Pediatric injury is highly prevalent and has significant impact both physically and emotionally. The majority of pediatric injuries are treated in emergency departments (EDs), where treatment of physical injuries is the main focus. In addition to physical trauma, children often experience significant psychological trauma, and the development of acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) is common. The consequences of failing to recognize and treat children with ASD and PTSD are significant and extend into adulthood. Currently, screening guidelines to identify children at risk for developing these stress disorders are not evident in the pediatric emergency setting. The goal of this systematic review is to summarize evidence on the psychometric properties, diagnostic accuracy, and clinical utility of screening tools that identify or predict PTSD secondary to physical injury in children. Specific research objectives are to: (1) identify, describe, and critically evaluate instruments available to screen for PTSD in children; (2) review and synthesize the test-performance characteristics of these tools; and (3) describe the clinical utility of these tools with focus on ED suitability.Computerized databases including MEDLINE, EMBASE, CINAHL, ISI Web of Science and PsycINFO will be searched in addition to conference proceedings, textbooks, and contact with experts. Search terms will include MeSH headings (post-traumatic stress or acute stress), (pediatric or children) and diagnosis. All articles will be screened by title/abstract and articles identified as potentially relevant will be retrieved in full text and assessed by two independent reviewers. Quality assessment will be determined using the QUADAS-2 tool. Screening tool characteristics, including type of instrument, number of items, administration time and training administrators level, will be extracted as well as gold standard diagnostic reference properties and any quantitative diagnostic data  where appropriate.Identifying screening tools to recognize children at risk of developing stress disorders following trauma is essential in guiding early treatment and minimizing long-term sequelae of childhood stress disorders. This review aims to identify such screening tools in efforts to improve routine stress disorder screening in the pediatric ED setting.CRD42013004893PROSPERO registration:  Pediatric injury is highly prevalent and has significant impact. Injuries are the largest cause of morbidity and mortality among children in the United States and Canada, and are the leading cause of emergency department (ED) visits for children greater than 1 year of age . Injury-The prevalence of stress disorders such as acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) following injury is high. Some children with sub-clinical features suffer as much distress and impairment as those diagnosed with full PTSD, and the risk factors to identify those children at greatest risk for subsequent development of PTSD have been outlined . Recent The consequences of failing to recognize and treat children at risk for PTSD are stark and prevail into adult life. PTSD is linked to changes in neurobiology ,13 durinThe ED is usually the first and is often the only point of medical care for children experiencing a physical trauma. Thus, the ED visit may be the best opportunity to screen for PTSD vulnerability and to connect patients to resources for future interventions or treatments ,21. SuchCochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.The systematic review protocol has been registered with the PROSPERO systematic review database (registration number CRD42013004893) and has been designed based on the PRISMA statement and guidelines established in the Database searches will be executed by a medical librarian (SC) using subject headings  and text words to retrieve articles related to the following concepts: (post-traumatic stress or acute stress) and (pediatric or children) and diagnosis. Databases searched will include: MEDLINE, EMBASE, EBM Reviews , Global Health, PsycINFO, Health and Psychosocial Instruments, ProQuest dissertations and theses as well as conference proceedings and contact with experts in the field. An additional search of gray literature will include Google Scholar and related field websites in pediatric mental health with screening tools evaluating PTSD in children. There will be no restrictions for articles by language, publication date or publication status. All references will be exported to RefWorks citation management software, where duplicates will be verified, recorded and removed. Search strategies are listed in Additional file Two independent reviewers will screen all articles by title and abstract against inclusion and exclusion criteria described in Table Screening tools, instruments, or questionnaires implemented after traumatic events with the purpose of identifying children/adolescents (<18 years) at risk for developing PTSD are eligible. Such measures, with diagnostic and psychometric study designs, will be described and evaluated. Studies will clearly describe the gold-standard criteria by which a diagnosis of PTSD was made (diagnostic studies)  or compaTwo reviewers will utilize a customized data extraction form (Additional file Review of citations/abstracts, included articles, data extraction, and quality rating will be performed by two team members using customized forms with pre-determined criteria (Additional file The ED is a unique environment. The pace, range of conditions and stress is high. Healthcare providers have multiple competing care duties and the chances of successfully implementing a screening tool into clinical care pathways for pediatric traumatic events will be maximized if the tool is carefully selected to suit the environment while maintaining accuracy in diagnosis to ensure improved outcomes. Given that pediatric injury is so prevalent and that EDs support the vast majority of these injuries acutely, it is logical for clinicians familiar with this unique environment and its patients to review and select the most suitable tool possible. To date, we are unaware of the availability of any such comprehensive review pertaining to the use of such tools in the acute-care ED. This review will address this deficiency by identifying, describing and evaluating such tools and comparing their features in a concise table. We will make screening recommendations based on the tools described and provide a foundation for the development of future practice guidelines in the psychological management of pediatric injury.AAP: American Academy of Pediatrics; ASD: acute stress disorder; ED: emergency department; MVA: motor vehicle accidents; PTSD: post-traumatic stress disorder.The authors declare that they have no competing interests.JO, the project lead, will complete PROSPERO registration, compile search results, remove duplicates, participate in screening, article retrieval, quality assessment and manuscript drafting. CC will participate in article screening, retrieval and quality assessment as well as provide revisions to the final manuscript. SC will develop and execute database search protocol and draft the database search manuscript methods section. SJC, AN, RG and CF initiated the project concept, will provide experience in evidence-based medicine methodology and data interpretation as well as contribute in manuscript preparation and review. SJC also drafted the initial review protocol and will act as third reviewer for article screening and inclusion. All authors read and approved the final manuscript.Appendix 1. Eligibility form for potentially relevant articles. Appendix 2. Data extraction form. Appendix 3. Search Strategy.Click here for file


Interstitial lung disease encompasses a diverse group of chronic lung conditions characterised by distressing dyspnoea, fatigue, reduced exercise tolerance and poor health-related quality of life. Exercise training is one of the few treatments to induce positive changes in exercise tolerance and symptoms, however there is marked variability in response. The aetiology and severity of interstitial lung disease may influence the response to treatment. The aims of this project are to establish the impact of exercise training across the range of disease severity and to identify whether there is an optimal time for patients with interstitial lung disease to receive exercise training.One hundred and sixteen participants with interstitial lung disease recruited from three tertiary institutions will be randomised to either an exercise training group (supervised exercise training twice weekly for eight weeks) or a usual care group (weekly telephone support). The 6-minute walk distance, peripheral muscle strength, health-related quality of life, dyspnoea, anxiety and depression will be measured by a blinded assessor at baseline, immediately following the intervention and at six months following the intervention. The primary outcome will be change in 6-minute walk distance following the intervention, with planned subgroup analyses for participants with idiopathic pulmonary fibrosis, dust-related interstitial lung disease and connective-tissue related interstitial lung disease. The effects of disease severity on outcomes will be evaluated using important markers of disease severity and survival, such as forced vital capacity, carbon monoxide transfer factor and pulmonary hypertension.This trial will provide certainty regarding the role of exercise training in interstitial lung disease and will identify at what time point within the disease process this treatment is most effective. The results from this study will inform and optimise the clinical management of people with interstitial lung disease.Australian New Zealand Clinical Trials Registry ACTRN12611000416998 The interstitial lung diseases (ILDs) are a disabling and diverse group of chronic lung conditions that have been broadly classified into four groups: ILD of known cause such as occupational or environmental exposures and/or collagen vascular disease; granulomatous ILD such as sarcoidosis; idiopathic interstitial pneumonias including idiopathic pulmonary fibrosis (IPF) and nonspecific interstitial pneumonia (NSIP); and other rare forms of ILD including lymphangioleiomyomatosis, pulmonary Langerhans’ cell histiocytosis/histiocytosis X, and eosinophilic pneumonia . Many ILThe classification of the ILDs has been the subject of criticism, due to its failure to reflect the marked heterogeneity in clinical course within disease subgroups. Idiopathic pulmonary fibrosis (IPF), the best characterized of the ILDs, is largely a fatally progressive disease with a median survival of 3–5 years . The proFew treatments have demonstrated improvements in either HRQoL or community functioning for any of the ILDs ,16. In IUncertainty remains regarding the clinical relevance of exercise training across the entire range of ILDs. Patients with IPF appear to have smaller gains in functional capacity than those with ILD of other aetiology . This raIn order for exercise training to be widely adopted in clinical practice, clinicians require more information regarding its role across the disease spectrum. The aims of this study are 1) to establish the impact of exercise training on ILDs of different aetiology and severity and 2) to identify whether there is an optimal timing for exercise training to achieve maximal benefit. We hypothesise that exercise training will be effective regardless of disease severity in patients with non-IPF related ILD, whereas in patients with IPF, the response to exercise training will be greatest in those with less severe disease.This multi-centre randomised controlled trial will be conducted at Alfred Health, Austin Health and Western Health, Melbourne, Australia.Participants with a documented diagnosis of ILD will be recruited for this study from the Departments of Respiratory and Sleep Medicine at Alfred, Austin and Western Health. The diagnosis of ILD will be made according to established criteria. In IPF, the diagnostic criteria will be consistent with those outlined in the International Consensus Statement . A surgiParticipants must be clinically