Contre les MAladies Chroniques pour un VIeillissement Actif) and ARIA (Allergic Rhinitis and its Impact on Asthma), (3) Commitments for Action to the European Innovation Partnership on Active and Healthy Ageing and the AIRWAYS ICPs network. It is deployed in collaboration with the World Health Organization Global Alliance against Chronic Respiratory Diseases (GARD). The European Innovation Partnership on Active and Healthy Ageing has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory disease action plan of the European Innovation Partnership on Active and Healthy Ageing.Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) focuses on the integrated care of chronic diseases. Area 5 (Care Pathways) was initiated using chronic respiratory diseases as a model. The chronic respiratory disease action plan includes (1) AIRWAYS integrated care pathways (ICPs), (2) the joint initiative between the Reference site MACVIA-LR (The online version of this article (doi:10.1186/s13601-016-0116-9) contains supplementary material, which is available to authorized users. Health and care services in Europe are undergoing changes to adapt systems to the growing demands caused by the expansion of chronic diseases and ageing. This restructuring involves the development and testing of innovative solutions as well as the implementation of the most successful pilots. The multitude of good practices developed throughout the European Union favours a comprehensive and multi-dimensional scaling-up strategy at European level .The European Commission DG Santé  and DG CNECT  launched the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) to enhance European Union competitiveness and to tackle societal challenges through research and innovation Table  2].Tabl.Tabl2].TEnabling European citizens to lead healthy, active and independent lives while ageing.Improving the sustainability and efficiency of social and health care systems.Boosting and improving the competitiveness of the markets for innovative products and services, responding to the ageing challenge and creating new opportunities for businesses.Chronic respiratory diseases are the pilot for chronic diseases of the EIP on AHA Action Plan B3 . SeveralThis paper presents the scaling up strategy for chronic respiratory diseases strictly following the five-step framework scaling up strategy of the EIP on AHA. It may be used as a model for scaling up activities in other areas of the EIP on AHA and other chronic diseases.Chronic respiratory diseases include a variety of diseases such as airway diseases , occupational lung diseases, sleep apnoea syndrome, interstitial diseases, pulmonary vascular diseases and genetic diseases such as cystic fibrosis , 6. OverThe initiative AIRWAYS ICPs (Integrated care pathways for airway diseases)  has beenThe objectives of AIRWAYS ICPs are to launch a collaboration to develop practical multisectoral care pathways (ICPs) to reduce chronic respiratory disease burden, mortality and multimorbidity. AIRWAYS-ICPs proposes a feasible, achievable and manageable project from science to guidelines and policies using existing networks and stakeholders committed to the Action Plan B3 of the EIP on AHA and GARD . It is iAIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and the World Health Organization Noncommunicable Diseases Action Plan 2013–2020). It adds value to existing public health knowledge  should be present, and sufficient capacity made available both for training and the extra time necessary in consultation with the individual patient. These were critical factors in achieving success in the Finnish asthma and COPD ten year plans . ClinicaAIRWAYS ICPs study groups exist in all but 2 European Union countries . They follow the GARD model deployed in Turkey , 47 and Governments of countries  or regions (e.g. Emilia-Romagna) are involved in AIRWAYS ICPs. One of the commitments for action (Norway) is a joint action between the Ministry of Health of Finland and Norway .Six commitments for action were submitted to the EIP on AHA to support AIRWAYS ICPs. Their good practices are complementary for the scaling up strategy Table .Table 4GThe Finnish plans for asthma , allergyThe Portuguese National Programme for Respiratory Diseases (PNDR), the first national programme including all respiratory diseases .In the Netherlands, the SMART-formulated collaborative National Action programme against Chronic Lung Diseases (NACL) aims to improve the cost-effectiveness of respiratory prescribing, while reducing hospitalisation days, productivity loss, adolescent smoking, and mortality due to asthma and COPD. Both the Ministry of Health and the collective Health Insurers Netherlands are funding the programme .Several national or regional plans on asthma, COPD, other chronic respiratory diseases and allergy.Guidelines or strategies for asthma –52, COPDCare pathways provided by national institutions .The World Health Organization guidelines for asthma and COPD in low-income settings (WHO PEN) .Management plans already successfully tested in low and middle-income countries .A common approach to severe asthma and allergic diseases , 19.In Spain, Polibienestar Research Institute is developing a Multi-Agent Simulator for people requiring prolonged mechanical ventilation based on the validated LTCMAS  and follMultimorbidity guidelines for chronic respiratory diseases do not exist, except for rhinitis and asthma .The risk for developing a COPD has only been studied in Italy and represents a chart risk applicable to the entire Europe.Palliative approaches to care in chronic respiratory disease, and planning end-of-life decisions and care/advanced care.Guidelines with a specific target on old age adults do not exist. A Delphi process is ongoing.Many guidelines, ICPs and national plans exist for the most common chronic respiratory diseases .https://www.theipcrg.org/display/ResMapping).Some guidance documents are specifically directed to primary care—where most patients with chronic respiratory diseases are managed—such as COPD-Australia  and Asthma Management in Australia . IPCRG  has undertaken a mapping on national guidelines used by primary care for COPD, asthma, rhinitis, obstructive sleep apnea and stop smoking . The meeting for the analysis of the viability took place in Lisbon , July 1-2, 2015 in collaboration with the World Health Organization GARD .Feasibility has been reviewed for the Finnish Asthma Plan Table . It is eThe ARIA programme includes over 300 members and AIRWAYS ICPs includes 445 members. The paper describing the AIRWAYS ICPs proposal is co-authored by 250 members  , many reAIRWAYS ICPs is in line with the mission and vision of scientific societies which aim to 1) promote research, (2) collect, assess and diffuse scientific information, (3) represent a scientific reference body for other scientific, health and political organisations and an advocate towards political organisation and the general public, (4) encourage and provide training, continuous education and professional development and (5) collaborate with patients and lay organisations in the area of their field in order to lead the way towards better understanding, prevention, management and eventual cure of diseases. The European Academy of Allergy and Clinical Immunology (EAACI), the European Respiratory Society (ERS), the European Rhinology Society (ERS), the European Union Geriatric Medicine Society (EUGMS), the International Academy of Pediatrics and the International Primary Care Respiratory Group (IPCRG) are the major societies in Europe of their respective field and are all members of AIRWAYS ICPs. A recent meeting on precision medicine in airways and allergic diseases was held at the European Union Parliament with these societies , 78. The promote The goal and rationale of patient involvement in medical decisions is patient empowerment. Empowered patients know their disease. Patient empowerment commences with the initial consultations at the primary care level encompassing discussions about the patient’s ideas, concerns and expectations coupled with patient education about the specific disease process, what can be done to ameliorate the disease and ultimately self-management. Patients have the skills and motivation to take good care in their everyday life, to adjust their treatment, and are prepared for new or potentially exacerbating situations. They are able to detect side-effects, contact healthcare professionals when necessary and they adhere to the treatment regime. Many tools support empowerment, shared decision making models and patient education. Patient empowerment should be included in the health care professional’s curriculum. For an optimal dissemination of good practices, there is a need for patient involvement and empowerment.There are recommendations to secure patient organization/patient involvement at national (e.g. The Netherlands ZonMW) and also at European Union level , 80.EFA (European Federation of Allergy and airways diseases patient’s association), the major patient’s organisation for respiratory and allergic diseases in Europe, has been very active for AIRWAYS ICPs , 78.All European Union countries should be included.Reference Site Network: The Reference Site Network is already committed to AIRWAYS-ICPs (decision taken during the Montpellier meeting).Action Groups: Area 5 of Action Group B3 is leading AIRWAYS ICPs.Event and dedicated scaling up/twinning sessions: Several events have already taken place , Reference Sites of the EIP AHA, the Global Allergy and Asthma European Network (GA2LEN) and members of AIRWAYS ICPs. GA2LEN, a Sixth European Union Framework Programme for Research and Technological Development (FP6) Network of Excellence, was created in 2005 as a vehicle to ensure excellence in research bringing together research and clinical institutions to combat fragmentation in the European research area and to tackle allergy in its globality [2LEN network has benefited greatly from the voluntary efforts of researchers who are strongly committed to this model of pan-European collaboration. The network was organized in order to increase networking for scientific and clinical projects in allergy and asthma around Europe.lobality . The GA2The European Geriatric Medicine, the official organ of the European Union Geriatric Medicine Society (EUGMS), has initiated a column of the EIP on AHA to publish important activities of the EIP on AHA in order to inform the medical community . SeveralNeeds for AIRWAYS ICPs, in particular in elderly adults and co-morbid diseases, are clear. AIRWAYS ICPs was developed following the research priorities set by the World Health Organization on chronic respiratory diseases [diseases .The strategy, the road map and the first implementation results have been published [ublished .ICPs for asthma have been shown to be highly cost-effective in different settings [settings , 35. StuGood understanding: The members of ARIA, GARD and AIRWAYS ICPs have perceived the need for innovation, and consider it beneficial and congruent with central ideas and concepts. Deployment has been made to all stakeholders including patients and citizens. The results of the ARIA and GARD initiatives are clear [re clear , 91–98. Implementation of emerging technologies for predictive and personalised medicine. Systems medicine is an emerging discipline [https://www.casym.eu). The first implementations may reach the clinic within the next five years for serious diseases that require costly treatments [scipline , 78, 99.eatments .Political endorsement: Several meetings have been organised by the European Union. In particular, the Polish Priority of the Council [2LEN) and Global Alliance against Respiratory Diseases (GARD)”. There are recommendation: (i) to give appropriate consideration to prevention, early diagnosis and treatment, (ii) to strengthen cooperation with relevant stakeholders, (iii)to exchange best practices, (iv) to support national centres and existing international research networks (v) to find cost-effective procedures by using health technology assessment, (vi) to improve health care system standards relating to chronic respiratory