The application of mobile computing and communication technology is rapidly expanding in the fields of health care and public health. This systematic review will summarise the evidence for the effectiveness of mobile technology interventions for improving health and health service outcomes  around the world.To be included in the review interventions must aim to improve or promote health or health service use and quality, employing any mobile computing and communication technology. This includes: (1) interventions designed to improve diagnosis, investigation, treatment, monitoring and management of disease; (2) interventions to deliver treatment or disease management programmes to patients, health promotion interventions, and interventions designed to improve treatment compliance; and (3) interventions to improve health care processes e.g. appointment attendance, result notification, vaccination reminders.A comprehensive, electronic search strategy will be used to identify controlled studies, published since 1990, and indexed in MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, the Cochrane Library, or the UK NHS Health Technology Assessment database. The search strategy will include terms (and synonyms) for the following mobile electronic devices (MEDs) and a range of compatible media: mobile phone; personal digital assistant (PDA); handheld computer (e.g. tablet PC); PDA phone ; Smartphone; enterprise digital assistant; portable media player (i.e. MP3 or MP4 player); handheld video game console. No terms for health or health service outcomes will be included, to ensure that all applications of mobile technology in public health and health services are identified. Bibliographies of primary studies and review articles meeting the inclusion criteria will be searched manually to identify further eligible studies. Data on objective and self-reported outcomes and study quality will be independently extracted by two review authors. Where there are sufficient numbers of similar interventions, we will calculate and report pooled risk ratios or standardised mean differences using meta-analysis.This systematic review will provide recommendations on the use of mobile computing and communication technology in health care and public health and will guide future work on intervention development and primary research in this field. M-health, the use of mobile computing and communication technologies in health care and public health, is a rapidly expanding area of research and practice. M-health programmes and interventions use mobile electronic devices (MEDs), such as personal digital assistants (PDAs) and mobile phones, for a range of functions from clinical decision support systems and data collection tools for healthcare professionals,2, to suCurrent documented M-health interventions and programmes include: mobile phone text messaging to support management of diabetes, hypertension, asthma, eating disorders and HIV treatment-7; mobilMobile communication technology is the fastest growing sector of the communications industry in low income countries,18. In tMobile technologies have a number of key features that give them an advantage over other information and communication technologies in particular activities within health care and public health. Firstly, many MEDs have wireless cellular communication capability, providing the potential for continuous, interactive communication from any location e.g. telephone calls, text and multimedia messaging and also internet access via Wireless Application Protocol (WAP) or mobile broadband internet. Secondly, the devices are portable because of their small size, low weight and rechargeable, long-life battery power. Finally, many MEDs have sufficient computing power to support multimedia software applications. The combination of these features varies between specific devices and their relative importance will change with the health activity in which they are used. However, with advances in technology development, single devices increasingly possess many or all of these functions.Existing systematic reviews of M-health interventions, and recently published protocols-26, focuThe objectives of this review are to: (1) describe the uses of mobile computing and communication technologies by patients, healthcare professionals and the general public in the context of health service and public health interventions that have been evaluated in controlled studies; (2) assess the effectiveness of mobile technologies for improving health and health service outcomes in high, middle and low income countries; and (3) describe the acceptability of mobile technologies to patients, healthcare professionals and the general public, in the context of health service and health promotion interventions.For the purposes of this review, MEDs will be defined as devices which either have interactive wireless cellular communication capability and/or those which run software applications and are highly portable. We will therefore include interventions using: mobile phones; personal digital assistants (PDA) and PDA phones ; Smartphones (e.g. the iphone); Enterprise digital assistants (EDA); portable media players ; handheld video-game consoles (e.g. Playstation Portable (PSP), Nintendo DS); handheld and ultra-portable computers such as tablet PCs (e.g. the ipad) and Smartbooks. A summary of the functions available with each of these devices is provided in Table Interventions must aim to improve or promote health or health service use and quality, employing any MED. This includes: (1) interventions designed to improve diagnosis, investigation, treatment, monitoring and management of disease; (2) interventions to deliver treatment or disease management programmes to patients, health promotion interventions, and interventions designed to improve treatment compliance; and (3) interventions to improve health care processes e.g. appointment attendance, result notification, vaccination reminders. We will therefore include:- Any intervention delivered using an MED owned or directly used by a patient or lay person;- Any clinical or practice aid delivered using an MED owned or directly used by a healthcare professional;- Any data collection or storage for the purposes of healthcare or health research using an MED.We anticipate that interventions will aim to address one of the health domains shown in Figure Studies must have used a controlled design to evaluate an MED intervention. We will include both randomised controlled trials and studies with non-random treatment group allocation. Previous reviews have highlighted the difficulty in assessing the impact of MED on health outcomes when the MED is used as an adjunct to other interventions and services e.g. text messaging in addition to clinician appointments for managing hypertension. We will- Interventions delivered via a single MED to the treatment group , where the control group receives no MED intervention;- Multi-MED interventions where the treatment group receives one or more interventions delivered through multiple MED, but no interventions through other (non-MED) modes and the control group receives no MED interventions;- Mixed MED and non-MED interventions where the treatment and control group both receive all non-MED components of the intervention and the MED intervention is delivered only to the treatment group, e.g. SMS plus group counselling for smoking cessation in the treatment group and the control group receives group counselling only;- Interventions delivered by different MED e.g. iphone vs. regular mobile phone;- The features and components of interventions delivered on a particular MED, such as the intensity, personalisation, content, duration and timing of an intervention, and the degree of software or other component customisation.We will exclude studies evaluating:- Mixed MED and non-MED interventions where the treatment and control group both receive the MED component;- Interventions where there are other treatment differences between the treatment and control groups besides the delivery of the MED component(s).There will be no limits on study participants in terms of age, gender, ethnicity, morbidities  or staff role and occupation . There will be no limits on study setting and we will include studies at all levels of healthcare setting  and those conducted in the community.All outcome measures reported in studies meeting the inclusion criteria will be extracted, both objective and self-reported measures. User-acceptability will be assessed as a self-reported outcome for all intervention types. We will also seek data on unintended adverse consequences of the interventions and process outcomes (e.g. repetitive strain injury or involvement in road traffic accidents).Primary outcome measures will include any objective measure of health, or health service delivery or use. These may include biologically confirmed smoking cessation or mean change in body mass index, blood pressure, blood lipids or blood glucose levels. Secondary outcome measures will include: cognitive outcomes relating to knowledge, motivation, self-efficacy and intention; self-reported outcomes related to health behaviours (e.g. number of cigarettes smoked), chronic disease management, health service delivery or use. Examples of outcome measures for each health domain in Figure We will use a three-part search strategy to identify studies meeting the inclusion criteria above that have been published since 1990: (1) we will search electronic bibliographic databases for published work, using a comprehensive search strategy for mobile technology interventions; (2) we will search trial registers for ongoing and recently completed trials; (3) we will search the reference lists of primary studies included in the review and the reference lists of relevant, previously published reviews.The following electronic bibliographic databases will be searched: MEDLINE, EMBASE, PsycINFO, Global Health, The Cochrane Library , Cochrane Methodology Register), NHS Health Technology Assessment Database, and Web of Science . The search strategy will include only terms relating to or describing mobile technologies because we will include all types of intervention and health