Older adults living in residential long-term care or nursing homes have increasingly complex needs, including more dementia than in the past, yet we know little about the unregulated workforce providing care. We surveyed 1,381 care aides in a representative sample of 30 urban nursing homes in the three Canadian Prairie provinces and report demographic, health and well-being, and work-related characteristics. Over 50 per cent of respondents were not born in Canada and did not speak English as their first language. They reported moderately high levels of burnout and a strong sense of their work’s worth. Few respondents reported attending educational sessions. This direct caregiver workforce is poorly understood, has limited training or standards for minimum education, and training varies widely across provinces. Workplace characteristics affecting care aides reflect factors that precipitate burnout in allied health professions, with implications for quality of care, staff health, and staff retention. This article describes the workforce providing the majority of direct care to the frail elderly in nursing homes. We report on health, well-being, job and continuing education characteristics of this workforce and discuss policy and management implications that arise. The current lack of information about the numbers and characteristics of this occupational group reduces our ability to undertake effective workforce planning and to monitor progress toward achieving workforce improvements that result in acceptable quality of care. Our research question on the current characteristics of the care aide workforce in long term care (LTC) homes illuminates effective routes to modify those characteristics. This analysis highlights factors that, if modified, could significantly improve quality of care and quality of life for LTC residents, and quality of work life for care aides.By 2036, the number of Canadians 65 and older will more than double to 10.4 million, with growth most rapid in those over 75 years of age  in Canada have become more complex care environments  provide 75 to 80 per cent of direct care to nursing home residents in Canada , over 40 years of age, born in the United States (77%), earn less than half the US national median annual earnings, and have a high school education or less (55%)  study, a five-year research program seeking to identify modifiable features of organizational context that are associated with better resident and staff outcomes in LTC home settings  in Alberta, Saskatchewan, and Manitoba. All nursing homes that met the TREC inclusion criteria were eligible to participate  demographic characteristics, (b) organizational context, (c) use of best practices, (d) staff outcomes, and (e) factors believed to influence the use of best practices. To sample, we used a census of eligible care aides. All care aides who met the inclusion criteria see  were invIn this article, we report on the following variables collected in our study from care aides: demographics, work-related variables, health status and burnout, and continuing education.We measured (a) job and vocational satisfaction, and (b) whether care aides had enough orientation and job knowledge. We did so by using single items scored on a five-point Likert agreement scale ranging from strongly disagree (1) to strongly agree (5). These single items have produced consistent findings in our previous pilot work with care aides . Each item was scored as yes or no.® scale   of all work-related and staff outcome variables before and after adjusting for three factors: sex, education (care aide certificate), and whether the care aide was born in Canada.We calculated means and standard deviations for interval data and frequency counts and proportions for categorical data. To assess differences between provinces, owner-operator models , and facility size  on categorical and interval-level variables, we used contingency chi-square tests and one-way ANOVA respectively with a post-hoc test . To assess for a possible province effect, we calculated statistical significance  were more strongly associated with the three educational and/or professional development opportunities for care aides that were available to us. To determine this possible association, we conducted two-level individual logistic regressions (one model for having a care aide certificate and one for in-services attended) using each of our three educational variables as dependent variables) that controlled for the three sampling dimensions. We compared these same sampling dimensions using the presence of a clinical educator (facility level) with Fisher’s exact test.Ethics approvals were obtained from the research ethics boards of all investigator-affiliated universities. Operational approvals were obtained from participating organizations.n = 837, 60.6%) were from Alberta, followed by Manitoba  and Saskatchewan . Many worked primarily day shifts , with 548 (39.7%) working evening shifts and 168 (12.2%) working night shifts. Just over half of the sample reported speaking English as their first language. We found statistically significant differences between provinces on all demographic characteristics with the exception of age and whether the care aide had completed a high school diploma. Select (but fewer) demographic variables also differed by owner-operator model  and facility size  .A total of 1,381 health care aides (representing approximately 70% of those eligible to participate during the period in which we collected data in each facility) completed the TREC survey in year two (July 2009–June 2010) see . The majSD = 8.7) and 49.4 (SD = 8.0) respectively. Care aides had moderate risk levels for burnout on two of the three burnout subscales: exhaustion and cynicism. On the third subscale, job efficacy, aides reported unusually high levels (higher is better).Mean scores by province for the work-related variables and health and well-being outcomes are presented in p < .05) between provinces , and whether or not the care aide was born in Canada, all variables except physical health status were significantly different  are sufficiently compatible across provinces to facilitate workforce migration across provincial boundaries.•Processes whereby a percentage of public funding going to nursing homes is earmarked for training and ongoing education of care aides.•Inter-provincial cooperation in developing and implementing health human resource plans – designed to ensure that we have adequate numbers of sufficiently trained care aides working with appropriate professional skill mixes in nursing homes to provide care that is not only safe, but at least meets minimum quality standards and, at best, is person-centred and an international exemplar of how care ought to be provided.•A national discussion that addresses the complex and challenging issue of regulation of this workforce and whether it would contribute to safer and higher quality of care for nursing home residents.•Special attention to issues of gender – this workforce is overwhelmingly female , as is the informal caregiver workforce  and the disproportionate and deleterious effects of long-term care on female caregivers are well-known globally  extraction  requiring residential care, with increasing complexity and dependency levels on admission. Admission occurs later in the trajectory of decline, creating much shorter lengths of stay and, consequently, higher levels of resident turnover in the system. All of these factors combine to create a pressing need for consistent and high-quality of life and quality of end-of-life care for these highly vulnerable residents. We must act urgently and with determination.While our sample is representative of urban nursing homes in the prairie provinces, we have no assurance that our findings are representative of urban nursing homes in Canada in general, and our care aide sample was not drawn randomly from a known population. We saw provincial differences suggesting that important provincial variations may exist across the country with respect to a number of characteristics. Our findings do not reflect the situation in rural Canada. Although the surveys were completed using in-person structured interviews and a rigorous quality assurance process (Squires et al., At present in Canada, we can offer only a partial and unsatisfying response to the question, “Who is looking after Mom and Dad?” We have an even sparser picture of care aide working conditions, health indicators, and work-life quality indicators – all areas that influence the quality of care. Further research will provide partial information; full information and the necessary initiatives to optimize this workforce will require action on the part of policy makers. We entrust the care of the most complex, frail, vulnerable, and challenging charges in our health and social system to this occupational group of care aides 24 hours a day – inaction is not a rational response.To view supplementary material for this article, please visit http://dx.doi.org/S0714980814000506Supplementary MaterialSupplementary information supplied by authors.Click here for additional data file.Supplementary MaterialSupplementary information supplied by authors.Click here for additional data file.