stable, ambulant, and suffer from dyspnoea on exertion despite maximal appropriate medical treatment. Participants will be excluded if they 1) have a concurrent and predominant diagnosis of another significant respiratory disorder  which is the primary cause of their symptoms; 2) have a history of syncope on exertion; 3) are too unwell to attend the hospital for exercise training; 4) have any other co-morbidities, such as severe orthopaedic or neurological deficits or unstable cardiac disease which would prevent exercise training; 5) have participated in a pulmonary rehabilitation program within the previous 12 months.One hundred and sixteen participants will be required to detect a significant difference in the primary outcome measure of change in functional exercise capacity . This is based on the 80% probability of detecting a difference in the change in 6MWD between the intervention and control group using data from our previous randomised control trial  and CochData from our previous study  indicateThe flow of participants through the study will reflect the recommendations from the Consolidated Standards of Reporting Trials statement  and is oRandomisation will be stratified according to the three subgroups IPF, dust-related ILD and connective tissue disease-related ILD. This will ensure that all subgroups of ILD are evenly distributed between the intervention and control groups. The randomisation will also be stratified for disease severity according to TLCO <or ≥40% to ensure that those with severe disease are evenly distributed between the intervention and control groups. A set of permuted blocks will be generated for each of the following subgroups: dust-related ILD, connective tissue disease-related ILD, IPF with TLCO < 40% and IPF with TLCO ≥ 40%. The random allocation sequence will be generated using a computer generated random number list. Concealment of group allocation will be achieved by giving the responsibility for allocation sequence generation and group allocation to a researcher independent of the study and its investigators. The group allocation will be kept in sealed, opaque envelopes in a central location. Following the baseline assessment, participants will be randomly allocated to either the exercise training group or to a control group by a researcher, who is not involved in the recruitment or assessment of the participants or the execution of the intervention, by opening the sealed opaque envelope.2 on room air is <88% whilst exercising and will be titrated to maintain a SpO2 ≥90%.The exercise training group will undergo a twice-weekly supervised exercise training program at the institution where they were recruited for a period of 8 weeks. The exercise program will follow the pulmonary rehabilitation guidelines for exercise prescription in chronic lung disease . Each seOnce the participant is safely established on a supervised exercise regimen, an unsupervised home exercise program will be prescribed as per current Pulmonary Rehabilitation guidelines  to achieParticipants randomised to the usual care group will not undergo any supervised exercise training and will not receive any recommendations regarding exercise training or physical activity. These participants will be contacted once weekly by telephone for the duration of the 8 week intervention period to provide general support and health advice and to answer any queries or concerns the participants may have. These phone calls will be conducted according to a standardised script. This is a commonly used control for exercise training interventions and was used in our earlier randomised controlled trial in ILD . The parOutcome measures will be collected at baseline, upon completion of the intervention period (nine weeks) and at six months following completion of the intervention Figure . A six m2 <88%. Supplemental oxygen will be used at a flow rate of 4L.min-1 for the second test if SpO2 <85% during the first 6MWT [2peak) in IPF and has shown responsiveness to change following pulmonary rehabilitation in IPF [1. Change in functional exercise capacity will be measured with 6MWT according to standardised criteria . Two tesrst 6MWT -43. Folln in IPF  and ILD n in IPF .1. Peripheral muscle strength will be assessed using a hand held dynamometer . Three maximal isometric contractions of the elbow flexors and knee extensors on the dominant side will be tested. Skeletal muscle weakness, in particular quadriceps weakness, has been shown to correlate strongly with reduced exercise tolerance and exercise capacity in patients with ILD ,44 and w2. Health-related Quality of Life (HRQoL) will be measured using the Chronic Respiratory Disease Questionnaire (CRQ), and St George Respiratory Questionnaire idiopathic pulmonary fibrosis specific version (SGRQ-I). The CRQ has been validated previously in ILD  and has 3. Dyspnoea will be measured using the University of California San Diego Shortness of Breath Questionnaire (UCSD SOBQ) and the Modified Medical Research Council dyspnoea scale (MMRC). The UCSD SOBQ comprises 24 items that assess dyspnoea over the preceding week and is a reliable and valid instrument used to assess dyspnoea associated with Activities of Daily Living (ADL)s in patients with chronic lung disease -48. The 4. Anxiety and Depression will be measured using the Hospital Anxiety and Depression Scale (HADS). The HADS has been designed to detect and measure the severity of anxiety and depression and has been shown to be a reliable instrument in evaluating anxiety and depression in IPF and ILD ,52.5. The Global Rating of Change Scale will be used to assess the participants’ self-perceived improvement or deterioration over time. The Global rating of change scale involves asking the participant whether there has been any change in their symptoms or walking ability since their commencement in the study . ParticiAt 9 weeks and at 6 months follow up participants will undergo repeat measurements of the 6MWT, peripheral muscle strength, CRQ, SGRQ-I, UCSD SOBQ, MMRC, HADS and Global Rating of Change to evaluate the immediate and long term effects of exercise training. An independent assessor, blinded to group allocation, will perform all outcome assessments.1) and will be performed at baseline and at six months follow up. Carbon monoxide transfer factor will be measured at baseline and at six months follow up. Static lung volumes measured via plethysmography will be measured at baseline only and will include total lung capacity (TLC), functional residual capacity (FRC) and residual volume (RV).1. Respiratory function testing will be performed in accordance with the American Thoracic Society guidelines  to quant2. Pulmonary Hypertension will be assessed by a trans-thoracic echocardiogram. Pulmonary hypertension is a common complication of ILD ,9 and paThe respiratory function tests and transthoracic echocardiogram will be performed by routine clinical personnel at the treating hospital and they will be unaware of the group allocation.Data will be analysed using intention-to-treat principles, with inclusion of all available data regardless of whether the intervention is completed. The response of exercise training and control groups will be compared for change in exercise and HRQoL variables using linear mixed model analyses. Planned subgroup analyses will be conducted for participants with IPF, dust-related ILD and connective tissue-related ILD. Multiple regression analysis will be undertaken to establish which subjects respond best to exercise training and when this treatment should be offered, with change in 6MWD following exercise training as the dependent variable. Baseline demographic and physiological variables such as age; gender; disease aetiology; percent predicted TLC; percent predicted FVC; TLCO; pulmonary artery pressure; and the extent of oxyhaemoglobin desaturation during exercise will be used as predictors.Interstitial lung disease represents a heterogeneous group of chronic, disabling lung disorders  which arThe most recent published guidelines on IPF  provide This study has been designed to define the role and impact of exercise training in ILD across the range of disease severity and aetiology and to identify whether an optimal time exists during which exercise training should take place in order to ensure that maximal benefit can be obtained. This study will provide patients and clinicians with certainty regarding the role of exercise training as well as the magnitude and duration of expected benefits. If this trial provides evidence of benefit, it will provide a scientific rationale for pulmonary rehabilitation to be considered standard care for people with ILD.ADLs: Activities of Daily Living; COPD: Chronic obstructive pulmonary disease; CRQ: Chronic Respiratory Questionnaire; FEV1: Forced expiratory volume in one second; FRC: Functional residual capacity; FVC: Forced vital capacity; HADS: Hospital Anxiety and Depression Scale; HRQoL: Health related quality of life; ILD: Interstitial Lung Disease; IPF: Idiopathic Pulmonary Fibrosis; MID: Minimal important Difference; MMRC: Modified Medical Research Council; RM: Repetition Maximum; RPE: Rating of perceived exertion; RV: Residual Volume; SGRQ-I: St George Respiratory Questionnaire idiopathic pulmonary fibrosis specific version; TLC: Total lung capacity; TLCO: Carbon monoxide transfer factor; UCSD SOBQ: University of California San Diego Shortness of Breath Questionnaire; 6MWD: Six-minute walk distance; 6MWT: Six-minute walk test.The authors declare that they have no competing interests.LD, AH, CM, CH, IG and NG designed the trial protocol. LD, AH, CM, CH, KB, CB, IG, NG, AS and AM procured the study funding. LD drafted the manuscript and AH, CM, CH, AL, KB, CB, IG, NG, AS, AB, AM, and RN contributed to the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2466/13/8/prepub


The research prevention project entitled “HIV/AIDS and Substance Abuse Primary Prevention in Minority Adolescents”, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), targets minority male and female adolescents 12-17 years old in the implementation and evaluation of a program designed to prevent adolescents from engaging in substance abuse and sexual activities which place them as risk for contracting the HIV/AIDS virus. The five-year intervention will serve 750 adolescents and 750 parents.The program combines the effects of a program that consists of two evidence-based primary components: 1) refusal skills training and education for the adolescent focusing on issues relating to sexuality and substance abuse; and 2) a family prevention educational and skills component involving the parent(s) of the participating adolescents. The small group educational techniques employed with the adolescent component are based on the Teams-Games-Tournaments (TGT) Alcohol Prevention curriculum, cited as a Model Program in SAMHSA’s National Registry of Effective Programs and Practices (NREP) and as a Model Program by the Office of Juvenile Justice and Delinquency Prevention, and the Reducing the Risk (RTR) curriculum, both of which have been empirically evaluated as effective methods of teaching adolescent skills development in the areas of substance abuse and high-risk sexuality prevention. The parent prevention component is based on extensive research in which problem-solving skills and communication procedures have been used effectively with parents of adolescents.The evaluation component of the project assesses participants (adolescents and parents) at baseline, post participation, and at 6-month follow-up periods. Dependent variables include the adolescents’ and parents’ knowledge of, attitudes toward, and behavior related to HIV AIDS and substance abuse. Additionally, adolescents’ self-efficacy and quality of peer and parental relationships are assessed. For all participating family members, conflict and communication measures are secured.Significant differences have been shown for adolescents and parents between baseline, post participation, and 6 month follow-up for all dependent variables. Training manuals provide program implementation requisites and materials to facilitate dissemination at local, state, and international levels.