or health service outcomes meeting the inclusion criteria described above. The search strategy for MEDLINE is shown in Additional File We will include data from dissertations that meet the inclusion criteria, where these are indexed in the above databases and retrieved in our search. We will not be retrieving or including any unpublished data.Ongoing, recently completed and unpublished clinical trials meeting the inclusion criteria described above will be identified from the following research registers: National Institutes of Health clinical trials registry (US); National Institute for Health Research Clinical Research Network Portfolio Database (UK); National Research Register Projects Database Archive (UK); and Current Controlled Trials .Titles and abstracts of studies retrieved using the search strategy and those from additional sources will be screened independently by two review authors to identify studies that potentially meet the inclusion criteria outlined above. The full text of these potentially eligible studies will be retrieved and independently assessed for eligibility by two review authors. Any disagreement between the two review authors over the eligibility of particular studies will be resolved through discussion with a third review author.A standardised, pre-piloted form will be used to extract data from the included studies for assessment of study quality and evidence synthesis. Extracted information will include: study setting (including country); study population and participant demographics and baseline characteristics; MED used; details of the intervention and control conditions; study methodology; recruitment and study completion rates; outcomes and times of measurement; indicators of acceptability to users; suggested mechanisms of intervention action; information for assessment of the risk of bias (see below). Two review authors will independently extract data, discrepancies will be identified and resolved through discussion (with a third author where necessary). Missing data will be requested from study authors via email.Two review authors will independently assess the risk of bias in included studies by considering the following characteristics, as recommended by the International Cochrane Collaboration:- Randomisation sequence generation: was the allocation sequence (used to assign participants to the treatment and control groups) adequately generated? - Treatment allocation concealment: was the allocated treatment adequately concealed from study participants and clinicians and other healthcare or research staff at the enrolment stage?- Blinding: were the personnel assessing outcomes and analysing data sufficiently blinded to the intervention allocation throughout the trial?- Completeness of outcome data: were participant exclusions, attrition and incomplete outcome data adequately addressed in the published report?- Selective outcome reporting: is there evidence of selective outcome reporting and might this have affected the study results?- Other sources of bias: was the trial apparently free of any other problems that could produce a high risk of bias?Disagreements between the review authors over the risk of bias in particular studies will be resolved by discussion, with involvement of a third review author where necessary. The level of risk of bias in each of these domains will be presented separately for each study in tables in the final review publication.We will provide a narrative synthesis of the findings from the included studies. We will structure the narrative synthesis by describing the studies according to the following characteristics:- The type of intervention e.g. individual behaviour change, chronic disease self-management, clinic appointment reminders or clinical diagnostic aid ;- The type of outcome e.g. smoking cessation or weight loss;- Intervention content - features of the MED employed , intervention components such as reminders, feedback or peer support, intensity, duration, personalisation and theoretical basis (if stated).We will provide summaries of intervention effects for each study by calculating risk ratios (for dichotomous outcomes) or standardised mean differences (for continuous outcomes) from the data presented in the published studies or obtained from study authors.2 test and the I2 statistic. We will consider an I2 value greater than 50% indicative of substantial heterogeneity. We will conduct sensitivity analyses based on study quality  in order to investigate possible sources of heterogeneity). We will use stratified meta-analyses to explore heterogeneity in effect estimates according to: study quality ; study populations ; the logistics of intervention provision ; and intervention content (information only versus explicit use of behaviour change theories and techniques for behaviour change interventions). We will assess evidence of publication bias using Egger's weighted regression method for continuous outcomes and Begg's rank correlation test for dichotomous outcomes.We anticipate that there will be limited scope for meta-analysis because of the range of different outcomes measured across the reasonably small number of existing mobile technology intervention trials. However, where studies have used the same type of intervention and MED, with the same outcome measure, we will use Stata v11.0  to pool This systematic review of M-health interventions will provide a detailed summary of the evidence for the effectiveness of mobile computing and communication technologies to improve a broad range of health and health service outcomes.The authors declare that they have no competing interests.PE and CF initiated and designed the study. LF, VP and LG participated in study design. GP participated in study design and drafted the manuscript. All authors read and approved the final manuscript.MEDLINE (Ovid) search strategy. Search terms used to identify studies of interventions using mobile computing and communication technologies in MEDLINE (Ovid).Click here for file


Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples, published in 2005, provide checklists for services to assist them to reduce the service gap for Indigenous people. This study describes health professionals' awareness, implementation, and perspectives of barriers to implementation of these guidelines based on semi-structured interviews conducted between November 2007 and June 2008 with health professionals involved in CR within mainstream health services in Western Australia (WA). Twenty-four health professionals from 17 services  listed in the WA Directory of CR services were interviewed.Cardiovascular disease is the major cause of premature death of Indigenous Australians, and despite evidence that cardiac rehabilitation (CR) and secondary prevention can reduce recurrent disease and deaths, CR uptake is suboptimal. The National Health and Medical Research Council (NHMRC) guidelines The majority of respondents reported that they were unfamiliar with the NHMRC guidelines and as a consequence implementation of the recommendations was minimal and inconsistently applied. Respondents reported that they provided few in-patient CR-related services to Indigenous patients, services upon discharge were erratic, and they had few Indigenous-specific resources for patients. Issues relating to workforce, cultural competence, and service linkages emerged as having most impact on design and delivery of CR services for Indigenous people in WA.Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals. The disproportionate burden of CVD morbidity and mortality among Indigenous Australians mandates urgent attention to this problem and alternative approaches to CR delivery. Dedicated resources and alternative approaches to CR delivery for Indigenous Australians are needed.This study has demonstrated limited awareness and poor implementation in WA of the recommendations of the NHMRC  Cardiac rehabilitation (CR) programs are widely recommended for individuals with coronary heart disease (CHD) and widely endorsed in public health policy ,2. DespiWhile the incidence of coronary heart disease (CHD) has been declining over the last three decades in the general population, this trend has not occurred in Indigenous Australians, in spite of an enabling policy context. Cardiovascular disease (CVD) also occurs at a younger age, with rates in the 35-54 year age group four times that in Indigenous compared to non-Indigenous populations . A previStrengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals [Guideline development is an important step in driving practice change and promoting cultural awareness. Yet it is well-recognised that guidelines alone do not result in either practice or workplace culture and values changes. This study investigated practitioners' awareness and implementation of ssionals  in CR seKey to increasing participation of Indigenous people in these programs is the understanding of barriers and facilitators from their perspectives.Guidelines (Appendix 2), but also allowed for more in-depth discussions not fully captured in the question list regarding the experiences and perceptions of CR services for Indigenous people. All but three interviews were audio-recorded with permission of participants. Written notes were taken for those who declined recording. Transcripts and notes were analysed using thematic content analysis [The sampling frame for this study included public hospitals and community-based public CR services listed in the Directory of Western Australian Secondary Prevention Services . Health analysis . Frequenanalysis . Relatedanalysis . Ethicaln = 4), serviced negligible numbers of Indigenous clients , or where staff were unavailable during data collection or failed to respond to invitations to participate (n = 3). Participating programs were in rural settings  and the metropolitan area . Twenty-four interviews were conducted with participants from 17 tertiary hospitals and community-based public CR services. Of the respondents who reported having received the Guidelines , few could recall any specific elements or recommendations, nor did they report attempting to implement the approaches recommended in the resource. Findings related to Indigenous