals, touching an aborted animal foetus, or being a herdsperson During the outbreak, a serious case of vertical transmission from mother to the baby was documented There was no evidence for horizontal transmission between humans in Sudan or elsewhere. However, health workers may contract many other viral diseases while dealing with patient excretions and therefore it is recommendable that the medical staffs take precautions with such cases. Laboratory personnel could also be at risk when handling samples The majority of the RVF patients in Sudan lived in rural areas, but the reported number of shepherds infected was rather low, probably explained by less availability to health care leading to underestimation of true affected population Outbreaks of RVF are associated with heavy rainfall and flooding, increasing the population of mosquitoes leading to transmission of the infection, such as in the devastating outbreak in East Africa in 2006–2007 Culex mosquito populations could function as secondary vectors The environment in the three affected states is suitable for agriculture with large numbers of susceptible animals serving as virus amplifiers. The humid climatic conditions support proliferation of the mosquitoes, the main vector of the disease. The El Gezira state was the worst affected area and most of the patients lived close to irrigation canal areas, linked to naturally occurring cycles involving livestock and mosquitoes Modification of the environment has been associated with outbreaks of diseases transmitted by mosquitoes. For instance, water impoundments like large dams have been shown to exacerbate malaria transmission in malaria endemic parts of sub-Saharan Africa Aedes species such as Aedes mcintoshi, Ae. ochraceous, Ae. vexans are considered the main mosquito vectors responsible for the vertical transmission of the virus Culex and Anopheles species followed by spread to additional animals and humans Mosquito species composition, densities, and infection varies within a country and different mosquito species could serve as epizootic/epidemic vectors of RVFV in diverse ecologies, creating a complex epidemiologic pattern Anopheles gambiae arabiensis in White Nile state, and Culex pipiens complex in Khartoum state Aedes aegypti, An. coustani, and Cx. poicilipes played a less important role. Since the vector collection was performed at the end of the outbreak the RVFV positive Anopheles and Culex mosquitoes were most probably secondary vectors considering previous reports Anopheles species Cx. pipens complex, An. gambiae arabiensis, An. coustani, and Ae. aegypti and in male An. gambiae arabiensis mosquitoes Anopheles species, but immature mosquitoes have been shown to be infected by ingesting RVFV infected material In December 2007, adult and immature mosquitoes were collected in the White Nile state, one of the epidemic regions in Sudan, and Khartoum state, which supposedly only had imported cases As discussed above, infected mosquitoes were found 2007 in Khartoum Infected mosquitoes and animals are important in maintaining the level of virus during the interepidemic/epizootic periods. Small recurring local outbreaks most likely appear and in a recent retrospective study of RVF activity in Kenya, national RVF epizootics were recorded with an average interepizootic period of 3–6 years Transmission of zoonotic diseases has increased worldwide in recent years because of increasingly intense livestock production in areas of proximity to human populations. An RVF outbreak results in human disease, but also large economic loss with an impact beyond the immediate influence on the directly affected agricultural producers Livestock and livestock products are Sudan's second most important source of foreign exchange after oil. In 2000, after the RVF outbreak in the Arabian Peninsula, Saudi Arabia declared a ban on animal export from East Africa and the export from Sudan decreased significantly in 2000 and 2001 The RVF outbreak in Sudan was connected to heavy rainfall, flooding, and increased mosquito breeding and was first reported in humans. The lesson from Sudan makes it clear that human health is the result of sustainable relationships between humans, animals, and the environment, summarized in the new concept “One Health One World” Rift Valley fever (RVF) is an important emerging viral zoonosis that causes disease both in animals and humans, and outbreaks of RVF are correlated to abundance of mosquitoes due to increased rainfall and flooding.The 2007 outbreak was the first reported RVF outbreak in Sudan for 36 years, although studies indicate that the virus has been circulating in Sudan for a long time.In the Sudan outbreak, humans, rather than livestock, served as sentinels. Surveillance could be improved by using animals as sentinels to prevent loss of human life.A One Health One World perspective is clearly needed for prevention and control of RVF. The capacity of