Introduction: Facial palsy is often associated with impaired facial function and altered appearance. However, the literature with regards to the psychological adjustment of children and adolescents with facial palsy has not been systematically reviewed to date. This paper aimed to review all published research with regards to psychosocial adjustment for children and adolescents with facial palsy. Methods: MEDLINE, CINAHL, Embase, PsychInfo and AMED databases were searched and data was extracted with regards to participant characteristics, study methodology, outcome measures used, psychosocial adjustment and study quality. Results: Five studies were eligible for inclusion, all of which investigated psychosocial adjustment in participants with Moebius syndrome, a form of congenital facial palsy. Many parents reported their children to have greater social difficulties than general population norms, with difficulties potentially increasing with age. Other areas of psychosocial adjustment, including behaviour, anxiety and depression, were found to be more comparable to the general population. Discussion: Children and adolescents with Moebius syndrome may experience social difficulties. However, they also demonstrate areas of resilience. Further research including individuals with facial palsy of other aetiologies is required in order to determine the psychosocial adjustment of children and adolescents with facial palsy. Facial palsy (FP) is characterised by damage to the facial nerve, resulting in weakness of the facial muscles. FP may be associated with a variety of acquired conditions including, but not limited to, Bell’s palsy, trauma, herpes zoster virus or acute otitis media . In neonWhether genetic in origin, congenital or acquired, impairments in facial function associated with FP can include difficulties producing effective facial expression of emotion . TypicalIn addition to the communication difficulties associated with impaired facial expression, the stigma experienced by children and young people with visible differences in facial appearance has been well documented , with asA review by Hotton et al.  highlighThis paper aimed to review the literature regarding the psychosocial adjustment of children and adolescents with FP and identify factors associated with poorer psychosocial adjustment.Methods of data extraction and eligibility criteria were specified in advance of the review being.Studies with a quantitative or mixed-methods methodology of any design other than case reports were eligible for inclusion in the review. Only articles published in the English language and in a peer reviewed journal were eligible for inclusion.We included studies examining children and adolescents (aged up to and including 17 years) with a diagnosis of FP of any aetiology. Studies investigating participants with and without FP were only eligible for inclusion if data for participants with FP was reported separately.Studies were included regardless of whether they were interventional or observational.Studies were included if they reported at least one validated measure of psychosocial adjustment. Studies investigating the neurodevelopmental or neurocognitive status of participants in the absence of a measure of psychosocial adjustment were not included.Studies were identified using electronic databases and reading the reference lists of relevant articles. The search was applied to MEDLINE (1946 onwards), CINAHL (1985 onwards), Embase (1974 onwards), PsychInfo (1806 onwards) and AMED (1985 onwards).We used the search terms in Two reviewers developed screening questions based on the inclusion criteria, which were used to screen titles, abstracts and the full-text of papers in an independent and standardised way. Any disagreements were resolved through discussion.The authors followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines in designing and reporting of studies . A data extraction form was developed to extract information from each study about: (1) psychosocial adjustment; (2) participant characteristics ; (3) outcome measures used and (4) sample size and study design.The National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies  was usedThe database search produced 2854 papers, of which 1031 were duplicates. Of the remaining 1823 papers, 1651 papers were discarded due to not meeting inclusion criteria following the screening of titles and abstracts. Agreement between the two reviewers at the abstract screening stage was good (Kappa = 0.83). Comprehensive screening of the full text of the remaining 172 papers resulted in 5 studies meeting inclusion criteria. The phases of selection are shown in n = 3) was the child behaviour checklist (CBCL) [All five studies were carried out in Germany and all recruited participants from the German Moebius Syndrome Foundation and all studies exclusively investigated the psychosocial adjustment of children and/or adolescents with Moebius syndrome. Sample sizes were generally small, ranging between 13  and 31 . All butt (CBCL) , with tht (CBCL)  being usM = 3.83 years). Parent reports on the CBCL indicated that only 16.7% (n = 2) of children scored above the clinical cut-off on at least one subscale.Briegel (2007)  carried Briegel et al. (2010)  also useUnfortunately, Briegel (2007)  and Brien = 7) scored higher than girls (n = 6) on the aggressive behaviour, oppositional defiant problems, anxiety problems and total problems CBCL subscales, indicating greater difficulties. Briegel et al. (2010) [Regarding gender, Briegel  found th. (2010)  and Brie. (2010)  did not n = 9) and those with unilateral FP (n = 3).Only one of the three studies to use the CBCL assessed the impact of FP laterality on behaviour, with Briegel (2007)  observinM = 11.59 years) scored their child as being in the abnormal range on at least the SDQ-Deu subscale, with parents reporting significantly higher total difficulties compared to German population norms. However, there were no significant differences on the hyperactivity/inattention, prosocial, conduct or emotional problems subscales. Briegel (2012) [The SDQ-Deu was an alternative measure of psychosocial adjustment used in two studies ,21. BrieStrobel and Renner (2016)  additionBriegel et al. (2010)  found thBriegel et al. (2010)  comparedUsing the SDQ-Deu, Briegel (2012)  found fiBriegel (2012)  found thStrobel and Renner (2016)  used theBriegel (2012)  used theBriegel (2012)  found chBriegel (2012)  found thThis review set out to identify the psychosocial adjustment of children and adolescents with FP. Five studies were eligible for inclusion, of which all exclusively included participants with FP due to Moebius syndrome, a form of congenital FP. Included studies measured a wide range of psychosocial constructs, including social function, behavioural difficulties, anxiety, depression and quality of life. Social difficulties were frequently reported for children with Moebius syndrome, while findings in the other areas of psychosocial adjustment were more varied.Parents of children with Moebius syndrome were three times more likely than parents in a normative study to rate their child as having peer problems, as measured by the SDQ-Deu . SimilarThe psychosocial difficulties experienced by people with Moebius syndrome, as well as others with FP of differing aetiology, may be explained by the impact of stigma