inpatients and outpatients are summarised below. The denominator for data reported below relates to participants in interviews (n = 24).Several services listed in the Directory of WA Secondary Prevention Services were not interviewed, including those who had few or no CR patients/referrals . A minority  reported having Indigenous community input into CR design and delivery.A quarter of respondents reported having joint initiatives with an Aboriginal Medical Service (AMS), while nearly one-third reported faxed or telephoned patient referrals to/from an AMS. Fewer than half of respondents reported that their service has a system in place for identifying Indigenous status (n = 7) reported discussing with them the importance of CR. The majority of respondents did not have access to Indigenous-specific education resources on common CVD conditions, tests, interventions, and medications for patients during their hospital stay. However, a minority  of programs reported providing culturally appropriate resources and had a buddy/mentoring scheme in place for Indigenous people hospitalised for a heart condition .Respondents explained that during a hospital stay, they usually did not visit Indigenous patients. Of those who do see Indigenous in-patients, 29% (n = 2) of services reported being notified by tertiary hospitals when local Indigenous patients were discharged back to their area following a cardiac event, while a further 46% (n = 11) reported inconsistent notification. When referrals were obtained, 58% (n = 14) reported seeing Indigenous patients following discharge and of these, 62.5% (n = 15) reported talking about the importance of CR during this time and 37% (n = 9) had Indigenous-specific education materials. Only one post-discharge mentoring system was reported.Only 8% ; lack of awareness of available services ; lack of transport ; other health issues ; and financial constraints . Many of the services offered CR only within very limited hours, compounding geographical barriers to access. Issues relating to workforce, cultural competence, and service linkages emerged as having most impact on design and delivery of CR services to Indigenous people in WA (Table Respondents identified the following barriers they were aware of that could prevent Indigenous people's access to services: family commitments and restrictions n = 5, 62.5%;Despite the ready availability of NHMRC guidelines to all CR services in WA, the majority of respondents reported that they were unfamiliar with this document and as a consequence had not attempted to implement its recommendations. Although there were examples of good practice, we were unable to identify evidence of a systematic implementation strategy or outcome assessment strategy across WA. It is well-documented that guideline implementation is a complex and multifaceted process that needs to consider systems, patient and provider issues . To effeAnother important consideration in of the delivery of CR services is the interface between state and federal government initiatives . CommonlWhen interpreting these study findings, consideration should be given to the method of sampling which may have reflected the view of health professionals who had not necessarily been working in that service over a long period. Further, although our informants were those most likely to know the situation within the CR service and at the patient-CR provider interface, there was no source data verification from health service management regarding the opinions expressed. In spite of these limitations, this study elucidated barriers and facilitators to guideline implementation and strategies to improve Indigenous Health in WA. In addition, it underscores the importance of following up guideline release with targeted implementation and evaluation strategies. Further, it emphasises the importance of policy diffusion from a state and federal level to a local service delivery context. Importantly, the views reported are the views of clinicians responsible for CR service implementation and guideline adherence in the real world. It is important to understand these views in improving services. This information provides a way forward for service planning and underscores an urgent need to invest in enabling health providers to provide culturally appropriate service models.Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals among the professionals at whom they were targeted. Potentially limited endorsement and recognition at a local policy level have influenced this. Unsurprisingly, limited uptake of the recommendations was also identified. The disproportionate burden of CVD morbidity and mortality among Indigenous Australians, particularly following an acute cardiac event, requires urgent attention to ensure culturally appropriate and competent secondary prevention services. Alternative approaches to how CR services could be delivered are needed.Although evidence-based guidelines are integral for clinicians and supporting service reform, this study demonstrated sub-optimal awareness in WA of The authors declare that they have no competing interests.SCT contributed to study design, securing funding, ethics approval, interpretation and writing, MLD assisted with analysis, interpretation and writing; JSS assisted with study design, data collection, stakeholder engagement and interpretation, KPT assisted with data collection and interpretation, LD assisted with conception, funding and stakeholder engagement, MA assisted with study conception and analysis, MMW assisted with stakeholder engagement, TGL assisted with study development and stakeholder engagement, PMD assisted with analysis, interpretation and writing. All authors approved the final manuscript.• Ensure cultural competency is integral to the core business of an organization and supported at all levels within the organization.• Involve Aboriginal Health Workers and family members in the care of Indigenous Australians and develop flexible approaches to highlighting the merit of CR.• Draw on existing CR and secondary prevention services as appropriate and engage with local community networks.• Ensure community involvement at every level in planning and implementing CR, including the development of culturally appropriate resources.• Develop and sustain partnerships between stakeholder agencies.• Tailor CR approach according to the specific needs of Indigenous Australians and develop supportive policies and procedures.• Develop specialist education resources for continuing professional development and support of all health professionals working in heart care, including Aboriginal Health Workers.• Awareness of NHMRC guidelines • Degree of incorporation of recommendations into routine practice• Barriers to implementation• Aboriginal Health Worker involvement in care of Indigenous patients• Collaboration and integration with existing service providers• Cultural competency training• Opportunities for continuing professional development• Type, structure, content, organisation, coordination, staffing and funding of the service with specific relevance to Indigenous people


In the United States and elsewhere, children are more likely to have poor oral health if they are homeless, poor, and/or members of racial/ethnic minority and immigrant populations who have suboptimal access to oral health care. As a result, poor oral health serves as the primary marker of social inequality. Here, the authors posit that school-based oral health programs that aim to purposefully address determinants of health care access, health and well-being, and skills-based health education across multiple levels of influence  may be more effective in achieving oral health equity than programs that solely target a single outcome  or operate only on the individual level. An ecological model is derived from previously published multilevel frameworks and the World Health Organization (WHO) concept of a health-promoting school. The extant literature is then examined for examples of evaluated school-based oral health programs, their locations and outcomes(s)/determinant(s) of interest, the levels of influence they target, and their effectiveness and equity attributes. The authors view school-based oral health programs as vehicles for advancing oral health equity, since vulnerable children often lack access to any preventive or treatment services absent on-site care provision at schools. At the same time, they are incapable of achieving sustainable results without attention to multiple levels of influence. Policy solutions that improve the nutritional quality of children's diets in schools and neighborhoods and engage alternative providers at all levels of influence may be both effective and equitable. Children who suffer from poor oral health are 12 times more likely to have restricted activity days than children with good oral health , and wheThe particular focus of this review is on the underappreciated topic of oral health equity . NotwithEcological models posit that factors at multiple levels influence disparities in access to and quality of services . InterveIt was adapted from a multilevel model of influences on oral health and health disparities that highlighted family and social factors , also byhealth care access, as schools are often the most efficient means of providing both preventive and treatment services for children  screening survey among third grade children during the 2009–2010 school year  25). Of. Of25). Certain school-based interventions focus on skills-based education, largely at the individual and interpersonal levels, as exemplified by the 4 programs presented in Overall, the 4 school-based health education programs reviewed were at most modestly effective in improving oral health-related knowledge and oral hygiene behaviors –29, mixeSchool influences on oral health practices are considered to be part of the interpersonal level in Launched an intensive oral hygiene education program for schoolchildren originally aged 10–11 years  Table 1Table 1. Various models exist for providing preventive and restorative dental services for students in schools, part of the community level in In terms of effectiveness, schools act as an accessible