The 2015 World Health Organization (WHO) guidelines recommend antiretroviral treatment (ART) for all people living with HIV, regardless of CD4 count. Treatment for all (TfA) represents a significant step towards meeting the ambitious United Nations’ 90–90–90 target by 2020 and ending AIDS by 2030 [To move from policy to action and achieve TfA, we urgently need to renew our operational agenda. We must rapidly expand access to and uptake of comprehensive HIV services while introducing efficiencies and new models of care that will enable overburdened health systems to sustain current patients while accelerating intake of new patients. This strategy must be based on realities on the ground and be designed to 1) make care simpler and more accessible, 2) create rational models of care that are responsive to patients’ needs and 3) identify and implement transformative tools to reach TfA.This article proposes the development and adoption of a differentiated care model as a practical approach to reach TfA and accelerate progress towards the 90–90–90 target.Efficient approaches to HIV testing, tailored to client values and preferences, have increased the detection of HIV infection. For example, several large community-based HIV testing studies have shown acceptance rates of 80% or greater, linkage to care of 80% and eventual treatment initiation of 73% . Two larAddressing the testing needs of vulnerable and priority populations may also result in increased testing yield and linkage to care. Men – who access the health system less frequently than women – are tested in higher numbers when HIV testing is offered at work sites as compared to HIV testing clinics (e.g. 51.1% vs. 19.2%) , 8. And,A number of evidence-based interventions have demonstrated success in simplifying ART initiation and treatment. Nurse-initiated and managed ART has been shown to be as or more effective at reducing mortality and achieving undetectable viral load when compared with standard physician-initiated ART care , 11. TheAs a significant loss to follow-up (32–54%) occurs in the period before ART initiation , 23, redThe TfA approach is not new. Since 2003, the Government of British Columbia has progressively expanded access to ART. In 2009, the province formalized a universal, fully funded TfA policy, known as Seek and Treat for Optimal Prevention of HIV/AIDS. This policy has been associated with marked and steady decreases in AIDS-related incidence, morbidity and mortality . SimilarAnother promising TfA strategy is Option B+, universal offer of lifelong ART to all HIV-positive pregnant and lactating women. The Elizabeth Glaser Pediatric AIDS Foundation has supported the rollout of Option B+ programmes in 12 countries since 2011 and shown that initiating ART regardless of CD4 count is feasible and effective in resources-constrained settings. It has also demonstrated the need to change the current system to enable earlier identification of patients and retention of large numbers of healthy patients in quality care. In fact, many women still presented late, with HIV Stage III or IV disease. Further, only 74% of women on ART (excluding transfer outs) were retained in care at 12 months in Malawi .TfA will require a comprehensive package of differentiated testing, care and treatment fit to different contexts and needs of different patient populations, including children and adolescents. Therefore, we must support decentralization and simplification at the individual and programmatic level for stable, suppressed individuals and for well-functioning programmes. We must also employ patient- and programme-level data to identify and act upon unstable, poorly functioning and immature programmes.A differentiated package of care should include proven interventions, tools and models to generate the greatest efficiencies and ensure maximum returns from limited healthcare resources. It will also be critical that these interventions are not only acceptable to but also desired by patients and communities. The proposed package  highlighUse of standard packages to optimize differentiated care must be field-tested for feasibility and impact on the achievement of TfA. Successful implementation of these packages will also be dependent on 1) the placement of policies that enable task shifting; 2) the development of metrics that reflect progress towards the 90–90–90 and assess the impact of the differentiated package of care; 3) the existence of sufficient programmatic infrastructure, including procurement and supply chains; and 4) support of sentinel sites to monitor transmitted and acquired drug resistance and to inform future first-line ART  – especiAs the TfA approach progresses globally, HIV epidemiology will evolve, resulting in larger cohorts of stable, virologically suppressed patients and a decrease in HIV incidence. A more simplified approach for the management of these stable cohorts will be possible, and a different strategy and treatment approach may be required. Both the health system and the patients in these stable cohorts will benefit from a pathway that includes fewer clinic visits, streamlined and community-based drug distribution and reduced laboratory monitoring requirements. Over time, the authors feel that normalizing TfA, identifying and treating patients earlier in the disease to keep them healthy and simplifying care by allowing community-based care will help reduce the stigma associated with HIV. Although TfA will generate long-term benefits and reduce costs overall, the strategy will initially require increased political and financial capital .Accept that excellent care can be algorithmic and performed by healthcare workers with limited trainingAllow stable, undetectable patients in treatment to manage their own care by accessing community-based care and reducing clinic visitsAssess and pilot innovative tools and models of careExchange CD4 monitoring for viral load monitoringNormalize and integrate ART through service provider education on the benefits of TfA and multi-disease programming that includes ART initiation and support alongside other primary health interventions such as hypertension screening or blood glucose testingSupport operational research on various packages of differentiated care to better define the impact, feasibility and cost-effectiveness of various models and expand the evidence supporting this promising model of careProvide appropriate investment in such models of care to reach TfAThe WHO's 2015 guidelines and the differentiated package of care are critical building blocks for designing and implementing a TfA strategy, but more must be done. Countries and operational partners should rapidly implement TfA while designing and documenting operational research to identify best practices, improve case finding and reach treatment success while simplifying, decentralizing and streamlining care to improve the rational use of resources. Communities, including populations living with HIV, service providers and national and global policymakers, will need toTo virtually end AIDS by 2030, a collective investment has to take place now, using our most effective tools, policies, strategies and resources to operationalize TfA.


As part of federal and local efforts to increase access to high quality, clinical preventive services (CPS) in underserved populations, the Los Angeles County Department of Public Health (DPH) partnered with six local health system and community organization partners to promote the use of team care for CPS delivery. Although these partners were at different stages of organizational capacity, post-program review suggests that each organization advanced team care in their clinical or community environments, potentially affecting >250,000 client visits per year. Despite existing infrastructure and DPH’s funding support of CPS integration, partner efforts faced several challenges. They included lack of sustainable funding for prevention services; limited access to community resources that support disease prevention; and difficulties in changing health-care provider behavior. Although team care can serve as a catalyst or vehicle for delivering CPS, downstream sustainability of this model of practice requires further state and national policy changes that prioritize prevention. Public health is well positioned to facilitate these policy discussions and to assist health system and community organizations in strengthening CPS integration. Multidisciplinary team care approaches, including the Patient-Centered Medical Home (PCMH) model, are broadly accepted sets of practice principles that can be used to improve health services delivery –5. AlthoIn 2011, the Centers for Disease Control and Prevention established the Community Transformation Grants (CTG) as part of the Patient Protection and Affordable Care Act of 2010 (ACA), Prevention and Public Health Fund , 8. The Beginning in 2011, DPH invested in variations of team care programming through partnerships with health systems and community organizations that served priority populations in LAC. In spite of growing interest in team care, there remains limited literature on how local public health agencies can help establish, enhance, and/or sustain this model of practice in a range of community and clinical settings . The preCounty of Los Angeles Board of Supervisors and 88 incorporated cities governed by mayors and city councils.DPH serves the most populous jurisdiction in the United States, spanning more than 4,000 square miles of urban, suburban, and rural settings . Home toHealthy People 2020 —28.6% and South SPA—32.5%] . In anotple 2020 .very interested or extremely interested) in being treated at a clinic that uses team care . Even fewer expressed interest in the use of health navigators or health coaches (23%), both of which are common components of team care.Evidence suggests that teamwork, care coordination, and continuity are key elements for improving the quality and efficiency of primary care delivery, including CPS delivery , 13, 14.Team care, in all of its configurations, provides comprehensive care for a patient’s physical and mental health needs through a team of health care and social services providers that could include physicians, nurses, pharmacists, nutritionists, social workers, health educators, medical assistants, and community health workers . The appDuring 2011–2014, a system change strategy utilizing team care principles was adapted by six local health