The Gomti River in Lucknow City, India, was an important source of water for the different uses few decades ago. However, because of the rapid global changes, current status of the river is very critical from environmental, aesthetic and commercial usage point of view. Henceforth, this research work focused on assessing the current as well as predicting its future situation using different scenarios while considering key drivers of global changes namely climate change and population growth. Water Evaluation and Planning (WEAP), a numerical simulation tool, was used to model river water quality using two scenarios viz. business as usual (BAU) and scenario with mitigation measures. Water quality simulation was done along 24 km stretch of the Gomti River from downstream of Near Moosa Bird Sanctuary to Near Bharwara. Comparison of simulated water quality parameters for the current and BAU status clearly indicates that the water quality by 2030 will rapidly deteriorate and will be not suitable for many aquatic lives in terms of simulated water quality parameters. Results from scenario with mitigation measures suggest current planned wastewater treatment plants and policies are not sufficient enough to achieve desirable river water quality within class B and hence call for immediate and inclusive action. At pAlthough water security issues differ across the countries, the most threatening issue is demographic changes along with their life style irrespective of their geographical locations Considering the complex issues of water security, mode of scientific research works gradually evolved from mono-disciplinary research i.e. working in silos for a common goal to transdisciplinary research i.e. working in an integrated way for a common goal. Integrated water resource management (IWRM) modeling tools, as a fine medium for transdisciplinary research targeting at different aspects  are the need of the hour to come up with scientific evidence based viable water policy decisions , 19, 20.Based on above argument, this study focussed on assessing the current situation and simulated future status of water quality in the Gomti River basin crossing Lucknow city, with ultimate goal to help formulate sustainable water resource management options for the area. Here climate change and population growth were accounted as main driving force behind water quality deterioration and planned wastewater infrastructure from existing master plan as a mitigation measure was considered to predict future water environment. The uniqueness of this research work will be to validate the importance of mitigation measures in the existing master plan for Lucknow city, being developed by the policy/decision makers by considering them in our simulation work for projecting future water environment. In addition, this was a retrofitting process based simulation, where policy makers were consulted while developing the model and after obtaining the primary simulation results for their feedback for the information/data considered for the simulation work. Finally, the obtained results will help them to understand and target the policy gaps necessary to be filled at urgent basis for the sustainable development of water resources. Because this retrofitting process thoroughly involve the decision makers for numerical simulation, they strongly feel ownership of the result and willing to implement the suggested additional measures. The reason to select Lucknow is that; Lucknow is the capital of largest state (Uttar Pradesh) of India, with one of the largest economic centre of the country and witnessing rapid economic/urban growth. Combination of high economic growth and uncoordinated rapid urban expansion results in unhealthy water environment especially around water bodies like the Gomti River basin. Despite its importance, it is very poorly documented for its current status and its management strategies for the near future. Finally, this research work will providing information relevant for the capacity building of the concerned people involved in water planning in right direction.22.1Lucknow, the capital of Uttar Pradesh (India), is located in the part of central Gangetic plain between North latitudes 26°30′ and 27°10′ and East longitudes 80°30′and 81°13’ . The citLucknow is cut across by a number of streams. Gomti, the major river, flows from North-West to South-East through the center of city. It is one of the major sources of public water supply in the city along with groundwater. Generation of sewage and proper treatment and disposal of this waste is the major problem in the city. Poorly drained sewerage system and lack of treatment capacity of sewage treatment units has resulted in severe degradation the quality of river water.2.2z1 and z2 as the initial relative storage (%) for the upper (root zone) and lower (deep) water capacity, respectively (Eqs. 1 and z2 = upper soil layer and lower soil layer (m), which represent shallow water and deep water capacities, respectively.Hydrological simulation with WEAP needs the entire study area to be divided into smaller catchments with consideration of confluence points, physiographic and climatic characteristics. Hydrology module within WEAP can simulate catchment runoff and pollutant transport process within a river/water bodies. To simulate different components of hydrological cycle, WEAP has different catchment methods available namely rainfall runoff (simplified coefficient method), irrigation demands only (simplified coefficient method) and rainfall runoff (soil moisture method). However, for this study, the soil moisture method, the most sensitive method, to estimate the different hydrological components is used. This method can simulate different components of the hydrologic cycle, including evapotranspiration, surface runoff, interflow, base flow, and deep percolation ely Eqs. .(1)ET=PoThe water quality module of the WEAP tool makes it possible to estimate pollution concentrations in water bodies and is based on the Streeter–Phelps model. In this model, two processes govern the simulation of oxygen balance in a river: consumption by decaying organic matter and reaeration induced by an oxygen deficit BODinit = BOD concentration at beginning of reach (mg/l), BODfinal = BOD concentration at end of reach (mg/l), t = water temperature (in degrees Celsius), H = water depth (m), L = reach length (m), U = water velocity in the reach, vs = settling velocity (m/s), kr, kd and ka = total removal, decomposition and aeration rate constants (1/time), kd20 = decomposition rate at reference temperature (20° Celsius). Oxygen concentration in the water is a function of water temperature and BOD:Ofinal = oxygen concentration at end of reach (mg/l), Oinitial = oxygen concentration at beginning of reach (mg/l).2.3The WEAP model was used to simulate future water quality variables in the year 2030 to assess alternative management policies in the Gomti River basin. For water quality modeling, a wide range of input data including point and non-point pollution sources, their locations and concentrations, past spatio-temporal water quality, wastewater treatment plants , population, historical rainfall, evaporation, temperatures , drainage networks Escherichia coli counts) were also collected at above all five stations, which were used for water quality modeling. All dataset required to build the model and scenario analysis for this study is shown in Daily rainfall was collected at IMD Meteorological Station, for the period from 1980 to 2016. Daily average stream flow data in 2011–2016 were measured at five stations, namely Bharwara, River Weir, Pipraghat, Kuriyaghat, Manjhighat and Near Moosa Bird Sanctuary collected from Indian Meteorological Department and were utilized to calibrate and validate the WEAP hydrology module simulation. Data for the water quality indicators biochemical oxygen demand (BOD) and total coliforms  and Representative Concentration Pathway (RCP) output were used after downscaling and bias correction. In order to evaluate the climate change on water quality, we have evaluated the change in monthly average precipitation. Statistical downscaling followed by trend analysis, a less demanding computation technique which enables reduction of biases in the precipitation frequency and intensity In order to estimate the effect of population growth on water quality status, the whole study area is being divided in to eight demand sites. These demand sites mainly represent the population of different cities lying on either side of the Gomti River within our study. Location of demand sites were chosen in such a manner that it will a give a symmetric representation of pollution load (in terms of domestic discharge) from the inhabitants living at both sides of the river banks. Result for the population distribution and its future trend at these demand sites were calculated by ratio method using UNDESA projected growth rate Apart of above mentioned components for model setup, other major considerations are the eight demand sites and two wastewater treatment plants (WWTPs) to represent the problem domain. Here, demand sites are meant to identify domestic (population) centers defined with their attributes explaining water consumption and wastewater pollution loads per capita, water supply source and wastewater return flow. Dynamic attributes are described as functions of time and include population. Wastewater treatment plants are pollution handling facilities with design specifications that include total capacity and removal rates of pollutants. Also, sewerage connection rate for households in the study area was assumed as equals to percentage of total domestic waste water being transported to the WWTPs. In other words, clogging and leakage of sewerage pipeline was neglected. In this study, domestic sewerage is only source considered for incoming wastewater into the Gomti River and its tributaries.Here, upflow anaerobic sludge blanket reactor coupled with sequencing batch reactor (UASB-SBR) type of wastewater treatment plant is considered in the modeling and its treatment efficiency is assumed as 97% for BOD and 99.69% for fecal coliform 33.1The comparative results of the monthly precipitation pattern are shown in 3.2The total population of 4589838 was considered at base year i.e. 2011 in our study area 3.33.3.1Before doing future scenario analysis, performance of the WEAP simulation is calibrated and validated with observed and simulated values of hydrological and water quality parameters. Hydrology module parameters (effective precipitation and runoff/infiltration) were adjusted using trial and error method during simulation in order to reproduce the observed monthly stream flows for the period of year of 2013–2015 in case of hydrology module validation . The fin3.3.2For water quality, simulation is done using two possible scenarios as shown in E. coli) using these two scenarios is shown in E. coli<1000CFU/100mL) E. coli will be deteriorating by a further 70.8% and 10.6 % respectively on an average in 2030 when compared to the current situation. Further, the effect of each individual parameter i.e. population growth and climate change is analyzed by keeping other parameters constant. For example, when calculating the individual effect of population growth, the value of rainfall as a representative of climate change in this case by year 2030 kept constant and vice-versa. The obtained result is shown in The simulation results for the water quality parameters , algal bloom and death of aquatic organisms like fishes (because of high BOD).However, based on scenario with measures, where whole domestic wastewater generated within the study area will be collected by 100 % sewerage collection rate and treated from increased WWTPs capacity of 1119 MLD, result for simulated water quality will be much better. The concentration of BOD and Finally, the logic of Drivers-Pressures-State change-Impact-Response (DPSIR) framework  is used 4This work gave a detailed picture of water quality of Gomti River in Lucknow City, India for both current (2015) and future (2030) time using different scenario analyses. Simulated result clearly indicated that Gomti River is moderately to severely polluted throughout the stretch when compared with class B given by Uttar Pradesh Pollution Control Board (UPPCB) for year 2015. In addition, for the business as usual scenario, the quality status will become worse by year 2030. However, considering the scenario with mitigation measures as mentioned in local master plan for water resources management, the quality of water will improve significantly. However, water quality at downstream areas like Pipraghat, Gomti River Weir and Near Bharwara does not comply with desirable water quality of class B, and needs further attention. Some of the other potential reasons behind the poor status of water quality are: a) at current stage, despite the considerable capacity of existing WWTPs, the wastewater coming to these plants are not sufficient because of poor sewerage collection rate or poor connection between each household and main sewerage line. The reason behind this is the non-willingness to pay the expensive connection fee by the local residents; and even once, connected they have to pay more money in terms of water or sewerage treatment bills; b) lack of proper coordination between different actors/stakeholders involved in water management to implement the master plan (water infrastructure) in a timely manner.Possible solutions to overcome these barriers can be: a) to create a political space where different stakeholders other than government agencies also have direct involvement to influence the governing processes and government decisions; b) provision of some monetary help like financial incentives in terms of tax exemption to encourage local people to connect there households to the main sewerage line; c) raising people awareness about the benefits of better water environment in terms of good health, good business opportunities by tourism; d) as creating different hard measure (wastewater treatment) is financial burden for many developing countries and that's why many projecting are running behind their scheduled progress rate. Henceforth, there should be more push to the local government to implement de-centralized WWTPs along with centralized WWTPs as other possible mitigation measure which is subject of future research; e) in order to complete the exiting master plan by the given timeline, regular monitoring for progress of implementation of master plan is highly recommended; f) consider more precise information for various pressures and drivers for global changes namely population density, population growth, climate change, land use/land cover change in the revised master plan for achieving desired future water environment both at short and long time scale.Pankaj Kumar: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors declare no conflict of interest.No additional information is available for this paper.


