Geography poses serious challenges to delivery of health services and is a well documented marker of inequity. Maternal, newborn and child health (MNCH) outcomes are poorer in mountainous regions of low and lower-middle income countries due to geographical inaccessibility combined with other barriers: poorer quality services, persistent cultural and traditional practices and lower socioeconomic and educational status. Reaching universal coverage goals will require attention for remote mountain settings. This study aims to identify strategies to address barriers to reproductive MNCH (RMNCH) service utilisation in difficult-to-reach mountainous regions in low and lower-middle income settings worldwide.A systematic literature review drawing from MEDLINE, Web of Science, Scopus, Google Scholar, and Eldis. Inclusion was based on; testing an intervention for utilisation of RMNCH services; remote mountain settings of low- and lower-middle income countries; selected study designs. Studies were assessed for quality and analysed to present a narrative review of the key themes.From 4,130 articles 34 studies were included, from Afghanistan, Bolivia, Ethiopia, Guatemala, Indonesia, Kenya, Kyrgyzstan, Nepal, Pakistan, Papua New Guinea and Tajikistan. Strategies fall into four broad categories: improving service delivery through selected, trained and supported community health workers (CHWs) to act alongside formal health workers and the distribution of critical medicines to the home; improving the desirability of existing services by addressing the quality of care, innovative training and supervision of health workers; generating demand by engaging communities; and improving health knowledge for timely care-seeking. Task shifting, strengthened roles of CHWs and volunteers, mobile teams, and inclusive structured planning forums have proved effective.The review highlights where known evidence-based strategies have increased the utilisation of RMNCH services in low income mountainous areas. While these are known strategies in public health, in such disadvantaged settings additional supports are required to address both supply and demand barriers. Geography can pose serious challenges to the delivery of health services and is a well documented marker of inequity in health outcomes Barriers to health service utilisation have been categorised into access, availability, acceptability and cultural and traditional preferences, confidence in care and quality of services, health awareness and knowledge, and affordability Significant mountain areas in many low- and lower-middle income countries represent the most extreme experiences of barriers to service utilisation. Actions with intensity proportionate to disadvantage may be required for such settings The purpose of this systematic literature review is to identify strategies to address barriers to RMNCH service utilisation in low resource, difficult-to-reach mountainous regions.This systematic review is registered with PROSPERO through which the protocol has been peer-reviewed during development, number CRD42012003282 An ethics statement was not required for this work.Literature was drawn from academic databases; MEDLINE, Web of Science, Scopus, Google Scholar, and Eldis up to 26 October 2012.The search terms, applied with various boolean operators and medical subject headings (MeSH), are summarised in Articles were included only if they; a) described testing of an intervention to overcome barriers to care-seeking, acceptability, satisfaction and/or utilisation of formal RMNCH services; b) took place in remote, sparsely populated mountain range setting above 1000 metres of low- and lower-middle income countries see ; with c From 4,130 articles, 34 studies were selected. To determine if studies were set in mountain ranges, rural or remote, and at altitude above 1000 m, National Geographic topographic global maps, satellite terrain maps, and country description documents were examined Data extraction was undertaken independently, reviewing full text papers, by four researchers using a piloted and revised spreadsheet. Finally, one researcher reviewed all inclusions and inconsistencies, which were minimal, were resolved in discussions between the four researchers.Data was extracted for: a) setting and population; b) relevant RMNCH service; c) intervention description; d) strengths/successes; e) weaknesses/challenges to the intervention identified by the study ; and f) quality .The quality of individual studies was assessed using the Effective Public Health Practice Project (EPHPP) Quantitative Assessment Tool The predominant summary measures of results are the proportion of change comparisons of before-after or intervention-control, odds ratio (OR), or relative risk (RR).The diversity of experimental designs used and strategies examined by these studies precludes a full meta-analysis and quantitative evaluation. Instead, we opted for a qualitative analysis identifying broad conclusions and present a narrative review of the key themes arising from the literature. Extracted data regarding the strategy used, quantitative results and author conclusions were used to group studies according to similarities in structure and outcomes.The search strategy yielded evidence for inclusion from 11 countries; regions of Afghanistan, Bolivia, Ethiopia, Guatemala, Indonesia, Kenya, Kyrgyzstan, Nepal, Pakistan, Papua New Guinea and Tajikistan. The majority of studies were cross-sectional (19) followed by experimental trials (12), case studies (2), and a case-control study (1). The quality ranks of quantitative studies (n = 29) was evenly spread across strong (8), moderate (13) and weak (8) although the evidence is heterogeneous and best judged for individual studies rather than pooled.The results, characteristics and quality features of individual included studies are shown in Strategies identified in the 34 studies can be divided into four broad categories: delivery of services to remote communities; improvements to the desirability of existing services through improved facility and provider performance; improving affordability of services; generation of demand for services and improving acceptability; and improving health knowledge for timely and appropriate care-seeking. Examples are summarised in community health workers (CHW) with small salaries, on-site monthly training and supplies package, and fortnightly supportive supervision has led to coverage of at least one monthly health visit for every household in Pakistan et al reported that CHWs have only been able to motivate those living near to facilities to use services highlighting the overlap of knowledge and access barriers, although they did demonstrate a 34% reduction in under-5 deaths through combined improved care-seeking and preventative child care practices  Providing Task-shifting has increased availability and acceptability of services. Auxiliary nurse-midwives trained to provide intrauterine contraceptive device (IUDs) services increased IUD users from 18 to 71 per month with only 0.6% complications in rural Guatemala Task-shifting of comprehensive emergency obstetric care (CEOC) to non-physician clinicians  through 9 months of training covered 63% of CEOC cases in Ethiopia where CEOC facilities were present  yet staffed with only 4 surgical physicians Home-based administration of misoprostol by CHWs attending home deliveries in a large community-based controlled trial of Ethiopia reduced the incidence of post-partum haemorrhage by 58%  and lowered severity with high safety Mobile camps providing permanent female contraception (sterilisation) have high satisfaction reported by clients with equivalent quality to hospitals although are rarely offered in the Mountains ecoregion of Nepal compared to the plains (Terai) (p<0.05) Maternity birthing homes in West Java, Indonesia, staffed with SBAs linked by radio to clinics increased skilled delivery care from 17 to 36% (p<0.05) however the study offers only weak evidence and sustainability was an issue with two of ten homes closed within two years Telemedicine with computers and wireless internet has connected health workers and patients in the mountain villages of Myagdi district, Nepal, with central hospitals to increase access to and utilisation of specialist doctors. Patients reported increased satisfaction and confidence in care Upgrading facilities with functional neonatal care equipment accompanied by training, guidelines and supervision for nursing staff has been linked with 44% lower neonatal mortality , largely averted pneumonia deaths, and a minor increase in service utilisation in only two years in the highlands of Papua New Guinea Integrating services by adding to or merging existing services has increased coverage where travel and access is challenging and points of contact are few. Moderate to strong evidence from various mountain range settings of Kenya shows that integrating HIV care with family planning, or with antenatal care services, increases uptake of HIV testing and treatment among women by up to 25%. Integrated care consistently is more time demanding however satisfaction among HIV-positive women was very high regardless of waiting times Coaching health workers for effective communication, responsive, and sensitive care through ‘Professional Attitude and Effective Communication’ skills training with orientation from community leaders and lay providers increased provider motivation and consumer satisfaction. Partner attendance for facility-based deliveries (FBDs) rose from 10 to 70%, and harmful practices reduced by 90%, with 30% fewer delivery and caesarean complications in Tajikistan and Kyrgyzstan Training and supervision through distance learning programs and job aids improves staff motivation and performance in remote areas. In Guatemala this improved the quality of family planning counselling and in turn utilisation by 12% (p<0.004) et al reported that the trial of supervision through a combination of supervisor visits and full-day district-level meeting was more preferred by remote health workers, less expensive, and increased CPR more effectively  compared to only supervisor visits or self-assessment workshops Free maternity care has reduced care-seeking delays in Nepal with fewer families hesitating due to inabilities to pay or acquiring loans. This has aligned with increased FBD for normal births by 19%, complications by 15% and caesarean by 18% although the cross-sectional study precludes assertion of causation Financial stimulants for demand, provider motivation and facility compensation, applied in Nepal's Safe Delivery Incentive Programme coincide with increased FBDs with those exposed being 24% more likely to have FBD. However, affordability and other barriers persist: in 2008 the FBD incentive covered only 30–50% of the average travel costs in mountain districts and promotion was