system and community organization partners. Each entity was tasked with addressing gaps in their standard delivery of the “ABC’s” of CPS, namely, aspirin use in appropriate age and patient groups; blood pressure control; cholesterol management; and tobacco cessation utilizing the standard protocol “Ask, Advise, Refer” . SelectiThe Long Beach Department of Health and Human Services offers a free 6-week Diabetes Prevention and Management Program designed to teach adults with prediabetes and diabetes and their family members on ways to prevent and manage diabetes. The goals of the program are to increase knowledge about the management and prevention of the disease, to increase self-management behaviors and utilization of appropriate health services, and to ultimately improve the health outcomes of adults living with diabetes. Under this partnership, steps were taken to enhance CPS delivery by including additional screening, education, and referrals for tobacco use, alcohol use, and depression.Through a community-based network, the Asian Pacific Liver Center (APLC) provides culturally tailored programming to a high-risk Asian community in Los Angeles. APLC provides comprehensive screening, vaccination, and preventive education for those at risk of developing viral hepatitis. Through the collaboration with DPH, APLC integrated blood pressure screening and tobacco screening into their outreach protocols and implementation, and expanded planning to include other potential screenings and referral support.The LA Best Babies Network (LABBN) is dedicated to achieving healthy pregnancies and births in LAC by providing the infrastructure, programs, advocacy, and support to increase the capacity of community partners to succeed in these efforts. As part of the collaboration with DPH, the Network served as the Team Leader for the LA County Healthy Weight Collaborative, a national pilot for the Breakthrough Series Learning Collaborative™. The Network team brought together organizations, including several federally qualified health centers (FQHCs), that share a commitment to improving preventive and treatment services, specifically services that reduce cardiovascular disease and diabetes risk. LABBN offered intensive education, tools, and technical assistance for implementing clinical quality improvement projects utilizing multidisciplinary care teams.The American Diabetes Association’s (ADA) Education Recognition Program endorses the National Standards for Diabetes Self-Management Education and Support and is one of the only two Centers for Medicare and Medicaid Services certifying bodies for diabetes self-management training. ADA recognition ensures that clinics are offering high quality, standardized care to their clients and provides clinics an opportunity to bill for diabetes education and related services.Achieving ADA recognition can be time and resource intensive, and thus clinics with limited resources are often not able to independently seek recognition. As part of their DPH supported effort, the ADA was asked to actively recruit low-income clinic/service providers and facilitate their achieving ADA recognition. ADA provided these organizations with extensive technical assistance to develop protocols and infrastructure needed to achieve the required clinical care standards; application submission support; and funding to cover the $1,100 application fee. Additionally, ADA was asked to strengthen their Community of Practice, which provided local ADA recognized programs with an opportunity to share best practices and lessons learned. Some of these best practices included strategies for delivering the ABC’s of CPS in a clinic or health education setting.The Pasadena Public Health Department (PPHD) serves the city of Pasadena in the county of Los Angeles. The department administers the Prevention, Adherence, Collaboration, Education (PACE) program for people over the age of 55 with type II diabetes. Patients are enrolled through the partnering FQHC, the Community Health Alliance of Pasadena (CHAP). Utilizing evidence-based concepts from the Chronic Care Model, the PACE program aims to reduce cardiovascular morbidity and mortality of patients with type II diabetes, improve quality of care in community clinics, and increase self-management of diabetes.Prevention, Adherence, Collaboration, Education care management includes one-on-one patient diabetes education, assessment for appropriate referrals , follow-up on lab testing and referral status, assistance with navigating the health care system, appointment reminders, chart review for medication adherence, and counseling on behaviors relating to nutrition and physical activity. PACE also provides outreach education to providers, which includes information on the A-L-L drug regimen , healthy eating, and physical activity to prevent diabetes and hypertension complications.In collaboration with DPH, PPHD codified additional protocols that were incorporated into the PACE program including screening for tobacco use and referral to tobacco cessation resources  for all patients with type II diabetes seen by a primary care provider in CHAP clinics; proactive panel management of both diabetic and prediabetic patients through chart review; and referrals to a care manager, nutritionist, and nutrition and physical activity classes.expected practice guidelines, and promotion of team care delivery protocols for use by DHS clinic providers and staff. Some of the work included:(a)Hypertension/prehypertension and obesity identification and referrals embedded as part of the clinic disease registry/electronic health records system. As part of the protocol, referrals to further services and/or linkages to community resources that address lifestyle modification became a common feature in the clinical environment.(b)Tobacco use screening, implementing the “Ask, Advise, Refer” brief intervention with follow-up on the referrals to the quit line and related treatment services.The LAC DHS is the second largest public-sector health system in the nation, serving more than 600,000 unique clients every year. DHS comprises 4 major hospitals and 19 comprehensive health centers. In this team care project, DHS was given the opportunity to accelerate the implementation of its plan to transform siloed personal health care delivery to the use of a PCMH-inspired model of care. This transformation process included structural changes made to the disease registry and electronic health records system, utilization of This team care effort was first piloted at 6 sites, and then later expanded to 95+ DHS-operated and -affiliated facilities over a 12- to 18-month period.Although DPH was successful in engaging and supporting six major health system and community organizations to improve access to CPS in the county , the actual population reached and institutionalization of these services varied and was difficult to fully monitor. Throughout the process, DPH documented several barriers and facilitators to team care . Reliance on short-term grant funding and lack of earmarked financial support from parent organizations also impeded consistent delivery and integration of CPS (n = 6). APLC, for example, saw its community-based CPS program sunset once DPH funding support was not available. This was in spite of the blood pressure screening and clinic referral program’s success, reaching nearly 1,500 people in just a little over 6 months ; features of the ACA that promoted reimbursement incentives for prevention services (n = 4); having physician champions (n = 3); and building CPS programming in alignment with the goals of other chronic disease management programs (n = 6).Despite the variation in team care infrastructure and implementation Figure , there wAdditionally, DPH’s effort to scale team care created new opportunities for the six health system and community organization partners to network and collaborate, benefiting from each other’s work. For example, out of the five organizations that actively engaged in the ADA recognition process, two of them were the Long Beach and Pasadena health departments.Despite existing infrastructure and DPH’s funding support of CPS integration, partner efforts continued to face key challenges. These included lack of sustainable funding for prevention services; limited access to community resources that support disease prevention; lack of co-location and proximity to health promotion resources; and difficulties in changing health care provider behavior , 5. The Although team care can serve as a catalyst or vehicle for delivering CPS, downstream sustainability of this model of practice requires further state and national policy changes that prioritize prevention , 2, 5. PTK and NB conceptualized the framework for the writing of this article. TK and NB also gathered and synthesized the information contained in the tables, figures, and text. NB compiled and summarized the quantitative data. HR provided programmatic input on the content presented. All authors reviewed and assisted with the writing of the article. All authors have reviewed and approved this submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Path loss models are often used by radio network engineers to predict signal coverage, optimize limited network resources, and perform interference feasibility studies. However, the propagation mechanisms of electromagnetic waves depend on the physical characteristics of the wireless channel. Therefore, efficient radio network planning and optimization requires detailed information about the specific propagation environment. In this data article, the path loss data and the corresponding information that are needed for modeling radio wave propagation in smart campus environment are presented and analyzed. Extensive drive test measurements are performed along three different routes  within Covenant University, Ota, Ogun State, Nigeria  to record path loss data as the mobile receiver moves away from each of the three 1800 MHz base station transmitters involved. Also, the longitude, latitude, elevation, altitude, clutter height, and the distance information, which describes the smart campus environment, are obtained from Digital Terrain Map (DTM) in ATOLL radio network planning tool. Results of the first-order descriptive statistics and the frequency distributions of all the seven parameters are presented in tables and graphs respectively. In addition, correlation analyses are performed to understand