location to provide preventive and responsive oral health care services to students –34. WithOnly 4 studies found in the published literature examined multilevel interventions on children's oral health, and thus were better able to assess impacts on oral health equity , 35–37 . An ecolThus, at both the regional , 35 and The implications of this review for the oral health and well-being of vulnerable children are potentially transformative, since all levels of determinants in Foremost among potential policy solutions are efforts focused on improving the nutritional quality of children's diets in schools and their surrounding neighborhoods , 35. IndAnother proposed policy solution is a universal pre-Kindergarten to 8th grade caries prevention program that is school-based and delivered twice a year . The bunWhile dental hygienists , 41, incFQHCs are community-based health centers that receive funds from the Health Resources and Services Administration (HRSA) Health Center Program to provide primary care services in underserved areas, regardless of the ability of individuals to pay for services, insurance coverage, or citizenship status , 51. TheFinally, it will be important to critically evaluate what is working well and what is not, and rely on evidence-based strategies to achieve oral health equity through school-based oral health programs. Recommendations include: (1) engage community stakeholders in intervention development and implementation; (2) train teachers, parents, and community activists to counter myths regarding the effectiveness of fluoride in preventing and reversing carious lesions; (3) collect and report economic and cost-effectiveness data, which is especially important to policy makers; and (4) strengthen the scientific approaches used, including implementation science and community-based participatory research , 48.School-based oral health programs that target multiple levels of determinants of health care access, health and well-being, and skills-based health education may not only be more effective than those that target only one level, but they may also be more equitable in terms of health and education outcomes and more just for children throughout the social gradient. Policy solutions that improve the nutritional quality of children's diets in schools and their surrounding neighborhoods and engage alternative providers at all levels of influence are priorities toward realizing sustainable improvements in the health and well-being of disadvantaged children and their families.LG, MM, and MN each contributed to the conceptualization, research, critical analysis, and writing of the article, and take public responsibility for its content.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The aim of this article is to summarise the virology content presented at the 9th Lorne Infection and Immunity Conference, Australia, in February 2019. The broad program included virology as a key theme, and the commentary herein highlights several key virology presentations at the meeting. The Lorne Infection and Immunity Conference is one of five scientific meetings held during each month of February in seaside town of Lorne, on the Great Ocean Road in Victoria . The specific aim of the meeting is to bring together basic, clinical and translational researchers - those who examine microbes and their impact on the innate or adaptive immune response, researchers who study the mechanisms that regulate immune responses, and those who apply this knowledge to preventing and treating infectious and inflammatory diseases. 2019 was the 9th Lorne Infection and Immunity Conference, convened by Heidi Drummer  and Paul Hertzog . The broad program included virology as a key theme, and the commentary herein highlights several key virology presentations at the meeting.Holy immune balance, batman’, about the highly adapted immune response of bats to viral infections.The ‘Infection and Inflammation’ session of the meeting was opened with a well-received presentation by Linfa Wang  entitled ‘Bats have been characterized as an important reservoir of various zoonotic viruses including Nipah, SARS, MERS, Marburg and Ebola viruses , but remDuring their evolutionary adaption to effective flight, bats not only developed elevated levels of basal alertness reflected in increased metabolic heart rate and body temperature, they also seem to have evolved a highly adapted immune defense against viral infections . RemarkaIn ‘Viruses and their Hosts’ session, Vinod Sundaramoorthy  discussed a novel defence mechanism in neurons against Rabies virus (RABV). RABV is a neurotropic virus, which causes tens of thousands of deaths every year, despite available vaccines . EndemicIn 2015, an association between Zika virus (ZIKV) infection during pregnancy as a cause of microcephaly and other congenital abnormalities in the developing fetus and newborn, was made . As suchIn the ‘Pathogenesis and Prevention of Infection’ session, Rosa Coldbeck-Shackley working with Michael Beard at the University of Adelaide, Australia, and also colleagues at the Hudson Institute, presented findings on the importance of interferon-epsilon (IFN-ɛ) in the innate immune response to ZIKV infection. IFN-ɛ is a novel type I IFN, encoded within the type I IFN locus in mice and humans, whose function has recently been characterized . Like otDisarming the killer: targeting of natural killer cells by varicella zoster virus’. Varicella zoster virus (VZV), is known to infect numerous immune cell types such as T-cells and dendritic cells [Also in the ‘Pathogenesis and Prevention of Infection’ session, Allison Abendroth (University of Sydney) presented ‘ic cells . Moreoveic cells  and leadic cells . In addiMost recently, Abendroth and colleagues found that VZV also productively infects natural killer (NK) cells and that NK cells effectively transmit infection to other permissive cell types  . The grA key highlight at the conclusion of the meeting was a presentation from the Victorian Infection and Immunity Network Young Investigator Prize winner, Simone Park (The University of Melbourne). Park, working alongside Thomas Gebhardt and Laura Mackay, has recently published seminal research investigating skin tissue-resident memory T cells (TRM cells). Specifically, Park has demonstrated how these cells contribute to antiviral immune memory in peripheral tissues, using a Herpes Simplex model of infection . Using ahttp://www.lorneinfectionimmunity.org/.The organisers are looking forward to celebrating the 10th Lorne Infection and Immunity meeting in 2020 and invite all researchers with an interest in infectious and inflammatory diseases and associated immune responses to participate. For more information:


Daily data of Global, Diffuse and Beam Horizontal Insolation and Global Vertical  insolation recorded in Burgos, Spain, are presented in this paper. Ten-minute irradiance data sets are collected over forty-five months in the experimental campaign to produce estimates of daily insolation levels. This data was derived in association with the article titled: “The PV Potential of Vertical Façades: a classic approach using experimental data from Burgos, Spain”   Specifications tableValue of the data•These data allow better estimates of the thermal load and the lighting needs in buildings, for the improvement of energy efficiency.•These data can be used to develop and test new decomposition models for solar radiation and daylighting.•The dataset can be used to calculated the total amount of solar energy incident on vertical and horizontal surfaces with different orientations.1Cumulative daily data of Global (GHI), Beam (BHI), Diffuse (DHI) Horizontal Irradiation and Global Vertical Irradiation (GVI), North, South, East and West orientations, measured from January, 2014 to September 2017, in Burgos, Spain, are presented in this paper. Data are listed in the file 22). The experimental thirty-second irradiance values were recorded every 10 min and were properly analyzed and filtered using traditional quality criteria 2) were calculated from the 10-min data sets series using the trapezoidal rule integration formula. Cumulative daily values were calculated from the hourly data.The meteorological and radiometric facility of the Research Group SWIFT (Solar and Wind Feasibility Technologies) has provided the experimental irradiance dataset used to calculate the cumulative daily insolation data. The experimental facility is located on the roof of the Higher Polytechnic School building at Burgos University  and it is equipped with seven pyranometers (Hukseflux/SR11) and a pyrheliometer (Hukseflux/DR01) for horizontal, tilted and for each cardinal orientation vertical measurements of the irradiance values (W/m