diseases, (vii) to consider the use of e-Health tools and innovative technologies for prevention, early diagnosis and treatment of chronic respiratory diseases, and finally (viii) to support Member States by the “Commission developing and implementing effective policies, improving networking among institutions responsible for the implementation of programmes.” Council , 8 whichA meeting at the European Union Parliament under the leadership of the Cyprus Presidency of the European Union Council  and a GAEngagement of relevant stakeholders: In ARIA, GARD and AIRWAYS ICPs, all relevant stakeholders have been included and are highly motivated: health care professionals , social workers, policy makers. A special effort has been made for patient empowerment. A European Union Parliament session led by EFA, the largest European patients’ organisation in asthma and airway diseases, has been organised in collaboration with MeDALL  [project) , 37, in Financial viability and business model: It has been shown that the implementation of the Finnish national plans, ARIA and GARD does not require large resources. However, AIRWAYS ICPs will require arrangements for the reimbursement of the services.MACVIA-LR is supported by a strong political endorsement at the regional level. ARIA has been adopted by several governmental policies. AIRWAYS ICPs has been launched in collaboration with NHS England, Scotland, Northern Ireland, the Ministry of Health of Portugal, Poland and Lithuania and several governments of regions .Investing in human capital: Training and reskilling the work force is an essential and fundamental component of AIRWAYS ICPs. This may require initial and continuing investment to ensure that the workforce possesses the appropriate knowledge, skills and equipment to fulfil its roles, as show by some very successful ARIA and GARD initiatives. AIRWAYS ICPs should shall go a step further, however, and be fully implemented countrywide. The EIP on AHA Reference Site Network has offered its help. The present paper has been co-authored by many professional leaders from over 70 countries to build a global momentum.Integrating ICT solutions: Telemedicine represents a possible specific advanced tool of ICT in chronic respiratory disease management and secondary prevention. ICT solutions are integrated to support AIRWAYS ICPs implementation and the MACVIA–ARIA Sentinel NetworK has been launched in Copenhagen . A clinical decision support system (CDSS) is being built and should be available at the end of the year. This system may form the prototype for a more complex one for asthma, COPD, other chronic respiratory diseases and co-morbidities.Organisational changes: Currently under discussion but will require flexibility in order to adapt to the needs of different areas.Assessment indicators: In asthma and COPD, hospitalisation rates and mortality are two indicators of interest and are responsive to change within 2–3 years. In rhinitis, these indicators cannot be used. Control is applicable to asthma, COPD and/or rhinitis and quality of life is applicable to all 3 diseases. An economic evaluation was found to be effective in asthma in many countries [ountries , 74.Mutual learning: Learning Networks for learning and sharing best practices are in place for chronic respiratory diseases. Scientific societies and patient’s organisations are of importance in the process.Dissemination activities: One of the strengths of ARIA and GARD, and also already AIRWAYS ICPs, is the great ability to disseminate information and guidelines in countries of the European Union and globally.Scaling up of the new good practices: Another strength of ARIA and GARD is the capacity to scale up good practices in countries of the European Union and elsewhere.These activities have been initiated by ARIA and GARD at the international level, but they are also part of the national and regional plans for chronic respiratory diseases. The Area 5 programme on chronic respiratory diseases will benefit from previous expertise, successes and failures to propose refined and updated activities.The scaling up strategy of AIRWAYS ICPs confirms that the proposed strategy of the EIP on AHA is simple and easy to follow. It may be used as a model for the scaling up strategies of other projects of the EIP on AHA.


Rare childhood cancers have not benefited to the same extent from the gains that have been made for their frequently occurring counterparts. In recent years, this gap has been recognized and a number of vehicles now exist to improve outcome, including rare tumor groups, disease-specific registries, and clinics. The multitude of approaches has allowed significant progress, however, this framework is limited by patient number and is not inclusive for every type of rare childhood cancer. These shortcomings can be overcome by a single global unified approach to the study of rare childhood tumors. A rare disease affects a small percentage of the population and the definition differs according to geographical location. In the United States, the Rare Diseases Act of 2002 defines a rare disease as “any disease or condition that affects less than 200,000 persons in the United States,” while the European Commission defines a rare disease as “a life-threatening or chronically debilitating disease with a low prevalence, affecting less than 5 per 10,000 persons in the European Union, and a high level of complexity.”Using these definitions, childhood cancer as a whole qualifies as a rare disease, with complete prevalence counts of 169,844 for children under 15 years of age in the United States Treatment of childhood cancer represents one of the success stories of modern medicine. As recently as the 1950s, children diagnosed with cancer were treated with palliative intent, whereas in the current era a curative approach is employed for the majority of childhood cancers. Since the 1970s, remarkable progress has been made in the understanding, management, and outcome of the more frequently occurring pediatric malignancies The difficulty of performing meaningful studies on the few patients treated in each pediatric oncology center has fostered the establishment of large international cooperative groups, such as the Children's Oncology Group (COG), and scientific organizations, such as the International Society of Paediatric Oncology (SIOP). These groups have facilitated the uniform conduct of clinical trials and molecular epidemiology studies, involving multiple institutions from different countries, enabling accrual of adequate patient numbers, and ultimately leading to significant improvements in outcome for the majority of childhood cancers. Historically, finite resources have directed the focus of these cooperative groups toward improving the outcome of the most frequently occurring childhood cancers, which provide the greatest burden.However, not all childhood cancers have benefited to the same extent from these advances. This group constitutes tumors so infrequent that they have historically been overlooked due to the limited ability to accrue in a timely fashion onto clinical trials. These barriers have occurred as a consequence of small patient numbers from a heterogeneous group of diseases and the difficulty in establishing funding for rare tumors when competing with the more frequently occurring childhood cancers. Hence, knowledge of the clinical presentation, management, and long-term outcome of these tumors has been based on limited single institution data or extrapolation from adult studies http://www.ppbregistry.org/), pediatric adrenocortical carcinoma , NUT midline carcinoma (http://www.nmcregistry.org/), and ovarian and testicular stromal tumors (http://www.otstregistry.org/); and an annual centralized clinic for pediatric gastrointestinal stromal tumor (GIST) (http://www.pediatricgist.cancer.gov/).In recent years, the gap in clinical and scientific knowledge for rare pediatric tumors has been recognized and a number of vehicles now exist to better define and improve outcome for these children. One initiative to study rare childhood tumors has been through the creation of international disease-specific registries and clinics. These include registries for pleuropulmonary blastoma .The COG Rare Tumor Committee was established in 2002 and initially comprised three subcommittees for germ cell, hepatic, and infrequent tumors. The retinoblastoma subcommittee was incorporated in 2008. Collectively, these four disease categories account for approximately 15–20% of all childhood malignancies Achievements of the COG Rare Tumor Committee include the development of prospective clinical trials for adrenocortical carcinoma and nasopharyngeal carcinoma In Europe, there were a number of national cooperative groups in several countries focusing on the study of rare pediatric tumors prior to 2008. These included the Italian TREP (Tumori Rari in Età Pediatrica) project The multitude of approaches into the study of rare childhood tumors has yielded remarkable clinical and biological success for a number of rare childhood cancers; however, for each individual tumor type significant resources are required to make such advances. Due to the broad heterogeneity of tumor types encompassing rare childhood tumors, the limited resources of the different groups, registries, and clinics has resulted in disparity within the clinical and biological study of rare pediatric tumors. While there is appropriate representation for certain tumor types or subtypes such as pleuropulmonary blastoma, adrenocortical carcinoma, and nasopharyngeal carcinoma, there is a paucity of clinical and/or biological representation for the majority of the other rare childhood tumors.In addition, the lack of a single unified approach has identified a number of limitations. The definition of infrequent tumors by the COG and very rare tumors by EXPeRT has attempted to capture the majority of those tumors considered rare within the pediatric setting. However, the definitions are nonsynonymous and neither is fully comprehensive, with the consequent exclusion of certain rare childhood tumors by each group. Infrequent tumors as defined by the COG result in the exclusion of tumors such as pleuropulmonary blastoma, pancreatoblastoma, sex cord stromal tumors Focused initiatives coordinated by disease-specific registries have been major drivers for research into rare childhood cancers; however, they are limited in their ability to perform prospective studies. In addition, the divided approach between disease-specific registries and rare tumor groups has resulted in competing interests for certain conditions such as pleuropulmonary blastoma http://clinicaltrials.gov/show/NCT01878617). Recent evidence has shown that even within these four classic subgroups, there is evidence for further subcategorization. This includes the use of cytogenetic biomarkers to stratify SHH, Group 3, and Group 4 tumors into clinical risk groups Such difficulties have now become applicable to some of the more frequently occurring childhood cancers, due to the discovery of molecular subgroups within tumor types http://www.mesotissue.org/). The success of establishing an international collaborative group to achieve global consensus can be exemplified by the proceedings of the International Medulloblastoma Working Group These shortcomings can be overcome by a single global unified approach to the study of rare childhood tumors and subgroups of the more frequently occurring childhood cancers. Although inherent administrative, financial, legal, drug supply, and regulatory difficulties may hinder the establishment of single unified studies for each rare childhood tumor, they are not insurmountable. Examples include the conduct of several global collaborative prospective pediatric cancer trials, including the European and American Osteosarcoma Study Group (EURAMOS) trial and the Intergroup trial for B-cell Non-Hodgkin lymphoma/mature B-cell leukemia; and the analysis of pooled clinical data to determine disease-specific prognostic and therapeutic features, highlighted by initiatives of the Children's Hepatic tumor International Collaboration (CHIC) None declared.


