Geographical Reconnaissance (GR) operations using Personal Digital Assistants (PDAs) and Global Positioning Systems (GPS) have been conducted in the elimination provinces of Temotu, Solomon Islands and Tafea, Republic of Vanuatu. These operations aimed to examine modern approaches to GR to define the spatial distribution of target populations to support contemporary malaria elimination interventions.Three GR surveys were carried out covering the outer islands of Temotu Province ; Santa Cruz Island, Temotu Province (February 2009) and Tanna Island, Tafea Province (July - September 2009). Integrated PDA/GPS handheld units were used in the field to rapidly map and enumerate households, and collect associated population and household structure data to support priority elimination interventions, including bed net distribution, indoor residual spraying (IRS) and malaria case surveillance. Data were uploaded and analysed in customized Geographic Information System (GIS) databases to produce household distribution maps and generate relevant summary information pertaining to the GR operations. Following completion of field operations, group discussions were also conducted to review GR approaches and technology implemented.2. An average of 45 households, 118 structures and a population of 184 people were recorded per handheld device per day. Geo-spatial household distribution maps were also produced immediately following the completion of GR fieldwork. An overall high acceptability of modern GR techniques and technology was observed by both field operations staff and communities.10,459 households were geo-referenced and mapped. A population of 43,497 and 30,663 household structures were recorded during the three GR surveys. The spatial distribution of the population was concentrated in coastal village clusters. Survey operations were completed over a combined total of 77 field days covering a total land mass area of approximately 1103.2 kmGR implemented using modern techniques has provided an effective and efficient operational tool for rapidly defining the spatial distribution of target populations in designated malaria elimination zones in Solomon Islands and Vanuatu. The data generated are being used for the strategic implementation and scaling-up of priority interventions, and will be essential for establishing future surveillance using spatial decision support systems. Following recent international attention, renewed political commitment and dedication of resources, the concept of malaria elimination and a refocusing of intensive malaria control is now back on the world agenda . Recent To achieve the desired outcomes of the GMAP, it is essential that all of these strategies proceed concurrently . As malaGeographical Reconnaissance (GR) involves census, mapping and sampling procedures to determine the quantity, location and accessibility of settlements within target areas. It provides the basis for the selection of field centres and depots, for designing schedules and itineraries of operations, planning deployment of transport, and assessing completion of planned activities . GR has Traditional GR operations required specialist skills, training and equipment in survey, navigation and cartography ,6. As suTo support the global elimination strategy of shrinking the malaria map from the endemic margins inward , progresTo date, little research has addressed the approach, relevance and feasibility of GR within current-day malaria elimination frameworks. The aims of this study were to examine a modern approach to GR using digital geospatial survey technology and explore its application in contemporary malaria elimination programmes. To support this study, GR operations were conducted in the elimination provinces of the Solomon Islands and Vanuatu. Additional aims of these operations were to define and quantify the target populations and household structures; to provide a framework for the planning, implementation and monitoring of nominated elimination interventions; and to establish a foundation from which future malaria elimination surveillance activities can be carried out in these remote communities.Baseline GR operations were conducted in the malaria elimination provinces of Solomon Islands and Vanuatu Figure . Two sepSelection of hardware and software was based upon the existing government systems and operational capacity within Solomon Islands and Vanuatu; practicality and durability of equipment in the field; and maximizing integration across all levels of data collection, management and analysis. Hardware included Trimble Juno ST  handheld PDA units with integrated GPS and Durabook  notebook computers for data management and daily backup. ArcPad 7.0  software was used for data collection and field mapping operations, with post-fieldwork data storage, backup and analysis using both Microsoft Access  and MapInfo Professional 8.0 . Otterbox casings were also used in the field to provide a protective cover for the handheld PDA/GPS units. Handheld PDA/GPS devices, accompanying software and protective casing were purchased prior to the GR operations, each collectively costing approximately $1500 per unit. All other hardware and software was sourced from existing Ministry of Health resources.Collaborative agreements were developed between the NVBDCP and relevant Government GIS data custodians (i.e. the Ministry of Lands in both countries) to gain access and share data between the Ministries. These data were then adapted to produce standardized baseline topographic maps. To aid general reconnaissance throughout the household surveys, these maps were uploaded onto the handheld PDA units as underlying GIS-based ArcPad maps. These were used to provide a base from which households could be rapidly mapped, surveyed and viewed in the field in relation to surrounding features such as watercourses, coastlines, and local infrastructure.Digital data collection forms Figure  were devi) Household identification and enumeration▪ A unique identification number for every household▪ Village name and name of the head of the household.ii) The number, gender and ages of individuals residing in each householdiii) The number and types of structures  per householdiv) The number of mosquito nets currently in the household, and the number and sizes of new LLINs distributed (if relevant).v) The geographical coordinates of the household (Projection: Longitude/Latitude WGS 84)Automated numbers, checkboxes and drop-down menus were used in the design of the digital data collection form, to simplify and standardize data entry procedures. Separate forms were developed for Solomon Islands and Vanuatu due different traditional household structure types being dominant in these island groups.A customized GIS application was developed using MapBasic  Figure  to enablMeetings were conducted with relevant NVBDCP and community stakeholders prior to the implementation of GR to identify target areas, develop operational timelines and assist in resource allocation. Priority was placed on minimising human resources, by keeping field teams small and utilising community volunteers whenever possible. Six VBDCP field officers participated in the survey in the outer islands of Temotu Province, Solomon Islands, eight in the Santa Cruz, Temotu Province survey, and five in the Tanna Island, Tafea Province, Vanuatu survey. VBDCP officers participating in operations had no initial mapping or GR experience and were sourced from both national and provincial levels depending on the availability of personnel. In each field operation, survey teams were divided into individual survey mapping units, consisting of 2-3 individuals per unit (including community volunteers). Each mapping unit operated one handheld PDA and divided digital data entry, household mapping and household enumeration activities between the team. Field supervisors were also selected from the survey teams to be responsible for daily data backup, quality assurance and GPS data monitoring, and electrical charging of PDAs. Teams were supplied with handheld PDA/GPS units (including spare batteries), a field laptop computer, small printer, stationary and a portable generator. Prior to the commencement of each survey, workshops were conducted in Temotu and Tanna to train participating VBDCP personnel in the use of handheld PDA/GPS units. Additional training was also provided for field supervisors on daily data backup and quality assurance, data security, PDA troubleshooting, and mobile mapping and summary analysis techniques.A standardized approach was applied across all three surveys. Following deployment to designated operation areas, field teams met with local community leaders to inform the community about the rationale of the survey. Local volunteers were also recruited from each village to act as guides and assist each unit in the household surveys. These volunteers served to increase community engagement, assist in language translation (when required), and provide local knowledge.Because blanket LLIN distribution and focal IRS within each of these nominated target areas is to be implemented and monitored at the household level, the household was used as the primary unit for GR. Households in Melanesian countries are often associated with multiple separate structures including traditional sleeping houses, outdoor kitchens, resting shelters and storage sheds. To standardize GR operations, GPS coordinates were taken adjacent to the main sleeping house of each household. All other associated household structures were then identified, counted and recorded.Cards were distributed as part of the household enumeration component to provide a hard-copy record of the household identity for future interventions. Survey teams  also painted the unique household number on the top right-hand side of the household door or the nearest possible alternative. No issues with compliance associated with this activity were observed. Other structures  were also mapped and enumerated as part of the survey and recorded as unoccupied structures.Following the completion of daily household survey and mapping operations, PDA data were backed-up automatically onto the field laptop computers using the customised GIS application. Following daily data backup procedures, household distribution maps and survey summaries were also automatically updated using the customized GIS application to provide an overview of household distribution within the survey area and detailing daily progress. Household data quality assurance checks were also conducted by the field supervisor as part of the daily backup process to identify and remedy obvious digital data entry or GPS errors.All household data were stored in central GIS-enabled databases located at the relevant national and provincial vector borne disease control programme offices of the elimination target areas. Data were automatically updated using the customized GIS application to link village, health operations zone, island, ward, and province names to each household unit. Using simple GIS techniques, descriptive maps of household distribution and summary statistics were then generated for elimination areas when required. Maps and household listings were printed in the field and given to local health facilities when relevant, providing a detailed overview of the spatial distribution of their health catchment populations.Plasmodium vivax and 1.0% for Plasmodium falciparum [GR data were overlayed onto existing