on the formation of social relationships . DiffereHistorically researchers have argued for increased prevalence of autism spectrum disorder (ASD) in children with Moebius syndrome . While tDespite providing initial evidence for children with Moebius syndrome experiencing greater social difficulties than the general population, it is important to consider several limitations to the discussed findings. All studies had small samples and did not include gender- or age-matched controls. Additionally, only Strobel and Renner (2016)  and BrieMany of the included studies found social difficulties to increase with age. For example, Briegel et al. (2010)  observedThe potential link between age and social difficulties may be explained by the physical, social and psychological changes that occur during adolescence, which can result in an increased focus on appearance and heightened vulnerability to appearance-related concerns, potentially leading to greater social withdrawal . ResearcGiven the discrepancies across studies, the small sample sizes and absence of relevant statistical analysis in several studies, it is not possible to draw firm conclusions about the role of age in social difficulties for children with Moebius syndrome. Furthermore, participants across all studies were recruited from the same charity, meaning they may have benefitted from charity support. Finally, without the inclusion of those with FP of other aetiologies it is not possible to draw conclusions about the wider role of age in the social difficulties potentially experienced by children and adolescents with FP.Further to the social difficulties observed across studies, Strobel and Renner 2016)  found pa  found pDespite the reviewed studies indicating difficulties with social function and greater overall difficulties compared to the general population, the results of this review also highlight how many children and adolescents do not have difficulties in other psychosocial domains. Indeed, with the exception of the friends domain of the KINDL , all stuThe findings of this review match qualitative research that has demonstrated how although most adolescents with Moebius syndrome report having experienced bullying and social exclusion, many also report highly valued and protective social support from peers . Bogart Studies also investigated the impact of gender on psychosocial adjustment. Boys scored higher than girls on the aggression, oppositional-defiant and anxiety domains of the CBCL in the youngest sample in this review ; howeverBriegel et al. (2007)  carried Two studies ,17,18 hiThis review highlights the importance of routinely screening children with Moebius syndrome for psychosocial difficulties, particularly with regards to social problems. Those identified as having difficulties may benefit from psychological intervention. Michael et al. (2015)  conducteOther evidence for the positive impact of psychological interventions in the wider FP population comes from Hotton et al. (2019) , who higAs well as indicating the importance of screening and psychological intervention, this review highlighted the role that parental factors may play in their children’s psychosocial adjustment. It is therefore recommended that Clinical Psychologists with specialist knowledge of Moebius syndrome, and other forms of FP, work within specialist FP services, in order to identify and provide psychological treatment for those children, adolescents and their families experiencing psychosocial difficulties.Despite this review being the first of its kind to evaluate the psychosocial adjustment of children and adolescents with FP, only studies investigating the impact of Moebius syndrome met the inclusion criteria. This is not representative of the wider paediatric FP population, as FP due to causes such as Bell’s palsy, trauma and hemifacial macrosomia, amongst others, are more common than Moebius syndrome . FurtherThe absence of any studies investigating the impact of FP of other aetiologies on psychosocial adjustment during childhood limits the ability to draw wider conclusions. Future research into the psychosocial adjustment of children and adolescents with FP and no other known comorbidities, as well as direct comparison between those with congenital and acquired FP, is required to understand the specific impact of FP on children and adolescents’ psychosocial functioning.A further limitation of the current review was that it did not include studies investigating populations, including those with genetic conditions, where some, but not all, of the individuals had a diagnosis of FP (unless those with FP were investigated separately). An example of such a population is children and adolescents with CHARGE syndrome, of whom an estimated 50–90% have FP . AlthougFour out of the five included studies came from the same research group ,16,18,21The outcome measures used across studies were often in the German language, which limits the ability to replicate findings across other studies in other countries. There was a degree of inconsistency with regards to the measures used, and none were designed specifically for individuals with FP, so may lack the sensitivity to detect condition-specific issues. Future research would therefore benefit from the development of measures specific to FP and the consistent application of measures across studies.Only one study had a longitudinal design  and no sAll of the included studies used a parental report as a measure of psychosocial adjustment, while Briegel (2012) and Strobel and Renner (2016)  also incFuture research would therefore benefit from several considerations. Firstly, research should be longitudinal in nature, providing the opportunity to observe how adjustment changes over time. Secondly, studies should include children with FP of varying aetiologies and be sufficiently powered to allow for comparison between different aetiologies. Thirdly, research should control for any additional physical or cognitive difficulties, as well as to report on the objective severity of FP symptoms. Fourthly, participants should be recruited from a variety of countries, in order to better explore the impact of cultural norms. Fifthly, research should include a combination of self- and parent-reported outcome measures, as well as ideally a combination of generic measures of psychosocial adjustment and those designed specifically for children with FP.Finally, there is a need for the development and evaluation of further evidence-based psychosocial interventions, in order to help children and adolescents and their parents to adjust to the functional and appearance aspects of conditions such as Moebius syndrome.FP is a condition that has wide-ranging functional and psychological consequences, however, to date the psychosocial impact of the condition in childhood and adolescence has only been investigated in those with Moebius syndrome. Studies provide some indication of specific difficulties with social functioning, which may increase with age. Further research with children with FP of varied aetiologies using a combination of outcome measures is required. These measures should include both facial-palsy specific measures and also generic measures to permit comparison with the general population; this combined approach will enable comprehensive assessment of the specific psychosocial impact of the condition.