Surgery has the potential to address one of the largest, neglected burdens of disease in low- and middle-income countries (LMICs), especially in sub-Saharan Africa (SSA). The Lancet Commission on Global Surgery (LCoGS) has provided a blueprint for a systems approach to making safe emergency and elective surgery accessible and affordable and has started to enable African governments to develop national surgical plans. This editorial outlines an important gap, which is the need for surgical systems research, especially at district hospitals which are the first point of surgical care for rural communities, to inform the implementation of country plans. Using the Lancet Commission as a starting point and illustrated by two European Union (EU) funded research projects, we point to the need for implementation research to develop and evaluate contextualised strategies. As illustrated by the case study of Zambia, coordination by global and external stakeholders can enable governments to lead national scale-up of essential surgery, supported by national partners including surgical specialist associations. Global Surgery: evidence and solutions for achieving health, welfare and economic development.4 This is an opportune point to take stock of the direction and progress in scaling up essential surgical care in sub-Saharan Africa (SSA), the region with the greatest need and lowest response capacity.5 The case for investing in making safe surgery accessible to underserved communities is compelling: 5 billion people lack access to safe, affordable surgical and anaesthetic care, with low- and middle-income countries (LMICs) worst affected6; and 33 million people endure catastrophic expenditure each year in paying for essential, often life-saving surgery.1 There is evidence that essential surgery can be delivered safely, cost effectively and is affordable and feasible, even in low resource settings.8 However, in much of SSA, elective and emergency general surgery is only available in the few urban hospitals that are staffed by specialist surgeons.9 District level hospitals (DLHs) in Malawi and Zambia and many other African countries deliver emergency obstetrical interventions – mainly caesarean sections, and occasional hysterectomies, as well as limited general surgery – mainly hernia repairs, but also laparotomies and hydrocoele repairs.10 In Zambia, such surgery is often undertaken by non-physician clinicians (NPCs) and medical officers with limited surgical skills and experience, lacking support and supervision and working in an uncertain legal and regulatory environment.11 Yet for rural populations they are often the only accessible source of elective and life-saving emergency surgery.11It is approaching three years since the Lancet Commission on Global Surgery (LCoGS) published 1: trained staff; essential infrastructure and equipment; reliable supply chains, sterilisation and blood supplies; information systems and financing mechanisms; and referral and care delivery protocols to minimise delays for communities and patients in receiving appropriate care. Because of the limited research evidence, the Commission relied on expert opinion and modelling of scarce existing data, framed by a comprehensive health systems analysis.12 It proposed three ‘must do,’ ‘bellwether procedures’ that first-level hospitals should be able to undertake – notably caesarean sections, laparotomies and management of open fractures; and a longer list of ‘should do’ and ‘can do’ procedures, to be undertaken at first level or referral hospitals, depending on the context.1 This paper looks critically at the link between two dimensions of global surgery, where the LCoGS made recommendations and where there has been some, albeit slow, progress in SSA in the last 2-3 years: the development of national surgical plans and the research agenda for informing the development, implementation and sustainable scale-up of surgical systems.The LCoGS produced a blueprint, outlining the inputs, processes and systems needed for the provision of safe surgical and anaesthesia care, including1 only 2% of 4064 health targets in national health strategic plans from 43 African countries covered surgical conditions or care; and 33% of national health policies had no surgical targets.13 The LCoGS proposed five dimensions as a framework for the development of National Surgery, Obstetric and Anaesthesia Plans: infrastructure, workforce, service delivery, information management and financing.1 The Harvard Program in Global Surgery and Social Change (PGSSC) has played a key role in the development of the national surgical plan in Zambia in 2015-2016.14 The plan was developed through reviews of national level data and semi-structured interviews of country specialists across the disciplines of surgery, obstetrics, and anaesthesia; and representatives of relevant government ministries; and national and international partners. The Harvard Program is also supporting the development of national plans in Ethiopia, Rwanda, Nigeria, Tanzania,15 and in Madagascar.17Up to 2015, the target year for reaching the millennium development goals and the year when the LCoGS published its report,14 Without a strong empirical base, there is a risk that national surgical plans will be unrealistic or remain aspirational.18 Surgical plans need a clear implementation strategy that involves local champions, under the leadership of governments, with strategic links to global leaders and funding agencies. Implementation strategies should be based on an understanding of national surgical systems as complex adaptive systems19; and should incorporate a surgical systems research arm for testing the feasibility of solutions in large population sites. Some countries, such as South Africa, have the capacity to bring together all these components,20 with a contextualised implementation and research agenda.21 Others may benefit from global-local research partnerships where large scale or complex research, as well as associated resource mobilisation, is required.22 Lessons from implementing the Millennium Development Goals (MDGs) and other global indicator strategies can inform investment choices and implementation priorities, ensuring that progress is measured and that governments  are held accountable by citizens.24While country national surgical plan design processes have been consultative, and rightly so, a lack of contextualised research findings to inform them has been a weakness and it remains a gap in respect to plans for evaluating implementation.25 Rural and district areas are the setting for most unmet population surgical need27; and new research evidence is emerging that makes the case for investing in district level surgical care.29 This can reduce the demands on referral hospitals, allowing specialist surgeons to deliver more complex surgery26; and enable DLHs to deliver the ‘must do’ and potentially many of the ‘should do’ procedures.31 In countries where surgery is undertaken by non-specialists, training and quality assurance systems are essential. Clear career paths are also needed to ensure professional progression paths exist for surgically trained NPCs and medical officers at the district level, reducing the need to pursue careers in urban areas.11 In many African countries, specialist surgeons lack the resources to undertake supervisory visits and have little direct contact with or experience of DLHs, which may lead them to underestimate the current scale and potential for district surgery10; and, as a result, to recommend that resources be channeled first to referral hospitals. The dearth of empirical research on surgical capacity at DLHs11 has meant that the debate on how rural populations can be served and who should deliver essential surgery to them – specialist surgeons, general medical officers or surgically trained NPCs – has become politicised.33Given the scarcity of empirical research on the reality and potential for making surgery available to rural populations through DLHs, the risk is that the voice of district stakeholders may not be represented in the consultations that inform national surgical plans.1 Yet, despite a World Health Assembly resolution in 2015, calling for surgical systems scale-up globally,34 there is still limited global policy attention to surgery in early 2018. This gap means there is a window of opportunity to coordinate research initiatives in support of nationally-led surgical systems development so as to: (i) inform national surgical plans, (ii) test innovative solutions; and (iii) provide feedback to inform national scale-up, based on evaluations of feasibility, quality and safety, affordability, cost-effectiveness and health impact. Subramanian and colleagues’ systematic review evaluated conceptual participatory action research models that involve country stakeholders in learning by doing, incorporating the critical factors that determine how the results of pilot projects feed into national programmes.35 The authors identified and evaluated six models for scaling-up health services and concluded that there is no ‘one size fits all’ optimal approach as strategies need to consider the political, organisational and functional dimensions of scale-up, supporting national stakeholders and developing local organisational capacity.35 Successful models place less emphasis on initial planning, and more on facilitating implementation and on “learning by doing, embracing error, and linking knowledge-building with action as implementation is occurring.”35The LCoGS identified some of the rate limiting steps and called for a systems research agenda to underpin the development and implementation of national surgical plans, emphasising the need to identify and test contextualised responses.35 we propose the building of country networks under the coordination of national ministries of health, supported by regional and global surgical and systems research stakeholders. The critical processes, when applied to surgical systems scale-up, should comprise: (i) leadership from ministries of health and national surgical specialist bodies, supported by surgical systems researchers; (ii) identification of workforce, other capacity and resource obstacles; and enablers to the delivery of essential surgical services through networks of district and referral hospitals; (iii) collaborations between ministries, researchers, non-governmental organisations and specialist surgeons in implementing and evaluating training and supervision interventions, involving government approved surgical clinicians at DLHs – be they NPCs or doctors; (iv) feedback loops to allow continuous adaptation of interventions to local contexts, informing the development and adjusting the implementation of national surgical plans; and (v) the use of implementation (mixed methods) research, combining rigorous quantitative measurements of cost, surgical outputs and outcomes, with qualitative explanatory evaluations of the complex interventions and processes needed to quality assure and scale up surgical services. In addition, as outlined by the Commission,1 countries need to invest in surgical infrastructure, purchase and maintain essential equipment, develop reliable supply chains, and ensure that financial mechanisms enable citizens to access surgical care regardless of social status.Drawing on this review,Zambia provides an interesting case where two independent processes for scaling up a national surgical service, both under the guidance of Government, developed between 2011 and 2016. Here we draw on our experience of developing, implementing and evaluating a national surgical training and supervision intervention in Malawi and Zambia, as part