malaria risk maps produced for Tanna, Tafea Province , to estilciparum . LocatioPost-fieldwork interviews and debrief sessions where conducted with all participating VBDCP field officers and provincial managers following the completion of each GR operation. Informal sessions were held to ask participants about their individual perceptions of the GR procedures applied and associated PDA/GPS handheld equipment used in the field, and the relevance of this fieldwork for future elimination interventions. Participants were also asked to give insight on how to improve field operations using modern survey equipment. Group discussions were also held to provide feedback into the future improvements and potential applications of these techniques relevant to the malaria programme.A total of 10,459 households were geo-referenced and mapped across the two countries. Data were recorded on a total of 30,663 household structures and a population of 43,497. Table The population of Temotu Province, Solomon Islands was concentrated in coastal village clusters. With the exception of West Santa Cruz, road infrastructure in Temotu was non-existent and access to most settlements was limited to the sea and/or walking trails. The highest populations in the outer islands were recorded on the low-lying Reef Islands and concentrated in coastal village clusters on the main islands of Ngawa, Ngalo and Fenualoa. Populations in Utupua, Vanikolo and Duff Islands were limited to patchy coastal villages, with no settlements in the inland mountainous regions.Population distribution on the most populous Temotu Province island group of Santa Cruz followed a similar pattern to the outer islands, with settlement clusters concentrated on the coastal fringes. However, settlements and household structures were also located within the low-lying inland regions of West Santa Cruz, where road infrastructure currently exists. Figure The population of the Tanna GR survey area in Tafea Province, Vanuatu, had greater spatial dispersion but was concentrated in coastal regions and highland plateaus Figure . A more Unoccupied structures, generally associated with agriculture , were recorded throughout the study areas. Whilst not permanently inhabited, these structures are still considered significant, particularly in target areas identified for IRS, because people are known to sleep in them on an intermittent basis.Figure 2 and a total area of approximately 30,904.5 km2 (including oceans). A total of 77 field days were required to complete operations for all three surveys, with an average of 45 households, 118 household structures and a population of 184 people recorded per PDA per day. Table Santa Cruz, Temotu Province, where one PDA malfunctioned in a remote region and could not be repaired for three days, resulting in a moderate reduction of productivity in this area over this period. Some minor technical difficulties were reported during GR operation 3 - Tanna IRS Zone, Tafea Province. However, these were dealt with by the field-teams independently within one day following standardised trouble-shooting methods covered during initial training operations. No significant problems were recorded with GPS accuracy or digital data entry. No problems or data losses were also reported during the daily automatic backup procedures, with all team supervisors reporting favourably on all aspects of the daily automatic back-up, map verification and digital data entry checking procedures.The three GR operations covered a land mass area of approximately 1103.2 kmAn overwhelmingly positive response to the modern GR approach and technology was expressed by both VBDCP field officers and provincial managers during post-operation interviews and group discussion. In particular, the time-saving benefits of no post-field work data entry requirements, the ability to map and visualise the spatial distribution of household data automatically, and the rapid generation of summary data was noted by provincial managers and information officers. Interest for applying GR techniques and mapping technology for other components of malaria field work such as entomological surveys, and for the expansion of these procedures into other malaria control provinces was also expressed. Additionally, the application of these techniques and technology to support other facets of provincial and regional health services was noted.A high degree of community acceptability of modern mapping techniques was also observed in the field, with many community members taking a keen interest in the handheld units and associated GPS components during demonstrations in the field.P. falciparum malaria prevalence, representing approximately 9.4% of the surveyed population. A total of 412 populated households, and 1,727 spray-able structures were estimated to be located in these focal areas. Similarly, it was estimated a total population of 3,782 reside in focal areas of above average P. vivax risk, representing 17.2% of the surveyed population. 713 populated households and 2,953 spray-able structures were also located in these areas. A total population of 13,818 and 12,453 spray-able structures were recorded in the designated coastal IRS intervention zone on Tanna, geo-referenced to a total of 3,365 individual household units.Based on the Tanna Island risk maps, it was estimated that a population of 2,070 are residing in areas of above-average To guide elimination interventions in these regions the NVBDCP of both countries highlighted a need for the collection of reliable, accurate and programme-specific data at a household level; particularly as relevant geo-spatial census data was unavailable at the level of precision required for the designated target elimination areas. Modern GR approaches and technologies were used to develop rapid and accurate field-based procedures for the collection, spatial definition and mapping of malaria elimination target populations. As these survey areas are located in remote Pacific islands, an emphasis was placed upon minimising the external resources (including human) required to undertake such operations and empowering local vector control programmes by introducing effective, user-friendly tools to support and efficiently guide the increased operational demands associated with malaria elimination.In the context of the target elimination areas, the coastal concentration and isolation of populations without roads and reliable infrastructure, transportation and access are likely to be limiting factors to the success of elimination. Sound planning will be essential to ensure interventions are efficiently and effectively carried out across all target areas. Data compiled and collected during GR activities will enable programme managers to visualize the spatial distribution of populations to assist in the delineation of operational zones, the development of intervention timelines, and identifying transportation routes and access strategies. Relevant data pertaining to these priority interventions such as populations requiring LLINs and the total number of spray-able structures within focal IRS zones will assist in the accurate allocation of resources to designated operational zones. Household checklists and maps will also provide field officers with a detailed mechanism for conducting and monitoring priority interventions in target areas to ensure maximum coverage is achieved. Reporting will also be enhanced as the progress and coverage of interventions can be mapped and visualized at the household level.Population and household structure results from GR operations carried out in the respective elimination zones illustrate the significant amount of detailed data that can be collected over large geographical areas by small teams and within short timeframes, highlighting the efficiency of modern approaches to GR. Whilst there is an increased need for pre-operation training when using the handheld units for data collection , the timObservations from the respective GR operations indicate a high willingness and capacity of VBDCP field staff to adopt and successfully utilize modern mobile mapping technology following initial basic training and technical guidance. The adoption of a simple customized GIS-based application to automate data back-up and mapping updates on a daily basis has also provided a rapid and effective mechanism for VBDCP staff to monitor progress and edit data easily in the field. As household mapping and PDA data entry operations were lead by VBDCP staff well known within their respective target communities, it is also likely this had an influence on the high level of community acceptability and compliance observed in the field, emphasising the importance of building local programme capacity to independently drive contemporary intervention strategies and approaches. Ethical approval was not sought for GR operations as they were considered routine operational activities of the national malaria programmes in both countries, with all collected data managed as per confidentiality requirements of the respective Ministries of Health.Whilst some data entry errors are expected as a result of the digital data entry at the point of collection approach, previous research suggests such errors are minimal when compared to traditional paper-based surveys ,24,25. TAdditional benefits such as the increased accuracy and resolution of GR data collected, and the immediate availability of summary information and maps relevant for priority elimination interventions also make integrated PDA/GPS handheld technologies favourable; overcoming constraining issues associated with traditional paper-based methodologies including low accuracy, and slow transaction times to verify data and prepare operational maps following fieldwork. The high portability of handheld PDA technology also provided considerable benefits in remote and difficult terrain where access and transportation posed significant logistical challenges.In addition to the traditional applications of defining target populations and providing operational support, GR also provides an effective mechanism for further strengthening current-day priority monitoring and evaluation interventions such as detailed surveillance and case investigation. Malaria elimination requires robust and efficient surveillance mechanisms with full geographical coverage of target areas . Active When coupled with additional tools such as malaria risk maps, entomology and mobility data, and local and historical knowledge of malaria transmission, strategic active surveillance can also be targeted and prioritized in key focal locations following GR operations. It is anticipated that the compilation of such data will provide the foundation for the establishment and expansion of spatial decision support systems (SDSS) in these elimination provinces. A SDSS developed from the ground up, offers the potential to provide a user-friendly tool to equip locally-based programmes in meeting the demands associated with the scaling-up of interventions and surveillance operations in malaria elimination as well as intensified malaria control regions.This study demonstrated a contemporary approach to GR to spatially define and enumerate target populations using modern geospatial survey technology. The focus was building inter-departmental capacity to independently carry-out GR operations to support priority interventions in the malaria elimination provinces in Solomon Islands and Vanuatu. This approach has