challenging in the sparsely populated mountains where women with no education or of Dalit caste were least likely to be informed Community-led planning activities have improved health knowledge, care-seeking, service utilisation and perinatal mortality in multiple sites however models are varied and overall the evidence from mountain range settings is not drawn from high quality controlled trials. Facilitated structured planning and action oriented women's group sessions moving from problem analysis, strategies, implementation and review in Bolivia, coincided with a decrease in perinatal mortality from 117 to 43 deaths per 1000 live births (p<0.001) and increased participation in women's organisations from 7 to 54% (p<0.001) Engaging traditional healers and clearly defining roles with them, has reduced delays in Guatemala with early referrals by TBAs for complicated births up from 26 to 36%, and non-complicated births from 5 to 21% Awareness-raising through intergenerational community discussions, mentor groups for youth, and literacy and livelihood training for women in Ethiopia diminished harmful traditional practices, increased school enrolment for girls aged 10–14 from 71 to 96% (p<0.05), improved reproductive health and family planning knowledge (p>0.001), and rose CPR among sexually active girls from 43 to 74% (p>0.001) “they (men) even encourage us to use contraceptives and remind us if we have taken the pill”  Shanker and colleagues (2009) present high quality evidence of community facilitators, recruited from local communities in Indonesia, displaying high levels of knowledge, care and thoroughness in their work, were able to motivate pregnant women for 85% compliance with micronutrient supplementation and increase in SBA utilisation from 35 to 53% with a resultant 33% reduction in early infant mortality  Information tools, such as cards, posters and charts, improved health knowledge and increased use of contraception services from 31 to 34 clients per day in Guatemala Delivering quality health care services to populations in hard-to-reach environments is challenging. There are some promising strategies that can address the burden of geographical inaccessibility. Task shifting, strengthened roles for CHWs and volunteers, mobile teams, incentives and removal of user fees, local awareness initiatives, and highly inclusive structured health promotion and planning forums have proved effective in a variety of difficult to reach mountainous settings in broadening both the scope and reach of RMNCH services. These are not novel strategies, and each has a proven efficacy in more accessible settings Geographical barriers limit the scope of health research that is conducted in these settings, creating further inequity in our understanding of the true barriers, or the potential strategies that may work. A possible limitation of this review is the shortage of evidence; studies concerning health services are not available for all relevant low resource mountain range settings of the world however this review does include 11 countries and should be considered representative of the context. In many cases the evidence for a particular strategy is drawn from one setting only. It is also likely that approaches that are successful in more accessible areas may well work in mountainous areas however setting-specific evidence is lacking. Of particular note is that while there exists many examples of strategies to take health services to the community, our search did not yield any such studies. Improved transport is a recognised means for increasing timely access to care, however examples of successful programs are largely based in non-mountainous settings. Air retrievals are notoriously difficult in mountainous terrain and initiatives that are promising in other settings, such as stretcher transport teams or other local initiatives, are not reported from the - very settings where they may be of most value. Additionally, there is evidence of the benefits of comprehensive, regular outreach teams for increased service coverage and facility-based care uptake however the evidence is not specifically available from remote high altitude sites From the available reviews however it appears that the most successful programs look beyond the tyranny of distance to also address the greater contribution of other utilisation barriers; that is strongly held cultural beliefs, greater socioeconomic disadvantage and lower levels of health knowledge. The reach of services must be extended through selected, trained and supported CHWs who team with formal health workers, task-shifting to peripheral cadres, home-based administration of medications to buy time for care-seeking. Facilities must be equipped with supplies and staff to deliver quality, reliable and culturally sensitive care and integrated services may be more efficient when users must traverse the mountains to reach providers. Health workers may be better able to provide this through innovative training and supervision solutions and support from peers and community leaders. With structured, facilitated input and health promotion that reaches youth, women, men and elders, communities may be able to self-mobilise for greater care-seeking. We need to recognise that ‘more of the same’ will not bring the health improvements that we seek for women and children in these difficult settings. We must concentrate efforts to increase the evidence of what works, and to deliver what we know can be effective.Figure S1Flow diagram of article selection process.(PDF)Click here for additional data file.Appendix S1Full search strategy of one database.(DOC)Click here for additional data file.Appendix S2Inclusion and exclusion criteria.(DOC)Click here for additional data file.Appendix S3Summary of the characteristics and quality of included studies.(DOC)Click here for additional data file.Checklist S1PRISMA Checklist.(PDF)Click here for additional data file.


A range of NMCP partners, state ministries, acadaemia, private sector, national and international non-governmental organizations, including regional and global policymakers attended the meeting. The conference represented a major milestone and made recommendations revolving around the five key elements of the IVM approach. The meeting endorsed that vector control efforts in RSS be augmented with other interventions within the confines of the IVM strategy as a national approach, with strong adherence to its key elements.Upon the signing of the Comprehensive Peace Agreement in 2005, the Republic of South Sudan (RSS) has faced a lot of challenges, such as a lack of infrastructure, human resources and an enormous burden of vector borne diseases including malaria. While a national malaria strategic plan 2006-2011 was developed, the vector control component has remained relatively weak. The strategy endorses the distribution of long-lasting insecticidal nets (LLINs) as the frontline intervention with other interventions recommended only when technical and institutional capacity is available. In 2006, a draft integrated vector management (IVM) strategic plan 2007–2012 was developed but never implemented, resulting in minimal coordination, implementation and coverage of malaria vector control tools including their inherent impact. To address this challenge, the vector control team of the National Malaria Control Programme (NMCP) is being strengthened. With the objective of building national capacity and technical collaboration for effective implementation of the IVM strategy, a national malaria vector control conference was held from 15-17 Anopheles gambiae s.s, Anopheles arabiensis and Anopheles funestus s.s are the major vectors of malaria in the country. Upon the signing of the Comprehensive Peace Agreement in 2005, a national malaria strategic plan 2006-2011was developed [increase the population coverage with effective malaria prevention as part of an integrated vector control strategy that utilizes all approaches, including long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS) and larval source management  when and where most suitable and sustainable”. However, due to lack of specialized technical capacity, appropriate infrastructure and sustainable financing in the post conflict environment, to date vector control has largely consisted of promoting the use of LLINs distributed through periodic mass campaigns  and via routine Antenatal Care (ANC) and Expanded Programme for Immunization (EPI) services to pregnant women and infants respectively [The Republic of South Sudan (RSS) is a heartland of several vector-borne diseases, including malaria . Anophelectively .Since 2008, more than seven million nets have been provided free-of-charge to recipients across the country . HoweverTo strengthen malaria vector control, the Ministry of Health (MoH) has adopted the integrated vector management (IVM) strategy for the control and prevention of vector-borne diseases – including malaria . This foth October 2012 in Juba to; 1) update malaria stakeholders on the IVM Global strategic framework as a WHO recommended approach for vector control; 2) review current LLIN implementation approaches, share experiences and propose means of increasing coverage and use of the intervention; 3) discuss the role and implementation arrangements for other malaria vector control interventions (IRS and LSM) and; 4) review the draft IVM strategic plan and discuss the engagement of other vector-borne disease control programmes. A range of NMCP partners, state ministries, academia, private sector, national and international non-governmental organizations, including regional and global policymakers attended the meeting  organized the first ever national malaria vector control conference from 15-17a rational decision-making process for the optimal use of resources for vector control’. Its goal is to make a significant contribution to the prevention, reduction or interruption of transmission of vector-borne diseases. The principles and approaches to IVM are set out in the Global Strategic Framework for IVM [IVM is defined as ‘ for IVM . CharactIn the RSS, the WHO-led IVM has been adopted as the main platform for vector control. A national vector control needs assessment has been conducted to thoroughly analyse the country requirements for a proper implementation of IVM through the determination of existing gaps in policies, strategies, legislation and capacity for improving vector control in view of IVM and its integration in the existing framework of national health policies in the RSS . A draftWhile deployment of LLINs remains the frontline intervention for malaria vector control, distribution and utilization has consistently been below the set targets necessitating the need to review the LLIN guidelines, policies and distribution strategies with a view of improving coverage and use. Effective vector control aims to