key: cord- -gcjgfasj authors: taylor, melanie r; agho, kingsley e; stevens, garry j; raphael, beverley title: factors influencing psychological distress during a disease epidemic: data from australia's first outbreak of equine influenza date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: gcjgfasj background: in australia experienced its first outbreak of highly infectious equine influenza. government disease control measures were put in place to control, contain, and eradicate the disease; these measures included movement restrictions and quarantining of properties. this study was conducted to assess the psycho-social impacts of this disease, and this paper reports the prevalence of, and factors influencing, psychological distress during this outbreak. methods: data were collected using an online survey, with a link directed to the affected population via a number of industry groups. psychological distress, as determined by the kessler psychological distress scale, was the main outcome measure. results: in total, people participated in this study. extremely high levels of non-specific psychological distress were reported by respondents in this study, with % reporting high psychological distress (k > ), compared to levels of around % in the australian general population. analysis, using backward stepwise binary logistic regression analysis, revealed that those living in high risk infection (red) zones (or = . ; % ci: . – . ; p < . ) and disease buffer (amber) zones (or = . ; % ci: . – . ; p < . ) were at much greater risk of high psychological distress than those living in uninfected (white zones). although prevalence of high psychological distress was greater in infected ei zones and states, elevated levels of psychological distress were experienced in horse-owners nationally. statistical analysis indicated that certain groups were more vulnerable to high psychological distress; specifically younger people, and those with lower levels of formal educational qualifications. respondents whose principal source of income was from horse-related industry were more than twice as likely to have high psychological distress than those whose primary source of income was not linked to horse-related industry (or = . ; % ci: . – . ; p < . ). conclusion: although, methodologically, this study had good internal validity, it has limited generalisability because it was not possible to identify, bound, or sample the target population accurately. however, this study is the first to collect psychological distress data from an affected population during such a disease outbreak and has potential to inform those involved in assessing the potential psychological impacts of human infectious diseases, such as pandemic influenza. equine influenza (ei) is an acute, highly contagious viral disease which can cause rapidly spreading outbreaks of respiratory disease in horses and other equine species. it does not infect humans, but the virus can be physically carried on skin, hair, clothing, shoes, vehicles and equipment and through these means can be transferred to other horses. in addition, the windborne virus can be spread for distances up to eight kilometres [ ] . australia's first outbreak of ei was confirmed on august th . it spread quickly, but was successfully contained within areas of south east queensland (qld) and new south wales (nsw). although ei was not detected in other states and territories, stringent disease control procedures were put in place across all states; which included an initial stand-still of all horse movements and subsequent controls, movement restrictions, and biosecurity requirements for many months. colour-coded ei control zones were established within four weeks of the outbreak based on the level of disease/disease risk in local government areas in nsw and qld; these were adjusted as the disease spread, and each zone was subject to specific controls and restrictions. controls were reviewed, revised and expanded as the disease spread, subsequent disease containment and control progressed, and policies were revised. these zones are summarized in table . further details of the outbreak, restrictions and zoning are available via the nsw department of primary industries (nsw dpi) and qld. department of primary industries and fisheries (dpi&f) websites [ , ] . throughout the outbreak movement restrictions and biosecurity requirements remained in place, and no (or very limited) horse movement was ever allowed from higher risk zones to lower risk zones. the disease outbreak peaked in late september/early october , and then declined as successful containment and eradication strategies were progressed. the last new infections of ei were reported in nsw and qld in december . in total approximately , properties and , horses were infected in nsw and at least , properties were infected in qld. current data from disease surveillance and monitoring indicates that no active infection is present in australia and the expectation is that australia will be declared ei-free by the end of june ; if successful, australia will be the only ei infected country in the world to have eradicated the disease. the effects of ei and the disease containment strategy, like the horse industry itself, were varied and wide-ranging; impacting differentially on horse owners and those involved with the horse industry nationally. in terms of support to those affected, a range of government financial support and assistance was available to many of those affected within a short time of outbreak onset and financial and economic impact surveys were undertaken to provide feedback information to government [ , ] . the current study was conducted to gain additional complementary data to assess the impacts of ei on the social and emotional health and well-being of those affected. this paper reports data collected on non-specific psychological distress; however the full study covered many other aspects, such as adherence to biosecurity requirements, effects of social isolation due to quarantine and the consequences of restricted horse movement and related activities, and sources of support and coping during the ei outbreak. although ei is endemic in europe and north america, and has occurred as an epidemic in many other countries, e.g. japan, south africa, hong kong, there does not appear to be any published studies of the human response or impacts to ei or the containment strategies used to control this disease. the best reported and documented research with respect to the impacts of infectious animal disease on people is the outbreaks of foot and mouth disease (fmd) in europe in , specifically in the uk and the netherlands. like ei fmd is highly contagious, however, fmd is considerably more serious as it spreads to cloven-hoofed animals including cattle, sheep, pigs, and goats. during these fmd outbreaks an estimated million livestock were slaughtered on , farms in the uk (including many healthy animals as part of 'contiguous' or preventative culling on farms neighbouring infected farms) and , were culled in the netherlands. the impacts on people were both economic, through financial/business/ tourism-related losses, and psychological, through the exposure to loss of livestock, culling, and massive funeral pyres; the latter affecting not just farmers and their families, but also the wider population through media images on the television and in newspapers [ ] [ ] [ ] . in the uk higher 'caseness' as indicated by the ghq(g) was found in farmers from 'badly infected' areas, although higher psychological morbidity generally, was reported in farmers from both badly infected and unaffected areas [ ] . in a study of dutch dairy farmers [ ] around half of those whose animals were culled suffered from severe post-traumatic distress, (identified as a clinical level of distress (> ) using the -item impact of events scale), with this reducing to one in five for those where severe restrictions were imposed (but where no culling took place). higher levels of symptoms were reported for older respondents and those with lower levels of education. in this same study differences in stress, psychological marginalization, and depression were reported for different disease control areas, i.e. culled-area, buffer-area, fmd-free area [ ] . within australia, the psycho-social impacts of ovine johne's disease have been reported [ , ] in which grief, depression, and anxiety were profound in affected farming families, and the perceptions of the management control process were the cause of much of the distress. government policies on quarantining and de-stocking farms were suspended due to mounting reports of severe emotional and social distress in farmers, rural families, and government employees implementing those policies. further discussion of stress in emergency responders managing agricultural emergencies is considered in an australian context in a recent paper by jenner [ ] . the role of the animal-human bond on disaster preparedness and response is key feature in human response to animal disease, and has been review by hall et al. [ ] . these authors report several aspects of relevance to the current study, including the increasing role of horses as companion animals as opposed to livestock or economic investments, and hence an increasing emotional attachment to horses; the complex and dynamic emotional relationship between farmers and their livestock; the emotional and practical implications of the animal-human relationship in disaster management, e.g. compliance with disaster management behaviours; and the impacts on veterinarians as first responders in disasters. these authors conclude that recognizing the mental health aspects of the animalhuman bond is an important factor in public health approaches to disaster and can be critical in promoting the resilience of individuals and communities. therefore, it follows that in an animal-centred disease outbreak, such as ei affecting horses, the potential disruption of the animal-human bond, and the impact of policies restricting animal-human activities could have significant implications for the mental health and resilience of those affected. the main outcome measure in this study is non-specific psychological distress, as measured by the kessler (k ) [ ] . the k was selected because it is a well-established and validated measure that is used widely in population research in australia, it has been used in population health surveys in nsw [ ] , victoria [ ] , south australia [ ] , and western australia [ ] , as well as in national surveys conducted by the australian bureau of statistics [ ] , and therefore state and national prevalence data are available as benchmarks for the current study. scores from the k can be related to levels of intervention, with 'very high' psychological distress scores (> ) equating to 'caseness' for a mental disorder, and high scores are strongly associated with current diagnosis of anxiety and depression using the composite international diagnostics interview (cidi) [ ] . the k is also able to discriminate between dsm-iv cases and non-cases, and is felt to be an appropriate screening instrument for identifying likely cases of anxiety and depression in the population providing a strong marker for a possible mental health disorder [ ] [ ] [ ] . in the most recent ( ) data from the nsw