Stillbirths have an estimated prevalence of 6 per 1,000 live births and fetal deaths combined in the United States (U.S.), yet major risk factors for these adverse birth outcomes remain elusive . HistoriData collection within the National Vital Statistics System is guided by the Model State Vital Statistics Act and Regulations (Model Law), which defines fetal loss as showing no signs of breath or cardiac activity after expulsion . The ModEach state in the U.S. develops its own definition, reporting criteria, and fetal death certificate, which can produce variability in reporting across states . AdditioAn alternative approach to surveillance of stillbirths is the use of established birth defect surveillance systems to incorporate active case finding for stillbirths. This approach permits population-based identification of affected pregnancies and characterization of the epidemiology of these pregnancies. In 2005, the Centers for Disease Control and Prevention established projects for stillbirth surveillance using the established infrastructures of the Metropolitan Atlanta Congenital Defects Program and the Iowa Registry for Congenital and Inherited Disorders, two premier birth defect surveillance systems in the U.S.The goals of our Iowa project, the Iowa Stillbirth Surveillance Project (ISSP), were to: evaluate the feasibility of expanding the Iowa Registry for Congenital and Inherited Disorders to incorporate data from existing records on stillbirths; monitor and report, as feasible, on the occurrence of stillbirths in the state of Iowa; serve as a registry for etiologic studies of stillbirths; and serve as a resource for education and evaluation of prevention programs that aim to reduce the occurrence of stillbirths .Active case finding and record abstraction approaches, originally developed for birth defect surveillance in Iowa, were used by the ISSP for state-wide ascertainment of stillbirths. We ascertained 1,301 reportable stillbirths (≥20 weeks gestation or ≥350 grams delivery weight) delivered from January 1, 2005 through December 31, 2011. Surveillance data collected are being used to estimate population-based prevalence estimates for stillbirths in Iowa and to examine fetal and parental characteristics associated with stillbirths. Also, these data are being used to conduct individual-level geospatial surveillance of stillbirths. Knowledge of the spatial patterns of stillbirths may provide important insights into possible links to environmental exposures and the opportunity to plan detailed etiological investigations.We continue to monitor stillbirths among the approximately 40,000 deliveries in Iowa annually. In 2012, we also expanded active case finding and record abstraction for stillbirths to include birth defect surveillance systems in Colorado, Hawaii, and New York State. This Stillbirth Surveillance Consortium (SSC) uses similar surveillance methods and tools to provide a systematic approach to population-based surveillance of stillbirths and covers more than 120,000 deliveries annually with a diverse racial/ethnic composition. To date, the SSC has ascertained 784 reportable stillbirths delivered from January 1, 2010 through December 31, 2011. Surveillance data collected by the SSC will expand ongoing analyses by the ISSP for prevalence estimation, examination of fetal and parental characteristics, and individual-level geospatial surveillance. The methods developed by the SSC can serve as a model for other states to expand birth defect surveillance programs to include active case finding and record abstraction for stillbirths.


Intimate partner violence (IPV) is a significant global public health issue. The consistent evidence that alcohol use by one or both partners contributes to the risk and severity of IPV suggests that interventions that reduce alcohol consumption may also reduce IPV. This study sought to review the evidence for effects on IPV of alcohol interventions at the population, community, relationship and individual levels using the World Health Organization ecological framework for violence.Eleven databases including Medline, PsycINFO, CINAHL and EMBASE were searched for English-language studies and grey literature published 1 January 1992 – 1 March 2013 investigating whether alcohol interventions/policies were associated with IPV reduction within adult (≥18) intimate relationships. Eleven studies meeting design criteria for attributing effects to the intervention and ten studies showing mediation of alcohol consumption were included in the review. The heterogeneity of study designs precluded quantitative meta analysis; therefore, a critical narrative approach was used.Population-level pricing and taxation studies found weak or no evidence for alcohol price changes influencing IPV. Studies of community-level policies or interventions  showed weak evidence of an association with IPV. Couples-based and individual alcohol treatment studies found a relationship between reductions in alcohol consumption and reductions in IPV but their designs precluded attributing changes to treatment. Randomized controlled trials of combined alcohol and violence treatment programs found some positive effects of brief alcohol intervention as an adjunct to batterer treatment for hazardous drinking IPV perpetrators, and of brief interventions with non-dependent younger populations, but effects were often not sustained.Despite evidence associating problematic alcohol use with IPV, the potential for alcohol interventions to reduce IPV has not been adequately tested, possibly because studies have not focused on those most at risk of alcohol-related IPV. Research using rigorous designs should target young adult populations among whom IPV and drinking is highly prevalent. Combining alcohol and IPV intervention/policy approaches at the population, community, relationship and individual-level may provide the best opportunity for effective intervention.The online version of this article (doi:10.1186/1471-2458-14-881) contains supplementary material, which is available to authorized users. The World Health Organization (WHO) defines intimate partner violence (IPV) as ‘any behaviour within an intimate relationship that causes physical, psychological or sexual harm’ . WHO recAlcohol use, especially heavy drinking and drinking large amounts per occasion, is linked to male-to-female partner violence . Across Alcohol is thought to influence aggressive behaviour through detrimental effects on the drinker’s cognitive executive functioning,  and probAlthough drinking can occur without IPV and IPV without drinking, both are sufficiently linked that the WHO proposed that primary prevention interventions to reduce the harm caused by alcohol could potentially reduce IPV . FurtherBecause alcohol use is ‘one of the factors most open to intervention and change,’  (p.viii)Eleven bibliographic databases were searched systematically for English language peer-reviewed and grey literature studies (such as non peer-reviewed government reports) published between 1 January 1992 and 1 March 2013 including: Medline, CINAHL, EMBASE, PsycINFO, Proquest Central, Cochrane Library, Campbell Collaboration Library, ATSI Health, Drug and Rural Health, and Women’s Studies International. The search strategy combined three concepts of interest: (i) alcohol use, (ii) IPV, and (iii) interventions, using medical subject headings (MeSH), database-specific thesauri search terms, and text-based keywords. Specific terms for alcohol prevention policies were added. Searches were conducted in two stages - the first searches were conducted between 30 October to 1 November 2012 with a second search to update the review conducted on 1 March 2013. A sample search strategy is at , studies in which he was first author or using his data were excluded.The search retrieved 1,810 citations as outlined in the flowchart Figure . IW condForty studies (44 papers) met the initial selection criteria. Data for each study was extracted using an agreed standardised template recording details of the study. This included the PICOS criteria - population/sample, intervention, controls or comparisons, outcomes  and study design. We also noted year of study, aims and strengths and limitations. Two additional criteria were applied prior to final study selection. First, we assessed whether the study design and sample size allowed outcomes to be attributed, at least partly, to the intervention or policy being evaluated. Eleven studies met these design criteria  that met the initial selection criteria but discuss in detail only the findings from the 21 studies that met either the design criteria or provided evidence that the effects of interventions on IPV were mediated through alcohol consumption.The breadth of the review and the heterogeneity in design and quality precluded formal meta-analysis; therefore, findings were synthesized using a critical narrative approach. This involved considering the theoretical basis for how the intervention might work within each level, critically appraising studies for methodological quality and juxtaposing findings within the ecological framework to draw conclusions across the body of evidence .Alcohol consumption is affected by the price of alcohol, which is largely determined by government policy on taxation . Thus, iOnly one study, conducted in the USA,  found a and commit homicide are sensitive to price.Of the other two studies of pricing/taxation, one longitudinal study  examinedThe third study  used a mIn summary, only weak or indirect evidence was found that increasing the price of alcohol reduces IPV.Alcohol consumption is affected by the physical availability of alcohol as well as other local interventions such as policing and enforcement policies relating to alcohol sales and service . These iOnly one  of eightThe one study with multiple time points  examinedEleven studies –55 conduAmong the longitudinal studies, Livingston  examinedA longitudinal study  from CalIn terms of support for the mediating role of alcohol consumption in the relationship between outlet density and IPV, a Western Australian study  found a Overall, evidence from community studies provides weak support for the association between alcohol availability restrictions and IPV.Couple-based alcohol treatment interventions have been shown to be effective for reducing alcohol consumption and improving relationships among treatment-seeking individuals with alcohol and drug problems who are in a married or cohabiting relationship . To the Five studies (seven papers) –63 evaluThe remaining four studies did not meet design criteria but did provide some evidence of mediation. These involved pre-post evaluations of behavioral couples-based treatment to address alcohol problems in one partner. These clinical samples were predominantly white, middle-aged and in long term relationships. Three studies reported significant reductions in male-perpetrated violence and