We conducted a cost of illness study to assess the economic burden of pediatric enteric fever (typhoid and paratyphoid) in Bangladesh. Results can inform public health policies to prevent enteric fever.The study was conducted at 2 pediatric health facilities in Dhaka. For the patient and caregiver’s perspective, we administered questionnaires on costs incurred from illness onset until the survey dates to caregivers of patients with blood culture positive cases at enrollment and 6 weeks later to estimate the direct medical, direct nonmedical, and indirect costs. From the perspective of the health care provider, we collected data on quantities and prices of resources used by the 2 hospitals to estimate the direct medical economic costs to treat a case of enteric fever. We collected costs in Bangladeshi takas and converted them into 2018 US dollars. We multiplied the unit cost per procedure by the frequency of procedures in the surveillance case cohort to calculate the average cost per case.Among the 1772 patients from whom we collected information, the median cost of illness per case of enteric fever from the patient and caregiver perspective was US $64.03 (IQR: US $33.90 –$173.48). Median direct medical and nonmedical costs per case were 3% of annual labor income across the sample. From the perspective of the healthcare provider, the average direct medical cost per case was US $58.64 .Our results show substantial economic burden of enteric fever in Bangladesh, with higher costs for patients receiving inpatient care. As antimicrobial resistance increases globally, the cost of illness could increase, due to more expensive and potent drugs required for treatment. In low- and middle-income tropical countries, enteric fever (typhoid and paratyphoid fevers) is a major public health problem due to low access to safe water, sanitation, and hygiene facilities. Globally, there are an estimated 10.9 million typhoid fever cases and 3.4 million paratyphoid fever cases per year . The cosAlthough previous literature has estimated the COI of enteric fever in other Asian countries, including India, Pakistan, Indonesia, Vietnam, China, and Nepal , no suchA COI study of enteric fever with recent data from Bangladesh can fill this knowledge gap and be used by policy makers to estimate the cost-effectiveness and return on investment of preventing enteric fever, including consideration of different strategies to introduce TCV vaccines. Moreover, a comprehensive COI using the patient and caregiver and the health care provider perspectives is important to inform public policies targeting high risk groups in settings such as Bangladesh, where patient expenditures constitute an estimated 63% of total health expenditures, with greater relative economic burden on the poorest households , who mayThis COI study was a prospective study coordinated with SEAP II, and conducted at 2 pediatric health facilities located in Dhaka (estimated population: 20 million ), the caSalmonella (S.) Typhi or Paratyphi, or with a nontraumatic terminal ileal perforation, regardless of blood culture result. Participants in the COI component were patients enrolled through the 2 participating health facilities or through their laboratories.Patients eligible for enrollment in the health facility-based surveillance component were those ≤ 17 years with blood culture-confirmed cases of This study included 3 types of costs incurred by the patient and their caregivers from illness onset until the survey dates: direct medical costs, direct nonmedical costs, and indirect costs. Direct medical costs included the monetary value of health facility registration fees, clinical examination, inpatient stay, laboratory tests, drugs and medications, and other diagnostic and treatment services . Direct nonmedical costs included transport, food, lodging, and care services for family members. Since the study sites were pediatric hospitals, patient indirect costs included only the days of school missed, which were not monetized. The indirect costs of caregivers included the value of work days missed and sick leave days taken to care for the patient, valued at the median of caregivers’ self-reported salary range . The value of the time spent by caregivers who did not routinely earn a wage  only included the time spent at health facilities and was monetized exclusively in the sensitivity analysis.Costs excluded were costs of nonenteric fever-related drugs and therapies such as antimalarial medications, costs of diagnosis and treatment of co-morbidities, and chronic conditions not directly related to enteric fever, intangible costs related to pain and suffering, and costs of services that the patient received at no charge at the health care facilities .Cost questionnaires were developed in English and piloted in the sites, then translated into Bengali. Questionnaires were administered in Bengali by bilingual SEAP II interviewers, with data recorded electronically via tablet. Cost data were collected from September 2016 to December 2018 through telephone by the same SEAP II interviewers who administered the surveillance questionnaires. The pediatric patients’ caregivers responded to the cost questionnaires at 2 time points: (i) 2 to 3 days after laboratory testing or hospital discharge, and (ii) 6 weeks (approximately 42 days) after study enrollment. The first cost questionnaire collected information about the costs incurred from illness onset to the enrollment visit, while the second cost questionnaire collected costs incurred after the enrollment visit until the follow-up call.COI measures included median patient direct medical and nonmedical costs, median number of days of school lost by patients, median number of days of work lost and sick leave by caregivers, and the median productivity loss due to lost wages by the caregiver. COI from the patient and caregiver perspective for an episode of enteric fever was calculated as the sum of the direct medical costs, direct nonmedical costs, and indirect costs.Costs were collected in local currency (Bangladeshi takas), adjusted to 2018 values based on inflation rates from the Central Bank of Bangladesh, and converted into 2018 US dollars using the annual average exchange rate for 2018 (83.47 takas per US dollar ). MissinS. Typhi, and S. Paratyphi.Two sensitivity analyses were conducted: (i) without outliers from each category of patient and caregiver costs, and (ii) imputing the wage level with the median wage reported in the sample and with the minimum daily wage rate of 220.42 takas (or US $2.64) for the indirect costs of the caregiver who routinely does not earn an income . OutlierCOI from the health care provider perspective was estimated for the same SEAP II study pediatric hospitals and included the direct medical economic costs  to the hospitals to treat a case of enteric fever regardless of the source of funding. Hospital-related data were collected for the 2015–2016 fiscal year.The medical procedures normally used to diagnose and treat a case of enteric fever and its associated complications at these sites were classified into 2 types: (i) medical procedures for which resource use did not differ between patients with enteric fever and patients with other diseases , and (ii) medical procedures particular to enteric fever . Top-down activity-based macro-costing was used to estimate the cost of procedures in the first category, namely: outpatient visits, inpatient bed days, emergency visits, neonatal intensive care unit bed days, outpatient surgery visits, and inpatient surgery bed days, as well as to allocate cross-cutting administrative services, utilities and communication, and clinical supportive services . Bottom-up ingredients-based micro-costing was used to estimate the costs of procedures in the second category, such as blood draws, blood culture tests, Widal tests, complete blood counts tests, C-reactive protein tests, abdominal X-rays, abdominal ultrasounds, surgeries for intestinal perforation, and gallbladder surgeries; and to calculate the cost of the personnel in the procedures of the first category.Cost categories included were personnel salaries, labor time, materials and supplies, equipment and instruments, contracted services, equivalent rental value of the building space, administrative services, and clinical support services . Costs excluded were those associated with magnetic resonance imaging and computed tomography scans (as these were reportedly infrequently used for enteric fever diagnosis in the study sites); patient registration; medication costs paid for by patients ; costs of nonenteric fever-related drugs and therapies ; costs of diagnosis and treatment of co-morbidities and chronic conditions not directly related to enteric fever; nonclinical costs  for study sites that are also academic training centers; evaluation-specific costs; and value of study team staff time for project management, technical assistance, and evaluation.The data collection tool was designed in Microsoft Excel and piloted in the sites. Data on prices and quantities of resources used, as well as service volumes, were collected in a paper-based version of the tool between March–August 2017 by 2 local SEAP research assistants, with technical assistance from CDC. Data sources were annual financial reports, administrative records from the accounting department and clinical wards, on-site observation, and interviews with administrative and medical staff. Data on the frequencies of the medical procedures conducted for the patients with blood culture-confirmed enteric fever or nontraumatic ileal perforation in these health facilities were collected in the surveillance component of the SEAP II study during the period September 2016 to December 2018. Missing prices of items in the various categories of supplies and materials and equipment and instruments were imputed with data from the UNICEF supply catalog . , 7. 