The international response to the severe acute respiratory syndrome (SARS) outbreak, fromMarch to July 2003, tested the assumption that a new and emerginginfection–one that had not yet demonstrated its full epidemiologic potentialbut was spreading from person to person and continent to continent–could beprevented from becoming endemic. Within 4 months after the first global alert about thenew disease, all known chains of transmission had been interrupted in an outbreak thataffected 27 countries on all continents. Most public health experts and scientistsbelieve that the question of whether SARS has become endemic can only be answered afterat least 12 months of postoutbreak surveillance. The SARS experience, however, made onelesson clear early in its course: inadequate surveillance and response capacity in asingle country can endanger national populations and the public health security of theentire world. As long as national capacities are weak, international mechanisms foroutbreak alert and response will be needed as a global safety net that protects othercountries when one nation’s surveillance and response systems fail.During the last decade of the 20th century, several outbreaks, including cholera in LatinAmerica, pneumonic plague in India, and Ebola hemorrhagic fever in the DemocraticRepublic of the Congo, caused great international concern , also a partner in GOARN, picked upmedia reports of an influenza outbreak in mainland China avian influenza virus in two persons, and WHO activated its influenza pandemicpreparedness plans (During that same week, laboratories of the WHO Global Influenza Surveillance Networkbegan analyzing specimens from a patient with severe atypical pneumonia hospitalized inHanoi after travel to Hong Kong. Concurrently, GOARN response teams in Vietnam and HongKong began collecting clinical and epidemiologic information about the patient and agrowing number of others with similar symptoms. As more specimens entered the networklaboratories, influenza viruses were ruled out as the causative agent. WHO made itsfirst global alert on March 12, followed by a second, on March 15, when more than 150suspected new cases had been reported from several geographic areas, including HongKong, Singapore, Vietnam and Canada (As many times occurs with emerging and reemerging infectious diseases, nationalsurveillance mechanisms failed to identify and respond to the emerging outbreak of SARSearly enough to prevent its toll of sickness, death, and international spread (


Telehealth and telecare projects do not always pay enough attention to the wider information systems architecture required to deliver integrated care. They often focus on technologies to support specific diseases or social care problems which can result in information silos that impede integrated care of the patient. While these technologies can deliver discrete benefits, they could potentially generate unintended disbenefits in terms of creating data silos which may cause patient harm or at least impede the ability of the clinician, carer or even patient to treat the patient in an integrated fashion. For instance, if clinical data  are captured in a telehealth or telecare system, but not integrated with the patient record in the GP or hospital system (or vice versa), then drug or treatment contra-indications could be missed and the patient put at risk.Telehealth and telecare technologies need to be designed and developed within information systems architectures that support the wider objectives of integrated care. Such architectures should be clear about the integration trade-offs implicit in the technology designs between: practical and earlier delivery of benefits in the short-term versus the ability of the care team in the longer-term to treat the whole patient in a patient-centred and fully integrated manner.There are several types of integrated information systems architectures. One of these is the one deployed by Kaiser Permanente in the US. Kaiser’s information systems architecture contains the following elements: (a) a fully integrated electronic patient record at its core; (b) operation across care settings; (c) patients’ electronic access to their doctor and health record; (d) population care with whole patient chronic care management  with a consolidated disease register; (e) development and real-time deployment of embedded clinical protocols; (f) secure access by remote health facilities; (g) centralised technical standards and architecture alongside local developments ; and (i) analytic tools for high volume, complex data.Integration architectures range from full functional integration to data interoperability. In full functional integration architectures, the electronic patient record is at the core. This patient record is the detailed (not summary) record and reflects a complex information system supporting the entire clinical process including: review of clinical data , assessments, documentation and correspondence, requesting tests, prescribing and administering drugs, clinical decision support with real-time alerts, multi-resource scheduling, care plans and integrated care pathways, research and patient access to his/her record.The fully integrated healthcare systems architecture applies to, and operates across, patients, clinicians, clinical teams, carers, social workers, GPs, community units and hospitals within the geographical community in which the patient lives and receives care.The recommended actions for UK telehealth and telecare projects are (a) define your systems architecture and its integration road map; (b) deploy road map and revise systems architecture; and (c) repeat to continuously improve information systems support for integrated care.


The Emerging Infections Programs (EIPs), a population-based network involving 10 state health departments and the Centers for Disease Control and Prevention, complement and support local, regional, and national surveillance and research efforts. EIPs depend on collaboration between public health agencies and clinical and academic institutions to perform active, population-based surveillance for infectious diseases; conduct applied epidemiologic and laboratory research; implement and evaluate pilot prevention and intervention projects; and provide capacity for flexible public health response. Recent EIP work has included monitoring the impact of a new conjugate vaccine on the epidemiology of invasive pneumococcal disease, providing the evidence base used to derive new recommendations to prevent neonatal group B streptococcal disease, measuring the impact of foodborne diseases in the United States, and developing a systematic, integrated laboratory and epidemiologic method for syndrome-based surveillance. During the 1980s, clinicians added newly recognized infectious diseases, such as toxic shock syndrome and AIDS, to their differential diagnoses when evaluating previously healthy young adults with severe illness. More recently, clinicians in the United States found themselves considering the possibility of inhalational anthrax among patients with influenzalike illnesses and adding West Nile virus infection to their workup of posttransfusion fevers  articulated the concept of emerging infections, discarding the naive view that infectious diseases were problems of the past and cautioning against complacency about public health preparedness for infectious diseases   coordinaThe principal functions of EIPs are to perform active, population-based surveillance for infectious diseases; conduct applied epidemiologic and laboratory research; implement and evaluate pilot prevention and intervention projects; and provide capacity for flexible public health response. EIPs also develop and evaluate public health practice and transfer what is learned to the public health and medical communities.These programs are supported through cooperative agreements between CDC and state health departments, who engage collaborators in local health departments, hospitals, and academic institutions. Additional funding for certain EIP activities comes from other sources; for example, the U.S. Department of Agriculture and the Food and Drug Administration provide support for activities involving foodborne illnesses, and the National Vaccine Program Office has provided support for postlicensure vaccine evaluations.The population base for EIP activities is approximately 36 million persons, though the base varies by project. This population represents an approximation of the U.S. population with respect to demographic characteristics such as age, gender, race, and urban residence, as well as health indicators such as population density and percentage of persons at or below the poverty level .Active, laboratory-based surveillance is the foundation of two core EIP projects conducted at all sites: Active Bacterial Core Surveillance (ABCs) and Foodborne Disease Active Surveillance (FoodNet) . These aIxodes scapularis) in the state  project, a prospective study that uses epidemiologic and laboratory methods to detect and investigate unexplained illnesses with clinical features suggesting infectious diseases, has been in place at four states with EIPs since the inception of the program (Streptococcus pneumoniae (pneumococcus), which is an important cause of serious illness among young children, is the leading cause of bacterial pneumonia and meningitis in the United States. For many years, immunization against pneumococcus with a 23-valent polysaccharide vaccine was recommended for persons >2 years of age who are at high risk and for all adults >65 years of age. Although disease incidence is highest in the first 2 years of life, the polysaccharide vaccine was poorly immunogenic in this group. In February 2000, a protein-polysaccharide pneumococcal conjugate vaccine for seven pneumococcal serotypes  was licensed for use in infants and children . While this “replacement disease” phenomenon was recognized for otitis media and colonization in the prelicensure vaccine trials, no evidence of replacement invasive disease has thus far been recognized.Clinicians were challenged by the emergence of multidrug-resistant pneumococci during the 1990s, when new treatment guidelines were developed for meningitis, otitis media, and pneumonia  disease. Since its emergence in the 1970s, GBS disease has been the leading invasive bacterial infection associated with illness and death among newborns in the United States. Surviving infants may have long-term developmental disabilities, such as mental retardation or hearing and vision loss. Newborns at increased risk for GBS disease are those born to women who are colonized with GBS in the genital or rectal areas. Although the use of intrapartum prophylaxis has led to a 70% decline in the incidence of GBS disease during the 1990s  ,An EIP population-based, retrospective cohort study compared the effectiveness of prenatal screening for GBS with the risk-based approach for preventing early-onset GBS sepsis , Listeria (35%), Campylobacter (27%), and Salmonella (15%)  . The comSalmonella Enteritidis, and increased consumer education in food safety , followed by respiratory (27%) and cardiac (21%) syndromes. Diagnostic testing through UNEX identified a cause in 34 (28%) of 122 cases from which specimens were available .Two recent outbreaks demonstrate the usefulness of the approach developed for UNEX. During a 1999 outbreak of West Nile encephalitis in the northeastern United States, which was recognized by an alert clinician  in collaboration with Ministries of Health and other international partners. The first IEIP was established in Thailand during 2001, and a second IEIP is being established in Kenya. Collaborations between EIPs and IEIPs will provide valuable opportunities for training. In addition, the new U.S. EIP in New Mexico will feature work along the U.S.-Mexico border and also promises to enhance international collaborations.Opportunities presented by new laboratory and information technologies, as well as challenges posed by potential bioterrorism, will influence the evolution of the EIPs over the next several years. EIP work will build on experience gained through the combined epidemiologic and laboratory evaluation of syndromes to enhance bioterrorism preparedness and develop the capacity for identifying previously unrecognized pathogens. However, even as new technologies are found, knowledgeable and engaged clinicians will remain a vital element in efforts to detect, respond to, and prevent emerging infectious diseases.