adult population health survey the combined proportion of the population reporting 'high' or above psychological distress ( - ) is . % [ ] . in addition, recent data collected in rural communities suggests that these figures may be slightly higher in rural-dwellers with 'very high' psychological distress of % reported in one study [ ] and . - . % for combined 'high'/'very high' psychological distress in another [ ] . these findings are of relevance in the current study as it would be expected that horse-ownership would be linked to rural and peri-urban residency. the questionnaire was designed for online completion to expedite data gathering whilst the ei outbreak was occurring. questionnaire content was reviewed by subject matter experts, including a small group of public health professionals in nsw health, some of whom had been involved in aiding the nsw dpi in disease control management, a nsw dpi local district control centre controller who was responsible for leading control activities, and representatives of the australian horse industry council (ahic). ethics approval for the study was obtained through the university of western sydney ethics committee. horse owners, and those involved in the horse industry were invited to take part in the study via an e-mail alerting service administered by ahic; using the national horse emergency contact database (hecd). the hecd had been established before the ei outbreak and was used as a network to contact and inform horse-owners during emergencies, such as bushfires, and disease outbreaks, and had been used previously by ahic for collecting financial impacts information relating to ei earlier in the outbreak. this alerting service was used regularly during the ei crisis to update registrants with government support agency communications and general industry news and support information. approximately , addressees were registered on the hecd; most were individuals, but also included were industry associations, pony clubs, and horse groups that would forward information to their own memberships nationally. horse owners in nsw were encouraged by the nsw dpi to register on the hecd to receive up to date information. the initial invitation to participate was sent to those registered on the hecd on november (week of the outbreak). the survey remained open until january (week of the outbreak) and date of completion was recorded with each respondent's data. the full survey comprised questions, covering a wide range of subject areas; those reported here include demographic information, i.e. gender, age category, number of children, highest level of educational qualification, and state/territory of residence. in addition, respondents were asked about the nature of their current main involvement with horses (i.e. their industry sector), for example breeding, equestrian, recreational; whether their primary source of income was linked to a horse-related industry, and their current colour-coded ei control zone. the main outcome measure reported in this paper is nonspecific psychological distress as measured by the k . this measure comprises questions that ask respondents how often they have experienced certain symptoms during the preceding four weeks and responses are scored on a scale of to depending on how frequently each symptom is experienced, where = 'none of the time', and = 'all of the time'. thus, a minimum score is , indicating no psychological distress, and a maximum score is , indicating the most severe level of psychological distress. scores on the k are subsequently categorized into four levels: low (scores of - ); moderate (scores of [ ] [ ] [ ] [ ] [ ] [ ] ; 'high' (scores of [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and 'very high' (scores of - ) [ ] . statistical analyses were undertaken using stata, version . ( ; stata corporation, college station, tx, usa). exploratory data analysis was conducted using frequency distributions for categorical variables. in the logistic model, a binary coding of psychological distress was used in which high psychological distress was a combination of 'high' + 'very high' levels of psychological distress = (i.e. k scores of or greater) and low psychological distress was a combination of 'low' + 'moderate' levels of psychological distress = (i.e. k scores of or less). simple binary logistic regression and backward stepwise multiple logistic analyses were performed to identify factors influencing high psychological distress. all variables were entered into the model initially, with the least significant variables removed one at a time until only significant variables associated with values of p ≤ . remained. all statistical tests were two-tailed. details of the study sample are presented in table . in total, , respondents completed the online survey, and of these % were male and % were female. more than a half of the sample ( . %) had no children. a total of . % of the respondents had a tertiary level educational qualification. just under half the sample ( %) was from nsw and respondents from qld. and victoria (vic) comprised a further % of the sample ( % from each state). thirty percent of respondents were in uninfected white zones in states other than nsw and qld, and % were from the restricted high ei risk red zones in nsw and qld. around three quarters of the sample ( %) were from three industry sectors; recreational, equestrian, and breeding/stud sectors ( %, %, and %, respectively). the majority of respondents ( %) reported that their main source of income was not linked to a horse-related industry. the prevalence of the four levels of psychological distress for the whole sample during the equine influenza outbreak; were % of respondents reporting 'low', % reporting 'moderate' % reporting 'high' and % reporting 'very high' levels of psychological distress. table shows the proportion of respondents reporting each level of psychological distress for the main socio-demographic survey variables. the greatest prevalence of 'very high' psychological distress was reported for those respondents in the - age group ( . %), and the lowest prevalence was reported by those in the - age group and those under ( . % and . %, respectively). with regard to the remaining socio-demographic variables the highest prevalence of 'very high' psychological distress were recorded for those respondents who were female, those with one child, and those with no formal educational qualifications. the prevalence of 'very high' psychological distress was greater for respondents from qld. ( . %) with prevalence figures being slightly lower for respondents from nsw ( . %) and lower again for respondents from vic. ( . %). the highest prevalence of 'very high' psychological distress was found for respondents in the red zones ( . %) and lowest for those in the white zones ( . %). those whose incomes were linked to horse-related industry had a higher prevalence of 'very high' psychological distress as compared to those whose main income was not linked to a horse-related industry ( . % and . %, respectively). the four levels of psychological distress were combined in pairs ('low'/'moderate', and 'high'/'very high') to form a binary variable for subsequent statistical modelling. figure shows the prevalence of this binary high/low psychological distress variable by ei disease zones. respondents in the red and amber zones reported higher prevalence of high psychological distress ( % and %, respectively) than those in the purple, green, and white zones ( %, %, and % respectively). univariate analysis table shows the unadjusted and adjusted odds ratios (ors) for the associations between high psychological distress (≥ ) and socio-demographic variables. total count = unless otherwise given in brackets respondents whose main source of income was from horse-related industry (unadjusted: or = . , % ci: . - . ; p < . ) were at a greater risk of high psychological distress than those whose main income was not linked to horse-related industry. chological distress as compared to those whose income was not linked to horse-related industry. the most salient finding was the extremely high prevalence of high psychological distress in horse owners and those involved in the horse industry during a serious horse disease epidemic; with just over one third ( %) reporting levels of psychological distress that might require some form of external intervention, and % of these ( % of the sample) reaching levels that may be considered indicative of 'caseness' for a dsm-iv disorder. the prevalence of 'very high' psychological distress in this sample was approaching five times the level reported in recent population health data for nsw [ ] . although this prevalence is very high, and there are some methodological reasons why this may be distorted (see study limitations section) it is certainly true that many of those impacted by ei, or the threat of ei, were subject to a wide range of acute stressors over a prolonged period, in a country where ei and such rigorous disease containment and control measures were previously unknown. analysis of psychological distress prevalence within the sample indicated that ei control zone was associated with psychological distress. those in the areas where ei was present had higher risk of high psychological distress, furthermore, risks were higher in areas where ei was more active or threatening and the tightest levels of disease control were in place (i.e. red and amber/buffer zones). this finding suggests high levels of anticipatory anxiety. interestingly, the risks of higher psychological distress in the purple zone (the region in nsw with the highest infection rate and earliest infections) were lower than in the red and amber areas. it is probable that during the timing of the study ei was more of a 'known' threat to those in the purple zone and there would have been some habituation to this risk; with many properties already infected or recovering, and restrictions eased due to the decision to let ei 'run its course' in this area at that time. as disease control (and zoning) was controlled at a state level there is geographical overlap and co-linearity of the australian state/territory and ei control zone variables in the analysis; in the backward stepwise multiple logistic analyses excluding one made the other a significant factor. with regard to analysis by state, it is interesting to note the high levels of psychological distress reported in victoria. although victoria remained ei-free throughout the crisis, those in victoria were . times more likely to experience high psychological distress that those in the other uninfected states. there are probably a number of reasons for this effect: victoria has a very extensive horse industry and is geographical closer to the infected states and diseaseaffected areas of nsw and qld; there is also a high level of business interaction and physical movement of horses between victoria and nsw and qld; hence the level of proximal threat and the degree of disruption caused by disease control measures was probably experienced more widely in victoria and may explain some of this effect. it should also be noted that although the remaining states were similarly uninfected, the overall prevalence of high psychological distress in horse owners from these states was still far higher than in the general