deploy interventions before the peak transmission season. However, there are notable gaps and challenges of coordination and communication, weak intersectoral collaboration at all levels, limited information on retention and use of LLINs, preferences by communities, vector bionomics and their insecticide resistance profiles, environmental and human safe guards. WHO recommends mass LLIN distribution conducted just before the transmission period targeting an average of about one net for every 1.8 people . CommuniIt is critical to strengthen routine distribution and explore the potential of other avenues for LLINs distribution such as community-based LLIN continuous distribution, including other replacement mechanisms to tackle the challenges of low LLIN durability - mainly physical integrity due to wear and tear and to a lesser extent due to insecticide residual efficacy . ImproveBacillus thuringensis var. israelensis or insect growth regulators, remains recommended for the urban areas of the country where breeding sites are few, fixed and findable. Effective control of malaria vectors will require exploring new innovations of mosquito control technologies, including biological control methods, such as the use of larvivorous fish Gambusia affinis in targeted areas.Given the unique context of South Sudan in having a long peak malaria transmission season (lasting 7–8 months in the southern parts and 5–6 months in the northern regions) and infrastructural challenges, deployment of LLINs remains the frontline intervention for malaria vector control . HoweverGenerally improved vector control entails capacity building which is not only the responsibility of public institutions but also private institutions . CurrentThe MoH/NMCP needs to take a leading role in malaria control and hold a stakeholders consensus workshop to discuss the modalities of engaging other vector-borne diseases and IVM consolidation through building of core capacities and implementation of new interventions. Incorporation of other vector-borne diseases requires establishment of a multi-sectoral steering committee to update the IVM strategic plan, to develop the technical guidelines, and spearhead their implementation. The current draft IVM strategic plan requires systematic reviewing with a wider representation of participants from other vector borne disease control programmes . While iThrough the IVM strategy, some countries have put malaria vector control high on the political agenda and are making steady progress towards focalized elimination of the disease . In ZambAlthough RSS is a post conflict environment characterized by a multiplicity of challenges, the potential to implement effective malaria vector control is enormous. The successful conference on strengthening malaria vector control within the IVM framework by reviewing the available and ongoing strategies and identifying complementary interventions represent a major milestone. The key recommendations of the conference revolving around the five key elements of the IVM approach were:1. The Republic of South Sudan (RSS) need to put malaria vector control on the political agenda of the government to advocate for national and international vector control resources in order to sustain the effort.2. Vector control is currently being implemented almost entirely by international NGOs, LLINs  and pilot IRS (Mentor Initiative). As national institutional capacity-including those of the communities is strengthened, it is necessary now to empower the NMCP to manage and coordinate the implementation of malaria vector control.3. To ensure that LLINs universal coverage is sustained and utilization improved, mass campaign should be conducted every two years based on the population figures generated from the local communities with strengthened routine distribution via ANC and EPI as well as continuous community distribution and IEC/BCC.4. Develop implementation frameworks for IRS including national insecticide policy and legislation, private sector involvement and guidelines for deploying pilot IRS programmes in state capitals because of logistical challenges in rural areas.5. Recognizing the recent recommendations by WHO, Larval Source Management using larviciding with WHOPES recommended products will only be amenable as a supplementary pilot intervention in selected urban areas where breeding sites are few, fixed and findable.6. To guide the choices and overall implementation of vector control interventions, there is need to establish sentinel sites across the country for entomological (vector bionomics and insecticide resistance) monitoring- including data on LLIN life span in the field, along with the establishment of a national group of experts to analyse and interpret resistance data to guide national policies and procurement decisions.7. To be able to measure the impact of vector control implementation, it would require strengthening epidemiological monitoring through a robust malaria case surveillance system and HMIS to improve malaria morbidity and mortality data.8. To ensure high quality of vector control commodities and equipment, decisions on their procurement should be evidence-based and compliant with the legally binding tender documents that follow the WHO guidelines on procurement .9. Establish national inter-sectoral committee to update the IVM strategy, integrate other vector-borne diseases and oversee planning and implementation of IVM at central, state and county levels.10. Strongly advocate for Government support and commitment in strengthening human resource and institutional capabilities for vector control at state and county levels.The main endorsement of the meeting was that current vector control efforts in RSS be augmented with other interventions within the confines of the IVM strategy as a national approach, with strong adherence to the five key elements of the approach. Implementation of these recommendations must be a shared responsibility of all partners and other relevant sectors of government . As a first step, establishing a functional national intersectoral coordination mechanism as part of IVM, will create a platform in which these recommendations can be implemented cost-effectively. This would also require the updating of the IVM strategic plan as a key component of the overarching National Malaria Control Strategy.ANC: Ante-Natal Clinic; BCC: Behavioural Change Communication; EPI: Expanded Programme for Immunization; GFATM: Global Fund to HIV/AIDS, Tuberculosis and Malaria; HMIS: Health Management Information System; IEC: Information, Education and Communication; IRS: Indoor Residual Spraying; IVM: Integrated Vector Management; LLIN: Long-Lasting Insecticidal Nets; LSM: Larval Source Management; MoH: Ministry of Health; NGO: Non Governmental Organization; NMCP: National Malaria Control Programme; RSS: Republic of South Sudan; SHHS: Sudan Household and Health Survey; WHO: World Health Organization; WHOPES: World Health Organization Pesticide and Evaluation Scheme.The authors declare that they have no conflict of interest.EC conceived the idea and drafted the manuscript, and CD, HP, RA, SB, and AM collaborated and critically reviewed the article. All authors read and approved the final manuscript.Conference Agenda.Click here for file


Tobacco use has been identified as the single biggest cause of inequality in morbidity. The objective of this study is to examine the role of social determinants on current tobacco use in thirteen low-and-middle income countries.We used nationally representative data from the Global Adult Tobacco Survey (GATS) conducted during 2008–2010 in 13 low-and-middle income countries: Bangladesh, China, Egypt, India, Mexico, Philippines, Poland, Russian Federation, Thailand, Turkey, Ukraine, Uruguay, and Viet Nam. These surveys provided information on 209,027 respondent's aged 15 years and above and the country datasets were analyzed individually for estimating current tobacco use across various socio-demographic factors . Multiple logistic regression analysis was used to predict the impact of these determinants on current tobacco use status. Current tobacco use was defined as current smoking or use of smokeless tobacco, either daily or occasionally. Former smokers were excluded from the analysis. Adjusted odds ratios for current tobacco use after controlling other cofactors, was significantly higher for males across all countries and for urban areas in eight of the 13 countries. For educational level, the trend was significant in Bangladesh, Egypt, India, Philippines and Thailand demonstrating decreasing prevalence of tobacco use with increasing levels of education. For wealth index, the trend of decreasing prevalence of tobacco use with increasing wealth was significant for Bangladesh, India, Philippines, Thailand, Turkey, Ukraine, Uruguay and Viet Nam. The trend of decreasing prevalence with increasing levels of knowledge on harmful effects of smoking was significant in China, India, Philippines, Poland, Russian Federation, Thailand, Ukraine and Viet Nam.These findings demonstrate a significant but varied role of social determinants on current tobacco use within and across countries. Socioeconomic inequality and its impact on health is a global public health concern National data on prevalence of tobacco use (with some limitations on age groups and gender representation) have been available from Demographic Health Surveys in Bangladesh Global Adult Tobacco Survey (GATS) is a component of the Global Tobacco Surveillance System (GTSS) which includes: the Global Youth Tobacco Survey (GYTS); the Global School Personnel Survey (GSPS); and the Global Health Professions Student Survey (GHPSS). The objectives of GATS in its first phase of implementation was to monitor tobacco use and tobacco control indicators in low and middle income countries bearing the highest burden based on number of adults smokers. The first phase of GATS was implemented in 14 countries during 2008–2010: Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russian Federation, Thailand, Turkey, Ukraine, Uruguay, and Viet Nam.GATS is a global standard for systematically monitoring adult tobacco use and tracking key tobacco control indicators. GATS is a nationally representative household survey of adults aged 15 years and older, using a consistent and standard protocol which enables unprecedented cross-country comparisons and change over time for countries that repeat the survey. This paper examines the influence of various socio-demographic variables on current tobacco use within a country and across countries using GATS data.GATS data from 13 low-and-middle income countries  conducted during 2008–2010 were used for analyses. GATS data from Brazil was not included in this paper as the information on important predictor variables collected in Brazil  was not comparable to other GATS countries. These surveys