Persistent disparities in pregnancy and birth outcomes between Aboriginal and Torres Strait Islander and other Australians evidence a need to prioritise responsive practice in Maternal Child Health (MCH). This study reviewed the existing knowledge output on Aboriginal and Torres Strait Islander MCH programs and services with the objective to advance understanding of the current evidence base and inform MCH service development, including the identification of new research priorities.A systematic search of the electronic databases Informit, Proquest, PubMed, Scopus, Wiley, and Cinahl, and 9 relevant websites was undertaken for the period 1993–2012. The reference lists of MCH program reviews were hand-searched for additional relevant studies which met the eligibility criteria. The study designs of included publications were classified and the characteristics extracted and categorized. Evaluation quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Program (CASP) tool for qualitative studies.Twenty-three search results were identified for inclusion, with the majority published in 2003–2012. Fifty two percent of publications reported on programs and services operating out of Aboriginal Community Controlled Health Organisations, with antenatal and postnatal care the main intervention type/s, and health promotion/education and advice/support the most common intervention component. Outcomes such as increased antenatal attendance and higher infant birth weights were reported in some intervention studies, however methodological quality varied considerably with quantitative studies typically rated weak.The prevalence of community controlled and/or community-based programs is significant given the health and wellbeing implications of self-determination. While the literature highlights the promise of many intervention models and program components used there are some significant gaps in the documentation and implementation of important MCH interventions. Similarly, while positive health outcomes were reported there are issues with key measures used and study quality. This review highlights the need to improve the quality of evaluations of MCH programs for Aboriginal and Torres Strait Islander women and to address the key evidence gaps in responding to their health and wellbeing needs. Early life experiences, beginning with those of the developing foetus, play an important role in creating the foundations for health and wellbeing throughout the lifetime . Due to There is a lack of a quality evidence base to guide Indigenous health and wellbeing programs globally, and particularly of intervention research focused on testing and analysing the effectiveness of potential solutions , 6. In cTwo prominent early reviews of the literature provide a range of evidence on MCH issues and responses for Aboriginal and Torres Strait Islander women and babies , 8. AsseImportantly, the review by Herceg  identifiThis systematic search was developed in response to the Queensland Government Centre for Social Science Innovation (QCSSI) research priority area of Aboriginal and Torres Strait Islander MCH. This review provides an overview of the literature describing or evaluating Aboriginal and Torres Strait Islander MCH programs and services in Australian primary health care settings from 1993–2012. Primary health care responses included in this review are first level health care services providing antenatal and postnatal care, and maternal and child care. These primary care responses, operating out of mainstream community health services, government health services and Aboriginal Community Controlled Health Services, are increasingly being recognised as the preferred approach for effecting key MCH outcomes, such as reducing the prevalence of low infant birth weight and pre-term births . The revFigure Studies were excluded if they: (a) were duplicates (n = 42); (b) did not focus on child and/or maternal health, or if the outcomes or predictor variables did not include or specifically relate to child and/or maternal health (n = 837); (c) did not focus on Indigenous people in Australia (n = 1587); (d) were not on primary health care programs and services (n = 429); e) were not journal articles, reports or book chapters (n = 621); f) were reviews, discussion papers, commentaries or case reports (n = 984); g) were focused only on child health (n = 8) and h) were published pre 1993 (n = 234). Step 1 excluded 4726 references, leaving 23 search results.Intervention research: defined as studies which test the effectiveness of public health Aboriginal and Torres Strait Islander child and maternal health responses or examines the impact of interventions designed to alter health-related knowledge, attitudes or behaviours, or to improve health care delivery; or 2) Program descriptions: defined as literature which describes the methods or processes applied to implement a child and maternal health response, but in which no data-based evaluation was reported [The remaining 23 studies were examined to identify studies that were; 1) reported .The characteristics of studies of Aboriginal and Torres Strait Islander child and maternal health responses were categorised by: 1) 1st author & year; 2) publication type and study type; 3) location and organisational setting; 4) intervention issue; 5) intervention types and components; 6) target group, sample; 7) outcomes or effects; and 8) study design and study quality (intervention studies only). Two researchers reviewed the publication characteristics and agreed on 22 out of 23, achieving 95.6% inter-rater reliability.Methodological quality of quantitative studies were assessed using the Dictionary for Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies . SectionTable From a low during the 1990’s, there was a significant increase in publications from 2003. With only three studies published in the period from 1993–2002 (13%) –17, the The programs and services identified in the literature operated from a range of locations throughout Australia. The distribution of documented programs and services by state was Western Australia 5/23, 22%) –34, 37, , 22% –34The majority of publications reported on programs and services operating from Aboriginal Community Controlled Health Organisations (ACCHO)  , 35–37. Six of the publications stated the target group for programs and services generally as Aboriginal and Torres Strait Islander mothers and their children/babies/families 6/23, 26%) [% 26, 28, 32 withNineteen of studies reviewed 19/23, 83%) , 36, 37 /23, 83% Antenatal and postnatal care were identified as the main intervention types in 14 (61%) of the search documents , 31–33. The most common component of interventions cited in the literature documenting MCH was health promotion/education and advice/support 16/23, 70%) /23, 70% , 36, 37.Of the 23 publications, 14(61%) reported program outcomes and/or effects. These included the 12 intervention studies plus two program descriptions  reported on MCH programs operating out of ACCHO’s is significant considering the connection between the need for self-determination and Aboriginal and Torres Strait Islander health and wellbeing. A lack of power and control has long been recognised as contributing to the health inequality experienced by Aboriginal and Torres Strait Islander peoples, hence the significance and continuing use of community control of decision-making processes and resources as a health improvement strategy . Along wIn regards to the types of responses outlined, the main intervention type reported in the publications was antenatal and postnatal care (61%), however details of what this care entailed were not provided. There are currently no Australian national guidelines for the provision of antenatal care and research has found that, although protocols used in different antenatal care settings have common areas, there is significant variation in coverage and recommendations about schedules and tests . In the The most common component of MCH interventions, documented in 70% of the literature reviewed, was health promotion/education and advice/support, a finding not identified in previous reviews. Education and health promotion is a prominent MCH care strategy, particularly used by midwives who emphasise their role in promoting the health and wellbeing of pregnant women . Brief hHome visitation and transport services were other intervention components commonly found in the literature, consistent with the findings of Herceg . HoweverThis review also identified some significant gaps in the literature. Consistent with previous research indicating the underutilisation of smoking cessation interventions with Aboriginal and Torres Strait Islander women who smoked during pregnancy , this reAnother important factor found to be lacking in evaluations was women’s subjective views and experiences of their health care, with only two publications reporting on this , 22. TheSimilar to those reported by Eades  and HercOther key outcomes reported includedan increase in infant birth weights after birth (22%) and a decrease in, or lower proportion of, infants born with low birth weight (13%). Although birth weight is a crucial measure of maternal and infant health being associated with a range of poor health outcomes throughout the lifetime , 57, it The outcomes reported in the literature reviewed paint a positive picture for progress in improving the health outcomes of Aboriginal and Torres Strait Islander mothers and infants. However it is impossible to conclusively state any cause and effect relationships between these and MCH programs due to issues of study quality. The methodological quality of intervention studies varied considerably, with quantitative evaluations and the quantitative components of mixed-method studies overwhelmingly rated as weak. Cluster Randomised Control Trials are an appropriate design for evaluations of interventions that naturally occur in groups of individuals  and shouAlthough a rigorous and thorough search strategy was employed, limitations include the possibility that the search did not locate all relevant studies. There is also a risk for publication bias in that programs and services which resulted in no overall benefit, or harmful effects may not have been reported on or published, and would therefore would not be included in this search. Other programs and services are likely to exist but were not included in this review because there was no publicly available literature concerning them. Since evaluations with statistically significant findings are more likely to be published, it is also possible that the published evaluations reviewed may over-estimate the true effectiveness of interventions . The genThere has been a substantial increase in publications documenting Aboriginal and Torres Strait Islander child and maternal health programs and services over the past decade. These publications outline responses to a range of health and wellbeing issues relevant to Aboriginal and Torres Strait Islander mothers, infants and children, with the majority of studies documenting programs targeting mothers and their babies through antenatal and postnatal care. There was a significant difference in the components of programs and services outlined in the literature, with health promotion/education and advice/support reported across a majority of maternal and infant health publications. The literature documents a serious underutilisation of tobacco smoking cessation interventions in antenatal care. Some improvements in health outcomes were reported on, however the true effectiveness of interventions documented in the quantitative studies is unclear due to poor study quality. Considering that it is unlikely that significant improvements in health outcomes will be achieved in the short term, research efforts need to focus on developing good quality longitudinal data to assess the impact of Aboriginal and Torres Strait Islander child and maternal health programs and services over several decades.