the relationships between the network parameters and the terrain information. For ease of reuse, the comprehensive data are prepared in Microsoft Excel spreadsheet and attached to this data article. In essence, the availability of these data will facilitate the development of path loss models for efficient radio network planning and optimization in smart campus environment. Specifications TableValue of the data•Availability of the data in this data article will facilitate the development of path loss models for efficient radio network planning and optimization in smart campus environment •Path loss data and terrain information provided in this article will aid comparative analysis and evaluation of existing and new empirical models •In order to accurately account for the peculiarity of smart campus environment, existing path loss models may be tuned or re-calibrated using the data obtained from real scenarios •Achieving accurate path loss prediction within smart campus context will guarantee better Quality of Service (QoS) for smart applications •The results of the correlation analyses will give better understanding about the relationships between the network parameters and the terrain information •The local content of the data may open doors of new research collaborations toward the development of a robust regional path loss model for wider coverage.1In the present Information Age, high proliferation of smart devices that have in-built sensors and capabilities for Wireless Fidelity (Wi-Fi) and cellular wireless connectivity is fast changing the way things are done in university communities Path loss may be defined as the difference in the transmitted signal power and the received signal power at varying separation distances between the transmitting antenna and the receiving antenna. Measurement campaigns were conducted along three survey routes within Covenant University, Ota, Ogun State, Nigeria. The path loss data and the terrain information about the smart campus environment are carefully explored in this data article. The terrain profile information available in this data article include: longitude; latitude; elevation; altitude; clutter height; and distance of separation between the transmitter and the receiver. These useful information are extracted from the Digital Terrain Map (DTM) of the study area. Detailed exploration of the dataset will facilitate the development of empirical models for radio wave propagation in smart campus environment. The descriptive first-order statistics of data obtained along Survey Route X, Y, and Z are presented in 2p-Value matrix is smaller than the significance level of 0.05.Extensive drive test measurements are performed along three different routes  within Covenant University, Ota, Ogun State, Nigeria  to record path loss data as the mobile receiver moves away from each of the three 1800 MHz base station transmitters involved. The signal path loss data were collected with an experimental setup of a Test Mobile Station (TEMS) Sony Ericsson W995 handset, Ericsson TEMS Investigation software (version 9.0), Garmin Global Positioning System (GPS) receiver, and a Window-based Personal Computer (PC). The RF measurements were carried out under good climatic conditions. Also, good vehicular accessibility to site locations were considered for a smooth test drive. Distances covered by the drive routes were considered long enough to allow the noise floor of the receiver to be reached. The whole set-up was carefully placed in a vehicle, and the vehicle was driven at an average speed of 40 km/h. This speed was maintained to minimize Doppler effects. Also, the longitude, latitude, elevation, altitude, clutter height, and the distance information, which describes the smart campus environment, are obtained from Digital Terrain Map (DTM) in ATOLL radio network planning tool. The DTM of the study area is shown in


Automated image analysis, measurements of virtual slides, and open access electronic measurement user systems require standardized image quality assessment in tissue-based diagnosis.To describe the theoretical background and the practical experiences in automated image quality estimation of colour images acquired from histological slides.Digital images acquired from histological slides should present with textures and objects that permit automated image information analysis. The quality of digitized images can be estimated by spatial independent and local filter operations that investigate in homogenous brightness, low peak to noise ratio , maximum gradients, equalized grey value distribution, and existence of grey value thresholds. Transformation of the red-green-blue (RGB) space into the hue-saturation-intensity (HSI) space permits the detection of colour and intensity maxima/minima. The feature distance of the original image to its standardized counterpart is an appropriate measure to quantify the actual image quality. These measures have been applied to a series of H&E stained, fluorescent , and immunohistochemically stained  slides. More than 5,000 slides have been measured and partly analyzed in a time series.Analysis of H&E stained slides revealed low shading corrections (10%) and moderate grey value standardization (10 – 20%) in the majority of cases. Immunohistochemically stained slides displayed greater shading and grey value correction. Fluorescent stained slides are often revealed to high brightness. Images requiring only low standardization corrections possess at least 5 different statistically significant thresholds, which are useful for object segmentation. Fluorescent images of good quality only posses one singular intensity maximum in contrast to good images obtained from H&E stained slides that present with 2 – 3 intensity maxima.Evaluation of image quality and creation of formally standardized images should be performed prior to automatic analysis of digital images acquired from histological slides. Spatial dependent and local filter operations as well as analysis of the RGB and HSI spaces are appropriate methods to reproduce evaluated formal image quality. The technological progress in image acquisition, transfer, and display prompted surgical pathologists to investigate and implement new image viewing techniques in their daily work. Telepathology, which is the transfer and viewing of macroscopic and microscopic images at a distance, was fully established at the beginning of the 1990s followed by the construction of specific telemedicine systems such as the iPATH or UICC-TPCC at the beginning of this century . Only a This scenario requires a formal and reproducible analysis of the image quality to be viewed electronically due to practical and also legal reasons. The definition of image quality is, however, not simple. The viewing of images induces, in addition to their optical properties, emotions that are not completely associated with the physical components: Quite independent from clearly defined terms, such as contrast, resolution and focus, pathologists often state that some images are easy to view at and others are not . Thus, tOn the other hand, formal parameters of image quality contribute to recognition of image information too. Especially the application of automated texture and object analysis requires formally standardized images prior to the image examination -4,11.In this article we describe the theoretical background and our experiences in applying formal standardization in microscopic images prior to automated information analysis. Digitized images obtained from H&E stains, performed immunohistochemistry, and applied fluorescent dyes served for this investigation.The preparation of histological glass slides is subject to quality influences that are induced by tissue fixation, embedding, and cutting procedures, followed by influences of stains and coverglass fixation, to name some of them. Adjustment of the microscope, illumination or brightness of light transmission, selection of fields of view at different magnifications, quality of mounted camera and its position play an additional role that influence the quality of the acquired image. How to measure and correct these parameters?Computerized tissue-based diagnosis uses at least two different image information sources which are called a) texture and b) object. Analysis of spatial distribution of grey values per pixel reveals texture information, and that of grey values per biological object, object information -4,11. GrIn aggregate, the minimum of image transformations to obtain a standardized image includes a) shading, b) grey value interval, and c) grey value level correction. Correction of shading results in equal distributed illumination and brightness, that of grey value interval in equal distributed grey value histogram, and that of grey value level in expanding grey values adjusted to the maximum possible one. These standardized images might not be of sufficient quality permitting efficient object detection. Thus, the same standardization procedures should be applied to the derived differentiated images (gradient procedures). The obtained distance of the original from the standardized image is obviously a reproducible and objective measure of image quality of grey value image or colour channel.Microscopic images usually consist of three colour spaces, most frequently displayed in the red-green-blue (RGB) space . AnalysiMicroscopic images should contain objects to be measured. Objects are related to grey value threshold in general, thus the number and areas covered by automated threshold procedures can serve as monitor for image quality related to biological information. We applied the algorithm described by Otsu for these purposes .A series of digital images acquired from H&E stained slides in the Institutes of Pathology, Research Center Borstel, Charite, Berlin, University of Campinas, Campinas, Brasil, University of Freiburg, Freiburg, University of Kerman, Kerman, and University of Novi Sad, Novi Sad, Serbia were subject to the described algorithm. In addition, images acquired from fluorescent and immunohistochemically stained slides  which have been submitted to the Electronic Automated Measurement User System (EAMUS™) have been included in this study. All in all, more than 5000 images have been analyzed and included in the statistical analysis.A survey of the applied measurements is depicted in table The results are partly accumulated in serial order, as demonstrated in figure A reliable and standardized quality of digitized images obtained from histological slides is a necessity to further extract information and correlate this information with external data such as diagnosis, prognosis, etc. . For exaAcknowledged limits of image quality parameters to classifying images of good or less good quality do not exist, to our knowledge. Therefore, a serial analysis of "distances" between original and standardized images seems an adequate procedure in estimating image quality. The results demonstrated in figure The correlation of hue and saturation spaces with the intensity space is closer than that between the different RGB spaces. Images of good quality display only one and strictly closed space in the corresponding figures (see figure The image measurements reported herein are performed on images of (.bmp) format without any compression mode. The influence of compression on image and tissue based diagnosis quality had been already extensively analyzed by several authors ,22-25. AImage quality analysis and implementation of standardized images for further image processing can be easily implemented into Grid technology  allowing