provided information on 209,027 respondent's aged 15 years and above and the country datasets were analyzed individually for estimating overall current tobacco use as well as by various socio-demographic factors.GATS used a multi-stage geographically clustered sample design to produce nationally representative data. For each participating country, a standard protocol with respect to questionnaire, sample design, data collection and management procedures was used. Survey information was collected using handheld devices. Additional details of individual country survey methodologies are available in country reports Current tobacco use is the dependent variable used in this analysis and was defined as current smoking or use of any smokeless tobacco product, either daily or occasionally Relevant independent variables included in the analyses were gender , age, place of residence , knowledge on harmful effects of smoking (three categories), educational level (four categories), and wealth index (five categories). The level of knowledge on harmful effects of smoking was measured using three core questions in each country: ‘based on what you know or believe does smoking tobacco cause the following: stroke , heart attack and lung cancer’. Respondents who answered all three questions correctly were classified as having ‘good knowledge’, those who answered any two questions correctly as having ‘some knowledge’ and rest were classified as having ‘little knowledge’. Educational level was grouped into five categories: no formal schooling, less than primary, primary complete, less than secondary, and secondary school complete and above  across all countries. Wealth index, a proxy measure for respondent socioeconomic status, was constructed using principal component analysis with information on household ownership of assets The data were appropriately weighted to ensure the true representation of the population of the country; SPSS® version 18.0 for complex samples was used to analyze the data. Statistical analysis included multiple logistic regression accounted for complex survey design for predicting the social determinants of tobacco use. The dependent variable used for this analysis was tobacco use . Former tobacco users were removed from the logistic regression analysis due to the fact that current tobacco use may not directly influence from current socioeconomic and demographic status. All the independent variables were categorical. Overall trend for each variable was assessed by assuming the categories of independent variables as continuous variables in the logistic regression, except for age variable where we used age in single years for obtaining the trend.Tobacco use included smoking, smokeless tobacco use and dual use (using both smoked and smokeless). Both For wealth index, odds ratios were computed taking the highest wealth category as reference. Most of odds ratios were significant with largest effect observed in Thailand. The trend  was significant for Bangladesh, India, Philippines, Thailand, Turkey, Ukraine, Uruguay and Viet Nam. The trend was opposite in Mexico and not significant in other countries. Knowledge level was also affected tobacco use, though to a lesser extent. An inverse relationship was observed for level of knowledge and tobacco use; as level of knowledge increased, the odds of tobacco use decreased and was significant for China, India, Philippines, Poland, Russian federation, Thailand, Ukraine and Viet Nam. The trend was not significant in remaining countries.This report provides information about 13 countries where 2.64 billion adults aged 15 years and above live, which constitutes more than half of the world's adult population (5.15 billion) in 2010 Our study reveal that the prevalence of current tobacco use, particularly smoking is quite lower among women compared with men in most countries and sex is a very strong determinant of tobacco use status. Stratified analysis of tobacco use by sex (not shown in tables) clearly indicated that the present findings apply to women as well as men. Our study also reveals that the prevalence of tobacco use is generally higher among urban, less educated and low economic groups and people with less knowledge about effects of smoking. Detailed questions about the health effects of smokeless tobacco use were asked only in Bangladesh. The level of knowledge  based on three specific diseases  that are caused by smokeless tobacco use showed that the smokeless tobacco use is higher among individuals with lower level of knowledge (little knowledge (30%), some knowledge (34.3%) and good knowledge (26.5%)).An important finding in this study is high prevalence of tobacco use in the middle ages (45 to 64). The health effects of tobacco use start becoming apparent in these age groups in a major way In this paper, we study social determinants as predictors of tobacco use, but in the long term tobacco use itself causes social inequalities At least two health parameters included in Millennium Development Goals (MDGs) are strongly related to tobacco use: deaths by tuberculosis and maternal and child health issues The findings in this report are subject to a few limitations. The prevalence results are based on self-reports without bioassay validation. Study design allowed for the investigation of only a limited number of socio-demographic variables. It is important to note that former tobacco users were excluded from the logistic regression. The proportion of former users was different in different countries and their distribution by socio-demographic variables used in the analysis might be different. This might affect some comparisons. The information on frequency and length of smoking, though available in GATS data, was not considered in the present study. In some countries the household possession items considered/used in the analysis are based on the items available in the country data and these items may not be a true representation of wealth across all countries.Despite these limitations, the current study provides evidence of the importance of social determinants on tobacco use. Findings indicate that social determinants and their role should be given high priority when addressing the issue of tobacco use.List S1GATS Collaborating Group.(DOCX)Click here for additional data file.


Cancer has been recognized to have environmental origin, but occupational cancer risk studies have not been fully documented. The objective of this paper was to identify occupations and industries with elevated colon cancer risk based on lifetime occupational histories collected from 15,463 incident cancer cases.A group matched case-control design was used. All cases were diagnosed with histologically proven colon cancers, with cancer controls being all other cancer sites, excluding rectum, lung and unknown primary, diagnosed at the same period of time from the British Columbia Cancer Registry. Data analyses were done on all 597 Canadian standard occupation titles and 1,104 standard industry titles using conditional logistic regression for matched data sets and the likelihood ratio test.Excess colon cancer risks was observed in a number of occupations and industries, particularly those with low physical activity and those involving exposure to asbestos, wood dusts, engine exhaust and diesel engine emissions, and ammonia.The results of our study are in line with those from the literature and further suggest that exposure to wood dusts and to ammonia may carry an increased occupational risk of colon cancer. Colon cancer is one of the leading cancer causes of death. In Canada, colon cancer is the third most common form of cancer (after prostate cancer and lung cancer in men and breast cancer and lung cancer in women) and the third leading cancer cause of death (after lung cancer and prostate cancer in men and lung cancer and breast cancer in women) .Despite the common occurrence of colon cancer, its etiology is not well established; age, family history , lifestyWe have, as part of a program aimed at detecting occupational risk factors in British Columbia, Canada, collected lifetime occupational histories from 15,463 incident cancer cases, of which 1,155 had a diagnosis of colon cancer. Occupational risks for this group of patients are presented in this article by assessing risk difference in comparison with internal controls consisting of all other cancer patients excluding lung and rectum cancer and cancer of unknown primary sites.The general methodology of the study has been described in detail in a previous article . BrieflyA group matched case-control design was used. Cases comprised all 1,156 colon cancer patients. Controls comprised internal controls with all other cancer sites, excluding lung cancer , rectum cancer  and cancers of unknown primary site (n = 708), matched to the cases on exact age and year of diagnosis. These were based on a few methodological considerations. First, using other cancers as controls has a few advantages over population controls with regard to recall and interviewer bias when using general population controls, a mixture of live and deceased controls can be expected when selecting other cancer patients as controls and there are logistical and cost advantages in using other cancer patients as controls. Thus the study design using cancers as controls is likely to be used increasingly in the future, particularly in cancer registry settings . Next, sP < 0.2) were then included in the model and the remaining ones were examined; the process was repeated until no factor with P < 0.2 was identified. In step 2, each occupation and industry was assessed separately using conditional logistic regression in which all significant confounding variables identified in step 1 were taken into account. The cut point of 0.20 was chosen in step 1 to ensure that the process has sufficient power to identify potentially important confounders.Data were analyzed using conditional logistic regression for matched sets and the likelihood ratio test ,37 in a versus never, and usual occupation/industry (job with the longest held lifetime employment in a given occupation/industry). People in either ever or usual occupation/industry categories were always compared to their counterparts who were never in such occupation/industry. Due to all 597 occupation titles and 1,104 industry titles were analyzed and small numbers of cases in many occupation/industry categories, we intended to maximally present results of the analyses in this article with occupations and industries as long as their number of cases is five and over.Matched case-control analyses were carried out using PECAN software , test ofMatching resulted in 1,155 colon cancer cases having at least one matching control and 7,552 controls, leaving an overall control to case ratio of 6.5:1. Site distribution of controls is listed in The characteristics of cases and