provided an effective mechanism for rapidly and accurately defining target populations where these interventions have been scheduled to take place. Data collected and modern techniques adopted during GR have empowered local VBDCP programmes with effective decision making and operational tools to coordinate and monitor scaled-up elimination interventions with the goal of ensuring universal coverage, and providing a foundation for future surveillance activities. Following the high acceptability and success of these initial GR operations, both the Solomon Islands and the Republic of Vanuatu Vector Borne Disease Control Programmes are now dedicated to the expansion and further refinement of GR using modern mapping techniques and integrated PDA/GPS handheld technologies, illustrating the high acceptability of these approaches and providing a basis for the future expansion of a comprehensive and integrated SDSS to guide progressive malaria elimination in the pacific.The authors declare that they have no competing interests.Authors that participated in the conception of the study design were GK and JH. Field training was conducted by GK. Field research operations were coordinated by EH, GK, JN, WB, & WD. SP provided technical guidance and support. ACAC provided guidance on the scientific aspects of the study and provided detailed commentary on manuscript drafts. Additional scientific and technical guidance was provided by AV, JH & MT. Manuscript drafting was carried out by GK with support from all authors. All authors read and approved the final manuscript.Demographic description of the population of Solomon Islands and Vanuatu Geographical Reconnaissance operation areas, 2009. Data provides a detailed demographic description by age and gender of the population recorded within each geographical reconnaissance operation areaClick here for fileHousehold structures summary table of Solomon Islands and Vanuatu Geographical Reconnaissance operation areas, 2009. Data provides a detailed breakdown of the number of structures recorded by type within each individual geographical reconnaissance operation area.Click here for file


Pejman Rohani discusses a new study that examined the dynamic relationship between climate variables and dengue incidence in Thailand, Mexico, and Puerto Rico. PLoS Medicine:This Perspective discusses the following new study published in doi:10.1371/journal.pmed.1000168Johansson MA, Cummings DAT, Glass GE (2009) Multi-Year Variability and Dengue: El Niño Southern Oscillation, Weather, and Dengue Incidence in Puerto Rico, Mexico, and Thailand. PLoS Med 6(11): e1000168. “Prediction is very difficult, especially about the future.”Niels BohrThe current H1N1 influenza pandemic has highlighted the practical usefulness of knowing ahead of time about an impending large outbreak. Specifically, as the flu season in the northern hemisphere gets into full swing, public health decision makers have been using information gleaned from epidemics in Mexico and the US earlier this spring to prepare proactive mitigation and control strategies.Plasmodium falciparumThe World Health Organization (WHO) has recently focused considerable attention on the development of early warning systems The most obvious—and well-studied—impact of climatic variables is on disease vectors. It is well established that the abundance and distribution of insect vectors is well explained by patterns of temperature, humidity, and rainfall. But these factors also affect vectors at a much smaller scale, by modulating metabolic activity, egg production, and, critically, feeding behavior In addition to the existence of plausible climatological determinants of epidemic risk, the implementation and reliability of early warning systems requires empirical proof of concept. This requirement has led a number of scientists to examine the association between annual and multi-annual climate variation and the incidence and dynamics of infectious diseases PLoS MedicineIn a new study by Johansson and colleagues published in this issue of Dengue fever, also known as breakbone fever, is caused by four closely related viral serotypes, members of the Flaviviridae. In recent decades, there has been an alarming increase in the geographical range and severity of dengue epidemics. The infection is now considered endemic in more than 100 countries. The WHO estimates that almost half the world's population is currently at risk, with perhaps as many as 50 million annual cases of dengue infection globally Aedes aegytpi but also Ae. albopictus. Environmental parameters, especially temperature and precipitation, affect the demography and behavior of these vectors, making dengue an obvious candidate for researching the impact of climate on disease. Johansson and colleagues show that dengue incidence is very strongly seasonal, in all three countries they studied. This seasonality is the footprint of local weather variables, which also vary seasonally, and their impact on the demography of the mosquito vectors and transmission dynamics Dengue transmission occurs via an insect vector, predominantly Johansson and colleagues use wavelet coherence analysis The absence of a predictable consequence of ENSO for dengue transmission is an important piece of information for the development of early warning systems. However, the authors are very careful in interpreting their findings and suggest that given the known mechanistic environmental drivers of vector biology, it remains formally possible that ENSO might play a role in dengue transmission. In this light, their findings may be explained along two distinct lines. They may reflect inadequacies in the time-series data , or that intrinsic processes such as human birth rates or serotype interactions via immunological mechanisms simply swamp any signatures of the impact of ENSO. For these reasons, this careful work by Johansson et al. is both scientifically interesting and very timely.


Six state groupings were identified: North Central and New England with the highest consumption and heavy drinking levels; Middle Atlantic, Pacific and South Coast with moderate drinking levels; and Dry South with the lowest drinking levels. Analyses of relationships between beer and spirits series for states within groups as compared to those in different groups failed to clearly indicate group cohesiveness.US state alcohol consumption patterns and trends are examined in order to identify groups of states with similar drinking habits or cultures. Rates of heavy drinking and current abstention and  Factors that may underlie or influence drinking culture include a state’s demographic make-up in terms of age, gender and race/ethnicity groups, the distribution of socio-economic characteristics such as educational attainment, income and wealth, a state’s mix of religions with differing perspectives on alcohol use, degree of urbanicity, state alcohol policies and regulatory regimes, the structure of the alcoholic beverage market in terms of wholesale and retail distribution networks, historical and cultural practices related to drinking (or not drinking) various alcoholic beverages, the size and importance of alcoholic beverage production industries both historically and currently, exposure to advertising for alcohol products and potentially other factors. Yet, clearly some of these aspects of drinking culture are shared across states, particularly those in geographic proximity to one another, and other aspects may be shared across states with similar populations throughout the country. Therefore, one would expect that drinking cultures and markets would not be defined by state borders in most cases. Media markets too may help create cultural sub-groups that cover multiple states or even market-related areas potentially spread across many parts of the country. Relative proportions of the various demographic and market-demarcated sub-groups, along with geographic proximity, should define the degree of shared drinking cultures between states. Thus, states may share similarities in terms of certain beverage types or drinking patterns but may be divergent on other beverages or trends. It is also relevant regarding drinking culture, to consider commonalities reflected in trends over time.per capita consumption and percentage of heavy drinkers and a relatively low abstention rate. Alternative definitions of “wetness” in terms of alcohol policy and alcohol availability could also be applied and future studies should address how these are related to the drinking outcome-based definition of wetness. Early work utilizing data from the first National Alcohol Survey (NAS) conducted in 1964 using nine Census-defined regions found the Northeast, North Central and Pacific regions to be Wet and the South, Mountain and West North Central states to be Dry [per capita consumption.Past research has generally focused on characterizing Wet and Dry regions of the US. In these studies and the current analysis “wetness” is determined by consumption patterns with Wet areas having a relatively high o be Dry . In thesper capita apparent consumption [Survey measures of consumption volume have been found to be highly correlated with sumption  and survsumption . Some hasumption . This masumption . Religiosumption .Survey-based models of the determinants and consequences of alcohol use typically utilize regional control variables to capture unmeasured aspects of drinking culture . Most USper capita apparent alcohol consumption. This paper aims to categorize the US states into regional groups based on the wetness of recent drinking patterns and to evaluate whether these groupings represent linked drinking cultures over time through pair-wise analyses of trends in per capita apparent consumption of beer and spirits within and outside of these regional groupings.No studies have specifically tried to group states empirically based on drinking pattern and alcohol sales data. Much more state-specific data is now available to fine tune these characterizations and to begin to empirically define state groupings in terms of shared drinking culture. Measures characterizing drinking culture in this study focus on the percentage of the population drinking five or more (5+) drinks in a day in the past month, drinking at all in the past month and 2.2.1.Survey estimates for each state are taken from synthetic state-level estimates for the 2005–2006 combined samples from the National Survey on Drug Use and Health (NSDUH) of past month 5+ drinks in a day and past month drinking among those aged 12 and older and other age sub-groups. These published estimates were used because to prevent identification, the public use files for this survey do not include geographic identifiers . The NSDPer capita (aged 15 and older) apparent alcohol consumption data for 1950 to 2002 and for 2005 are estimates from the Alcohol Research Group (ARG) state alcohol per capita ethanol database. Tax and sales based estimates of per capita apparent consumption of beer, wine, spirits and total ethanol for 1950 to 2005 are calculated using %ABV conversions developed by ARG and population estimates are from the US Census Bureau [s Bureau –13.2.2.per capita apparent consumption of alcohol. Also considered were the past month 5+/4+ binge measure taken form the 2007 BRFSS survey and the past year abstention rate in the 2005–2006 NSDUH surveys. The NSDUH estimates are seen as more reliable than the BRFSS estimates due to higher response rates and