population; those uninfected were not unaffected. one of the other primary factors associated with high psychological distress was age. those in the - year age category reported the highest levels of high psychological distress and analysis indicated that although prevalence and comparative risks of high psychological distress reduced from age onwards, these reduced risks only became reliably statistically significant from age onwards, and high psychological distress was certainly still a risk to those in the - year age category. this is interesting because in the general population psychological distress is generally found to peak around middle age ( s- s). the study findings would suggest that younger people were particularly vulnerable and were coping less well with the consequences of ei. the reasons for this finding are not known, however, research literature suggests that younger people form stronger emotional attachments to animals [ ] , and they are also less likely to be resilient or practised, generally, when it comes to coping with adversity. from the general perspective of mental and physical health of younger people, it is interesting to consider the longer term consequences and potential burden of disease if these effects are enduring. it is also interesting to note here the association of psychological distress with having children. data in this study indicated that those with one child had a . times higher risk of high psychological distress than those with no children; and having three or more children appeared somewhat protective against high psychological distress. national statistics would support the suggestion that those with one child are generally younger adults and/or are 'young families' with a single younger child. in this study, . % of respondents with one child reported 'very high' levels of psychological distress (k score = - ). given these family circumstances such a finding may be a cause for concern. the final main factor associated with high psychological distress was having an income linked to horse-related industry. unsurprisingly, those with financial dependence on an industry facing such a crisis are likely to be significantly predisposed to high psychological distress. nothing has been mentioned in this paper on the industry sector from which respondents had their main involvement with horses. these data were reported as part of the sample description to illustrate the wide range of industries affected by ei and the complexity of the affected population, and to provide information to aid interpretation of the findings. the nature of the potential psychological impacts of ei on those in different sectors is extremely diverse; from purely economic impacts, to loss of leisure pursuits and disruption of social networks, to loss of futures and missed opportunities in time, and many other possible impacts. time, money and support will help most recover but it is possible that some people's mental and physical health will be permanently affected by ei and some will take many years to recover professionally if they choose to stay in these professions. given the level of psychological distress noted in the current study, it is interesting to consider the distress that might result from other epizootics, such as foot and mouth disease or avian influenza, and how this, in turn, might compare to the levels of distress resulting from human epidemics, such as sars and h n /pandemic influenza. as mentioned earlier, foot and mouth disease in europe resulted in high distress and ptsd in farmers. in relation to avian influenza, most research has focussed on risk perception and compliance with protective behaviours. a large european union project on risk perception to avian influenza in europe and asia found moderate levels of risk perception generally, with higher levels of risk perception noted in europe, and in females in most countries [ ] . considering distress and risk perception in relation to human epidemics; it is likely that psychological distress would be far greater, since these present a threat to human health and possibly death. certainly data collected during and after sars in hong kong found high levels of fear and ptsd in health care workers and hospital workers [ ] , and high levels of emotional disturbance in the general population [ ] . research in canada found enduring psychological distress, up to two years following sars, among health care workers in a hospital that treated sars patients [ ] . this study had a number of limitations that should be considered when interpreting the data. firstly, the target population; those affected by ei, is a complex, disparate, and unknown population and therefore it is difficult to comment accurately on the representativeness of the sample. all horse owners in australia are not registered on a centralized database, or otherwise controlled, and as a result, it is not possible to know how extensive the database used to access horse owners (the hecd) was. however, at a national cross-industry sector level it is believed that this was the most extensive and efficient online route to access the target population, and the use of the database as a central communication facility during the ei crisis meant that this was likely to have been a focus for those affected during the epidemic. due to demographic bias in the sample, in particular, a greater proportion of women, and those with higher levels of education it is possible that there will be response bias in the data. the high proportion of women in the sample may be due to greater interest and participation in studies of this nature, but may also be indicative of higher levels of females in the target population, in particular in the main industry sectors represented in the data, i.e. recreational and equestrian. there are no official statistics on gender breakdown across horse industry sub-populations in australia, but data indicate that the equestrian sector in the united states may comprise % women [ ] , so the gender bias may reflect a gender bias in the main industry sub-populations in our data. research data often report higher levels of psychological distress in women in the general population, and therefore, the gender demographic bias in our study might have led to an elevation in the levels of psychological distress reported in this study. however, the absence of a significant gender effect in this study, and the close matching of relative levels of psychological distress in men and women with data from the australian general population, suggests that ei, as an adversity, was exerting similar impacts on males and females. it is not possible to explain why there was an absence of a gender difference in the data. one possible explanation is that the timing of the study; around the height of the ei epidemic, and the high levels of psycho-logical distress generally, reflected peak, acute levels in which gender differences were minimised and insignificant. as with gender bias, it is hard to define the impacts of education level in the data. unlike the (female) gender bias in the data, higher levels of education offer a protective effect (as identified in the univariate analysis). therefore, this source of bias may have led to an under-reporting of high psychological distress. again, it is not possible to define or quantify the extent of this. finally, the use of an online survey imposes potential limitations. it is probable that the study findings under-represent the responses of those in certain demographics, e.g. those who are less educated (as noted), those less affluent, and older respondents. not all horse owners would have access to the internet, and online survey methodology is relatively uncontrolled, e.g. the sample was self-selected and therefore may be more prone to response bias than a sample that was randomly selected or otherwise controlled. also, those experiencing higher distress may have been more motivated to respond. the extent of this response bias on the data cannot be accurately estimated, however, in anticipation of potential response bias, actions were taken to ensure that the study was presented to potential respondents in a way that would minimize such effects; e.g. the study was presented as independent of any industry group or government organization and it was clearly identified as a university research study. it was hoped that such presentation of the study would reduce political or self-interest motivation for completing the study. despite some methodological limitations, this study was able to determine the psychological impact of australia's first outbreak of equine influenza on a substantial sample of horse owners and those involved in horse-related industry. study findings indicated that this affected population had highly elevated levels of psychological distress and that, although prevalence of high psychological distress was greater in infected ei control zones and states, elevated levels of psychological distress were experienced in horse-owners nationally, and not just in areas where equine influenza was present. statistical analysis indicated that certain groups were more vulnerable to high psychological distress; specifically younger people, those with no formal educational qualifications, and those whose main income was linked to a horse-related industry. findings from this study generate further questions: what were the determinants of elevated psychological distress? was it the risk of the disease itself, e.g. fear of the disease, or concern for horses? was it the social and emotional impacts of disease control measures and restrictions, e.g. social isolation, quarantine, loss of freedom or control, stigma of being 'infected'? was it loss of income or sporting aspirations? more importantly, how enduring is this elevated psychological distress, and what are the longer term mental or physical health consequences for those affected? the latter is of critical importance given the increased prevalence of high psychological distress reported in young people in this study. some of these questions can be addressed using additional data collected in the wider study; however, the issue of enduring psychological distress will require further assessment. publish with bio med central and every scientist can read your work free of charge online equine influenza fact sheet: queensland government department of primary industries and fisheries equine influenza outbreak: queensland government department of primary industries and fisheries australian horse industry council: equine influenza impact study results australian horse industry council: follow-up equine influenza impact study impact of the foot-andmouth disease outbreak in britain: implications for rural studies the british foot and mouth crisis: a comparative study of public risk perceptions, trust and beliefs about government policy in two communities psychological impact of the animal-human bond in disaster preparedness and response psychological impact of foot-and-mouth disease on farmers impact of a foot and mouth disease crisis on post-traumatic stress symptoms in farmers the psychological impact of the foot and 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emerging infectious diseases fear of severe acute respiratory syndrome (sars) among health care workers factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in toronto equines and their human companions this study was funded by nsw health. the authors would like to acknowledge and thank g. barry smyth and the australian horse industry council for the support they provided for this study at such a challenging time; both their subject-matter expertise and practical assistance in accessing horse owners. we would also like to thank a number of horse industry groups for supporting the study, in particular, harness racing australia, the equestrian federation of australia, equine veterinarians australia, and the australian racing board. we would like to thank dr paul armstrong and staff at nsw health for their comments on the survey design. the authors declare that they have no competing interests. mt was involved in all aspects of the research project; design, conducting the research, data handling, exploratory analysis, drafting and editing the paper. gs, and br assisted with the design of the study and provided input in all aspects of the review, data interpretation and editing of the paper. ka conducted the statistical analysis and contributed to the drafting and review of the paper. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- - hu k y authors: nhan, charles; laprise, réjean; douville-fradet, monique; macdonald, mary ellen; quach, caroline title: coordination and resource-related difficulties encountered by quebec's public health specialists and infectious diseases/medical microbiologists in the management of a (h n ) - a mixed-method, exploratory survey date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: hu k y background: in quebec, the influenza a (h n ) pandemic was managed using a top-down style that left many involved players with critical views and frustrations. we aimed to describe physicians' perceptions - infectious diseases specialists/medical microbiologists (idmm) and public health/preventive medicine specialists (phpms) - in regards to issues encountered with the pandemics management at the physician level and highlight suggested improvements for future healthcare emergencies. methods: in april , quebec idmm and phpms physicians were invited to anonymously complete a web-based learning needs assessment. the survey included both open-ended and multiple-choice questions. descriptive statistics were used to report on the frequency distribution of multiple choice responses whereas thematic content analysis was used to analyse qualitative data generated from the survey and help understand respondents' experience and perceptions with the pandemics. results: of the respondents, . % reported difficulties or frustrations in their practice during the pandemic. the thematic analysis revealed two core themes describing the problems experienced in the pandemic management: coordination and resource-related difficulties. coordination issues included communication, clinical practice guidelines, decision-making, roles and responsibilities, epidemiological investigation, and public health expert advisory committees. resources issues included laboratory resources, patient management, and vaccination process. conclusion: together, the quantitative and qualitative data suggest a need for improved coordination, a better definition of roles and responsibilities, increased use of information technologies, merged communications, and transparency in the decisional process. increased flexibility and less contradiction in clinical practice guidelines from different sources and increased laboratory/clinical capacity were felt critical to the proper management of infectious disease emergencies. on june th, , the world health organization (who) declared that the circulating influenza a (h n ) strain had reached the pandemic level; [ ] canada launched, as planned, a top-down pandemic response [ , ] . as healthcare management is a provincial responsibility, this response was carried out by provinces and territories; each assuming coordination among healthcare system stakeholders within their respective jurisdictions. regional agencies were responsible for the implementation at the local level. overall, the canadian response was based on the who framework, which outlines essential aspects for an effective response, and included components of surveillance, healthcare response, public health intervention, communication, and command. communication, amongst all aspects of an effective public health response [ ] [ ] [ ] , was identified as a key element: to share evidence, to aid in risk assessment, healthcare planning, and public health responses but also to encourage changes in behaviors and to convey messages [ , ] . in the province of quebec, the vast majority of practicing physicians are members of their respective disciplinary association [ ] . the quebec's college of physicians is legally responsible to ensure physicians' competence [ ] and requires that these associations provide their members with continuing medical education (cme) focused on societal needs and in agreement with canadian accreditation standards [ ] . in line with this mandate and in the face of public criticisms [ ] and members' frustrations with the overall ph n management, quebec associations of infectious diseases and medical microbiologists (ammiq) and of public health and preventive medicine (amsscq) surveyed their members in preparation for a joint, interdisciplinary cme activity, to identify learning needs as to who guidelines for effective healthcare emergencies response and perceived implementation issues as experienced during the influenza a (h n ) pandemic (ph n ). there is scant literature about physicians' perceptions about healthcare system's management of ph n [ , ] . we report the results of a secondary analysis of this exploratory survey, describing ammiq and amsscq members' perceptions of critical issues in regards to pandemic management, and highlight suggested improvements. infectious diseases/medical microbiologists (idmm) and public health/preventive medicine specialists (phpms) who were active members of either ammiq or amsscq were eligible to participate. two authors (cq and mdf), involved in the management and implementation of the pandemic response at the provincial, regional, and local levels, drafted a webbased questionnaire to document physicians' perceptions on the ph n response. items on the questionnaire reflected the authors' respective medical-specialty expert knowledge of the guidelines as well as literature on effective healthcare emergencies interventions. this drafted questionnaire was then reviewed with members of each association's cme committee ( for ammiq and for amsscq). the final questionnaire was composed of broad questions, each with sub-questions. the first question asked whether participants were involved in the ph n management (y/n). the second question used a set of multiple-choice drop-down menus and asked participants to describe their practice profile: specialty, practice field and setting, and type of health care region. free text fields allowed respondents who chose "other" to further describe their practice profile. the third question aimed to document types of difficulties/frustrations, if any, physicians encountered in their practice during the ph n episode. a checklist of items grouped in categories was provided and participants were asked to check off all that applied. each category addressed a different aspect of the ph n management: at the clinical and public health level, overall crisis management, communication process, vaccination, overall management of the two pandemic waves, and issues not covered in previous categories. within each category, physicians had the opportunity to report on issues not previously listed. at the end of each category, they were also invited to describe, in free text, issues experienced. the final question was open-ended and asked participants to suggest improvements for the management of future ph n -like healthcare emergencies. there were no mandatory questions. the survey url link was e-mailed on april th and th, to members of both associations. e-mail reminders were sent twice to participants and the survey was closed on may nd, . participation was voluntary and both respondents and non-respondents, remained anonymous. data (quantitative, qualitative) were analysed to describe and understand critical issues and suggest improvements associated with the pandemic response implementation as perceived by respondents. descriptive statistics were used to summarize responses to multiple-choice questions. thematic content analysis was used for qualitative data [ ] . for this qualitative analysis, open coding was used to break down free text into small units (meaning units) that conveyed distinct messages, maintaining participant's original wording. codes were assigned to these meaning units. the data was then reorganized using these codes as the unit of analysis. the codes were organized into thematic categories. these categories, created by one investigator (cn), were then reviewed and reworked by two others (cq, rl), using team consensus. the categories were then ordered into analytic trees (themes) with branches (subthemes) grouping the categories into higher and lower levels of conceptual abstraction. finally, using concept mapping [ ] , flowcharts were created in an iterative team process to explore and refine the relationships between the meaning units, codes, categories, subthemes, and themes: this concept mapping also ensured an overarching understanding of the entire data set. two core themes were ultimately determined: coordination and resources. representative verbatim quotations were then chosen to illustrate each subtheme of these core themes. the anonymous survey was prepared and administered jointly by both association's cme committees in fulfilment of cme accreditation standards [ ] . preliminary survey results were presented at a one-day, interdisciplinary cme meeting organized around healthcare emergencies management and involving members of both associations (also respondents to the survey); recommendations for improvements of the healthcare response at various levels were proposed. participants suggested that both associations advocate for those changes and that the survey results be published in support of these recommendations, which was later adopted by elected representatives of both associations. we therefore conducted "a secondary analysis of a suitably anonymized dataset that does not require ethics committee review" [ ] for publication. forty-two percent ( / ) of eligible physicians completed the survey. five respondents were excluded, as they did not indicate their specialty. practice profiles of the remaining respondents, representing % ( / ) and % ( / ) of ammiq and amsscq members, respectively, are described in table . a greater proportion of idmm ( . %) than phpms ( . %) were involved in ph n management. practice profiles of idmm involved and not involved in ph n management were similar. phpms involved in ph n management were more likely to practice in the field of infectious disease ( . % vs. . %) and in a regional public health team ( . % vs. . %) than those who were not. other practice characteristics were similar for both subgroups. frequency of issues experienced during the ph n table summarizes responses to the