The results showed that Cd intoxication impaired hepatorenal function and significantly prolonged prothrombin time and activated partial thromboplastin time and decreased fibrinogen level, red blood cells and platelets counts, hemoglobin concentration, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration. Interestingly, all these hematological, blood coagulation, and hepatorenal deteriorations of Cd toxicity were significantly prevented by CAPE. Additionally, CAPE significantly reversed the significant decreases in levels of total reduced glutathione and superoxide dismutase and increases in levels of thiobarbituric acid reactive substances that were observed in the sera and liver and kidney homogenates of Cd group. It is concluded that CAPE is a promising compound that can counteract the hematological and blood coagulation disturbances, oxidative stress, and hepatorenal damages in Cd intoxication. However, further studies are crucially needed to improve this treatment in patients.The preventative effect of caffeic acid phenyl ester (CAPE) against hematological, blood coagulation, and hepatorenal disturbances in cadmium (Cd) intoxication was investigated in rats. Male Wistar rats were randomly assigned into control group, Cd-group, and Cd + CAPE group. Cd intoxication was induced by intraperitoneal injection (i.p.) of CdCl Caffeic acid phenyl ester (CAPE) is one of the main medicinal components of honeybee propolis that possesses a variety of biological and pharmacological actions such as potent free radical scavenging, antioxidant, anti-inflammatory, cytoprotective, immunomodulatory, and antiviral and promising anticancer properties . Also, tCadmium (Cd) is classified as a very harmful environmental pollutant to the humans that transfers between various levels of the food chain . Though Over the past decade, a variety of research studies have reported that medications with free-radical scavengers and antioxidants are useful in protecting against Cd toxicity , 13, 14.2) and caffeic acid phenethyl ester (CAPE) were purchased from Sigma-Aldrich Chemical Company . Commercial assay kits of total reduced glutathione (GSH) content, superoxide dismutase (SOD) activity, and thiobarbituric acid reactive substances (TBARS) concentration were purchased from Cayman Chemical . All other used chemicals and reagents were of analytical grade and obtained from standard commercial supplies as stated under the sections of their applications.Cadmium chloride (CdCln = 10), Cd-group (n = 15), and Cd plus CAPE group (n = 15). In Cd and Cd + CAPE groups, CdCl2, dissolved in physiological saline (0.9% sodium chloride in distilled water), was intraperitoneally injected at a dose of 1 mg/kg/day for 21 days, and in Cd + CAPE group, CAPE was coadministered i.p. at a dose of 10 micromol/kg for also 21 days. The doses of both Cd and CAPE were chosen on the basic of previous studies [Forty adult male Wistar albino rats, weighing 230–250 g, were used in the present study. The rats were housed five per cage under controlled temperature (20–25°C) and 12 h light-dark cycle and allowed free access to water and a commercial rat pellets stock diet. All experimental protocols were approved by the Committee for the Care and Use of Laboratory Animals at Umm Al-Qura University, KSA, and all animals received care according to the criteria outlined in the Guide for the Care and Use of Laboratory Animals prepared by the National Academy of Sciences and published by the National Institutes of Health. The rats were randomly divided into 3 experimental groups: control group  and used for plasma preparation for screening of the following blood coagulation tests: prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen concentrations (FIB), by using Dade Behring reagents and following manufacturer's instructions as previously described . The second sample was collected in a tube contained disodium salt of ethylene diamine tetra acetic acid (EDTA) anticoagulant and used for determination of the following hematology parameters: counts of red blood cells (RBCs), white blood cells (WBCs) and platelets (PLTs), hemoglobin (HGB) concentration, hematocrit (HCT), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC). These hematological parameters were determined by standard hematological techniques. The last portion of the collected blood was placed in a plain centrifuge tube without any anticoagulant and after centrifugation process, its corresponding serum was obtained and used for the below mentioned assays.The prepared sera samples were employed for measurement of the serum concentrations of liver function enzymes (aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP)), albumin (ALB), and kidney function biomarkers (serum creatinine (CRE), and blood urea nitrogen (BUN)).The levels of total reduced glutathione (GSH) and activities of superoxide dismutase (SOD)  were measured in the serum and homogenates of the liver and kidney tissues. On the other hand, the concentrations of thiobarbituric acid reactive substances (TBARS), indices of lipid peroxidation, and oxidative stress were also determined in these sera, liver, and renal biological samples. During these three assays, specific commercial kits  were used, and all samples were processed in duplicate and according to the manufacturer's instructions. t-test were used to analyze the statistical differences. P < 0.05 was considered to represent a statistically significant difference.The results were expressed as the mean ± standard deviation (SD) and statistical analysis was carried out using SPSS software, version 16.0 . One-way analysis of variance (ANOVA) followed by a Student'sThe hematological and blood coagulation changes are shown in Intoxication with Cd had also resulted in significant deteriorations on blood coagulation. As demonstrated in The results of serum biochemistry reflect that both the hepatic and renal function of rats had been altered due to Cd intoxication and these damaging effects of Cd had been attenuated by CAPE therapy. As shown in Level of GSH (an example of nonenzymatic antioxidant defense mechanism), activity of SOD (an example of enzymatic antioxidant defense mechanism), and concentration of TBARS (an index of lipid perioxidation and oxidative stress) were measured in the sera samples and liver and kidney tissue homogenates of all animal groups. As demonstrated in Cadmium (Cd) is classified as a highly toxic environmental pollutant to the humans and animals. Caffeic acid phenyl ester (CAPE) is a biological active component of honeybee propolis extracts with potent free radical scavenger and antioxidant activity . This stThere is a compelling body of evidence that Cd exposure importantly contributes to human and animal liver and kidney diseases , 20. AftHematopoietic system is one of the most sensitive systems to evaluate the hazards effects of poisons and drugs in humans and animals . In consData of blood clotting tests demonstrated that exposure to Cd had resulted in a significant hypocoagulation state in form of marked prolongation of the coagulation tests PT, APTT, low platelet count, and decreased fibrinogen levels and this Cd's hemostatic dysregulation effect was significantly improved by CAPE treatment. It is well known that the liver is the major organ for synthesis of procoagulation factors and substances. Thus, the hypocoagulation state that was observed her in Cd group but not in Cd + CAPE group might be related to Cd-induced liver injury with decreased production of the procoagulation factors and reduced hepatic clearance of plasminogen activators leaded to enhanced fibrinolytic activity , 25. TheEarlier studies had indicated that treatment with free-radical scavengers and antioxidants are useful in protecting against Cd toxicity , 13, 14.Based on the presented results, it can be concluded that Cd intoxication was resulted in development of hematological and hemostatic alterations, as well as hepatorenal dysfunctions in rats, and this might be due to enhancing of lipid peroxide concentration and/or depletion of the activity of antioxidant defense elements. Furthermore, the ability of CAPE to protect against the hematological, blood coagulation, and hepatic and renal toxic effects of Cd could also be attributed to restore the antioxidant activity and/or inhibit lipid peroxidation in both blood and organs. Therefore, CAPE could be a promising agent for the treatment of Cd intoxication; however, further studies are crucially needed to improve this treatment in patients.


Deep venous thrombosis (DVT) is a blood clot in a large vein, usually in the leg or pelvis. Sometimes a DVT detaches from the site of formation and becomes mobile in the blood stream. If the circulating clot moves through the heart to the lungs it can block an artery supplying blood to the lungs. This condition is called pulmonary embolism. The disease process that includes DVT and/or pulmonary embolism is called venous thromboembolism (VTE). Each year in the United States, an estimated 350,000–900,000 persons develop incident VTE, of whom approximately 100,000 die, mostly as sudden deaths, the cause of which often goes unrecognized ,3. FinalVTE can result from three pathogenic mechanisms: hypercoagulability (increased tendency of blood to clot), stasis or slow blood flow, and vascular injury to blood vessel walls. Individual characteristics include congenital and acquired factors, such as advanced age or cancer, and interact with external factors, such as hospitalization or surgery . HospitaAs a health-care–associated condition, VTE is receiving increased attention from patient safety experts, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare & Medicaid Services (CMS). Despite that recognition, the number of secondary diagnoses of VTE in hospital patients has increased , and durBoth pharmacologic and mechanical prophylaxis can be used to prevent VTE . PharmacPrevention of VTE can be complicated because physicians must balance the risk for thrombosis with the risk for bleeding from anticoagulants by considering each patient’s risk for VTE and bleeding relative to the risks and benefits of prophylaxis. The 2012 American College of Chest Physicians VTE-prevention guidelines endorsed three quantitative risk-stratification models and suggested that VTE prophylaxis might not be beneficial for low-risk hospitalized patients –13. AsseIn 2004, the Johns Hopkins Medical Institutions Center for Innovations in Quality Patient Care assembled a multidisciplinary VTE-prevention team to develop a VTE education program for health-care providers, design evidence-based risk-appropriate prophylaxis strategies, establish a mechanism to assess performance, and review data with staff to improve performance ,16. PapeThe Johns Hopkins experience emphasizes the key elements of an optimal VTE-prevention strategy: 1) VTE-prevention risk assessments must be a mandatory part of patient care; 2) clinicians must identify VTE risk factors and contraindications to prophylaxis; 3) clinicians must order risk-appropriate VTE prophylaxis; 4) patient risk factors must be reassessed during their hospital stay; 5) the system must collect patient and provider data to monitor performance; 6) adverse outcomes  must be monitored; and 7) performance must be measured regularly to promote continuous improvement .VTE is the subject of numerous patient-safety quality or performance measures developed and promoted by federal agencies, such as AHRQ and CMS, and professional organizations, such as the Joint Commission and the National Quality Forum. Such measures are typically based on administrative data that are routinely collected and reported, but accurately ascertaining HA-VTE can be difficult without reviewing medical charts. In two studies conducted by the Institute for Healthcare Improvement using hospital patient chart reviews to identify adverse events, VTE was a fairly frequent cause of harm  and accounted for one out of 17 preventable deaths .VTE is one of nine hospital-acquired conditions (HACs) targeted for an overall 40% reduction in preventable harms by the Partnership for Patients, a collaborative national health-care quality initiative led by CMS.AHRQ developed a VTE-prevention guide containing sample forms and protocols for clinicians to help implement processes to prevent VTE . It prov†Patient safety improvements can help achieve the “triple aim” as defined by the Institute for Healthcare Improvement: 1) to provide better patient experience of health care, 2) to improve population health, and 3) to decrease health-care costs . A positIn 2011, CDC convened an expert panel to discuss prevention of HA-VTE. The experts identified the need for strategies to address the use of VTE prophylaxis among hospital patients and better ways to track HA-VTE.Surveillance will be critical for assessing the impact of interventions to reduce HA-VTE. A comprehensive surveillance approach would collect information not only on the incidence of VTE but also information on the prevention practices implemented to assess the relationship between them. However, there are multiple major challenges for conducting surveillance for VTE. First, for various reasons, diagnosis codes for VTE in administrative databases often do not accurately identify patients with acute VTE. One strategy to minimize false positives for VTE in outpatient records is to require confirmation of a diagnosis code through the appearance of the same code in subsequent encounters and a filled prescription of an anticoagulant. However, because of false positives, only review of medical records in which the results of imaging tests document VTE can validate a diagnosis. Second, distinguishing new from recurrent VTE is challenging because an accurate medical history is needed but often is not available from administrative data sources. Third, mortality attributable to pulmonary embolism can lead to missed cases because of sudden death; thus, collecting additional information from autopsies and death records is critical for capturing cases and outcomes. Fourth, because VTE can be asymptomatic as well as symptomatic, temporal trends in VTE incidence might reflect institutional variations in screening and diagnosis practices instead of actual changes in overall incidence. Information on why screening was done is important for distinguishing these situations. Finally, because many cases of HA-VTE occur after discharge, data must be collected from multiple settings in which VTE is diagnosed and treated. Therefore, in 2012, CDC funded two pilot surveillance programs for a 2-year project to develop methods that combine use of administrative data with review of electronic medical records to yield more complete population-based estimates of VTE incidence and to inform the development of surveillance methods to overcome the challenges described. Data and methods from these pilot surveillance programs will lay the foundation for more accurate ongoing monitoring of VTE nationally.VTE is a problem of major public health importance, with hundreds of thousands of persons affected each year. Because nearly half of VTE cases occur during or soon after a hospital stay, there is overlap between VTE as a public health problem and a preventable patient safety problem. Public health programs and patient safety stakeholders, such as hospital networks and health-care payers, are encouraged to collaborate to promote effective risk-stratification and VTE prevention in inpatient settings and to assess trends in the use of risk-appropriate VTE prophylaxis for HA-VTE events and complications.


