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1.  How can scientists bring research to use: the HENVINET experience 
Environmental Health  2012;11(Suppl 1):S2.
Health concerns have driven the European environmental policies of the last 25 years, with issues becoming more complex. Addressing these concerns requires an approach that is both interdisciplinary and engages scientists with society. In response to this requirement, the FP6 coordination action “Health and Environment Network” HENVINET was set up to create a permanent inter-disciplinary network of professionals in the field of health and environment tasked to bridge the communication gap between science and society. In this paper we describe how HENVINET delivered on this task.
The HENVINET project approached the issue of inter-disciplinary collaboration in four ways. (1) The Drivers-Pressures-State-Exposure-Effect-Action framework was used to structure information gathering, collaboration and communication between scientists in the field of health and the environment. (2) Interactive web-based tools were developed to enhance methods for knowledge evaluation, and use these methods to formulate policy advice. (3) Quantification methods were adapted to measure scientific agreement. And (4) Open architecture web technology was used to develop an information repository and a web portal to facilitate collaboration and communication among scientists.
Twenty-five organizations from Europe and five from outside Europe participated in the Health and Environment Network HENVINET, which lasted for 3.5 years. The consortium included partners in environmental research, public health and veterinary medicine; included medical practitioners and representatives of local administrations; and had access to national policy making and EEA and WHO expertise. Dedicated web-based tools for visualisation of environmental health issues and knowledge evaluation allowed remote expert elicitation, and were used as a basis for developing policy advice in five health areas (asthma and allergies; cancer; neurodevelopmental disorders; endocrine disruption; and engineered nanoparticles in the environment). An open searchable database of decision support tools was established and populated. A web based social networking tool was developed to enhance collaboration and communication between scientists and society.
HENVINET addressed key issues that arise in inter-disciplinary research on health and environment and in communicating research results to policy makers and society. HENVINET went beyond traditional scientific tools and methods to bridge the communication gap between science and policy makers. The project identified the need for a common framework and delivered it. It developed and implemented a variety of novel methods and tools and, using several representative examples, demonstrated the process of producing politically relevant scientific advice based on an open participation of experts. It highlighted the need for, and benefits of, a liaison between health and environment professionals and professionals in the social sciences and liberal arts. By adopting critical complexity thinking, HENVINET extended the traditional approach to environment and health research, and set the standard for current approaches to bridge the gap between science and society.
PMCID: PMC3388450  PMID: 22759502
2.  One World, One Health, One Medicine: An Assessment of Intersectoral Collaboration in Avian Influenza Control in Lagos State 
To assess the collaborative efforts in Avian Influenza control that could be harnessed for the control of other Zoonotic diseases.
The livestock sector is vital to the socio-economic development of Nigeria; it contributes about 9–10% of agricultural GDP. Livestock represents an important source of high quality animal protein providing about 36.5 % of total protein intake of Nigerians (1). Lagos State, located in the south-western part of Nigeria, has the smallest landmass (3577 sq. km) and the highest human population density (2519.75 per sq. km) in the Country (2). The State has a poultry population of 2.5 million birds and the largest outlet for poultry products with 207 Live bird markets, 375 poultry farms and a large number of poultry products consumers (3). Avian influenza (“bird flu”) is an infectious disease of birds caused by type A strains of the influenza virus. The infection is known to cross species barrier to infect humans (4). Between March 2006 and September 2007 Avian influenza (AI) outbreaks occurred in 99 poultry farms in Lagos State (3). The only human case of AI in Nigeria was detected at a health facility in Lagos in January 2007.
Following the AI outbreaks in Nigeria, a lot of human and material resources were devoted to the control of AI in the Health, Information and Veterinary sectors at all levels of administration. A desk review of the AI response activities and collaborative efforts at the State level was conducted.
The inter-ministerial State Steering Committee and State Technical Committee on Avian Influenza (STCAI) were established comprising of stakeholders in the Health, Information and Veterinary sectors drawn from public and private institutions. A number of interventions were carried out including formation of Public enlightenment, Health and Veterinary sub-committees to deal with sector-specific issues. Also, reconstitution and training of State and local council Epidemic Response Teams (ERT), training/retraining of State and local council Health, Information and Veterinary officers on Epidemic Preparedness and Response to Avian Influenza, establishment and equipping of desk offices in the State departments of Health, Veterinary and Information, and appointment of AI desk officers the local council level. These interventions facilitated the conduct of joint surveillance of poultry and live bird markets by stakeholders, joint outbreak investigation and response, joint sensitization of Human and animal Health workers on AI, joint public enlightenment and community/grassroots mobilization activities (including advocacy visits to local government council administrators, traditional leaders and trade union leaders) on Avian Influenza Control. All of these were instrumental in the quick containment of AI in Lagos State.
The collaboration between Health, Information and Veterinary departments following the AI epidemic helped to curb the disease within the State. A good structure has been put in place for control of AI that can be harnessed for the control of other Zoonotic diseases in the spirit of One World, One Health, One Medicine (OWOHOM).
PMCID: PMC3692840
Collaborate; Avian Influenza; Zoonotic
3.  Fat Dogs and Coughing Horses: K-12 Programming for Veterinary Workforce Development 
Journal of veterinary medical education  2013;40(4):10.3138/jvme.0313-053R.
Workforce development strategies to educate, inform, and diversify the veterinary profession of the future must begin with children in elementary school. This manuscript provides a description of the Fat Dogs and Coughing Horses program, which takes a multifaceted approach toward informing young students, beginning in first grade, about the interesting work and career opportunities available in the field of veterinary medicine. The program, a collaboration among Purdue University and Indiana public schools, is supported by a Science Education Partnership Award from the Office of Research Infrastructure Programs, a component of the National Institutes of Health. The overall goal of the program is to provide formal and informal educational opportunities for students, parents, teachers, and the public about the science involved in keeping people and their animals healthy. Examples of health concerns that impact both people and their pets are used to inform and excite children about careers in the health sciences. The program resulted in (1) curricula for students in grades 1–3, 6, and 9; (2) four children’s books and a set of collectible cards which highlight veterinarians, veterinary technicians, and research scientists who work with animals; and, (3) four traveling museum-grade exhibits. Preliminary assessment data has shown that the implementation of the curricula enhanced student science learning, and science attitudes and interests. The program provides evidence that partnerships among professionals in veterinary medicine and K-12 education can result in impactful workforce development programs.
PMCID: PMC3837546  PMID: 24052417
Workforce development; K-12 education; veterinary medicine; curricula; traveling exhibit; children’s books
4.  One Health Surveillance with Electronic Integrated Disease Surveillance System 
The objective of this demonstration is to show conference attendees how one-health surveillance in medical, veterinary and environmental sectors can be improved with Electronic Integrated Disease Surveillance System (EIDSS) using CCHF as an example from Kazakhstan.
EIDSS supports collection and analysis of epidemiological, clinical and laboratory information on infectious diseases in medical, veterinary and environmental sectors. At this moment the system is deployed in Kazakhstan at 150 sites (planned 271) in the veterinary surveillance and at 8 sites (planned 23) in human surveillance. The system enforces the one-health concept and provides capacity to improve surveillance and response to infectious disease including especially dangerous like CCHF.
EIDSS has been in development since 2005 and is a free-of-charge tool with plans for open-source development. The system development is based on expertise of a number of US and international experts including CDC, WRAIR, USAMRIID, et al.
Effective monitoring and control of zoonotic diseases requires integrated approach to surveillance in medical, veterinary and environmental sectors. Capability to rapidly collect and analyze information from these sectors is challenging due to diversity of different systems often used in these areas. EIDSS presented a unique integrated solution which allows collecting, sharing and analyzing data across these sectors. In those countries where this system is implemented both in human and veterinary surveillance (Georgia, Azerbaijan and Kazakhstan), it provides a unique opportunity to improve monitoring and control capability.
In Kazakhstan and other countries experts are working on creating and improving effective analysis methods. In particular a method of real-time control of CCHF situation was developed in Kazakhstan. It allows the assembly of raw data gathered at the lower level in, surveillance system throughout the country on CCHF cases in humans, assemble ticks vector surveillance campaigns and laboratory diagnostic results and analyze these data against population density. This gives a one-step tool to an epidemiologist to understand the situation and plan response at the national and regional level (see sample map). A quick link with the veterinary response teams allow to rapidly act with domestic animals prophylaxis measures.
Demonstration of the tool encouraging the One Health approach to the surveillance which is already in place in a number of countries provides an exclusive opportunity to review different aspects of its utilization in practice as well as discuss challenges and benefits of this method in resource limited environments.
EIDSS provides a capacity to improve one-health disease surveillance in human, veterinary and vector sectors by rapidly collecting, disseminating and analyzing data on infectious diseases. Particular methods which are being developed in Kazakhstan and other participating countries provide an instrument to epidemiologists to make decisions and more effectively plan response measures. Currently particular methods were tested for CCHF infection. It is planned to introduce methods for brucellosis and other infectious diseases of special interest in Central Asia and Caucasus Region.
PMCID: PMC3692852
EIDSS; electronic surveillance; one-health
5.  Synergies Between Human and Animal Health Syndromic Surveillance: Triple-S Outputs 
The objective of this study, based on the Triple-S project outputs, was to present the existing synergies between human and animal health syndromic surveillance (SyS) systems in Europe and a proposal to enhance this kind of collaboration.
The Triple-S project (Syndromic Surveillance Systems in Europe,, co-financed by the European Commission and involving twenty four organizations from fourteen countries was launched in September 2010 with the following objectives 1) performing an inventory of existing or planned SyS systems in Europe both in animal and public health, 2) building a network of experts involved in SyS 3) producing guidelines to implement SyS systems, 4) developing synergies between human and animal health SyS systems. The project is based on a cooperation between human and animal health experts, as supported by the One Health initiative [1].
A network of European experts involved in SyS was identified through the Triple-S inventory of SyS systems. A meeting of human health experts was organized back to back with a similar meeting with animal health experts in Paris, September 12–14, 2011. A joint session human/animal health allowed experts to discuss the interest of synergies between both sides. The objectives were to 1) encourage experience and knowledge transfer, 2) discuss what and how information should be shared between both sides to improve respective performances.
The results of the inventory of veterinary SyS systems showed that 40% of identified systems already shared or had planned to share information with human health sector. For these systems the collaboration between human and animal health sectors consisted in meetings on a regular basis to discuss the surveillance results.