Hantaviruses are endemic throughout the world and hosted by rodents and insectivores. Two human zoonoses, hemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome (HPS), are caused by hantaviruses and case fatality rates have reached 12% for HFRS and 50% for HPS in some outbreaks. Symptomatic hantavirus infections in Europe are summarised as HFRS mainly due to Puumala, Dobrava-Belgrade and Saaremaa virus. While HFRS has an overall low incidence in Europe, the number of cases varies from 100 per year in all Eastern and Southern Europe up to 1,000 per year only in Finland. To assess the quality of hantavirus diagnostics, the European Network for the Diagnostics of “Imported” Viral Diseases (ENIVD) organised a first external quality assurance (EQA) in 2002. The purpose of this second EQA study is to collect updated information on the efficiency and accurateness of hantavirus serological methods applied by expert laboratories. A serum panel of 14 samples was sent to 28 participants in Europe of which 27 sent results. Performance in hantavirus diagnosis varied not only on the method used but also on the laboratories and the subclass of antibodies tested. Commercial and in-house assays performed almost equally. Enzyme immunoassays were mainly used but did not show the best performances while immunoblot assays were the less employed and showed overall better performances. IgM antibodies were not detected in 61% of the positive IgM samples and IgM detection was not performed by 7% of the laboratories indicating a risk of overlooking acute infections in patients. Uneven performances using the same method is indicating that there is still a need for improving testing conditions and standardizing protocols. Hantaviruses are endemic throughout the world and naturally hosted by rodents. The vast majority of human hantavirus infections are asymptomatic. In Europe, symptomatic hantavirus infections are summarised as hemorrhagic fever with renal syndrome (HFRS) mainly due to Puumala, Dobrava-Belgrade and Saaremaa virus. HFRS can cause fever, headache, and flank and abdominal pain. Moreover, renal dysfunction can lead to acute renal failure. Despite numerous research efforts, there is still no safe and effective vaccine or specific antiviral treatment against hantavirus infections. In this context, an accurate diagnosis as well as a reliable surveillance of hantavirus infections is essential. The diagnostics of hantavirus infections are based on serology using in-house or commercial assays. To assess the quality of hantavirus diagnostics, the European Network for the Diagnostics of “Imported” Viral Diseases organised a first external quality assurance (EQA) in 2002. In this publication we describe a second EQA study launched in 2011 with the objective to collect updated information on the efficiency and accurateness of hantavirus serological methods applied by expert laboratories. The study shows uneven performances indicating that there is still a need for improving testing conditions and standardizing protocols. Hantaviruses are endemic throughout the world and naturally hosted by rodents and insectivores. Humans are mostly infected by inhalation of virus-containing aerosolized excretions  or bites from host rodents, and there is no transmission between humans. Two human zoonoses, hemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome (HPS), are caused by hantavirus infections and case fatality rates can reach up to 50% for Sin Nombre and New York virus infections causing HPS and 12% for hantavirus infections causing HFRS. Nevertheless, the vast majority of human hantavirus infections are asymptomatic.Myodes glareolus (bank vole), Dobrava-Belgrade virus (DOBV) carried by Apodemus flavicollis (yellow-necked mouse) and Saaremaa virus (SAAV or DOBV-A.a) carried by Apodemus agrarius (striped field mouse) HPS are reported mainly in the Americas while symptomatic hantavirus infections in Europe are summarised as HFRS which occurs mainly due to infections by Puumala virus (PUUV) carried by Despite numerous research efforts, there is still no safe and effective vaccine or specific antiviral treatment against hantavirus infections.Hantavirus infections were probably highly under-diagnosed before reliable diagnostic tools became available in the 1990s. Due to the short-term and difficult detection of virus and viral nucleic acid in infected humans, the diagnostics of human hantavirus infections is mainly based on serological assays. For many years, the serological diagnosis of hantavirus infections was mainly based on immunofluorescence assays. However, in the recent years, enzyme-linked immunosorbent assays, immunoblotting, and immunochromatographic rapid tests have been developed http://www.enivd.org) organised a first external quality assurance (EQA) study in 2002 with 18 laboratories participating To assess the quality of the hantavirus diagnostics in Europe, the European Network for Diagnostics of ‘Imported’ Viral Diseases (ENIVD)  or national/regional reference laboratories for hantaviruses or vector-borne diseases. The study was announced as an EQA study on hantavirus serological diagnostic methods proficiency, which included publishing the results in a comparative and anonymous manner.The ENIVD-CLRN coordinated this EQA as in other previously performed EQA studies A panel of 14 samples was prepared with anti-hantavirus positive sera from seven patients infected with hantavirus diluted with fresh frozen plasma previously confirmed as negative for hantavirus. After dilution, the samples were heat inactivated . Aliquots of 100 µl were number-coded, freeze dried for 24 h  and stored at 4°C until dispatch.All sera used in the panel come from an already-existing collection of patient sera from routine laboratory investigations. Sera samples were taken with the written consent from the patients and all samples were anonymized.The proficiency panel was composed of :a set of 6 positive samples consisting of serial 2-fold dilutions of a Puumala positive serum from Sweden (IgM and IgG positive)one serum from Slovenia positive for Puumala one serum from Slovenia positive for Puumala (IgM and IgG positive)one serum from Slovenia positive for Dobrava-Belgrade one serum from Slovenia positive for Dobrava-Belgrade (IgM and IgG positive)one serum from Finland positive for Puumala one antiserum containing antibodies reactive for inner cell structures as specificity controlone negative serum from Finland as negative controlone sample with plasma used for dilution as negative controlBefore shipping, the serum panel was evaluated by two expert laboratories. The testing methods used included in house IFA and ELISA as well as commercial IFA.The EQA panels were distributed to participants with full instructions. Samples were shipped by normal post at ambient temperature to the participating laboratories. We requested participant laboratories to resuspend the samples in 100 µl of water and to analyse the material as serum samples for detection of IgM and IgG antibodies against hantaviruses. They were asked to report their results and any problems encountered as well as information on the protocol details using a common formulary included in the documentation.To guarantee anonymous participation, an individual numerical identification code was assigned to the results reported by each laboratory. This number was followed by a letter  when different data sets of results based on different methods were sent.The results were scored in reflection of sensitivity and specificity. We assigned one point for correct virus type and one point for correct positive or negative result whereas false- negatives/positives results were not scored. Equivocal or borderline results were considered as positive. IgM and IgG results were considered separately. Data collected were entered into Microsoft Excel .Among the 28 invitees, the following 27 laboratories coming from 20 countries of the European region sent back their results  and participated to the EQA:Medical University of Vienna, Austria; Institute of Tropical Medicine, Antwerp, Belgium; Reference Laboratory for Vector-Borne Diseases, Brussels, Belgium; National Reference Vector-borne infections and leptospirosis laboratory, Sofia, Bulgaria; National Reference Laboratory for Arboviruses, Ostrava, Czech Republic; National Institute for Health Development, Virology Department, Tallinn, Estonia; Institut Pasteur, Department of Virology, Lyon, France; Institut für Medizinische Virologie, Berlin, Germany; Friedrich-Loeffler-Institut, Greifswald, Germany; EUROIMMUN AG, Lübeck, Germany; Institut für Mikrobiologie der Bundeswehr, Munich, Germany; Firm Mikrogen, Neuried, Germany; National Reference Laboratory for Viral Zoonoses, Budapest, Hungary; National Institute for Infectious Diseases, Rome, Italy; Microbiologia e Biotecnologie mediche Università di Padova, Italy; Policlinico San Matteo, Pavia, Italy; Infectiology Centre of Latvia, Riga, Latvia; Laboratoire National de Santé, Luxembourg, Luxembourg; Norwegian Institute of Public Health Department of Virology, Oslo, Norway; National Institute of Health, Águas de Moura, Portugal; Laboratory for Vector-Borne Infections and Medical Entomology, Bucharest, Romania; University of Ljubljana Medical Faculty, Ljubljana, Slovenia; Centro Nacional de Microbiología Instituto de Salud Carlos III, Madrid, Spain; Spiez Laboratory, Spiez, Switzerland; Erasmus MC Department of Virology, Rotterdam, the Netherlands; Refik Saydam National Public Health Agency, Ankara, Turkey; Reference Unit Centre for Emergency Preparedness and Response, Wiltshire, United Kingdom.Of all data sets of results received, 46% (15/33) reported the use of enzyme-linked immunosorbent assays (EIA), 27% (9/33) immunofluorescence assays (IFA), 15% (5/33) immunoblot assays (IBA) and 12% (4/33) EIA combined EIA with IBA or IFA.Participants used mainly commercial tests  and the remaining tests were in house methods. The performance of commercial tests was equal to that of in-house methods for both IgM and IgG detection.Performances varied depending not only on the diagnostic method used but also on the laboratory performing the test and the subclass of antibodies detected by the test. Two out of 33 reports (6%) did not include IgM testing results and tested only for the presence of IgG antibodies by IFA . On the We can have indications on the specificity of the diagnostic methods looking at the testing results of the two negative controls and the unspecific serum. Concerning IgM antibody detection, only one false positive result was obtained with an in-house IFA in the negative control containing the plasma used for dilution (sample #7). Concerning IgG antibody detection, false positives were observed in the specificity control, sample #5 . Surprisingly more false positives were observed among the two negative controls, samples #3 and #7 . False positives results were all obtained by commercial IFA or EIA.To have indications on the specificity of the methods used we can also compare between the different strains of hantavirus by virus type or by place of origin. Comparing the DOBV and PUUV positive sera, we observe that the DOBV positive serum was detected more accurately by IgM detection methods than by IgG detection contrary to the PUUV sera. In fact only two of the 31 methods used for IgM detection  have failed to detect anti-DOBV IgM while 14 of the 33 methods used for IgG detection (42%) have failed to detect anti-DOBV IgG in sample #10.Comparing the detection of PUUV positive sera by country of origin , no main differences in performance were observed for IgM or IgG antibody detection.We can have indications on the sensitivity of the diagnostic methods looking at the testing results of the 6 serial dilutions of PUUV positive sera . Regarding the testing of IgM antibodies, at least one false negative was reported by all participants except one (97%). The only method which presented no false negatives in its results was a combination of in house EIA and IFA. In contrast, IgG testing has shown to be more sensitive as half of the results for IgG detection did not report false negatives. All IBA results revealed no false negatives in IgG detection and thus showed to be very sensitive. IFA showed lower performance concerning sensitivity of IgG detection  and EIA showed the lowest performance in this regard . In house versus commercial assays showed similar sensitivities