verbal aggression between male alcoholics and their female partners, –61 and tOverall, other than weak evidence from uncontrolled studies, the only support for the effectiveness of couple interventions focused on alcohol comes from a single well-designed study of a couples-based brief intervention focused on relationship and lifestyle factors, including alcohol use; however, post intervention reductions in alcohol consumption and IPV were not linked. There was evidence of mediation, however, from the uncontrolled studies of persons in treatment for alcohol problems.Individual treatment interventions aim to reduce or eliminate problem drinking in individuals with an alcohol disorder diagnosis or who drink in hazardous or harmful ways. To the extent that their drinking is linked to IPV perpetration, reducing or eliminating alcohol use would be expected to also reduce or eliminate IPV.Twelve studies –75 involTwo studies trialled brief interventions. The first, a well-designed randomized controlled trial of a batterer program with a personalised alcohol component,  recruiteThe second trial  assessedThe third study,  an integOf the seven studies of alcohol treatment that did not meet design criteria, three pre-post studies with samples of treatment-seeking male alcoholics –73  but these effects were not sustained and none of the studies tested the relationships between reductions in drinking and reductions in IPV. The study of dating couples,  though uThis is the first systematic review to examine studies that have addressed the effects of alcohol interventions on IPV at the population, community, relationship and individual levels. These studies included a variety of research methods from across different disciplines. Despite the importance of this comprehensive approach to examining effects of alcohol interventions on IPV, the existing research on which the review is based has some significant limitations. First, the relatively small literature and the heterogeneity of the study designs precluded meta-analysis or even comparison of effects by characteristics of participants or type of intervention. Second, not all studies included alcohol consumption measures that could be used to test the central assumption that alcohol interventions affect IPV by changing alcohol consumption. Third, most population and community studies used police or hospital statistics to measure IPV which represent the most severe cases of IPV, and none of these studies was able to separate estimates of alcohol-related and non alcohol-related IPV. Thus, one reason for the general null findings of the population and community studies we reviewed could be that a substantial proportion of incidents of IPV do not involve alcohol, with this proportion varying considerably for different countries . Finallybetter theoretical models of the links between IPV and alcohol consumption, pricing and availability;greater focus on those at risk in many countries, such as heavy episodic drinkers and young adults;stronger designs, specifically – (i) randomized controlled trials, where possible, or studies with an appropriate comparison group/community, (ii) prospective and longitudinal designs with sufficient statistical power and (iii) designs able to test the mediating role of alcohol consumption;more reliable measures distinguishing alcohol-related IPV from IPV not involving alcohol;greater consistency of measurement across studies; andevaluation of interventions in low and middle income countries where the incidence of IPV is often higher and the link with alcohol stronger .Alcohol-related IPV is a complex, multi-dimensional problem much neglected in intervention and prevention research. Despite the consistent link between alcohol consumption and IPV and evidence that alcohol use contributes to increased risk and severity of IPV, our review found few studies of the effects of alcohol interventions and alcohol policy interventions on IPV where the design allowed changes in IPV to be clearly attributed to the intervention. An appropriately funded research agenda is urgently needed to investigate the potential impact of alcohol/policy interventions on IPV at the population, community, relationship and individual-level, and provide answers to the gaps in the evidence base. This includes:Employing strategies to reduce problematic alcohol use integrated at all levels of the ecological framework  and combining alcohol and IPV interventions could have the potential to reduce the incidence of IPV and enhance the safety of victims where alcohol use is intertwined with patterns of IPV perpetration.Sample Medline search strategy - 1 March 2013.(DOCX 14 KB)Additional file 1:Additional file 2: Table S1: Studies of alcohol and policy interventions to reduce IPV that met design criteria for assessing the effectiveness of the intervention. (DOCX 31 KB)Additional file 3: Table S2: Studies of alcohol and policy interventions to reduce IPV that did not meet design criteria but that provided evidence of mediation of alcohol consumption on IPV. (DOCX 26 KB)


Residents of rural communities in the United States are at higher risk for obesity than their urban and suburban counterparts. Policy and environmental-change strategies supporting healthier dietary intake can prevent obesity and promote health equity. Evidence in support of these strategies is based largely on urban and suburban studies; little is known about use of these strategies in rural communities. The purpose of this review was to synthesize available evidence on the adaptation, implementation, and effectiveness of policy and environmental obesity-prevention strategies in rural settings.RecommendedCommunity Strategies and Measurements to Prevent Obesity in the United States, commonly known as the “COCOMO” strategies. We searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Public Affairs Information Service, and Cochrane databases for articles published from 2002 through 2013 that reported findings from research on nutrition-related policy and environmental strategies in rural communities in the United States and Canada. Two researchers independently abstracted data from each article, and resolved discrepancies by consensus.The review was guided by a list of Centers for Disease Control and Prevention Of the 663 articles retrieved, 33 met inclusion criteria. The interventions most commonly focused on increasing access to more nutritious foods and beverages or decreasing access to less nutritious options. Rural adaptations included accommodating distance to food sources, tailoring to local food cultures, and building community partnerships.Findings from this literature review provide guidance on adapting and implementing policy and environmental strategies in rural communities. Healthy People 2020  rategies , which arategies . This strategies . Our a pWe conducted a systematic review of the literature to identify, extract, and integrate findings from empirical research on the use of nutrition-related policy and environmental strategies for obesity prevention in rural communities. The review was conducted by members of the Rural Food Access Work Group of the CDC-funded Nutrition and Obesity Policy Research and Evaluation Network (NOPREN), a nationwide network of more than 15 funded and affiliated partners that identifies and prioritizes a policy research agenda to improve access to healthy, affordable foods in rural communities . This prPubMed, Cumulative Index of Nursing and Allied Health Literature, Public Affairs Information Service, and Cochrane databases were searched for articles published between January 1, 2002, and June 30, 2013, in English, that reported findings from formative, process, or outcome research on nutrition-related policy and environmental strategies in rural settings. To be comprehensive and capture strategies in addition to those of COCOMO, we searched broadly for nutrition-related policy and environmental strategies applied to obesity prevention. Each search was conducted by using the following terms: rural AND (nutrition or food) AND (community or environment or policy) AND (obesity or overweight or “chronic disease”). In addition to using the search term “rural,” the search was repeated in each database by using predominantly rural states as search terms. The predominantly rural states were identified using the Rural-to-Urban Continuum Codes, the Office of Management and Budget maps, or the Rural Assistance Center’s Frontier map where substantial portions of the state are frontier. The search included relevant references cited in each of the identified studies and in prior reviews of the literature on nutrition-related policy and environmental strategies. NOPREN colleagues also recommended relevant articles.At least 2 members of the research team screened titles and abstracts and then reviewed the complete text of relevant articles to select articles for inclusion. To be included, the article had to report findings from empirical formative, process, or outcome research related to policy or environmental obesity-prevention strategies in rural communities in the United States or Canada. The term “rural” was broadly defined so as to allow for inclusion of any study in which authors described the setting as “rural,” “non-metro,” “small town,” or “remote” or a study conducted in counties that the Health Resources and Services Administration characterized as rural in 2005 . Policy Data were abstracted from each article by using a standardized form. The form included information about study population , setting, geographic location, approaches used to adapt the intervention or its implementation to a rural setting, design, methods, and findings. All 17 data abstractors were trained using a strategy similar to that employed by the US Department of Agriculture (USDA) Center for Nutrition Policy and Promotion Nutrition Evidence Library . SimilarData from the consensus abstraction forms were integrated using data matrices. Four members of the research team reviewed the matrices to identify themes, and tables and narratives were created summarizing data related to those themes.The search identified 663 articles, and 33 articles (reporting the findings from 29 studies) met inclusion criteria after exclusions  . FindingOf the 29 studies included, 4 took place in Canada (14%) and 25 in the United States (86%) . ApproxiThe COCOMO strategy used most often was strategy 1, “increase availability of healthier food and beverage choices” . That isThe literature reviewed yielded 3 themes related to strategy adaptation and implementation in rural communities .Accommodate long distances to food sources when implementing strategies. In 11 studies, investigators discussed how the design and implementation of interventions in rural communities accommodated long distances between food suppliers and retailers and between retailers and consumers. For example, several studies noted that long distances