checklist of potential issues for the respondents involved in the ph n episode. overall, . % (n = ) of respondents encountered difficulties or experienced frustrations in their practice during ph n and this proportion was similar for both specialties. issues related mainly -for idmm -to laboratories and infection prevention and control, vaccine availability, communication process (clinical practice guidelines' [cpg] dissemination, and communication routes), and with the overall management of the two pandemic waves. phpms reported problems mainly with the decision-making process in the prioritization and vaccination of high-risk groups. in addition, more than % reported issues with the topdown management process, communication processes (cpgs' dissemination and communication routes), and patient management at the public health level (expert committees, case reporting, and epidemiological investigation). sixty-two of ( idmm and phpms) respondents ( . %) involved in ph n provided written comments. breaking down these comments resulted in distinct meaning units. figure illustrates the hierarchy of groupings that was developed from coding these meaning units into categories, subthemes, and themes. overall, comments could be grouped under two core themes: coordination, at all levels of implementation of the pandemic response, and availability of resources required to manage the pandemic. open codes associated with coordination (n = ) were more frequent than those relating to resources (n = ). the following sections report the results for each of the two core themes and their subthemes. representative verbatim quotations of the subthemes are provided in table . issues and suggested improvements with coordination comprised the following subthemes: a communication: a slow communication process, an overwhelming number of communication sources, and an overwhelming number of divergent messages, sometimes lacking clarity, were identified as the main problems. respondents suggested that these issues were in part due to communication routes used to relay information. participants mainly suggested improvements to communication management such as greater centralization and use of the internet instead of teleconferences. b clinical practice guidelines (cpg): respondents found that cpgs' content was inconsistent between the different pandemic management levels and advisory committees; physicians were confused as to which to follow, especially when contradictory. the changing nature and the slow dissemination of these cpgs were also perceived as problematic. cpgs were perceived as too rigid to accommodate particular regional and local situations. c decision-making: physicians expressed unhappiness with the top-down management model and speed of decision-making, which was associated by some to the large number of people involved at the top administrative level. physicians also found that there was a lack of autonomy and transparency in the decision-making process. suggestions were made to involve more medical specialists in the decision-making process and to increase autonomy at the regional and local levels. d roles and responsibilities: physicians complained about increased workload related to pandemic activities, such as meetings attendance that they found inefficient. some found financial compensations inadequate for the additional workload. respondents also mentioned that the exact role of the different actors involved in the pandemic was unclear, which generated confusion in the local management of the pandemic. suggestions were to improve meetings' structure and to better define roles at the beginning of a healthcare emergency. e epidemiologic investigation: public health epidemiologic investigations were mentioned as an issue, in particular the changing nature of the case report form. there was also a concern with how surveillance, modelling and analysis of data were handled and with lack of timely data feedback to the local level. the main suggestion was to increase processes transparency and improve local access to data. f public health expert advisory committees: respondents were mainly concerned with the lack of communication between physicians in the field and expert advisory committees. they also questioned the credentials of committees' members and their decisions. needs of specific regions were felt as neglected. suggestions included increasing speed of dissemination of advisory committees decisions and provision of committee members credentials, as well as increased involvement of physicians from various disciplines in committees' decision-making process. this core theme included laboratory-related resources, patient management, and vaccination process. a laboratory resources: limited availability of diagnostic material and human resources and poor access to diagnostic tests such as nucleic acid amplification tests (e.g. pcr) were raised as issues. b patient management: many patients with influenzalike symptoms were sent to emergency rooms without prior evaluation, resulting in overburdened emergency rooms. respondents suggested that those patients be coordination a) communication "there was too much information, and too many sources" "there needs to be better coordination between the two specialties" "difficult to communicate changing recommendations to different services" "use the current network rather than creating a parallel network" b) clinical practice guidelines "the waiting times to get cpg was long, and like already mentioned, documents were coming from everywhere" "changing and contradicting cpg complicated the situation when it came time to disseminate to other health professionals and sometimes rendered the infection control guidelines less credible since they were constantly changing" "cpgs were not adjusted based on clinical reality" c) decision-making "very little flexibility... again, the decisions were unclear and not very well explained" "lack of latitude at the regional level" "too many stakeholders and too many messages" "give more autonomy to the regional-local levels due to differences between different areas" "it is clear that an interdisciplinary expert committee should work together on the management of pandemics and other infectious disease emergencies" d) roles and responsibilities "it is frustrating to not be remunerated for the overwhelming number of calls answered and for infection control management" "there needs to be a better distinction between hierarchical roles and expert roles" "avoid having too many meetings and instead have a better, more transparent structure that avoids daily (and multiple) changes" "clarify roles and responsibilities quickly at the start of crises to the different parties involved" e) epidemiologic investigation "there was a big problem in accessing data (local cases: clinical presentation, severity, etc.)" "lack of information in the beginning, late access to pertinent quebec epidemiological data" f) public health expert advisory committees "more openness from experts and less closure of government leaders, professional associations, etc." "very little information given about the experts on advisory committees and from the different levels of government and public health" "difficulty with decisions and conclusions of the committees and treatment recommendations" "delay in the transmission of clinical practice guidelines from the committee of...*" clinical resources a) laboratory resources "long delays in obtaining results" "regional labs should have access to proper diagnostic technologies" "the number of lab technologists available is insufficient" "allow diagnostic pcr analysis at the local level, which will allow faster results and thus better management of patient beds" b) patient management "lack of individual rooms" "difficulties encountered in transferring patients to intensive care" "patients were referred directly to our hospital's emergency department without prior evaluation" c) vaccination process "peculiar recommendations for different risk groups" "too late to have the most impact" "late vaccination of the general population" "late access to vaccines; only supplied by one company; lack of non-adjuvanted vaccine for target groups" evaluated elsewhere. some also mentioned a lack of hospital single rooms to accommodate patients with ph n , as well as difficulty in transferring patients. c vaccination process: vaccines arrived late after the onset of the second wave of the pandemic and notifications of availability were last minute. physicians expressed disagreement with high-risk group prioritization, especially in regards to school-aged children and the elderly population, who were targeted late in the vaccination campaign. respondents proposed approaching group prioritization based on a better risk assessment. other suggestions included earlier accessibility to the vaccine for the general public and the need for specialized clinics to serve chronically ill patients. physicians would also have liked to receive more information on the vaccine. in this study, the majority of physicians who answered this exploratory survey reported difficulties or frustrations in their practice during the ph n . quantitative results suggest that some of the reported issues, such as access to laboratory material, were specialty-specific while others, such as communication processes, were experienced by both groups of physicians. exploration of the qualitative data contributed greatly to the interpretation of the quantitative data. the qualitative analysis suggested that most difficulties experienced during ph n were related to coordination of response between stakeholders. most problems were experienced within the areas of cpg, communications processes, and decision-making. communication is especially crucial in risk management [ ] but also in information transfer, such as infection control measures [ ] and new data on disease processes [ ] . difficulties, resulting from too many different and contradicting sources, as well as lack of flexibility, were the main areas identified as problematic. various advisory committees may have interpreted available evidences differently, leading to contradictions. however, trust in guidelines is highly dependent on believing that the sources of those guidelines are credible. transparency in the decision-making process and decision makers' credentials is crucial. as in other studies [ ] [ ] [ ] , efficient communication between various actors was felt to be important. it was suggested that the excessive amount of communication sources and messages might be solved by streamlining communications and through better use of the internet rather than traditional communication routes such as teleconferences. a need for increased use of newer communication technologies, facilitating transfer of information between those on the front lines and authorities, had been advocated for effective use of cme during outbreaks and to develop flexible plans [ ] . in a public health emergency, actors involved must acknowledge their roles and responsibilities. physicians, who are usually autonomous professionals with important decision-making freedom, seemed to have difficulty with the top-down managerial style that was imposed with the implementation of the pandemic response. there may have been a lack of communication about the managerial