especially higher reported volumes of drinking, implying better coverage of alcohol sales [Per capita apparent consumption figures are generally seen as the most reliable estimates of overall drinking, not being subject to non-response and self-report biases. However, an exception to this rule is states with large cross-border and/or tourist sales relative to their populations, particularly, Nevada, Alaska, Hawaii, District of Columbia, New Hampshire and Delaware. Correlations between reporting 5+ drinks in a day in the last month and monthly drinkers in the 2005–6 NSDUH, 2005 per capita apparent consumption and 5+/4+ drinks in a day monthly based on the 2007 BRFSS were also calculated to determine the degree to which these measures indicated similar rankings of states. The percentage of past month drinkers reporting having 5+ drinks in any day in the past month in the 2005–6 NSDUH was also calculated to illustrate the prevalence of heavy drinking among drinkers. Based primarily on inspecting the proportion of heavy drinkers and per capita apparent consumption of alcohol, but also considering the other measures, states were generally characterized as Wet, Moderate or Dry. States within these categories were then grouped according to geographic proximity with some exceptions made in order keep the number of groups relatively small and to include nearly all states in some group. For example, Utah was grouped with the other Dry states that form a geographically contiguous group in the South and the Moderate states in the South were grouped together although they do not all share borders.State groupings were created based on geographic proximity and primarily on the estimate, from the NSDUH 2005–2006 combined sample, of the percentage of those 12 and older drinking 5+ drinks in a day on any day in the past month, as well as from the 2005 ol sales . Per capper capita apparent consumption by beverage type were examined to give an indication of whether alcohol consumption trends within the state groupings appear to move together and to have similar levels and general trends. To establish whether relationships between states within a resultant regional grouping where stronger and more common than those with states outside of the groupings, Granger Causality tests [per capita beer consumption in Ohio) to predict the current value of another series . These tests incorporated two lagged values and a 0.05 significance level was used for rejecting the null hypothesis of no relationship. The proportion of significant relationships (in either or both directions) between states within a group was then compared to the proportion with states outside of the group to determine the relative degree to which beverage series trends were more closely related within regional groups.Following the grouping, based on cross-sectional results, data on trends in ty tests  were estty tests  between 3.WetNorth Central- Alaska, Colorado, Illinois, Iowa, Kansas, Michigan, Minnesota, Montana, Missouri, Ohio, Nebraska, North Dakota, South Dakota, Wisconsin, WyomingNew England- Maine, Massachusetts, New Hampshire, Rhode Island, VermontModerateMiddle Atlantic- Connecticut, Delaware, Maryland, New Jersey, New York, PennsylvaniaPacific- California, Hawaii, Idaho, Nevada, Oregon, WashingtonSouth Coast- Arizona, Florida, Louisiana, New Mexico, South Carolina, TexasDryDry South- Alabama, Arkansas, Georgia, Indiana, Kentucky, Mississippi, North Carolina, Oklahoma, Tennessee, Utah, Virginia, West VirginiaSix state groups were identified by consideration of the variables mentioned in Methods, as shown in per capita apparent consumption estimates but residents’ drinking in surveys clearly fits with the New England group. Alaska also has a relatively high tourist/visitor impact and being geographically separated from the contiguous mainland states it is difficult to place its drinking culture in this environment. per capita apparent consumption for 2005 and the percentage of the population 18 and older reporting past month 5+/4+ days in the 2007 BRFSS survey. The states are listed in descending order by the past month 5+ percentages for those 12 and older in the 2005–6 NSDUH. Considering the regional groupings using the group name variable in terms of the ordering by 5+ percentages shows the groups to make sense in terms of this ordering. The US average is included for reference and all but one (Alaska) of the North Central states and all but one (Maine) of the New England states are seen to be above this average. These are the two groups of states represented as Wet. The Dry South states, seen as the Dry group, are all found below the US average. The three middle groups, Pacific, Middle Atlantic and South Coast are more distributed both above and below and are generally categorized as Moderate in terms of wetness.The District of Columbia was not grouped due to unique characteristics but if a complete grouping is necessary for analytic purposes it would be included in the Middle Atlantic group. The District of Columbia is situated between Maryland in the Middle Atlantic and Virginia in the Dry South but has much higher alcohol consumption than both and differs in many ways, reflecting its unique features. Other states were also difficult to clearly classify. Nevada has increased in the number residents relative to visitors recently and now fits better into the Pacific region while Utah’s drinking pattern fits the Dry South although its drinking culture may not be closely linked to the other member states due to geographic and cultural separation. New Hampshire is another special case where out-of-state buyers inflate per capita apparent consumption illustrates a general but far from complete agreement  survey measures of drinking patterns and e states . These ce states  and to c05–7 surve states . The natFuture studies at the individual-level should utilize and compare the efficacy of these two nested groupings to evaluate differences in drinking patterns, attitudes towards alcohol, and alcohol-related problems and outcomes in US surveys offering detailed measures of these constructs such as the National Alcohol Survey (NAS) and the National Epidemiologic Survey of Alcohol Related Conditions (NESARC). These groups should also be valuable for defining pooled models and matched control groups for cross-section time-series analyses of alcohol policy effectiveness and in estimating relationships between alcohol use measures and mortality or other outcomes in aggregate analyses at the US state level. Tests of the homogeneity of state time-series relationships between alcohol sales and specific mortality causes within and across these groups should also be undertaken to further evaluate group cohesiveness.per capita apparent consumption of alcohol, while a large group of mostly Southern states are found to stand out as relatively low on these measures. The groups incorporate a variety of differing alcohol availability policies and tax levels suggesting the importance of exploring cultural factors such as religion and religious involvement [This paper updates the analyses of US drinking regions last considered over 20 years ago by Alcohol Research Group scientists ,2. The aolvement ,22, raceolvement –25 and molvement . These folvement  and the olvement , as appe


This article, developed for the Betty Ford Institute Consensus Conference on Graduate Medical Education , presents a model curriculum for Family Medicine residency training in substance abuse.The authors reviewed reports of past Family Medicine curriculum development efforts, previously-identified barriers to education in high risk substance use, approaches to overcoming these barriers, and current training guidelines of the Accreditation Council for Graduate Medical Education (ACGME) and their Family Medicine Residency Review Committee. A proposed eight-module curriculum was developed, based on substance abuse competencies defined by Project MAINSTREAM and linked to core competencies defined by the ACGME. The curriculum provides basic training in high risk substance use to all residents, while also addressing current training challenges presented by U.S. work hour regulations, increasing international diversity of Family Medicine resident trainees, and emerging new primary care practice models.This paper offers a core curriculum, focused on screening, brief intervention and referral to treatment, which can be adapted by residency programs to meet their individual needs. The curriculum encourages direct observation of residents to ensure that core skills are learned and trains residents with several "new skills" that will expand the basket of substance abuse services they will be equipped to provide as they enter practice.Broad-based implementation of a comprehensive Family Medicine residency curriculum should increase the ability of family physicians to provide basic substance abuse services in a primary care context. Such efforts should be coupled with faculty development initiatives which ensure that sufficient trained faculty are available to teach these concepts and with efforts by major Family Medicine organizations to implement and enforce residency requirements for substance abuse training. Despite numerous faculty development initiatives related to primary care substance abuse training over the past three decades -10, rateTwo recent federally-funded initiatives have created new opportunity for Family Medicine to enhance substance abuse teaching in U.S. residency programs. The first was the Multi-Agency Initiative on Substance Abuse Training and Education for America (Project MAINSTREAM), which created a strategic plan for interdisciplinary faculty development in substance use disorders across 16 different disciplines including medicine, nursing and social work -20. ThisIn order to identify barriers to effective substance abuse training and successful approaches to overcoming these barriers, a literature search was conducted in PubMed/MEDLINE for articles discussing substance abuse education in Family Medicine using the MeSH terms 'Family Practice', 'Medical Education', and 'Substance-Related Disorders'. From among the 326 articles identified, authors selected and reviewed all articles related to substance abuse education or training. Criteria for inclusion were articles specifically related to substance abuse education, curriculum or training programs in primary care. Criteria for exclusion were articles from disciplines other than primary care, and education, curriculum or training programs not specific to substance abuse. Additional articles were identified from reference lists of collected articles, resulting in 88 articles relevant to the curriculum. Authors then reviewed current training guidelines of the Accreditation Council for Graduate Medical Education (ACGME) and their Family Medicine Residency Review Committee (RRC), identifying both those general core competencies which Family Medicine residents are expected to attain and existing RRC guidelines specific to substance abuse education. An internet search was conducted to find substance abuse curriculum materials available on the worldwide web. Core competencies for substance abuse training, as defined by Project MAINSTREAM , were taCurriculum was developed using traditional design methods, based on existing substance abuse objectives and structured to link with family medicine's core competencies. Steps in the design model included stating the learning