The role of governance in strengthening tuberculosis (TB) control has received little research attention. This review provides evidence of how institutional designs and organisational practices influence implementation of the national TB control programme (NTP) in Nigeria.We conducted a scoping review using a five-stage framework to review published and grey literature in English, on implementation of Nigeria’s NTP and identified themes related to governance using a health system governance framework. We included articles, of all study designs and methods, which described or analysed the processes of implementing TB control based on relevance to the research question.The review shows a dearth of studies which examined the role of governance in TB control in Nigeria. Although costed plans and policy coordination framework exist, public spending on TB control is low. While stakeholders’ involvement in TB control is increasing, institutional capacity is limited, especially in the private sector. TB-specific legislation is absent. Deployment and transfer of staff to the NTP are not transparent. Health workers are not transparent in communicating service entitlements to users. Despite existence of supportive policies, integration of TB control into the community and general health services have been weak. Willingness to pay for TB services is high, however, transaction cost and stigma among patients limit equity. Effectiveness and efficiency of the NTP was hindered by inadequate human resources, dilapidated service delivery infrastructure and weak drug supply system. Despite adhering to standardized recording and reporting format, regular monitoring and evaluation, revision of reporting formats, and electronic data management system, TB surveillance system was found to be weak. Delay in TB diagnosis and initiation of care, poor staff attitude to patients, lack of privacy, poor management of drug reactions and absence of infection control measures breach ethical standards for TB care.This scoping review of governance of TB control in Nigeria highlights two main issues. Governance for strengthening TB control programmes in low-resource, high TB burden settings like Nigeria, is imperative. Secondly, there is a need for empirical studies involving detailed analysis of different dimensions of governance of TB control.The online version of this article (10.1186/s40249-019-0556-2) contains supplementary material, which is available to authorized users. Please see Additional file Governance plays a key role in structuring responses to global health challenges such as tuberculosis (TB) but the role of governance in strengthening TB control has received little attention. Tuberculosis remains a major health problem in many low and middle-income countries (LMICs) including Nigeria, a country among the 30 high TB burden countries and one of the top three of ten countries that accounted for 80% of the total gap between TB incidence and reported cases in 2017 [To eliminate TB as a major public health problem, Nigeria initially adopted directly observed treatment short-course (DOTS) strategy in 1993 [Governance encompasses a set of processes: institutions, rules, customs, policies or laws, that are formally or informally applied to distribute roles and responsibilities or accountability among societal actors . Health The national strategic plan for TB control (NSP-TB) prioritises health system governance to accomplish universal access to high quality, patient-centred prevention, diagnosis and treatment services for TB . The NSPResearch evidence for TB control which focus primarily on how governance processes and practices inform the design and implementation of NTP interventions in LMICs are scarce. However, studies from settings outside Nigeria reveal poor governance practices. Absence of specific TB legislation, inconsistent enforcement of policies on isolation of TB patients in health facilities or incarceration , 10; andThere is a need to generate more evidence of the governance imperatives for achieving universal access to prevention, diagnosis and treatment of TB in resource-constrained countries. This paper aimed to answer the question what governance factors enable or constrain the implementation of TB control in Nigeria?, and to explore the significance of governance for TB control policy effectiveness will provide evidence that would be relevant to health system actors in Nigeria and other high TB burden countries in planning, design and implementation of TB care and prevention.We undertook a scoping review of grey and published literature on implementation of Nigeria’s TB control programme and identified themes related to health system governance. Scoping review was deemed an appropriate research design for this study because of the paucity of analytical reviews on the role of health system governance in TB control in Nigeria. Our review was based on the York methodology which included five stages namely, identifying the research question; identifying relevant studies; selecting the studies for review; charting the data; and collating, summarising and reporting results .This review used the Siddiqi et al. health system governance framework . We adapIn November 2018, we searched the main database in health and medicine, namely Scopus, MEDLINE, Complementary Index, Academic Search Complete, Science Citation Index, Directory of Open Access Journals, Supplementary Index, ScienceDirect and CINAHL for peer-reviewed articles published in English between 2000 and 2018. The search strategy was adapted for each database consistent with their indexing and used a combination of Mesh Terms or keywords with Boolean operators : tuberculosis, TB, control, programme, governance, management, implementation, evaluation, strategy, intervention, Nigeria and Nigerian. In addition, in consultation with the NTP officials, we identified policies and NTP reports to ensure comprehensive coverage of all sources providing information related to governance factors in TB control in Nigeria.Initially, we intended to include only studies focusing on governance analysis of the Nigeria’s TB control programme but found only one study directly related to governance of TB care on screening the titles of the studies. Following review of the abstracts and detailed examination of the studies, this review therefore included articles, of all study designs and methods, describing or analysing the processes of implementing TB control based on significance, level detail and relevance to the research question. The articles must focus on Nigeria, published in English language between 2000 to 2018 and findings included a governance outcome. No study was excluded based on risk of bias of the study. 270 articles were eliminated because they were exact duplicates, while 537 articles were excluded because they were one of epidemiological, clinical, laboratory, pharmacological, nutritional and genetic studies. The flowchart showing the process of article selection for this review is shown in Fig. The selected documents were imported into NVivo software . Codes were deduced from the ten dimensions of Siddiqi and colleagues’ health system governance framework  guidelines . AlthougAdherence to World Health Organisation’s recording and reporting standard, regular data review and statistical report, data- verification visits, annual joint missions, frequent revision of reporting formats, transition from paper to an electronic data management system, alignment of reporting formats to national health management information system, , 30, 44,Although standards for TB care exist, ethics was breached by delays in TB diagnosis and initiation of care ; poor stThis review shows that studies related to governing TB control in Nigeria are limited. Most studies describe or analyse the processes of implementing TB control, offering insights into how institutional designs and organisational practices affect the NTP in Nigeria. The application of the Siddiqi et al. governance framework to these studies and policy documents has revealed some enablers and many constraints to governing TB control in Nigeria.The existence of strategic plans and guidelines for TB control, policy coordination framework, clarity of roles of different actors and donor funding facilitated TB control. Since inception of the NTP in 1991, several guidelines and strategic plans have been developed for TB control. The policies set clear priorities, define roles and performance targets as well as shared long-term goals for TB care and control. These findings align with WHO’s pillar 2 of the End TB Strategy, ‘bold policies and supportive systems’ for TB care and prevention. However, existence of policy coordination framework did not translate to effective coordination in practice. Although plans are costed, funding gaps persisted due to low public spending and unpredictable release of funds by all tiers of government. These findings are similar to the low government funding found in Pakistan and India , 13. In An increasing engagement of all stakeholders in the development and implementation of policies for TB control is another finding. The structures and guidelines for TB/HIV collaborative activities exist at both facility and programme management levels but programme implementation is weak. The NTP also recognises the need to engage the private sector using evidence-informed guidelines, capacity building, stakeholders’ consensus building meeting and supportive supervision. Nonetheless, the capacity of private health facilities to deliver TB services has been limited by poor organisational factors, inadequate human resources, non-compliance with patient monitoring requirements and weak regulatory framework, which results in sub-optimal quality of care as is the case in India . AddressA weak legal environment for TB control resulted from absence of TB-specific legislation, lack of laws regulating sale of anti-TB drugs, no clear policy on isolation and involuntary isolation of people with TB, and exclusion of TB from health insurance act. This finding is consistent with evidence from several studies highlighting absence of specific TB legislation, inconsistent enforcement of policies on isolation of TB patients in health facilities or incarceration , 10; andDeployment and transfer of staff to the NTP is not transparent due to absence of clear staff needs, frequent changes in leadership of the NTP and NTP’s lack of authority to influence staff recruitment and distribution at all levels. Notwithstanding that staff allocation and training should be based on needs, primary health workers in Nigeria could be posted or transferred punitively, for political patronage or leniently closer to their