regarding IgG detection. Only 2 diagnostic methods (6%) failed in the detection of IgG antibodies in the highest PUUV sera dilution (sample #13) and both were commercial EIAs.Comparing the scores obtained by the participants and the sensitivity of the tests for IgG detection, it seems that better performances were achieved by the laboratories using IBA which were all commercial assays . The first EQA study run in 2002 had shown similar good performances for commercial IBAs. No major differences were found in terms of performance concerning IgG/IgM antibody detection with IFA or EIA.Although most of the participants used EIA, these tests have not shown the best performances concerning both specificity and sensitivity characteristics.Among all participants, two have not included the detection of IgM antibodies in their routine diagnosis algorithm (6%). Furthermore the proportion of samples correctly diagnosed for IgM detection  was much lower than the proportion of samples with an accurate IgG antibody diagnosis . These elements indicate a risk of overlooking acute infections in patients with early hantavirus infections. In fact the sole presence of IgG antibodies in a serum sample could be the sign of previous contact with hantaviruses and is not enough to prove a recent infection. To confirm the diagnosis, the analysis of a second sample is required. Differences of test sensitivity depending on the antibody type detected have already been reported in the first hantavirus EQA study Regarding strain typing, it is important to point out that, because of the scoring system used in this EQA, the laboratories reporting lower scores are not necessarily the ones with lower performances. In fact, data sets reporting correct positive and negative results but not specifying the strain type obtain rather low scores although the diagnostic is entirely correct. These results are completely satisfactory in the context of clinical diagnosis as there is no specific treatment for the different hantavirus infections. The most important information is whether the patient is diagnosed positive for hantavirus or not and further analyses can always be performed. On the other hand information on the strain type is relevant for surveillance activities.Although HFRS has a low incidence in most of Europe, the disease can be very severe. Therefore, the sensitivity of the tests used for diagnostics is more critical than its specificity. False negatives may be considered more critical than reporting a false positive as positive results can always be submitted to further testing for confirmation. In other words, in case of low disease prevalence, the predictive value of a negative test (PVN) should be higher than the predictive value of a positive test (PVP), meaning the proportion of non affected people among those tested negative should be higher than the proportion of affected people among those tested positive.Overall, commercial and in-house assays performed almost equally. The method used  was not the main factor to have impact on the quality of the test results. From the results of this EQA, it appears clearly that the quality of the results is mostly linked to the laboratories and their use of the different protocols since their performance differ greatly even when using the same techniques. Such problems could be solved by the standardisation of the protocols and controls used and the optimisation of conditions during testing.The previous hantavirus EQA performed in 2002 Further external quality controls should be performed for hantavirus detection as EQAs are not only important for the most prevalent viral pathogens but also for rarely suspected viruses. Performing EQAs on a regular basis enables to ensure the reliability of diagnostic results, to guarantee a continuous quality of the existing diagnostic methods and further improve them.


Human influenza infection poses a serious public health threat in Cambodia, a country at risk for the emergence and spread of novel influenza viruses with pandemic potential. Prior pandemics demonstrated the adverse impact of influenza on poor communities in developing countries. Investigation of healthcare resource distribution can inform decisions regarding resource mobilization and investment for pandemic mitigation.A health facility survey performed across Cambodia obtained data on availability of healthcare resources important for pandemic influenza response. Focusing on five key resources considered most necessary for treating severe influenza , resource distributions were analyzed at the Operational District (OD) and Province levels, refining data analysis from earlier studies. Resources were stratified by respondent type . A summary index of distribution inequality was calculated using the Gini coefficient. Indices for local spatial autocorrelation were measured at the OD level using geographical information system (GIS) analysis. Finally, a potential link between socioeconomic status and resource distribution was explored by mapping resource densities against poverty rates.Gini coefficient calculation revealed variable inequality in distribution of the five key resources at the Province and OD levels. A greater percentage of the population resides in areas of relative under-supply (28.5%) than over-supply (21.3%). Areas with more resources per capita showed significant clustering in central Cambodia while areas with fewer resources clustered in the northern and western provinces. Hospital-based inpatient beds, doctors, and nurses were most heavily concentrated in areas of the country with the lowest poverty rates; however, beds and nurses in Non-Hospital Medical Facilities (NHMF) showed increasing concentrations at higher levels of poverty.There is considerable heterogeneity in healthcare resource distribution across Cambodia. Distribution mapping at the local level can inform policy decisions on where to stockpile resources in advance of and for reallocation in the event of a pandemic. These findings will be useful in determining future health resource investment, both for pandemic preparedness and for general health system strengthening, and provide a foundation for future analyses of equity in health services provision for pandemic mitigation planning in Cambodia. The serious public health impact of human influenza infection in Cambodia is increasingly apparent. Highly pathogenic avian influenza is now considered enzootic among poultry in the country, with a total of 34 human cases of H5N1 infection confirmed as of early July 2013, of which 28 have been fatal . DevelopThe H1N1-2009 pandemic also demonstrated the limitations of health system pandemic response capacities, even in developed countries ,11. WhilThis report builds upon the findings of a previous research project, AsiaFluCap . The AsiThe current analysis constitutes a sub-component of an overarching project, the CamFlu Project, which draws on current health service resource distribution patterns in Cambodia to model scenarios for cost-effective options to improve pandemic response capacity and evaluate the public health impact of scaling up resources for influenza pandemic response. Thus, the present study aims to further explore the challenges involved in efficiently and effectively distributing key health system resources in Cambodia for pandemic influenza mitigation, specifically by refining previous distribution analyses from the Province to the OD level and investigating associations with a socioeconomic indicator, the Predicted Family Poverty Rate (PPR).et al. . Similarly, the IDPoor data identifies poor households on the basis of a standard questionnaire that utilizes proxy indicators for poverty, with a focus on observable and verifiable assets, as well as social indicators such as household composition, dependency ratios, and school attendance . The PPRIn order to link the PPR to the resource data obtained through the survey collection described above, a composite PPR was calculated for each OD and Province by determining a weighted average for all communes within the relevant area. Both resource densities and weighted PPR averages were calculated using population data derived from the General Population Census of Cambodia (2008) . All resThe questionnaire response rates for both government-based hospitals and DHOs was 100 percent. There were two instances of missing data among the variables reported in this analysis, both of which were for oseltamivir . Results presented here include extrapolated data for these missing questionnaire items, as described previously .The statistical distributions of the densities  for the five key resource items across Provinces and ODs are presented as box plots in Figures Gini coefficients for each of the five key resources across Provinces and ODs are shown in Table As described in the methods section, areas of relative under-supply are classified as those with resource densities in the lowest quintile of resource distribution across all ODs or Provinces, respectively, while areas of relative over-supply are characterized by resource densities in the highest quintile .With reference to the Moran’s Index Table , all resAnalysis of resource densities by PPR, stratified by clinical setting , revealed discernible patterns Figure . Of note2 = 0.61), with a U-shaped distribution for the remaining poverty quintiles. Among NHMF, in contrast, there was a nadir in inpatient bed availability in the middle (third) poverty quintile, with resource availability increasing alongside increasing poverty level in the fourth and fifth quintiles (R2 = 0.34). Doctors were very heavily concentrated in the wealthiest areas (first quintile), although this pattern was more pronounced in the hospital than NHMF setting . If Phnom Penh OD is excluded from the analysis of NHMF resources, per capita density of doctors is relatively equally distributed across poverty quintiles . The distribution of NHMF nurses, however, showed a clear pattern of increasing concentrations in poorer areas (R2 = 0.74). Both oseltamivir and ventilators were most heavily concentrated in areas in the first and second poverty quintiles, with supplies sparsely distributed throughout poorer areas , clinical setting , geography , and poverty level. The results build and expand on previously published data on pandemic health resource distribution in Cambodia ,17 by foIn the event of a pandemic, inpatient beds can be redistributed to affected areas with insufficient resources relatively quickly, particularly among ODs within a given Province. Indeed, the Cambodian Ministry of Health anticipates the need for redistribution of certain resources, such as isolation beds and personal protective equipment (PPE), from areas of high concentration to areas experiencing a pandemic-related surge in demand. Detailed knowledge of existing resource density by OD is, thus, essential for rapid and efficient redistribution in the event of a pandemic.In terms of doctors and nurses, there may be benefit to temporarily deploying medical personnel most heavily concentrated in Phnom Penh to remote ODs in the event of a pandemic influenza, assuming that affected individuals are unable to voluntarily travel to the capital to seek care (either due to distance or illness severity). The fact that the distribution of doctor and nurses by OD exhibited markedly different patterns, particularly by PPR, is worth noting and raises the question of whether enhancing clinical capacity of nurses to serve as physician extenders in areas of the country where doctors are scarce might also be beneficial in a resource-constrained setting. Indeed, this may present an opportunity to improve pandemic preparedness and prevention through maximizing population health, as nurses represent core workforce capacity for basic primary care provision and many public health education activities. At the same time, increased investment in health care workers (both doctors and nurses) in relatively undersupplied ODs is prudent. In order to achieve its articulated goals of improving baseline health in three identified priority areas – reducing newborn, child and maternal morbidity and mortality while improving reproductive health; reducing morbidity and mortality attributable to communicable diseases, including HIV/AIDS, tuberculosis, and malaria; and reducing the burden of non-communicable and other diseases – the Ministry of Health has acknowledged