needs based on an assessment of gaps in current curricula, determining the objectives, defining the content and organizational plan of the curriculum, describing the learning experiences to take place, and developing an evaluation plan and plans to solicit support for the curriculum ,25. The The medical literature reveals a long list of clinician barriers to management of substance abusing patients, including stigmatization of substance abusers ,27, lackSystems issues within training institutions also generate additional barriers to substance abuse training, including a lack of curriculum time ,19, inadIn the U.S., three new realities of the twenty-first century also present new challenges and opportunities. First, resident work hour rules have decreased attendance at traditional afternoon conferences at many residency programs by as much as one-third . In addiA recent international review of twenty years of substance abuse training efforts by el-Guebaly et al  defined One of the greatest challenges in substance abuse training is that of changing negative attitudes. While evidence-based conclusions in this area are limited, contact with recovering individuals appears to achieve positive results. A Project SAEFP (Substance Abuse Education for Family Physicians) module that included an Alcoholics Anonymous (AA) meeting involving recovering professionals was rated as the project's most powerful teaching components, resulting in increased referrals to both AA and formal treatment programs . El-GuebThe above literature review suggests application of the following principles, which have guided design of this curriculum: combine didactic and interactive learning strategies, offer regular reinforcement of substance abuse concepts, encourage systems changes that facilitate screening and intervention, provide contact with recovering individuals, and create a network of trained faculty who will teach, reinforce, and model SBIRT skills throughout residents' clinical careers.The model curriculum's goal is to equip residents to achieve all of the core substance abuse competencies listed in Table Figure Figure Substance abuse skills should be modeled and taught across the clinical continuum of care, including the outpatient clinic, emergency department, and inpatient practice. Learning activities at inpatient or residential treatment centers, which have been shown to increase residents' diagnosis and documentation of DSM substance use disorders , may be In order to demonstrate clinical competence in the management of patients with unhealthy substance use, we propose that each resident be required to demonstrate the core SBIRT competencies listed in Table Some previous faculty development efforts ,10 have Additional File This curriculum has been carefully designed to address some of the new challenges presented by current work hour regulations and the emerging model of Family Medicine. In order to address challenges of decreased conference attendance by residents due to work hour regulations, the curriculum's core content should be prepared in web-based modules which can be completed by residents unable to attend conferences, and completion of 80-100% of such modules should be included as a graduation requirement. The new model of Family Medicine encourages each practice to offer a "basket of services." This curriculum offers residents a number of "new skills" that many current primary care practices do not offer which add value and potential practice income for graduating residents who practice in fee-for-service settings. These include screening and brief intervention, which are now reimbursable by Medicare, many private insurers, and Medicaid in some states; office detoxification for alcohol dependence; and office medical management of alcohol dependence and opioid dependence using medications such as naltrexone, acamprosate, and buprenorphine. The electronic health record (EHR) can be used to streamline SBIRT procedures by programming periodic routine alcohol and drug screening for all patients; automatically linking to assessment instruments for patients with positive alcohol and drug screens; providing click-and-print intervention guides, patient education materials, and treatment resource lists; coding for optimized billing for services such as substance abuse screening, brief intervention, and buprenorphine induction; and facilitating improved care of patients with SUDs by appropriately adding SUD diagnoses to problem lists. Group visits can be utilized for patients on medication management for alcohol and opioid dependence, who also benefit from adding counseling interventions to their medical visits, and for patients with stress symptoms or medical problems due to other family members' substance use. Quality improvement initiatives can be developed to document and improve screening and intervention rates. Patient safety features such as drug interaction programs can be used to avoid potentially dangerous interactions such as acetaminophen use with alcohol use disorders and benzodiazepine use with buprenorphine. International medical graduates with limited previous substance abuse experience may require additional training, but may also demonstrate fewer negative attitudes toward patients and readily embrace an active role in their treatment. Faculty may utilize Module 1a to initiate discussions regarding the epidemiology of SUDs in residents' countries of origin, as well as typical attitudes toward patients with SUDs. Likewise Modules 1b and 1c should include training in cultural competency, so that residents understand how screening, assessment and treatment are carried out in a way that is culturally sensitive with all patients.The ACGME recommends using aggregate data to evaluate the efficacy of residency programs . This saIn order to achieve its intended impact in residency programs across the U.S., this curriculum must be combined with other interventions which address important systems barriers to effective substance abuse teaching. A faculty development initiative, modeled after the 1987-1988 STFM/NIAAA /NIDA  program , is needLeadership for national efforts to increase substance abuse teaching should include a working group with representatives from the key national Family Medicine organizations such as STFM, AFMRD, AAFP, and the Family Medicine Residency Review Committee (RRC) of the ACGME. In order to increase motivation among programs which currently offer little or no substance abuse teaching, RRC requirements for teaching substance abuse should be strengthened and monitored at the RRC's periodic site visits. The current RRC requirement for substance abuse training is a brief comment tucked in the middle of a paragraph describing various curricular areas in Human Behavior and Mental Health that must be taught . A desigTo develop and implement a model curriculum will incur both national and local costs. The most costly portions of this implementation plan are sponsorship of a national faculty development fellowship initiative to train ten new fellows, which we estimate to cost $500,000; the cost of a curriculum development and dissemination project, which we estimate to cost an additional $2.5 million over five years to train 240 faculty members; and the expense of developing "Centers of Excellence" (no cost estimate available at this time). Support for these programs should be actively sought with federal agencies including NIAAA, NIDA, HRSA, Center for Substance Abuse Prevention (CSAP), and the Center for Substance Abuse Treatment (CSAT).Local curriculum implementation costs in terms of money and time for a model program are modest, consisting primarily of 1) the faculty time needed to learn and teach the curriculum, and (2) evaluation of learning. National faculty development efforts would offer local faculty the opportunity to learn and teach substance abuse curriculum. Sponsorship may be offered jointly between the government or other organizational sponsors and the local residency program. Most curricular materials are available free of charge via the internet (see Table  the facuThough somewhat limited by the absence of specific evaluation data, this curriculum integrates components of previous effective education programs, while also offering several new and unique elements. It builds on lessons from past educational research and curriculum projects by adopting the substance abuse competencies defined by Project MAINSTREAM  and provst century, we propose a curriculum approach that would train residents with a combination of didactic and interactive learning strategies, offer periodic reinforcement of substance abuse concepts, encourage systems changes that facilitate screening and intervention, provide contact with recovering individuals, and document clinical competency by direct observation of resident skills. Implementation of such a curriculum on a broad scale would require a new faculty development initiative to train a new cadre of national substance abuse teaching experts; a series of dissemination workshops to create a network of trained faculty who could teach, reinforce, and model SBIRT skills throughout residents' clinical careers; and development of centers of teaching excellence to provide long-term continuity. Efforts could be greatly enhanced by networking with national Family Medicine organizations to implement and enforce clear RRC requirements for substance abuse curriculum training.In response to the clinical and training challenges facing U.S. Family Medicine residencies in the 21Abbreviations found within the text, tables, figures and supporting materials are as follows: AA: Alcoholics Anonymous; AAFP: American Academy of Family Physicians; ACGME: Accreditation Council for Graduate Medical Education; AFMRD: Association of Family Medicine Residency Directors; AMERSA: The Association for Medical Education and Research in Substance Abuse; CRIT: Boston University's Chief Resident Intensive Training; CSAP: Center for Substance Abuse Prevention; CSAT: Center for Substance Abuse Treatment; EHR: Electronic Health Record; HRSA: Health Resources and Services Administration; I&CS: Interpersonal and Communication Skills; MERF: The Medical Education and Research Foundation for the Treatment of Alcoholism and Drug Dependencies; MK: Medical Knowledge; NIAAA: National Institute on Alcohol Abuse and Alcoholism; NIDA: National Institute on Drug Abuse; OSCE: Objective Structured Clinical Exams; PBL&I: Practice-Based Learning and Improvement; PC: Patient Care; PRO: Professionalism; Project MAINSTREAM: Multi-Agency Initiative on Substance Abuse Training and Education for America; R25: National Institutes of Health Research Education Grant Cycle; RRC: Family Medicine Residency Review Committee; SAMSHA: Substance Abuse and Mental Health Services Administration; SAEFP: Substance Abuse Education for Family Physicians; SBIRT: Screening, Brief Intervention and Referral to Treatment; SBI: screening and brief intervention; SBP: Systems-Based Practice; STFM: Society of Teachers of Family Medicine; SU: Substance Use; SUD: Substance Use Disorders; TWEAK: a validated alcohol screening test for pregnant women.The authors declare that they have no competing interests.SS created the curriculum outline and tables, JPS created the introduction and discussion, DCC assisted SS and JPS with the literature search and created Additional File The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/10/33/prepubCurriculum Objectives and ACGME Competencies. Legend of ACGME Competencies: Patient Care - PC, Medical Knowledge - MK, Practice-based learning and Improvement - PBL&I, Interpersonal and Communication Skills - I&CS, Professionalism - PRO, and Systems-based Practice - SBP.Click here for fileStrategies for Overcoming Substance Abuse Training Barriers.Click here for file