5, 7Our results show that the potential economic burden of enteric fever to patients and their caregivers, as well as to health care providers, can be substantial in Bangladesh. Median direct medical costs to patients and caregivers due to enteric fever represented 152% of Bangladesh’s health expenditure per capita of US $37.10 , and 52Our results are subject to several limitations. The patient and site samples are not representative of Bangladesh, nor of Dhaka. Although the number of patients is much larger than in previous studies, all cases are pediatric patients that sought care in urban private hospitals. Thus, care should be taken when using these results to estimate economic burden for different populations. Interviews were conducted by phone instead of in person, which could have affected the response rate (80.4% of eligible patients and 76.9% for the 6-week follow-up questionnaire). Patient and caretaker costs may also be subject to recall or reporting biases for direct expenses and time spent seeking and receiving care. A control group to account for potential background patient morbidity and health care costs was not included. The risks of increasing antimicrobial-resistant enteric fever and its associated costs were not modeled. For health care provider costs, some missing data  had to be imputed based on third party sources , which may have resulted in higher or lower estimated costs. In addition, the costs of personnel time per procedure may be subject to recall or reporting biases.Costs were not combined across perspectives due to the limited health facility sample that did not represent all health facilities visited by patients at which patient and caregiver costs were incurred. Also, there was limited ability of questionnaire respondents to recall and report expenses for specific clinical procedures  to match these with health facility costs. Thus, although related, the COI from the patient and caregiver perspective includes at least one health facility per patient and is larger than the COI from the provider perspective, which only includes the average cost of treating a patient in one health facility.Quantifying the economic burden of enteric fever to patients, caregivers, and health care providers can provide evidence of the economic value of preventive interventions, such as typhoid vaccines and improvements to water and sanitation. While recognizing the challenge of limited laboratory facilities for blood culture confirmation, future research on the economic burden of enteric fever would benefit from expanding the types and locations of health facilities included to obtain more representative costs at different levels of the health system, and from a diversity of geographic areas and patient populations in which epidemiology and care seeking patterns may vary. Further methodological efforts to integrate costs paid by patients and caregivers with those incurred by health care providers and other payers  would also contribute to a fuller societal perspective estimate of the economic burden of enteric fever.


Inadequate dietary diversity intake during pregnancy results in increased risks of negative maternal and perinatal outcomes. About one million neonates die on the first day of life due to inadequate dietary intake during pregnancy as a result of maternal complication and adverse birth outcomes. This review summarizes the burden of inadequate dietary diversity and its determinants among pregnant women at the national level of Ethiopia.  Studies were retrieved from selected electronic databases, including PubMed, Cochrane Library, and Google Scholar. Random-effects model meta-analysis was used to estimate the pooled burden of inadequate dietary diversity and its determinants at a 95% confidence interval with its respective odds ratio (OR) using statistical R-software version 3.6.1. Moreover, quality appraisal of the included studies, publication bias, and level of heterogeneity were checked with subgroup analysis and sensitivity influential test. The searches were restricted to articles published in the English language only, and Medical Subject Headings (MeSH terms) was used to help expand the search in advanced PubMed search.  A total of 850 articles were identified through the initial search of which 21 studies were included in the final review yielding a total sample size of 9,230 pregnant women. The pooled prevalence of inadequate dietary diversity was 53% . Food insecurity , family size of greater than four , rural residence , no formal educational status , and a lack of counseling about dietary diversity  were among the significantly associated factors for inadequate dietary diversity.  In this review, there was a high prevalence of inadequate dietary diversity among pregnant women at the national level in Ethiopia. Therefore, strengthening early counseling and diagnosis of dietary intake and undernutrition during the antenatal care period is important. Dietary diversity refers to an increase in the variety of foods across and within food groups , 2. InadDietary diversity in pregnant women is not only critical to reducing maternal mortality but morbidity and is a foundation to the developing fetus' growth and reduced perinatal outcome complications , 6. InadMany women in sub-Saharan Africa including Ethiopia remain particularly exposed to inadequate intake of micronutrients, resulting in different types of malnutrition and its complications. Seven percent of the global disease burden and at least one-fifth of maternal deaths and poor maternal outcomes are as the result of maternal inadequate dietary diversity , 11. AboAlthough insufficient attention has been given to the extent, causes, and consequences of such nutritional deficiency, the lack of dietary diversity in pregnant women in Ethiopia remains a leading cause of maternal and perinatal complications. Ethiopia has a wide range of agroclimatic conditions and grows a variety of cereals, root crops, and vegetables; however, money of these are not fully utilized because of maternal and environmental factors, dependency on single food crops, inadequate antenatal care (ANC) follow-up, unwanted pregnancy, maternal knowledge, lower socioeconomic health status, and season variability .The prevalence of inadequate dietary diversity and its determinant variables among pregnant women is inconsistent across regions resulting in variabilities and uncertainties over time among different studies done at the national level of Ethiopia. In addition to this gap, lack of documented and published peer-reviewed data on the pooled prevalence of dietary diversity and its determinants among pregnant women at the national level in Ethiopia hinders program managers in designing and implementing effective strategies. With there being minimal existing evidence in developing countries, including Ethiopia, evidence based on pooled results at the national level on burden and determinant of inadequate dietary diversity is needed to guide decision-making and implementation programs. Therefore, this review would pool the evidence of inadequate dietary diversity and its determinants among pregnant women at the national level of Ethiopia.We systematically reviewed and analyzed published research articles to determine the pooled prevalence of inadequate dietary diversity and its determinants among pregnant women in Ethiopia. We identified and searched published articles using major electronic databases, including PubMed, Cochrane Library, JURN, Hinari library, AJOL , Google Scholar, and Science Open, as well as a manual search from grey literature was conducted accordingly. The key terms/phrases employed used for PubMed search were “Prevalence” OR “Incidence” OR “Burden” AND “Determinant” OR “Predictors” OR “Factors” AND “Insecurity” OR “Undernutrition” OR “Diet” OR “Diversity” OR “Inadequate” AND “Pregnant” OR “Reproductive age” AND “Women” AND “Ethiopia'‘. The searches were restricted to articles published in the English language only. The search terms were predefined to allow a comprehensive search strategy that included all fields within records, and Medical Subject Headings (MeSH terms) was used to help expand the search in advanced PubMed search. This study also used Boolean operators (we combined keywords with the “OR” operator and then linked the search strategies with the “AND” operator).We reviewed articles from the initial search using defined inclusion and exclusion criteria.All studies which focused on the burden of inadequate dietary diversity and its determinants among pregnant women across Ethiopia were included in this systematic review and meta-analysis. Both community- and facility-based cross-sectional and cohort studies irrespective of their size were included. Articles published from 2013 until 2019 in the English language were included.Studies that did not report specific outcomes either for the burden of inadequate dietary diversity, determinants of dietary diversity, or both quantitatively were excluded from this systematic review and meta-analysis. These papers which could not be fully accessed at the time of our search process were excluded from this review after a contact was attempted with the principal investigator through e-mail on two occasions.The database search results were combined, and duplicate articles were removed using EndNote (version X8). Data were extracted by two authors using a standardized data extraction spreadsheet. Data extraction spreadsheet was pretested on five randomly selected articles, and modification was done accordingly. The spreadsheet included study characteristics such as authors' name, regions, publication year, total sample size, sampling technique, study design, prevalence of dietary diversity (adequate and inadequate), and data also extracted for determinants of respective studies with their frequency of adequate and inadequate dietary diversity including family size, residence, age group, monthly income, women education, food insecurity, and counseling about dietary diversity during ANC follow-up were extracted from each article.The initial screening of the articles by title, abstract, and full text was carried out by two authors (HDH and MM) independently based on the predefined inclusion and exclusion criteria. After each screening round , the authors met and resolved any discrepancies by discussion, while potential disagreements were solved by the involvement of the third authors (YH and FT). The reference lists of the included full-text articles were appraised to ascertain additional articles of relevance to determine necessity of retrieving the full text. Finally, all the included accessible full-text articles were extracted to assemble appropriate information based on the inclusion criteria.The quality of all the included articles was assessed for their risk bias using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI)  adapted The primary aim was to know the pooled prevalence of inadequate dietary diversity among pregnant women at the national level, while the secondary aim of this review was to identify different factors affecting inadequate dietary diversity among pregnant women in Ethiopia. By aggregating these two levels of information, it will build understanding for future implemented for a policy intervention program in order to decrease the high burden of maternal mortality and perinatal outcome complication.I2) with the Cochrane Q statistic test. Forest plots to visualize heterogeneity for the pooled prevalence using the random-effect model and p value less than 0.05 to determine heterogeneity were also conducted. Risk factors obtained from each primary study were thematically organized, and their effect sizes were pooled accordingly using the random-effect model. In case of significant heterogeneity using visual forest plots in the random-effect model along with 95% confidence interval, we did subgroup analysis and sensitivity test of influential test and we did not get significant variation on the value of heterogeneity. Subgroup analysis was conducted using sampling technique, study design , publication year, sample size, and regions and no changed value on the heterogeneity was observed except for the sample size variation. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement for reporting a systematic review and meta-analysis was used to clearly present the study inclusion, exclusion, and rationales.Burden of inadequate dietary diversity and estimates for risk factors obtained from each study were determined as a single estimate pooled. The extracted data were entered into the computer via an Excel sheet for screening their title, abstract, and full texts and then exported to R-statistical software version 3.6.1 for analysis. Evidence of publication bias was assessed using visual inspection of funnel symmetry test, sensitivity test, and Eggers regression test, and trim fill analysis for the asymmetric funnel was conducted. The heterogeneity test across studies was done using the inverse variance  and supplementary from unpublished (3) searches of which 211 duplicated articles were excluded. From the remaining 639 articles, 614 articles were excluded after reading their titles and abstracts based on the predefined inclusion criteria. Finally, 25 full-text articles were accessed and assessed for eligibility criteria. Based on the predefined criteria and after critical appraisal, only 21 articles were included for the final systematic review and meta-analysis .A total of twenty-one articles had met the inclusion criteria. All the included studies were published between 2013 and 2019 in the English language. Twenty facility, community-based cross-sectional and one cohort studies were included using an estimated sample size ranging from 153  up to 75The pooled prevalence of inadequate dietary diversity among pregnant women at the national level in Ethiopia was found to be 53% , using visual forest plots in the random-effect model along with 95% confidence interval . Level oFamily size, educational status, food insecurity, economic status, residence, history of counseling about dietary diversity, and age group were the variable found to have a significant association with the occurrence of inadequate dietary diversity at the national level. The odds of inadequate dietary diversity were 2.18 times higher among food-insecure pregnant women compared with food-secure pregnant women  . The oddThe finding of this review revealed that more than half of pregnant women were found with inadequate dietary diversity in Ethiopia. During the meta-analysis, potential sources of heterogeneity were investigated using the sensitivity influential test, and subgroup analysis on the sampling size, regions, sampling technique, facility- and community-based cross-sectional study, and year of publication was conducted.The source of heterogeneity in this review might be due to the difference in sample size with in the individual articles because as the two extreme sample size (the lowest and largest size) was removed based on the sensitivity analysis, the value of heterogeneity was changed. The pooled prevalence of inadequate dietary diversity among pregnant women at the national level in the current systematic review and meta-analysis was found to be 53% from the random-effect model, which is higher than prevalence reported in studies conducted in Kenya 37%, 39.4%) , 35, Fra%, 39.4% The strength of the current review lies in the international standardized guidelines on the conduct and reporting of systematic review and meta-analysis at the national level of Ethiopia. Though searching was done for unpublished papers and analytical studies (cohort and case-control studies), only published studies and most of the cross-sectional study design were included because we did not find any published case-control studies through the searching engine we had used.The pooled result of this systematic review and meta-analysis showed a high prevalence of inadequate dietary diversity among pregnant women at the Ethiopia national level in which more than half of pregnant women were found to lack sufficient dietary diversity. The review had found that factors like food insecurity, lack of counseling, low economic status, no formal, primary, and secondary educational status, family size, and rural residence were positively significant associated with the occurrence of inadequate dietary diversity among pregnant women in Ethiopia. The value of high heterogeneity might be due to the sample size variation among the individual studies.Therefore, the responsible stakeholders and governmental health officers should strengthen the system and procedures for early counseling about the importance of dietary diversity for pregnancy and perinatal outcomes. To alleviate the inadequate dietary problem among pregnant women at the national level in Ethiopia, the government should coordinate and integrate dietary diversity programs at all levels with different sectors working on the maternal and nutritional services. There should also be strict and frequent monitoring of their nutritional status during antenatal follow-up than previous and should work in collaboration with agricultural sectors especially for the rural settings in order to avail themselves on dietary access in terms of quality and quantity to minimize inadequate dietary diversity burdens and to strengthen the availability and utilization of the service that is available on each health facilities.