can increase food costs and limit the availability of foods that have limited shelf lives or are sensitive to long transit times  reporting outcomes documented healthier food environments and policies following the intervention in schools , health facilities , child care centers , restaurants , farmers markets , and worksites .Ten studies included interventions’ effects on health behaviors or theoretical constructs that are predictive of those behaviors . Though Weight status was the only health outcome reported in the reviewed studies  . Each ofWe assessed the state of research on nutrition-related policy and environmental strategies for obesity prevention in rural communities. The review identified 29 studies that implemented COCOMO nutrition-related policy and environmental strategies in rural communities. Other obesity prevention reviews have typically focused on effectiveness or looked at specific populations and settings. This review included studies conducted with varied populations and settings and thus findings were too diverse to empirically assess effectiveness. Instead, our findings provide guidance on adapting and implementing policy and environmental strategies in rural communities.In support of our a priori hypothesis, we found that many, but not all, COCOMO strategies were applied in rural settings  and thatIn rural communities, policy and environmental strategies that aim to increase access to healthy foods may also promote economic development through support of farmers, retail stores, and other businesses involved in food production, distribution, and sales . ResearcAlmost one-third of the studies n = 10; 34%) were conducted with American Indian tribes or First Nations of Canada. Most of these studies (70%) were conducted in small retail settings  and 3. R4% were cOur aim was to obtain a broad picture of nutrition-related policy and environmental strategies to prevent obesity in rural communities to identify gaps and guide future research. Efforts were made to identify all relevant studies. Formative, process, and outcome evaluation studies were identified for this review, which limited our ability to compare findings across studies, as did what data were collected and reported. Many of the studies were formative. Those studies that assessed outcomes typically involved only a small number of settings and were often quasi-experimental in design. Furthermore, as with all reviews, the study was constrained by limitations in the existing literature and publication bias. Only a limited amount of research on nutrition-related policy and environmental strategies for obesity prevention in rural areas has been published in peer-reviewed journals. The authors recommend consulting websites, gray literature, and other forms of reporting for additional insight into effectiveness and implementation considerations for policy and environmental-level nutrition interventions in rural areas. Finally, we used several strategies to identify studies that were conducted in rural settings; however, studies conducted in rural areas that did not explicitly indicate that they dealt with rural settings may not have been captured in our search.Explicitly compare the effectiveness of interventions in urban and suburban settings versus rural settings. None of the studies included in the review explicitly compared the effectiveness of policy changes in rural and urban communities. Future investigations should report observed differences in rural settings compared with other settings to inform future research aiming to reduce health disparities in rural areas. Only 14 of the 29 studies identified in this study assessed intervention outcomes at the environmental, policy, or individual level. Therefore, more work is needed to assess policy and environmental, social, psychosocial, behavioral, and biological outcomes associated with nutrition-related policy and environmental strategies.Experiment with a variety of intervention settings. Among the studies reviewed, the most common settings were schools, small retail food outlets, and worksites. Additional research is needed to explore the feasibility and effectiveness of nutrition-related policy and environmental strategies in other rural settings, such as parks and recreational sites and hospitals, to identify the mix of settings that will yield the greatest population-level reach and effects.Explore the possibility of aligning federal food and nutrition assistance programs with efforts to increase access to local foods. The limited research to date on COCOMO strategy 5, “improve availability of mechanisms for purchasing foods from farms,” has focused on examining the effectiveness of voucher or coupon programs through USDA. This aligns with a study conducted by the NOPREN Rural Food Access Working Group (RFAWG), examining rural stakeholders’ views about the most promising strategies for improving healthy food access in rural areas, finding that one of the highest ranked policy and research priorities included improving access to federal food and nutrition assistance programs (programs .Report costs associated with implementing intervention strategies. Decision-makers often need information about costs as well as effectiveness when deciding whether to invest in evidence-based nutrition-related policy and environmental strategies (rategies . Unforturategies ; Saksvigrategies ; and Ruerategies . When auExplore the economic impact and the role of local champions related to increasing access to local foods. A recent NOPREN Rural Food Access Working Group study examined rural stakeholders’ views about the most promising strategies for improving healthy food access in rural areas (al areas . Among tal areas . For exaal areas . The stuThese findings help to inform the adaption and implementation of nutrition-related policy and environmental strategies for obesity prevention in rural communities. Although our review was not able to provide policy-makers with information about the effectiveness of different policy approaches, these findings offer insights into the various options available to improve the food environment in rural communities. Moreover, decision-makers should understand the limitations of adopting strategies generated from and tested in geographically diverse settings. The findings also indicate the need for additional research. One major research gap that remains is the limited number of studies testing effectiveness of nutrition-related policy and environmental strategies in rural communities. Future work could identify strategies that have not yet been formally evaluated but that could be feasible in rural communities, such as mobile farmers markets and community garden initiatives.


One hallmark of human evolution is the expansion of a part of the brain called the neocortex, which is involved in high-level functions such as sensory perception, language, and conscious thought. Despite considerable progress in the study of brain size evolution, the adaptive mechanism that evolved along certain mammalian lineages to produce a large and folded neocortex has not been clear.PLOS Biology, Eric Lewitus and Wieland Huttner of the Max Planck Institute of Molecular Cell Biology and Genetics and their collaborators addressed this question by analyzing 37 physiological and life-history traits for 102 mammalian species using phylogenetic tools and mathematical techniques. They found that mammalian species form two distinct groups that are separated by a threshold value of cortical folding, and neocortical expansion beyond that threshold requires symmetric proliferative divisions of basal progenitor cells during development  An Adaptive Threshold in Mammalian Neocortical Evolution.doi:10.1371/journal.pbio.1002000


Streptococcus pneumoniae  are safe and effective for reducing illness and deaths caused by eumoniae . Recommeeumoniae ,2 and fuWorldwide, an estimated 14.5 million episodes of serious pneumococcal disease  occur each year in children aged <5 years, resulting in approximately 500,000 deaths, almost all of which occur in low- and middle-income countries . PCV wasTo assess the status of global PCV introduction, a WHO database tracking vaccine introductions was used to identify countries that included PCV in routine infant immunization schedules as of December 2012. PCV introductions were characterized by WHO region , eligibiAs of December 2012, 86 (44%) of 194 WHO member states had introduced PCV into national immunization programs, up from one (1%) in 2000 , represeReports from 11 postintroduction evaluations conducted during 2010–2012 in low- and middle-income African countries described programmatic issues related to PCV introductions. First, programs need accurate data to define target populations, accompanied by clear messages to health workers and the community to prioritize target populations. In several countries, children outside the target infant age group also were brought for vaccination and, in most cases, were vaccinated, creating shortages of PCV for the target age group. Second, health worker knowledge that PCV provides protection against only one cause of pneumonia was crucial to ensure that they educated caretakers about other options for prevention and treatment of pneumonia. Third, weaknesses were identified in the underlying capacity of the immunization systems, including needs for 1) innovative training approaches to address the complexity of messages relating to use of new vaccines, 2) improvement of supportive supervision, and 3) further enhancement of injection safety, injection waste management, and monitoring of adverse events after immunization.Streptococcus pneumoniae will help guide policy decisions about PCV introduction and sustained use  as a comprehensive approach to reducing pneumonia morbidity and mortality and as an important strategy for achieving United Nations Millennium Development Goal 4 to reduce child mortality  are safe and effective for prevention of this disease, and the World Health Organization (WHO) recommends that PCV be included in all routine immunization programs.GloballyWhat is added by this report?PCV use increased from one (1%) WHO member state in 2000 to 86 (44%) in 2012. Gaps in PCV introductions were noted in Asia and in countries with large birth cohorts; only 31% of the world’s birth cohort currently has access to PCV. WHO recommendations for use, financial support through the GAVI Alliance for PCV introduction in lower-income countries, and newer PCV formulations that protect against additional serotypes likely contributed to the increased use of PCV.What are the implications for public health practice?Increased use of PCV will help reduce the incidence of pneumonia and pneumococcal disease worldwide. The success of PCV introductions and the lessons learned from countries that have added PCV to their immunization programs will help guide decisions about future PCV introductions and sustained use.