This paper presents findings from the Tobacco Control in Arizona Healthcare Systems Survey, conducted in 2000. The purpose of the survey was to assess the status of Arizona healthcare systems' awareness and implementation of tobacco cessation and prevention measures.The 20-item survey was developed by The University of Arizona HealthCare Partnership in collaboration with the Arizona Department of Health Services Bureau of Tobacco Education and Prevention. It was mailed to representatives of Arizona's 40 healthcare systems, including commercial and Medicare managed care organizations, "managed Medicaid" organizations, Veterans Affairs Health Care Systems, and Indian Health Service Medical Centers. Thirty-three healthcare systems (83%) completed the survey.The majority of healthcare systems reported awareness of at least one tobacco cessation and prevention clinical practice guideline, but only one third reported full guideline implementation. While a majority covered some form of behavioral therapy, less than half reported covering tobacco treatment medications. "Managed Medicaid" organizations administered through the Arizona Health Care Cost Containment System were significantly less likely to offer coverage for behavioral therapy and less likely to cover pharmacotherapy than were their non-Medicaid counterparts in managed care, Veterans Affairs Health Care Systems and Indian Health Service Medical Centers.Arizona healthcare system coverage for tobacco cessation in the year 2000 was comparable to national survey findings of the same year. The findings that only 10% of "Managed Medicaid" organizations covered tobacco treatment medication and were significantly less likely to cover behavioral therapy were important given the nearly double smoking prevalence among Medicaid patients. Throughout the years of the program, the strategic plan of the Arizona Department of Health Services Bureau of Tobacco Education and Prevention has included the goal of identifying and eliminating tobacco related disparities for special populations, including low-income groups. Of importance, in 2008 the Arizona Health Care Cost Containment System was authorized to provide tobacco cessation pharmacotherapy as a covered benefit for its members. In 1995, the Arizona Department of Health Services (ADHS) launched its first comprehensive public Tobacco Education and Prevention Program (TEPP). The name was changed to Bureau of Tobacco Education and Prevention (BTEP) in 2007. Since ADHS-BTEP's inception, Arizona's overall adult smoking rate declined by 23% between 1994 and 2006, from 23.5% to 18.1%  up the private physician network to Medicaid recipients and [allow] AHCCCS members to choose a Health Plan and a Primary Care Provider" .The Tobacco Control in Arizona Healthcare Systems Survey was modeled on the series of national surveys first conducted in 1997 as part of the Robert Wood Johnson Foundation's Addressing Tobacco in Managed Care initiative . The AriTreating Tobacco Use and Dependence, released in June 2000 by the U.S. Public Health Service. Other evidence-based guidelines were also available to promote and encourage development of healthcare system policies for tobacco dependence treatment, including the Agency for Healthcare Policy and Research's Smoking Cessation Clinical Practice Guideline No. 18 (the 1996 precursor to Treating Tobacco Use and Dependence) and evidence-based recommendations developed by the National Cancer Institute and the Veterans Affairs Health Care System. The 2000 Clinical Practice Guideline, in particular, drew from an exhaustive search of the available literature to recommend that all tobacco users receive treatment in accordance with their readiness to quit, that clinicians and healthcare systems standardize the identification and documentation of all tobacco users who present in a healthcare setting, and that health plans and purchasers ensure reimbursement for clinically effective behavioral and pharmacotherapeutic treatments for tobacco dependence [The year 2000 presented an historical time to conduct the Tobacco Control in Arizona Healthcare Systems Survey. This year marked the publication of The Clinical Practice Guideline: pendence . Given tIn existence since 1995, the ADHS-TEPP program was well established by 2000. ADHS-TEPP was tasked with bringing the Arizona healthcare community up to speed with the accelerating changes in tobacco dependence treatment. Awareness and implementation of public prevention and treatment resources in 2000 would establish a knowledge base for assessing program progress in subsequent years.The Master Settlement Agreement (MSA) of 1998 brought into sharp focus the need to monitor delivery of health services for the prevention or treatment of tobacco dependence. Anti-tobacco momentum had reached a threshold whereby state governments needed to take stock of clinical skills and resources available for tobacco dependence treatment.The 20-item survey was developed by the University of Arizona HealthCare Partnership in conjunction with ADHS-TEPP in early 2000. Health Services Advisory Group, Inc., Arizona's healthcare quality improvement organization, served as a consultant for the survey project. Survey questions addressed the following domains: 1) demographic profile of healthcare systems, including type, enrollment, delivery model, tax status, and accreditation; 2) presence of written tobacco-free workplace policies for employees and/or written tobacco cessation protocols or policies for enrollees; 3) awareness and self-reported implementation of tobacco dependence treatment clinical practice guidelines; 4) awareness of and referral to ADHS-TEPP cessation services; and 5) availability of and coverage for tobacco cessation behavioral interventions and medications for enrollees  respond to and rank a list of barriers to implementation of tobacco dependence treatment clinical practice guideline recommendations, including such items as "insufficient staff," "cost of implementing guidelines," and "lack of requests from plan purchasers" and 7) respond to and rank a similar list of barriers to provision of tobacco dependence treatment behavioral interventions and medications  describe methods and frequency used to measure enrollee tobacco use; 9) respond to a list of strategies used to motivate clinicians and/or their staff, including such items as "clinician education in tobacco cessation and prevention" and "increased reimbursement for tobacco cessation counseling/assistance"; and 10) identify whether tobacco dependence treatment services were offered as part of a disease management or health promotion program .Forty healthcare systems were identified within Arizona, including• Nine commercial MCOs,• Eight Medicare MCOs,• Twelve Arizona Health Care Cost Containment System (AHCCCS) MCOs,• Three Veterans Affairs (VA) Health Care Systems, and• Eight Indian Health Service (IHS) Medical Centers.In the summer of 2000, medical directors of all 40 healthcare systems received a draft survey questionnaire, as well as a letter that apprised them of the project and asked them to identify the appropriate individual within the organization to whom the actual survey should be directed. In addition, the letter explained that all responses from individual healthcare systems would be kept confidential, and that survey reports would reflect aggregate data only. The 20-item questionnaire was then mailed to the medical directors or their designees. Measures to increase response rate included reminder telephone calls, follow-up postcards, and additional questionnaire copies sent to non-respondents after initial contact. Surveys were collected July through September 2000.Responses to survey questionnaires were reported in aggregate by healthcare system type. Descriptive analyses of frequency measures and cross-tabulations by type of healthcare system and dominant delivery model were compared. Fisher's exact test was used to test whether AHCCCS MCOs differed significantly from non-AHCCCS commercial and Medicare MCOs in providing behavioral therapy including and beyond self-help.Of the 40 healthcare systems contacted, 33 (83%) responded to the survey. These included 7 commercial, 7 Medicare, 10 AHCCCS MCOs, 3 VA Health Care Systems, and 6 IHS Medical Centers. Response rates by healthcare system type were 82% for commercial and Medicare MCOs, 83% for AHCCCS MCOs, 100% for VA Health Care Systems, and 75% for IHS medical centers. Surveys were completed most frequently by a Health Care Quality Manager (24%); other responders included Medical Directors (15%), Clinical Directors (9%), and Health Educators (9%).Among responding healthcare systems, 88% – including 100% of non-AHCCCS MCOs, VA Health Care Systems, and IHS Medical Centers – reported awareness of at least one clinical practice guideline for tobacco dependence treatment  reported coverage of at least one tobacco dependence treatment medication  and local county health department projects, as well as tribal projects and Indian Health Service initiatives throughout the state. Fifty-eight percent of healthcare systems reported referring patients to the Arizona Smokers' Helpline, while an additional 12% were aware of the Helpline but did not refer patients to it. Non-AHCCCS (79%) and AHCCCS (70%) MCOs were more likely to refer patients to the Helpline than were VA Health Care Systems (0%) and IHS Medical Centers (17%). Forty-five percent of healthcare systems reported referring patients to ADHS-TEPP-funded community-based projects offering tobacco dependence treatment services, and an additional 21% reported awareness of these projects. Again, non-AHCCCS (57%) and AHCCCS (50%) MCOs were more likely to refer patients to local projects than were VA Health Care Systems (0%) and IHS Medical Centers (33%).required providers to ask new patients about smoking status, 68.3% to deliver "strong advice" to quit, and 36.5% to arrange follow-up visits with patients making quit attempts.The results of the Arizona Healthcare Systems 2000 survey were compared with the Addressing Tobacco in Managed Care (ATMC) survey executed in 2000 . Both su2 test for proportions. Though awareness of clinical practice guidelines was not measured per se in the national survey, it could be inferred that national awareness was at least as high as in Arizona, given the similar extent of self-reported guideline implementation as reported nationally.The 2000 ATMC survey and the Arizona Healthcare Systems survey results were comparable in response rates and findings Table . In factThe survey was undertaken during an important time in tobacco control history. Arizona, the site of the first-ever public smoking bans in 1972, lagged slightly but not significantly behind the U.S. as a whole in terms of behavioral therapy and medication coverage in the year 2000. More importantly, Arizona's "Managed Medicaid" organizations appeared to lag behind commercial MCOs for coverage of behavioral therapy and tobacco dependence treatment medication, even though tobacco use is higher among the medically indigent.  