There is increasing evidence that electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitative approaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support.Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library , Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest and SCOPUS. In addition, other sources will be searched for ongoing studies  and grey literature: Healthcare Management Information Consortium, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by 2 reviewers. Qualitative studies, either standalone or in the context of mixed-methods designs, reporting the perspectives of any actors involved in the implementation, management and use of ePrescribing/CPOE systems in hospital-based care settings will be included. Data extraction will be conducted by 2 reviewers using a piloted form. Quality appraisal will be based on criteria from the Critical Appraisal Skills Programme checklist and Standards for Reporting Qualitative Research. Studies will not be excluded based on quality assessment. A postsynthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method.The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.CRD42016035552. Although a number of systematic reviews have been conducted to date on electronic prescribing (ePrescribing) or computerised provider/physician order entry systems, only a few have focused on hospital settings.According to the scoping searches conducted by the authors, only two existing reviews included qualitative studies, of which only one focused on providers' perceptions in a hospital setting.To the best of the knowledge of the authors, this is the first systematic review of qualitative evidence relating to the management and use/optimisation of ePrescribing systems in hospital settings, not limited to the implementation process, and including any reported perspectives .The review will not address perceptions and experiences related to non-hospital-based settings.In recent years, an increasing body of evidence supports that electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve medication safety and quality of healthcare services by reducing risks of medication errors3However, alongside the potential benefits of ePrescribing applications for patients, professionals and healthcare systems/organisations, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use,15–17Qualitative approaches are particularly well suited to (1) understanding how systems are used in practice, including the identification of unintended consequences, to inform the implementation, development and optimisation of ePrescribing systems in specific contexts;23–26On this basis, the proposed systematic review will collate, assess and analyse the current evidence relating to perceptions and experiences of those involved in the implementation, management, use and optimisation of ePrescribing systems in the hospital setting.A number of systematic reviews have been conducted to date on ePrescribing/CPOE systems: five reviews used quantitative approachesThe aim of this review is to explore the perceptions and experiences of the implementation, management, use and optimisation of ePrescribing/CPOE systems with or without clinical decision support (CDS) in the hospital setting.To identify, appraise and synthesise primary qualitative studies on ePrescribing/CPOE systems, with or without CDS, in hospital settings.To explore/interpret the contribution of such findings to the understanding of the perceptions and experiences of those involved in the implementation, management, use and optimisation of ePrescribing/CPOE systems in hospital settings.This systematic review will follow the reporting guidelines formulated in the ‘Enhancing transparency in reporting the synthesis of qualitative research’ (ENTREQ) statement.34Bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library , Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts (ASSIA) via ProQuest and SCOPUS.Sciences and Social Sciences Citation Index (Web of Science) for citation searching.ClinicalTrials.gov for ongoing studies.Checking of citation lists of included studies and relevant reviews.Grey literature sources: Healthcare Management Information Consortium, Conference proceedings citation index (Web of Science) and Sociological abstracts.Selected specialist journals in the field of health informatics and qualitative research will be hand searched for additional relevant studies.The following sources will be searched for primary studies:A comprehensive search strategy will be conducted with the use of search filters10.1136/bmjopen-2016-011858.supp1supplementary appendixThe literature search results will be imported into EndNote X7.4  in order to remove duplicate records and complete the study selection process. Two reviewers will independently screen articles for eligibility using predetermined inclusion/exclusion criteria . Any dis40Any hospital-based care setting will be included. Other settings such as primary care, non-hospital-based clinics, non-hospital-based secondary/tertiary care, non-hospital-based community care and residential care settings will be excluded. In cases where a study includes non-hospital-based and hospital-based settings, a decision regarding study inclusion will be made on the basis of the reported data that belong to the hospital side of the study being identifiable and extractable.This review will not focus on a particular perspective, and therefore, studies of any types of participants will be included. Participants/perspectives included in the review may comprise, but are not limited to, the following: service providers , service users (including patients and relatives/carers of patients), personnel involved in the management and/or implementation of ePrescribing systems and policymakers or commissioners responsible for the introduction of ePrescribing systems.Any electronic system, or subsystem, involved in the prescription and/or administration of medication will be included. This comprises studies of CDS systems within or alongside ePrescribing/CPOE and studies of electronic health records systems that include ePrescribing/CPOE. In the latter case, studies will only be included if the ePrescribing/CPOE-related data are identifiable and extractable. Electronic systems only involved in other phases of the medication process  will be excluded.No restrictions applied.Any qualitative studies focusing on the perceptions and experiences of those involved in the implementation, management, use and optimisation of ePrescribing systems in a hospital setting. The main outcome of this review will be to identify key issues and areas of importance from the users' perspectives to inform the quality and safety of healthcare services delivery.Quality appraisal of included studies will be conducted using a tool developed specifically for the review based on items from the Critical Appraisal Skills Programme Qualitative Research Checklist,Given the inherent difficulty of appraising all aspects of quality of qualitative research,Purpose of the study and specific objectives or research questions;Study characteristics, study location ;Population ;Qualitative approach and research paradigm ;Data collection methods;Data analysis methods;Results.Data extraction will be conducted by two reviewers using a standardised piloted data extraction form. Discrepancies will be resolved through discussion or referral to a third reviewer. The following (but not limited to) information will be extracted from all included studies:We will understand the findings to be all of the text labelled as ‘results’ or ‘findings’ in the selected papers. Included data will therefore include verbatim data extracts from participants as well as authors' descriptions, summaries and interpretation of primary data. These will also be used to contextualise and facilitate the interpretation of primary findings included in the review.The results sections of the included studies will be entered, verbatim, into QSR NVivo 10 software and will be treated as qualitative data.We will then undertake a thematic synthesis,46Following Thomas and Harden,Multiple coding: data will be codified independently by two reviewers.Reviewer triangulation: three reviewers will compare their interpretations of the two codebooks.Data sessions: these will be held at various stages and will involve all members of the review team to (1) discuss and agree on the coding framework; (2) establish and refine descriptive themes; (3) discuss and agree analytical themes and interpretative framework and (4) discuss any emerging issues from the sensitivity analysis and establish final results.To ensure the robustness of the findings, various verification procedures will be undertaken including:Those involved in and/or affected by technologies aimed at supporting the medication prescription and administration process in hospital settings will include not only health professionals and also other actors such as patients and relatives/carers, managers, commissioners or HIT professionals.A better understanding of the range of actors and their perspectives of implementing and using ePrescribing technologies in hospital settings could help to develop new measures of impact for future research and quantitative impact evaluations, and offer new insights into the implementation process of such technologies by bringing together perspectives from strategic, social, organisational and technical backgrounds.22Also, this work might open up new angles from which to consider key findings from previous similar reviews in this area, including the introduction of profound workflow changes (such as staff communication patterns or dependence on technology) and new safety hazards ,33In addition, the analysis of existing qualitative evidence on the implementation and regular use of ePrescribing in hospital settings from the perspective of those involved in and/or affected by such technologies could shed new light on the issue of addressing complex data about healthcare quality and safety that cannot be straightforwardly classified, quantified or elicited from sources such as audit data, routine metrics and statistics or incident-reporting systems.47Finally, the findings of this review will inform an ongoing longitudinal study exploring the effects of implementing an ePrescribing system on care provision and hospital work in paediatric hospital ward settings.48