Bacteroides, Clostridium, Bifidobacterium, and Faecalibacterium, which predominate in the human gut microbiome , the microbial adhesive capacity and colonization of the gut, the safety status of probiotic strains, as well as gut microbiome homeostasis maintenance by competitively inhibiting the growth of pathogens or producing antimicrobial compounds. However, new probiotic strains are (or will be) screened for natural bioactive substances, immunomodulation capacity, as well as anticancer and other health benefits. Fifteen Research Topics (RTs) on these important subjects have been submitted to the Food Microbiology section. A new era within probiotics research has started with an increasing interest in the use of gut commensal bacteria as potential probiotics, such as strains belonging to the genera At the same time, several studies dealing with health-promoting benefits associated with the consumption of fermented foods and beverages have been proposed. Global fermented foods—classified into nine major groups on the basis of raw materials—can be represented by more than 5,000 varieties being consumed around the world by billions of people. In the last 20 years, culture-independent methods have emerged as a convenient complement for analyzing the microbiota of fermented foods. Polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE) was employed for monitoring microorganisms during food production, storage, and distribution . In the last decade, the high-throughput DNA sequencing (HTS) technologies have made possible the evaluation of microbiota of complex matrices, having a major influence on food microbiology for the determination of the whole genome sequence (WGS) of a single cultured isolate and for generating sequences of multiple microorganisms in a sample (metagenomics). The application of metagenomics can give information on the presence of spoilage and pathogen microorganisms or characterize unknown microbiota, particularly in fermented foods Ronholm, . A very The stress response in food microbes has been the focus of more than 400 articles published in the last 10 years, and more than 20 RTs have targeted microbial resistance. A wide range of food bacteria, pathogens or not, have been described to possess many adaptive mechanisms and specific stress responses that are useful to guarantee and improve fitness under specific environments. An important bacterial stress response is related to cross-protection, which plays a significant role in minimally processed foods. In fact, sub-lethal stress can induce multiple stress responses posing major public health concerns since many bacterial pathogens can become resistant to new preservation technology or processing. Many injured pathogens either retain or exhibit enhanced virulence in foods, thus making their detection crucial to safeguard the food supply chain. In addition, a cell fraction of the stressed bacterial population can remain metabolically active; they enter a non-culturable physiological state and represent a challenge for traditional food microbiology analytical methods. Future research should focus on the implementation of new methodologies for analytical methods able to detect and enumerate viable—but not culturable—cells as well as their stress responses and adaptation , with specific studies being conducted on Escherichia coli (227), Salmonella spp. (167), Listeria spp. (153), Campylobacter spp. (104), Vibrio spp. (89), and Yersinia spp. (13).Bacterial pathogens associated with foodborne disease worldwide include Continuous monitoring of food contaminants and the identification of risk factors are crucial for assuring food safety. Many original research articles included in these RTs have addressed issues related to the genetic diversity, prevalence, resistance, and novel transmission vectors of pathogenic bacteria, but they have also reported new findings on bacterial pathogenesis, such as antimicrobial or desiccation resistance associated with diverse genotypes or the identification of virulence determinants produced and secreted by pathogenic bacteria. Among the future targets of food microbiology, it could be interesting to pursue new findings and studies on the expression of critical virulence factors, which allow for niche adaptation and successful colonization, such as the persistence in food processing facilities via growing predominantly as biofilms rather than in a planktonic mode  that have been poorly studied in terms of microbiological composition, microbial dynamics, and technological processes. These fermented foods represent a particular niche that could be rich with new positive and beneficial microbial strains influencing food quality and safety and that can also improve human health among other aspects.Saccharomyces and non-Saccharomyces yeasts for alcoholic fermentation and Bacillus spp. for alkaline fermented foods. However, new starter cultures should be identified that involve natural adaptation and evolution, such as a direct selection of mutants with the desired properties, adaptative laboratory evolution, and genetic methods besides genome sequencing of wild type strains, for guiding safety assessments and strain-improvement activities  in winemaking, and the production of toxic compounds by microorganisms, such as ochratoxin and biogenic amines, were proposed. In general, the main relevant topics in the next years, related to fermented foods, can be summarized: microbiota involved in product fermentation; a selection of technological, protective, and probiotic starters as well as safety concerns related with their use; the genomic and metabolomics characterization of microorganisms with a technological impact on fermented products; the control and inhibition of pathogens and spoilage organisms; the relationship between technological procedures and microbiota of fermented foods; and traditional and ethnic fermented foods and beverages. In contrast to other habitats, foods are generally characterized by a not relevant number of microbial species. Among these, LAB play an essential role in the development of probiotics and starter cultures. In fact, LAB are an industrially important group of microorganisms used throughout the world for a large variety of food fermentations, such as those of dairy, wine, bread, vegetables, and others, much discussed in the RT “Industrial and health applications of LAB and their metabolites.” More than 30 RTs have focused on LAB, and more than 340 articles have been published on this topic. LAB in particular constitute a diverse group of Gram-positive, catalase-negative bacteria producing lactic acid. Some food-associated LAB obtained the status of “Qualified Presumption of Safety” (QPS) by the European Food Safety Agency (EFSA) or the “General Recognized As Safe” (GRAS) status by the U.S. Food and Drug Administration. Nowadays, the use of these microorganisms and their metabolites for food preservation has been extended to several additional bioactivities. The RT “Application of protective cultures and bacteriocins for food preservation” (Hammami et al., Looking forward, conventional food sources may be complemented by edible microbial biomass derived from bacteria, yeasts, filamentous fungi, or microalgae. Nowadays these groups of microorganisms are evaluated as an important and good source of proteins, vitamins, and beneficial bioactive compounds. It appears that the human population will increase up to about 9–12 billion people by the year 2100, and microorganisms could be an integral part of the sustainable production system. The “Food Microbiology” section of “Frontiers in Microbiology” could provide good guidance through its RTs on new advances in microbiology for the improved utilization, production, and supply of food in the food industry and related fields, which can help to ensure global food safety and security.GS and AC gave the same contribution to the drafting of the article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The purpose of this paper is to provide an overview of key aspects of specialised dermatology nursing practice in the management of patients with moderate to severe atopic dermatitis. The role of dermatology nurse specialists in supporting patients and promoting disease