SpeAccording to subsequent ATMC surveys , health Several recent developments in Arizona's tobacco control landscape represent major policy changes that may affect the future of tobacco dependence treatment throughout the state. In April 2008, the Arizona Department of Health Services Bureau of Tobacco Education and Prevention issued its new strategic plan, which targets at-risk populations with tailored media messages directing tobacco users to the Quitline and other prevention and treatment resources . For theAnother positive development in 2008 provides coverage for Medicaid enrollees seeking pharmacotherapeutic assistance with tobacco cessation. On April 29, 2008, Arizona Senate Bill 1418 was signed into law, authorizing the Medicaid program to cover tobacco dependence treatment medications for eligible members . This isThe 2000 survey was a timely assessment and inventory of the stock and status of tobacco control resources within Arizona healthcare systems. Cigarette taxes and price increases in 2002 and 2006, followed by a statewide smoking ban in 2007, and a deluge of media coverage on all fronts of tobacco control, have all likely stimulated continued interest in quitting tobacco use. Whether the current resources needed for tobacco dependency are met by healthcare system resources is a topic left to future research. The two new frontiers for Arizona in tobacco dependence treatment are likely to be further treatment for the medically indigent and primary prevention of tobacco use in vulnerable youth.MEG is a member of the Speaker's Bureau for Pfizer, Inc.MEG conceived of the study, participated in its design and coordination, and led the drafting of the manuscript. LJS, LS, and RL participated in the design and execution of the study. JMM and CF performed the statistical analysis and drafted the manuscript. All authors read and approved the final manuscript.Survey questions discussed in this article.Click here for file


Employers are implementing workplace health promotion programs that address modifiable health risk factors such as overweight and obesity, smoking, high blood pressure, high cholesterol, physical inactivity, poor diet, and high stress. Research with large employers has found that these programs can improve workers' health and decrease the costs associated with medical care, absenteeism, and presenteeism. Despite their promise, health promotion programs are not widely embraced by small businesses, especially those in rural communities. This article reviews the barriers encountered by small and rural businesses in implementing health promotion programs. We describe an approach developed in cooperation with the New York State Department of Health's Healthy Heart Program and the Cayuga Community Health Network to engage small businesses in health promotion. We review the development and implementation of an assessment tool created to evaluate current workplace health promotion programs, policies, and practices targeting cardiovascular disease among small, rural employers in upstate New York. Potential benefits of the assessment tool are discussed, and the instrument is made available for the public. Harris and colleagues recently presented the results of a pilot study in which 8 large employers from the Pacific Northwest, ranging in size from 7,500 to 115,522 employees, were recruited into a marketing study aimed at increasing adoption of evidence-based practices focused on cancer prevention  (Recommendations from 2 government-supported task forces -17 can hy Guide) , also reHowever, very little research has been directed at the application of evidence-based programs and practices to small businesses so that they too can achieve outcomes comparable to those attained by larger employers. This may be because small employers are often limited in the expertise and experience necessary to design, implement, and evaluate evidence-based programs on their own.We report on an initiative begun by the Institute for Health and Productivity Studies at Cornell University in association with the New York State Department of Health (NYS DOH) and the Cayuga Community Health Network (CCHN) to engage small businesses in rural communities that wish to adopt evidence-based chronic disease prevention practices. We first describe some of the challenges faced by small, rural employers and the approach taken by the NYS DOH to raise awareness of the need for workplace health promotion programs with the ultimate aim of engaging them in activities to reduce CVD among their employees.Small firms, defined as those with fewer than 500 workers, make up about 99% of employers in America and employ more than half of the private sector workforce . In New According to the 2004 National Worksite Health Promotion survey, only 11% of worksites with 50 to 99 employees used HRAs compared with 45% of those with more than 750 employees . The samA 2005 survey of more than 2,000 firms identified a sharp divide between small employers (3-199 workers) and larger firms . Almost half of large companies provided on-site fitness or health facilities, compared with 8% of small firms. Similarly, larger firms were more likely than small firms to offer smoking cessation programs, injury prevention programs, and weight-loss programs .The disparity between large and small employers is not surprising since small businesses confront significant challenges in implementing health promotion programs. The lack of dedicated resources is a key obstacle for small businesses. Most have limited human resources staff. Thus, they are unlikely to have experts who know how to design and organize a health promotion program or who can commit the time to develop those skills . This isSmall employers also have limited access to commercial worksite vendors. Although some health insurance providers offer some forms of health promotion programs, these are often limited and only provided through the medical care system. Furthermore, many small businesses do not offer health insurance. While 99% of large firms (200 or more workers) offered health benefits in 2007, only 59% of small firms (3 to 199 workers) did . Small eSmall businesses in rural settings face a unique set of challenges to promoting healthier lifestyles. Representing about 20% of the US population, they are diverse in their demographic composition, availability of community resources, and public health presence. Compared with metropolitan areas, rural areas have higher rates of smoking, more high-fat diets, and higher percentages of people with sedentary lifestyles and decreased perception of heart disease risk . FurtherDespite these challenges, small, rural employers also have certain strengths that can be leveraged to develop and sustain health promotion programs. For example, they tend to have visible and accessible senior leaders who may exemplify good health practices and become internal champions for health-promoting behaviors. In a small business, it is often easier to communicate with employees and create a sense of community among workers. Furthermore, human resources managers often develop close, trusting relationships with workers and are therefore more likely to engage them in programs that workers may otherwise find suspicious . Finallywww.sph.emory.edu/ihps so that other small employers in rural communities might apply the tool to their prevention efforts.The NYS DOH, in partnership with CCHN, sought to heighten awareness among small, rural employers in upstate New York so that they would adopt evidence-based practices to prevent CVD among their employees. A first step in that process involved designing and distributing a Community-Wide Cardiovascular Risk Reduction Assessment instrument to participating organizations. The assessment asked employers to provide information about their adoption of evidence-based prevention and health promotion programs and policies, and was meant to educate them about steps they could take to achieve CVD prevention among their workers. The project, although small in scale, was meant to serve as a model for other small businesses and business coalitions that may wish to partner with their local public health agencies to design and implement workplace programs. We describe the assessment and offer it for download at www.sph.emory.edu/ihps) sought to recruit employers to the initiative by providing an overview of the project, its objectives, a timetable, sample assessment questions, report templates, time commitments, and a summary of what employers would gain from the project.We met with officials from the NYS DOH and CCHN to develop, in broad strokes, the elements of the assessment. We asked for and received support for recruiting small employers from CCHN. We developed a rationale and business case presentation for the CCHN, highlighting evidence for the efficacy of CVD health promotion and disease prevention programs at the workplace. The business case presentation ; diet and nutrition ; exercise and physical activity ; tobacco use ; and stress and emotional health .Services , produceModule 3: Organizational Support assessed the extent to which the organizations supported workplace health promotion and disease prevention efforts through senior managers' commitment to a "healthy company" culture. Employers also completed an 18-item instrument entitled "Leading by Example" or LBE  providing incentives to participate in such programs; 2) establishing a network of available, on-site physical activity group facilitators; and 3) working with community-based organizations that provide and promote physical activity, such as the American Diabetes Association Tour for the Cure, the American Cancer Society Relay for Life, or the American Heart Association Heart Walk.Employers can offer healthy food options at company-sponsored meetings and functions; promote healthful food options; develop model healthy food and beverage vending contracts; negotiate corporate rates for worksite-based weight control programs; and develop working relationships or partnerships with local greenmarkets and farmers' markets to offer coupons and promotions.To reduce tobacco use among workers, employers can establish partnerships with local tobacco control coalitions; establish policies for smoke-free worksites; prohibit smoking in company-owned vehicles and workplace entrances; ban sales of tobacco products on site ; and provide coverage for the treatment of nicotine addiction through the use of medications and counseling for smoking cessation.Other actions employers can institute include issuing regular messages from senior managers about policies supporting healthy behaviors and health promotion; providing managers with training on the importance of employee health promotion; establishing performance objectives for managers related to workplace health improvement; offering free or low-cost educational materials  supporting healthy behaviors; and granting prizes, awards, and recognition for employees or managers who participate or promote participation in health promotion programs.These actions are relatively low-cost and low-effort and can be adopted by many small employers on their own, working as part of community coalitions, or in partnership with their health plans. These initiatives may produce health improvement outcomes similar to those realized by many large employers. They also have the potential to achieve cost savings in the form of reduced health care spending, lower absenteeism rates, fewer safety incidents, and heightened worker productivity.