Discussions during the Triple-S meeting highlighted two reasons for enhancing synergies between both sides. First human health and animal health epidemiologists face common statistical and epidemiological issues when dealing with SyS, i.e. use of data collected for other purpose than surveillance; standardization of clinical observations; syndrome definition; anomaly detection; interpretation of unspecific signals; response to alerts. Both sides have thus interest in sharing their experiences and knowledge to improve their respective systems.
Second, systems on both sides have similar objectives and target health events potentially threatening both animal and human populations: zoonoses, extreme weather events, environmental / food contamination, bioterrorist attack... For those events, animal population can play the role of sentinel for human population. Regular information flow between human and animal SyS could thus enhance the timeliness and sensitivity of SyS systems for detecting unexpected health events. Moreover, sharing information could help animal and human health experts to interpret and confirm unspecific signals, and confirm the impact of common health threats.
All participants of the meeting agreed on the idea to routinely share outputs of the systems but were sceptical about sharing raw data to perform global analysis.
Each aspect of the Triple-S project includes both human and animal health and will thus contribute to build natural collaboration between both sides. Such a project has demonstrated that scientific community is more and more willing to collaborate beyond the boundaries of these two health fields.
Synergies between human and animal health seem as necessary for syndromic surveillance as it is for traditional surveillance, if not more. They seem especially important for the detection of emerging zoonotic threats but not only. Sharing surveillance outputs from both sides would be the first step of collaboration but deeper synergy, e.g. sharing data and analyse them globally, could also be considered. Triple-S guidelines for implementation of SyS systems in Europe will take into account and promote synergies between human and animal health.
PMCID: PMC3692807
syndromic surveillance; synergy; early warning
6.  Geographic trends in research output and citations in veterinary medicine: insight into global research capacity, species specialization, and interdisciplinary relationships 
Bibliographic data can be used to map the research quality and productivity of a discipline. We hypothesized that bibliographic data would identify geographic differences in research capacity, species specialization, and interdisciplinary relationships within the veterinary profession that corresponded with demographic and economic indices.
Using the SCImago portal, we retrieved veterinary journal, article, and citation data in the Scopus database by year (1996–2011), region, country, and publication in species-specific journals (food animal, small animal, equine, miscellaneous), as designated by Scopus. In 2011, Scopus indexed 165 journals in the veterinary subject area, an increase from 111 in 1996. As a percentage of veterinary research output between 1996 and 2010, Western Europe and North America (US and Canada) together accounted for 60.9% of articles and 73.0% of citations. The number of veterinary articles increased from 8815 in 1996 to 19,077 in 2010 (net increase 66.6%). During this time, publications increased by 21.0% in Asia, 17.2% in Western Europe, and 17.0% in Latin America, led by Brazil, China, India, and Turkey. The United States had the highest number of articles in species-specific journals. As a percentage of regional output, the proportion of articles in small animal and equine journals was highest in North America and the proportion of articles in food animal journals was highest in Africa. Based on principal component analysis, total articles were highly correlated with gross domestic product (based on World Bank data). The proportion of articles in small animal and equine journals was associated with gross national income, research and development, and % urban population, as opposed to the proportion of food animal articles, agricultural output, and % rural population. Co-citations linked veterinary medicine with medicine in the United States, with basic sciences in Eastern Europe and the Far East, and with agriculture in most other regions and countries.
Bibliographic data reflect the demographic changes affecting veterinary medicine worldwide and provide insight into current and changing global research capacity, specialization, and interdisciplinary affiliations. A more detailed analysis of species-specific trends is warranted and could contribute to a better understanding of educational and workforce needs in veterinary medicine.
PMCID: PMC3699432  PMID: 23758872
Agriculture; Bibliometrics; Economics; Education; Journal; Medicine; Research publication
7.  “Working the System”—British American Tobacco's Influence on the European Union Treaty and Its Implications for Policy: An Analysis of Internal Tobacco Industry Documents 
PLoS Medicine  2010;7(1):e1000202.
Katherine Smith and colleagues investigate the ways in which British American Tobacco influenced the European Union Treaty so that new EU policies advance the interests of major corporations, including those that produce products damaging to health.
Impact assessment (IA) of all major European Union (EU) policies is now mandatory. The form of IA used has been criticised for favouring corporate interests by overemphasising economic impacts and failing to adequately assess health impacts. Our study sought to assess how, why, and in what ways corporations, and particularly the tobacco industry, influenced the EU's approach to IA.
Methods and Findings
In order to identify whether industry played a role in promoting this system of IA within the EU, we analysed internal documents from British American Tobacco (BAT) that were disclosed following a series of litigation cases in the United States. We combined this analysis with one of related literature and interviews with key informants. Our analysis demonstrates that from 1995 onwards BAT actively worked with other corporate actors to successfully promote a business-oriented form of IA that favoured large corporations. It appears that BAT favoured this form of IA because it could advance the company's European interests by establishing ground rules for policymaking that would: (i) provide an economic framework for evaluating all policy decisions, implicitly prioritising costs to businesses; (ii) secure early corporate involvement in policy discussions; (iii) bestow the corporate sector with a long-term advantage over other actors by increasing policymakers' dependence on information they supplied; and (iv) provide businesses with a persuasive means of challenging potential and existing legislation. The data reveal that an ensuing lobbying campaign, largely driven by BAT, helped secure binding changes to the EU Treaty via the Treaty of Amsterdam that required EU policymakers to minimise legislative burdens on businesses. Efforts subsequently focused on ensuring that these Treaty changes were translated into the application of a business orientated form of IA (cost–benefit analysis [CBA]) within EU policymaking procedures. Both the tobacco and chemical industries have since employed IA in apparent attempts to undermine key aspects of European policies designed to protect public health.
Our findings suggest that BAT and its corporate allies have fundamentally altered the way in which all EU policy is made by making a business-oriented form of IA mandatory. This increases the likelihood that the EU will produce policies that advance the interests of major corporations, including those that produce products damaging to health, rather than in the interests of its citizens. Given that the public health community, focusing on health IA, has largely welcomed the increasing policy interest in IA, this suggests that urgent consideration is required of the ways in which IA can be employed to undermine, as well as support, effective public health policies.
Please see later in the article for the Editors' Summary
Editors' Summary
The primary goal of public health, the branch of medicine concerned with the health of communities, is to improve lives by preventing disease. Public-health groups do this by assessing and monitoring the health of communities, by ensuring that populations have access to appropriate and cost-effective health care, and by helping to formulate public policies that safeguard human health. Until recently, most of the world's major public-health concerns related to infectious diseases. Nowadays, however, many major public-health concerns are linked to the goods made and marketed by large corporations such as fast food, alcohol, tobacco, and chemicals. In Europe, these corporations are regulated by policies drawn up both by member states and by the European Commission, the executive organ of the European Union (EU; an economic and political partnership among 27 democratic European countries). Thus, for example, the tobacco industry, which is widely recognized as a driver of the smoking epidemic, is regulated by Europe-wide tobacco control policies and member state level policies.
Why Was This Study Done?
Since 1997, the European Commission has been required by law to assess the economic, social (including health), and environmental consequences of new policy initiatives using a process called an “impact assessment” (IA). Because different types of IA examine the likely effects of policies on different aspects of daily life—a health impact assessment, for example, focuses on a policy's effect on health—the choice of IA can lead to different decisions being taken about new policies. Although the IA tool adopted by the European Commission aims to assess economic, environmental and social impacts, independent experts suggest this tool does not adequately assess health impacts. Instead, economic impacts receive the most attention, a situation that may favour the interests of large businesses. In this study, the researchers seek to identify how and why the EU's approach to IA developed. More specifically, the researchers analyze internal documents from British American Tobacco (BAT), which have been disclosed because of US litigation cases, to find out whether industry has played a role in promoting the EU's system of IA.
What Did the Researchers Do and Find?
The researchers analyzed 714 BAT internal documents (identified by searching the Legacy Tobacco Documents Library, which contains more than 10 million internal tobacco company documents) that concerned attempts made by BAT to influence regulatory reforms in Europe. They also analyzed related literature from other sources (for example, academic publications) and interviewed 16 relevant people (including people who had worked at the European Commission). This analysis shows that from 1995, BAT worked with other businesses to promote European regulatory reforms (in particular, the establishment of a business-orientated form of IA) that favor large corporations. A lobbying campaign, initiated by BAT but involving a “policy network” of other companies, first helped to secure binding changes to the EU Treaty that require policymakers to minimize legislative burdens on businesses. The analysis shows that after achieving this goal, which BAT described as an “important victory,” further lobbying ensured that these treaty changes were translated into the implementation of a business-orientated form of IA within the EU. Both the tobacco industry and the chemical industry, the researchers argue, have since used the IA to delay and/or weaken EU legislation intended to protect public health.
What Do These Findings Mean?
These findings suggest that BAT and its corporate allies have fundamentally altered the way in which EU policy is made by ensuring that all significant EU policy decisions have to be assessed using a business-orientated IA. As the authors note, this situation increases the likelihood that the EU will produce policies that favor big business rather than the health of its citizens. Furthermore, these findings suggest that by establishing a network of other industries to help in lobbying for EU Treaty changes, BAT was able to distance itself from the push to establish a business-orientated IA to the extent that Commission officials were unaware of the involvement of the tobacco industry in campaigns for IA. Thus, in future, to safeguard public health, policymakers and public-health groups must pay more attention to corporate efforts to shape decision-making processes. In addition, public-health groups must take account of the ways in which IA can be used to undermine as well as support effective public-health policies and they must collaborate more closely in their efforts to ensure effective national and international policy.
Additional Information
Please access these Web sites via the online version of this summary at
Wikipedia has a page on public health (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
More information on the European Union (in several languages), on public health in the European Union, and on impact assessment by the European Commission is available
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The World Health Organization provides information about the dangers of tobacco (in several languages)
The Smoke Free Partnership contains more information about smoking prevalence in Europe and about European policies to tackle the public health issues associated with tobacco use
For more information about tobacco industry influence on policy see the 2009 World Health Organization report on tobacco industry interference with tobacco control
PMCID: PMC2797088  PMID: 20084098
8.  Establishment of a One Health Surveillance Initiative in the CA/Baja CA Border Region 
To showcase One Border One Health, a binational, multidiscipli-nary initiative in the California/Baja California (CA/BC) border region whose aim is to reconfigure traditional species-specific approaches to surveillance for emerging and re-emerging pathogens.