Majid Ezzati and colleagues examine US data on risk factor exposures and disease-specific mortality and find that smoking and hypertension, which both have effective interventions, are responsible for the largest number of deaths. Knowledge of the number of deaths caused by risk factors is needed for health policy and priority setting. Our aim was to estimate the mortality effects of the following 12 modifiable dietary, lifestyle, and metabolic risk factors in the United States (US) using consistent and comparable methods: high blood glucose, low-density lipoprotein (LDL) cholesterol, and blood pressure; overweight–obesity; high dietary trans fatty acids and salt; low dietary polyunsaturated fatty acids, omega-3 fatty acids (seafood), and fruits and vegetables; physical inactivity; alcohol use; and tobacco smoking.We used data on risk factor exposures in the US population from nationally representative health surveys and disease-specific mortality statistics from the National Center for Health Statistics. We obtained the etiological effects of risk factors on disease-specific mortality, by age, from systematic reviews and meta-analyses of epidemiological studies that had adjusted (i) for major potential confounders, and (ii) where possible for regression dilution bias. We estimated the number of disease-specific deaths attributable to all non-optimal levels of each risk factor exposure, by age and sex. In 2005, tobacco smoking and high blood pressure were responsible for an estimated 467,000  and 395,000  deaths, accounting for about one in five or six deaths in US adults. Overweight–obesity  and physical inactivity  were each responsible for nearly 1 in 10 deaths. High dietary salt , low dietary omega-3 fatty acids , and high dietary trans fatty acids  were the dietary risks with the largest mortality effects. Although 26,000  deaths from ischemic heart disease, ischemic stroke, and diabetes were averted by current alcohol use, they were outweighed by 90,000  deaths from other cardiovascular diseases, cancers, liver cirrhosis, pancreatitis, alcohol use disorders, road traffic and other injuries, and violence.Smoking and high blood pressure, which both have effective interventions, are responsible for the largest number of deaths in the US. Other dietary, lifestyle, and metabolic risk factors for chronic diseases also cause a substantial number of deaths in the US.Please see later in the article for Editors' Summary A number of modifiable factors are responsible for many premature or preventable deaths. For example, being overweight or obese shortens life expectancy, while half of all long-term tobacco smokers in Western populations will die prematurely from a disease directly related to smoking. Modifiable risk factors fall into three main groups. First, there are lifestyle risk factors. These include tobacco smoking, physical inactivity, and excessive alcohol use . Second, there are dietary risk factors such as a high salt intake and a low intake of fruits and vegetables. Finally, there are “metabolic risk factors,” which shorten life expectancy by increasing a person's chances of developing cardiovascular disease  and diabetes. Metabolic risk factors include having high blood pressure or blood cholesterol and being overweight or obese.It should be possible to reduce preventable deaths by changing modifiable risk factors through introducing public health policies, programs and regulations that reduce exposures to these risk factors. However, it is important to know how many deaths are caused by each risk factor before developing policies and programs that aim to improve a nation's health. Although previous studies have provided some information on the numbers of premature deaths caused by modifiable risk factors, there are two problems with these studies. First, they have not used consistent and comparable methods to estimate the number of deaths attributable to different risk factors. Second, they have rarely considered the effects of dietary and metabolic risk factors. In this new study, the researchers estimate the number of deaths due to 12 different modifiable dietary, lifestyle, and metabolic risk factors for the United States population. They use a method called “comparative risk assessment.” This approach estimates the number of deaths that would be prevented if current distributions of risk factor exposures were changed to hypothetical optimal distributions.The researchers extracted data on exposures to these 12 selected risk factors from US national health surveys, and they obtained information on deaths from difference diseases for 2005 from the US National Center for Health Statistics. They used previously published studies to estimate how much each risk factor increases the risk of death from each disease. The researchers then used a mathematical formula to estimate the numbers of deaths caused by each risk factor. Of the 2.5 million US deaths in 2005, they estimate that nearly half a million were associated with tobacco smoking and about 400,000 were associated with high blood pressure. These two risk factors therefore each accounted for about 1 in 5 deaths in US adults. Overweight–obesity and physical inactivity were each responsible for nearly 1 in 10 deaths. Among the dietary factors examined, high dietary salt intake had the largest effect, being responsible for 4% of deaths in adults. Finally, while alcohol use prevented 26,000 deaths from ischemic heart disease, ischemic stroke, and diabetes, the researchers estimate that it caused 90,000 deaths from other types of cardiovascular diseases, other medical conditions, and road traffic accidents and violence.These findings indicate that smoking and high blood pressure are responsible for the largest number of preventable deaths in the US, but that several other modifiable risk factors also cause many deaths. Although the accuracy of some of the estimates obtained in this study will be affected by the quality of the data used, these findings suggest that targeting a handful of risk factors could greatly reduce premature mortality in the US. The findings might also apply to other countries, although the risk factors responsible for most preventable deaths may vary between countries. Importantly, effective individual-level and population-wide interventions are already available to reduce people's exposure to the two risk factors responsible for most preventable deaths in the US. The researchers also suggest that combinations of regulation, pricing, and education have the potential to reduce the exposure of US residents to other risk factors that are likely to shorten their lives.http://dx.doi.org/10.1371/journal.pmed.1000058.Please access these Web sites via the online version of this summary at MedlinePlus encyclopedia contains a page on healthy living (in English and Spanish)The healthy livingThe US Centers for Disease Control and Prevention provides information on all aspects of Healthy People 2010 is a national framework designed to improve the health of people living in the US. The Healthy People 2020 Framework is due to be launched in January 2010The World Health Report 2002Reducing Risks, Promoting Healthy Life provides a global analysis of how healthy life expectancy could be increasedNational Health and Nutrition Examination Survey (NHANES) is “a program of studies designed to assess the health and nutritional status of adults and children in the United States”The Smoking and Tobacco Use offers a large number of informational and data resources on this important risk factorThe US Centers for Disease Control and Prevention's site American Heart Association and American Cancer Society provide a rich resource for patients and caregivers on many important risk factors including diet, sodium intake, and smokingThe  Valid and comparable information on mortality caused by diseases, injuries, and their modifiable risk factors is important for health policy and priority setting Healthy People 2010 and (the forthcoming) Healthy People 2020. The US also has high-quality data on disease-specific mortality and on population exposure to a range of risk factors from nationally representative health examination and interview surveys. Our results provide, to our knowledge, the most comprehensive and comparable quantitative assessment of the mortality burden of important modifiable risk factors in the US population, and the only one to include the effects of multiple dietary and metabolic factors.We estimated the number of deaths attributable to major dietary, lifestyle, and metabolic risk factors in the US using consistent, comparable, and current definitions, methods, and data sources. We conducted the analysis in the US because the results can inform priority-setting decisions for policies and programs that aim to improve the nation's health, e.g., We conducted a population-level CRA (comparative risk assessment) for 12 major modifiable dietary, lifestyle, and metabolic risks. The CRA analysis estimates the number of deaths that would be prevented in the period of analysis if current distributions of risk factor exposure were changed to a hypothetical alternative distribution. The inputs to the analysis are (1) the current population distribution of risk factor exposure, (2) the etiological effect of risk factor exposures