residence . MoreoveThis review further indicates that integration of TB control into the community and general health services have been weak despite existence of supporting policies. Poor integration of TB into general health services was also seen in Vietnam . EffectiWhereas transaction cost and stigma among patients limited equity and inclusiveness of TB care, the willingness to pay for TB services for self and others was high in this review. The findings about transaction cost is consistent with evidence of high cost of TB care despite free care policy in Burkina Faso, South Africa and China , 18, 76 The finding that effectiveness and efficiency of the NTP was hindered by inadequate human resources, dilapidated service delivery infrastructure and weak drug supply system indicates the need for health systems strengthening for infectious diseases control. Similar to our findings, inadequate human resources for TB control was found in Malaysia and many TB high burden countries , 77. AttCitizen participation in TB control is low. Absence of social accountability initiatives limited citizens’ oversight of TB care despite the existence of advocacy, communication and social mobilisation policy. Conversely, greater participation of stakeholders was found in southeast Asian countries , and in We also found that adherence to standardized recording and reporting format, TB prevalence survey, regular monitoring and evaluation, revision of reporting formats, electronic data management system and training of health workers are key factors that could strengthen TB surveillance system in Nigeria. Yet, TB surveillance system in Nigeria is weak similar to experiences in South Africa . MathemaThe review findings also highlight the need for adherence to ethical standards for TB care. Delay in TB diagnosis and initiation of care resulting in long waiting times, diagnostic drop outs and loss before treatment; poor staff attitude to patients; lack of privacy; poor management of drug reactions and absence of infection control measures, confirm the breach of both the international standards for TB care and patient-centred TB care , 81. SinThis study fills a significant gap in knowledge about the role and importance of governance in TB control in Nigeria. It addressed this gap by applying the governance framework of Siddiq and colleagues to identify factors that either enabled or constrained effective implementation of Nigeria’s NTP. Secondly, it contributes to the policy debate on health system strengthening for infectious disease control programmes. Evidence from the review can be used by LMICs to improve the design and implementation of their TB control programmes. This study is, however, limited by paucity of studies on many dimensions of governance. Further empirical studies, involving detailed analysis of the different aspects of governance, are needed.In conclusion, this review has identified the governance imperatives to strengthen TB control programme in Nigeria and similar settings. Effective governance for TB control would entail adequate policy coordination; increased, predictable TB financing; and collaborative design and implementation of strategies for TB control. Stronger legal and regulatory environment consistent with a human rights-based approach would be helpful. Transparent posting and transfer of staff; clear communication of service entitlements and obligations to patients are imperative. Equally, need-based integration of TB control into communities and general health services; and inclusion of TB services in UHC schemes are warranted. It is also necessary to ensure effective organisation of service delivery; adequate and motivated health workforce; regular and uninterrupted drug supply; and stronger roles for citizens in policy engagement and oversight of health facilities. Furthermore, functional TB surveillance system, and adherence to ethical standards for TB care are crucial.Additional file 1:Multilingual abstracts in the five official working languages of the United Nations. (PDF 567 kb)Additional file 2:Descriptive content of the 38 selected articles and 11 documents reviewed. The file provides the detailed characteristics of the journal articles and documents included in this scoping review. The table includes authors, year of publication, methods, population and sample, key outcome and conclusion. (DOCX 32 kb)


This presentation will highlight Ohio’s innovative model to address the prevalence, risk factors, and consequences of elder abuse and neglect. We will begin with an overview of the mission and duties of the recently codified Ohio Attorney General’s Elder Abuse Commission. These include: (1) to raise awareness, improve education, and boost the level of research regarding elder abuse in Ohio, (2) to provide a forum for improving the elder justice system, and (3) to identify policy, funding, and programming recommendations to address elder abuse. Next, we will share findings from the Research Committee’s first statewide survey on elder abuse research priorities. Completed by frontline practitioners, program administrators, advocates, researchers, and policy makers, the online survey received 459 responses from individuals across the state. Findings reflect gaps in the elder abuse literature, as respondents prioritized funding for research in how elder abuse can be prevented, and what programs/policies can best serve victims and their families after elder abuse has begun. We will conclude with recommendations regarding how the Elder Abuse Commission model may be adapted or modified to elevate awareness of elder abuse and elder abuse research in other parts of the country.


Categorization of terms/concepts/constructs that allows for better understanding and comparison of public health interventions is often lacking in program implementation and evaluation. A classification system such as a lexicon, when used appropriately, can help address this need. The present narrative describes a lexicon of policy, systems, and environmental change strategies (PSEs) that was developed and prototyped to aid local implementation of Supplemental Nutrition Assistance Program Education (SNAP-Ed) interventions in obesity prevention. The lexicon was reviewed and refined by a panel of experts who provided iterative feedback on the system's scope and utility. To develop the lexicon, a team from the local health department: (i) conducted an inventory (community context scan) of SNAP-Ed PSEs implemented in Los Angeles County during 2010–2015; (ii) assessed commonalities among PSEs that were translated into “index factors” to contextualize terms/concepts/constructs relevant to SNAP-Ed services planning; and (iii) convened a panel of experts to review and test the classification system for quality and usability. In the latter activity, the panel reviewed the terms/concepts/constructs within the context of two geographical areas and by the selected PSEs. The final version of the lexicon organized the terms/concepts/constructs of the local SNAP-Ed PSEs into overarching categories, so they can be compared/assessed by type, content, and/or impact. The goal of the project was to create a classification system that can help facilitate meaningful communications among program implementers, evaluators, and community stakeholders. The lexicon has practical implications and potential applications for other jurisdictions interested in reducing obesity rates through SNAP-Ed PSEs. •Policy, systems, and environmental changes (PSEs) in prevention can vary widely.•Comparison of PSE strategies is limited by a lack of standard categorization.•A lexicon can improve communications among PSE implementers and evaluators.•A lexicon can enhance data comparability and help shape PSE designs/evaluations. StandarThe lexicon developed and presented in this narrative is specific to public health interventions focused on obesity prevention, a priority area that is well-characterized in the literature . The nar22.1Healthy, Hunger-Free Kids Act, the federal United States Department of Agriculture (USDA) SNAP-Ed program adopted a socioecological framework to guide service delivery of nutrition education and related health promotion resources (With passage of the esources . A benefesources . Under tesources .During the latest SNAP-Ed funding cycle (2013–2016), planners of the Los Angeles County effort recognized, early on, that a common language describing the SNAP-Ed interventions may be necessary to facilitate meaningful communications and coordinated actions among implementers, evaluators, and community stakeholders. They understood that such a classification system  should be constructed based on data and information from a landscape analysis of regional policies and programming before and after the start of the latest cycle of SNAP-Ed funding, an accurate assessment of population health burden, and qualitative input from experts who have extensive knowledge and experience in implementing PSEs.2.2To develop the lexicon, the project team utilized data derived from several program sources, including: (1) a community context scan, (2) a health indicators project that synthesized health data by geographical region, and (3) a convening of an expert panel, using the modified Delphi method to pilot test and refine the classification system. The Delphi method is an iterative process framework based on multiple rounds of queries, typically asking experts to reach consensus or to explore areas of future thinking that goes beyond what is currently known . The itehealthy food and beverage standards, community gardens, healthy retail makeover, and farmers markets.