Saint Louis encephalitisvirus (SLEV) transmission and hydrologic conditions in Indian River County, Florida, from 1986 through 1991, a period with an SLEV epidemic. Virus transmission followed periods of modeled drought . Further evidence from collections of Culex nigripalpus (the major mosquito vector of SLEV in Florida) suggests that during extended spring droughts vector mosquitoes and nestling, juvenile, and adult wild birds congregate in selected refuges, facilitating epizootic amplification of SLEV. When the drought ends and habitat availability increases, the SLEV-infected Cx. nigripalpus and wild birds disperse, initiating an SLEV transmission cycle. These findings demonstrate a mechanism by which drought facilitates the amplification of SLEV and its subsequent transmission to humans.We used a dynamic hydrology model to simulate water table depth (WTD) and quantify the relationship between  Saint Louis encephalitis virus (SLEV). Five epidemics (>20 human cases each) of SLEV have been recorded in south Florida since 1952 Florida is vulnerable to epidemic transmission of The annual SLEV transmission cycle in south Florida can be divided into four phases: January–March, maintenance; April–June, amplification; July–September, early transmission; and October–December, late transmission Others have proposed that SLEV epidemics may result from a specific combination of biotic and abiotic conditions that favor early season virus amplification followed by transmission Culex nigripalpus Theobald is the epidemic and epizootic vector of SLEV . Such techniques have been used to predict mosquito abundance in temperate settings Cx. nigripalpus taken in Indian River County during the same time period.For this study, we used a dynamic hydrology model Variations of WTD in space and time determine where and when pools of water form at the land surface, thus creating potential mosquito breeding habitats. WTD, however, is not merely a function of precipitation. Other meteorologic variables, as well as soil and vegetation type and antecedent conditions, must be considered if evapotranspiration, water movement within the soil column, and river runoff are to be quantified. Topography must also be constrained if the flow of water across the land surface, runoff rates, and the local convergence of water in lowlands (surface pooling) are to be modeled accurately.2) 2) We combined a soil column model, which simulates the vertical movement of water and heat within the soil and between the soil surface, plus vegetation and the atmosphere, with the TOPMODEL (TOPography-based hydrology MODEL) approach  and twice a month during the rest of the year. Blood samples were assayed for hemagglutination inhibition antibodies to SLEV at the Florida Department of Health and Rehabilitative Services, Tampa Branch Laboratory. Individual chickens testing positive for hemagglutination inhibition antibodies were replaced with fresh sentinels, and the entire flock was replaced each spring.We defined SLEV transmission intensity for each sentinel flock as the number of seropositive chickens per weekly sample. We also defined SLEV transmission incidence for each flock as a categorical data set: one, if one or more chickens were SLEV seropositive per weekly sample; or zero, if no chickens were seropositive. Data from all sentinel sites were also pooled, and SLEV transmission intensity and incidence were similarly determined.Cx. nigripalpus of both sexes and female Cx. nigripalpus in all gonotrophic stages Western Indian River County is dominated by citrus groves intermixed with hammock “islands” of southern live oak and cabbage palm Hourly meteorologic data were assembled from National Climate Data Center archives for Vero Beach, Florida. Gaps in the record were filled with hourly data from National Climate Data Center archives for Melbourne and West Palm Beach. Solar radiation data were provided by the Northeast Regional Climate Center from analysis of the National Climate Data Center data by using the Northeast Regional Climate Center solar energy model The hydrology model was run from 1984 through 1995 and provided a daily series of mean WTD for the study area. Because of the channelization and water control in south Florida, the model was validated by using groundwater well measurements and surface  water levels, provided by the St. John’s Water Management District. The partitioning of runoff and evapotranspiration matched bulk estimates taken from U.S. Geological Survey and St. John’s Water Management sources.Univariate and bivariate logistic regression was used to associate the probability of SLEV transmission incidence with single time lags of modeled WTD and combinations of two time lags of WTD. Whole model goodness-of-fit was measured by log-likelihood ratio and the pseudo r-squared (uncertainty) coefficient. Individual parameter estimates were made by Wald’s chi-square test.All five sentinel flocks had SLEV transmission recorded during the study period (1986–1991). Univariate logistic regression was performed to explore the relationship between SLEV transmission incidence and time lagged modeled WTD. A range of time lags (0–29 weeks) was tested for the individual sites and for all five sites combined. A second, bivariate logistic regression analysis was performed to explore the effects of both antecedent drought and coincident wetting conditions. Modeled WTD time lags of 10 to 25 weeks were paired with modeled WTD time lags of 0, 1, 2, or 3 weeks and used together in bivariate analysis of SLEV incidence. <1.2 m 17 weeks before transmission is there any probability of SLEV transmission. This probability, however, is modulated by a rise in the WTD 2 weeks before transmission. This moderating effect is also shown in The results from analysis of SLEV transmission incidence with modeled WTD were highly statistically significant but did not fully explain why the sequence of drought and wetting fosters SLEV transmission. However, a probable mechanism is suggested by mosquito collection data taken in the area.Cx. nigripalpus versus mean modeled WTD for each calendar year from 1986 through 1991. Total collected female Cx. nigripalpus display a bimodal distribution with respect to mean modeled WTD for 3 years . Similar bimodality was evident in the yearly distributions of Cx. nigripalpus males and the individual female age-grades (data not shown). For 1989 and 1990, the driest years, one of the maxima of Cx. nigripalpus developed sharply at WTDs <1.4 m. None of the other years, including 1987, had this level of drought or this sharp bimodality. Two inferences may be drawn from these data: either the mosquito population increased at both the driest and wettest times of the year, or during the drought of 1989 and 1990, mosquitoes congregated in the hammock collection site. The latter inference is consistent with field observations that the hammocks in Indian River County and throughout south Florida provide refuge for mosquitoes during periods of drought Cx. nigripalpus activity to densely vegetated hammock habitats where nestling, juvenile, and adult wild birds are found. This forced convergence of mosquito vectors and avian amplification hosts provides an ideal environment for the rapid epizootic amplification of SLEV. When the drought ends and water resources increase, infected mosquitoes and birds disperse from the hammocks, initiating the early transmission phase of the Florida SLEV cycle.Our findings suggest the following sequence of events for SLEV transmission in Indian River County. Springtime drought restricts The relationship reported here between modeled WTD and SLEV incidence has only two explanatory variables and provides a simple predictive framework for forecasting SLEV transmission. To be sure, additional factors influence the dynamics of SLEV transmission. Pre-drought conditions may moderate hammock amplification by increasing or decreasing the overall abundance of mosquito vectors and avian amplification hosts. Data from other Florida counties and previous epidemics will have to be examined to elucidate how such population variability affects SLEV amplification and transmission. Future validation of the model should also include census of wild bird populations and sampling of seropositivity rates in the wild birds. Such data were not available for this study.Whether a critical period of drought is necessary for maximum epizootic amplification also requires exploration. The 1986 data, for which the drop in WTD was short-lived and SLEV transmission was limited, suggest that the longer droughts of 1989 and 1990 were necessary for adequate amplification to produce the mosquito infection rates needed for epidemic transmission. However, if a drought persists for too long, the vectors may die, thus precluding SLEV transmission. Certainly, the biological cycles of virus, vector, and amplification hosts must be coordinated to produce an SLEV epidemic.The mechanism of drought-induced amplification described here for Indian River County may also operate in regions outside south-central Florida that have similar epidemic SLEV transmission. In fact, the development of SLEV epidemics after drought has long been noted in many regions of the United States (Eastern equine encephalitis virus and West Nile virus in northern Florida, which came on the heels of a drought broken by the landfall of Hurricane Allison, suggests that these other disease systems warrant similar study.Comparable drought-induced amplification may also occur in other arboviruses. The recent sporadic outbreak of Modeling the hydrologic cycle permits quantification of the relationship between drought and SLEV transmission and enables real-time monitoring and forecasting of SLEV transmission incidence. Using the hydrology model in conjunction with climate forecast projections, we are developing an arboviral forecast for Florida.


The relationship between prostate cancer and indicators of nutrition, diet and social factors was evaluated in a case-control study of 166 patients with histologically confirmed prostatic carcinoma and 202 control subjects hospitalized for acute diseases other than malignant, hormonal or urogenital. The relative risk increased with increasing body mass index, men being moderately overweight showing a 2.3 elevated risk, and those grossly overweight an over four-fold higher risk of prostate cancer, when allowance was made for several identified potential confounding factors. Cases also reported more frequent consumption of milk and other dairy products and meat, but no significant difference was noted for vegetable intake. The risk of prostate cancer was unrelated to marital status or indicators of social class based on occupation.


We report 4 cases of equine rhinosporidiosis in the United Kingdom. These cases provide evidence of spread of infectious agents from rhinosporidiosis-endemic areas to nonendemic areas by increased international movement of livestock. Surveillance should continue for this infective agent of potential relevance for numerous species, including humans. Rhinosporidium seeberi, an organism that was previously classified as a fungus but has been regrouped into the class Mesomycetozoa (family Rhinosporideacae). This class consists of several parasitic and saprophytic organisms, most of which infect fish and amphibians; only R. seeberi infects mammals , as described  by using a commercially available kit  according to the manufacturer’s protocol. R. seeberi, were seen (<100 μm in diameter) structures had an eosinophilic and periodic acid Schiff–positive wall enclosing eosinophilic to basophilic fibrillar material , spherical to polygonal structures had a thin eosinophilic wall with closely opposed basophilic stippled material and basophilic and eosinophilic ovoid structures (endospores) within the central lumen , Brazil, and Argentina (R. seeberi (Coccidioides immitis or Chrysosporium parvum (the causative agent of adiaspiromycosis) and neoplasia  could lead to introduction of this infective agent, because lesions may not be apparent at the time of importation. Direct transmission of R. seeberi between humans and animals has not been proven , and other ponies come from New Zealand, Australia, and the United States. Thus, a relatively large number of potentially exposed ponies are imported into the United Kingdom each year. For


Staphylococcus aureous, pseudomonas aeruginosa, Klebsiella pneumonae and Proteus vulgarus, and the results are reported.Hydrazine derived compounds and its Co(II), Cu(II) and Ni(II) chelates having the same metal ion but different anions  have been synthesised andcharacterised by their physical, spectral and analytical data. In order to evaluate the participating role of anions in the antibacterial activity, these synthesised ligands and its metal chelates have beenscreened against bacterial species such as