on disease-specific mortality, (3) an alternative exposure distribution, and (4) the total number of disease-specific deaths in the population.We also calculated the proportion of the mortality burden of risk factors among people in specific exposure ranges and categories that correspond to current clinical and public health guidelines, e.g., the proportion of deaths attributable to high blood pressure, that is, among individuals with systolic blood pressure (SBP) ≥140 mmHg. This threshold-based analysis helps evaluate the relative impact of programs that focus on people whose high-risk status is either undiagnosed or remains uncontrolled after receiving the currently administered usual care.Among dietary, lifestyle, and metabolic factors, we selected specific risks that fulfilled the following criteria. (1) Sufficient evidence was available on the presence and magnitude of likely causal associations with disease-specific mortality from high-quality epidemiological studies; (2) available or envisionable interventions existed to modify exposure to the risk; and (3) data on risk factor exposure were available from nationally representative surveys and epidemiological studies without systematic bias.The 12 major modifiable risk factors selected based on these criteria are shown in Several other important risk factors were considered, but could not be included because sufficient or unbiased data on their national exposure distributions and/or effects on disease-specific mortality were not available, or because the evidence on causal effects was less convincing. Examples of important risk factors not included in this work because of insufficient data on exposure or on the presence and magnitude of causal effects include illicit drug use, caloric intake, triglycerides and high-density lipoprotein (HDL) cholesterol, whole-grain intake, gun ownership, and risk factors that primarily affect mental health outcomes. The focus of our analysis was not on environmental and occupational risks , primarily because for many of these risks nationally representative data on population exposure using the same metrics as used in epidemiological studies are unavailable. Comparative analyses of these risks should be a priority for future research.We obtained risk factor exposure distributions from nationally representative health examination and interview surveys, etiological effect sizes from published or new systematic reviews and meta-analyses of epidemiological studies, and the number of deaths by cause from the National Center for Health Statistics (NCHS).http://www.cdc.gov/nchs/nhanes.htm. We adjusted the intakes of fruits and vegetables, omega-3 fatty acids, and salt (sodium) from NHANES for total energy intake using the residual method For most risk factors in this analysis, we used data from the National Health and Nutrition Examination Survey (NHANES) to measure population exposures . NHANES http://www.census.gov/rophi/www/nesarc.html.We used the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to measure the quantity of alcohol consumed and the pattern of consumption. NESARC is a multi-stage, stratified, cluster-sampling, nationally representative survey of the noninstitutionalized US population, whose target population includes boarding houses, rooming houses, nontransient hotels and motels, shelters, facilities for housing workers, college quarters, and group homes. The 2001–2002 sample size was 43,093. Detailed information on frequency, amount, and type of beverage during the previous 12 mo was sought using computer assisted personal interviewing. Average daily alcohol consumption in NESARC was estimated using responses to questions on both the usual quantity-and-frequency of drinking, and quantity-and-frequency of binge drinking. This method provides a more valid estimate of average consumption than do calculations based solely on questions regarding usual drinking We accounted for complex survey design and sampling weights in estimating exposures. Using one-off measurements in health examination surveys overestimates the standard deviation (SD) of the “usual” population exposure distribution, due to within-person variation. We estimated the usual population SD of blood pressure, fasting plasma glucose (FPG), and LDL cholesterol by multiplying the SD of NHANES sample by the dilution ratio from studies that had multiple exposure measurements We obtained the relative risk (RR) per unit of exposure (for risks measured continuously) or for each exposure category (for risks measured in categories) for diseases with probable or convincing causal associations with each risk factor, based on the most recent published systematic reviews and meta-analyses of epidemiological studies or by conducting new systematic reviews and meta-analyses when they were not available in the published literature –7.The studies used for etiological effect sizes included both randomized intervention studies of exposure reduction and observational studies (primarily prospective cohort studies) that estimated the effects of baseline exposure. The majority of observational studies used for effect sizes had adjusted for important potential confounding factors. Each RR used in our analysis represents the best evidence for the proportional effect of risk factor exposure on disease-specific mortality in the population based on the current causes and determinants of the population distribution of exposure .We used RRs for blood pressure, LDL cholesterol, and FPG that were adjusted for regression dilution bias using studies that had repeated exposure measurement For each risk factor–disease pair, we used the same RR for men and women except where empirical evidence indicated that the RR differed by sex: colon and pancreas cancers caused by high BMI The current evidence suggests that when measured comparably the proportional effects of the risk factors considered in this analysis are similar across populations, e.g., Western and Asian populations The number of disease-specific deaths, by age and sex, was obtained from the NCHS, which maintains records for all deaths in the US. Although the US has automated (computerized) assignment of an International Classification of Diseases (ICD) code for the underlying cause of death, the validity and comparability of cause of death statistics may be affected at the time of medical certification, especially for cardiovascular causes and diabetes Several risk factors have different effects on ischemic and hemorrhagic stroke . Slightlx = exposure level; P(x) = actual distribution of exposure in the population; P′(x) = alternative distribution of exposure in the population; RR(x) = relative risk of mortality at exposure level x; and m = maximum exposure level.For each risk factor and for each disease causally associated with its exposure, we computed the proportional reduction in disease-specific deaths that would occur if risk factor exposure had been reduced to an alternative level. This is known as the population-attributable fraction (PAF) and measures the total effects of a risk factor (direct as well as mediated through other factors). For risks measured continuously , we computed PAFs using the following relationship.For risks measured in categories of exposure , we used the discrete version of the same estimator for PAF.We used a different method of estimating the PAFs for effects of alcohol use on injuries. A number of emergency room studies have collected information on alcohol consumption in the 6 h prior to the injury among injury patients. Injuries that occur among patients who had consumed alcohol prior to their injury were classified as “alcohol-related” injuries. Because some of these injuries would have occurred in the absence of alcohol, not all are caused by alcohol use; in other words, the proportion of alcohol-attributable injuries is lower than that of alcohol-related injuries. Highway studies have quantified the increased risk of road traffic deaths among drivers who have consumed alcohol according to the drivers' blood alcohol concentration, often reported as odds ratios (ORs). Ideally, ORs would be used in conjunction with data on population prevalence of intoxication to calculate PAF. Because intoxication data were not available, we used a slightly modified equation to calculate the PAF using ORs from highway studies and data on alcohol-related injuries:http://www-fars.nhtsa.dot.gov/Main/index.aspx. The sources for ORs are provided in The proportion of alcohol-related injuries was obtained from Fatality Analysis Reporting System (FARS) for road traffic injuries and from a meta-analysis of emergency room studies for other types of intentional and unintentional injuries We calculated the number of deaths from each causally related disease outcome attributable to a risk factor by multiplying its PAF by total deaths from that disease. Disease-specific deaths attributable to each risk factor were summed to obtain the total  attributable deaths. Deaths from different diseases attributable to a single risk factor are additive because in mortality statistics based on the ICD, each death is categorically assigned to a single underlying cause (disease) with no overlap between disease-specific deaths. However, the deaths attributable to individual risk factors often overlap and should not be summed see .To measure the mortality effects of all non-optimal levels of exposure consistently and comparably across risk factors, we used an optimal exposure distribution, referred to as the theoretical-minimum-risk exposure distribution (TMRED), as the alternative exposure distribution . The TMRWe conducted all analyses separately by sex and age group . We restricted analyses to ≥30 y because there are limited data on the mortality effects of these risk factors at younger ages and because there are few deaths from diseases affected by these risks in younger ages . The exception was the effect of alcohol use on injuries for which we also included 0- to 29-y-olds because there are substantial injury deaths at these ages. Therefore, we can assess both the role of alcohol use as a cause of injuries in young drinkers and the effect of alcohol use by any drinker  on injury in young nondrinkers.We estimated the uncertainty of the number of deaths attributable to each risk factor as caused by sampling variability. To compute sampling uncertainty, we used a simulation approach to combine the uncertainties of exposure distributions