Globally, more than two billion persons have been infected at some time with the hepatitis B virus (HBV) , and appData for this study were collected from four sites: the Minnesota Department of Health, the State University of New York-Upstate Medical University (SUNY-Upstate), Thomas Jefferson University, and Yale-New Haven Hospital. The Minnesota Department of Health contributed surveillance data spanning 2008–2011, while each of the clinical sites provided retrospective chart review data from multiyear periods during 2006–2011, based on data availability. HBV prevalence rates among the three largest refugee groups  that resettled in the United States over this period were specifically evaluated. Institutional review board approval or exemption from review was obtained at each participating site.On the basis of the hepatitis B antibody and antigen data, the HBV status of refugees was characterized as: 1) active infection, 2) past infection without demonstration of active disease or immunity, 3) past infection with demonstration of immunity, 4) demonstration of immunity without past exposure, or 5) no evidence of past exposure or current immunity .Each site submitted aggregate de-identified data on HBsAg for adults (aged >18 years) and children (aged ≤18 years). Minnesota Department of Health, Thomas Jefferson University, and Yale-New Haven Hospital also submitted data on hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb), which permitted more comprehensive evaluation of current HBV status and previous exposure. In addition, both Minnesota Department of Health and Thomas Jefferson University provided information on HBV antibody titers by sex. Data from each site were compiled demographically by age, sex, and country of origin .Data for prevalence of HBV infection in refugees resettled in the United States were analyzed by age, sex, and country of origin using separate Z-tests for population proportions (p = 0.05) . The 6,1Data were analyzed for HBV infection status and confirmed past or current infection by country of origin, sex, and age . PrevalePrevalence of any past HBV or chronic infection was higher in adults than in children . Consistent with the implementation of routine childhood hepatitis B immunization programs for refugees from Bhutan,Refugees are almost universally screened for HBV infection on arrival in the United States , in part, because of limited data on the prevalence of HBV infection among different refugee groups. The prevalence of past infection among Burmese, Bhutanese, and Iraqi refugees screened by participating sites at the time of U.S. resettlement was 36.0%, 5.7%, and 3.8%, respectively. Notably, the prevalence of acute or chronic HBV infection in Bhutanese refugees observed in this study more closely tracks rates seen in Nepal than in Bhutan ; most of these refugees have been living in refugee camps located in Nepal since the mid-1990s or were born in these camps  among children without past infection with HBV (HBcAb negative) supports the value of overseas immunization programs, including the WHO Expanded Programme on Immunization and the CDC-Bureau of Population, Refugees, and Migration (U.S. State Department) predeparture immunization program for refugees in contributing to reduced susceptibility to, and rates of, HBV infection among refugee populations. Public health officials and health providers can use these results to target outreach efforts and screening for populations found to be at increased risk for HBV infection.The findings in this report are subject to at least two limitations. First, although the sample is relatively large, it represents only a portion of refugees resettled in the United States during the past 5 years. Although it does contain adequate numbers of refugees from Bhutan, Burma, and Iraq to enable differentiation of the prevalence of HBV infection among these groups, refugees within each group screened at participating sites might not be representative of the group as a whole. Therefore, these results might not be generalizable to all recently resettled refugees. Second, since resettlement depends on congressional and executive actions, the refugee populations resettled in the future will likely be different from those currently being resettled in the United States. Therefore, additional studies and surveillance efforts will be required to evaluate the prevalence of HBV in these new populations.Similar heterogeneity in disease prevalence for other diseases (both infectious and noncommunicable) has been demonstrated among other refugee populations. For example, clinically significant vitamin B12 deficiency occurs most commonly among Bhutanese refugees –9, whileWhat is already known on this topic?Hepatitis B can cause acute or chronic disease and is a significant public health concern both globally and in the United States. CDC guidelines recommend hepatitis B screening in U.S.-bound refugees from countries with a prevalence of chronic hepatitis B infection ≥2%. However, many U.S. refugee health programs screen refugees universally for hepatitis B.What is added by this report?Evidence of active or past hepatitis B infection was found in refugee groups from Bhutan, Burma, Iraq, and other countries and varied significantly by ethnic group. Both active and past infection rates were higher among men than women.What are the implications for public health practice?Public health officials and health care providers can use these results to further support overseas immunization programs and to target outreach efforts to populations found to be at increased risk for HBV infection.


In a Collection Review for the Universal Health Coverage Collection, Knut Lönnroth and colleagues propose a framework for monitoring both health and social protection coverage, as well as their impact on TB epidemiology. Tuberculosis (TB) remains a major global public health problem. In all societies, the disease affects the poorest individuals the worst. A new post-2015 global TB strategy has been developed by WHO, which explicitly highlights the key role of universal health coverage (UHC) and social protection. One of the proposed targets is that “No TB affected families experience catastrophic costs due to TB.” High direct and indirect costs of care hamper access, increase the risk of poor TB treatment outcomes, exacerbate poverty, and contribute to sustaining TB transmission. UHC, conventionally defined as access to health care without risk of financial hardship due to out-of-pocket health care expenditures, is essential but not sufficient for effective and equitable TB care and prevention. Social protection interventions that prevent or mitigate other financial risks associated with TB, including income losses and non-medical expenditures such as on transport and food, are also important. We propose a framework for monitoring both health and social protection coverage, and their impact on TB epidemiology. We describe key indicators and review methodological considerations. We show that while monitoring of general health care access will be important to track the health system environment within which TB services are delivered, specific indicators on TB access, quality, and financial risk protection can also serve as equity-sensitive tracers for progress towards and achievement of overall access and social protection. This paper is part of the PLOS Universal Health Coverage Collection.The WHO has developed a post-2015 Global TB Strategy emphasizing that significant improvement to TB care and prevention will be impossible without the progressive realization of both universal health coverage and social protection. This paper discusses indicators and measurement approaches for both.While access to high-quality TB diagnosis and treatment has improved dramatically in recent decades, there is still insufficient coverage, especially for correct diagnosis and treatment of multi-drug resistant TB.Continued and expanded monitoring of effective coverage of TB diagnosis and treatment is needed, for which further improvements to existing surveillance systems are required.Many households face severe financial hardship due to TB. Out-of-pocket costs for medical care, transport, and food are often high. However, income loss is the largest financial threat for TB-affected households.Consequently, the financial risk protection target in the post-2015 Global TB Strategy—“No TB affected families experience catastrophic costs due to TB”—concerns all direct costs as well as income loss. This definition is more inclusive than the one conventionally used for “catastrophic health expenditure,” which concerns only direct medical costs.The WHO has developed a post-2015 global tuberculosis (TB) strategy  with an VISION:A world free of tuberculosiszero deaths, disease, and suffering due to tuberculosisGOAL: End the global tuberculosis epidemicMILESTONES FOR 2025:75% reduction in tuberculosis deaths (compared with 2015);50% reduction in tuberculosis incidence rate No affected families facing catastrophic costs due to tuberculosisTARGETS FOR 2035:95% reduction in tuberculosis deaths (compared with 2015)90% reduction in tuberculosis incidence rate No affected families facing catastrophic costs due to tuberculosisPRINCIPLES:Government stewardship and accountability, with monitoring and evaluationStrong coalition with civil society organizations and communitiesProtection and promotion of human rights, ethics, and equityAdaptation of the strategy and targets at country level, with global collaborationPILLARS AND COMPONENTSINTEGRATED, PATIENT-CENTERED CARE AND PREVENTIONEarly diagnosis of tuberculosis including universal drug susceptibility testing; and systematic screening of contacts and high-risk groupsTreatment of all people with tuberculosis including drug-resistant tuberculosis; and patient supportCollaborative tuberculosis/HIV activities; and management of co-morbiditiesPreventive treatment of persons at high-risk; and vaccination against tuberculosisBOLD POLICIES AND SUPPORTIVE SYSTEMSPolitical commitment with adequate resources for tuberculosis care and preventionEngagement of communities, civil society organizations, and public and private care providersUniversal health coverage policy; and regulatory frameworks for case notification, vital registration, quality and rational