The CA/BC border region encompasses a wide range of ecosystems, topography, dense urban areas, and agricultural developments that coexist in a limited geographic area and create numerous human-animal-environmental interfaces. The region is recognized for its high biodiversity, the presence of over 85 endangered plant and animal species, its importance on the Pacific migratory pathway, high levels of population mobility, and hosts the busiest international border in the world. These interfaces pose a significant risk to animal, human, and environmental health, as evidenced by frequent wildlife die offs, antibiotic resistant bacteria in streams, beach closures due to fecal contamination, pesticide toxicities, zoonotic infectious disease outbreaks, and vector borne diseases. In the marked absence of any organization comprehensively addressing the health risks posed by these complex interfaces and recognizing that these issues necessitate a binational, cross-sectoral One Health approach, the Early Warning Infectious Disease Surveillance Program (EWIDS) founded One Border One Health (OBOH) in 2011.
OBOH recognizes that early warning systems should systematically monitor animal, human, and environmental health and that early detection is key to control. Hence OBOH’s primary aim is to create and integrate early warning surveillance systems that gather data from disparate sources in order to protect and improve animal, human, and environmental health. This information can be used to inform decision makers about important public health events in the CA/BC border region.
OBOH is a unique multi-disciplinary initiative comprised of over 30 institutions from Mexico and 60 institutions from the United States, with representation from government, academia, non-profit, private and military sectors. Professionals with expertise in public health, veterinary medicine, ecology, biology, urban planning, epidemiology, wildlife health, and environmental health are working in concert rather than in the traditionally isolated human, environmental health, domestic animal and wildlife sectors. OBOH is actively seeking to translate One Health theory into practice through its diverse, binational network. This demonstration presents OBOH’s surveillance, informatics, and education activities, focusing on its strengths, challenges, and future directions.
To the authors’ knowledge this is the first trans-border regional network established to enhance cross border epidemiologic information exchange and surveillance using One Health concepts in North America. Despite the large disparities between health systems, cultures, languages, socioeconomics, politics, animal management strategies, industries and ecosystems in the CA/BC border region, professionals from diverse disciplines are dedicated to OBOH and to the creation of a sustainable integrated surveillance system. OBOH is building the infrastructure for an early warning system in the border region, while improving regional infectious disease surveillance capacity and educating a new cadre of students and professionals about the importance of a One Health approach. Challenges include identifying cross-sectoral/multi-disciplinary funding opportunities to support activities, systematically operationalizing One Health without such funding, identifying and involving partners from different sectors, promoting data exchange, and maintaining an equal understanding of One Health surveillance within the initiative as membership increases. This demonstration provides recommendations on how to initiate and sustain cross-border, multidisciplinary, cross-sectoral surveillance engagements in resource-constrained environments.
PMCID: PMC3692860
cross-border surveillance; emerging and re-emerging pathogens; One Health; collaboratives; early warning systems
9.  Translating stem cell therapies: the role of companion animals in regenerative medicine 
Veterinarians and veterinary medicine have been integral to the development of stem cell therapies. The contributions of large animal experimental models to the development and refinement of modern hematopoietic stem cell transplantation were noted nearly five decades ago. More recent advances in adult stem cell/regenerative cell therapies continue to expand knowledge of the basic biology and clinical applications of stem cells. A relatively liberal legal and ethical regulation of stem cell research in veterinary medicine has facilitated the development and in some instances clinical translation of a variety of cell-based therapies involving hematopoietic (HSC) and mesenchymal stem cells (MSC) as well as other adult regenerative cells and recently embryonic stem cells (ESC) and induced pluripotent stem cells (iPSC). In fact, many of the pioneering developments in these fields of stem cell research have been achieved through collaborations of veterinary and human scientists. This review aims to provide an overview of the contribution of large animal veterinary models in advancing stem cell therapies for both human and clinical veterinary applications. Moreover, in the context of the “One Health Initiative”, the role veterinary patients may play in the future evolution of stem cell therapies for both human and animal patients will be explored.
PMCID: PMC3670702  PMID: 23627495
Veterinary; stem cells; cell-based therapies; regenerative medicine
10.  Veterinary homeopathy: an overview. 
The Canadian Veterinary Journal  1999;40(8):592-594.
Complementary and alternative therapies, including homeopathy, have a definite place in veterinary medicine today. The public is demanding access to a full range of conventional and complementary therapies, and the best scenario is to have all therapies available, for there is a place and a need for all of them in the right situation. In my own practice, I use both alternative and conventional therapies, as well as referring patients to specialists, for services such as ultrasound and surgery. I believe that the wave of the future is to have veterinarians skilled in both complementary and conventional therapies, and to have veterinary practitioners who are well enough educated to be able to treat the majority of their patients, but who are willing to refer to the appropriate "specialist," if the case and the client demand it. Veterinarians are definitely becoming more aware of the need for and showing more interest in alternative medicine. There are currently several associations in North America for veterinarians with an interest in complementary therapies. In 1998, the International Veterinary Acupuncture Society (IVAS) boasted 1400 members, and the American Holistic Veterinary Medical Association (AHVMA) over 800 (1). There are professional courses in veterinary acupuncture, chiropractic, and homeopathy, all 150-200 hours in length, which provide a good basic understanding of these modalities. In most of these modalities, there is also advanced training. Conventional teaching institutions are recognizing the need to have veterinarians well versed in all aspects of veterinary medicine. Colorado State University has offered elective courses for students and on-site courses for practitioners on alternative therapies for 3 years (1). These are designed to teach veterinarians what the alternative modalities are, whether they are effective, and what it takes to become qualified to practise them. The overriding goal in most veterinarians' minds is to heal animals and provide the best in care, so that animals can live healthy productive lives. Education to keep up with new therapies and medications is paramount to this goal. It follows easily that knowledge of noninvasive treatments with few or no side effects that have the potential to heal animals should be welcomed, and homeopathy, as well as other complementary therapies, fits this description.
PMCID: PMC1539764  PMID: 12001344
11.  Bovine Respiratory Disease Questionnaire 
The Canadian Veterinary Journal  1981;22(10):295-299.
The purpose of the questionnaire was to gain an insight into the state of the art and to give direction to control measures for, and research into, bovine respiratory disease. Workers with an active interest in bovine respiratory disease were asked to respond. With the approval of the Committee on Large Animal Practice, it was distributed in Canada by the office of the Canadian Veterinary Medical Association to the veterinary colleges, the federal animal diseases research laboratories and the directors of provincial veterinary services for further distribution, and also to the Veterinary Infectious Diseases Organization and Connaught Laboratories.
Twenty-six questionnaries were returned and one letter was received in response. Replies were from 13 research scientists (including clinicians), six laboratory diagnosticians, four regulatory workers, three administrators, and one person of unknown specialization.
PMCID: PMC1789920  PMID: 7343068
12.  Inauguration of the Cameroonian Society of Human Genetics  
The conjunction of “hard genetics” research centers, with well established biomedical and bioethics research groups, and the exceptional possibility to hold the 6th annual meeting of the African Society of Human Genetics (AfSHG, 13th–15th March 2009) was an excellent opportunity to get together in synergy the entire Cameroonian “DNA/RNA scientists” . This laid to the foundation of the Cameroonian Society of Human Genetics (CSHG) that was privilege to hold its inaugural meeting in conjunction to the 6th annual meeting of the AfSHG. The theme was "Human Origin, Genetic Diversity and Health”. The AfSHG and CSHG invited leading African and international scientists in genomics and population genetics to review recent data and provide an understanding of the state-of-knowledge of Human Origin and Genetic Diversity. Overall one opening ceremony eight session, five keynote and guest speakers, 18 invited oral communications, 13 free oral communications, 43 posters and two social events could summarize the meeting. This year’s conference was graced by the presence of one Nobel Prize winner Dr Richard Roberts (Physiology and Medicine 1993). The meeting registered up to ten contributions of Cameroonian scientists from the Diaspora (currently in USA, Belgium, Gambia, Sudan and Zimbabwe). Such Diaspora participation is an opportunity to generate collaborations with home country scientists and ultimately turn the “brain drain” to “brain circulation” that could reduce the impact of the migration of health professional from Africa. Interestingly, the personal implication of the Cameroonian Ministry of Public Heath who opened the meeting in the presence of the Secretary General of the Ministry of Higher Education and a representative of the Ministry of Scientific Research and Innovation was a wonderful opportunity for advocacy of genetic issues at the decision-makers level. Beyond our expectation, a major promise of the Cameroonian government was the creation of the National Human Genome Institute. If this goal comes true, this will be a critical step to bring more genetics for the purpose of Public Health to the Cameroonian people. The sub-Saharan African Region needs significant capacity building in the broad area of basic research in general and Genetics (especially Human Genetics) in particular. In that respect, the existence and current activities of the AfSHG and its impact at the National levels in Africa, is a major development for the continent and an initiative that needs further encouragement from the international community.
PMCID: PMC2984290  PMID: 21532717
Human Genetics ;  Africa
13.  Eurocan plus report: feasibility study for coordination of national cancer research activities 
The EUROCAN+PLUS Project, called for by the European Parliament, was launched in October 2005 as a feasibility study for coordination of national cancer research activities in Europe. Over the course of the next two years, the Project process organized over 60 large meetings and countless smaller meetings that gathered in total over a thousand people, the largest Europe–wide consultation ever conducted in the field of cancer research.
Despite a strong tradition in biomedical science in Europe, fragmentation and lack of sustainability remain formidable challenges for implementing innovative cancer research and cancer care improvement. There is an enormous duplication of research effort in the Member States, which wastes time, wastes money and severely limits the total intellectual concentration on the wide cancer problem. There is a striking lack of communication between some of the biggest actors on the European scene, and there are palpable tensions between funders and those researchers seeking funds.
It is essential to include the patients’ voice in the establishment of priority areas in cancer research at the present time. The necessity to have dialogue between funders and scientists to establish the best mechanisms to meet the needs of the entire community is evident. A top priority should be the development of translational research (in its widest form), leading to the development of effective and innovative cancer treatments and preventive strategies. Translational research ranges from bench–to–bedside innovative cancer therapies and extends to include bringing about changes in population behaviours when a risk factor is established.