and RRs in each age–sex group. In the simulation method, we drew repeatedly from the distributions of exposure mean and SD (for continuous risks) or prevalence in each exposure category . The uncertainty of these parameters was characterized using normal, Chi-square, or binomial distributions. RRs for each disease were drawn from a log-normal distribution independently from exposure. Each set of exposure and disease-specific RR draws was used to calculate the PAFs for all diseases associated with the risk factor, separately by age and sex. We used 500 draws for each risk factor, and report 95% confidence intervals (CIs) based on the resulting distributions of 500 estimated attributable deaths. Further simulation details and computer code are available from the authors by request.In addition to sampling uncertainty, we examined the sensitivity of our results to important methodological factors and data sources. The methodological factors and data sources in the sensitivity analyses included the choice of exposure metrics, the shape of the exposure distribution, the TMREDs, disease outcomes causally associated with risk factors, and etiological effect sizes .We used RRs adjusted for major potential confounders to estimate the causal components of risk factor–disease associations. However, if there is also a correlation between exposure and disease-specific mortality, due to correlations of exposure with other risks or other unobserved factors, the above equations may result in under- (when there is positive correlation) or over-estimation (negative correlation) of the true PAF when used with adjusted RRs Analyses were conducted using Stata version 10  and SAS version 9.1 .In the year 2005, 2,448,017 US residents died; 49% of these deaths were among men. Ninety-six percent of all deaths in the US were in people ≥30 y of age. After adjustment for comparability of cause-of-death assignment Tobacco smoking was responsible for an estimated 467,000  deaths and high blood pressure for 395,000  deaths, each accounting for about one in five or six deaths in US adults in 2005 , Table 8Most deaths attributable to these risks were from cardiovascular diseases . CancersHigh blood pressure was the leading cause of death in women , whereas smoking remains the leading cause of death in men . The leading causes of death in men and women were different because women have higher blood pressure and men higher cumulative  smoking. Overweight–obesity, physical inactivity, and high blood glucose were the third to fifth causes of death for both sexes . High diThe mortality effects of all individual risk factors except alcohol use were almost equally divided between men and women . Seventy percent of all deaths attributable to alcohol use occurred in men , because men consumed more alcohol and had more binge drinking.Four percent of all deaths in the US occurred in people between 30 and 45 y of age. No individual risk factor was responsible for more than 7% of deaths in this age group. However, this age group bore 34% of alcohol-caused injuries , making There was substantial variation in how deaths attributable to these risks were distributed below or above commonly used thresholds and guidelines : close tThe burden of smoking was almost equally distributed among current and former smokers, because harmful effects continue among many Americans who have quit smoking. Twenty-nine percent of the chronic disease mortality effects of alcohol use occurred among heavy drinkers ; this group did not have any mortality benefits from alcohol use. In contrast, in those who had light alcohol consumption (up to 40 g per day for men and 20 g per day for women), the protective effects on IHD and diabetes mortality were larger than the hazardous effects from other chronic diseases, leading to an overall reduction in mortality in this group (unpublished results).2, respectively, the number of deaths attributable to them would be 18% and 19% lower. Similarly, lowering the TMRED of physical activity to the (less ambitious) current recommended level of 600 met·min per week  would prevent 62,000 (32%) fewer deaths than if people pursued a higher goal of 1,600 met·min per week (including at least one hour of vigorous activity per day). The TMRED for alcohol use must balance its harmful and beneficial effects. If the entire adult US population had light alcohol consumption, a total of 12,000 cardiovascular deaths would be prevented, largely among adults aged ≥45 y. However, this level of alcohol consumption would also cause an estimated 8,000 deaths due to road traffic accidents largely among adults aged <30 y.The results of the sensitivity analyses in Incorporating correlation of a risk factor with disease-specific mortality and with other risks changed the estimated number of deaths attributable to a risk factor by 3%–31%, depending on the specific risk factor and disease. The results were robust to whether exposure in the population was approximated with a normal distribution and to the inclusion of the few disease outcomes for which the evidence of causal association was weaker. Mortality effects of dietary salt were sensitive to the magnitude of its effects on SBP, because there was an almost 2-fold difference between two separate meta-analyses of salt reduction trials Our analysis of the mortality effects of major dietary, lifestyle, and metabolic risk factors in the US using comparable methods showed that tobacco smoking and high blood pressure were the leading risk factors for mortality, responsible for nearly one in five and one in six deaths in US adults, respectively. The large effects of tobacco smoking were caused by long-term cumulative exposure in current smokers as well as the remaining effects in former smokers, especially in men. The large numbers of deaths attributable to high blood pressure were related to high exposure levels, particularly in women Each RR used in our analysis represents the best evidence for the impact of risk factor exposure on disease-specific mortality in the population, based on the current causes and determinants of the population distribution of exposure. The mortality effects of a risk factor may depend on whether an expected increase in exposure is prevented or whether exposure is reduced after it has risen. It may also depend on the specific intervention used to prevent or reverse risk factor exposure. The estimated effects of blood pressure, LDL cholesterol, omega-3 fatty acids, and PUFA-SFA replacement have been generally consistent between observational studies that measure exposure at baseline and intervention studies that reduce exposure prospectively Our results estimate the total effects of each individual risk factor. Disease-specific deaths are caused by multiple factors acting simultaneously, and hence could be prevented by intervening on single or multiple risk factors, e.g., some IHD deaths may be prevented by reducing SBP, LDL cholesterol, smoking, or combinations of these risks There are a number of innovations and strengths in our analysis. This is, to our knowledge, the first population-level analysis of the mortality effects of risk factors to include a relatively large number of dietary and metabolic risk factors, and to use consistent and comparable methods. This comparative quantification helped identify the important roles of diet and physical inactivity, other lifestyle factors, and metabolic risks as preventable causes of death in the US population. Effect sizes were derived from large meta-analyses of either randomized trials or observational studies that had adjusted for important confounders. RRs from meta-analyses tend to reduce random error relative to individual studies; they may also reduce bias if the directions of bias are not the same in individual studies. We used exposure distributions and effect sizes that accounted for measurement error associated with one-off measurements to the extent possible. Our study presented deaths attributable to risk factors by age and sex, and by exposure level. The latter helped identify whether those whose exposure remains uncontrolled with current diagnosis and treatment programs versus those who are currently below clinical thresholds should be targeted for greatest effects on mortality. Finally, we quantified the sampling uncertainty of our estimates; we also analyzed how specific methods and data sources affected our quantitative results in extensive sensitivity analyses. This demonstrated that although the specific numerical results are uncertain, our overall findings on the relative mortality effects of these dietary, lifestyle, and metabolic risk factors are robust.Population level analyses of mortality effects of risk factors such as ours are also affected by some limitations and uncertainties. First, several potentially important risk factors were considered, but could not be included because sufficient or unbiased data on their national exposure distributions and/or effects on disease-specific mortality were not available, or because the evidence on causal effects was less convincing. Second, for many risks the choice of disease outcomes and effect sizes were derived from observational studies. In such cases, whether the collectivity of evidence established a causal association had to be assessed using multiple criteria, such as those proposed by Hill The hazardous effects of some risk factors accumulate gradually after exposure begins and decline slowly after exposure is reduced. This is illustrated by results from trials that have lowered blood pressure and cholesterol, and from studies in which some people quit smoking The results of our analysis of dietary, lifestyle, and metabolic risk factors show that targeting a handful of risk factors has large potential to reduce mortality in the US, substantially more than the currently estimated 18,000 deaths averted annually by providing universal health insurance The risk factors in this analysis can be influenced through both individual-level and population-wide interventions. In particular, effective interventions are available for tobacco smoking and high blood pressure, the leading two causes of mortality in the US Table S1Sensitivity of results to methodological choices and data sources.(0.08 MB DOC)Click here for additional data file.Table S2Comparison of estimated number of deaths attributable to risk factors with those from previous studies.(0.07 MB DOC)Click here for additional data file.