use of medicines, and infection controlSocial protection, poverty alleviation, and actions on other determinants of tuberculosisINTENSIFIED RESEARCH AND INNOVATIONDiscovery, development, and rapid uptake of new tools, interventions, and strategiesResearch to optimize implementation and impact, and promote innovationsTB remains a major public health challenge worldwide, with an especially high burden among the poorest individuals in low- and middle-income countries, and among other marginalized populations. About 3 million of the estimated 8.6 million people who develop TB each year are either not diagnosed or are diagnosed but do not access TB care that meets international quality standards The coverage gap is large despite much improved availability of quality-assured basic TB diagnosis and treatment services over the past two decades Although, basic TB services are available, in principle, free of charge in almost all countries, the process required for people with TB to reach facilities that provide those services is often time-consuming, cumbersome, and costly The total cost of TB illness and care can be catastrophic, causing further impoverishment and forcing people to resort to potentially irreversible coping mechanisms, such as taking on large loans or selling property or livestock. The risk is particularly high for people who require lengthy treatment for MDR-TB and people in the lowest socioeconomic groups For all of these reasons, universal health coverage (UHC)—defined as “universal access to needed health services without financial hardship in paying for them” There is growing evidence that social protection interventions can help improve, directly and indirectly, clinical outcomes for people with TB, especially among the poorest. Economic support in combination with other types of assistance, has been associated with improved uptake of TB services The post-2015 Global TB Strategy includes two epidemiological targets: a 95% reduction in deaths caused by tuberculosis and a 90% reduction in the tuberculosis incidence rate between 2015 and 2035. These targets are much more ambitious than the current United Nations Millennium Development Goal (MDG) goal to “halt and begin to reverse TB incidence by 2015” and the MDG-related target to halve death rates between 1990 and 2015 A putative framework for the impact of UHC and social protection on TB epidemiology is provided in Possible TB-specific indicators related to UHC and social protection that could be used as part of the post-2015 global TB strategy and a broader post-2015 development framework are listed in Most of these indicators are already well-established and captured in existing recording and reporting systems. Since the inception of “DOTS”  and expanded in the Stop TB Strategy, 2006–2015, there has been a strong focus on monitoring and evaluation Early mathematical modelling predicted that achieving at least a 70% case detection ratio and an 85% treatment success rate would lead to a significant decline in TB transmission and incidence Standardized TB recording and reporting systems generate, when used correctly, solid direct measurements of the quality of TB diagnosis and treatment, through patient-based laboratory and treatment registers. Cohort analysis is routinely done for TB patients in almost all countries, which provides information about the proportion of patients who are successfully treated, and can be disaggregated by age and sex TB service availability data, such as the number of diagnostic and treatment facilities per capita, can be obtained from national TB programme management data and through general service availability mapping. While these indicators can be easily measured in most settings, they only provide a partial indication of actual service access and coverage.The most attractive coverage indicator is conceptually one that accurately measures the proportion of incident TB cases that are correctly diagnosed with TB and put on appropriate treatment. Combined with data on the proportion of TB patients who are successfully treated, such an indicator can provide information about effective coverage . However, accurately measuring the denominator for this indicator is challenging. Throughout the past decade, TB incidence has proved difficult to measure or estimate in most countries, and therefore estimates of the case detection ratio are often uncertain. Incidence surveys (very large population-based cohort studies) are resource-intensive and highly impractical. For this reason, no country has ever successfully implemented a nationwide representative TB incidence survey. When incidence is derived from routine case notifications, there is uncertainty about the number of cases not captured by routine surveillance. In high-income countries with high-performance TB surveillance and health systems, case notification systems capture almost all incident cases. In other countries, however, routine case notifications provide biased data because of under-diagnosis (cases not diagnosed) and under-reporting . WHO derives estimates of incidence in most low- and middle-income countries through a standard analytical framework that uses the available surveillance and programmatic data . The outcome has considerable uncertainty and may be biased. Inventory studies to measure TB under-reporting are increasingly being used and will lead to better estimation of the total number of detected cases. When certain assumptions are met, capture-recapture modelling using data collected in inventory studies can also be used to estimate under-diagnosis and TB incidence Models based on an assumed fixed relationship between the annual risk of TB infection (ARTI) and incidence of TB disease have been used in the past, but have been abandoned since it has been shown that the underlying assumptions are incorrect in most settings In recent years, a growing number of national population-based surveys of TB prevalence have been conducted, to better measure the disease burden caused by TB and to help monitor progress towards the epidemiological impact targets The main solution for the future is to strengthen the performance of TB surveillance systems so that they cover all providers of health care and minimize the level of under-reporting. WHO has developed a checklist, the “standards and benchmarks for TB surveillance and vital registration systems,” to assess a national surveillance system's ability to accurately measure TB cases and deaths Mapping existing social protection schemes and assessing the extent to which people with TB are covered by them and actually use them is essential. Several political, financial, and operational challenges may limit real access for the intended target population. Monitoring coverage and outcomes will help identify the need for investigating and addressing bottlenecks. Such monitoring and related targets are relevant at the national level only, since the availability and types of schemes vary greatly among countries. Once schemes have been mapped out, countries can design specific data entry forms as part of the routine TB recording and reporting system , to monitor coverage among people with TB. Whether such data collection is done routinely or as ad hoc research should be decided at the country level. In some settings, where social protection databases exist, there is the potential for establishing efficient cross-checking across databases.Financial risk protection should be monitored globally and nationally to assess progress towards the catastrophic cost target for TB-affected households. Repeat patient surveys will be required unless a simple proxy indicator can be included in routine monitoring. Data can be collected at randomly selected facilities or in sentinel sites.For overall (not TB specific) monitoring of financial risk protection, WHO has proposed to use “catastrophic health expenditure,” defined as the direct health care expenditures corresponding to >40% of annual discretionary income  The TB-specific indicator for financial risk protection includes all care-related expenditures, including non-medical direct costs, as well as income losses . MeasuriTB affects the most vulnerable individuals It has been proposed that UHC monitoring should have a particular focus on the poorest 40% of the population The monitoring of TB service coverage and quality to inform and improve performance has been an essential element of WHO's global TB strategy for decades. A new post-2015 strategy that places strong emphasis on the importance of universal access and social protection for effective TB care and prevention has been developed. Refined coverage and quality indicators for TB prevention and care, as well as new indicators for financial risk protection have been developed by WHO. The coverage indicators also cover social protection interventions, while the financial risk protection indicator encompasses both the direct and indirect costs of TB. The monitoring framework therefore moves towards a vision of going beyond the conventional concept of UHC through the inclusion of social protection elements, either as an integral part of UHC, a “UHC+” concept, or as a separate package with robust links to UHC.A few indicators should be used for global monitoring, such as the TB-affected success rate, the case detection ratio, and the proportion of TB-affected households experiencing catastrophic costs, as well as their impact on TB incidence and death rate. Additional operational indicators are needed for national and sub-national monitoring. Indicators on TB access, quality, and financial risk protection can serve as proxies for overall coverage and social protection progress.Ensuring strong linkages to extend access to health and broader social protection is relevant not just for TB but for all health priorities, including chronic conditions, such as many non-communicable diseases that are debilitating, entail major indirect medical costs for frequent interaction with health services, and can lead to catastrophic income loss and other adverse socioeconomic consequences. Improving coordinated monitoring and evaluation of whether affected persons are receiving health services and social protection benefits is one way of stimulating improvement in access, and thereby better health and socioeconomic outcomes.