approach that would be implemented. however, the roundtable on healthcare and emergency service sector pandemic preparedness, reported that top-down is essential in emergencies management, but that a bottom-up method of feedback is also needed to allow adaptation to varying circumstances [ ] . flexibility in guidelines and in the decision-making process is also necessary to enable adaptation by allowing faster changes [ ] . as previously reported [ , ] , participants suggested that a mixed group of experts including top academic experts [ ] in collaboration with front lines of care, and the public health sector would be beneficial [ ] . public health components are needed to support the command system in place to ensure evidence-based decisions and proper coordination of interventions [ ] . some authors have emphasized informational transparency in several decision-making aspects [ , ] to improve collaboration [ ] . this study is based on a survey designed to develop a cme intervention and thus has limitations: we relied on a convenience sample; the questionnaire did not have established construct validity and recall bias in participants' answers is possible. this paper is one of the few reporting on physicians' perceptions on management of public health emergencies. important highlighted areas were coordination between all involved, decision-making transparency, greater collaboration of health professionals in decisionmaking, greater flexibility, and a better definition of roles and credentials. results emphasize the need to improve transparency and build stronger working relationships between physicians and health authorities. in times of emergency, a greater involvement of professional associations both in the planning of services and as a communication channel should be considered. studies based on other qualitative research approaches (e.g., grounded theory) are needed to further understand how healthcare systems can improve the implementation of emergency response plans and empower stakeholders involved. it would also be useful to study identified gaps between national health authorities' pandemic plans and what actually happened in response at the different levels of implementation. in vitro and in vivo characterization of new swine-origin h n influenza viruses the canadian pandemic influenza plan for the health sector pandemic influenza h n -the canadian experience who: world health organisation outbreak communication planning guide association cs: voices from the h n influenza pandemic front lines: a white paper about how canada could do better next time. roundtable on healthcare and emergency service sector pandemic preparedness canada in the face of the h n pandemic. influenza and other respir viruses getting back to basics during a public health emergency: a framework to prepare and respond to infectious disease public health emergencies transparency during public health emergencies: from rhetoric to reality in: justice mo, ed . . . professional code. rsq, c c- committee on the accreditation of continuing medical education. the accreditation of canadian university cme/cpd offices accreditation standards menacing pandemic or typical flu?; a top story : the h n flu. the montreal gazette why do i need it? i am not at risk! public perceptions towards the pandemic (h n ) vaccine pandemic influenza and major disease outbreak preparedness in us emergency departments: a survey of medical directors and department chairs basics of qualitative research the theory underlying concept maps and how to construct and use them requirements for ethics committee review for studies submitted to implementation science a(h n ) pandemic influenza and its prevention by vaccination: paediatricians' opinions before and after the beginning of the vaccination campaign the experiences of health care workers employed in an australian intensive care unit during the h n influenza pandemic of : a phenomenological study pandemic (a)h n influenza (swine flu) -the manitoba experience public health management of pandemic (h n ) infection in australia: a failure lessons learnt from pandemic a(h n ) influenza vaccination severe acute respiratory syndrome and the delivery of continuing medical education: case study from toronto a pandemic of hindsight? pre-publication history the pre-publication history for this paper can be accessed here coordination and resource-related difficulties encountered by quebec's public health specialists and infectious diseases/medical microbiologists in the management of a (h n ) -a mixed-method, exploratory survey we are extremely thankful for the participation of the members of both the ammiq and amsscq in the survey. we also want to thank michelle laviolette and charlotte lavoie for the administration of the survey to ammiq and amsscq members, and ammiq, amsscq and fédération des médecins spécialistes du québec for providing human and material resources used in this project. authors' contributions cq, mdf and rl developed the survey and contributed to data collection. rl and cq determined data analyses. cn analyzed qualitative data and rl analyzed quantitative data. cq and rl challenged coding. cn, rl and cq wrote the manuscript. all authors contributed to data interpretation and critically reviewed the manuscript. all authors read and approved the final manuscript. at the time of the survey, cq (an infectious diseases specialist and medical microbiologist) and mdf (a public health specialist) were chairing their respective cme committees. rl was acting as an expert cme research consultant for ammiq and amsccq, and cn was a pre-med student jointly supervised by cn and rl. mem joined the research team as a qualitative methodologist. the authors declare that they have no competing interests. key: cord- -wrru zg authors: pfeil, alena; mütsch, margot; hatz, christoph; szucs, thomas d title: a cross-sectional survey to evaluate knowledge, attitudes and practices (kap) regarding seasonal influenza vaccination among european travellers to resource-limited destinations date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: wrru zg background: influenza is one of the most common vaccine-preventable diseases in travellers. by performing two cross-sectional questionnaire surveys during winter and winter among european travellers to resource-limited destinations, we aimed to investigate knowledge, attitudes and practices (kap) regarding seasonal influenza vaccination. methods: questionnaires were distributed in the waiting room to the visitors of the university of zurich centre for travel' health (cth) in january and february and january prior to travel health counselling (cth and cth ). questions included demographic data, travel-related characteristics and kap regarding influenza vaccination. data were analysed by using spss(® )version . for windows. differences in proportions were compared using the chi-square test and the significance level was set at p ≤ . . predictors for seasonal and pandemic influenza vaccination were determined by multiple logistic regression analyses. results: with a response rate of . %, individuals were enrolled and ( . %) provided complete data. seasonal influenza vaccination coverage was . % (n = ). only ( . %) participants were vaccinated against pandemic influenza a/h n , mostly having received both vaccines simultaneously, the seasonal and pandemic one. job-related purposes ( , %), age > yrs ( , %) and recommendations of the family physician ( , . %) were the most often reported reasons for being vaccinated. in the multiple logistic regression analyses of the pooled data increasing age (or = . , % ci . - . ), a business trip (or = . , % ci . - . ) and seasonal influenza vaccination in the previous winter seasons (or = . , % ci . - . ) were independent predictors for seasonal influenza vaccination in or . influenza vaccination recommended by the family doctor ( , . %), travel to regions with known high risk of influenza ( , . %), and influenza vaccination required for job purposes ( , . %) were most frequently mentioned to consider influenza vaccination. conclusions: risk perception and vaccination coverage concerning seasonal and pandemic influenza was very poor among travellers to resource-limited destinations when compared to traditional at-risk groups. previous access to influenza vaccination substantially facilitated vaccinations in the subsequent year. information strategies about influenza should be intensified and include health professionals, e.g. family physicians, travel medicine practitioners and business enterprises. pandemic and seasonal influenza are still a challenging field of the public health system. influenza -a mild to severe respiratory infection caused by rna viruses of the family orthomyxoviridae -is one of the most common vaccine-preventable disease in travellers. worldwide, between ' and ' deaths are estimated to be due to seasonal influenza infection each year [ ] . influenza is also responsible for tremendous economic costs both from admissions to hospital and loss of productivity [ ] . influenza affects all age groups and is usually self-limited. common symptoms include acute fever, muscles pain, headache, cough and chills [ ] . special risk groups, such as very young children, the elderly and those suffering from chronic lung or heart diseases are at risk for serious influenza complications, e.g. bacterial pneumonia [ , ] . influenza reaches peak prevalence in winter in the northern hemisphere (nov-apr) -as well as in the southern hemisphere (apr-oct) and circulates yearround in the tropics [ , ] . seasonal influenza vaccination is an effective prevention strategy and is therefore routinely recommended for special risk groups [ , ] . of note, the seasonal influenza vaccine recommendations of the u.s. centres for disease control were recently expanded and include now about % of the population [ ] . influenza is known to be a quite frequent infection among travellers to tropical and subtropical destinations compared to other infections, e.g. vector-borne ones. about one of hundred travellers abroad gets infected [ ] . the risk of infection depends on the travel destination and the season. travellers crossing hemispheres may be confronted with different antigenic variants of the influenza virus. by returning home, the new variant may be transmitted to contact persons [ ] . the first pandemic of the st century has highlighted the need for international influenza prevention strategies [ ] . the objective of this study was to investigate the vaccination coverage as well as knowledge, attitudes and practices (kap) regarding influenza vaccination among travellers to resource-limited countries to improve or adapt current preventive strategies. two cross-sectional surveys were conducted at the university of zurich centre for travel' health during january and february and january , respectively. selfadministered, anonymous questionnaires including items were distributed to travellers waiting for pre-travel health advice. participation was voluntary. individuals above years, understanding german or english, residing in switzerland and planning to travel to a resourcelimited destination were included. questions included demographic data (gender, age, nationality, education, profession), travel-related characteristics (destination country, duration of