the importance of improving health service delivery at the OD level, including through more effective human resource planning and management ,25. FocuThe availability of oseltamivir reported here must be interpreted within the regional context in which Cambodia is embedded. As a member of ASEAN since 1999, Cambodia received an initial national stockpile of antivirals (as well as PPE) from the Japan-ASEAN Antiviral Stockpile for ASEAN Countries and is eligible to draw on additional stores from the central stockpile storage site in Singapore in the event of a pandemic. Cambodia was the site of a test exercise in early 2007 to determine adequacy of protocols for redistributing antivirals and PPE from the central stockpile, suggesting that such a strategy could efficiently augment Cambodia’s existing supplies of these important resources .For resources that require the presence of trained medical personnel and reliable electricity to be clinically useful, such as ventilators, it will likely prove most efficient to refer or transport patients to areas where these resources are known to be concentrated. Given the low absolute numbers of ventilators available in Cambodia and the logistical challenges (i.e. requirements for attendant electricity and personnel) involved in mobilizing ventilators either domestically or from other countries in the region, it is likely that the capacity of even the most well-supplied areas would be rapidly overwhelmed during a pandemic by patients seeking care at referral hospitals.It is important to emphasize that the data presented here reflect only the distribution of selected resources provided through the public health care system in Cambodia and do not account for complementary resources available in the private and non-government organization (NGO) sectors. Given the historical development of the Cambodian health care system over the past few decades, with substantial reliance on donor investment and NGO health programming activities in addition to an intentional strategy of decentralized health system management and public-private partnerships, a comprehensive assessment of resource distribution requires complementary data on resources available in these other sectors. Indeed, an estimated 50-60% of all health treatments are provided by the private sector and 15-20% by practitioners outside the traditional medical sector , compared with approximately 20% through government facilities ,28. ThusThere is substantial variation in health care resources important for pandemic influenza response across Cambodia. This diversity is related to a number of factors, including geographic location, resource type, clinical setting, and poverty rates at the OD level. Absolute availability of specific key resources also plays a role, as resources that are scarce nationwide are concentrated in selected areas. The implications of these findings vary by resource type, as the strategies for distribution and improved accessibility must take into account clinical appropriateness as well as resources available from outside the country. Further assessment of the feasibility and appropriateness of resource distribution options requires a more comprehensive understanding of complementary health resources available in the private and NGO sectors. In conjunction with such data, the resource distributions presented here will prove useful for strategic health resource investment around the country, both for future pandemic mitigation and to strengthen the baseline functioning of the Cambodian health care system.Understanding the existing distribution of selected healthcare resources important for treating severe influenza is a necessary condition for ensuring equity in future pandemic mitigation planning in Cambodia. Health-related equity is a broad concept that encompasses health service financing, health service delivery, and health outcomes. Although there are numerous definitions for health equity, most authors agree that achieving equity in health requires minimizing avoidable inequities  in health determinants and outcomes by ensuring equal access to a minimum standard of healthcare ,29-31. TCDB: Commune Database; DHO: District Health Office; GIS: Geographical information system; GIZ: Deutsche Gesellschaft für Internationale Zusammenarbeit; HSP: Health Sector Strategic Plan 2008–2015; LISA: Local indicators of spatial autocorrelation; NCDD: Cambodian National Committee for Sub-National Democratic Development; NGO: Non-governmental organization; NHMF: Non-hospital medical facilities; OD: Operational District; PPE: Personal protective equipment; PPR: Predicted Family Poverty Rate.SUSK: The author declares no competing interests.JWR: JWR has worked on an unrelated project funded by Hoffman La Roche, the maker of oseltamivir.TD: The author declares no competing interests.IC: The author declares no competing interests.KB: The author declares no competing interests.ST: The author declares no competing interests.RC: RC has held grants unrelated to this research from Hoffman La-Roche, the maker of oseltamivir.SSK carried out the socioeconomic analysis and drafted the manuscript. JWR participated in study coordination and data analysis and helped draft the manuscript. TD coordinated data analysis and helped draft the manuscript. IC performed the GIS analysis and drafted corresponding sections of the manuscript. KB and ST facilitated data collection and participated in resource characterization. RC conceived, designed and coordinated the study. All authors read and approved the final manuscript.Map of Operational Districts (ODs) in Cambodia. Description: Map enumerating the Operational Districts (ODs) in Cambodia with corresponding OD names, for reference in interpreting Figures Click here for fileLorenz Curves of Healthcare Resource Densities (Province and OD). Description: Lorenz curves showing inequality in healthcare resource densities per capita across Provinces and Operational Districts (ODs) in Cambodia.Click here for fileNHMF-based Doctors per Capita, Excluding Phnom Penh (OD). Description: Per capita density of doctors based in non-hospital medical facilities stratified by Predicted Family Poverty Rate at the Operational District level, excluding Phnom Penh.Click here for fileOseltamivir and Ventilators per Capita (OD). Description: Per capita density of oseltamivir and ventilators (both adult and pediatric) stratified by Predicted Family Poverty Rate at the Operational District level.Click here for file


India is urbanizing at a rapid pace. Moreover, a quarter of the urban population lives in slum areas . UnfavorThere has been a growing concern among public health researchers/programmers regarding the neglect of urban poor in governments’ health policies/programs ,8. The gKG Halli is the field site of the Urban Health Action Research Project (UHARP) designed and implemented by the Institute of Public Health (IPH). Its purpose is to enhance access to quality healthcare for the KG Halli residents.We used the data collected over a period of almost four years (2009-2012) through following tools:(1) A census covering 9,299 households with a response rate of 98.5% in KG Halli using a structured questionnaire collecting data about socio-demographic factors, self-reported illnesses, healthcare seeking behavior and expenditure;(2) Audio recordings of six of the periodic meetings of healthcare providers in KG Halli, facilitated under the UHARP;(3) Field notes from UHARP researchers; and(4) In-depth interviews with eight diabetes patients , and semi-structured interviews with 14 healthcare providers, staff from two pharmacies and two laboratories in KG Halli .For the survey, interviews, and meetings, an informed consent was obtained prior to collecting data. We used the health system dynamics framework developed by Van Olmen et al  as analyOf the two government facilities in the area, the Community Health Center (CHC), run by the state government, provides care for diabetes. In the private sector, there are at least 18 doctor clinics, four hospitals, three laboratories, and many pharmacies. These clinics are staffed by general practitioners (GPs) who reported their training being in various medical systems; modern medicine (four), unani (eight), ayurveda (four), homeopathy (one) and others.There is a lack of administrative and operational integration across providers. Only two of the private providers were aware of and registered under the Karnataka Private Medical Establishment Act (KPMEA), a mandatory mechanism to ensure minimum quality in private healthcare provision. All GPs, except for three who were not trained in modern medicine, were practicing modern medicine. None of the providers interviewed were aware of the standard treatment guidelines for diabetes developed at national level. Both interviewees who were managing private pharmacies were untrained pharmacists. Pharmacies and laboratories interviewed reported the practice of kickbacks (10 to 25% of investigation or medication costs) given by them (and other laboratories/pharmacies) to most GPs in the area.Medical specialists were available with prior appointment in hospitals. The CHC, which is supposed to provide specialist care, neither had specialist services nor offered laboratory investigations for diabetes. Other factors affecting diabetes care at CHC included the frequent stock-outs of diabetes medicines and the limited availability of medical doctors due to frequent deputations and/or turnover. For primary care on an outpatient basis, only five GPs followed some form of medical record system aimed at organizing clinical information over the time. Most GPs prescribed branded medicines and reported negative perceptions of generic medicines . Though generic medicines were available at some of the private pharmacies, the cost was comparable to that of branded medicines.Over 85% of diabetes patients sought care form private providers that operate on fee-for-service basis. 72% of diabetes patients incurred out-of-pocket (OOP) expenditure for outpatient care and of those 22% spent over 10% of their family income on diabetes care. In 3.3% of the episodes, families resorted to borrowing money and/or selling assets.People’s participation in the health system was limited to exercising choice in selecting providers, self-care/medication, and funding the system. Public and private orientation to healthcare delivery coexisted with dominance of the latter one.Some of the challenges highlighted in this paper  are not unique to KG Halli, but affects the government system as a whole. The National Rural Health Mission launched in 2005, aims to address these challenges. Unfortunately, the National Urban Health Mission, an initiative similar to its rural counterpart for urban areas, has remained in draft stage since 2010.Considering the dominant presence and utilization by diabetes patients of poorly regulated private providers, there is need to enhance the implementation of the existing regulatory mechanisms e.g. KPMAE. In a pluralistic medical system like the one in KG Halli, there is need for some sort of steering mechanism that enhances coordination across health providers and directs the system towards a common goal. The UHARP has been facilitating actions in this direction with some positive outputs including enhanced coordination and collaboration across the providers in addressing local health issues.Rastriya Swasthya Bima Yojana) to include urban poor, as well as the service package to include outpatient care for chronic conditions might significantly reduce OOP payments. Motivating providers to prescribe generic medicines through various mechanisms  and making generic medicines available at low prices are other ways of reducing OOP spending. Karnataka government has recently implemented a pilot making generic medicines available at low prices at selected tertiary government hospitals. Expansion of such schemes and making outlets within the community would be a positive step.High OOP spending and related impoverishment implies the need for financial protection mechanisms. Expanding the coverage of existing schemes , Government of Belgium, through the institutional collaboration between the Institute of Public Health, Bangalore and the Institute of Tropical Medicine, Antwerp. The first author is supported by a PhD scholarship from the Institute of Tropical Medicine, Antwerp under the DGD grant mentioned above.