of the Clinical Officer Surgical Training project (COST-Africa), 2011-2016. Lessons were used to design a new implementation research project to scale up safe surgery for district and rural populations (SURG-Africa) in Malawi, Zambia, and Tanzania, 2017-2020. The European Union (EU) awarded 9 million euros to support these research projects.14 One of the erstwhile provincial surgeons, who had road-tested the COST-Africa supervision model, was appointed Deputy National Director for Clinical Services in 2017, tasked with implementation of the national plan. At a meeting in March 2017 of the Ministry of Health with the new SURG-Africa project team, again led locally by the Surgical Society of Zambia, it was agreed that the new SURG-Africa project would conduct an in depth-evaluation of the new supervision model, comprising remote and in-the-field supervision of surgical services at DLHs.The COST-Africa project, which was originally conceived and funded as research of a national NPC training intervention, was adapted in Zambia in 2012, as advised by national ministries, to focus on supervision of existing surgically trained NPCs. Ten NPC graduates were deployed during 2013-2014 as surgical clinicians in nine DLHs across nine different provinces, supervised by four provincial specialist surgeons. In 2015, representatives of the local implementing partner, the national Surgical Society of Zambia, were invited to join a national working group that was tasked with drafting Zambia’s national surgical plan. Thereby, lessons from COST-Africa, specifically a well-documented supervision model, were incorporated into the national surgical plan in 2016, which was launched in 2017.19: “the processes or pathways for introducing and scaling up interventions can be as important as the content of the intervention itself… (and need to comprise) highly heterogeneous groups of actors.” In Zambia, there has been a serendipitous confluence of events, including: (i) responsibility for district hospitals was restored to the Ministry of Health in 2015 after a gap of three years, during which responsibility lay with the Ministry of Community Development & Maternal and Child Health; (ii) a collaborative approach by the Harvard Global Program and the Zambia Ministry of Health, including surgical champions, led to the development of a national surgical plan; and (iii) implementation of the two large EU-funded surgical systems research projects, one generating lessons to inform the plan and the second providing an opportunity to evaluate implementation. While there is debate on the sequencing of investments in national and referral hospitals vis-à-vis district level investments, the processes of developing national surgical plan as a blueprint for scale up of surgical services have been collaborative and have avoided some negative features of global health initiatives that impose disease specific interventions on countries with little regard to context or sustainability.38 However, if developed without an adequate evidence-base and if implemented without in-built feedback loops,19 implementation failure or unsustainable programmes are real risks.As Paina and Peters stateIn Zambia, where the national surgical plan is due to be implemented, and in Tanzania, where such a plan is being developed in 2017-2018, SURG-Africa aims to test the components of a scalable national surgical system in 2017-2020, feeding emerging results to national ministries and their partners, from early 2018. The COST-Africa and SURG-Africa coordinator at the Royal College of Surgeons in Ireland and the coordinator of the Harvard Program in Global Surgery have established links, enabling coordinated support to country plans by ‘northern’ partners. However, little can be achieved without the engagement of country stakeholders, through national surgical associations working with and under the leadership of Ministries of Health. Participatory action research focusing on implementation of national surgical plans can then provide the mechanism for translating evidence on the feasibility, cost-effectiveness, impact and potential for scale-up of tested strategies into sustainable national programmes for making safe surgery accessible to district and rural populations in Africa.Not applicable.Authors declare that they have no competing interests.All authors contributed substantively to all drafts. All authors read and approved the final manuscript. RB conceived the concept of the paper and drafted the first sketch. KG led on the development of the manuscript with inputs from LB and RB.1Royal College of Surgeons in Ireland, Dublin 2, Ireland. 2Radboud University Medical Centre, Nijmegen, The Netherlands.


There have been recent advances concerning research of the feeding and nutritionof dairy goats in a wide array of areas. Ruminally emitted methane andsupplementary feedstuffs to a lesser extent make appreciable contributions tothe carbon footprint of dairy goats, with the former affected by type ofproduction system and associated dietary characteristics. Unique behavior ofgoats necessitates careful consideration of the nature of confinement facilitiesto achieve optimal production by animals differing in social hierarchy.Physiological conditions such as nutritional needs and perhaps health status mayinfluence diet selection by goats in both grazing and confinement settings. Someresearch suggests that low concentrations of protein and fat in milk ofhigh-yielding dairy goat breeds could involve the type and nature of dietaryingredients as influencing end products of ruminal fermentation. With therelationship between milk urea nitrogen concentration and efficiency of dietaryprotein utilization, through future research the measure may be a useful toolfor diet formulation as in dairy cattle. Effects of dietary inclusion of sourcesof fats and oils vary considerably depending on their nature, as is also truefor byproduct feedstuffs and conventional ones being substituted for.Supplementation of dairy goats with sources of polyunsaturated fatty acids canaffect oxidative stress and various feedstuffs influence antioxidant status;however, research addressing the significance of such changes under practicalproduction settings would be beneficial. Dairy goats are raised under a wide array of conditions; therefore, studiesconcerning their feeding and nutrition have addressed a large variety of topics.Ones receiving attention include production system considerations of the carbonfootprint, effects of confinement conditions on behavior, stress, and productivity,and factors influencing diet selectivity. Diet composition aspects investigated areeffects of concentrate and forage levels on yield and composition of milk and milkproducts, dietary protein characteristics, influences of the inclusion of differentsources of fats and oils, and usage of low-cost and abundant byproducts. Moreover,an increasing number of experiments have addressed stress conditions, including heatand dietary addition of feedstuffs eliciting oxidative stress or improvingantioxidant status. The objective of this review is to highlight some of the recentstudies conducted in these areas. In this regard, recently there were two relatedsummaries of dairy goat feeding and nutrition research presented at the 3rd and 4thAsian-Australasian Dairy Goat Conferences ,2. Altho2-equivalents per ton) ranging from 0 for brewers grain (notconsidering transportation) and 190 for corn grain to 734, 800, and 940 for avon(byproduct of corn for manufacture of glucose/starch), palm kernel expeller, andcow milk, respectively. Perhaps surprisingly, the carbon footprint relative tofat- and protein-corrected milk production was only numerically lower for indoorvs outdoor farms and similar to New Zealand dairy cattle farms. The carbonfootprint on a product basis is usually lower for more intensive than extensiveproduction systems because of generally greater dietary levels of concentrate,use of breeds highly selected for level and efficiency of production, and lessenergy expended in the act of grazing [Enteric methane emission by ruminants makes a considerable contribution to thecarbon footprint of various livestock production systems , althoug grazing . Convers grazing .2/animal. Moreover, anoutside run area such as used by Stachowicz et al [Due to the common behaviors of goats and strength of their social hierarchy,feeding and feed access conditions may be relatively more important than forcattle and sheep. This was studied by Jørgensen et al  with midcz et al  could beThe study of Stachowicz et al  was withIn addition to overall pen design and feeder availability, the nature of feedersand associated management practices are important to realize high levels andefficiencies of production by all animals in a group regardless ofcharacteristics such as size, age, presence or horns, and social rank. The studyof Hillmann et al  with SwiThe experiment of Nordmann et al  was simiGoats have considerable ability to select different plants and plant partscompared with cattle and sheep, with the botanical composition of the diet morereflective of the array of species available . MoreoveFedele et al  noted coConsumption by ruminants of feedstuffs containing phenolic compounds can have avariety of effects in addition to ruminal protein binding. One addressedrecently by Chávez-Servín et al  is that The nature of the diet influences not only the level of milk produced by dairygoats but also its composition, with an impact on yield and quality of products,namely cheese. In this regard, through a survey of dairy goat farms in ItalySandrucci et al  addresseAlthough research to specifically address the postulate put forward above isneeded, there may be some support in the study described by Inglingstad et al andSteiAs alluded to above, in some cases dairy goats are fed diets with high levels ofconcentrate that can result in acidotic conditions in the rumen, acute or morecommonly subacute (SARA). In a review of recent literature in this area,Giger-Reverdin  noted thThe concentration of urea in milk (MUN) is commonly used to evaluate theefficiency of dietary CP utilization by dairy cattle ,43. The http://www.luresext.edu/?q=Nutrient-Calculators), requirementswere 