The EUROCAN+PLUS Project recommends the creation of a small, permanent and independent European Cancer Initiative (ECI). This should be a model structure and was widely supported at both General Assemblies of the project. The ECI should assume responsibility for stimulating innovative cancer research and facilitating processes, becoming the common voice of the cancer research community and serving as an interface between the cancer research community and European citizens, patients’ organizations, European institutions, Member States, industry and small and medium enterprises (SMEs), putting into practice solutions aimed at alleviating barriers to collaboration and coordination of cancer research activities in the European Union, and dealing with legal and regulatory issues. The development of an effective ECI will require time, but this entity should be established immediately. As an initial step, coordination efforts should be directed towards the creation of a platform on translational research that could encompass (1) coordination between basic, clinical and epidemiological research; (2) formal agreements of co–operation between comprehensive cancer centres and basic research laboratories throughout Europe and (3) networking between funding bodies at the European level.
The European Parliament and its instruments have had a major influence in cancer control in Europe, notably in tobacco control and in the implementation of effective population–based screening. To make further progress there is a need for novelty and innovation in cancer research and prevention in Europe, and having a platform such as the ECI, where those involved in all aspects of cancer research can meet, discuss and interact, is a decisive development for Europe.
Executive Summary
Cancer is one of the biggest public health crises facing Europe in the 21st century—one for which Europe is currently not prepared nor preparing itself. Cancer is a major cause of death in Europe with two million casualties and three million new cases diagnosed annually, and the situation is set to worsen as the population ages.
These facts led the European Parliament, through the Research Directorate-General of the European Commission, to call for initiatives for better coordination of cancer research efforts in the European Union. The EUROCAN+PLUS Project was launched in October 2005 as a feasibility study for coordination of national cancer research activities. Over the course of the next two years, the Project process organized over 60 large meetings and countless smaller meetings that gathered in total over a thousand people. In this respect, the Project became the largest Europe-wide consultation ever conducted in the field of cancer research, implicating researchers, cancer centres and hospitals, administrators, healthcare professionals, funding agencies, industry, patients’ organizations and patients.
The Project first identified barriers impeding research and collaboration in research in Europe. Despite a strong tradition in biomedical science in Europe, fragmentation and lack of sustainability remain the formidable challenges for implementing innovative cancer research and cancer care improvement. There is an enormous duplication of research effort in the Member States, which wastes time, wastes money and severely limits the total intellectual concentration on the wide cancer problem. There is a striking lack of communication between some of the biggest actors on the European scene, and there are palpable tensions between funders and those researchers seeking funds.
In addition, there is a shortage of leadership, a multiplicity of institutions each focusing on its own agenda, sub–optimal contact with industry, inadequate training, non–existent career paths, low personnel mobility in research especially among clinicians and inefficient funding—all conspiring against efficient collaboration in cancer care and research. European cancer research today does not have a functional translational research continuum, that is the process that exploits biomedical research innovations and converts them into prevention methods, diagnostic tools and therapies. Moreover, epidemiological research is not integrated with other types of cancer research, and the implementation of the European Directives on Clinical Trials 1 and on Personal Data Protection 2 has further slowed the innovation process in Europe. Furthermore, large inequalities in health and research exist between the EU–15 and the New Member States.
The picture is not entirely bleak, however, as the European cancer research scene presents several strengths, such as excellent basic research and clinical research and innovative etiological research that should be better exploited.
When considering recommendations, several priority dimensions had to be retained. It is essential that proposals include actions and recommendations that can benefit all Member States of the European Union and not just States with the elite centres. It is also essential to have a broader patient orientation to help provide the knowledge to establish cancer control possibilities when we exhaust what can be achieved by the implementation of current knowledge. It is vital that the actions proposed can contribute to the Lisbon Strategy to make Europe more innovative and competitive in (cancer) research.
The Project participants identified six areas for which consensus solutions should be implemented in order to obtain better coordination of cancer research activities. The required solutions are as follows. The proactive management of innovation, detection, facilitation of collaborations and maintenance of healthy competition within the European cancer research community.The establishment of an exchange portal of information for health professionals, patients and policy makers.The provision of guidance for translational and clinical research including the establishment of a translational research platform involving comprehensive cancer centres and cancer research centres.The coordination of calls and financial management of cancer research projects.The construction of a ‘one–stop shop’ as a contact interface between the industry, small and medium enterprises, scientists and other stakeholders.The support of greater involvement of healthcare professionals in translational research and multidisciplinary training.
In the course of the EUROCAN+PLUS consultative process, several key collaborative projects emerged between the various groups and institutes engaged in the consultation. There was a collaboration network established with Europe’s leading Comprehensive Cancer Centres; funding was awarded for a closer collaboration of Owners of Cancer Registries in Europe (EUROCOURSE); there was funding received from FP7 for an extensive network of leading Biological Resource Centres in Europe (BBMRI); a Working Group identified the special needs of Central, Eastern and South–eastern Europe and proposed a remedy (‘Warsaw Declaration’), and the concept of developing a one–stop shop for dealing with academia and industry including the Innovative Medicines Initiative (IMI) was discussed in detail.
Several other dimensions currently lacking were identified. There is an absolute necessity to include the patients’ voice in the establishment of priority areas in cancer research at the present time. It was a salutary lesson when it was recognized that all that is known about the quality of life of the cancer patient comes from the experience of a tiny proportion of cancer patients included in a few clinical trials. The necessity to have dialogue between funders and scientists to establish the best mechanisms to meet the needs of the entire community was evident. A top priority should be the development of translational research (in its widest form) and the development of effective and innovative cancer treatments and preventative strategies in the European Union. Translational research ranges from bench-to-bedside innovative cancer therapies and extends to include bringing about changes in population behaviours when a risk factor is established.
Having taken note of the barriers and the solutions and having examined relevant examples of existing European organizations in the field, it was agreed during the General Assembly of 19 November 2007 that the EUROCAN+PLUS Project had to recommend the creation of a small, permanent and neutral ECI. This should be a model structure and was widely supported at both General Assemblies of the project. The proposal is based on the successful model of the European Molecular Biology Organisation (EMBO), and its principal aims include providing a forum where researchers from all backgrounds and from all countries can meet with members of other specialities including patients, nurses, clinicians, funders and scientific administrators to develop priority programmes to make Europe more competitive in research and more focused on the cancer patient.
The ECI should assume responsibility for: stimulating innovative cancer research and facilitating processes;becoming the common voice of the cancer research community and serving as an interface between the cancer research community and European citizens, patients’ and organizations;European institutions, Member States, industry and small and medium enterprises;putting into practice the aforementioned solutions aimed at alleviating barriers and coordinating cancer research activities in the EU;dealing with legal and regulatory issues.
Solutions implemented through the ECI will lead to better coordination and collaboration throughout Europe, more efficient use of resources, an increase in Europe’s attractiveness to the biomedical industry and better quality of cancer research and education of health professionals.
The Project considered that European legal instruments currently available were inadequate for addressing many aspects of the barriers identified and for the implementation of effective, lasting solutions. Therefore, the legal environment that could shelter an idea like the ECI remains to be defined but should be done so as a priority. In this context, the initiative of the European Commission for a new legal entity for research infrastructure might be a step in this direction. The development of an effective ECI will require time, but this should be established immediately. As an initial step, coordination efforts should be directed towards the creation of a platform on translational research that could encompass: (1) coordination between basic, clinical and epidemiological research; (2) formal agreements of co-operation between comprehensive cancer centres and basic research laboratories throughout Europe; (3) networking between funding bodies at the European level. Another topic deserving immediate attention is the creation of a European database on cancer research projects and cancer research facilities.
Despite enormous progress in cancer control in Europe during the past two decades, there was an increase of 300,000 in the number of new cases of cancer diagnosed between 2004 and 2006. The European Parliament and its instruments have had a major influence in cancer control, notably in tobacco control and in the implementation of effective population–based screening. To make further progress there is a need for novelty and innovation in cancer research and prevention in Europe, and having a platform such as the ECI, where those involved in all aspects of cancer research can meet, discuss and interact, is a decisive development for Europe.
PMCID: PMC3234055  PMID: 22274749
14.  A Health Department’s Collaborative Model for Disease Surveillance Capacity Building 
Highlight one academic health department’s unique approach to optimizing collaborative opportunities for capacity development and document the implications for chronic disease surveillance and population health.
Public Health departments are increasingly called upon to be innovative in quality service delivery under a dwindling resource climate as highlighted in several publications of the Institute of Medicine. Collaboration with other entities in the delivery of core public health services has emerged as a recurring theme. One model of this collaboration is an academic health department: a formal affiliation between a health professions school and a local health department. Initially targeted at workforce development, this model of collaboration has since yielded dividends in other core public health service areas including community assessment, program evaluation, community-based participatory research and data analysis.
The Duval County Health Department (DCHD), Florida, presents a unique community-centered model of the academic health department. Prominence in local informatics infrastructure capacity building and hosting a CDC-CSTE applied public health informatics fellowship (APHIF) in the Institute for Public Health Informatics and Research (IPHIR) in partnership with the Center for Health Equity Research, University of Florida & Shands medical center are direct dividends of this collaborative model.
We examined the collaborative efforts of the DCHD and present the unique advantages these have brought in the areas of entrenched data-driven public health service culture, community assessments, program evaluation, community-based participatory research and health informatics projects.
Advantages of the model include a data-driven culture with the balanced scorecard model in leadership and sub-departmental emphases on quality assurance in public health services. Activities in IPHIR include data-driven approaches to program planning and grant developments, program evaluations, data analyses and impact assessments for the DCHD and other community health stakeholders.
Reports developed by IPHIR have impacted policy formulation by highlighting the need for sub county level data differentiation to address health disparities. Unique community-based mapping of Duval County into health zones based on health risk factors correlating with health outcome measures have been published. Other reports highlight chronic disease surveillance data and health scorecards in special populations.
Partnerships with regional higher institutions (University of Florida, University of North Florida and Florida A&M University) increased public health service delivery and yielded rich community-based participatory research opportunities.
Cutting edge participation in health IT policy implementation led to the hosting of the fledgling community HIE, the Jacksonville Health Information Network, as well as leadership in shaping the landscape of the state HIE. This has immense implications for public health surveillance activities as chronic disease surveillance and public health service research take center stage under new healthcare payment models amidst increasing calls for quality assurance in public health services.