Mortality rates in the United States vary based on race, individual economic status and neighborhood. Correlations among these variables in most urban areas have limited what conclusions can be drawn from existing research. Our study employs a unique factorial design of race, sex, age and individual poverty status, measuring time to death as an objective measure of health, and including both neighborhood economic status and income inequality for a sample of middle-aged urban-dwelling adults (N = 3675). At enrollment, African American and White participants lived in 46 unique census tracts in Baltimore, Maryland, which varied in neighborhood economic status and degree of income inequality. A Cox regression model for 9-year mortality identified a three-way interaction among sex, race and individual poverty status (p = 0.03), with African American men living below poverty having the highest mortality. Neighborhood economic status, whether measured by a composite index or simply median household income, was negatively associated with overall mortality (p<0.001). Neighborhood income inequality was associated with mortality through an interaction with individual poverty status (p = 0.04). While racial and economic disparities in mortality are well known, this study suggests that several social conditions associated with health may unequally affect African American men in poverty in the United States. Beyond these individual factors are the influences of neighborhood economic status and income inequality, which may be affected by a history of residential segregation. The significant association of neighborhood economic status and income inequality with mortality beyond the synergistic combination of sex, race and individual poverty status suggests the long-term importance of small area influence on overall mortality. Mortality disparities across racial and economic groups in the United States (US) are well established . In 1995The influence of economic status on overall health and mortality extends beyond the individual to the neighborhood . Place oIn addition to average economic levels, neighborhood influences also include income disparities within neighborhoods. A number of studies have linked high income inequality with an increase in adverse health outcomes such as overall mortality , 21. ThiMany studies of race, individual poverty and neighborhood economic status on mortality are limited in their conclusions due to existing correlations among these primary factors , 13. OurThe Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study is a prospective longitudinal cohort study of 3720 socioeconomically diverse African American and White adults initially 30–64 years old. Participants were selected using an area probability sample from thirteen local communities in Baltimore, Maryland, during 2004–2009. The local communities were chosen to span diverse levels of income and socioeconomic status and provide a representative distribution of Baltimore residents. Participants were 30–64 years old at enrollment, and selected based on a factorial crossed design of sex, race, 5-year age group, and poverty status . The factorial design allows analysis of the separate and combined associations of sex, race, and poverty status on health outcomes . ParticiParticipants were followed prospectively via matching to National Death Index data . Individual data for matching included name, date and state of birth, sex, race, maiden name, and social security number. Minimal loss of follow-up was expected because 94% of the participants provided a social security number, and participants were actively contacted for follow-up visits throughout the study period. NDI data were available from the date of HANDLS enrollment (August 2004–March 2009) through December 31, 2013, providing up to 9 years of follow-up (mean and median of 6.9 years). Details included date of death and primary cause .The entire city of Baltimore, Maryland was included with census tracts used as small areas following the 2010 Census definitions. Census tracts include 4000 residents on average and are adequately sized for detecting spatial gradients and trends over time in overall mortality . Data foThe 19 selected neighborhood-level variables were included in a principal component analysis (PCA) to select a set of variables for the index see . Retainea priori based on the design of the study and not removed during variable selection. Models were built separately using the NEI (Model 1) and neighborhood median income (Model 2), and Akaike information criterion (AIC) values were compared between the two resulting models. The assumption of proportionality was assessed by inspection and testing of the Schoenfeld residuals [Cox proportional hazards models were used to estimate mortality hazard ratios (HR) and their Wald 95% confidence intervals (CI). Exact age at entry and exit of the study were used as the measurement of time for the models . Enrollmesiduals .All analyses were performed in the R program  version Baltimore, Maryland has 200 census tracts and 198 of them contain at least one household. The PCA identified six variables for the index: percent of households with unemployed, percent of households with people out of the workforce, percent of households receiving food stamps, percent of households earning less than $30,000 annually, percent of households with no car and percent of households in poverty  or neighborhood median income (Model 2) resulted in the same general model structure . The CoxBoth NEI and median household income were significant when added to models separately. NEI was significantly and negatively associated with overall mortality, indicating that participants in areas of higher economic level had a lower risk and thus greater survival than their counterparts living in lower economic areas. The 75th percentile of NEI values for HANDLS participants had a 20% decrease in mortality relative to those at the 25th percentile of NEI values . Neighborhood median income, in units of $10,000, was significantly and negatively associated with overall mortality. The 75th percentile of median household income values for HANDLS participants had a 17% decrease in mortality relative to those at the 25th percentile of median household income values . Both models had adequate fit upon testing and review of the Schoenfeld residuals. The AIC scores for the NEI Model 1 of 4137.5 and neighborhood median household income Model 2 of 4139.0 indicate that the models performed similarly.This study uses the power of the HANDLS stratified sample to examine race, and individual and neighborhood economic status as they relate to disparate rates in mortality. We found that overall neighborhood economic status and income inequality for those below poverty were independently related to mortality, beyond the synergistic effects of sex, race and individual poverty status. While African American men living below poverty had the highest overall mortality among the sex, race and individual poverty groups, higher levels of neighborhood economic status were associated with decreased mortality for all. This effect held whether NEI or neighborhood median household income was used as the measure of neighborhood economic status. We showed that the NEI was an objective measure of neighborhood economic status with high internal validity, consistency over short time periods, and low redundancy with individual measures of socioeconomic status, although neighborhood median household income had the same relationship with mortality and resulted in a similar model.While individual factors of race, sex and individual poverty level are known to be related to mortality, we identified a significant interaction among these variables. African American men with household incomes below 125% of the federal poverty level had the highest risk of mortality compared to other race, sex and poverty groups in the study. Racial disparities in mortality have persisted over the last century , and disAfrican American men may experience exceptional barriers to maintaining their health in their communities. African Americans in prison have lower mortality than non-institutionalized men; African American male prisoners aged 15–64 have an age adjusted mortality rate 43% lower than the general population . Prison Governmental economic policies that improved employment and income for African Americans also differentially benefitted African American women, leaving many African American men behind . UnemploRacial and economic disparities are often confounded, which along with residential segregation yields racial and spatial differences in health . In HANDWe identified a significant relationship between the NEI and mortality after accounting for individual level variables of race, sex and poverty status. This finding is similar to the association between neighborhood economic status and mortality observed in a recent larger study , althougThe association between income inequality and mortality differed based on individual poverty status. High levels of income inequality were associated with higher HR for poverty status on mortality than for those with low levels of income inequality. There are well-known effects of macro-level income inequality on health. A recent review concluded that large income disparities damage health, and that countrywide income disparities are increasing over time . In ecolThis study has several limitations. The HANDLS sample is representative of the diverse urban-dwelling population in Baltimore, Maryland, and may not be representative of African Americans and Whites living in other areas, especially those in suburban or rural communities. Independent demographic analyses of the HANDLS sample determined it representative of urban populations from U.S. cities with similar population densities and racial distribution, namely, Atlanta, GA; Bridgeport, CT; Bridgeton, NJ, Buffalo, NY; Camden, NJ; Carson, CA; Chicago, IL; Cleveland, OH; Detroit, MI; Harrisburg, PA; Hartford, CT; Oakland, CA; Springfield, MS; and Trenton, NJ . Also, sUse of composite indices has been a natural solution to measuring the complex social and economic factors in a small area which could affect health outcomes. While originally these indices were based on previous research and theory , recentlThis study leveraged the HANDLS study's unique factorial design of race, sex, age and individual poverty status, measuring time to death as an objective measure of health, and included both neighborhood economic status and income inequality for a population of middle-aged urban-dwelling adults. Our findings add to the current body of knowledge by describing the combined association of race, sex and individual poverty with mortality in an adult cohort. African American men living below 125% of the federal poverty level were disproportionately likely to suffer early mortality. The additional neighborhood variables of economic status, as measured by the NEI, and income inequality, as measured by the Gini coefficient significantly added to the model, indicating the separate association of these variables with mortality.Future research should examine in more detail the effect of neighborhood economic level on mortality by taking into account movement of people over time, as well as examining possible interventions. While our findings support the use of median household income across small areas as an indicator of overall neighborhood economic status, it should be explored if these findings hold for suburban and rural environments.S1 Appendix(DOC)Click here for additional data file.S1 FigLocations of Healthy Aging in Neighborhoods of Diversity Across the Life Span African American and White Participants in Baltimore, Maryland 2004–2009, with Gini Income Inequality Coefficient (A) and Neighborhood Economic Index (B) by Census Tract.