controls are shown in Statistically significant ORs were noted for the following variables: smoking duration and education level as shown in Odds ratios by ever and usual occupation and industry categories are shown in insurance sales jobs (SOC 5171), rail transport equipment mechanics and repairers (SOC 8583), brick and stone masons-tile setters (SOC 8782), ship engineering officers (SOC 9153), and at P = 0.10 for: administrators in teaching and related fields (SOC 1133), financial management (SOC 1135), livestock farm workers (SOC 7183), sawmill sawyers and related (SOC 8231), cabinet and wood furniture makers (SOC 8541), and taxi drivers and chauffeurs (SOC 9173); the ORs were significantly low at P = 0.10 for sales clerks and salespersons in commodities, not else classified (SOC 5135) and welding and flame cutting (SOC 8335).In the usual occupation category, significant excess risk in the major occupation groups (two-digit codes) was only observed at P = 0.10 for occupations in social sciences and related (SOC 23). Excess risks for minor groups (three-digit codes) were significant at P = 0.05 for occupations in fabricating, assembling and repairing wood products (SOC 854) and at P = 0.10 for occupations in other managers and administrators (SOC 113/114), bookkeeping and account-recording (SOC 413), and lodging and other accommodation services (SOC 613). Several unit occupations (four-digit codes) had significantly increased ORs at P = 0.05 for: membership organizations (SIC 98); ORs for printing, publishing and allied (SIC 28) industry was low at P = 0.10. Excess risks were significant at P = 0.05 for the following minor industry groups (three-digit codes): brewery products (SIC 113), defense services (SIC 811), and human resource administration (SIC 826) and at P = 0.10 for livestock farms  (SIC 011), and dairy products (SIC 104). Odds ratio was significantly low at P = 0.10 for interior and finishing work (SIC 427). Several industry classes (four-digit codes) had significantly increased ORs at P = 0.05 for poultry and egg farms (SIC 0114), construction, mining machinery, materials handling (SIC 3192), exterior close-in: masonry work (SIC 4231), used goods moving and storage (SIC 4562), and specialty food stores (SIC 6012). ORs were significantly low at P = 0.10 for general freight trucking (SIC 4561), motor vehicle repair garages  (SIC 6351) and general hospitals (SIC 8611).In the usual industry category, a significant excess risk in the major industry group was noted at P = 0.05 for motor vehicle, parts and accessories, wholesale (SIC 55) and insurance and real estate agencies (SIC 76) and at P = 0.10 for beverage (SIC 11), federal government services (SIC 81) and In the validation study of the questionnaire, company job records of 81 individuals who reported having been employed in one of two large companies in BC were compared with information from their questionnaire; and the interclass correlation was 0.996 for starting year of employment and 0.971 for duration of employment.Significant associations between colon cancer and a number of occupations and industries were observed in our study. Several sedentary occupations in management, administration, bookkeeping and recording, financial management, insurance and real estate, and lodging and accommodation showed significantly increased risk of colon cancer either at P = 0.05 or at P = 0.10, which are consistent with findings from the previous studies –29.In this study, we found some occupations and industries with significantly elevated risks of colon cancer in both ever and usual employment categories: workers working in occupations or industries with low physical activity, including insurance sales, human resource administration and membership organizations; rail transport equipment mechanics and repairers who were exposed to asbestos that has been reported to be associated with a higher risk of colon cancer; taxi drivers/chauffeurs who were exposed to engine exhaust and diesel engine emissions, a known carcinogen for colon cancer ; workersElevated colon risks were also found in usual employment categories for occupations in wood products fabricating, assembling and repairing with exposure to wood dusts, a controversial agent without sufficient evidence of the association by the International Agency of Research on Cancer by far; industries of poultry and egg farms with exposure to gaseous agents such as ammonia from litter, carbon monoxide from poorly ventilated gas-fired heaters and hydrogen sulphide from liquid manure. Also, particles of organic or agricultural dust are aerosolized from poultry house litter; livestock farms  and dairy products and relevant occupations with exposure to noxious gases such as hydrogen sulfide, and ammonia and methane in the ambient barn air; sawmill sawyers and workers working in motor vehicle parts and accessory wholesale and truck transportation on used goods, with exposure to engine exhaust and diesel engine emissions ; workersThe strengths of this study are several folds. It is population-based with ascertainment of pathology confirmed cancer incident cases and includes lifetime occupational history with the ability to control for potential confounding factors and effect modifiers. Our study has revealed a number of occupational risk factors for colon cancer. Interpretation of those findings is limited by the lack of information on occupational exposures and the possibility that statistically significant results may have occurred by chance because of multiple comparisons; also, especially for many usual occupations and industries, numbers are few. In addition, other cancer cases used as controls may not be representative of the general population. Particularly, other cancers may also have some occupational risks that are common to those of colon cancer cases; in such situation, the corresponding estimated OR’s noted in this study would underestimate the true risks. A missing value category was used in the analysis to avoid reducing the study sample size and that may yield biased results. However, since the proportion of missing data is small and it is unlikely that missing information on education and smoking is correlated with job classification, the biases if any should be relatively small. Some of the confounding factors such as measures of body-mass index and physical activities were not collected for this study. Nevertheless, our validation study demonstrates that self-reported employment history bear little recall errors in out study.Some of the risks observed may not apply to current workers because of a potential decrease in industrial exposures. However, the results of our study are in line such as elevated colon cancer risk by exposure to asbestos and to engine exhaust and diesel engine emissions from the literature and further suggest that exposure to wood dusts and to ammonia may carry an increased risk of colon cancer. More specific studies using population controls are needed to investigate associations between occupation and exposures to chemical substances, taking into account changes in concentration levels over time.


Objectives. Review of burden of congenital transmission of malaria, challenges of preventive measures, and implications for health system strengthening in sub-Saharan Africa. Methods. Literature from Pubmed (MEDLINE), Biomed central, Google Scholar, and Cochrane Database were reviewed. Results. The prevalence of congenital malaria in sub-Saharan Africa ranges from 0 to 23%. Diagnosis and existing preventive measures are constantly hindered by weak health systems and sociocultural issues. WHO strategic framework for prevention: intermittent preventive therapy (IPT), insecticide-treated nets (ITNs), and case management of malaria illness and anaemia remain highly promising; though, specific interventions are required to strengthen the health systems in order to improve the effectiveness of these measures. Conclusion. Congenital malaria remains a public health burden in sub-Saharan Africa. Overcoming the challenges of the preventive measures hinges on the ability of national governments and development partners in responding to the weak health systems.  Plasmodium falciparum infection during pregnancy is estimated to cause as many as 10,000 maternal deaths each year, 8% to 14% of all low birth weight babies, and 3% to 8% of all infant deaths [Malaria remains a significant burden in sub-Saharan Africa as it continues to be the leading cause of infant morbidity and mortality in Africa. It is believed that malaria contributes up to about 25% of infant mortality in Nigeria . Furtherin utero or during delivery [Congenital malaria is defined as malaria in a newborn or infant, transmitted from the mother . Congenidelivery . It is adelivery . Malariadelivery , 7. Congenital malaria was thought to be rare in developing countries , 9. ThisLiterature providing information on the prevalence, burden, diagnosis, prevention, and control of congenital malaria, published between 2000 and 2010 was reviewed. Search terms included “congenital,” “Malaria,” “burden,” “diagnosis,” “prevention”, “control,” and “sub-Saharan Africa.” These literatures were accessed from Pubmed (MEDLINE), Biomed central, Google Scholar, and Cochrane Database of Systematic Reviews. Searches were also supplemented with recommendations from outside experts, reviews of bibliographies of other relevant articles, and systematic reviews.Congenital malaria is rare in developed countries such as the United States of America, where only three infants out of 4.1 million live births were reported to have congenital malaria . The sitFurthermore, while a study in Kenya reported a prevalence of malarial parasitaemia in <0.5% of neonatal admissions , high prIt is estimated that placental malaria is responsible for 35% of preventable low birth weight in developing countries . It is aμL blood) [The detection of malaria parasites in the infant's blood is essential for diagnosis, although blood smears can be negative if there are low parasite counts (50 parasites/L blood) . PengsaaL blood) . The capL blood) –14.Cord malaria can also be detected by polymerase chain reaction (PCR). The use of PCR has suggested that congenital malaria may be more frequent, although it is unclear if a positive PCR represents an active infection . Though,Apart from the laboratory constraints, low antenatal care attendance and skilled delivery rates in African countries will also affect detection and prevention of congenital malaria. Antenatal care utilization in the developing countries is about 65%; this is low compared to that of the developed countries, which is 97% . The impThe clinical diagnosis of congenital malaria usually poses a challenge. This is because its clinical findings may be indistinguishable from those of neonatal sepsis ; hence, Thus, the clinical distinction from other congenital