Cardiovascular disease is the leading cause of deaths and illnesses in US adults, and the prevalence is disproportionately high in underserved populations. In this study, we assessed respondents' understanding of context-specific differences in knowledge and perceptions of disease, risk, and prevention in 6 underserved communities, with the longer-term goal of developing appropriate interventions.Thirty-nine small-group sessions and 14 interviews yielded data from 318 adults. Each site's researchers coded, analyzed, and extracted key themes from local data. Investigators from all sites synthesized results and identified common themes and differences.Themes clustered in 3 areas . Barriers spanned individual, social and cultural, and environmental levels; women in particular cited multiple roles . Programmatic suggestions included the following: personal, interactive, social context; information in language that people use; activities built around cultural values and interests; and community orientation. In addition, respondents preferred health-related information from trusted groups , health care providers (but with noticeable differences of opinion), family and friends, and printed materials.Interventions to decrease barriers to cardiovascular health are needed; these strategies should include family and community context, small groups, interactive methods, culturally sensitive materials, and trusted information sources. New-immigrant communities need culturally and linguistically tailored education before receiving more substantive interventions. Coronary heart disease (CHD) and stroke are the leading causes of deaths and illnesses in US adults ,2. More Various ethnic and socioeconomic groups differ in individual health beliefs and practices . KnowledThe Prevention Research Centers Cardiovascular Health Intervention Research and Translation Network (PRC CHIRTN) conducted this study to increase understanding of differences in knowledge and perceptions of CVD, risk, and prevention in underserved and understudied populations, with the longer-term goal of addressing the disparities through community-specific interventions and communications. PRC CHIRTN is a collaboration among 6 universities and their partner communities — University of Colorado Denver (UCD), University of Illinois at Chicago (UIC), University of North Carolina at Chapel Hill (UNC), University of Rochester School of Medicine and Dentistry , University of Washington (UW), and West Virginia University (WVU). Details on its history, mission, and structure are available elsewhere . The divInvestigators from all of the 6 PRC CHIRTN sites shared leadership for the project, first to select the research topic and then to reach consensus on a core protocol. Local community teams or advisory committees participated to ensure relevance to partner communities and to assess the language and clarity of discussion questions and research materials for participants. Institutional review boards at each university reviewed and approved the protocols for that site. Investigators met monthly by telephone conference and in March 2008 in person at a national PRC CHIRTN meeting to develop the core protocol and then to track progress and resolve questions.The protocol included a series of discussion questions for use at all sites and suggested demographic items to document the diversity of samples and allow comparisons between sites. A full list of questions and prompts is available from the corresponding author. Four categories framed the discussion questions:knowledge and perceptions of heart disease and strokeknowledge and perceptions of preventionsources and usefulness of health informationdissemination methods and strategiesThe suggested set of demographic information included age, sex, race/ethnicity, education, geographic location , and length of residence in the United States (if an immigrant population). Several sites also collected information about participants' knowledge of their cardiovascular risk status or history.Each site chose the appropriate qualitative method for its partner community and site-specific goals, which in some cases extended beyond this study's aims. Five sites  conducted small-group sessions of ethnically, geographically, or socioeconomically underserved groups, and 1 (UR) conducted in-depth interviews and neighborhood walking tours with families of urban school children. The facilitators or interviewers for all research sessions were experienced university-based researchers trained in qualitative methods. Following principles of community-based participatory research that promote collaborative partnerships in all phases of research , communiSmall-group sessions were conducted in English with 2 exceptions; new-immigrant Hispanic sessions were conducted in Spanish (UIC), and Asian immigrant groups were conducted in separate sessions in Mandarin, Cantonese, Vietnamese, or Korean (UW). Small-group sessions took place during the summer of 2007. All sessions were audio-recorded; researchers at each site transcribed (and if necessary translated into English) that site's recordings, removing any personal identifiers. Site-specific details about the groups are provided .Investigators from all sites assembled a "universal" codebook. The codebook consisted of a priori codes derived from the discussion questions and additional concepts that emerged during analysis. The major coding categories were the following:individual factorsprevention/factors and typesprevention/being at riskdisease/symptoms knowledge and understandingdisease/disease outcome knowledge and understandingdisease/risk knowledge and understandingdisseminationinterventionsPersonnel at each site open coded  that sitA total of 380 community members participated in qualitative projects across the 6 sites. Participants included 62 children  with their parents and other interested adults. This analysis includes only the 318 adults . Of the Recruitment achieved the desired oversampling of at-risk populations. Most of the participants (89%) were of Hispanic ethnicity or nonwhite race; 39% reported themselves as African American, 25% Hispanic, and 24% Asian. More than one-fourth (27%) of respondents had less than a high school education. Although only 2 sites collected information on insurance coverage , the rate of those with no insurance (43%) was almost twice the national average (23%) . Three sAcross varied sites and diverse populations, we found that participants who were not recent immigrants had basic general knowledge about CVD, risk factors, disease outcomes, and prevention but experienced locally specific challenges to putting knowledge into practice. Most participants generally recognized high blood pressure and high blood cholesterol levels as risk factors for heart disease, understood the roles of lifestyle and genetics in these risk factors, knew the numbers that indicate high blood pressure and high blood cholesterol levels, and recognized lifestyle and medications as components of reducing risk.New immigrant populations  had only rudimentary or incomplete knowledge about CVD, compared with the more established populations. For example, most participants in the UW small-group sessions knew high levels of blood pressure were bad but had difficulties describing what high blood pressure is. Participants in the UIC groups knew that CVD was related to lifestyle factors including diet but did not know the numbers defining high blood pressure and high blood cholesterol levels. Participants in these settings did not understand the importance of taking medication to treat high blood pressure and cholesterol levels.Participants at all sites had less knowledge about stroke than about heart disease, and they reported fear of stroke. They expressed concern about the loss of independence associated with stroke, the resultant economic implications for families, and the burden on family members who provide care.Across small-group sessions and interviews, common socioecological themes emerged as barriers to translating knowledge into healthy behaviors: multiple role demands, lack of economic resources, social and cultural issues that include lack of family and community support for healthy habits, and concerns about health care. Particularly for women, their multiple roles as wage-earners, household managers, child care providers, providers of elder care, and people responsible for dealing with health care demands for all family members left them too exhausted to attend to their own health, without time to exercise, and too overextended to prepare nutritious meals at home as often as they liked or knew they should.Many respondents lamented the high price of fresh fruits and vegetables, the cost of gas for transportation, and the cost of health insurance. Living in resource-poor communities contributed to their difficulties.Respondents at most sites remarked on the number of fast-food restaurants, citing them as often the only source of meals outside the home. They observed that corner stores with limited fresh foods were more accessible than well-stocked supermarkets. Their neighborhoods often lacked safe walking environments or facilities such as parks, gyms, and playgrounds. Additionally, at some sites, a strong street culture  competed with families for the attention of their children and created barriers to healthy behaviors in the young. Even for respondents with health insurance, difficult access  created barriers to appropriate health care. Hispanic respondents noted the lack of providers who speak Spanish, and new immigrants had problems navigating the US health care system and integrating it with traditional beliefs and practices. Asian respondents preferred to use their own community physicians and pharmacists for advice and to rely on their own traditional remedies and products because they perceived that they had access to few other resources for information. Respondents spoke of weather and transportation as barriers to healthy physical activity.Community and social context in some cases facilitated healthy behavior . Family Respondents identified a number of information sources that included health care providers, family and friends, printed materials, and other media . Asian immigrants (UW) trust health information from physicians despite communication problems. They also trust information from other providers , family or friends, and community centers when offered in their native languages. Recent immigrant Hispanic respondents (UIC) reported receiving little CVD information in any form. Nonimmigrant groups  preferred peer-to-peer discussion groups and family and friends for information and to generate strategies for putting knowledge into practice. Respondents from all sites found currently available print and other media materials of limited usefulness.Respondents provided suggestions for disseminating health information into their communities. They identified the following characteristics of successful strategies: responding to the influences of intrapersonal (motivation), interpersonal , community , and institutional contexts. They cited interactive personal contact, use of preferred language , and tailoring to cultural values and priorities of the local community . Respondents recommended family-friendly group sessions . They preferred to hear from informed family and friends, especially those who speak of their own experiences; trusted groups ; and health care providers, but not always . Asian and Hispanic immigrants  expressed the need for educational materials in their own languages and for dissemination approaches sensitive to community and culture.The diversity of PRC CHIRTN communities and successful sampling made it possible to collect new insights into knowledge, perceptions, and preferred dissemination methods that will facilitate community-specific prevention activities. The results from this study indicate that many people (but not new immigrants) have adequate knowledge of heart disease and its risk factors, including information about healthy lifestyles, but are less well informed about stroke. Another study found that underserved people with known elevated risk of CVD  had limiEven with adequate knowledge, members of underserved populations have difficulty putting what they know into practice. In particular, they, especially women, identify barriers related to multiple family- and work-based responsibilities ,19-23 anParticipants offered valuable suggestions for culturally appropriate, community-specific approaches to promote cardiovascular health:Interactive, hands-on programs in small groups, including social support to bolster motivation to comply with prevention and treatment regimens.Information from informed peers who have personal experience to relate. We know from the literature and experience in our communities that lay health workers, who have an intimate understanding of their community's sociocultural background, experiences, challenges, and strengths are in a unique position to provide peer support for community members ,25,26."Real-world" vocabulary in the preferred language. A need exists particularly in low-literacy communities for accurate, credible, and current information  in clearImproved communication with and information from health care providers.Assistance with child care and transportation.More community resources for physical activity and healthy food.These suggestions emphasize the need to engage the community and the consumer in assessing needs and developing materials and programs, as recommended by the National Expert Panel on Community Health Promotion . AlthougSmall-group sessions and interviews may not adequately mirror the characteristics of the community or population that they represent. The diversity of settings we reached suggests that the results described here reflect similarities and differences across underserved groups with increased CVD risk. Although the research sites used different data collection methods, the development of common protocols, discussion questions, and coding schemes means that we spoke of the same issues in the same ways. Investigators from all sites collaborated to conduct the highest level of analysis and synthesis, which increased the rigor of the results and the implications drawn from them.Public health practitioners and programs must reach people at high risk and engage them in prevention activities. The results of this study make it clear that we need to move beyond individual- and knowledge-based interventions to new approaches that involve social marketing; environmental change to improve access to nutritious food, physical activity, and health care; and strategies tailored to the context.This study identified a number of common barriers to cardiovascular health across groups of underserved populations that community interventions may address. Although sensitivity to unique cultural settings must be considered, many similarities exist across groups concerning suggestions for approaches to improve knowledge and CVD prevention practice. The socioecological perspective provides a framework for creating multifaceted disease prevention interventions and related communication strategies that simultaneously target the different levels of influence and build on community strengths.