DCHD is currently hosting a CDC-funded fellowship in applied public health informatics. Some of the projects materializing from the fellowship are the mapping of the current public health informatics profile of the DCHD, a community based diabetes disease registry to aid population-based management and surveillance of diabetes, development of a proposal for a combined primary care/general preventive medicine residency in UF-Shands Medical Center, Jacksonville and mobilization of DCHD healthcare providers for the roll-out of the state-built electronic medical records system (Florida HMS-EHR).
Academic health centers provide a model of collaboration that directly impacts on their success in delivering core public health services. Disease surveillance is positively affected by the diverse community affiliations of an academic health department. The academic health department, as epitomized by DCHD, is also better positioned to seize up-coming opportunities for local public health capacity building.
PMCID: PMC3692891
Academic Health Departments; collaborative model; health informatics projects
15.  Detection of a Swine Erysipelas Outbreak Using Enhanced Passive Surveillance 
To describe detection and response for an erysipelas outbreak in market swine in the United States (U.S.) using Food Safety and Inspection Service (FSIS) slaughter condemnation data, and coordination with the swine industry in an Enhanced Passive Surveillance (EPS) pilot project.
EPS is a comprehensive effort to complement other types of surveillance and provide early detection and situational awareness of significant endemic, zoonotic, and emerging diseases of livestock. The concept for EPS involves gathering syndromic and observational data from multiple animal health surveillance sources, including private practitioners, livestock markets, livestock harvest facilities, and veterinary diagnostic laboratories. A signal indicating a potential animal health event in one data stream can be corroborated in the other streams. For swine surveillance in the U.S., USDA-APHIS monitors the number of swine condemned for specific reasons. Likewise, industry practitioners share front-line clinical information within their practitioner network to detect anomalies. This case summary demonstrates the successful outcome of implementing an EPS pilot program through Federal and industry partnership.
FSIS Animal Disposition Reporting System swine condemnation data are monitored by USDA-APHIS Veterinary Services (VS) for several condemn conditions, including erysipelas, a bacterial disease of swine. Typically, slaughter condemnations for erysipelas are rare. The monitored data represent 83 market swine harvest facilities throughout the U.S. A modification of the ‘C3’CUSUM aberration detection method from the Early Aberration Reporting System (EARS) is applied to the data at both the slaughter plant level and at a larger multi-plant swine catchment basin level which represents separate swine production areas. The National Pork Board (NPB), a U.S. swine producer association, hosts a quarterly conference call with a sentinel network of swine veterinarians to exchange information about anomalies in swine health observed by practitioners. During mid-February 2012, several practitioners suspected a local increase in erysipelas in finishing swine. Absent baseline data on erysipelas occurrence nationally, the scope of the problem was uncertain. Following the call, the NPB in collaboration with VS attempted to validate the information reported by swine practitioners.
Beginning the week of January 8, 2012, VS analysts noted a slight increase in erysipelas CUSUM signaling activity in the greater Iowa catchment basin slaughter plants. During the seven-week period between January 8 and February 25, eight weekly plant-level CUSUM signals were observed, while the previous 36-week period yielded only fourteen plant-level signals. On average, 0.39 signals per week were noted in the weeks prior to the outbreak period while the corresponding average for the seven-week outbreak period was 1.14 plant signals per week. Seven of the eight plants that signaled during the outbreak period did not report large weekly spikes; however, the weekly accumulation of condemns were sufficient to trigger concern. Since the erysipelas signals were not large compared to the background noise, there was uncertainty whether the increased signaling activity truly represented a disease event. After cross validating the slaughter surveillance data with front line practitioner information, a swine health alert regarding the increase in erysipelas cases was issued by the American Association of Swine Veterinarians. Intervention measures were initiated as deemed appropriate by each private veterinarian.
This example of an Enhanced Passive Surveillance Program demonstrates use of independent streams of information from government and private industry to detect an outbreak of erysipelas in market swine. The communication process was facilitated by the NPB and the American Association of Swine Veterinarians, and coordinated with the industry resulting in an appropriate response to prevent swine losses at very early stages of the outbreak. Corroboration and validation between the two data streams (slaughter and practitioner) provided confidence that an outbreak was beginning and assisted the swine industry in decision making to enhance disease prevention activities. This type of early warning and response can reduce the cost of disease outbreaks to swine producers as well as provide confidence in the national disease status for swine in the United States.
PMCID: PMC3692889
animal health surveillance; Federal and industry partnership; enhanced passive surveillance; swine erysipelas
16.  RES6/466: Toward a Discovery Support System Based on Medical and Health Unifying Principles to Formulate Recombinant Hypotheses through Internet Online Databases 
Since the 17-century, scientists have been enquiring for the logical scientific principles of medicine and informatics, among other disciplines, encouraged by the instance of Newtonian physics. In the 20-century, the main principles of informatics were found making possible the development of present computers & Internet. However, very little research has been done seeking medical & health scientific principles, allowing among other functions, assistance in scientific hypotheses formation beside empirical data. One important effort on hypothesis formulation, has been the running of the Arrowsmith system of software and database search strategies at (Swanson & Smalheiser, 1997), which evokes hypothesis using the relational structure of the NCBI PubMed Internet on-line database (1966-). Nevertheless, although it uses a powerful logical mathematical method, it does not include any logical scientific principle from experimental or clinical medicine, & public health sciences. The aim of this paper is to give an outline of the design & rationale of an international collaborative research, complementary to Arrowsmith system, whose outcomes would be the logical basis of content seeking a more rational discovery support system.
Crucial fragmented information of multiple specialities and cognitive levels, synthesised by an international cross-disciplinary team or teams of experts, through a complex inductive method using Internet research facilities.
Expected Results:
Medical & health unifying principles that would perfect Arrowsmith target search strategies or other formal discovery computer-assisted systems to formulate recombinant hypotheses, using PubMed on-line database, and even in the future, the NCBI E-Biomed Internet on-line database proposed at (Varmus, Lipman & Brown, 1999). The perfected system will complete then, the premises to receive the benefits of Artificial Intelligence concepts & tools, to continue its improving.
PMCID: PMC1761764
Unifying Principles; Inductive Method; Hypothesis Formulation; Internet; Discover Support System
17.  The Good and the Bad of Poisonous Plants: an Introduction to the USDA-ARS Poisonous Plant Research Laboratory 
Journal of Medical Toxicology  2012;8(2):153-159.
This article provides an overview of the Poisonous Plant Research Laboratory (PPRL), about the unique services and activities of the PPRL and the potential assistance that they can provide to plant poisoning incidences. The PPRL is a federal research laboratory. It is part of the Agricultural Research Service, the in-house research arm of the U.S. Department of Agriculture. The mission of the PPRL is to identify toxic plants and their toxic compounds, determine how the plants poison animals, and develop diagnostic and prognostic procedures for poisoned animals. Furthermore, the PPRL’s mission is to identify the conditions under which poisoning occurs and develop management strategies and treatments to reduce losses. Information obtained through research efforts at the PPRL is mostly used by the livestock industry, natural resource managers, veterinarians, chemists, plant and animal scientists, extension personnel, and other state and federal agencies. PPRL currently has 9 scientists and 17 support staff, representing various disciplines consisting of toxicology, reproductive toxicology, veterinary medicine, chemistry, animal science, range science, and plant physiology. This team of scientists provides an interdisciplinary approach to applied and basic research to develop solutions to plant intoxications. While the mission of the PPRL primarily impacts the livestock industry, spinoff benefits such as development of animal models, isolation and characterization of novel compounds, elucidation of biological and molecular mechanisms of action, national and international collaborations, and outreach efforts are significant to biomedical researchers. The staff at the PPRL has extensive knowledge regarding a number of poisonous plants. Although the focus of their knowledge is on plants that affect livestock, oftentimes, these plants are also poisonous to humans, and thus, similar principles could apply for cases of human poisonings. Consequently, the information provided herein could be of benefit to healthcare providers for human cases as well.
PMCID: PMC3550245  PMID: 22367563
Poisonous plants; Chemical analysis; Plant toxins; Toxicology; Plant identification
18.  A Collaborative Epidemiological Investigation into the Criminal Fake Artesunate Trade in South East Asia  
PLoS Medicine  2008;5(2):e32.
Since 1998 the serious public health problem in South East Asia of counterfeit artesunate, containing no or subtherapeutic amounts of the active antimalarial ingredient, has led to deaths from untreated malaria, reduced confidence in this vital drug, large economic losses for the legitimate manufacturers, and concerns that artemisinin resistance might be engendered.
Methods and Findings
With evidence of a deteriorating situation, a group of police, criminal analysts, chemists, palynologists, and health workers collaborated to determine the source of these counterfeits under the auspices of the International Criminal Police Organization (INTERPOL) and the Western Pacific World Health Organization Regional Office. A total of 391 samples of genuine and counterfeit artesunate collected in Vietnam (75), Cambodia (48), Lao PDR (115), Myanmar (Burma) (137) and the Thai/Myanmar border (16), were available for analysis. Sixteen different fake hologram types were identified. High-performance liquid chromatography and/or mass spectrometry confirmed that all specimens thought to be counterfeit (195/391, 49.9%) on the basis of packaging contained no or small quantities of artesunate (up to 12 mg per tablet as opposed to ∼ 50 mg per genuine tablet). Chemical analysis demonstrated a wide diversity of wrong active ingredients, including banned pharmaceuticals, such as metamizole, and safrole, a carcinogen, and raw material for manufacture of methylenedioxymethamphetamine (‘ecstasy'). Evidence from chemical, mineralogical, biological, and packaging analysis suggested that at least some of the counterfeits were manufactured in southeast People's Republic of China. This evidence prompted the Chinese Government to act quickly against the criminal traders with arrests and seizures.
An international multi-disciplinary group obtained evidence that some of the counterfeit artesunate was manufactured in China, and this prompted a criminal investigation. International cross-disciplinary collaborations may be appropriate in the investigation of other serious counterfeit medicine public health problems elsewhere, but strengthening of international collaborations and forensic and drug regulatory authority capacity will be required.
Paul Newton and colleagues' international, collaborative study found evidence that counterfeit artesunate was being manufactured in China, which prompted a criminal investigation.