(i)Community context scanThe lexicon groupings were referred to as “index factors” in this project, representing observed commonalities or identified patterns of PSEs that are organized or contextualized in a meaningful, consistent way. To group and assign terms/concepts/constructs to these index factors, data were obtained and synthesized for four key SNAP-Ed PSE strategy interventions implemented in two of the eight Service Planning Areas (SPAs) in LAC –Metropolitan (SPA 4) and South Los Angeles (SPA 6). Both SPAs covered geographic areas where there were high densities of low-income, SNAP-Ed eligible households. SNAP-Ed eligibility is determined primarily based on census tracts where at least 50% of the population have income at or below 185% of the Federal Poverty Level (FPL). The four selected interventions (focus areas) included: (ii)Health indicators projectThe community context scan, developed in partnership with Ad Lucem Consulting, included an initial review of relevant obesity prevention efforts in Los Angeles County during 2010–2015. The resulting database cataloged obesity prevention activities in the region for the past 5 years. It included information derived from a series of 51 key informant interviews with leaders of various sectors such as academia, non-profit, government, community clinics, and the private sector . Special focus was placed on capturing a snapshot of target areas of SPAs 4 and 6 where many residents were poor and were eligible for SNAP-Ed services. The context scan provided qualitative and quantitative data that aided the development of the lexicon, including information on type, setting, reach, factors associated with program implementation, and sustainability of key PSE strategy interventions. The scan was not an exhaustive review of all PSEs in LAC during 2010–2015.Communities of Excellence in Nutrition, Physical Activity, and Obesity Prevention (CX3) project contained pertinent neighborhood-level data that were acquired using the recommended community assessment tool developed by the California Department of Public Health. In combination, this information provided context and contributed to the methodology that was used to categorize and operationalize the health elements (terms and constructs) of SNAP-Ed interventions and services implemented in LAC.(iii)Panel of expertsPopulation-level health indicators for SPAs 4 and 6 were assessed in parallel to the community context scan during the 2010–2015 time period using the California Health Interview Survey (CHIS). CHIS data were broken down by SPA designations; for comparison, data for SPA designations other than 4 and 6 were also included. To explore differences in the health indicator by selected geography and demographics, several statistical analyses were conducted to describe the associations between the indicators and known risks of obesity and nutrition-related diseases . When feasible, these indicators and other existing sources of data were used to inform and select key terms/concepts/constructs for inclusion in the lexicon. For example, data sources such as the Using a modified Delphi method, the lexicon categories that were derived from the community context scan and the health indicators project were further contextualized with input from a panel of experts convened by DPH. The panel of experts (there were four of them) comprised members with expertise in PSE implementation and community design. As a condition of participation and to preserve confidentiality, each member's organizational affiliation(s) were not disclosed. These experts' input allowed for selective testing/prototyping of terms/concepts/constructs identified in the first two phases of the lexicon development process. The overall Delphi process took approximately 6 months to complete – two rounds of surveys, one group discussion, and the synthesis of data gathered.3Using the community context scan results , Table 2In the convening of the panel of experts, the terms/concepts/constructs derived from these first two phases of lexicon development were pilot tested and further refined for quality and usability – i.e., how the terms/concepts/constructs should be interpreted and applied in real world situations; under which context should they be used to plan and/or inform action , Table 6distribution or receptivity of PSE strategies or programming in the field or in each community/region that may correlate with the reach and/or impact of a program or PSE activity in that community.The results of the modified Delphi allowed the project team (representing the SNAP-Ed project in LAC) to fine-tune several of the terms/concepts/constructs in the lexicon. For example, “intervention spread” became more multi-dimensional with added complexity based on inputs from the panel. The term or concept was ultimately defined as the Because the overarching categorization approach was not intended to be exhaustive , they should be interpreted within the context of continuous learning and application of best practices using data from the most available evidence base. The lexicon ultimately serves as a starting point for facilitating a more standardized dialogue among program implementers, evaluators, and community stakeholders; these groups are responsible for making the various SNAP-Ed interventions a success across the county. It has been estimated that during 2010–2015, >150 PSE strategy interventions were successfully implemented throughout LAC .4Despite consensus on how to improve nutrition and related health behaviors, little is known about which mix of strategies is optimal for preventing these obesity risk factors in different settings . This laSystematic naming or classification of intervention parameters and related index factors can provide greater opportunities to standardize data collection and analysis. Over time, having commonalities in information management and synthesis terminology can lead to more reliable and accurate longitudinal tracking of progress in program implementation. This in turn can lead to better designs of program improvement efforts; not to mention greater confidence in the validity of the information being gathered, communicated, and used. More specific intervention descriptors and classification protocols can enhance surveillance and allow for greater ease in replicating interventions because of reduced guesswork in the definition and application of what is/are effective in a specific community. The capacity to generate and use this type of iterative process can, if done meaningfully, help lower the overall cost of intervention selection and implementation, and may help facilitate quicker diffusion of innovations .The lexicon is intended to address these and other issues about program implementation and evaluation. By categorizing a broad range of factors that could be considered within each PSE type, the system ultimately aims to help program implementers, evaluators, and community stakeholders communicate their vision and roadmap for program implementation, using a consistent vocabulary to describe, execute, and evaluate PSEs. The need for clear delineations within and between the selected strategy interventions was apparent during the modified Delphi discussion. The panel of experts was given an opportunity to pilot test or prototype  several key terms/concepts/constructs within the context of implementation nuances for each of the selected strategies. The resulting inputs were invaluable for refining the lexicon – e.g., variations among communities around safety, gentrification, organizational capacities, political will, and density of eligible populations within eligible census tracts became added considerations in the construction of the system.The present narrative describes the development and refinement of a lexicon that can be used to better understand PSEs in their “real world” context, especially as they relate to the growing obesity epidemic in LAC. The classification system (a tool) is proposed as an iterative approach for program planning and implementation, with built-in flexibility for ongoing adjustments and updates. By organizing PSEs into lexicon categories, the present project sought to establish a usable framework for improving local program communication and implementation of SNAP-Ed strategies. Future efforts should consider adapting and optimizing this lexicon for use by other LHDs that are interested in streamlining or improving SNAP-Ed delivery across the United States.5Public health practice is driven by an ongoing process of systematic surveillance, data collection, analysis, and interpretation of results. The value of these outputs depends on their comparability, application, and how they are communicated among program implementers, evaluators, and community stakeholders. Current PSE categories are generally too broad or amorphous to allow for meaningful, consistent comparisons or documentation of program progress/impact. A lexicon on intervention type, content, and impact, based on agreed upon terms/concepts/constructs, can help address this gap in public health practice. During a time of heightened scrutiny of public health programs, the need for meaningful categorization of program interventions is critical. In the case of SNAP-Ed in LAC, a lexicon of PSE strategy interventions appeared to confer added value for addressing this accountability process in social and health services delivery.The authors report no financial disclosures or conflicts of interest.


Saimiri boliviensis boliviensis) that were experimentally infected with ZIKV (Strain Mexico_1_44) and an additional two uninfected squirrel monkeys. Nucleic acids were extracted from these samples, and RT-qPCR was used to assay for the presence of ZIKV using primers flanking a 101 bp region of the NS5 gene. In both ZIKV-inoculated animals, ZIKV was detected 5–11 days post-infection, but was not detected in the uninfected animals. We compare the fecal results to ZIKV detection in serum, saliva, and urine samples from the same individuals. Our results indicate that fecal detection is a cost-effective, noninvasive method for monitoring wild populations of Neotropical primates as possible ZIKV reservoirs.A strain of Zika virus (ZIKV) of Asian origin associated with birth defects and neurological disorders has emerged and spread through the Americas. ZIKV was first isolated in the blood of nonhuman primates in Africa and has been detected in the blood, saliva, and urine of a few catarrhine species in both Africa and Asia, suggesting that nonhuman primates may serve as both a source and a reservoir of the virus. The recent introduction of ZIKV to human populations in the Americas presents the potential for the virus to spread into nonhuman primate reservoirs. Thus, it is critical to develop efficient and noninvasive detection methods to monitor the spread of the virus in wild nonhuman primate populations. Here, we describe a method for ZIKV detection in noninvasively collected fecal samples of a Neotropical primate. Fecal samples were collected from two captive squirrel monkeys ( Flaviviridae, which spread throughout South America, Central America, and Mexico in 2014–2017 [The majority of emerging infectious diseases (EIDs) are zoonotic in origin, with transmission occurring between humans and wildlife ,2. Under014–2017 ,4. ZIKV 014–2017 ,6. Littl014–2017 . The recCallithrix and Sapajus species in Brazil [Neotropical primates have been identified as reservoirs of other flaviviruses that threaten human health, including yellow fever virus (YFV) and dengue (DENV) –15; notan Brazil . Therefon Brazil ,24.ZIKV monitoring in wild nonhuman primates is limited by the lack of an efficient, noninvasive detection method. ZIKV was first isolated in the blood of a rhesus macaque in Uganda and has since been