Immigrants are among the most vulnerable population groups in North America; they face multidimensional hurdles to obtain proper healthcare. Such barriers result in increased risk of developing acute and chronic conditions. Subsequently a great deal of burden is placed on the healthcare system. Community navigator programs are designed to provide culturally sensitive guidance to vulnerable populations in order to overcome barriers to accessing healthcare. Navigators are healthcare workers who support patients to obtain appropriate healthcare. This scoping review systematically searches and summarizes the literature on community navigators to help immigrant and ethnic minority groups in Canada and the United States overcome barriers to healthcare.We systematically searched electronic databases for primary articles and grey literature. Study selection was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Articles were selected based on four criteria: (1) the study population was comprised of immigrants or ethnic minorities living in Canada or the United States ; (2) study outcomes were related to chronic disease management or primary care access; (3) the study reported effects of community navigator intervention; (4) the study was published in English. Relevant information from the articles was extracted and reported in the review.Only one study was found in the literature that focused on navigators for immigrants in Canada. In contrast, 29 articles were found that reported navigator intervention programs for immigrant minorities in the United States. In these studies navigators trained and guided members of several ethnic communities for chronic disease prevention and management, to undertake cancer screening as well as accessing primary healthcare. The studies reported substantial improvement in the immigrant and ethnic minority health outcomes in the United States. The single Canadian study also reported positive outcome of navigators among immigrant women.Navigator interventions have not been fully explored in Canada, where as, there have been many studies in the United States and these demonstrated significant improvements in immigrant health outcomes. With many immigrants arriving in Canada each year, community navigators may provide a solution to reduce the existing healthcare barriers and support better health outcomes for new comers. Community navigators are trained, culturally perceptive healthcare workers who serve as a link between patients and healthcare providers in order to reduce healthcare disparities –3. They Community navigators were created to provide appropriate support to underserved populations who have the least ability to access healthcare . A signiCommunity navigators are particularly relevant for Canada  and the Although Canada has a universal healthcare system, there is ample evidence documenting that vulnerable populations including immigrants and refugees experience substantial barriers to accessing healthcare, including primary care , 16, 17.We systematically searched the following electronic databases: Medline, EMBASE, EBM Reviews (Cochrane), PsycINFO, PubMed, PubMed Central, Scopus, Web of Science, CINAHL, and Academic Search Complete for studies that employed community navigators to address healthcare disparities among immigrants and ethnic minority populations in North America. Additionally, we searched OpenDOAR, Health Sciences Online (HSO), Turning Research into Practice (TRIP), OAISter (WorldCat), Canadian Institute for Health Information (CIHI), Public Health Agency of Canada (PHAC), Health Canada and National Institutes of Health (NIH) for grey literature. Medical Subject Heading (MeSH) terms and keywords for community navigators  were combined with those for chronic disease or primary care , immigrant or ethnic minority population  and North America (Canada/USA/United States/America/ US/North America). We conducted this scoping review according to the methods described by Arksey and O’Malley  and the We included primary studies that met the following criteria: (1) the study population was comprised of immigrants or ethnic minorities living in Canada or the United States ; (2) study outcomes were related to chronic disease management or primary care access; (3) the study reported effects of community navigator intervention either qualitatively and/or quantitatively; (4) the study was published in English. Conference abstracts, poster summaries and dissertation reports were considered eligible for inclusion in order to ensure incorporation of all relevant studies. We excluded articles that reported the study design only but no outcomes. Review articles were also excluded.For each study, we extracted the following: information regarding study design and period, target population along with size (n) and age, clinical characteristics of the study population, primary outcomes and major effects of the community navigator intervention. The major focuses of data extraction were cardiovascular disease, diabetes and other chronic disease management and acceptance of primary care in the vulnerable ethnic population under study.Our initial search resulted in 501 potentially relevant peer-reviewed abstracts and grey literature papers  was found to meet the inclusion criteria that assessed the role of community navigators in Canada . The autCommon themes were found among the United States based studies. Community navigators were employed to address health disparities among immigrants and assist them in moving through the healthcare system in the United States. Navigators were selected from the community based on their cultural competence, interpersonal skills and helping attitude towards their community and were given comprehensive training by health professionals. Major roles of the navigators included providing culturally tailored health education, lifestyle workshops, self-care training and guidance to overcome barriers to accessing the healthcare system. The initial training was usually conducted through a series of individual or group sessions and workshops; the patients are monitored afterwards through telephone calls, home visits, support groups, and walking clubs at regular intervals over the trial period. The navigators also distributed educational materials and videos describing healthy diet, exercise, self-monitoring of health risk factors, handling emergency conditions and medication adherence , 21.Both controlled trials and single arm intervention studies were employed to evaluate the effectiveness of community navigators in the United States. In the controlled trials the control groups did not receive any intervention from the community navigators; rather they received usual care, or only educational materials, or alternative education –25. The Navigators have been successfully employed in order to reduce the burden of diabetes in the United States. Eight studies examined the effects of patient navigators in improving outcomes for patients with diabetes. All included adult participants belonging to the target community diagnosed with , 22, 27 To cite a specific example, project RICE (Reaching Immigrants through Community Empowerment) at New York State University investigated the effect of community navigators in diabetes prevention in both the Sikh Asian Indian and Korean communities in New York City , 34. In The other studies in diabetes management did not directly focus on immigrants; rather they targeted ethnic minorities (Hispanic and African-American) and did not distinguish between immigrant and non-immigrant groups. In several studies, culturally designed diabetes education from Spanish-speaking community navigators led to significant reduction of blood HbA1c levels among Hispanic adults with type 2 diabetes , 35–37. Our search found several studies that examined the National Heart, Lung, and Blood Institute (NHLBI) Community Health Worker (CHW) Health Disparities Initiative where trained community navigators educated underserved communities using a standard curriculum known as ‘heart health curriculum’ developed by NHLBI , 21. TheA community navigator-led wellness program was designed to reduce the risks of metabolic syndrome among Hispanic adults . The proIn one study  African In addition to guiding vulnerable population in chronic disease self-management, community navigators also aided in chronic disease prevention by increasing their compliance with routine preventative exams .Studies on immigrant minority groups in the United States showed that they have lower screening rates for cervical, breast, and colorectal cancer . InadequPromotores de Salud’ . Among the studies identified in this review, five [Promotores de Salud’ model community navigators known as promotores were recruited from the residents of target Latino communities and were trained by a team from a community based outreach program known as ‘Salud Para Su Corazon’ (SPSC) , which was developed by the National Heart, Lung, and Blood Institute (NHLBI) for prevention and control of cardiovascular risks among vulnerable Latino population. Subsequently the trained community navigators (promotores) recruited study participants from target Latino communities by direct approach, advertisement, and referral from medical professionals and randomly divided them in control and intervention groups. The participants in the intervention group received training from the navigators in accordance with the ‘heart health curriculum’ developed by NHLBI, which is a 9-week program comprising different educational approaches to train Latinos for cardiovascular disease management [Promotores de Salud’, the approaches used were quite similar and most of the studies reported positive outcomes after navigator intervention.Although different community navigation programs were described across the studies, the only established model of care used was ‘ew, five , 39, 41 nagement . Study onagement . AlthougAlthough cost-effectiveness is a major factor for any community outreach program, none of the selected studies reported cost-effectiveness. However, we found one study in our search that reported a cost-effectiveness analysis of a community navigator intervention in Hispanic adults with type 2 diabetes . We did Canada is at a very early stage in adopting community navigators for immigrant populations, which is reflected by the fact that only one Canadian study qualified for the review . HoweverAccording to Canadian Partnership Against Cancer (CPAC), the application of navigators in cancer care has achieved multifaceted benefits for patients, healthcare providers and the system , 52. TheOutcomes from the majority of the studies we reviewed suggest that there is an opportunity for Canada to address healthcare gaps for immigrant and ethnic minorities as well as the general population by introducing community navigator programs. The navigators should be recruited from the target community to ensure they are culturally and linguistically sensitive to the community and well accepted by the community members. It is crucial to provide rigorous training by healthcare professionals so that navigators are well prepared to educate the target population in chronic disease management, and support them in navigating the primary healthcare system.The small number of studies in immigrant populations limited our review. Only three articles were found that studied immigrant populations specifically. All other studies were about ethnic or racial minority groups, which may have included new immigrants, but the researchers did not distinguish recently immigrated participants from others. While some of the findings of the studies among ethnic minorities may be generalizable to immigrant populations, there are differences in the challenges faced between these groups.Community navigators have served as educators and conducted outreach programs in order to improve the health disparities among immigrant and ethnic minorities in the United States. In all but four –34, 46 o


Dear Sir:Leptospira serogroups in cattle herds and dogs in France.” Ayral and othersLeptospira serogroups revealed that current vaccines in France are not fully capable of preventing leptospirosis. In total, 394 cattle were diagnosed with clinical leptospirosis, and the results suggested infection by serogroups Australis (43%), Sejroe (33%), and Grippotyphosa (17%).We read with interest the study reported by Ayral and othersWe share our experience with bovine leptospirosis in Brazil and compare it with the scenario described in France. Infected cattle are commonly asymptomatic and may shed the bacterium in urine for long periods.lipL32In a study conducted by our group in 2013, 208 cows were randomly selected in a slaughterhouse located close to Rio de Janeiro, Brazil. After clinical pre-slaughter examination, the animals were considered free of signs of leptospirosis. Blood samples (208) for serology (MAT)Serogroup distribution differed between Brazil and France. In our study, both seronegative and seroreactive cows were shedding leptospires. Therefore, the direct detection of leptospires in urine by culturing or PCR is an important tool for the success of control programs in cattle. Additionally, an active surveillance approach should also include asymptomatic animals, because they may shed the bacterium to the environment and consequently, play an important role in the epidemiology of leptospirosis.