Editors' Summary
Malaria is one of the world's largest public health problems, causing around 500 million cases of illness and at least one million deaths per year (the estimates vary widely). The most serious form of malaria is caused by the parasite Plasmodium falciparum, which has become resistant to multiple drugs that had previously been the cornerstones of antimalarial regimens. One group of drugs for treating malaria, the artemisinin therapies including artesunate, are based upon a Chinese herb called qinghaosu; these have now become vital to the treatment of P. falciparum malaria. But counterfeit artesunate, containing none or too little (“subtherapeutic levels”) of the active ingredient, is a growing problem especially in South and East Asia. Fake artesunate is devastating for malaria control: it causes avoidable death, reduces confidence in the drug, and takes away profit from legitimate manufacturers. Of major concern also is the potential for subtherapeutic counterfeit artesunate to fuel the parasite's resistance to the artemisinin group of drugs.
Previous estimates have suggested that between 33% and 53% of artesunate tablets in mainland South East Asia are counterfeit. In this paper the authors report on an unprecedented international collaboration and criminal investigation that attempted to quantify and source counterfeit artesunate among some of the most malarious countries in Asia.
Why Was This Study Done?
Previous reports have identified the problem of fake artesunate, but as of yet there have been few reports on the potential solutions. Concerned health workers and scientists, the regional World Health Organization (WHO) office and the International Criminal Police Organization (INTERPOL) got together to discuss what could be done in May 2005 when it became clear the counterfeit artesunate situation was worsening in the Greater Mekong Sub-Region of South East Asia (comprising Cambodia, Lao People's Democratic Republic, Myanmar, Thailand, Vietnam, and Yunnan Province in the People's Republic of China). Their subsequent investigation combined the goals and methods of a range of concerned parties—police, scientists, and health workers—to identify the source of counterfeit artesunate in South East Asia and to supply the evidence to help arrest and prosecute the perpetrators.
What Did the Researchers Do and Find?
The researchers conducted forensic analyses of samples of genuine and counterfeit artesunate. They selected these samples from larger surveys and investigations that had been conducted in the region beginning in the year 2000. Genuine samples were supplied by a manufacturer to provide a comparator. The authors examined the physical appearance of the packages and subjected the tablets to a wide range of chemical and biological tests that allowed an analysis of the components contained in the tablets.
When comparing the collected packages and tablets against the genuine samples, the researchers found considerable diversity of fake artesunate in SE Asia. Sixteen different fake hologram types (the stickers contained on packages meant to identify them as genuine) were found. Chemical analysis revealed that all tablets thought to be fake contained no or very small quantities of artesunate. Other ingredients found in the artesunate counterfeit tablets included paracetamol, antibiotics, older antimalarial drugs, and a range of minerals, and there were a variety of gases surrounding the tablets inside the packaging. Biological analyses of pollen grains inside the packaging suggested that the packages originated in the parts of South East Asia along the Chinese border.
What Do these Findings Mean?
The results were crucial in helping the authorities establish the origin of the fake artesunate. For example, the authors identified two regional clusters where the counterfeit tablets appeared to be coming from, thus flagging a potential manufacturing site or distribution network. The presence of wrong active pharmaceutical ingredients (such as the older antimalarial drugs) suggested the counterfeiters had access to a variety of active pharmaceutical ingredients. The presence of safrole, a precursor to the illicit drug ecstasy, suggested the counterfeits may be coming from factories that manufacture ecstasy. And the identification of minerals indigenous to certain regions also helped identify the counterfeits' origin. The researchers concluded that at least some of the counterfeit artesunate was coming from southern China. The Secretary General of INTERPOL presented the findings to the Chinese government, which then carried out a criminal investigation and arrested individuals alleged to have produced and distributed the counterfeit artesunate.
The collaboration between police, public health workers and scientists on combating fake artesunate is unique, and provides a model for others to follow. However, the authors note that substantial capacity in forensic analysis and the infrastructure to support collaborations between these different disciplines are needed.
Additional Information.
Please access these Web sites via the online version of this summary at
The World Health Organization in 2006 created IMPACT—International Medical Products Anti-Counterfeiting Taskforce—with the aim of forging international collaboration to seek global solutions to this global challenge and in raising awareness of the dangers of counterfeit medical products. The task force membership includes international organizations, nongovernmental organizations, enforcement agencies, pharmaceutical manufacturers' associations, and drug and regulatory authorities. IMPACT's Web site notes that trade in counterfeit medicines is widespread and affects both developed and developing countries but is more prevalent in countries that have weak drug regulatory systems, poor supply of basic medicines, unregulated markets, high drug prices and/or significant price differentials. IMPACT holds international conferences and maintains a rapid alert system for counterfeit drugs.
The drug industry's anticounterfeit organization, Pharmaceutical Security Institute, works to develop improved systems to identify the extent of the counterfeiting problem and to assist in coordinating international inquiries. Its membership includes 21 large pharmaceutical companies.
The Web site of David Pizzanelli, a world expert on security holography, contains a PowerPoint presentation co-authored by Paul Newton that illustrates the different types of fake holograms found on fake artesunate packages, and their implications for artemisinin resistance (
PMCID: PMC2235893  PMID: 18271620
19.  Cost-Effectiveness of Preventing Loss to Follow-up in HIV Treatment Programs: A Côte d'Ivoire Appraisal 
PLoS Medicine  2009;6(10):e1000173.
Based on data from West Africa, Elena Losina and colleagues predict that interventions to reduce dropout rates from HIV treatment programs (such as eliminating copayments) will be cost-effective.
Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up (LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa.
Methods and Findings
We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infection-related drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health Organization criteria of <3× gross domestic product per capita (3× GDP per capita = US$2,823 for Côte d'Ivoire) as a plausible threshold for “cost-effectiveness.” The main results are based on a reported 18% 1-y LTFU rate. With full retention in care, projected per-person discounted life expectancy starting from age 37 y was 144.7 mo (12.1 y). Survival losses from LTFU within 1 y of ART initiation ranged from 73.9 to 80.7 mo. The intervention costing US$22/person/year (e.g., eliminating ART co-payment) would be cost-effective with an efficacy of at least 12%. An intervention costing US$77/person/year (inclusive of all the components described above) would be cost-effective with an efficacy of at least 41%.
Interventions that prevent LTFU in resource-limited settings would substantially improve survival and would be cost-effective by international criteria with efficacy of at least 12%–41%, depending on the cost of intervention, based on a reported 18% cumulative incidence of LTFU at 1 y after ART initiation. The commitment to start ART and treat HIV in these settings should include interventions to prevent LTFU.
Please see later in the article for the Editors' Summary
Editors' Summary
Acquired immunodeficiency syndrome (AIDS) has killed more than 25 million people since the first reported case in 1981. Currently, about 33 million people are infected with the human immunodeficiency virus (HIV), which causes AIDS. Two-thirds of people infected with HIV live in sub-Saharan Africa. HIV infects and destroys immune system cells, thereby weakening the immune system and rendering infected individuals susceptible to infection. There is no cure for HIV/AIDS. Combination antiretroviral therapy (ART), a mixture of antiretroviral drugs that suppress the replication of the virus in the body, is used to treat and prevent HIV infection. ART is expensive but major international efforts by governments, international organizations, and funding bodies have increased ART availability. According to World Health Organization (WHO) estimates, at least 9.7 million people in low- and middle-income countries need ART and as of 2007, 3 million of those people had reliable access to the drugs.
Why Was This Study Done?
Although ART is an effective treatment for HIV, a large number of individuals who initiate ART do not receive long-term follow-up care. These patients are generally sicker and have a worse long-term outcome than those who receive follow-up care. Loss to follow up (LTFU) is a significant problem that can undermine the benefits of expanding ART availability. Strategies to improve follow up concentrate on bringing lost patients back into the health care system, but such patients often die before they can be contacted. Prevention of LTFU might be a better strategy to improve HIV care after ART initiation, but there is little information available on which specific interventions might best accomplish this goal.
What Did the Researchers Do and Find?
Given the lack of reported data on the actual costs and effectiveness of LTFU prevention, the researchers used a model to estimate the clinical impact and cost-effectiveness of several possible strategies to prevent LTFU in HIV-infected persons receiving ART in Côte d'Ivoire, West Africa. The researchers used the previously developed Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model and combined it with data from a program of ART delivery in Abidjan, Côte d'Ivoire. They then projected the clinical benefits and the cost required to attain a given level of benefit (cost-effectiveness ratio) of different LTFU-prevention strategies from the perspective of the payer (the organization that pays all the medical costs to provide care). Several interventions were considered, including reducing costs to patients (eliminating patient co-payments and paying for transportation) and increasing services to patients at their visits (improving staff training in HIV care, and providing meals at clinic times). LTFU was predicted to cause a 54.3%–58.3% reduction in the estimated life expectancy beyond age 37; patients continuing HIV care were predicted to live a further 144.7 months whie those lost to follow up by 1 year after ART initiation were predicted to live only for a further 73.9–80.7 months. LTFU-prevention strategies in the Côte d'Ivoire were deemed to be cost-effective if they cost less than $2,823 (which is 3× gross domestic product per capita) per year of life saved. The efficacy and cost of the different LTFU-prevention strategies varied in the analyses; stopping ART co-payment alone would be cost-effective at a cost of $22/person/year if it reduced LTFU rates by 12%, while including all the LTFU-prevention strategies described would be cost-effective at $77/person/year if they reduced LTFU-rates by 41%.
What Do These Findings Mean?
The findings suggest that moderately effective strategies for preventing LTFU in resource-limited settings would improve survival, provide good value for money, and should be used to improve HIV treatment programs. Although modeling is valuable to explore the costs and effectiveness of LTFU-prevention strategies it cannot replace the need for more reported data to shed light on problems leading to LTFU and the prevention strategies required to combat it. Also, Côte d'Ivoire might not be representative of all West African countries or resource-limited settings. A similar analysis using data from other ART programs in different countries would be useful to provide better understanding of the impact of LTFU in HIV treatment programs. Finally, the research highlights the cost of second-line ART (a new antiretroviral drug combination for patients in whom first-line treatment fails) as a crucial issue. It is estimated that 5% of all people receiving ART in low- and middle-income countries receive second-line ART and these numbers are expected to increase. Second-line ART had major effects on cost-effectiveness, and a reduction in the cost of this treatment is critical in order to guarantee continued access to HIV treatment.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Gregory Bisson and Jeffrey Stringer
WHO provides information on disease prevention, treatment, and HIV/AIDS programs and projects
The UN Millennium Development Goals project site contains information on worldwide efforts to halt the spread of HIV/AIDS
aidsmap, a nonprofit, nongovernmental organization, provides information on HIV and supporting those living with HIV
PMCID: PMC2762030  PMID: 19859538
20.  Pharmacy Refill Adherence Compared with CD4 Count Changes for Monitoring HIV-Infected Adults on Antiretroviral Therapy 
PLoS Medicine  2008;5(5):e109.