detected in the blood, saliva, and urine of a few Old World primates in Africa and Asia –12. MethTo establish a non-invasive method for identifying and monitoring ZIKV in wild primate populations, we tested a semi-quantitative fecal detection method using reverse transcription quantitative PCR (RT-qPCR). Here, we describe a method for detecting a Mexican lineage ZIKV strain in feces of captive squirrel monkeys. These findings represent a significant advancement in our ability to monitor ZIKV in wild reservoirs with implications for monitoring other EIDs.This study was performed in strict accordance with the recommendations described in the Guide for the Care and Use of Laboratory Animals and in accordance with the Office of Laboratory Animal Welfare and the United States Department of Agriculture. All animal work was approved in advance by The University of Texas MD Anderson Cancer Center’s (MDACC) Institutional Animal Care and Use Committee in Houston, TX (Protocol #0001528-RN00), and all studies were carried out at the Michale E. Keeling Center for Comparative Medicine and Research in Bastrop, TX (Keeling Center), which is accredited by the Association for Assessment and Accreditation of Laboratory Animal Care.All procedures were performed by trained personnel under the supervision of veterinary staff. Fetal ultrasound examinations used manual restraint, and all other procedures were carried out under ketamine anesthesia. Every effort was made to ameliorate the welfare and to minimize animal suffering in accordance with the “Weatherall report for the use of nonhuman primates” recommendations. Animal health and welfare was monitored twice daily, and all animals were housed under controlled conditions of humidity, temperature, and light (12-hour light/12-hour dark cycles) in an animal biosafety level 2-qualified research room at the Comparative Medicine Research Building. All animals received three types of enrichment; social, food, and housing. All animals were housed in pairs to provide social partners. Animals were fed commercial monkey chow twice daily and water was available ad libitum. Daily food enrichment included various in-season fruits and vegetables, as well as frozen and dry forage provided in destructible enrichment devices. All animals were also provided multiple layers of perching and different travel paths through their housing as a form of enrichment. Euthanasia was performed under an anesthetic plane with ketamine/xylazine, using either sodium pentobarbital (100 mg/kg) or Beuthanasia Solution or equivalent at 1 ml/5 kg intravenously. All nonhuman primate euthanasia procedures were performed in accordance with the AVMA Guidelines for the Euthanasia of Animals (2013 Edition).Saimiri boliviensis boliviensis) being socially housed in pair groups at the Keeling Center. To reduce the number of animals being infected with ZIKV, we collected samples from animals that were inoculated with the virus for a parallel study on ZIKV and pregnancy. Two monkeys  were experimentally infected with ZIKV as described in Vanchiere et al. [5 genome equivalents of ZIKV strain Mexico_1_44 divided into 10 subcutaneous injections of 100 μl per animal. The estimated gestation age at the time of inoculation was 31 days. Blood, saliva, urine, and fresh fecal samples (approximately 2 grams) were collected from the females every other day after inoculation for approximately two weeks and then again on day 29 and day 59. Fecal samples were collected from the uninfected pair approximately every other day for two weeks. Samples were stored frozen after collection until RNA extraction and analysis.The subjects for this study were captive squirrel monkeys , however, animal #5574 had intrauterine fetal demise, based on failure to detect heartbeat activity or fetal movement by high-resolution ultrasound. A C-section was performed to recover amniotic fluid, fetal tissues, and placenta. The amniotic fluid was clear. The fetal tissues were very fragile, but the placenta appeared healthy. The estimated post-mortem interval was 48–72 hours. Plaque assays were performed as previously described  and are Viral RNA from blood was extracted and detected using RT-qPCR methods at the University of Texas MD Anderson Cancer Research Center according to Vanchiere et al. . Viral Rin vitro (IDT gBlock) using sequence from the Asian lineage Z1106033 strain , and 5 μl of the cDNA product was used as a template for RT-qPCR using either Power SYBR-Green (Applied Biosystems) or Taqman Fast (Applied Biosystems) detection chemistries. The primer and probe sequences used in RT-qPCR reactions are specific to the ZIKV NS5 coding region conserved between the African and Asian ZIKV lineages, and are designed to account for sequence variability between sequenced ZIKV strains  Table 1Table 1. KU312312 ). StandaSquirrel monkeys are an established nonhuman primate model of ZIKV pathogenesis , and we in vitro. A known concentration of this DNA product was serially diluted to produce a standard curve for ZIKV quantification, demonstrating linear detection as low as approximately 20 NS5 copies per reaction  [Sapajus flavius) [Alouatta belzebuth) [Callithrix penicillata) [Callithrix jacchus) and black-striped capuchin monkeys (Sapajus libidinosus) in Brazil and found that the strain of ZIKV found in these primates was identical to the strain circulating in human populations in the Americas. Improved ZIKV surveillance requires verification of the strain carried by Neotropical primates, identification of the geographic range of the disease, and development of specific and efficient detection methods.In Brazil, antibodies against ZIKV have been detected in samples from black-striped capuchin (dinosus) , blond cflavius) ,21, red-cillata)  used PCRCallithrix jacchus), and was only conducted on males. In that study, the marmosets also showed variation in detection patterns between subjects and sample types, but generally followed a similar pattern to what we observed here. One notable difference was that ZIKV was only detected in the blood of the marmosets as late as day 7, whereas in our study ZIKV was detected in the blood of squirrel monkeys until day 15; however, the longer lasting viremia we noted could also be due to gender differences or pregnancy rather than species differences [We demonstrate here that ZIKV can be detected in feces of squirrel monkeys following experimental infection using a simple, cost-effective, RT-qPCR based assay. One other study has detected ZIKV in nonhuman primate feces ; howeverferences . The perferences  and daysferences , extend ferences . These fThe use of RT-qPCR for ZIKV detection is a cost effective and high throughput method for monitoring ZIKV infection in wild nonhuman primates. Although shorter than the ZIKV detection period in serum for squirrel monkeys, fecal ZIKV detection is possible for a portion of the time that ZIKV is detected in blood and is a non-invasive method for assessing infection in wild populations, although the cellular origin of the virus in feces is unclear. Our methodology, as described here, is best considered semi-quantitative, due to the fact that fecal content is immensely variable, especially in wild primates, and because ZIKV detection in feces was not normalized to the mass of source material. Nevertheless, this approach eases the burden of field collection and increases throughput, but could easily be modified to yield more quantitative results.Further studies will need to be conducted to determine the impact of field conditions on the preservation of virus in fecal materials; however, current practices of primatologists to collect fresh feces and store them frozen or in a nucleic acid preservation buffer will be sufficient to preserve the virus in these samples. It is common practice for scientists studying nonhuman primates in the wild to have teams that follow the animals on a daily basis and collect samples from known individuals. These methods allow collection of fecal samples that are regularly preserved and processed for laboratory analyses for hormonal, genetic, and disease studies –34, and Alouatta spp.) in Argentina [Alouatta, Ateles, Saimiri, and Aotus commonly die from YFV, species of Cebus and Lagothrix do not [Considerable variation in flavivirus susceptibility and the associated symptoms of flavivirus infections is demonstrable in nonhuman primates. For example, compared to infection of Old World primates, YFV presents with more severe symptoms in Neotropical monkeys  and has rgentina  and Brazrgentina ,37. Althx do not –40. Thisx do not ). Such r


Introduction: In recent years, a wide variety of rating scales and questionnaires for movement disorders have been developed and published, making reviews on their contents, and attributes convenient for the potential users. Sleep disorders are frequently present in movement disorders, and some movement disorders are accompanied by specific sleep difficulties.Aim: The aim of this study is to perform a narrative review of the most frequently used rating scales for movement disorders with sleep problems, with special attention to those recommended by the International Parkinson and Movement Disorders Society.Methods: Online databases , related references from papers and websites and personal files were searched for information on comprehensive or global rating scales which assessed sleep disturbances in the following movement disorders: akathisia, chorea, dystonia, essential tremor, myoclonus, multiple system atrophy, Parkinson's disease, progressive supranuclear palsy, and tics and Tourette syndrome. For each rating scale, its objective and characteristics, as well as a summary of its psychometric properties and recommendations of use are described.Results: From 22 rating scales identified for the selected movement disorders, only 5 included specific questions on sleep problems. Movement Disorders Society-Unified Parkinson's Disease Rating scale (MDS-UPDRS), Non-Motor Symptoms Scale and Questionnaire (NMSS and NMSQuest), Scales for Outcomes in Parkinson's Disease (SCOPA)-Autonomic and Progressive Supranuclear Palsy Rating Scale (PSPRS) were the only rating scales that included items for assessing sleep disturbances.Conclusions: Despite sleep problems are frequent in movement disorders, very few of the rating scales addresses these specific symptoms. This may contribute to an infra diagnosis and mistreatment of the sleep problems in patients with movement disorders. A wide variety of rating scales and questionnaires for the wide range of movement disorders that can affect patients have been developed and are currently available for clinical practice and research. These instruments may be classified as “rater-based,” which