Parasitic isopods of Bopyroidea and Cryptoniscoidea (commonly referred to as epicarideans) are unique in using crustaceans as both intermediate and definitive hosts. In total, 795 epicarideans are known, representing ∼7.7% of described isopods. The rate of description of parasitic species has not matched that of free-living isopods and this disparity will likely continue due to the more cryptic nature of these parasites. Distribution patterns of epicarideans are influenced by a combination of their definitive (both benthic and pelagic species) and intermediate (pelagic copepod) host distributions, although host specificity is poorly known for most species. Among epicarideans, nearly all species in Bopyroidea are ectoparasitic on decapod hosts. Bopyrids are the most diverse taxon (605 species), with their highest diversity in the North West Pacific (139 species), East Asian Sea (120 species), and Central Indian Ocean (44 species). The diversity patterns of Cryptoniscoidea  are distinct from bopyrids, with the greatest diversity of cryptoniscoids in the North East Atlantic (18 species) followed by the Antarctic, Mediterranean, and Arctic regions . Dajidae  exhibits highest diversity in the Antarctic (7 species) with 14 species in the Arctic and North East Atlantic regions combined. Entoniscidae  show highest diversity in the North West Pacific (10 species) and North East Atlantic (8 species). Most epicarideans are known from relatively shallow waters, although some bopyrids are known from depths below 4000 m. Lack of parasitic groups in certain geographic areas is likely a sampling artifact and we predict that the Central Indian Ocean and East Asian Sea  hold a wealth of undescribed species, reflecting our knowledge of host diversity patterns. Within crustaceans, a wide range of groups including amphipods, barnacles, copepods, and isopods have formed parasitic relationships with invertebrate and vertebrate hosts. Three taxa within Isopoda  are composed of parasites that attach either permanently or during larval stages to their hosts (some cymothooids such as Aegidae are temporary ectoparasites or micropredators of fish). Cymothooids (∼1250 species) are ectoparasites of fish, with most cymothooids feeding on the blood and tissue of hosts as larvae and adults whereas gnathiids only parasitize fish during larval stages Paleontological evidence shows bopyroids and cryptoniscoids , online sources nomina nuda, all “species” of Microniscus , any replacement names for homonyms, and Proteolepas bivincta Darwin, 1854 (which may be an epicaridean but is presently considered a nomen dubium). Rate of species descriptions over time is reported by decade, excepting the years 1798–1859, where 1 to 7 species per decade were described and these data are therefore combined. Total number of described species and genera were reported for the biogeographic regions (“Marine Regions”) of Data were gathered from the literature since 1864  and again in the 1970s and 1980s (primarily the work of Bourdon and Markham) . The earParasitization of decapods by bopyrids is seen in the fossil record and extends back to at least the Jurassic Asymmetrione (Pseudioninae) and attachment suckers on the oostegites in some species of Hemiarthrinae. All epicaridean species have sexual dimorphism, with larger females having more modified features than the dwarf males.The morphology of epicarideans can be quite modified from free-living isopods, and females of some taxa are scarcely recognizable as being isopods. Although loss of structures in derived taxa may occur , it cannot be stated that all aspects of epicaridean morphology display such reduction. In fact, many species have highly specialized features developed for aid in attachment to hosts, such as the dactyl sockets of species in Members of Bopyridae are nearly all ectoparasitic on decapod hosts , includiDajids are ectoparasitic on the cephalothorax, head, gills, or sometimes in the marsupium of euphausiid, mysid and shrimp hosts. Females are typically ovate in shape and highly modified, sometimes with claw-like pereopods or antennae Cryptoniscoidea contains seven families composed of endoparasitic species associated with a diverse assemblage of crustacean hosts and include some species that are hyperparasitic Unlike parasitic isopods in Cymothooidea that are monoxenous and produce manca larvae that parasitize fish hosts, epicarideans are heteroxenous, infesting two hosts during their life cycle. For all epicaridean species that have been investigated, a pelagic calanoid copepod acts as the intermediate host and another crustacean acts as the definitive host. Intermediate host specificity is poorly known, with little research having investigated any of the interactions between bopyrids and copepod hosts e.g., .Sex determination is not fully known in epicarideans but can be genetically or epigametically controlled Species of the endoparasitic bopyroid subfamily Entophilinae create an exit pore near the base of the fourth pereopods of hosts and it is probably through this pore that larvae are released into the water The life cycles of all Dajidae species are assumed to include pelagic copepod intermediate hosts, but this has only been confirmed in a small number of species Cryptoniscoidea are protandric sequential hermaphrodites and, for those few species that have been studied, exhibit a similar life cycle to bopyrids Through their actions as hemolymph and ovarian fluid feeders, epicarideans can be parasitic castrators of their hosts. Some species of bopyrids and dajids are best considered partial parasitic castrators, since they have not been shown to wholly shut down reproduction of hosts Epicarideans are a diverse group, representing 7.7%  of described isopods. The rate description of parasitic species has not matched that of free-living isopods; in the late 1980s, approximately 13% of described isopods were epicarideans incertae sedis. Bopyrids exhibit highest diversity within the North West Pacific (139 species), East Asian Sea (120 species), and Central Indian Ocean (44 species). However, we predict that the Central Indian Ocean and the East Asian Sea  hold a wealth of undescribed species, reflecting our knowledge of host diversity patterns Of these 795 described parasitic isopods The diversity patterns of Cryptoniscoidea are distinct from bopyrids, with the greatest diversity of cryptoniscoids at the high and low latitudes. Specifically, cryptoniscoids exhibit highest diversity in the North East Atlantic (18 species) and, when combined with the Arctic (8 species), >26% are found in this region of the northern hemisphere; the other areas of high diversity are the Antarctic (13 species) and Mediterranean (12 species) . SimilarMost epicarideans are known from relatively shallow waters, although two described species of bopyrids are known from depths below 4000m, with undescribed species known down to 5210 m The epicarideans are currently divided into Cryptoniscoidea and Bopyroidea within Cymothoida Currently, Bopyridae is divided into nine subfamilies Rhopalione are found under the abdomens of their pinnotherid hosts. In Athelginae, the females are located on the dorsal abdomen of the host hermit or king crab, while in Phyllodurinae, the female isopod is situated on the ventral surface of the Upogebia (Gebiidea) host abdomen. Female isopods of Hemiarthrinae are found either on the dorsal or ventral surface of the abdomen, laterally on the carapace, or, uniquely for one species, inserted into the buccal region of the host shrimp In the subfamilies Pseudioninae, Bopyrinae, Argeiinae and Orbioninae, the adult female parasite is located on the decapod host in the right or left branchial chamber. The branchial chamber is also the usual site of attachment for members of Ioninae, but species of Until recently, no phylogenetic testing of the monophyly of any epicaridean taxa has ever been attempted using morphological or molecular data, although non-cladistic hypotheses of subfamilial relationships exit Argeia pugettensis (Argeiinae) that infests at least 20 species of crangonid shrimp hosts, some of which are commercially important Parasitic isopods impact a variety of commercially important hosts, including brachyuran crabs, false kings crabs, king crabs, and shrimp e.g.,  or are pOrthione griffenis Markham, 2004 (Pseudioninae) infests the gebiid mud shrimp Upogebia pugettensis along the west coast of the United States. This parasite was apparently introduced from Asia sometime during the late 1980s Although many native parasites do not markedly impact host populations, introduced parasitic isopods have been shown to cause severe negative impacts on host populations. For example, the bopyrid Parasitic isopods have been evaluated for use in a variety of applied contexts. For example, some parasitic isopods have been examined as potential biological controls for introduced host decapods


Diet, physical activity (PA) and sedentary behavior are important, yet modifiable, determinants of obesity. Recent research into the clustering of these behaviors suggests that children and adolescents have multiple obesogenic risk factors. This paper reviews studies using empirical, data-driven methodologies, such as cluster analysis (CA) and latent class analysis (LCA), to identify clustering patterns of diet, PA and sedentary behavior among children or adolescents and their associations with socio-demographic indicators, and overweight and obesity. A literature search of electronic databases was undertaken to identify studies which have used data-driven methodologies to investigate the clustering of diet, PA and sedentary behavior among children and adolescents aged 5–18 years old. Eighteen studies  were identified that met the inclusion criteria, of which eight examined the clustering of PA and sedentary behavior and eight examined diet, PA and sedentary behavior. Studies were mostly cross-sectional and conducted in older children and adolescents (≥9 years). Findings from the review suggest that obesogenic cluster patterns are complex with a mixed PA/sedentary behavior cluster observed most frequently, but healthy and unhealthy patterning of all three behaviors was also reported. Cluster membership was found to differ according to age, gender and socio-economic status (SES). The tendency for older children/adolescents, particularly females, to comprise clusters defined by low PA was the most robust finding. Findings to support an association between obesogenic cluster patterns and overweight and obesity were inconclusive, with longitudinal research in this area limited. Diet, PA and sedentary behavior cluster together in complex ways that are not well understood. Further research, particularly in younger children, is needed to understand how cluster membership differs according to socio-demographic profile. Longitudinal research is also essential to establish how different cluster patterns track over time and their influence on the development of overweight and obesity. The unacceptably high prevalence of childhood overweight and obesity is a major public health issue in developed countries world-wide . ObesityDespite the importance of these modifiable factors in obesity etiology, there is evidence to suggest that many children and adolescents do not engage in these behaviors at the recommended levels  or latent class analysis (LCA) to investigate cluster patterns have become increasingly common. These approaches aim to maximally separate people into mutually exclusive groups who share similar characteristics ,15. DataTherefore the aim of this paper is to critically review published studies in the peer-reviewed literature that have used data-driven methods to investigate the clustering patterns of diet, PA and sedentary behavior in children and adolescents and their associations with socio-economic indicators  and overweight and obesity.Searches were conducted by using Medline, PubMed, Science Direct, Scopus and Google Scholar Databases using the following key words and their alternatives (provided in parentheses) in their truncated forms : children, adolescents, clustering patterns  dietary behavior , physical activity  and sedentary behavior . A manual inspection of the bibliographies of recent references was also undertaken. One reviewer screened the titles and the abstracts of the articles yielded from the searches to identify potentially-relevant articles. These articles were then examined in full to determine their eligibility for inclusion.To be eligible for inclusion in this review, studies had to be published before November 2012, use data-driven methods (e.g. CA or LCA) and include school-aged children and adolescents ages 5–18 years). All identified articles were checked and only those that included an examination of the “patterning”, “clustering” or “co-existence” of two or more obesogenic indicators of diet quality ; PA , and sedentary behaviors  were retained for this review. These behaviors are important correlates of overweight and obesity ,5,27,28.