(PDF)Click here for additional data file.S1 Table(DOC)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Contemporary malaria vector control relies on the use of insecticide-based, indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs). However, malaria-endemic countries, including Eritrea, have struggled to effectively deploy these tools due technical and operational challenges, including the selection of insecticide resistance in malaria vectors. This manuscript outlines the processes undertaken in consolidating strategic planning and operational frameworks for vector control to expedite malaria elimination in Eritrea.The effort to strengthen strategic frameworks for vector control in Eritrea was the ‘case’ for this study. The integrated vector management (IVM) strategy was developed in 2010 but was not well executed, resulting in a rise in malaria transmission, prompting a process to redefine and relaunch the IVM strategy with integration of other vector borne diseases (VBDs) as the focus. The information sources for this study included all available data and accessible archived documentary records on malaria vector control in Eritrea. Structured literature searches of published, peer-reviewed sources using online, scientific, bibliographic databases, Google Scholar, PubMed and WHO, and a combination of search terms were utilized to gather data. The literature was reviewed and adapted to the local context and translated into the consolidated strategic framework.In Eritrea, communities are grappling with the challenge of VBDs posing public health concerns, including malaria. The global fund financed the scale-up of IRS and LLIN programmes in 2014. Eritrea is transitioning towards malaria elimination and strategic frameworks for vector control have been consolidated by: developing an integrated vector management (IVM) strategy (2015–2019); updating IRS and larval source management (LSM) guidelines; developing training manuals for IRS and LSM; training of national staff in malaria entomology and vector control, including insecticide resistance monitoring techniques; initiating the global plan for insecticide resistance management; conducting needs’ assessments and developing standard operating procedure for insectaries; developing a guidance document on malaria vector control based on eco-epidemiological strata, a vector surveillance plan and harmonized mapping, data collection and reporting tools.Eritrea has successfully consolidated strategic frameworks for vector control. Rational decision-making remains critical to ensure that the interventions are effective and their choice is evidence-based, and to optimize the use of resources for vector control. Implementation of effective IVM requires proper collaboration and coordination, consistent technical and financial capacity and support to offer greater benefits. Malaria remains an important vector-borne disease worldwide . The gloBacillus thuringensis var israelensis (Bti) or Bacillus sphaericus (Bs) was proposed for testing and deployment as and alternative to temephos. Distribution and use of LLINs began in 1995 in Gash-Barka and 1997 in Anseba. Biological control of mosquitoes using larvivorous fish, Aphanius dispar, a top-feeding predator of mosquito larvae and pupae, was evaluated on a small scale in both the Semenawi Keih Bahri and Southern Red Sea zobas. IRS was conducted in malaria epidemic-prone areas and in resettlement zones using DDT in Gash-Barka, Anseba and Dabub. Pyrethroids were proposed as a potential alternative insecticide to replace DDT. During 1998 and 1999, Anopheles gambiae were susceptible to 4 % DDT and 5 % malathion by standard World Health Organization (WHO) protocol in Gash-Barka, Debub and Anseba [Eritrea has been implementing vector control since the establishment of the National Malaria Control Programme (NMCP) in 1995. The number of malaria cases reported and treated by health facilities and community malaria agents increased from 141,213 in 1994, to 466,016 in 1998, and 293,671 in 1999 . Historid Anseba . NotablyAnopheles arabiensis is the primary malaria vector. Anopheles d’thali, Anophelescinereus, Anophelesrhodesiensis, Anopheles squamosus, and Anopheles rupicolus are secondary vectors [Anopheles arabiensis has a facultative indoor and/or outdoors resting behaviour and readily feed on either humans or cattle, making it more difficult to control. It prefers to breed in temporary, widely dispersed rain pools, hoof prints around the edges of dams. The other species have a predilection of feeding on animals and resting outdoors [The WHO emphasizes IVM for combating vector-borne diseases (VBDs) . The IVM vectors . Howeveroutdoors . Like maoutdoors . The cououtdoors .Table 1KPlasmodium falciparum prevalence. Nevertheless, incidence of malaria has risen in the last 3 years with an increase in malaria deaths from 2011 to 2012 coupled with occurrence of sporadic outbreaks in various sub-zones of the country [In Eritrea, malaria currently accounts for 2.1 % of the total outpatient morbidity and about 2.9 % of all hospital admissions. Approximately 70 % of the population resides in malaria-endemic areas, mostly in Gash-Barka, Debub, Semenawi Keih Bahri (SKB), and Anseba .Eritrea  country . Attempt country . The couDuring 2014 other VBDs emerged (dengue fever) and re-emerged (schistosomiasis and lymphatic filariasis) and malaria remains endemic and is increasing in four endemic regions of the country. This prompted a process to redefine and relaunch the IVM strategy with integration of other VBDs as the focus. Eritrea was successfully awarded the Global Fund to fight HIV/AIDS, tuberculosis and malaria rounds 2, 6 and 9 for malaria control in addition to previous World Bank grants under the HIV/AIDS, malaria, sexually transmitted diseases and tuberculosis (HAMSET) project, and was provided with seed funding by WHO to initiate the implementation of the GPIRM . CognizaThe effort by the MoH and the WHO country office to strengthen strategic frameworks for vector control in Eritrea was the ‘case’ for this study. IVM strategy in Eritrea was developed in 2010 but was not well executed. The strategy was primarily used for malaria vector control. Until recently, the geographic distribution of most VBDs was not well assessed. Neither operational research nor sustainable vector control has been implemented for lymphatic filariasis and dengue due to lack of countrywide mapping. Insecticide resistance was selected in malaria vectors. Furthermore, systematic monitoring of vector bionomics and their resistance profiles, including a comprehensive entomological database, are lacking; available entomological laboratories are not functioning optimally; and, collaboration with relevant agencies has been very limited. Equally, IEC/BCC on VBDs, including improved environmental and personal hygiene, has been minimal. This situation resulted in a rise in transmission of malaria and other VBDs, prompting a process to redefine and relaunch the IVM framework with integration of other VBDs as the focus.To revitalize IVM, Eritrea sought WHO technical support to develop and consolidate strategic frameworks for vector control by: updating the IVM Strategy (2015–2019), IRS and LSM guidelines; developing training manuals for IRS and LSM; training of national staff in malaria entomology and vector control, including insecticide resistance monitoring techniques and initiating the GPIRM; conducting needs’ assessments and developing standard operating procedure for insectaries; developing a guidance document on malaria vector control based on eco-epidemiological strata and harmonized mapping, data collection and reporting tools; elaborating an insecticide resistance monitoring and management plan and a vector surveillance plan.Structured literature searches of published, peer-reviewed sources using online, scientific, bibliographic databases were utilized to gather data on VBDs in Eritrea. PubMed , Google Eritrea is located in the Horn of Africa, between latitudes 12°42′N and 18°2′N and longitudes 36°30′E to 43°20′E. It is bounded by the Sudan to the north and west, the Red Sea to the east, Ethiopia to the south and the Republic of Djibouti to the southeast  and The Eritrean WHO Country Office (WHO/ERI) to facilitate implementation of key strategic framework activities, including training of national staff in insecticide resistance monitoring techniques and initiating the GPIRM process following WHO’s guidelines; providing technical support in conducting VBD-related studies; giving guidance on malaria vector control based on eco-epidemiological strata, capacity building in malaria entomology and vector control and harmonizing mapping, data collection and reporting tools.In 2014, the current IVM Strategy 2015–2019) for Eritrea was developed with full consideration of the prevailing epidemiological situation in the country and the currently existing opportunities for vector control . The str–2019 forEritrea has embarked on efforts to implement the GPIRM process according to the WHO guidelines . HoweverThe NMCP in Eritrea has developed a guidance document for vector control interventions based on the prevailing malaria eco-epidemiological strata and socio-economic factors in the country  to proviLimited data on insecticide resistance profiles of vectors and their bionomics present invariable constraints to effective and sustainable scaled-up malaria vector control. Strong entomological teams at national and local levels are crucial to coordinate routine monitoring of resistance, data analysis and interpretation to inform policy decisions, translate policies and guidance into action. Strengthening and streamlining vector control efforts in response to the current eco-epidemiology of malaria and the challenge of insecticide resistance is needed. The country has embarked on capacity building in malaria entomology and vector control for public health officers in the MoH to support and provide expertise for evidence-based, operational implementation of the IVM strategy. To strengthen malaria vector control, entomological laboratories have been established and entomological monitoring sentinel sites set up in three highly malarious zones. Initial training of national staff in entomological monitoring and insecticide resistance surveillance was conducted in 2014 . FurtherConsidering the co-endemicities of different VBDs , efforts have been embarked upon to harmonize mapping, data collection and reporting tools. As the country re-orients towards malaria elimination, it is imperative that data collection is streamlined within the NMCP. In 2014, national data on the implementation on malaria vector control, including coverage of IRS and status of ownership and use of LLINs during the period 2008–2013, were collated . SelectiMobilization of requisite human and financial resources would require establishing intersectoral collaboration for decision-making in entomology and vector control. In this regard, linkage with external research and teaching institutions, including collaboration with local training institutes, such as Asmara College of Heath Sciences, is being launched. Such collaboration with external research institutions, with development of a database and establishing modalities for sharing and disseminating information, will facilitate determination of underlying resistance mechanisms that is vital for rational IRM strategies and to inform policy formulation. The implementation of these activities will be coordinated by the NMCP.Through implementation of effective interventions based on the IVM policy , the malPoor targeting of vector control interventions has adversely affected their efficacy in earmarked areas due to lack of harmonization in timing of combination of interventions and areas targeted . DiffereInsecticide susceptibility tests on malaria vectors and contact bioassays on both sprayed walls and bed nets have been intermittently conducted in Eritrea. This information is critical for planning purposes and should be collected regularly and professionally . SelectiThe recent mapping of lymphatic filariasis and schistosomiasis  coupled Well-established IVM programmes with adherence to the five key attributes demonstrate enhanced intervention impact and leverage additional resources . AccordiEritrea has successfully consolidated strategic frameworks for malaria vector control. Rational decision-making remains critical to ensure that interventions are effective and their choice is evidence-based to optimize the use of resources. Implementation of an effective IVM strategy requires proper collaboration, advocacy and consistent technical and financial capacity and support. An insecticide resistance monitoring and management plan involving a decision-making body would be essential for effective and sustainable insecticide-based vector control. A well-coordinated IVM approach supported by viable vector surveillance may offer greater benefits.