infections rests primarily on maternal history of exposure to malaria and absence of a skin rash . A studyPrevention of any disease condition requires the availability of methods for prediction of those at high risk of the disorder. If there were tests which are adequately sensitive for detecting placenta malaria in the antenatal period, it would have helped in assessing the efficacy of antimalarial drug during pregnancy and identifying the infants at risk of congenital malaria . HoweverTherefore, malaria preventive measures in pregnancy still remain as priority interventions required to protect the foetus and the newborn against the adverse effects of congenital malaria. The World Health Organization (WHO) has recommended a three-pronged strategic framework in areas of high or moderate (stable) malaria transmission of sub-Saharan Africa: intermittent preventive therapy (IPT), insecticide-treated nets (ITNs), and case management of malaria illness and anaemia . Intermittent preventive therapy (IPT), also known as chemoprophylaxis for pregnant women, especially those in their first pregnancies, has been widely used in sub-Saharan Africa. In line with WHO recommendation, most national guidelines stipulate that all pregnant women should receive at least two doses of IPT given as sulphadoxine-pyrimethamine (SP) combination after quickening as part of preventive treatments at antenatal care . EvidencDespite the beneficial impact of sulphadoxine-pyrimethamine on maternal and infant health, its utilization is threatened by weak health systems and sociocultural issues in sub-Saharan Africa. Studies have shown that a substantial proportion (20% to 80%) of pregnant women in this setting make their first antenatal visit in their third trimester –35. FurtWithin the sociocultural context, it is thought that noninitiation of care in the first trimester seems to be a widespread cultural practice in sub-Saharan Africa. In rural Gambia, women do not usually “announce” pregnancy but wait for other family members to discover it, thereby presenting for care well into the third trimester . While fRandomized control trials in sub-Saharan Africa have consistently shown the effectiveness of insecticide-treated nets (ITNs) in the prevention of malaria in pregnancy. Studies in Ghana and Kenya have documented reduced placental malaria, low birth weight, and fetal loss resulting from use of ITNs . Though Access to ITNs by vulnerable populations including pregnant women continues to increase due to the efforts of national governments and supporting development agencies through multiple approaches such as stand-alone campaigns, health facilities, and antenatal clinic , 38. AccDespite these efforts, recent findings revealed low utilization of ITNs among pregnant women. Though increasing trends in ownership and use of ITNs by households were reported in national demographic surveys, the reports indicated that 5% to 57% of pregnant women aged 15–49 years slept under an ITN the past night. Furthermore, gaps between ownership and use of an ITN continue to exist as about 50% or less of pregnant women aged 15–49 years in households with an ITN slept under the net the past night , 46, 47.Supporting and promoting access to correct, affordable, and appropriate treatment within 24 hours of the onset of symptoms of malaria is the third essential component of malaria prevention and control during pregnancy in malarious endemic countries of sub-Saharan Africa . The WorHowever, prompt and effective case management of malaria illness is hinged on early and correct diagnosis of the condition. As noted above, this is seriously hindered by lack of capacity to conduct quality malaria diagnostic tests by local health facilities in sub-Saharan African countries –14. WhilThe World Health Organization (WHO) recently recommended prompt parasitologic confirmation by microscopy or alternatively by rapid diagnostic tests (RDTs) in all patients suspected of malaria before treatment is commenced unless parasitological diagnosis is not accessible . FindingOn the other hand, malaria rapid diagnostic testing (RDT) has been found useful as an attractive alternative to routine microscopy with good sensitivity and specificity profiles , 51. In From the foregoing, utilization of RDTs in resource-poor settings would seem to be an appropriate technology as it has the potential of improving the quality of malaria diagnosis and treatment services provided to all cases of malaria, including pregnant women and newborns. Therefore, it is suggested that national governments and development partners in sub-Saharan Africa should support widespread use of rapid diagnostic tests (RDTs) for malaria diagnosis. The capacity of local health facilities providing maternal and child health services should be strengthened with the provision of adequate supplies of equipment and consumables required to provide the diagnostic services. In addition, targeted trainings and supportive supervision of local health staff are highly desirable in order to meet up with the challenges of newly-assigned task. In order to increase uptake of IPTs and facilitate prompt diagnosis and treatment of malaria in pregnancy, national governments and development partners in sub-Saharan African countries should also consider improving the poor maternal health service indicators—nonbooking, late antenatal visits and low antenatal service rate—as an essential task to be concertedly pursued. To achieve this task, strategies aimed at improving maternal health service should be implemented. For example, proven-specific interventions such as the World Health Organization (WHO) training on Life Saving Skills  are suggIn addition, health staffs' familiarization and adherence to WHO guidelines on provision of effective, efficient, safe, and culturally appropriate services to pregnant women and newborn under the Integrated Management of Pregnancy and Childbirth (IMPAC) would assist to ensure best practices . It is eOn a long term basis, strategies which would bring about over 80% antenatal service utilization rate should be pursued vigorously. Therefore, it is suggested that redirecting and repackaging health education and service content of antenatal care service using a social marketing approach acceptable within the sociocultural context would be found useful. Therefore, placing the antenatal care service content and its benefits on public agenda through different media and matrices may be helpful in the study setting as opposed to the current practice of restricting information to women who make antenatal visits. Despite male economic dominance and decision making power in developing countries, their involvement in reproductive health issues is reportedly low . HoweverWith regard to closing the gap between ownership and use of an ITN, a carefully designed qualitative research may be useful in eliciting the factors responsible or reasons for not sleeping under an ITN despite its availability in the household. While it is suggested that national governments and development partners should not relent on their efforts in making ITNs universally accessible to pregnant women either free of charge or at a subsidized price, experiences of other researchers on factors which promote or inhibit ITN usage may be found useful in packaging educational messages aimed at promoting its usage. ITN usage promoting factors such as high perception on the seriousness of malaria and its effect on pregnant women and children, high perceived benefit of ITNs in protecting children and pregnant women against malaria, and high awareness of the prevention of malaria as a better and cheaper option compared with treatment should be intensified. Whereas inhibitory factors such as fear of the chemical that is used to treat nets and unsupportive spouses should be demystified .Evidence abound that congenital malaria constitutes a public health burden in sub-Saharan Africa. However, efforts of the national governments and development partners at instituting the recommended cost-effective interventions are continuously thwarted by challenges brought about by weak health systems and sociocultural factors among others, thereby, militating against the progress towards attainment of Millennium Development Goal (MDG) 6 . Health system strengthening and appropriate public health promoting and educating messages delivered through a social marketing approach may be found useful in putting back on track the race towards 2015 with respect to attainment of MDG 6.


Molecular breeding of rice for high yield, superior grain quality, and strong environmental adaptability is crucial for feeding the world’s rapidly growing population. The increasingly cloned quantitative trait loci and genes, genome variations, and haplotype blocks related to agronomically important traits in rice have provided a solid foundation for direct selection and molecular breeding, and a number of genes have been successfully introgressed into mega varieties of rice. Here we summarize China’s great achievements in molecular breeding of rice in the following five traits: high yield, biotic stress resistance, abiotic stress resistance, quality and physiology. Further, the prospect of rice breeding by molecular design is discussed. Rice is one of the most important staple crops in the world and serves as a model for monocots. In rice breeding, two breakthroughs have been made in China over the last century. The first breakthrough is the development of a semi-dwarf rice variety in the 1960s, which raised rice yield by more than 20 % per unit area; the second breakthrough is the development of a hybrid rice variety with the three-line or cytoplasmic male sterile system in the 1970s, which led to another great increase in average rice yield by 20 % Yuan . The preConventional breeding selects genotypes indirectly through phenotypes, which is generally effective for qualitative traits only but not for quantitative traits. It is due to that quantitative traits with continuous variations are controlled by multiple genes and environmental factors. Over the past few decades, advances of molecular markers, transgenic technology, and genomics have exerted far-reaching influences on the concept and means of conventional rice breeding, allowing applications of molecular breeding technology in rice. Molecular breeding refers to the development of new rice varieties by integrating the means of modern biotechnology into conventional breeding methods Fig. , which mCompensating the deficiencies of conventional breeding, molecular markers designed for direct genotypic identification are unrestricted to the ontogenetic periods of plants and can be used to select target traits directly. MAS involves four steps: overall program design, selection of target genes and parental materials, construction of breeding populations, and molecular marker screening