are applied by a health professional or trained person, and “patient-based,” which are directly completed by patients themselves. Rater-based scales (clinician-reported outcomes measures) are used to evaluate observable signs of the disorder  by means of clinical examination, and other non-observable aspects through interview with the patient and/or caregiver. Patient-based instruments (patient-reported outcomes measures) allow the assessment of non-observable, subjective features, and perceptions  . Some efTheir simplicity of use, as well as the amount and quality of information the rating scales provide, justify why rating scales and questionnaires are widely used in clinical and research settings.Sleep disorders are frequently present in movement disorders, as they can share pathophysiological mechanisms and damage to brain structures . InsomniThe aim of this study is to perform a narrative review of most frequently used rating scales for those movement disorders that comprise sleep dysfunction among their primary manifestations or sleep problems secondary to the movement disorder, with special attention to the scales recommended by the International Parkinson and Movement Disorders Society (IPMDS) Task Force .Authors made a list of the movement disorders that can course with sleep symptoms that included akathisia, chore, dystonia, essential tremor, multiple system atrophy, myoclonus, Parkinson's Disease, progressive supranuclear palsy, and tics and Tourette syndrome. The literature search, carried out using PubMed, Web of Science and Scopus, included these terms plus “sleep” and “rating scales.” In addition, the reviews published by IPMDS on these movement disorders  and relaThe main rating scales for Parkinson's disease (PD), such as the Movement Disorders Society–Unified Parkinson's Disease Rating Scale (MDS-UPDRS) and the Non-Motor Symptoms Scale (NMSS), are also included. Table Akathisia has been associated to nocturnal periodic limb movements and increased number of awakenings . HoweverResults of an online survey of juvenile Huntington's disease (HD) suggests that disrupted sleep is the most prevalent common, unrecognized symptom (87%), followed by periodic limb movements, tics, and pain , 37. HD The Universidade Federal de Minas Gerais Sydenham's Chorea Rating Scale (USCRS) assesses signs and symptoms of children and adults with Sydenham's Chorea and related disorders . It is fThe UHDRS was developed by the Huntington Study Group as a research tool, and it has been used as an outcome measure in clinical trials . It is fA IPMDS task force rated the UHDRS behavioral section (UHDRS-b) as a “suggested” scale for assessing severity of and screening for behavioral symptoms in patients with HD . The UHDThere is a growing interest on non-motor symptoms of dystonia patients, including sleep problems . Sleep iOn the basis of their psychometric properties and clinical and research application, a review commissioned by the IPMDS qualified five disease-specific scales as “recommended,” and two scales as “listed” for laryngeal dystonia . None ofThe UDRS , a ratinThe Fahn-Marsden Dystonia Rating Scale , a predecessor of the UDRS, was initially developed to assess primary torsion dystonia in 9 body parts . It has The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS)  is a “reBesides motor features, essential tremor also includes non-motor symptoms such as sleep problems –55, whicDespite increasing evidence of sleep problems in essential tremor, none of the currently available rating scales to assess tremor include items about sleep. The IPMDS Task Force recommends several rating scales for evaluating tremor severity.The Fahn-Tolosa-Marin Tremor Rating Scale provides a comprehensive assessment of tremor, rated by the clinician and the patient . It is fThe Bain and Findley Clinical Tremor Rating Scale assesses tremor severity  and impaIn the Bain and Findley Spirography Scale, action tremor is assessed through Archimedes spirals. Rating are on a 0–10 scale, and rating examples are provided , 19. ItsThe Washington Heights -Inwood Genetic Study of Essential Tremor (WHIGET) Rating Scale is aimed at assessing the severity of essential tremor during the performance of several tasks . The cliThe Tremor Research Group Essential Tremor Rating Assessment Scale (TETRAS) is formed by two subscales . The perMSA affects sleep in several ways: sleep-disordered breathing , sleep fThe most used scale for MSA is the UMSARS developed by the European MSA Study Group . It compClinical presentations of myoclonus are divided into physiological, essential, epileptic, and symptomatic . While pThe main tool for assessing myoclonus is the Unified Myoclonus Rating Scale (UMRS) . It asseSleep disorders are common in PD: they can affect up to 60–90% of PD patients, with increasing prevalence as the disease progresses . InsomniThe MDS-UPDRS is the revised version of the widely used UPDRS . It has The NMSS, which is administered by interview, was designed to assess the burden (frequency and severity) of non-motor symptoms (NMS). It is composed of 30 items, grouped in nine domains: cardiovascular (2 items), sleep/fatigue (4 items), mood/cognition (6 items), perceptual problems/hallucinations (3 items), attention/memory (3 items), gastrointestinal tract (3 items), urinary (3 items), sexual function (2 items), and miscellaneous (4 items). In the domain sleep/fatigue, there are three questions to rate daytime sleepiness, problems falling or staying asleep and restless legs syndrome, while in the urinary domain, one item assesses nocturia. All items are scored 0–3 for severity and 1–4 for frequency. The total item score is obtained by multiplication of both aspects and domain and scale score by sum of the respective items scores. The scale, validated, and available in several languages, has good psychometric properties, including responsiveness –87.An instrument related with the NMSS is the Non-Motor Symptoms Questionnaire (NMSQuest) , which wAnother recommended rating scale  is the SThe SCOPA-Autonomic , the firA wide set of other rating scales for assessing specific symptoms and manifestations of PD are recommended by the IPMDS , but theInsomnia and impaired sleep architecture are the most common sleep abnormalities in PSP, and are more frequently described in PSP than in other atypical parkinsonisms . In partThe Progressive Supranuclear Palsy Rating Scale (PSPRS)  is the ITics and TS can be associated with sleep disturbances such as insomnia and abnormal behaviors during sleep . SpecifiFive rating scales have been recommended for the IPMDS Task Force for assessment of tics and Tourette syndrome . The mosThe Shapiro Tourette Syndrome Severity Scale (STSSS)  rates inFinally, the Premonitory Urge for Tic Disorders Scale (PUTS), the only specific scale for tic-related premonitory urges, presented satisfactory psychometric properties only for patients older than 10 years .Several conditions, toxic agents, and metabolic dysfunctions can produce effects on brain structures and functional circuits in such a way that movement disorders and sleep disorders are manifested simultaneously. On the other hand, some movement disorders are associated with disturbed physiological sleep patterns, adding to the distress, and quality of life deterioration these patients suffer. Correct management of both types of disorders is mandatory and thus requires close evaluation and monitoring. However, as frequently occurs in the realm of movement disorders, the existence of non-motor symptoms and, specifically, sleep disturbances may remain undeclared  and undeObjective methods, based on wearable devices and technological developments, can be used for the appraisal of severity of movement disorders, sleep disturbances, and both types of conditions simultaneously when they are present in combination. Objective methods are also used for the diagnosis of several sleep disorders according to sleep disorder diagnostic criteria , and particularly when the sleep dysfunction is due to several different causes as in atypical Parkinsonism or HD.Polysomnography is very useful for this objective, but due to the complexity and costs of the sleep laboratories, this resource can be applied usually to a limited proportion of patients . InertiaThe main disadvantages of rating scales are the influence of subjectivity in score assignment and the ordinal level of measurement  adopted for the huge majority of them. Nonetheless, rating scales have the advantage of low cost, simplicity of application without need of special circumstances and settings, long time frame evaluation, and the multitude of facets they can assess. These characteristics have favored the wide use of these instruments in clinical daily practice and research.Many of the rating scales described in this review are focused on the specific abnormal movement they evaluate and, therefore, do not include other elements for sleep assessment. However, the fact that several comprehensive scales that were designed to gather those components representing the most relevant aspects of the corresponding disorder, do not include sleep evaluations even when sleep disorders are frequently present in such condition, is striking. In general, it seems that the field of motor disorders has difficulty recognizing the presence of non-motor manifestations as disturbances causing important health problems to patients. The existence of similar non-motor symptoms in the general population , although usually with lower prevalence and severity, may explain why these symptoms remained hidden to the attention of clinicians interested in movement disorders. In turn, the lack of systematic screening of these non-motor problems, has possibly led to the infradiagnosis and treatment of these disorders.The present review offers a rapid and pragmatic vision of the properties of the most used rating scales in those movement disorders with related sleep disorders and reflects how most scales do not cover the simultaneous evaluation of sleep disturbances. The inclusion of instruments for screening and appraisal of sleep disorders in the assessment of patients with, for example, essential tremor or chronic tics, and the development of new rating scales including items and domains for evaluation of sleep disorders in movement disorders will help to recognize the magnitude of the problem this combination represents.CR-B and MF conception and design of the study and wrote the first draft of the manuscript. MK, RB, and PM-M revised the work critically for important intellectual content. All authors contributed to manuscript revision, read, and approved the submitted version.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.