The 2002 Keystone symposia held in Taos, New Mexico (21–26 February) saw the convergenceof two related fields; Epigenetics in Development and Disease, and RNA Interference,Cosuppression and Related Phenomena. The meeting highlights presented hereconcentrate upon the sessions within the Epigenetics in Development and Disease meeting,although there were joint sessions which will also be discussed. Of course epigeneticregulation is not restricted to the vertebrates but I have chosen, rightly or wrongly, to limitthe highlights to those concerning vertebrates.


The neglected tropical diseases are not always exclusively tropical as defined by their endemicity between the Tropic of Cancer in the northern hemisphere and in the Tropic of Capricorn in the southern hemisphere. Indeed, in previous articles, it has been pointed out that neglected infections occur wherever extreme poverty occurs In Canada, the major indigenous peoples of the Arctic are the roughly 50,000–60,000 Inuit  [8],[9].PLoS Neglected Tropical Disease Web site (http://www.plosntds.org) and the geographic regions and countries of the Arctic, over the last two decades but with emphasis on the last 10 years , reveals a modest literature on infectious diseases of the North American aboriginal populations but far less on the larger Russian-Siberian populations. This observation likely reflects the bias introduced by examining only literature in English, together with more than 20 years of outstanding work by several Canadian universities and institutes, particularly studies in Nunavik conducted by investigators at McGill University and in Alaska by the Arctic Investigations Program of the United States Centers for Disease Control and Prevention.A review of literature (papers or abstracts in English only), using as MEDLINE/PubMed medical subject headings (MeSHs) the specific diseases listed as the neglected tropical diseases on the In their recent overview on indigenous health Gracey and King point out that globally, the almost 400 million indigenous people live in poor health linked to “poverty, malnutrition, overcrowding, poor hygiene, environmental contamination, and prevalent infections” Haemophilus influenzae type b, Streptococcus pneumoniae, and Bordetella pertussis have been noted among Alaska natives H. influenzae type b, a new serotype, H. influenzae type a, has emerged among children less than 2 years of age among Alaskan natives and the Inuit in Canada Helicobacter pylori among the Inuit and Alaskan natives has been observed H. pyloriIt is not surprising that in this setting of stress, socioeconomic deprivation, and environmental degradation infectious diseases would flourish. Indeed, overall the world's indigenous people in general suffer from high rates of infections such as ectoparasitic skin infestations, upper and lower respiratory tract infections and central nervous system infections from bacterial invasive organisms and tuberculosis, childhood illnesses (due to low vaccine coverage), diarrheal and intestinal helminth infections, urinary tract infections, bone and musculoskeletal infections, and in some cases, HIV/AIDS and malaria Parasitic helminth and protozoan infections are also common among the Inuit in Canada and Greenland and among Alaskan natives. The concept of neglected infections of poverty among the Inuit and Alaska natives was introduced previously The major helminthiases among indigenous Arctic populations are trichinellosis, diphyllobothriasis, and echinococcosis. Arctic outbreaks of trichinellosis have been described since the 1940s when a large outbreak in West Greenland from infected walrus and polar bear resulted in more than 400 cases and 37 deaths Trichinella nativa species that has the ability to withstand freezing temperatures T. nativa infection also exhibits several unique clinical features. Whereas primary infection resembles other forms of trichinellosis, i.e., a short intestinal phase followed by the classical features associated with muscle invasion including fever, muscle pain and weakness, and edema, recurrent infection with T. nativa produces largely prolonged diarrhea Trichinella larvae and then rapidly disseminate the testing results to potentially affected communities More recently, outbreaks of trichinellosis were noted among the Canadian Inuit Echinococcus granulosus, the etiologic agent of cystic echinococcosis in the Arctic region where natural enzootic life cycles between wolf and wild reindeer and wolf and elk exist. At one time human cystic echinococcosis was highly prevalent among aboriginal populations living in Alaska and the Canadian Arctic as a consequence of using dogs for hunting and herding activities Echinococcus multilocularis is a rare infection, although sporadic cases have been described in a small hyperendemic area in Western Alaska In addition to trichinellosis, diphyllobothriasis (fish tapeworm) is endemic to Alaska and elsewhere in the Arctic region Toxoplasma gondii infection was considered very high at 60% T. gondii infection and consumption of unfiltered surface water. Given the overall absence of cats in this area there is interest in determining whether lynx (a wild cat in the region) could be responsible, and whether infective oocysts could wash into the sea by surface water runoff thereby contaminating the marine environment Giardia parasites in seals in Nunavik suggests the possibility that this infection is acquired through zoonotic transmission In terms of prevalence and disease burden toxoplasmosis is probably the most important parasitic infection in the North American Arctic The high rates of neglected infection of poverty among indigenous populations living in Alaska, Greenland, and the Canadian Arctic require further investigation, especially the identification and role of definitive and intermediate hosts in the transmission of toxoplasmosis, trichinellosis, and giardiasis. Given the high rates of toxoplasmosis a program of newborn screening should be implemented for these populations, so that at-risk infants could begin antiprotozoan chemotherapy. The dearth of information on neglected infections among indigenous populations living in Russia and Siberia also suggests that increased efforts are required for active surveillance for the most common infections in this region and to step up measures for studying the area's unique ecology and infection transmission dynamics. Ultimately, programs for prevention of neglected infections may need implementation for all of the indigenous peoples living in the Arctic region.Metorchis conjunctus). Dr. MacLean died on 22 January 2009 following complications from surgery. In recognition of his exemplary career, McGill University has re-named the TDC the J. D. MacLean Centre for Tropical Diseases. His greatest legacy, however, is reflected in the generations of students, trainees, and colleagues who benefited from his teaching and counsel and who were inspired by him to become better citizens of the world.Dr. J. Dick MacLean  completeContributed by Theresa W. Gyorkos, Michael Libman, and Brian J. Ward


To validate the utility of a chief complaint–based emergency department surveillance system, we compared it with respiratory diagnostic data and calls to Telehealth Ontario about respiratory disease. This local syndromic surveillance system accurately monitored status of respiratory diseases in the community and contributed to early detection of respiratory disease outbreaks. The threat of emerging infectious diseases, such as severe acute respiratory syndrome and pandemic influenza, makes early detection of health events critical for effective control and intervention of such outbreaks. By using alternative, electronic data sources  as recorded by a triage nurse. Respiratory CC data correlate strongly with discharge data  to monitor respiratory and gastrointestinal CCs temporally and spatially. Seven hospitals from the southeastern Ontario region fed electronic CC data into the system. Routine patient data collected without identifiers include date and time of visit, demographic information, 5-digit postal code of residence, Canadian Triage Acuity Score, and CC or reason for visit. The National Ambulatory Care Reporting System (NACRS) gathers data for hospital- and community-based ambulatory care, day surgery, outpatient clinics, and EDs. Records contain patient diagnosis according to International Classification of Diseases, 10th Revision–Canadian Enhancement (ICD-10-CA) codes. Every hospital in Ontario submits data to NACRS, and the system includes demographic, clinical, and administrative data for the entire province  and health unit code in the NACRS database and by specific reporting hospital in the EDSS data set. Weekly Telehealth Ontario counts of respiratory disease based on guidelines were also obtained. We categorized Telehealth Ontario calls into episodes of upper or lower respiratory disease on the basis of a priori classification schemes verified by other research  ; howeverOne consideration for interpreting EDSS data is that the hospitals in this surveillance system include large referral hospitals that have high volumes of patients visiting from outside our health unit boundaries. Although this large referral area may result in higher counts of visits than reflected in the NACRS database, we believe it does not affect our interpretation of the data. Even though each hospital is required to submit data, it is still possible that not all records from each hospital are sent on time to NACRS.Although the public health system has accepted syndromic surveillance as a useful tool, doubts remain about its anticipated early warning benefits (