of early generation materials. The breeding process of MAS is similar to that of conventional breeding, except that in the former method, molecular marker detection is involved in every breeding generation on the basis of conventional phenotypic identification.GEB of rice mainly involves in vitro recombination of a specific target gene with the transformation vector, followed by transferring into rice for stable integration, expression, and heredity. This breeding method avoids the impacts of adverse genes caused by genetic linkage in the process of sexual hybridization and gets rid of reproductive isolation between different rice cultivars. Therefore, GEB provides an efficient way for cultivating new rice varieties.In recent years, great efforts have been made in rice genome sequencing and there have been significant developments of functional genomics. The increasingly cloned quantitative trait loci (QTL)/genes, genome variations, and haplotype blocks related to agronomically important traits in rice provide a solid foundation for direct selection and molecular breeding of rice. A number of genes are successfully transferred into mega rice varieties. Multiple chromosome segment substitution lines are constructed, and a large number of QTLs are identified. Many breeds carrying objective QTLs or genes are applied in rice production Table , and an High yield is the eternal theme pursued by rice breeders. Super rice breeding in the model of ideal plant architecture using molecular design is the mainstream of future development in this field. Yield-related traits in rice include plant height, tiller number, grain weight, and panicle type. Of these, plant height is the most important trait related to plant architecture and linearly correlates with biomass. Panicle number, which consists of planting density and effective tiller number, is a major influencing factor of the total grain production per unit area. Panicle characters are directly linked with the yield of rice  gene, closely related to plant type, has been cloned  gene  of China National Rice Research Institute (CNRRI) cooperated with the research group of Academician Li Jiayang from Chinese Academy of Sciences to complete the cloning of rice MOC1 transgenic pure lines were hybridized with conventional varieties such as Zhi-7 and Zhongchao-123, and a series of MOC1-containing breeding materials from different generations were obtained by transformation, including 40 intermediate materials from advanced lines.In addition, GEB has been applied for screening transgenic plants with less or no tillers, good agronomic traits, and great potential for high yield. To date, more than 50 transgenic lines have been bred using the pedigree methods and 30 transgenic intermediate materials are obtained. Of these, three transgenic varieties were further selected for significantly improved production and potential for application compared to the control lines; four lines with fewer tillers were used for variety demonstration; and some lines were used as intermediate materials. In addition, IPA1, great breakthroughs have been made in understanding the mechanism of ideal plant architecture in rice. It has been reported that IPA1 contributes mostly to more panicles, strong culms, and high-yield potential. This gene has been transferred into the rice cultivar Xiushui 11 through backcross breeding and the obtained mutant lines exhibit ideal plant architecture with a 10 % increase in the yield in field experiments  have been cloned and applied in rice production  and maintainer and restorer lines pyramiding a rice blast resistance gene (Pi-25) with two bacterial blight resistance genes (Xa-23 and Xa-21) were created. With the help of MAS, new resistance rice lines pyramiding multiple bacterial blight resistance genes  were screened out from the offspring of a cross between the variety IBRR60 and multiple disease-resistant varieties  as male parent to breed new disease-resistant rice lines with good cooking quality , rice blast (Pi9), and rice stem borer and leaf roller (Bt) were pyramided into the same lines using MAS to obtain a pure line with comparable resistance to specific biotic stresses mentioned above  and a rice blast resistance gene (Pib) were pyramided into the same lines to obtain anti-aging, bacterial blight-resistant, and rice blast-resistant intermediate materials for crossbreeding  and soil adversity ; artificial adversity is mainly human-induced environmental pollution. In recent years, molecular breeding for abiotic stress tolerance in rice has been developed significantly, and a series of genes and QTLs have been identified for their high application potential in rice breeding for resistance to adversity Table .Table 4MqDT5 and qDT12, were detected at seedling stage and located at GA41–GA257 on chromosome 5 and RG457–Y12817R on chromosome 12  was transferred into the japonica variety Hejiang 19 using an Agrobacterium-mediated method, and the screened positive plants showed improved salt tolerance at the seedling stage with less damage to cell membrane, strong vitality of leaf tissues, and enhanced salt tolerance under salt stress at the booting stage  gene from leguminous plants was transferred into rice using the gene gun method and the transgenic plants obtained increased content of proline with enhanced salt tolerance in transgenic cells  gene and 6-phosphate, sorbitol dehydrogenase (gutD) gene, or double genes such as choline monooxygenase (CMO) gene/betaine aldehyde dehydrogenase (BADH) gene into rice varieties  gene, gutD, and S-adenosylmethionine decarboxylase (SAMDC) gene, into the conventional japonica varieties Xiushui 11 and Zhonghua 11, indica varieties Teqing and hybrid restorer line Minghui 63 using Agrobacterium-mediated and gene gun methods; the five salt tolerance genes were then pyramided through conventional cross breeding and the rice line Xiushui 11 with nine genotypes was bred; further, these rice lines were chosen for comprehensive evaluation and effective utilization in south Zhejiang Province. Using map-based cloning, Ren et al. (SKC1 that is involved in regulating K(+)/Na(+) homeostasis under salt stress, providing a potential tool for improving salt tolerance in crops.In 2006, Guo et al.  gene into the three-line maintainer lines Tianfeng B, Rongfeng B, Taifeng B, and Zhenfeng B as well as the elite restorer lines Guanghui 998, Guanghui 290, and Guanghui 372. New wx-containing rice lines with low content of amylose were developed .Using MAS with the functional marker GRM04, new hybrid rice materials with strong fragrance were bred in Guangdong Academy of Agricultural Sciences by introducing fragrant  with improved quality, disease resistance, yield, and agronomic traits was screened out and bred by a combination of field breeding, resistance identification, and grain endosperm appearance identification  and dominated the trait of rice fragrance; these two genes were successfully introgressed in Minghui 63 lines according to the progress of backcross pyramiding using the two developed molecular markers; the improved Minghui 63 lines exhibited significant low GT and high gel consistency (GC), while the white core chalkiness decreased and fragrant trait expressed in these lines; the results elucidated that the quality of Minghui63 has been improved significantly in terms of rice appearance, cooking, and eating quality.Hybrid combinations were configured for pyramid breeding using Wuyunjing 7 as female parent and the High-photosynthetic efficiency is one of the most physiological traits for enhancing rice biomass and grain yield potential. In China, a number of rice genes related to physiological traits have been cloned Table . These g2 fixation in C4 plants. A maize PEPC gene was transformed into rice variety to produce new transgenic rice materials. Scholars have investigated the possible mechanisms of unique CO2 assimilation and high-photosynthetic efficiency in the rice variety carrying PEPC; high-yielding rice plants with stable high-photosynthetic efficiency were obtained by system selection and multi-generation cultivation; finally, high-yielding rice varieties with high-photosynthetic efficiency were bred  is the key enzyme for COPEPC transgenic rice varied in the tillering and heading stages, as well as different growth stages of flag leaf, all significantly higher than that in the parent Kitaake  have mapped multiple high-yield, high-photosynthetic efficiency genes , so as to select dominant combinations (Sun et al. S5 of rice was cloned in 2008 (Yang et al. S5, Yang et al. (S5-n. The functional markers of S5-n were useful to identify rice resources and detect hybrid purity (Zhang et al. The wide compatibility gene g et al.  have scrIn recent years, great progress has been made on molecular breeding in rice and the per unit area yield of this crop has been significantly improved in China. What then is the best path to increasing grain yield and further improve the quality of rice?First is to pay more attention to the development and utilization of wild rice. Narrow genetic background of parent materials is the main cause for the undesirable crop yield, quality, and resistance, while wild rice provides rich genetic resources with good traits such as strong pest resistance and stress tolerance. Second is to understand the vital role of wide compatibility resources in rice heterosis. Wide compatibility rice materials have been continuously discovered and applied to hybrid rice breeding. Wide compatible genes can overcome the hybrid obstacles in subspecies and play an important role in the utilization of indica–japonica heterosis.Likewise, it is urgent to find out intermediate resources with different degrees of compatibility between the cultivated and wild rice, which will overcome the incompatibility between cultivated and wild rice. In this way, high-quality resources of wild rice can be continuously integrated into cultivated rice.Furthermore, it is recommended combining transgenic technology and MAS for MDB. The so-called MDB in crop is a novel breeding method with bioinformatics as the platform and genomic and proteomic databases as the basis, which integrates valuable information on crop genetics, physiology and biochemistry, and biological statistics in the crop breeding process. According to the breeding objectives and growth environment of specific crop, MDB designs the optimal scheme and then carries out trials of crop breeding.MDB mainly involves three steps (Xu and Zhu The development of rice breeding from conventional genetics to molecular design of new varieties is a general trend, which ensures the breeding of new varieties with improved agronomic traits in terms of the yield, grain quality, select efficiency, disease and pest resistance, and stress tolerance, further contributing to the protection of national food and environmental security.