World Health Organization (WHO) guidelines for monitoring HIV-infected individuals taking combination antiretroviral therapy (cART) in resource-limited settings recommend using CD4+ T cell (CD4) count changes to monitor treatment effectiveness. In practice, however, falling CD4 counts are a consequence, rather than a cause, of virologic failure. Adherence lapses precede virologic failure and, unlike CD4 counts, data on adherence are immediately available to all clinics dispensing cART. However, the accuracy of adherence assessments for predicting future or detecting current virologic failure has not been determined. The goal of this study therefore was to determine the accuracy of adherence assessments for predicting and detecting virologic failure and to compare the accuracy of adherence-based monitoring approaches with approaches monitoring CD4 count changes.
Methodology and Findings
We conducted an observational cohort study among 1,982 of 4,984 (40%) HIV-infected adults initiating non-nucleoside reverse transcriptase inhibitor-based cART in the Aid for AIDS Disease Management Program, which serves nine countries in southern Africa. Pharmacy refill adherence was calculated as the number of months of cART claims submitted divided by the number of complete months between cART initiation and the last refill prior to the endpoint of interest, expressed as a percentage. The main outcome measure was virologic failure defined as a viral load > 1,000 copies/ml (1) at an initial assessment either 6 or 12 mo after cART initiation and (2) after a previous undetectable (i.e., < 400 copies/ml) viral load (breakthrough viremia). Adherence levels outperformed CD4 count changes when used to detect current virologic failure in the first year after cART initiation (area under the receiver operating characteristic [ROC] curves [AUC] were 0.79 and 0.68 [difference = 0.11; 95% CI 0.06 to 0.16; χ2 = 20.1] respectively at 6 mo, and 0.85 and 0.75 [difference = 0.10; 95% CI 0.05 to 0.14; χ2 = 20.2] respectively at 12 mo; p < 0.001 for both comparisons). When used to detect current breakthrough viremia, adherence and CD4 counts were equally accurate (AUCs of 0.68 versus 0.67, respectively [difference = 0.01; 95% CI −0.06 to 0.07]; χ2 = 0.1, p > 0.5). In addition, adherence levels assessed 3 mo prior to viral load assessments were as accurate for virologic failure occurring approximately 3 mo later as were CD4 count changes calculated from cART initiation to the actual time of the viral load assessments, indicating the potential utility of adherence assessments for predicting future, rather than simply detecting current, virologic failure. Moreover, combinations of CD4 count and adherence data appeared useful in identifying patients at very low risk of virologic failure.
Pharmacy refill adherence assessments were as accurate as CD4 counts for detecting current virologic failure in this cohort of patients on cART and have the potential to predict virologic failure before it occurs. Approaches to cART scale-up in resource-limited settings should include an adherence-based monitoring approach.
Analyzing pharmacy and laboratory records from 1,982 patients beginning HIV therapy in southern Africa, Gregory Bisson and colleagues find medication adherence superior to CD4 count changes in identifying treatment failure.
Editors' Summary
Globally, more than 30 million people are infected with the human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS). Combinations of antiretroviral drugs that hold HIV in check (viral suppression) have been available since 1996. Unfortunately, most of the people affected by HIV/AIDS live in developing countries and cannot afford these expensive drugs. As a result, life expectancy has plummeted and economic growth has reversed in these poor countries since the beginning of the AIDS pandemic. Faced with this humanitarian crisis, the lack of access to HIV treatment was declared a global health emergency in 2003. Today, through the concerted efforts of governments, international organizations, and funding bodies, about a quarter of the HIV-positive people in developing and transitional countries who are in immediate need of life-saving, combination antiretroviral therapy (cART) receive the drugs they need.
Why Was This Study Done?
To maximize the benefits of cART, health-care workers in developing countries need simple, affordable ways to monitor viral suppression in their patients—a poor virologic response to cART can lead to the selection of drug-resistant HIV, rapid disease progression, and death. In developed countries, virologic response is monitored by measuring the number of viral particles in patients' blood (viral load) but this technically demanding assay is unavailable in most developing countries. Instead, the World Health Organization recommends that CD4+ T cell (CD4) counts be used to monitor patient responses to cART in resource-limited settings. HIV results in loss of CD4 cells (a type of immune system cell), so a drop in a patient's CD4 count often indicates virologic failure (failure of treatment to suppress the virus). However, falling CD4 counts are often a result of virologic failure and therefore monitoring CD4 counts for drops is unlikely to prevent virologic failure from occurring. Rather, falling CD4 counts are often used only to guide a change to new medicines, which may be even more expensive or difficult to take. On the other hand “adherence lapses”—the failure to take cART regularly—often precede virologic failure, so detecting them early provides an opportunity for improvement in adherence that could prevent virologic failure. Because clinics that dispense cART routinely collect data that can be used to calculate adherence, in this study the researchers investigate whether assessing adherence might provide an alternative, low-cost way to monitor and predict virologic failure among HIV-infected adults on cART.
What Did the Researchers Do and Find?
The Aid for AIDS Disease Management Program provides cART to medical insurance fund subscribers in nine countries in southern Africa. Data on claims for antiretroviral drugs made through this program, plus CD4 counts assessed at about 6 or 12 months after initiating cART, and viral load measurements taken within 45 days of a CD4 count, were available for nearly 2,000 HIV-positive adults who had been prescribed a combination of HIV drugs including either efavirenz or nevirapine. The researchers defined adherence as the number of months of cART claims submitted divided by the number of complete months between cART initiation and the last pharmacy refill before a viral load assessment was performed. Virologic failure was defined in two ways: as a viral load of more than 1,000 copies per ml of blood 6 or 12 months after cART initiation, or as a rebound of viral load to similar levels after a previously very low reading (breakthrough viremia). The researchers' statistical analysis of these data shows that at 6 and 12 months after initiation of cART, adherence levels indicated virologic failure more accurately than CD4 count changes. For breakthrough viremia, both measurements were equally accurate. Adherence levels during the first 3 months of cART predicted virologic failure at 6 months as accurately as did CD4 count changes since cART initiation. Finally, the combination of adherence levels and CD4 count changes accurately identified patients at very low risk of virologic failure.
What Do These Findings Mean?
These findings suggest that adherence assessments (based in this study on insurance claims for pharmacy refills) can identify the patients on cART who are at high and low risk of virologic failure at least as accurately as CD4 counts. In addition, they suggest that adherence assessments could be used for early identification of patients at high risk of virologic failure, averting the health impact of treatment failure and the cost of changing to second-line drug regimens. Studies need to be done in other settings (in particular, in public clinics where cART is provided without charge) to confirm the generalizability of these findings. These finding do not change that fact that monitoring CD4 counts plays an important role in deciding when to start cART or indicating when cART is no longer protecting the immune system. But, write the researchers, systematic monitoring of adherence to cART should be considered as an alternative to CD4 count monitoring in patients who are receiving cART in resource-limited settings or as a way to direct the use of viral load testing where feasible.
Additional Information.
Please access these Web sites via the online version of this summary at
This study is discussed further in a PLoS Medicine Perspective by David Bangsberg
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including an article about adherence to antiretroviral therapy
Information is available from Avert, an international AIDS charity, on HIV and AIDS in Africa and on providing AIDS drug treatment for millions
The World Health Organization provides information about universal access to HIV treatment (in several languages) and on its recommendations for antiretroviral therapy for HIV infection in adults and adolescents
The US Centers for Disease Control and Prevention also provides information on global efforts to deal with the HIV/AIDS pandemic (in English and Spanish)
PMCID: PMC2386831  PMID: 18494555
21.  SketchBio: a scientist’s 3D interface for molecular modeling and animation 
BMC Bioinformatics  2014;15(1):334.
Because of the difficulties involved in learning and using 3D modeling and rendering software, many scientists hire programmers or animators to create models and animations. This both slows the discovery process and provides opportunities for miscommunication. Working with multiple collaborators, a tool was developed (based on a set of design goals) to enable them to directly construct models and animations.
SketchBio is presented, a tool that incorporates state-of-the-art bimanual interaction and drop shadows to enable rapid construction of molecular structures and animations. It includes three novel features: crystal-by-example, pose-mode physics, and spring-based layout that accelerate operations common in the formation of molecular models. Design decisions and their consequences are presented, including cases where iterative design was required to produce effective approaches.
The design decisions, novel features, and inclusion of state-of-the-art techniques enabled SketchBio to meet all of its design goals. These features and decisions can be incorporated into existing and new tools to improve their effectiveness.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2105-15-334) contains supplementary material, which is available to authorized users.
PMCID: PMC4287593  PMID: 25359079
Molecular modelling; Animation; Collision detection
22.  What Do We Feed to Food-Production Animals? A Review of Animal Feed Ingredients and Their Potential Impacts on Human Health 
Environmental Health Perspectives  2007;115(5):663-670.
Animal feeding practices in the United States have changed considerably over the past century. As large-scale, concentrated production methods have become the predominant model for animal husbandry, animal feeds have been modified to include ingredients ranging from rendered animals and animal waste to antibiotics and organoarsenicals. In this article we review current U.S. animal feeding practices and etiologic agents that have been detected in animal feed. Evidence that current feeding practices may lead to adverse human health impacts is also evaluated.
Data sources
We reviewed published veterinary and human-health literature regarding animal feeding practices, etiologic agents present in feed, and human health effects along with proceedings from animal feed workshops.
Data extraction
Data were extracted from peer-reviewed articles and books identified using PubMed, Agricola, U.S. Department of Agriculture, Food and Drug Administration, and Centers for Disease Control and Prevention databases.
Data synthesis
Findings emphasize that current animal feeding practices can result in the presence of bacteria, antibiotic-resistant bacteria, prions, arsenicals, and dioxins in feed and animal-based food products. Despite a range of potential human health impacts that could ensue, there are significant data gaps that prevent comprehensive assessments of human health risks associated with animal feed. Limited data are collected at the federal or state level concerning the amounts of specific ingredients used in animal feed, and there are insufficient surveillance systems to monitor etiologic agents “from farm to fork.”