stay, influenza risk perception, previous travel health advice, travel purpose, travel costs) and general attitudes and practices towards influenza vaccination (vaccination coverage, reasons to be vaccinated, reasons to refuse vaccination, motivations to consider vaccination with options for multiple answers except for the vaccination coverage). in , an additional question targeting the pandemic influenza a/h n vaccination coverage was included. the questionnaires were checked for completeness. a written letter of exempt was received by the ethical commission of the canton of zurich. statistical analyses were conducted by using spss ® version . for windows. differences in proportions of demographics, travel-related data and attitudes and practices were compared using the chi-square test. the significance level was set at p ≤ . . for the multiple logistic regression analysis the surveys were analysed as well as pooled dataset and each survey, cth- and cth- , separately. the seasonal influenza vaccination was used as outcome and all demographic, travel-related and attitude-and practices-related factors were evaluated as independent predictors. odds ratios (or) were determined by stepwise backward elimination of variables with p > . . for sensitivity analyses, each dataset of the cth studies, and , was analysed separately and additionally, predictors for pandemic influenza vaccination were determined by multiple logistic regression analyses. from a total of eligible individuals, ( . %) were included in the analysis ( figure ). overall, ( . %) were females and ( . %) males. the great majority of participants ( , . %) were between and years old with a median age of years (range - yrs). only ( . %) responders were above years of age. in general, participants were highly educated with ( . %) being university graduates. overall, the characteristics of participants planning to travel to resource-limited destinations are presented in table . of all vaccinated participants, ( %) declared to be vaccinated for business reasons and ( %) due to age ( travel as risk factor for an influenza infection is poorly established among international travellers when regarding the low vaccination coverage as well as the low selfperceived travel-associated risk estimates. of note, previous influenza vaccinations facilitated receiving an influenza vaccination in the following year by about times. therefore, easy access to the influenza vaccine is important. high media coverage was not considered sufficient to increase the vaccination rate substantially as is indicated by the low increase of the vaccination coverage between the two surveys in and and also by the low pandemic influenza vaccination coverage of only . %. therefore, multiple efforts need to complement one another including information strategies provided by family physicians and travel medicine practitioners, but also job-and age-related activities need to be considered. our sample of travellers is comparable to other studies performed at our centre for travel' health [ ] with respect to the age distribution, educational level and travel duration. inherent limitations include a selection bias: frequently visited destinations such as the middle east, north africa and the caribbean are underrepresented as travellers to those destinations generally do not consider a pre-travel health consultation as indicated [ ] but destinations with higher risk for faecal-orally transmitted infectious diseases, such as td or bacterial meningitis, are well represented, such as e.g. india and sub-saharan countries. therefore, our sample may represent a best practice sample. the fact, that the high proportion of university graduates indicates a health literate population may result in an even overestimated risk perception as well as influenza vaccination coverage. all data collections relied on self-reported information. hence, the results of the studies might be limited by a potential bias such as disclosure bias, although self-report of influenza vaccination status has been found to be reliable when checked against medical record documentation [ ] . most seasonal influenza activity occurs during november to april on the northern hemisphere and vaccination is usually administered between october and november. therefore, travellers visiting the opposite hemisphere have to be counselled accordingly and the seasonal influ-enza vaccine also for the southern hemisphere has to be available as there is year-round influenza activity in tropical and subtropical areas. risk perception and vaccination coverage regarding seasonal and pandemic influenza was very poor among european travellers to resource-limited destinations reducing the burden of influenza-associated complications with antiviral therapy the pathology of influenza virus infections influenza: changing approaches to prevention and treatment in travelers the scientific basis for offering seasonal influenza immunisation to risk groups in europe absolute humidity and the seasonal onset of influenza in the continental united states influenza virus infection in travelers to tropical and subtropical countries awareness of vaccination status and its predictors among working people in switzerland influenza vaccination coverage rates in five european countries during season / and trends over six consecutive seasons centers for disease control and prevention (cdc) -cdc's advisory committee on immunization practices (acip) recommends universal annual influenza vaccination knowledge, attitudes and practices in travel-related infectious diseases: the european airport survey h n influenza influenza vaccination uptake and socioeconomic determinants in european countries we thank all participating travellers and we acknowledge the technical assistance of patricia blank. the authors declare that they have no competing interests.authors' contributions tds, mm and ch conceived and supervised the study. ap performed all data collection and data analysis and drafted the manuscript. mm participated in designing the study and the questionnaire and organised access to the data of the airport-study. all authors have read and approved the final manuscript. key: cord- -b s es authors: kelso, joel k; halder, nilimesh; postma, maarten j; milne, george j title: economic analysis of pandemic influenza mitigation strategies for five pandemic severity categories date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: b s es background: the threat of emergence of a human-to-human transmissible strain of highly pathogenic influenza a(h n ) is very real, and is reinforced by recent results showing that genetically modified a(h n ) may be readily transmitted between ferrets. public health authorities are hesitant in introducing social distancing interventions due to societal disruption and productivity losses. this study estimates the effectiveness and total cost (from a societal perspective, with a lifespan time horizon) of a comprehensive range of social distancing and antiviral drug strategies, under a range of pandemic severity categories. methods: an economic analysis was conducted using a simulation model of a community of ~ , in australia. data from the pandemic was used to derive relationships between the case fatality rate (cfr) and hospitalization rates for each of five pandemic severity categories, with cfr ranging from . % to . %. results: for a pandemic with basic reproduction number r( ) = . , adopting no interventions resulted in total costs ranging from $ per person for a pandemic at category (cfr . %) to $ , per person at category (cfr . %). for severe pandemics of category (cfr . %) and greater, a strategy combining antiviral treatment and prophylaxis, extended school closure and community contact reduction resulted in the lowest total cost of any strategy, costing $ , per person at category . this strategy was highly effective, reducing the attack rate to %. with low severity pandemics costs are dominated by productivity losses due to illness and social distancing interventions, whereas higher severity pandemic costs are dominated by healthcare costs and costs arising from productivity losses due to death. conclusions: for pandemics in high severity categories the strategies with the lowest total cost to society involve rigorous, sustained social distancing, which are considered unacceptable for low severity pandemics due to societal disruption and cost. results: for a pandemic with basic reproduction number r = . , adopting no interventions resulted in total costs ranging from $ per person for a pandemic at category (cfr . %) to $ , per person at category (cfr . %). for severe pandemics of category (cfr . %) and greater, a strategy combining antiviral treatment and prophylaxis, extended school closure and community contact reduction resulted in the lowest total cost of any strategy, costing $ , per person at category . this strategy was highly effective, reducing the attack rate to %. with low severity pandemics costs are dominated by productivity losses due to illness and social distancing interventions, whereas higher severity pandemic costs are dominated by healthcare costs and costs arising from productivity losses due to death. conclusions: for pandemics in high severity categories the strategies with the lowest total cost to society involve rigorous, sustained social distancing, which are considered unacceptable for low severity pandemics due to societal disruption and cost. keywords: pandemic influenza, economic analysis, antiviral medication, social distancing, pandemic severity, case fatality ratio background while the h n virus spread world-wide and was classed as a pandemic, the severity of resulting symptoms, as quantified by morbidity and mortality rates, was lower than that which had previously occurred in many seasonal epidemics [ ] [ ] [ ] . the pandemic thus highlighted a further factor which must be considered when determining which public health intervention strategies to recommend, namely the severity of symptoms arising from a given emergent influenza strain. the mild symptoms of h n resulted in a reluctance of public health authorities to use rigorous social distancing interventions due to their disruptive effects, even though modelling has previously suggested that they could be highly effective in reducing the illness attack rate [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . had the h n influenza strain been highly pathogenic, more timely and rigorous responses would have been necessary to mitigate the resultant adverse health outcomes. furthermore, there is continuing concern that a highly pathogenic avian influenza a(h n ) strain may become transmissible between humans. this scenario is highlighted by the large reservoir of influenza a(h n ) in poultry in south-east asia [ ] , and recent experimental results which have shown that the a (h n ) virus may be genetically modified to become readily transmissible between ferrets, a commonly used animal model for human influenza transmission studies [ ] [ ] [ ] . the severity of a particular influenza strain directly impacts on the cost of any pandemic; increased severity increases health care costs and escalates productivity losses due to a) absenteeism arising from increased illness and b) increased mortality rates. in this study, the role which pandemic severity