11.2% metabolizable protein and 16.6%, 15.9%, and15.2% CP with rumen undegraded protein levels of 20%,40%, and 60% of CP, respectively. The average MUN in the studyof Rapetti et al [Usefulness of MUN for dairy goats has not been extensively studied. However,recently Rapetti et al  addresseti et al  was 34.2ti et al , at whicti et al . Some diti et al  had dietEffects of dietary fat and oil supplementation on milk yield by dairy goats aremore likely in early lactation than later presumably because of differences inDIM at which DM intake and milk yield peak . Moreovetrans andconjugated FA in dairy ruminants, Ferlay et al [In a review of literature concerning the production of ay et al  includeday et al ,51.With the increasing cost of conventional feedstuffs, many agricultural andindustrial co- or byproducts, as well as various novel materials, continue to beevaluated as ruminant feedstuffs. The recent study of Arco-Pérez et alprovidesThe recent study of Sousa et al  with forAnother byproduct continuing to receive research attention in various settings iscrude glycerin of the biodiesel industry. One factor influencing its use inruminant diets is purity, although effects can be minimized by limiting dietarylevels. For example, Novais-Eiras et al  includedSchizachy trium sp. to determine its optimal dietary level. Inaddition to measures such as feed intake and milk yield and concentrations of fat,protein, and specific FA, antioxidant activity and extent of oxidative damage werecharacterized. Dietary concentrate consumed by Alpine×local Greek goats at150 DIM included a commercial product to achieve daily microalgae intake of 0, 20,40, or 60 g. But, the 60 g treatment decreased concentrate intake most likely aconsequence of the smell and(or) palatability of the product, resulting inmicroalgae intake of 40 g/d. Milk fat concentration was markedly decreased by the 40and 60 g treatments, presumably because of adverse effects of some of thepolyunsaturated FA on the activity of fibrolytic bacteria and, thus, decreasedacetate production and concomitant de novo FA synthesis in the mammary gland.Although, there would also seem potential for effect of bioactive CLA isomersreaching the mammary gland because of decreased ruminal biohydrogenation. Based onchanges in indicators of antioxidant activity  and of oxidative stress realized  in blood andmilk, the 20 g level appeared optimal. But, milk fat concentration was numerically0.53 percentage units less than for the control treatment . Even though there is considerable interest in oxidative stress asaffected by dietary and environmental conditions because of the potential impact onimmunity, health, and longevity of dairy animals, it is difficult for such factorsto be considered in typical relatively short-term experiments to determine practicaland economic implications.As mentioned above, diets of lactating goats as well as cattle often are supplementedwith polyunsaturated FA that can increase milk fat concentration and(or) improve theFA profile of milk and milk products for beneficial effects on human health.However, because of potential oxidation, polyunsaturated FA supplementation canincrease oxidative stress, leading to the study of Mavrommatis et al  with theSomewhat converse to the experiment of Mavrommatis et al , one posGracilaria birdiae may mitigateheat stress in lactating dairy goats in a different manner. Seaweed was included at0%, 4%, 8%, and 12% of the diet of Saanen goats at60 DIM. There were improvements in respiration rate, rectal temperature and surfacetemperature when air temperature was elevated. Heat stress normally elevates theformation of reactive free radicals that can elicit oxidative damage to adverselyaffect immune function and overall health status. It was proposed that these effectsrelated to inhibition of free radical formation by seaweed antioxidants  that lessened total oxidative stress.Goetsch overviewZea mays L.)stover silage was included in the diet of multiparous Saanen goats at 75 DIMcompared with sticky corn silage. Similar to phenolic compounds addressed byChávez-Servín et al [The study of Tian et al  concerneín et al , dietaryMethane emission by dairy goats makes a greater and less variable contribution to thecarbon footprint of outdoor vs indoor production systems on a product basis, thoughsuch comparisons may vary if land area and soil carbon sequestration are considered.Because of the unique behaviors and a strong social hierarchy of dairy goats, thedesign of confinement facilities could influence the level and(or) efficiency ofproductivity. Diet selection of dairy goats can vary with the physiological state,and there is evidence for nutritional wisdom and self-medication warranting furtherstudy. Moreover, research is needed to address optimal dietary composition forproduction of milk of high quality for processing, as is also true for the widearray of byproduct feedstuffs dairy goats will consume. The numerous effects offeedstuffs high in FA vary considerably with factors such as source and level andother dietary characteristics. The inclusion of various dietary ingredients caninfluence oxidative stress conditions and antioxidant status, but long-termpractical influences on production are unclear.


Background: Low-income countries with relatively weak-health systems are highly vulnerable to public health threats. Effective public health system with a workforce to investigate outbreaks can reduce disease impact on livelihoods and economic development. Building effective public health partnerships is critical for sustainability of such a system. Uganda has made significant progress in responding to emergencies during the past quarter century, but its public health workforce is still inadequate in number and competency.Objectives: To reinforce implementation of priority public health programs in Uganda and cultivate core capacities for compliance with International Health Regulations.Methods: To develop a competent workforce to manage epidemics and improve disease surveillance, Uganda Ministry of Health (MoH) established an advanced-level Field Epidemiology Training Program, called Public Health Fellowship Program (PHFP); closely modelled after the US CDC’s Epidemic Intelligence Service. PHFP is a 2-year, full-time, non-degree granting program targeting mid-career public health professionals. Fellows spend 85% of their field time in MoH placements learning through service delivery and gaining competencies in major domains.Results: During 2015–2018, PHFP enrolled 41 fellows, and graduated 30. Fellows were placed in 19 priority areas at MoH and completed 235 projects ; made 194 conference presentations; prepared 63 manuscripts for peer-reviewed publications (27 published as of December 2018); produced MoH bulletins, and developed three case studies. Projects have resulted in public health interventions with improvements in surveillance systems and disease control.Conclusion: During the 4 years of existence, PHFP has contributed greatly to improving real-time disease surveillance and outbreak response core capacities. Enhanced focus on evidence-based targeted approaches has increased effectiveness in outbreak response and control, and integration of PHFP within MoH has contributed to building a resilient and sustainable health system in Uganda. The burden of communicable and non-communicable diseases (NCDs) in Uganda is high. Most major health outcome indicators fall well short of desired targets: 343 women die for every 100,000 live births, and 131 of every 1,000 children die before age 5 years. Nearly one in three children under 5 years is stunted . The emeHealth system resilience comprises both health system strengthening and sustainability. Health system strengthening refers to significant and purposeful efforts to improve the system’s performance, while sustainability has been defined as the implementation and continuous use of new practices that are able to produce the intended outcomes over a long period of time . The WorHealth workforce challenges have been recognized as a critical bottleneck to the delivery of high-quality health services, including response to epidemics. The spread of Ebola in West Africa during 2013–2016 was compounded by weak-health systems characterized by lack of public health capacity for outbreak detection and control ,9. WhileField epidemiologists respond to public health emergencies, including outbreaks, as well as conducting epidemiologic research, evaluating and improving surveillance systems, implementing public health programs, and publishing data to facilitate evidence-based decision-making. The shortage of field epidemiologists in Uganda to address critical aspects of health in the public sector prompted the Uganda Ministry of Health (MoH), with support of key partners including Makerere University School of Public Health (MakSPH) and US Centers for Disease Control and Prevention (CDC), to establish the Uganda Public Health Fellowship Program (PHFP) in 2015. PHFP is an in-service, post-master’s-degree field epidemiology training program (FETP) that attempts to address human resources for health needs. As part of the MoH’s long-term sustainability vision, PHFP will exist as a directorate and capacity-building arm of the Uganda National Institute of Public Health (UNIPH); UNIPH is an initiative of the MoH to create an integrated disease control centre, analogous to the US CDC. This paper describes the PHFP, its development and organization, and its contribution to building a resilient and sustainable health system by training a critical mass of competent field epidemiologists in Uganda.The PHFP is a 2-year, non-degree-granting, full-time, competency-based fellowship program modelled after the US CDC’s Epidemic Intelligence Service (EIS) program. The program is primarily funded by the US Government through the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative (PMI), and the Global Health Security Agenda (GHSA). The PHFP trains mid-career professionals who have a master’s degree (or higher) in a health-related discipline and who aspire to become public health leaders. During the two-year fellowship period, fellows are required to attain certain