understanding, education and treatment adherence continues to evolve. As features of specialised nursing care can also inform other nursing staff in a wide range of care settings, an overview of key components is examined. Observations presented are from a pan-European perspective and represent the collected view of a group of dermatology nurse specialists, dermatologists and patient advocates following two round-table discussions.Atopic dermatitis is a common, chronic, inflammatory disease characterised by erythematous/scaling skin lesions, with often intense pruritus. Disease course is cyclic with periodic disease flares of varying intensity, presenting management challenges to patients and families. Dermatology nurse specialists play a key role in providing education and substantial patient support to improve treatment outcomes and quality of life to patients and their family, delivered within a multidisciplinary team framework. Nurse-led education and 'eczema schools’ are of benefit in reducing disease severity and improving quality of life by enhancing self-management, adherence and patient engagement. eHealth tools, such as patient portals or online training platforms, can provide online learning, individualised education, and help to improve engagement. These and other initiatives, such as written action plans, are all essential to improve or maintain treatment adherence, self-management and quality of life.Dermatology nurse specialists play a central role in the assessment and management of moderate to severe atopic dermatitis patients and families. This places them in an ideal position to build strong and often long-term relationships with patients and parents. Such engagement promotes trust, assists in setting realistic expectations of treatment and outcomes, and enhances self-management and engagement in their own care. Providing emotional support, as well as formal and systematic education  all contribute to improved treatment adherence and can enhance the quality of life of patients and their families throughout the course of this long-term condition. The purpose of this article is to provide a contemporary overview of the key aspects of specialised dermatology nursing practice in patients with atopic dermatitis (AD) – also known as atopic eczema – and in particular to examine the evolving role of dermatology nurse specialists in supporting patients and promoting disease understanding, education and treatment adherence in those living with moderate to severe AD. A range of different nurse roles exist that may be involved in the care of AD patients, including general nurses working within dermatology, registered dermatology nurses, and nurses with additional training and responsibilities such as dermatology clinical nurse specialists, advanced nurse practitioners and nurse consultants. For simplicity in this manuscript we have used the term ‘dermatology nurse specialists’ to refer to those nurses with additional expertise in specialised dermatology nursing care. These observations are from a pan-European perspective formed from a group of specialist dermatology nurses , a dermatology nurse researcher (HvO), dermatologists  and a patient advocate (TW), who met to develop a consensus on selected topics of specialised dermatology nurse care in AD.AD is a chronic, inflammatory skin disease characterised by erythematous and scaling lesions, often with intense pruritus . DiseaseTypically, the disease course is cyclic with periodic exacerbations/disease flares of varying intensity . The chrAD disease management may be delivered in different health settings . The majority of patients have mild disease and are often managed in the primary care/community setting; only up to 10% are considered to have severe disease . SpecialNurses in all settings play a vital and valued role in providing care for the patient with AD , 18  and the lead physician and other team members to support continuity of care . Nurses Establishing and managing realistic patient expectations in their treatment and their role in self-management is fundamental. These may vary greatly in patients (and the parents of children) as may engagement in the shared decision-making process. Some parents/patients are highly motivated and informed, while others are more reluctant or cautious when seeking information and receiving appropriate clinical management; some may rely completely upon guidance from the healthcare team. Initial attitudes may change during the clinical disease course, and with patient experience and age. Providing patients/parents with the most appropriate and realistic information on their disease status, including the efficacy, safety, and suitability of proposed treatments, based upon their individual needs at each stage of the disease, is vital. Such information should be delivered in a clear, consistent fashion by all members of the healthcare team to inspire confidence and minimise confusion or misunderstanding on the part of the patient or parent , 25–28.Active engagement of the patient in decision making is paramount. A genuine sense of personal responsibility should be encouraged – especially regarding the importance of treatment adherence in achieving optimal self-management and optimal outcomes . For exaDiagnosis of AD is based on family and personal history and clinical features. Most diagnostic criteria consider cutaneous aspects , pruritus and a personal or family history of allergic skin or respiratory disease  as major diagnostic criteria, with disease chronicity and/or a relapsing pattern, and early onset (< 2 years of age) supportive of a diagnosis , 30. IdeMost treatment recommendations are based on disease severity and therapeutic response; a framework for categorizing AD severity as mild, moderate, or severe is important to understand and anticipate an individual’s treatment needs , 15, 25.Since AD is characterised by exacerbation and disease flares, followed by remission, severity should be assessed both at presentation and throughout the disease course; sequential measurements are ideal to generate reliable estimates . A wide The principles of treatment for moderate to severe AD are four-fold; (1) identification and avoidance of trigger factors; (2) skin rehydration to repair/restore the impaired skin barrier; (3) reducing itching/pruritus; (4) reducing skin inflammation, especially during disease flares, via topical and systemic therapies. Dermatology nurse specialists provide a crucial resource for patient education and support in all aspects of treatment.Environmental irritants and known allergens can aggravate affected skin of AD patients and promote disease flares . Well-reKey factors determining emollient use are the level of dryness of the skin and patient preference . As individual preference is important to promote adherence ; it may Wet-wrap therapy is a useful adjunct to standard skincare and topical therapies –44. TheiMedical therapies include topical agents, in particular TCS or topical calcineurin inhibitors (TCIs), phototherapy and systemic or biologic agents (immunosuppressants or biologic therapies e.g. dupilumab). Evidence-based guidelines recommend a stepwise approach to agent selection with a range of topical agents being considered as first-line before systemic immunosuppressants or biologic therapies are considered , 25–28 . Phototherapy is usually given in schedules of 3–5 weekly treatments for 6–12 weeks, with discontinuation if little response is seen within 2 months . TreatmePatients with moderate-to severe AD may require systemic therapy with immunosuppressants  or targeted biologics such as dupilumab. Whilst decision-making should be shared between the patient and the physician to take account of patient preference, screening for the suitability of immunosuppressants or biologics, along with monitoring for adverse effects and clinical responses, are often coordinated by dermatology nurse specialists . This maPatients with moderate to severe AD are at an increased risk of a wide range of co-morbidities, including cardiovascular, autoimmune, and psychiatric diseases , 9. The Other important aspects of wellbeing include the identification of those patients with a psychological disturbance. It should be recognised