Policy action in the coming decade will be crucial to achieving globally agreed upon goals to decarbonize the economy and build resilience to a warmer, more extreme climate. Public health has an essential role in climate planning and action: “Co-benefits” to health help underpin greenhouse gas reduction strategies, while safeguarding health—particularly of the most vulnerable—is a frontline local adaptation goal. Using the structure of the core functions and essential services (CFES), we reviewed the literature documenting the evolution of public health’s role in climate change action since the 2009 launch of the US CDC Climate and Health Program. We found that the public health response to climate change has been promising in the area of assessment ; mixed in the area of policy development ; and relatively weak in assurance . We suggest that the CFES model remains important, but is not aligned with three concepts—governance, implementation and adjustment—that have taken on increasing importance. Adding these concepts to the model can help ensure that public health fulfills its potential as a proactive partner fully integrated into climate policy planning and action in the coming decade. With accelerating frequency and intensity, severe storms, heatwaves, wildfires, droughts and other extreme weather events are having ever-more evident impacts on human health and wellbeing. Among these impacts are heat-related illness, injuries and losses due to flooding; exacerbation of asthma, respiratory and cardiovascular conditions with air pollution; and growing risks of vector-borne diseases ; water-borne diseases  and chemical pollutants; undernutrition; and forced migration ,2. TheseWhile the causes of climate change are global, health impacts are inherently local—they happen where people live, work, learn, play and travel. Due to geography, exposure, and sensitivity to health effects, some local populations are substantially more vulnerable than others . For exaMore recently, the public health field has begun to assume higher visibility in climate change policy. The World Health Organization (WHO) called the Paris Agreement “a fundamental public health agreement” , and majA decade ago, scientists from the US Centers for Disease Control and Prevention (CDC) published an influential paper laying out the conceptual and ethical rationale for a public health approach to climate change based on the ten “essential public health services”  that guiBox 1The three core functions of public health—assessment, policy development, and assurance—were originally recommended by an Institute of Medicine (IOM) committee as a way to organize public health activities . EffortsThe ten essential services, as organized by the core public health functions of assessment, policy development and assurance, also served as underpinning to CDC’s nation-wide Climate and Health Program (CHP), launched in 2009. Designed to support local government efforts toward climate adaptation, CHP developed new tools, including the “Building Resilience Against Climate Effects” (BRACE) assessment framework for sub-national governments implemented through the Climate Ready States and Cities Initiative . NumerouThis narrative review examines progress toward implementing a public health approach to climate change by carrying out a ten-year update on the analysis underpinning the CHP  using thTo achieve these aims, we carried out a “review of reviews” of research in each of the ten essential service areas. We performed a targeted search of the English-language literature published between end-2008 and end-2018 to capture developments after publication of the CDC work mentioned above. Both PubMed and Web of Science were searched to identify relevant climate and health and climate science and health literatures, respectively. Search terms were related to each of the essential services as well as terms for climate change and health. We also scanned bibliographies of recent reviews for relevant papers and agency reports. Given the large literature available, we limited inclusion in our synthesis to review papers; however, when no (or limited) reviews were available we relied upon recent non-review articles. Separately, we identified climate and health practice examples using online sources.We provide in Results below a narrative synthesis of findings, highlighting a selection of major themes in the evolution of practice over the last decade, organized by core function and essential service. In the process of review and synthesis, we also examined the fit of the CFES model to the public health-related risks and opportunities of climate change based on evolving knowledge, elaborated in the Discussion section. Public health assessment entails collecting data, and analyzing, investigating and identifying public health problems; it informs policy development and sets the stage for public health assurance, the second and third of the core functions . When inFrumkin et al. identified three categories of data needed to monitor health status in the context of a changing climate: (i) environmental risk or exposure ; (ii) population vulnerability ; and (iii) disease-related surveillance  . Since tRecognition of the need for appropriately scaled climate forecasts to determine exposure to climate hazards was a key data concern a decade ago. Readily accessible “climate services” information—that is, climate and weather data along with their interpretation and downscaling to the local level—are essential to developing preventive climate-health policy responses. A major development toward this goal was creation in 2012 of the Global Framework for Climate Services (GFCS) led by the World Meteorological Organization (WMO); GFCS aims to improve meteorological information and targets public health among its key priorities . JancloeHowever, despite increasing supply of climate services information, access across countries has been found to be uneven . SpatialIdentifying population vulnerability is a key component of assessment frameworks supporting climate change adaptation . Since 2008, recognition of the importance of vulnerability factors and how they differ across populations has increased; one author referred to a “new landscape of inequality” . For exaA decade ago, vulnerability indices for flood risk were flagged as a key tool for targeting those at greatest risk. Since that time, the literature reflects broader use of such indices. For example, the Social Vulnerability Index (SVI) developed by the US CDC (based on census data for factors such as socioeconomic status and available infrastructure), has been adjusted for climate-specific risks; linkage to GIS mapping helps to visualize climate-related health risks and can be used to target emergency response ,33. OtheResearch suggests that enhancements are warranted in vulnerability targeting tools, however. Preston et al. reviewed 45 climate vulnerability index studies of various sorts, finding diversity in framing of determinants and suggesting greater clarity was needed regarding the goals of these tools, and encouraging “capitalizing on the power of maps” to more systematically visually engage stakeholders . A revieSurveillance for infectious diseases is part of the standard public health toolkit. A decade ago, the challenge was seen as strengthening non-infectious climate-sensitive disease surveillance while harmonizing collection of exposure, vulnerability and surveillance data at similar temporal and spatial scales to support climate-adaptive responses. Modifying existing systems, such as the US National Environmental Public Health Tracking (EPHT) Program was seen as a promising approach . Since tAt a global level, The Lancet Countdown on Health and Climate Change, a collaborative effort of 27 universities and international agencies, launched a set of 41 indicators (to be updated over time) that offer an independent monitoring system for comprehensive data collection on health and climate change across five thematic areas: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; finance and economics; and public and political engagement . The goaNevertheless, despite this substantial progress, effective and harmonized climate-health surveillance remains a challenge. Moulton and Schramm  point ouTen years ago, the long-established public health roles of outbreak investigation and intervention were seen as critical in responding to the changing climate, while fine-tuning risk assessment methods was considered a pathway to addressing the challenge of attributing health outcomes to climate-related exposures and estimating burden of disease . Among kHealth Impact Assessment (HIA) has become an additional assessment tool to identify climate hazards and risks to health due to projects and programs being implemented across a range of non-health sectors. HIA’s five-step process—screening, scoping, appraisal, reporting, and monitoring —is a flePolicy development is the second phase of the core functions cycle ; it builThe challenges identified a decade ago were to take into account varying levels of climate-related understanding in the population, emphasize constructive health behaviors, and evaluate communication interventions . EvidencHealth communications research has also provided useful insights for simplifying, translating and reframing scientific messages about climate change and health ,66. DepoIn 2008, the public health approach to climate change recommended was one that “emphasizes the coordination of government agencies , academia, the private sector, and nongovernmental organizations” . The litGovernments at both national and subnational level play a key role in public health climate policy, with the most commonly employed tool being climate adaptation planning. In their review of ten OECD health adaptation efforts, Austin et al., found that the role of national governments in health adaptation centered largely on indicating policy priorities, research, funding, coordination and guidance for population-level initiatives; examples cited were Switzerland, Belgium, and the US, which have national-level programs . Local gResearch over the last decade emphasizes that climate-related health outcomes are often affected (and sometimes even determined) by service quality in sectors other than health . In partWhile governments have a primary role in developing policy that is protective of public health in the context of climate change, multiple reviews observed the critical role non-governmental organizations play in health adaptation ,79. BoweA decade ago, public health was seen as having a role in both explaining the rationale for climate mitigation through reduced health risks and providing evidence for health co-benefits and climate adaptation planning . Since tSubstantial research over the decade has involved modeling and quantifying expected economic benefits related to population health from policies to reduce GHGs, particularly from power generation, transport, agriculture, household and industrial energy sectors . For exaHIA has increasingly been employed to identify and quantify co-benefits ,88. An HProgress toward health adaptation planning has progressed from an aspirational goal to accomplishments over the decade and effective adaptation strategies are emerging, particularly for heat and vector-borne diseases, as further discussed below. Berry et al. reviewed vulnerability and adaptation assessments internationally, and found that these assessments had helped raise awareness, identify risks, build capacity and bring health into broader climate adaptation efforts . HoweverSome adjustments are needed to adaptation policy planning. For example, Hayes and Poland 2018) argue in particular for including mental health concepts more explicitly in health vulnerability and adaptation assessments . Araos e018 argueAssurance is the third phase of the core functions cycle ; it is aIn 2008, Frumkin et al. wrote that “few public health laws and regulations have a direct bearing on climate change .” That iIn a systematic review of 15 studies in the heat early warning system (HEWS) literature, Toloo et al. found evidence of their cost-effectiveness; these authors noted the importance of careful targeting to the most vulnerable and observed that costs of some adaptive actions (such as running air conditioners) were of concern . Lowe etEarly warning systems (EWS) also have been explored for a range of the vector-borne and infectious diseases tracked by public health agencies ,104,105.Ten years ago, the challenge was seen as planning for emergency medical capacity at all levels in preparation for more frequent and intense weather-related disasters, as well as the need to strengthen mental health capacities for such crises . There hThe health sector is also an important contributor to greenhouse gas emissions, and over the decade has become more engaged in quantifying them . Health The progression of work on provision of health care services in a changing climate overlaps with findings in other CFES areas . Climate change and mental health research and response is now an active area of work . BaA decade ago, priority was placed on the need for a basic set of competencies as well as building academic professionals’ skills in—and creating partnerships with—sectors not typically part of the health care and public health curriculum, such as economics, and vulnerability modeling . At thatSince 2008, the number of universities and schools of public health with climate change centers, or climate-related education and research missions, has increased to include most major schools of public health. Several of these programs focus on particular aspects of climate change and health, such as Columbia University’s Mailman School which curates a clearinghouse of information on climate change and health educational programs around the world . EffortsFrumkin et al. noted evaluation of preparedness plans and health communication strategies and identified the importance of linking evaluation to surveillance and a well-trained work force . A decadEbi and Otmani del Barrio evaluated health adaptation assessments across a number of low- and middle-income countries and recommended assessments address both shorter-term climate variability and longer-term climate changes . These aA decade ago, research needs included developing the relationship between climate hazards and health outcomes, forecasting of health impacts, identification of population vulnerability, and defining strategies to reduce risk, including their effectiveness and cost . Since tIn this review, we found evidence of progress in terms of climate change-related public health activities and active use of specific climate and health tools in each of the ten essential services areas . Meanwhile, our review suggests modest achievements in partnerships, with public health playing a growing role in providing needed data and indicators  in multi-disciplinary teams. Public health is poised to take a substantially greater leadership in this domain. However, comparatively less progress seems to have been made in communicating climate and health messaging. Climate health literacy remains low, even among the trusted health care professional population. Finally, progress since 2008 in the assurance function was also mixed. In the areas of work force development and intervention evaluation for climate and health related programs, progress over the decade has been disappointingly limited. Uncertainty regarding mandates and resources seems to present practical obstacles to more widespread public health workforce training on climate change, and critical understanding of best practice interventions. However, in the area of enforcing regulations, there was notable forward movement in particular with heat and other early warning systems being developed and overseen by public health authorities. Moreover, in the area of linking to health care, there is evidence of greater hospital and health care system climate risk-awareness and extreme weather preparedness, as well as increased health care system attention toward reducing its own GHG emissions.Information gathered from our review presented an opportunity to re-consider some aspects of the CFES model. As noted above, we identified several concepts emerging from the literature which are not addressed in the CFES model. Aligning the CFES model with the steps common to the adaptive risk assessment framework increasingly used in climate and health is helpful in illustrating this . In partOur review has several limitations. Our search was limited in scope  and language (English only), and therefore is not an exhaustive examination of all published literature that may be relevant when considering climate change and the ten essential public health service areas. However, we believe that focusing on English-language review papers has given us a representative summary of some of the major themes emerging over the last ten years for the purpose of stock-taking, which was our goal. The nature of the literature itself also presents limitations. Many reviews included in our paper noted that their findings were based upon studies in populations in North America, Europe or Asia, with a corresponding lack of studies in countries in Africa, Latin America and non-China Asia. For example, the review literature on heat early warning systems is largely based on evaluations in the US and Europe due to sparse evaluation studies in other regions. Yet an influential heat warning system in Ahmedabad, India, has recently provided evaluation experience from a low-income heat-vulnerable city —the findOver the past decade, the health impacts of climate change have been keenly felt and will become even more pressing over the decade to come. There has been progress in all of the essential service areas across the core public health functions but in many ways public health has been “playing catch-up” compared to sectors with more experience in climate change planning. To meet the urgent needs of the next decade—decarbonizing the economy and creating resilience for more extreme climate conditions—the public health community must build on this progress. An updated CFES model with strong governance, implementation and dynamic adjustment activities will ensure that the public health field fulfills its potential as a highly valued and proactive partner in climate policy planning and action.