To the Editor: The World Health Organization recommends that persons who return from pilgrimages to the Middle East with acute severe respiratory infections be tested to determine the cause of infection; the aim is to identify infections with the Middle East respiratory syndrome coronavirus (MERS-CoV), which have been occurring in Saudi Arabia since 2012. Each year, >2.5 million persons from >180 countries, including 240,000 pilgrims from Europe, participate in Hajj, the Muslim pilgrimage to Mecca, Saudi Arabia. The gathering of mass numbers of persons during the Hajj increases the risk for the spread of respiratory infections among participants, and this risk has raised global concern that travelers returning from this pilgrimage could contribute to the international spread of MERS-CoV. During the 2012 and 2013 Hajj and Umrah (a minor pilgrimage) pilgrimages, no MERS cases in pilgrims were reported  . Therefore, it is likely that these 7 patients became infected while at the Hajj, as reported for patients during previous Hajj seasons (Our results showed that MERS-CoV was not detected in any of these patients, and our findings support those from reports investigating illness among 2013 Hajj pilgrims (Our preliminary data indicate that influenza virus infection was the cause of severe respiratory illness in 5 of 7 Austrian pilgrims returning from the 2014 Hajj. Because influenza is a serious and potentially life-threatening illness, seasonal influenza vaccination is recommended for Hajj pilgrims. Accurate and rapid testing for MERS-CoV and other respiratory viruses, including influenza, is essential for identifying persons who may be contagious and for timely and effective antiviral drug treatment and, thus, should be considered for pilgrims with severe respiratory illness.


Biological stability of drinking water refers to the concept of providing consumers with drinking water of same microbial quality at the tap as produced at the water treatment facility. However, uncontrolled growth of bacteria can occur during distribution in water mains and premise plumbing, and can lead to hygienic , aesthetic  or operational  problems. Drinking water contains diverse microorganisms competing for limited available nutrients for growth. Bacterial growth and interactions are regulated by factors, such as (i) type and concentration of available organic and inorganic nutrients, (ii) type and concentration of residual disinfectant, (iii) presence of predators, such as protozoa and invertebrates, (iv) environmental conditions, such as water temperature, and (v) spatial location of microorganisms . Water treatment and distribution conditions in water mains and premise plumbing affect each of these factors and shape bacterial community characteristics  in distribution systems. Improved understanding of bacterial interactions in distribution systems and of environmental conditions impact is needed for better control of bacterial communities during drinking water production and distribution. This article reviews (i) existing knowledge on biological stability controlling factors and (ii) how these factors are affected by drinking water production and distribution conditions. In addition, (iii) the concept of biological stability is discussed in light of experience with well-established and new analytical methods, enabling high throughput analysis and in-depth characterization of bacterial communities in drinking water. We discussed, how knowledge gained from novel techniques will improve design and monitoring of water treatment and distribution systems in order to maintain good drinking water microbial quality up to consumer’s tap. A new definition and methodological approach for biological stability is proposed. The A number of methods to assess bacterial growth-supporting properties of water have been developed during the last three decades to provide support to water utilities for the improvement of water treatment and distribution conditions in the context of biological stability . In addiThe objective of the present paper is to review existing knowledge, future challenges and emerging ideas that aim to achieve and monitor biological stability of drinking water in full-scale distribution systems. We examine existing definitions and approaches to address biological stability, highlight information gaps and propose an updated definition and a strategy for assessment and monitoring of biological stability.per se is not an issue, as long as no pathogenic organisms are present: there are bacteria in drinking water, even in relatively high numbers (103 to 106 cells/mL), without consequences on human health , or act as hosts for pathogenic bacteria such as Legionella pneumophila (Asellidae), worms  or snails  in distribution systems . An overview of primary conditions for bacterial growth and influencing factors on bacterial competition processes is given in Figure 2). Heterotrophic organisms constitute the majority of bacteria in drinking water, and draw their energy from degradation of organic carbon compounds. Due to bacterial elemental composition (ratio C:N:P), organic carbon is most often the growth limiting compound and thus is particularly important for biological stability. BOM comprises a broad spectrum of different organic carbon compounds ranging from simple organic acids and sugars to complex polymeric substances, such as humic compounds , are also required for heterotrophic growth, though in considerable smaller amounts than organic carbon  and iron-oxidizers  were associated with microbially induced corrosion processes (Nitrosomonas) or nitrite oxidizing bacteria . As discussed above, drinking water contains numerous different nutrients at very low concentrations of individual compounds . Dechloromonas and Acidovorax were most sensitive to monochloramine compared to highly resistant genera, such as Geobacter or Legionella. One possible consequence is that a lower variety of substrate is covered by the remaining bacterial community, meaning that more niches are available for bacterial growth once disinfectant is depleted. The available substrate pool can also be modified by reaction of residual disinfectants with NOM, resulting in formation of low molecular weight assimilable organic carbon compounds   present in drinking water distribution systems is still unclear. Bacteria represent the start of a trophic chain in drinking water, and are subject to predation by organisms, such as protozoa, which in turn are targets for invertebrates (igure 3) . Selectiigure 3) . The preotozoa/L , and hasotozoa/L . Moreoveotozoa/L .Figure 3), which has considerable influence on abundance, growth rates, and composition of the bacterial community . Biofilm cell density in drinking water distribution systems can vary significantly with cell numbers in the range of 104 to 108 cells/cm2, and with the amount of active biomass, as measured with ATP concentrations in the range of 102 to 104 pg ATP/cm2 , and distribution networks can contains as much as 3000 mg/m loose deposits (Rhodoferax sp. and Geobacter sp.). Particle sedimentation combined with biofilm formation and EPS production consolidates the sediment structure, which expands as long as sediments are not re-suspended during high hydraulic peaks . During sediment expansion, anoxic or anaerobic conditions are likely to be created, providing a selective environment for the growth of bacteria not found in the bulk water phase . The study showed that bacterial production in the bulk water constituted 37% of the total bacterial production in a model drinking water system. Recently, Mechanisms of interactions between biofilm, sediment, and bulk water bacteria have been investigated to estimate to which extent biofilms and sediments affect the bacterial community in bulk water in terms of abundance and community composition and structure, thus how these interactions might affect biological stability. Biofilms have long been considered as containing the largest fraction (up to 95%) of bacterial cells in drinking water distribution systems . HoweverFigure 4).Both water treatment and distribution conditions can significantly affect biological stability in drinking water distribution systems, by shaping bacterial community characteristics and/or modifying bacterial growth environment. Achieving biological stability therefore requires to (i) produce biological stable water, i.e., a water that does not support bacterial growth, considering the composition of its nutrients and its bacterial community, and (ii) distribute water in conditions that do not promote changes in the microbial community, in full-scale systems as well as in households (3–104 cells/mL), are often anaerobic and contain low organic nutrients  but potentially high methane  and ammonium concentrations  and relatively high concentrations of organics In recent years, application of membrane filtration methods rather than chemical additions to water, have been proposed as an alternative primary or secondary disinfection approach . Several3 cells/mL in the bulk water after 20 days residence time)and in the form of a biofilm (containing 8 × 103 cells/cm2) developed on PVC coupons in a biofilm reactor fed with the RO-treated water during 20 days. Bacterial cell numbers remained, however, extremely low in comparison with a similar system fed with the same tap water without prior RO treatment , showing a reduced growth potential of the water after RO filtration. In summary, membrane filtered water remains unstable due to the permeability of certain compounds through the membrane, the lowest growth potential being obtained by membranes retaining the highest proportion of nutrients .The use of membrane-based filtration methods, however, potentially leads to production of unstable water . While bIon exchange has also been proposed as an additional step in full-scale conventional drinking water treatment system to improve color of final water and biological stability e.g., . IEX is In many cases, a secondary disinfection is applied to the produced drinking water before distribution, typically with free chlorine, chlorine dioxide, or monochloramine . The aimFigure 4). Various factors influence microbial processes described in Section “A Deeper Look into Microbial Dynamics in Drinking Water,” including water temperature, residence time, hydraulic conditions, pipe material, and/or disinfectant residual decay. An overview of microbial dynamics in a drinking water pipeline section is provided in Figure 3.Water distribution conditions can have a considerable impact on biological stability . A single distribution system typically includes diverse materials such as metal pipes , cement, and/or synthetic polymers , on which widely different growth rates, bacterial densities, and community compositions were measured , on which organic and inorganic compounds adsorb, and which act as attachment sites, where bacteria are protected from disinfectant residuals , modifying the available nutrient source for bacteria to grow . Low water consumption periods result in low flow velocities or even water stagnation in reservoirs and parts of distribution systems, enabling particle deposition, increased residence time, and offering favorable conditions for bacterial growth to occur . Hydraulic peaks can cause release of hygienically relevant organisms , such as hygienic risks, deterioration of aesthetic aspects of water, malfunctioning of water installations, exceeding of legal