core competencies in domains that include public health emergency response, surveillance data analysis, surveillance system evaluation, applied epidemiologic study, cost analysis of outbreaks, quality improvement science, burden of disease estimation, and leadership skills. Their attainment of these competencies is demonstrated by completing a portfolio of projects in each of these domains.PHFP is integrated as an arm of MoH, and, together with the Integrated Epidemiology and Surveillance Department (IESD), the Public Health Emergency Operations Centre (PHEOC), and other important public health programs in the MoH, conducts investigations and studies that provide data for decision-making for the National Task Force (NTF). The NTF is an arm of the MoH created to coordinate emergency health response, and is responsible for bringing partners together, providing strategic direction to response, and coordinating functions that contribute to prevention and control of public health emergencies.The PHFP Secretariat is the operational and administrative unit responsible for coordinating the program. Its functions include: (a) coordination of PHFP partner collaboration with MoH, (b) organizing and supervising fellows’ placements within MoH, (c) performance review of fellows, (d) back-up mentorship for Fellows and coordination of mentorship activities, and (e) development of strategic and operational plans for approval by the PHFP Steering Committee (SC). The PHFP secretariat comprises a field coordinator, two field supervisors, a scientific writer, a training manager, and an administrative assistant, based at the Ministry of Health. The CDC Resident Advisor, who provides technical and programmatic guidance, supports the Secretariat, but is not a part of it.Applications are solicited through the print media, the program website, the alumni association, and professional associations. Short-listed candidates are required to undergo a rigorous interview process comprising an in-person interview, a Power point presentation on a given relevant topic, and an essay on a selected topic. Approximately 10 fellows are selected annually.The service-in-training program comprises two didactic courses of approximately six weeks in duration each (~15% of the program time): an introductory course at the beginning, and an advanced course towards the end of the first year. The remaining weeks (~85% of time), the fellows are placed at an MoH host site, where they implement activities stipulated in their scope of work and work plans, tailored towards accomplishment of host site activities and fellowship deliverables. The hands-on-learning is anchored around intense continuous mentorship by mentors at the host site, the Secretariat, and staff at Makerere University College of Health Sciences.Fellows’ progress is monitored and performance appraised on a quarterly and annual basis. Supportive supervision is offered to the host site to ensure prompt identification of problems and possible solutions.Enrolment: The program was launched in January 2015 with 10 fellows in the first cohort. In 2018, the 4th cohort was enrolled, and in August 2018, the 5th cohort was selected. The four cohorts of 41 fellows  were recruited and trained with each group commencing in January of the year of enrolment; the 5th cohort of 14 fellows commenced their fellowship in January 2019. Fellows entering the program held various advanced degrees in general public health , medicine , epidemiology or clinical epidemiology , entomology/parasitology/zoology , international health/public health , and health services research/management . One fellow each have also held degrees in veterinary preventive medicine (VPM), medical microbiology (MSc), infectious disease management (MSc), and health policy (MSc). Applications increased from 44 in 2015 to 195 in 2017, but dropped to 83 and 89 in 2018 and 2019. Fellows have been placed in 19 MoH priority areas during their training  or are working with MoH-affiliated or linked institutions or organisations  (47%) (C] (47%) .10.1080/Field projects: During the nearly four years of the program implementation, the 41 PHFP fellows completed more than 235 applied epidemiology projects, of which 91 were outbreak investigations and 12 were emergency refugee health assessments. In addition, fellows have conducted 50 surveillance projects, including analysis of surveillance data or evaluation of a surveillance system, and completed 60 epidemiological studies, 18 quality improvement projects, and 3 cost analyses for outbreaks  serve as sites where the fellows and other MoH epidemiologists publish valuable public health information for immediate local use. The quarterly MoH Epidemiological Bulletin has published 131 articles based on the fellows’ projects, and the Weekly Epidemiological Bulletin has been running since August 2015 with fellows taking a lead in its production. National newspapers have also published articles from many fellows, written to inform the public about current public health challenges, such as outbreaks and tips on disease prevention. These publications have contributed to use of their public health recommendations on a wider scale nationally., Uganda  were wid, Uganda ,12 In adContribution to building a resilient system: Prior to PHFP, there was no investigative arm for outbreak response at MoH; the PHFP created and now leads this arm, as part of the National Rapid Response Team. Outbreak reports prepared by fellows are routinely submitted to the PHEOC and presented at the National Task Force for Epidemic Preparedness and Response, which helps to guide outbreak prevention and control in the country. Examples includeidentification and investigation of a large typhoid outbreak in 2015, which affected over 10,000 residents in Kampala, in which investigation findings helped to guide the successful control of the outbreak, early identification and investigation of a yellow fever outbreak in 2016, leading to a subsequent mass vaccination campaign by MoH, and investigation of a meningitis (serogroup W) outbreak in an institutionalized population in 2016, with subsequent control efforts potentially preventing spread into the civilian population. PHFP also provided epidemiologic support for nationwide outbreaks of cholera, malaria, measles and anthrax . PHFP feThe prompt epidemiologic investigations conducted by the PHFP have resulted in shortened time to identify dangerous pathogens, and prevented potential spread of outbreaks. For example, due to timely investigation and prompt response, a yellow fever outbreak that occurred in 2016 was confirmed within 12 days and controlled within three weeks of the initial outbreak report. In comparison, the previous yellow fever outbreak in Uganda in 2010 took 40 days to confirm and 3 months to control . Due to PHFP and the MoH are also supported by a Frontline FETP program, established by the MoH in partnership with the CDC in 2016. Frontline FETP augments disease surveillance and outbreak detection and response at the district level [In just four years of operation, Uganda’s Public Health Fellowship Program has demonstrated the ability to address multiple gaps in the Uganda health system. They have generated quality products, experienced adoption of recommendations from their projects, and received national and international recognition . As an iMuch as established literature guides response to epidemics, we are aware that each outbreak is unique. Before PHFP, outbreak responses in Uganda typically had only minimal epidemiological investigation . The comVertical MoH programs have benefitted from having embedded Fellows routinely analyse their data and ensure that alerts are generated promptly. Because PHFP is non-degree awarding and Fellows are required to already have at least a Master’s degree on entry, fellows spend more time working on program-oriented projects that address national health needs, and less time in didactic courses. This is different from most FETPs, in which residents earn degrees while in their programs . This moBeyond the health benefits to the country, PHFP and similar programs almost certainly provide return on investment through early detection, investigation and control of outbreaks, improvement in surveillance system, and provision of urgently needed data for public health programs. The recent Ebola outbreak in West Africa cost the global community $3.6B to respond to and contain and an additional $2.2B in GDP loss to Guinea, Liberia, and Sierra Leone . Had a fAll fellows who have graduated have been absorbed either within MoH or are employed by institutions that work closely with the MoH. Because the program Secretariat and most host sites are in the MoH, having graduates working in the different programs within the MoH provides opportunity for mentorship of new fellows . IncreasAlthough PHFP has made strides in contributing to building a resilient system, there are still some challenges. The use of evidence generated for disease prevention and control is still limited, partially due to the multiple layers of implementation existing in the Ugandan system. Even when evidence is available, poor dissemination, rigid mindset, poor coordination of partners, and inadequate resources may hamper its utilization. Improved stakeholder engagement with the MOH should be able to address this challenge in the long run. Funding also has some challenges: although PHFP is currently funded by the USA Government, for full integration and institutionalization within the Uganda MoH system there must be domestic resource allocation to support this program. Recognizing this need, MoH has made PHFP a key component of the proposed Uganda National Institute of Public Health (UNIPH) by designating it as a unique directorate . Once thDuring its four years of operation, the PHFP has contributed greatly to improving the real-time disease surveillance and outbreak response core capacities of the Uganda Ministry of Health. The enhanced focus on evidence-based targeted approaches has increased effectiveness in outbreak response and control, and the integration of PHFP within the MoH has contributed to building a resilient and sustainable health system in Uganda.