The incidence of extreme precipitation has increased with the exacerbation of worldwide climate disruption. We hypothesize an association between precipitation and the distribution patterns that would affect the endemic burden of 8 infectious diseases in Taiwan, including water- and vector-borne infectious diseases. A database integrating daily precipitation and temperature, along with the infectious disease case registry for all 352 townships in the main island of Taiwan was analysed for the period from 1994 to 2008. Four precipitation levels, <130 mm, 130–200 mm, 200–350 mm and >350 mm, were categorized to represent quantitative differences, and their associations with each specific disease was investigated using the Generalized Additive Mixed Model and afterwards mapped on to the Geographical Information System. Daily precipitation levels were significantly correlated with all 8 mandatory-notified infectious diseases in Taiwan. For water-borne infections, extreme torrential precipitation (>350 mm/day) was found to result in the highest relative risk for bacillary dysentery and enterovirus infections when compared to ordinary rain (<130 mm/day). Yet, for vector-borne diseases, the relative risk of dengue fever and Japanese encephalitis increased with greater precipitation only up to 350 mm. Differential lag effects following precipitation were statistically associated with increased risk for contracting individual infectious diseases. This study’s findings can help health resource sector management better allocate medical resources and be better prepared to deal with infectious disease outbreaks following future extreme precipitation events. Global climate disruption appears to have increased the intensity of tropical cyclones, including typhoons in Southeast Asia, hurricanes in Central America and the Southeast United States, consequently resulting in much greater probability of extreme precipitation Extreme precipitation events, increasing the amount of regional precipitation and flooding, have heightened the risk and concern over the transmission of various infectious diseases which may affect their distribution and chances of becoming epidemics th percentile, and 68% to levels above the 80th percentile rd percentile increases the risk of water-borne disease outbreaks by a factor of 2.283 Giardia lamblia, CryptosporidiumLyme borreliosis, and hantavirus infection, especially when there was the concurrent presence of high temperatures Significant associations between increased precipitation and greater incidences of contracting water-borne infectious diseases were found in various geographic regions As global climate change is predicted to increase the trend of extreme precipitation events occurring is more likely, so determining the role of weather in the incidence of infectious disease is a public health priority The Pearson product-moment correlation identified that extreme precipitation events were associated with the occurrence of 8 infectious diseases with lags of 0–70 days. trend<0.001), and even stronger linear relationships between precipitation and bacillary dysentery, dengue fever, and leptospirosis (Ptrend<0.0001).Adjusted relative risks for the extreme precipitation categories, as they relate to the baseline control precipitation category (<130 mm), are presented in A relative risk measure for each disease was created individually for each township. This allowed for determination of the specific townships at risk for particular precipitation-disease outbreaks. t-test = 0.0042) along with the average elevation of a township  in those townships that had a significant relationship between extreme precipitation and the occurrence of Bacillary dysentery as compared to townships that did not have this particular significant relationship. In addition, the relative number of elderly living alone was higher  in those townships at risk for Scrub Typhus following extreme precipitation events. Furthermore, townships with higher population densities were the ones associated with extreme precipitation related enterovirus infections  and dengue fever .From the 12 socioeconomic, demographic and geographical characteristics examined, the proportion of natives were significantly higher  that are impacted by extreme precipitation-mediated outbreaks of each infectious disease.For intestinal infectious diseases, the positive relationships between precipitation and enterovirus infection and bacillary dysentery were similar to previous reports For vector-borne diseases, higher precipitation has been associated with dengue fever, scrub typhus, and Japanese encephalitis Aedes Aegypti (the main vector of dengue fever in Taiwan) is about 9 days, its lifespan is about 30 days, and the incubation period is 3 to 14 days).Although precipitation events usually last on the order of days, in preceding studies, the analytic lags of precipitation effects were mostly performed on the weekly or monthly scale In Australia, the United States, Germany, India, Malaysia, and Thailand, it has been reported that high-intensity precipitation is associated with reports of leptospirosis or melioidosis The results provide quantitative risk values  and idenFrom 1961 to 2005 the incidence of intense precipitation (defined as the top 10% precipitation events) had doubled In general, for regions vulnerable to extreme precipitation related disease outbreaks regional risk assessments should be performed, as has been done for Taiwan in this study, in order to determine what local areas are at greatest risk, and identify those specific associated characteristics that contribute to the outbreak. This analysis provides decision makers with essential information to guide their proper implementation of technology- and knowledge-based strategies to best manage precipitation related infectious disease outbreaks. Technology-based approaches include creating better, more efficient monitoring and prediction systems, improving emergency medical aid, promoting environmental conservation, and improving emergency alert systems The infrequent occurrence of the most extreme torrential precipitation in Taiwan limited the statistical power of the analysis in this study; it is possible that more significant associations between extreme precipitation and the occurrence of the diseases we studied exist. This study did not specifically identify the particular vulnerable clusters, for each infectious disease, present within the entire general population. The population characteristics addressed by the t-test comparisons suggest what particular characteristics define each specific cluster. In our future studies, using a cohort follow-up design, the particular vulnerable clusters for infectious disease in a region will be identified for one of the specific infectious diseases examined in this study. This information would be helpful to medical agencies that want better targeted interventions Previous studies have demonstrated that extreme precipitation has an impact on the occurrence of infectious diseases. The model presented here successfully demonstrated relationships between extreme levels of precipitation and the incidences of water-borne and vector-borne infectious diseases. This is the first study to use nationwide records to conduct spatial statistical analysis focusing on high-spatial-resolution. Our study exhibits the first systematic and quantitative risk assessment of the relationship between daily extreme precipitation and 8 infectious diseases at national and regional levels. There were significant correlations between specific infectious diseases and the occurrences of extreme precipitation events in Taiwan. Results also highlight the local characteristics that may exacerbate infectious disease outbreaks following extreme precipitation conditions. This study’s findings provide critical information that aid in the creation of effective health policies, and the establishment of relevant technology- and knowledge-based strategies so Taiwan is better prepared for the climatic emergencies of the future.Hourly data from 33 fixed–site monitoring stations, and approximately 300 auto-monitoring stations from the CWB , that had complete precipitation and temperature records from 1994 to 2008, were obtained. Since the weather monitoring stations in Taiwan are mostly clustered in urban areas along the east coastline, we could not obtain direct measures of precipitation distribution throughout the entire island, especially from rural and mountain areas. In order to generate representative daily precipitation and temperature measures for each of the 352 total townships in Taiwan, we used the Ordinary Kriging geo-statistical method as part of the ArcGIS 9.3 system. This method is useful to generate optimal spatial-linear temperature and precipitation data, by interpolating the temperature and precipitation at an unobserved location using the actual values from nearby locations. We extrapolated precipitation and temperature data in a stepwise procedure at a resolution of 1×1 square kilometres since this was the smallest geographical unit for disease notification th percentile of precipitation for all 352 townships in Taiwan over the 15 year period was 92.80 mm/day . The heavy rain events in Taiwan were 17.4 days, torrential rain events were 11.7 days and extreme torrential rain events were 1.8 days of each township happened in the 15 years.As defined by the Taiwan CWB, precipitation events were categorized as follows: regular: daily accumulated precipitation below 130 mm; heavy rain: at 130–200 mm; torrential rain: at 201–350 mm; and extreme torrential rain: above 351 mm The computerized database, with recorded daily registry of the occurrence of the 8 mandatory-notified infectious diseases, along with age, gender, township of residence, and the time of disease onset for each case, was retrieved from the Taiwan CDC (Center Disease Control) for the period from 1994–2008, with a signed agreement for confidentiality; all diagnoses were confirmed by the reference laboratory at the Research and Diagnostic Center of the Taiwan CDC. Only the “indigenous” cases for each disease, after verification of travel history, disease onset, and virus subtype classification by the National Virus Diagnosis Laboratory in Taiwan, were analysed Twelve selected socioeconomic and demographic characteristics for each township, including medical resources (the number of clinics and doctors) and demographic characteristics , type of employment , and socioeconomic conditions  were estimated using the health statistics obtained from the Department of Health, as determined from the national census taken in 2000 (performed once per decade) The database included the aggregated daily case registry of 8 infectious diseases and weather monitoring data of precipitation and temperature from 1994 to 2008 for each township. Pearson product-moment correlation analyses assessed the specific lag effects  between the number of case occurrences and the direct measures of precipitation amount and temperature levels. Only weekly lag intervals were considered, since these are easier to interpret and act upon from a disease management standpoint. Determination of the length of lag time designated for analysis took into account the incubation period of the pathogen by only considering lag times in excess of the minimum incubation period such as the time needed for vector-associated infection to occur and biologically mature. The number of daily registered cases was a dependent variable (count data), and the daily accumulated precipitation level was the major independent variable. Poisson regression, using a generalized additive model (GAM), has been the suggested method of analysis in time-series studies Poisson regression, using a Generalized Additive Mixed Model (GAMM), was used to evaluate the multiple-lag effects of stratified precipitation levels on specific diseases The functions are as follows:Overall statistical functionFunction 1: analysis averaged over all of Taiwani  = 1, 2,…, 8 infectious diseases and j  = 1, 2,…, 352 townships of Taiwan. Function 2: analysis performed on each township