veterinary authorities and entomologists should be enhanced to implement early warning systems.There is a need to carry out vector competence studies to determine the epidemiological capacity of different mosquito species and their role in the virus maintenance and transmission.Daubney R, Hudson JR (1931) Enzootic hepatitis or Rift Valley fever. An undescribed virus disease of sheep, cattle and man from East Africa. J Pathol Bacteriol 34: 545–579.Eisa M, Obeid HMA, El Sawi ASA (1977) Rift Valley fever in the Sudan. I. Results on field investigations of the first epizootic in Kosti District, 1973 Bull Anim Health Prod Afr 24: 343–347.Wilson ML (1994) Rift Valley fever virus ecology and the epidemiology of disease emergence. Ann N Y Acad Sci 740:169–180.Nguku PM, Sharif SK, Mutonga D, Amwayi S, Omolo J, et al. (2010) An investigation of a major outbreak of Rift Valley fever in Kenya: 2006–2007. Am J Trop Med Hyg 83: 5–13.Anyamba A, Linthicum KJ, Small J, Britch SC, Pak E, et al. (2010) Prediction, assessment of the Rift Valley fever activity in East and Southern Africa 2006–2008 and possible vector control strategies. Am J Trop Med Hyg 83: 43–51.The development of RVF early warning systems and surveillance on an applicable regional level is of utmost importance, but policy makers have to be convinced by research and facts to understand that it is achievable and worthwhile.Lack of a One Health approach exacerbates RVF outbreaks in resource poor regions. Collaboration between veterinarians, entomologists, physicians, and environmental specialists must be encouraged to facilitate better surveillance.Capacity building and training is needed to improve recognition of human and animal cases and set-up of diagnostic methods.Livestock trade is the backbone of the rural economy and embargos could have devastating economic effects. Disease notification has to be encouraged, for instance by international collaboration and help with compensation to prevent further spread.No antiviral or human RVFV vaccine exist and the use of animal vaccines during outbreaks have been questioned


Stopping the spread of the cholera epidemic in Haiti required engaging community health workers (CHWs) in prevention and treatment activities. The Centers for Disease Control and Prevention collaborated with the Haitian Ministry of Public Health and Population to develop CHW educational materials, train >1,100 CHWs, and evaluate training efforts. CHWs are typically laypersons selected by the community  died in the community, 60 (69%) did not suspect their illness was cholera or recognize the severity, 22 (26%) lived too far from health facilities to access care, and 30 (77%) of the 39 community decedents did not take oral rehydration solution (ORS) at home . Populations with poor access to health care often experience higher case-fatality rates during cholera epidemics, which means that local provision of treatment and supplies through less specialized health workers such as CHWs is essential  and MSPP developed a set of technically accurate, lower literacy, and culturally adapted training and educational materials for CHWs during the cholera outbreak in Haiti. The materials are comprehensive in scope and can be adapted for use in cholera preparedness and response activities in other countries.Training materials were based on the World Health Organization technical guidelines for cholera; guidelines and educational materials from the International Centre for Diarrhoeal Disease Research, Bangladesh; cholera prevention messages, guidelines, and materials from CDC; online manuals and guides from various nongovernmental organizations; and information from manufacturers of point-of-use water treatment products. Consensus for all materials was reached among CDC subject matter experts and communications personal, MSPP, and CDC staff in Haiti. Amendments were made after field review and use in Haiti, and messages concerning culturally appropriate burial practices, stigma prevention, and additional water treatment options were added as the epidemic progressed and additional content needs were identified.The materials now include comprehensive cholera prevention, treatment, and control training modules , Table 2www.cdc.gov/haiticholera) and cholera-specific website (www.cdc.gov/cholera). As of July 27, 2011, the websites had received >6,300 total views and 1,352 downloads. The training manual was also included as an appendix to CDC’s national clinical cholera training course for medical staff in Haiti, which was initiated on November 15, 2010.As part of CDC’s response to the cholera outbreak in Haiti, this manual was made available through both CDC’s emergency website  indicated that CHWs were able to demonstrate proper preparation of safe water and ORS. In addition, 12 of the 14 participants who completed surveys reported training other types of community workers, including midwives, professors, group