Increased funding for integrated veterinary and human health surveillance systems and increased collaboration among feed professionals, animal producers, and veterinary and public health officials is necessary to effectively address these issues.
PMCID: PMC1867957  PMID: 17520050
animal feed; animal waste; concentrated animal feeding operations; fats; human health effects; nontherapeutic antibiotics; rendered animals; roxarsone; zoonoses
23.  Fifteen Years after “Wingspread”—Environmental Endocrine Disrupters and Human and Wildlife Health: Where We are Today and Where We Need to Go 
Toxicological Sciences  2008;105(2):235-259.
In 1991, a group of expert scientists at a Wingspread work session on endocrine-disrupting chemicals (EDCs) concluded that “Many compounds introduced into the environment by human activity are capable of disrupting the endocrine system of animals, including fish, wildlife, and humans. Endocrine disruption can be profound because of the crucial role hormones play in controlling development.” Since that time, there have been numerous documented examples of adverse effects of EDCs in invertebrates, fish, wildlife, domestic animals, and humans. Hormonal systems can be disrupted by numerous different anthropogenic chemicals including antiandrogens, androgens, estrogens, AhR agonists, inhibitors of steroid hormone synthesis, antithyroid substances, and retinoid agonists. In addition, pathways and targets for endocrine disruption extend beyond the traditional estrogen/androgen/thyroid receptor–mediated reproductive and developmental systems. For example, scientists have expressed concern about the potential role of EDCs in increasing trends in early puberty in girls, obesity and type II diabetes in the United States and other populations. New concerns include complex endocrine alterations induced by mixtures of chemicals, an issue broadened due to the growing awareness that EDCs present in the environment include a variety of potent human and veterinary pharmaceutical products, personal care products, nutraceuticals and phytosterols. In this review we (1) address what have we learned about the effects of EDCs on fish, wildlife, and human health, (2) discuss representative animal studies on (anti)androgens, estrogens and 2,3,7,8-tetrachlorodibenzo-p-dioxin–like chemicals, and (3) evaluate regulatory proposals being considered for screening and testing these chemicals.
PMCID: PMC2721670  PMID: 18281716
endocrine disruptors; androgens; estrogens; dioxins; PCBs; Pharmaceuticals; Mixtures; Screening and Multigenerational Testing
24.  The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya: A Prospective Mixed-Methods Study 
PLoS Medicine  2012;9(8):e1001295.
Janet Turan and colleagues examined the role of the perception of women in rural Kenya of HIV-related stigma during pregnancy on their subsequent utilization of maternity services.
Childbirth with a skilled attendant is crucial for preventing maternal mortality and is an important opportunity for prevention of mother-to-child transmission of HIV. The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which we examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilization of maternity services.
Methods and Findings
From 2007–2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up (all women who tested HIV-positive or were not tested for HIV, and a random sample of HIV-negative women, n = 598); 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews with community health workers, childbearing women, and family members (n = 48) aided our interpretation of the quantitative findings and highlighted ways in which HIV-related stigma may influence birth decisions. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Our quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery (adjusted odds ratio = 0.44, 95% CI 0.22–0.88).
Our findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families.
Please see later in the article for the Editors' Summary.
Editors' Summary
Every year, nearly 350,000 women die from pregnancy- or childbirth-related complications. Almost all these “maternal” deaths occur in developing countries. In sub-Saharan Africa, for example, the maternal mortality ratio (the number of maternal deaths per 100,000 live births) is 500 whereas in industrialized countries it is only 12. Most maternal deaths are caused by hemorrhage (severe bleeding after childbirth), post-delivery infections, obstructed (difficult) labor, and blood pressure disorders during pregnancy. All these conditions can be prevented if women have access to adequate reproductive health services and if trained health care workers are present during delivery. Notably, in sub-Saharan Africa, infection with HIV (the virus that causes AIDS) is an increasingly important contributor to maternal mortality. HIV infection causes maternal mortality directly by increasing the occurrence of pregnancy complications and indirectly by increasing the susceptibility of pregnant women to malaria, tuberculosis, and other “opportunistic” infections—HIV-positive individuals are highly susceptible to other infections because HIV destroys the immune system.
Why Was This Study Done?
Although skilled delivery attendants reduce maternal mortality, there are many barriers to their use in developing countries including cost and the need to travel long distances to health facilities. Fears and experiences of HIV-related stigma and discrimination (prejudice, negative attitudes, abuse, and maltreatment directed at people living with HIV) may also be a barrier to the use of skilled childbirth service. Maternity services are prime locations for HIV testing and for the provision of interventions for the prevention of mother-to-child transmission (PMTCT) of HIV, so pregnant women know that they will have to “deal with” the issue of HIV when visiting these services. In this prospective mixed-methods study, the researchers examine the role of pregnant women's perceptions of HIV-related stigma in their subsequent use of maternity services in Nyanza Province, Kenya, a region where 16% women aged 15–49 are HIV-positive and where only 44.2% of mothers give birth in a health facility. A mixed-methods study combines qualitative data—how people feel about an issue—with quantitative data—numerical data about outcomes.
What Did the Researchers Do and Find?
In the Maternity in Migori and AIDS Stigma (MAMAS) study, pregnant women with unknown HIV status living in rural regions of Nyanza Province answered questions about their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal clinic visit. After delivery, the researchers asked the women who tested HIV positive or were not tested for HIV and a sample of HIV-negative women where they had delivered their baby. They also gathered qualitative information about barriers to maternity and HIV service use by interviewing childbearing women, family members, and community health workers. The qualitative data indicate that labor in a health facility is commonly viewed as being most appropriate for women with pregnancy complications such as HIV infection. Thus, women delivering at health facilities risk being labeled as HIV positive, a label that the community associates with promiscuity. The quantitative data indicate that women with more negative attitudes about HIV-positive people (higher perceptions of HIV-related stigma) at baseline were about half as likely to deliver in a health facility with a skilled attendant as women with more positive attitudes about people living with HIV.
What Do These Findings Mean?
These findings suggest that HIV-related stigma is associated with the low rate of delivery by skilled attendants in rural areas of Nyanza Province and possibly in other rural regions of sub-Saharan Africa. Community mobilization efforts aimed at increasing the use of PMTCT services may be partly responsible for the strong perception that delivery in a health facility is most appropriate for women with HIV and other pregnancy complications and may have inadvertently strengthened the perception that women who give birth in such facilities are likely to be HIV positive. The researchers suggest, therefore, that health messages should stress that delivery in a health facility is recommended for all women, not just HIV-positive women or those with pregnancy complications, and that interventions should be introduced to reduce HIV-related stigma. This combined strategy has the potential to increase the use of maternity services by all women and the use of HIV and PMTCT services, thereby reducing some of the most pressing health problems facing women and their children in sub-Saharan Africa.
Additional Information
Please access these Web sites via the online version of this summary at
The United Nations Children's Fund (UNICEF) provides information on maternal mortality, including the WHO/UNICEF/UNFPA/World Bank 2008 country estimates of maternal mortality; a UNICEF special report tells the stories of seven mothers living with HIV in Lesotho
The World Health Organization provides information on maternal health, including information about Millennium Development Goal 5, which aims to reduce maternal mortality (in several languages); the Millennium Development Goals, which were agreed by world leaders in 2000, are designed to eradicate extreme poverty worldwide by 2015
Immpact is a global research initiative for the evaluation of safe motherhood intervention strategies
Maternal Death: The Avoidable Crisis is a briefing paper published by the independent humanitarian medical aid organization Médecins Sans Frontières (MSF) in March 2012
Information is available from Avert, an international AIDS charity on all aspects of HIV/AIDS, including information on women, HIV and AIDS, on HIV and pregnancy, on HIV and AIDS stigma and discrimination, and on HIV in Kenya (in English and Spanish); Avert also has personal stories from women living with HIV
The Stigma Action Network (SAN) is a collaborative endeavor that aims to comprehensively coordinate efforts to develop and expand program, research, and advocacy strategies for reducing HIV stigma worldwide, including mobilizing stakeholders, delivering program and policy solutions, and maximizing investments in HIV programs and services globally
The People Living with Stigma Index aims to address stigma relating to HIV and advocate on key barriers and issues perpetuating stigma; it has recently published Piecing it together for women and girls, the gender dimensions of HIV-related stigma
The Health Policy Project has prepared a review of the academic and programmatic literature on stigma and discrimination as barriers to achievement of global goals for maternal health and the elimination of new child HIV infections (see under Resources)
More information on the MAMAS study is available from the UCSF Center for AIDS Prevention Studies
PMCID: PMC3424253  PMID: 22927800
25.  Ensuring the supply of highly qualified pharmaceutical scientist specialists in product development and related technologies for present and future needs—Report of the 2004 PT Section Education Committee 
AAPS PharmSciTech  2007;8(1):E125-E136.
The 2004 PT Section Education Committee took the first steps in addressing the charge: “How can the supply of highly qualified pharmaceutical scientist specialists in product development and related technologies that meet current and future needs be ensured?” This charge was borne out of earlier reports and current experience that suggest that: (1) graduate programs in colleges of pharmacy are increasingly failing to produce sufficient numbers of appropriately qualified specialists in product development and related pharmaceutical technologies and, (2) the pharmaceutical industry has been forced to recruit and train scientists from other disciplines. Surveys conducted by this committee of the membership (PT, PDD and BT sections) and a representative group of pharmaceutical executives validated this concern and provided insight into its nature and depth. For example, the executives reported that 50% or less of product development staff have undergraduate degrees in pharmacy and that 50% or less have advanced degrees in pharmaceutics/industrial pharmacy/pharmaceutical technology, yet entry-level PhDs in these specialties bring a better mix of skills to the product development table than their counterparts from other science disciplines, and that this advantage persist even after 4–6 years experience on the job. And the great difficulty in finding candidates with the, right mix of experience and education was also made clear by the surveys. Based in part on an analysis of these surveys, this committee developed an extensive list of issues to be addressed by future PT Education committees and AAPS. Among these were: (1) Should AAPS encourage and assist in the establishment of graduate programs in product development/technology and/or tracks in academic institutions whether or not they are colleges of pharmacy?, (2) Should AAPS develop standards for and qualify such educational programs and tracks? (3) How do we and what role should AAPS play in creating awareness in colleges and universities of our needs and the incentives to develop and maintain programs that meet these needs?, and (4) How can stable funding be provided for programs in product development and technology?
PMCID: PMC2750429

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