Humans and their associated microbiomes are exposed to numerous xenobiotics through drugs, dietary components, personal care products as well as environmental chemicals. Most of the reciprocal interactions between the microbiota and xenobiotics, such as halogenated compounds, occur within the human gut harboring diverse and dense microbial communities. Here, we provide an overview of the flux of halogenated compounds in the environment, and diverse exposure routes of human microbiota to these compounds. Subsequently, we review the impact of halogenated compounds in perturbing the structure and function of gut microbiota and host cells. In turn, cultivation-dependent and metagenomic surveys of dehalogenating genes revealed the potential of the gut microbiota to chemically alter halogenated xenobiotics and impact their fate. Finally, we provide an outlook for future research to draw attention and attract interest to study the bidirectional impact of halogenated and other xenobiotic compounds and the gut microbiota. The term xenobiotic is usually used in the context of environmental pollutants to refer to synthetic compounds produced in large volumes for industrial, agricultural and domestic use  xenobiotic compounds, such as persistent organic compounds (POPs), pesticides, pharmaceuticals and personal care products (PPCPs), and food additives. Site-specific microbiomes associated with the gut, skin, or respiratory tract are the first to encounter xenobiotics and mediate “first pass” metabolism prior to compound absorption to internal organ systems  xenobiotic compounds and the gut microbiota, i.e., toxicant-microbiota interactions.Here, we address the present state of the art on the flux, impact and fate of halogenated compounds in the gut. We first provide an overview of the The main sources of halogenated (micro)pollutants are from industry , agriculture , domestic use  and disinfection by-products (DBPs). Some examples of the halogenated (micro)pollutants that are discussed in this review are shown in Figure 1 in Figure 9) leads to production of the more toxic 4-chlorophenol , and the biocidal compounds triclosan (18) and triclocarbon (19). These compounds can desorb and contaminate soil and water, once biosolids are applied as fertilizer  and enrofloxacin (21) can be taken up by plants such as lettuce , dichlorodiphenyltrichloroethane (5), hexachlorobenzene (6), polychlorinated biphenyls (7), γ-hexachlorocyclohexane , perfluorooctanesulfonic acid, polybrominated diphenyl ethers, etc.POPs are long lived organic compounds that resist biological, chemical, and photolytic degradation. They exhibit high lipid solubility and hence bioaccumulate in fatty tissues and become concentrated as they move up the food chain. POPs are dominated by organohalogens such as polychlorinated dibenzo-p-dioxins and furans, polybrominated diphenyl ethers, and polychlorinated biphenyls. The e-waste recycling industry in developing countries has drawn the world's attention as a new source of environmental contamination by POPs , the broad-spectrum chlorinated organophosphate chlorpyrifos (11) and the herbicide atrazine (12) are among the most intensively used pesticides worldwide  is a highly mobile and persistent groundwater pollutant that originates from transformation of the widely used herbicide dichlobenil  (14)  at a concentration of up to 31 mg/L, that exceeds levels toxic to some bacteria by over 1000-fold  (up to 1.2 mg/L) in two lakes in the same region impacted by the wastewater treatment plant effluent , haloacetic acids  (30–34), and oxyhalides  (35–36)  microbiota has not been well-incorporated into the study of interactions between environmental exposures and health outcomes     mice did not show large shifts in gut microbial composition in response to 2,3,7,8-tetrachlorodibenzofuran exposure , that is a transcription factor involved in the regulation of biological responses to planar aromatic (aryl) hydrocarbons  model was inoculated with feces from healthy humans, and subsequently exposed to chronic and low-doses of the insecticide chlorpyrifos (11). This induced major changes in the microbial community, in particular, increased numbers of Enterococcus and Bacteroides spp., and decreased numbers of lactobacilli and bifidobacteria, the latter including probiotics commonly associated with health benefits  induced microbial changes, increased putative genes for oxidative phosphorylation and declined sugar metabolism and peptidase potential  (200 μg/L) did not affect gut bacterial diversity or community composition of tadpoles (in vivo or in vitro) or adult frogs , a medication used to treat thyroid hormone deficiency, and the anti-inflammatory diclofenac (25) were among the tested compounds  the gut of honey bees exposed to the organochlorine fungicide chlorothalonil (16)  antibiotics in inducing major but partly reversible changes in gut microbiota composition  functional groups to the corresponding amines are an important group of enzymes identified for the gut microbial xenobiotic metabolism -5-(2-bromovinyl)uracil  that is synthesized by some human gut microbes  metabolites from polychlorinated biphenyls (PCBs) through a series of reactions in combination with the host cells  -2-haloacid dehalogenase was the most abundant in both the genome 214 genes) and metagenome (2612 genes in human and 4549 genes in non-human) datasets indicating exposure of gut microbiota to haloacids that are common DBPs  that is known for its active organohalogen respiration metabolism toxification and sequestration at the interphase between the external environment and our mucosal epithelial cells. An important class of toxicants are halogenated compounds from anthropogenic and natural sources that come into contact with the human gut and other body parts mainly by ingestion of, or exposure to contaminated food and water. Although canonical toxicological approaches using short-term high-dose exposure experiments are informative about the toxicity and impact of halogenated compounds, they do not represent scenarios of chronic exposure to low-level xenobiotic cocktails throughout life. The ingested concentrations of the halogenated xenobiotics in food and water resources are in most cases below the regulatory thresholds. However, little is known about the physiological impact, reactivity, bioaccumulation in food chains, additive/cumulative toxicity of these emerging contaminants, and their (bio)transformation products. For example, even at trace concentrations, mixtures of biocides, antibiotics, and heavy metals have the potential to contribute to the emergence, maintenance and transmission of antibiotic-resistant and disease-causing bacteria (Gullberg et al., Even less information is available on the specific microorganisms responsible for halogenated xenobiotic metabolism, the molecular mechanisms and biotransformation pathways involved that can either diminish or enhance the toxicity. The metagenomic approach described here showed that genes involved in dehalogenation are widespread among gut bacteria, and this may impact flux, toxicity, bioavailability and fate of halogenated compounds. Future cultivation and omics experiments are necessary to test the actual metabolism of the halogenated compounds by the gut microbiota. To this end, we can immensely benefit from the wealth of knowledge gained about the metabolism of halogenated xenobiotic compounds in terrestrial and aquatic environments (Janssen et al., Given the immense potential of gut microbiota to alter the chemical structure and bioactivity of xenobiotics with beneficial (Shin et al., SA, HS and WMdV have designed the study, SAS has performed the metagenomic analysis and all authors wrote the manuscript.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.