guidelines, for e.g., heterotrophic plate counts . In this regard, specific attention is given to the influence of anticipated global warming on drinking water quality, as average water temperatures are expected to increase, concomitantly with longer periods at higher temperatures . Average water temperatures are generally higher in households than in the distribution system, sometimes reaching 20°C or more, due to pipes installed through heated rooms or nearby heat sources  and in a shift in bacterial community composition .There are three types of indicators for biological instability of a drinking water system. Firstly, indirect signs of instability for water utilities are customer complaints about taste, color, turbidity, and/or odor, and the deterioration or malfunctioning of water installations, due to fouling or (bio-) corrosion. Secondly, biological stability/instability is traditionally predicted based on growth-promoting properties of treated water and/or materials in contact with water, and associated with guideline values  of drinking water and are traditional indicators for biological stability . In esseInitial focus of these methods was on biodegradable organic carbon and included the assessment of AOC, initially proposed by Both AOC and BDOC methods focus primarily on organic carbon as the only growth-limiting substrate in drinking water. However, other compounds were identified as possible microbial growth controlling substances . To evaluate the distribution effect, the best approach is to directly characterize bacterial communities in the system. A change in bacterial abundance, viability and/or community composition can be considered as indicative for biological instability.Legionella, Mycobacterium, Pseudomonas aeruginosa, total coliforms, Enterococcus and E. coli ], respiratory activity , and subsequent detection with epifluorescence microscopy or flow cytometry  prediction and (ii) direct assessment of changes in bacterial community characteristics during water distribution. Both approaches have major advantages and drawbacks, as detailed in this section and summarized in One usual approach to evaluate biological stability is the prediction of changes that could potentially occur during water distribution, based on controlled laboratory-scale methods . As a result, prediction does not necessarily reflect what actually occurs during water distribution system, as many factors are likely to affect bacterial dynamics.Another approach to assess biological stability relies on measurement of changes in bacterial community characteristics directly in distribution systems , and is 4 to 1.3 ± 0.1 × 105 cells/mL; 5 to 4.3 ± 0.4 × 105 cells/mL; However, the absence of a defined toolbox and clear guideline values represents a major difficulty for water utilities to implement the direct approach. There is currently no specification of which parameters should be measured, as there is no unified method to describe and quantify microorganisms and particularly bacterial communities in water. Most likely different conclusions could be obtained from different methods, as they target part or all the bacterial community, and/or specific features related to bacterial activity or viability , and direct comparison of results from different studies is difficult. More importantly, there is a major knowledge gap, related to the “degree of acceptable change” or the degree of instability that would cause problems such as deterioration of water aesthetic aspects or of installations. During studies performed with flow cytometry, small changes in bacterial cell abundance have been detected in drinking water distribution systems  is detected in time or distance in the distribution system. Practically, current knowledge still does not allow for stating specific guideline values of acceptable change in the water quality.Figure 4). Consequently, we propose a comprehensive, integrated approach for the study of bacterial dynamics in drinking water distribution systems, requiring the use of both predictive methods in controlled laboratory tests for the assessment of water growth-promoting properties, and analytical methods for direct on-site spatial and temporal monitoring of bacterial communities . Parts of the comprehensive approach can be selected depending on the application, for e.g., regular water monitoring, collection of information toward targeted improvement of treatment or distribution conditions, or in-depth research (cf. details in section “Applications”).Achieving biological stability requires that (i) biological stable water is produced and (ii) distributed in conditions that do not promote uncontrolled changes in the microbial community, until the point of consumption . The sampling scheme should therefore include the treatment eﬄuent and various locations in the distribution system. •Assess temporal variations in bulk water quality in the treatment eﬄuent and at selected locations in the distribution system. Temporal variations should be assessed on both short (hour-to-week) time-scales to detect diurnal patterns and events  and long•Spatial and temporal investigations of biofilm and sediments should ideally also be included in the design of studies on microbial dynamics in full-scale distribution systems. These two phases are, however, more difficult to sample and therefore not ideal for high frequency monitoring. Sediment sampling can be achieved by distribution networks flushing . BiofilmThe analysis of water quality should be performed with a combination of methods to analyze microbial and environmental parameters. The following combination of methods is suggested:•Assessment of bacterial abundance with flow cytometry e.g., ;•Assessment of bacterial activity/viability with flow cytometry combined with viability-targeted fluorescent dye and complemented with ATP measurements e.g., ;•Detection of basic shifts in bacterial community composition by analysis samples with flow cytometric fingerprints ;•In-depth analysis of bacterial community composition with 16S rRNA-gene sequencing methods  and inorganic nutrients . AOC and BDOC tests in this regard are not used as growth predictive methods but rather as measurements of organic content of water, useful for interpretation of data collected with other analysis.Predictive methods are useful to provide supportive information for decision-making of water treatment and/or distribution conditions improvements. Tests should be applied to the treatment eﬄuent and on a selection of distribution locations to evaluate both properties of treated water and how these are affected by distribution conditions. Depending on the question addressed, laboratory tests can include:•Evaluation of the inherent growth potential of drinking water samples, by direct, untreated incubation of water under controlled laboratory conditions . Incubat•Identification of growth-limiting nutrients in treated water, by adding a selection of nutrients prior incubation of the treated water in controlled laboratory conditions ;•Evaluation of promoting properties of water for biofilm formation, using e.g., the BFR method;•Evaluation of growth-promoting properties of pathogenic organisms, alone or in competition with the indigenous bacterial community , 2012b;•Evaluation of growth-controlling properties of materials in contact with water e.g., .The extensive tests proposed can be applied individually or combined depending on targeted information. Below are listed a number of applications.Routine monitoring of drinking water quality is essential for surveillance of water quality. A number of chemical/environmental parameters  are nowadays used for water quality monitoring in real time with on-line apparatus. However, monitoring of microbial aspects remain conservative with the use of cultivation methods for both general water quality (HPC) and hygienically relevant organisms. Disadvantages of cultivation-based methods have been discussed in Section “How is Biological Stability Assessed?”, but essentially, results are only obtained few days after sampling, which does not allow for rapid detection of system failure  and for immediate corrective actions. Flow cytometry in this regard is an excellent candidate as rapid method for general microbial water quality monitoring, by providing results within 15 min . Moreove4 cells/mL. Flow cytometry enables the counting of bacterial cells down to concentrations of 100 cells/mL. Theoretically, this implies that FCM would enable to quantify bacterial growth occurring from the consumption of 0.01 μg C/L. In comparison, detection limits of AOC methods are usually in the range of 1–10 μg C/L, while the current analytical techniques for DOC measurements have higher detection limits .One key advantage of implementing monitoring of microbial parameters in water on a high-frequency basis is the sensitivity for detection of a change in drinking water quality or characteristics. Any change in chemical/environmental property of water would result in a change in the bacterial community . This change could be detected sensitively by flow cytometry, ATP or 16S rRNA-gene sequencing methods, while other methods for measuring chemical properties of water would not be sufficiently sensitive. As an example, an increase in organic components in water of 1 μg C/L would result in an increase of 10in situ and laboratory-scale analyses provide a basis for water treatment and distribution conditions evaluation. The extent of bacterial growth that water can support in bulk water and in biofilm can be assessed using growth potential tests without sample pre-treatment , including the occurrence of autotrophic growth or the interactions between bulk water, sediments, and biofilms. Similarly, growth potential tests would be of specific value to investigate water limitations in inorganic nutrients. Furthermore, systematic large-scale studies applying the combined methods would provide information related to the establishment of guideline values for a degree of acceptable change in drinking water distribution systems.The production and distribution of biological stable drinking water should be a non-negotiable goal for water utilities with the perspective of providing the same water quality to consumers than produced at the treatment facility. This can only be achieved by adequate monitoring and control of microbial processes during water treatment and distribution. Research in the past 30 years has significantly increased knowledge on factors driving changes in microbial water quality during drinking water distribution. These findings have led to implementation and improvement of new water treatment strategies, distribution system designs, and good operation and maintenance practices. However, there are still large knowledge gaps, and a change in microbial water quality is not systematically avoided. Emerging analytical and molecular methods, such as flow cytometry and high-throughput sequencing methods, open new ways for increased understanding of drinking water distribution pipeline ecology. These should be combined and implemented in unified approaches for the study of microbial dynamics in full-scale drinking water distribution systems. Moreover, new perspectives for drinking water quality monitoring are offered by novel analytical methods such as fully automated and on-line flow cytometric analysis.All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.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.