that adverse mood and poorer QoL can also develop in families of patients with moderate to severe AD. These may be formally measured and monitored by appropriate validated measures  , althougAlthough beyond the scope of this article, a range of factors may adversely impact the patient’s sense of well-being. Sleep disturbance, self-esteem and social anxiety, intimate personal relationships and financial concerns due to treatment costs and impact upon work productivity and absences, can each contribute to lower mood and poorer disease-related life quality. Anxiety frequently relates to poor adherence to therapies, which may itself be associated with factors such as steroid aversion . Nurses Nurses play a key role in the development and provision of systematic education on AD, both to patients, their relatives, and the wider healthcare community, on disease background, standards of care, and detailing risks and benefits of the available recommended treatments. In most therapeutic patient education (TPE) programmes, nurses often play a primary role in providing evidence-based and often individualised information to support self-management and promote active participation in shared decision making , 50–54. Two main service delivery models for education delivery exist; nurse-led focused group education and a broader multidisciplinary “eczema school” approach , 56. To Patients with moderate to severe AD may suffer a sense of isolation and learning about fellow patients’ experiences can help to alleviate this. The DIPEx  international collaboration is a useful resource, providing videos of patient interviews on a wide range of medical conditions to provide genuine insight into the experiences of patients, family, and carers –62. WhilElectronic digital health services  – the use of information and communication technologies for health  – provideHealth strategies are considered favourably by both healthcare workers and patients, and nurses are an important contact in supporting access to eHealth resources. Such resources can range from static tools (providing core disease information) to more dynamic ones providing interactive online learning, self-management training or a personal ePortal providing patient-specific access to their electronic health records . Mobile Providing a suite of tools such as these can deliver individualised education and engagement , 74. IncThe educational and eHealth strategies described above can inform and support adherence. The chronic relapsing disease course, which requires rigorous attention to skincare, and different treatments over a prolonged period, can translate into a complex management plan, with episodes of disappointment and frustration regarding outcomes with topical therapies. This can result in reduced levels of adherence and subsequently poorer outcomes in moderate to severe AD.The use of written eczema action plans, which provide patients or parents with a checklist of instructions, are also valuable to support self-management. Plans such as these are already an established aspect of asthma care, and although data on their effectiveness in AD is limited, they would seem to provide an important aspect to supporting care in AD and patient engagement –80. ActiDermatology nurse specialists are key players in the assessment and management of patients with moderate to severe AD. Their central role within a multidisciplinary team places them in an ideal position to build strong and often long-term relationships with patients and parents. Such engagement promotes trust, assists in setting realistic expectations of treatment and outcomes, and enhances self-management and engagement in their own care. Providing emotional support, as well as formal and systematic education and individualised practical advice, may contributes to improved treatment adherence and can enhance QoL of patients and their families throughout the course of this chronic disease. The aspects described in this review may have value in educating non-specialist nursing staff in the evolving role of dermatology nurse specialists in moderate to severe AD patient management and holistic care.


The risk of a zoonotic pandemic disease threatens hundreds of millions of people. Emerging infectious diseases also threaten livestock and wildlife populations around the world and can lead to devastating economic damages. China and the USA—due to their unparalleled resources, widespread engagement in activities driving emerging infectious diseases and national as well as geopolitical imperatives to contribute to global health security—play an essential role in our understanding of pandemic threats. Critical to efforts to mitigate risk is building upon existing investments in global capacity to develop training and research focused on the ecological factors driving infectious disease spillover from animals to humans. International cooperation, particularly between China and the USA, is essential to fully engage the resources and scientific strengths necessary to add this ecological emphasis to the pandemic preparedness strategy. Here, we review the world’s current state of emerging infectious disease preparedness, the ecological and evolutionary knowledge needed to anticipate disease emergence, the roles that China and the USA currently play as sources and solutions to mitigating risk, and the next steps needed to better protect the global community from zoonotic disease.The online version of this article (10.1007/s10393-020-01471-2) contains supplementary material, which is available to authorized users. The catastrophic health and economic impacts of recent human and agricultural epidemics and the continued risk of novel infectious disease emergence, stemming from the alteration of our planet, are clear  strains in people living in proximity to these farms  originating from overcrowding and high-intensity farming of pigs in China , livestock  and human  populations, as well as impact complete wildlife–livestock–human systems   in West Africa existed prior to this health crisis. Distribution and migration patterns of the hammer-headed fruit bat (Hypsignathus monstrosus), little collared fruit bat (Myoncycteris torquata), straw-colored fruit bat (Eidolon helvum)   (Kupferschmidt The first outbreak of Ebola virus disease (EVD) outside of Central Africa demonstrated the importance of focusing on wildlife host and human ecological risk factors in advance of major disease outbreaks and the need for international collaboration in outbreak response Fig. . DespiteRhinolophus sinicus) and provided strong evidence that bats are the natural reservoir of SARS-CoV  pandemic caused by a novel zoonotic coronavirus (SARS-CoV) was the first pandemic of the twenty-first century and spread to more than 30 countries Fig. . InitialBatrachochytrium dendrobatidis, is responsible for massive losses of biodiversity to an entire Class of organisms (Amphibians). The global pandemic lineage of the pathogen originated in Eastern Asia  can also result in devastating impacts to a country’s biodiversity and natural resources. For example, amphibian chytridiomycosis, caused by the novel pathogen Global-scale, government-sponsored EID preparedness efforts, initiated or supported to date by joint China–US partnerships, have focused on improving early-warning capabilities for known and novel human pathogens in both humans and animal reservoirs. These initiatives have included the US CDC Global Disease Detection program (CDC-GDDP), which has collaborated with China CDC and 10 other nations to develop international centers that help countries prevent, detect and respond to public health threats   revealed that from 2000–2007, 43% of publications on ecology/environment that included disease/pathogens were authored by US researchers exclusive of Chinese participation, while only 2.2% were authored by Chinese researchers exclusive of US participation. These figures changed to 36% and 8%, respectively, from 2010 to 2017. If this trend continues into the next decade (2020–2027), then under a linear extrapolation we can expect the USA and China to publish around 30% and 15% of ecological and evolutionary infectious disease-related research Below is the link to the electronic supplementary material.