leaders, nurses, brigadiers, promoters, voodoo priests, and other religious leaders.In an attempt to quickly and efficiently reach the most underserved areas of Haiti during a deadly cholera outbreak, we developed comprehensive training materials for CHWs and implemented training using a Train-the-trainer model. However, this process had many challenges. The urgent need for training in Haiti required us to draft messages without the benefit of formative research or pilot testing of the materials. Translating materials into Haitian Creole, which only became an official language in Haiti in 1987 and which remains a predominantly verbal language with several dialects, was difficult and required multiple quality assurance steps. Because of resource constraints, Train-the-trainer events were not initiated in Haiti until March 2011, >4 months after the epidemic began. More timely training might have helped mitigate the impact of the epidemic on remote and underserved populations. These materials can now be adapted to train CHWs in other cholera-affected countries more rapidly than we were able to do in Haiti. Additional evaluation activities are planned at the community and household levels to assess the impact of these materials on cholera knowledge, prevention activities, and treatment among CHWs and community members and to guide revisions of these materials.In many rural areas of Haiti, CHWs are the backbone of the health care system and can play an essential role in preventing cholera illness and death among medically underserved populations. We prepared standardized materials and training modules for CHWs that focused on prevention, treatment, and control of cholera. We conducted a Train-the-trainer workshop that led to training CHWs across 9 departments of Haiti. Additional monitoring and evaluation activities are needed to assess the reach and impact of the training materials and implementation.


Inconsistencies in research findings on the impact of the built environment on walking across the life course may be methodologically driven. Commonly used methods to define ‘neighbourhood’, from which built environment variables are measured, may not accurately represent the spatial extent to which the behaviour in question occurs. This paper aims to provide new methods for spatially defining ‘neighbourhood’ based on how people use their surrounding environment.Informed by Global Positioning Systems (GPS) tracking data, several alternative neighbourhood delineation techniques were examined . Compared with traditionally used buffers , differences were found in built environment characteristics within the newly created ‘neighbourhoods’. Model fit statistics indicated that exposure measures derived from alternative buffering techniques provided a better fit when examining the relationship between land-use and walking for transport or leisure.This research identifies how changes in the spatial extent from which built environment measures are derived may influence walking behaviour. Buffer size and orientation influences the relationship between built environment measures and walking for leisure in older adults. The use of GPS data proved suitable for re-examining operational definitions of neighbourhood. The influence of the built environment on healthy behaviours such as walking has received significant attention in the past decade ,2. ScholMethods typically used to define neighbourhood include: predefined spatial units; circular buffers; and polygon-based road network buffers . But preThe use of buffers (circular or polygon network) to define the spatial extent for which measures of the built environment are derived has been the target of increasing criticism -29. SpatStudies using GPS technology to measure location-based physical activity are emerging in the health literature. For example, Badland et al.  recentlyPossibly the first study of its kind, Zenk et al.  utilisedCreate alternative neighbourhood buffers, based on objective GPS walking data, which better represent the spatial extent in which older adults actually walk;Explore the differences between the new neighbourhood buffers and standard buffers commonly used in the literature  for built environment measures; andExamine the relationship between land-use exposure and self-reported walking in older adults for each neighbourhood buffer.The Active Living Study – a mixed-method, cross-sectional study conducted in 2009 – investigated active living among retirement village residents and the influence of village and neighbourhood environments. The exploratory qualitative phase informed the development of a quantitative survey instrument, which was administered to 325 residents in 32 retirement villages across Perth, Australia. A convenience sub-sample of residents from seven of the 32 study villages were approached to take part in the GPS component (n = 74). Additional information sheets were provided, and written consent received from 41 residents (55%). Ethics approval was granted by The University of Western Australia Human Research Ethics Committee (RA/4/1/2151).Study participants met with researchers on a pre-arranged day and time within the retirement village to complete a questionnaire and receive equipment. Among other items, the questionnaire included demographics , self-reported height and weight , and previously validated and reliable measures of physical activity ,39 and pThe GPS sub-sample received a GlobalSat DG-100 data logger on an additional elastic belt, and were required to wear the device at the same time as their accelerometer, on the left side of the body. The epoch length was 15 seconds. Additional verbal and written instructions were given, highlighting the need to recharge the GPS unit each night. Similar to the accelerometer diary, a GPS diary to encourage compliance, monitor daily wear time, and remind participants to recharge the device was distributed.Approximately 126 MB of GPS data and 10 MB of accelerometer data were collected for the 41 sub-sample participants. These data were processed using the Physical Activity Location Measurement System (PALMS) currently under development at the University of California, San Diego School of Medicine and California Institute for Telecommunications and Information Technology . Whilst some simply vary buffer size, there has been limited progress in understanding the spatial extent of healthy behaviours, in order to select the most appropriate space in which to measure environmental influences that relate to behaviour within that space. That is to say, behaviour, in this case walking, may or may not occur within a predefined buffer ,30. DiscThe use of objective movement data from GPS devices was a strength of the study and found to be appropriate for analysis of this kind. Using GPS data made it possible to observe travel patterns, without the participant burden and recall bias issues related to travel logs or diaries. However, the use of GPS technology in Health research is still fairly new and there are several issues to consider in terms of data collection, data accuracy, behaviour classification, and analyses.Technically speaking, physical and built features such as dense tree canopies, topography, tall buildings (urban canyons), and transportation tunnels can result in signal loss and multipath errors ,43,53. OOn the ground, technological advancements such as dead reckoning, increased sensitivity of receiver antennas, positional augmentation using coordinates collected by a mobile phone , mobile Whilst data management in GPS studies is a critical issue because of the massive quantities of data produced by interval recordings  we foundOur use of PALMS was during the developmental stages of the system therefore visual examinations were used to validate trip classifications. Misclassification of trips included stationary trips classified as vehicle, bicycle and walking, mixed tips classified as a single type and vice versa, and one type of trip classified as another. Distinguishing between walking and use of electric mobility scooters proved difficult in our cohort of older adults as their speeds of movement can be similar. The most recent version of PALMS allows the user to specify thresholds however in our case we identified thresholds through trial and error relaying our new parameter requirements to the PALMS staff. Therefore, further research is needed to overcome problems in data treatment in order to make sense of large and highly accurate data, an issue PALMS is continuing to address.As several studies have identified, the elderly tend to walk more frequently in their neighbourhood than younger people ,50,53 anIn conclusion, this pilot study highlights the possibilities that exist for re-examining the spatial extent from which built environment measures are derived in health related research. The use of GPS technology allowed for an objective view of how humans interact with their environment across space, and provided a tool to challenge the way in which neighbourhoods are defined and operationalized. Spatially informed buffers specific to the behaviour in question showed better model fit and influenced relationships between built environment measures and walking for leisure among older adults. Future research should capitalise on the potential of GPS technology to explore (and be creative in) how we define neighbourhoods in research studies across a wider range of population age groups and types of healthy behaviours.The authors declare that they have no competing interests.BJB conceived of the project, oversaw GIS analysis and prepared much of the manuscript. AN collected the GPS data, provided statistical analysis and contributed to the manuscript development and editing. SN provided GIS analysis, contributed to the development of new GIS methods and early drafts of the manuscript. All authors have read and approved the final manuscript.