–18 yearsWhile this review was not designed to be systematic, in order to provide a critical appraisal of literature and to identify potential gaps in the study of the clustering of obesogenic behaviors, the following characteristics of the studies were identified: 1) age range 2) sample size 3) study design 4) whether the reliability and validity of measures were reported 5) employment of strategies to minimise the subjectivity of data-driven methods to determine clusters, and 6) whether weight status was derived from self-reported or objective measures.From the online literature search, 23 potential articles were initially retrieved. A further potential six articles were identified after manual inspection of several bibliographies. Of these articles, nine were excluded because focused on describing bivariate associations -31, co-pEight of the 18 studies examined the clustering of all three diet, PA and sedentary behavior ,45,48,49Only one study used 24-hour recall methodology to collect dietary data , two stuFor studies that used CA, the methodological steps taken to ensure clusters were a reliable representation of the data were largely well described . The infThe number of clusters observed across the studies ranged from three ,48,51 toTwo studies ,44 foundA common pattern across eight studies ,47,50,51Six studies ,46,47,50All three diet, PA and sedentary behavior were found to cluster in healthy ,43,45,49Of seven studies ,48,50,51Nine of the 18 studies ,39-45,48Gender differences in cluster patterns have been found in studies that have examined a broader range of obesogenic behaviors. For example, Gorely et al. and MarsNine studies were identified that examined whether cluster patterns could be characterised by SES ,44,50-52Additional file Across four studies, clusters characterised by either low PA ,40,46 orBivariate analyses of a four year longitudinal study conducted in a subsample (n = 389) of German children aged ten at baseline found obesity incidence was significantly higher (p < 0.05) in the low PA/mixed diet quality/moderate media time cluster . One larThis review of studies that have used data-driven methodologies to examine clustering of obesogenic behaviors has shown that diet, PA and sedentary behavior cluster in children and adolescents in both healthy and unhealthy ways. It has also demonstrated that cluster patterns are complex with all studies observing the co-occurrence of both healthy and unhealthy behaviors. This review found a high frequency of clusters defined by high levels of sedentary behavior. This is of concern given the growing evidence to suggest that sedentary behavior is independently and positively associated with poor health outcomes ,56. ClusIt has been previously suggested that CA may be a potential tool for screening populations because it reveals what behaviors actually coexist within populations ,44; howeMost of the studies included in this review were cross-sectional. This is an important limitation because children and adolescents who are overweight or obese may be actively trying to lose weight therefore confounding important associations. Currently it is unclear whether obesogenic cluster patterns are longitudinally associated with different socio-demographic indicators and overweight and obesity. Furthermore the stability of cluster patterns over time has not been explored. The types of dietary, PA and sedentary behaviors examined across the studies were heterogenous, making studies difficult to compare. Cluster patterns tended to differentiate more strongly for PA and sedentary behavior than for dietary behaviors; however almost all the studies included the examination of PA and sedentary behavior and just over half of the studies examined dietary behaviors. Few studies have specifically examined the clustering of diet and PA and no study could be found that has examined the clustering of diet and sedentary behavior. The dietary behaviors examined across the studies were inconsistent and highly variable which limits comparisons across studies.While the scope of this review was limited to school-aged children and adolescents (age-range: 5–18 years), the majority of studies identified focused on older children or adolescents aged nine years and over. Approximately half of the studies reviewed investigated the socio-demographic correlates of cluster patterns, making it difficult to draw definitive conclusions about associations. In addition, indicators of SES, other than parental education, have been little researched.Another limitation of the included studies is that self-report surveys were used to collect data on the examined behaviors with a number of studies not reporting their reliability and validity, particularly for the sedentary behavior variables. Where reported, most instruments had acceptable reliability but low to moderate validity. Only one study measured diet using a 24 hour recall, two studies used an objective measure of PA, and no study used an objective measure of sedentary behavior. The recall and social-desirability biases that accompany self-report measures are well known and may lead to misclassification bias ,63. ThisThis review was the first to examine the clustering of diet, PA and sedentary behavior in children and adolescents, and their associations with socio-demographic indicators and overweight/obesity. Studies were identified from an extensive search of the published literature conducted in a range of data-bases. The broad definition of search terms applied across multiple databases enabled the identification of many potential studies; however, as this was not a systematic review, it is possible that some studies may have been missed. This review focussed on a limited range of diet behaviors , socio-demographic indicators , and included only studies that have used data-driven methodologies, therefore narrowing its scope. This review also included studies that have examined other health behaviors such as smoking or alcohol. It is unclear whether these behaviors influenced the types of clusters generated and whether this influenced the relationship between obesogenic behaviors and socio-demographic characteristics and obesity outcomes. Nonetheless, this review may provide important insights into how obesogenic behaviors cluster together and in whom they cluster together, that may assist the design and targeting of public health initiatives aimed at combating obesity.This review of studies that have used data-driven methodologies to examine clustering of obesogenic behaviors has shown that diet, PA and sedentary behaviors can cluster in complex ways that are both conducive and deleterious to good health and that these clusters differ across socio-demographic groups and are not consistently associated with overweight/obesity. The complexity of these findings implies that we cannot assume that healthy levels of one behavior is indicative of an overall healthy lifestyle. Healthy behaviors may potentially compensate unhealthy ones and explain the equivocal association with overweight/obesity. This suggests that screening of populations may help to appropriately select and target behaviors for obesity prevention, which may in turn maximise the reach and cost-effectiveness of these interventions .Of concern, is the number of clusters defined by high levels of sedentary behavior with some evidence suggesting important gender differences in the types of sedentary behaviors pursued by children and adolescents ,38. FutuGiven the consistent finding of age and gender differences in the types of obesogenic cluster patterns found among children and adolescents, future research should incorporate samples sizes sufficient to determine cluster patterns separately by age and gender. There is also a need for clusters to be determined from valid and reliable measures of diet, PA and sedentary behavior; however, additional evidence examining a broader range of behaviors and their contextual and/or environmental mediators would also provide rich information to inform future interventions.Longitudinal evidence that examines younger children is crucial; understanding how the clustering of obesogenic behaviors track over time and the critical periods where PA declines and poor dietary habits and sedentary behavior increase during childhood are imperative to inform the timing of interventions. Large-scale prospective studies are also needed to establish how cluster patterns vary by different socio-demographic indicators and the long-term exposure of different clustering patterns on the development of overweight and obesity.BMI: Body mass index; CA: Cluster analysis; EMA: Ecological momentary assessment; EDNP: Energy-dense nutrient poor; FFQ: Food frequency questionnaire; FV: Fruit and vegetable; LCA: Latent class analysis; OR: Odd ratio; PA: Physical activity; SES: Socio-economic status; TV: Television.All authors declare that they have no competing interests.RML retrieved and critically analysed the studies within the review. RML drafted the manuscript. AT and SAM supervised the study and assisted with the analysis and interpretation of the reviewed studies. All authors critically reviewed drafts of the manuscript. All authors read and approved the final manuscript.RML was an Honours student at Deakin University at the time the manuscript was drafted and is currently a Ph.D. student, also at Deakin University. RML is a registered Associate Nutritionist (ANutr). RML’s qualifications also include a Bachelor of Food Science & Nutrition (Honours) and a Master of Clinical Epidemiology (coursework). AT (Ph.D.) is an Associate Professor and Senior Researcher at Deakin University. SAM (Ph.D.) is an Australian Research Council Future Fellow and an Accredited Practising Dietitian (APD) at Deakin University.Characteristics of studies included in review of clustering of diet, PA and sedentary behaviors of children and adolescents*.Click here for fileAssociations of clustering patterns of diet, PA and sedentary behaviors with BMI or weight status in children and adolescents.Click here for file