has on the total cost of a pandemic for a range of potential intervention strategies is analysed, and for highly pathogenic influenza strains inducing significant morbidity and mortality, as occurred during the pandemic [ , ] , the results suggest which intervention strategies are warranted in terms of reduction of illness and total pandemic cost. this study adopts a societal perspective on the cost of a pandemic, with the time horizon being the lifetime of individuals experiencing the pandemic. we used a detailed, individual-based simulation model of a real community in the south-west of western australia, the town of albany with a population of approximately , , to simulate the dynamics of an influenza pandemic. comparing simulations with and without interventions in place allowed us to analyse the effect which a range of interventions have on reducing the attack rate and on the health of each individual in the modelled community. epidemic outcome data produced by the simulation model were used to determine health outcomes involving hospitalisation, icu treatment, and death. in turn, these healthcare outcomes, together with productivity losses due to removal from the workforce, were used to estimate the overall cost of interventions. figure provides an overview of this analysis methodology, showing each of the processes that make up the methodology, their input parameters and the resulting data generated by the process. the simulation model captures the contact dynamics of the population of albany, western australia using census and state and local government data [ ] . these data allowed us to replicate the individual age and household structure of all households in this town of approximately , individuals, and also allowed for the construction of an explicit contact network linking households, schools, workplaces and other meeting places by allocating individuals to workplaces and schools. the modelled community was chosen so as to be representative of a developed world population, and selfcontained in the sense that all major locales for interpersonal mixing were represented within the community. the model includes both urban and rural components, a central commercial core, a complete set of schools (covering all age groups), and a mix of large and small employers. the community is also of a size where public health interventions could be uniformly implemented based on local information. the model captures explicit person-to-person contact with the contact network describing population mobility occurring between households, schools, workplaces and the wider community as shown in figure . the virus spreads through the community due to this mobility, as transmission occurs between individuals when they are co-located, possibly following a move from one location to another. for figure overview of pandemic cost analysis methodology. input parameters are shown on the left in boxes with blue text, with arrows indicating to which part of the cost analysis methodology they apply. boxes with white text represent different processes of the methodologyeach process is described in the methods section under a subsection of the same name. boxes with green text appearing at the bottom and on the right represent results generated by the analysis. example, an infectious child moves from household to school on a given day, and infects two further children; they return to households and and, following virus incubation, become infectious and may infect other household members in their households. note that these households may be geographically separate, but are connected via contact of children at school. each household contains uniquely identified individuals. children and adults were assigned by an allocation algorithm to school classes and workplaces, respectively. the assignment of children to classes was based on age, school class size data, and proximity between schools and households; the assignment of adults to workplaces was based on workplace size and commuter survey data. in addition to contact occurring in households and mixing hubs, community contact was introduced to capture mixing which occurs outwith these locales and in the wider community. the number of contacts made by each individual each day in school, work and community settings were adjusted to reproduce the proportion of cases occurring in different settings as reported by empirical studies, specifically % of infections occurred in households, % in schools and workplaces, and % in the wider community [ ] [ ] [ ] . contacts within schools and workplaces occurred in fixed-size mixing groups of maximum size . within mixing groups contact was assumed to be homogeneous. community contacts occurred between randomly selected individuals, weighted toward pairs of individuals located in neighbouring households. a simulation algorithm, realised in the c++ programming language, manipulates the underlying demographic model and captures both population mobility and the time-changing infectivity profile of each individual. each individual has their infectivity status denoted by one of the four (susceptible, exposed, infectious, recovered) states at any time point during the duration of the simulated period. the simulation algorithm captures the state of the whole population twice per day, a daytime pointin-time snapshot and an evening snapshot, with individuals (possibly) moving locations between successive day or night periods, such as household to school or workplace for the day phase, returning to home for the night period. individuals come into contact with other individuals on a one-to-one basis in each location, with possible influenza transmission then occurring. individuals in each household and contact hub make contacts within a close-contact mixing group, taken to be the entire household or a subset of larger hubs, and also make additional non hub-based random community contacts. the attributes of the various locations in which individuals come into potentially infectious contact are summarized in table . using the contact, mobility and transmission features described above, stochastic simulations of influenza spread were conducted. all simulations were repeated times with random numbers controlling the outcome of stochastic events (the locality of seeded infected individuals and the probability of transmission) and the results were averaged. analysis of this simulation model has shown that the -run mean attack rate is highly unlikely ( % confidence) to differ by more than . % from the mean attack rate of a much larger set of experiment repeats. one new infection per day was introduced into the population during the whole period of the simulations, and randomly allocated to a household. this seeding assumption of case per day was chosen to reliably begin a local epidemic in every stochastic simulation. for the transmission characteristics described above, analysis shows that seeding at this rate for days results in a sustained epidemic in > % of the simulation runs and % with two weeks of seeding, with higher percentages for the higher transmissibility scenarios. seeding at this rate is continued throughout the simulation in order to capture the case where an epidemic may be initially suppressed by a rigorous intervention strategy, but may subsequently break out if intervention measures are relaxed. after the beginning of a sustained local epidemic, any subsequent variation in the amount of seeding has very little effect on the progress of the local epidemic, as the number of imported cases is much smaller than those generated by the local epidemic. preliminary analyses using the present model have shown that even if the seeding rate is increased to infections per day, after days the number of infections generated from the selfsustained local epidemic is twice the number of imported infections, and by days local infections outnumber imported infections by a factor of . the simulation period was divided into hour day/ night periods and during each period a nominal location for each individual was determined. this took into consideration the cycle type (day/night, weekday/weekend), infection state of each individual and whether child supervision was needed to look after a child at home. individuals occupying the same location during the same time period were assumed to come into potential infective contact. details of the simulation procedure are presented in [ ] . in the simulation model, we assumed that infectious transmission could occur when an infectious and susceptible individual came into contact during a simulation cycle. following each contact a new infection state for the susceptible individual (either to remain susceptible or to become infected) was randomly chosen via a bernoulli trail [ ] . once infected, an individual progressed through a series of infection states according to a fixed timeline. the probability that a susceptible individual would be infected by an infectious individual was calculated according to the following transmission function, which takes into account the disease infectivity of the infectious individual i i and the susceptibility of susceptible individual i s at the time of contact. maximum group size is . tertiary and vocational education institutions, number and size determined from state education department data. weekdays during day cycle. young adult and adult individuals who are allocated into the hub if they are active*. maximum group size is . workplace number and size of determined for local government business survey data. weekdays during day cycle. adult individuals who are allocated into the hub if they are active * . maximum group size is . community represents all contact between individuals in the community that is not repeated on a daily basis. everyday during day cycle. all individuals make contacts if they are active*, contact is random but weighted towards pairs with nearby household locations. * all individuals are active during day cycles unless: he/she is symptomatically infected and chooses to withdraw to household ( % chance for adults, % for children); or if his/her school or workplace is affected by social distancing interventions; or if he/she is a parent of a child who is inactive (only one parent per family is affected this way). the baseline transmission coefficient β was initially chosen to give an epidemic with a final attack rate of . %, which is consistent with seasonal influenza as estimated in [ ] (in table three of that paper). to achieve simulations under a range of basic reproduction numbers (r ), β was increased from this baseline value to achieve epidemics of various r magnitudes; details of the procedure for estimating β and r are given in [ ] . a reproduction number of . was used as a baseline assumption, and the sensitivity of results to this assumption was gauged by repeating all simulations and analyses for alternative reproduction numbers of . and . . a pandemic with a reproduction number of . corresponds to some estimations of the basic reproduction number of the pandemic [ ] [ ] [ ] [ ] , while a reproduction number of . corresponds to an upper bound on estimates of what may have occurred in the pandemic, with most estimates being in the range . - . [ , ] . the disease infectivity parameter inf(i i ) was set to for symptomatic individuals at the peak period of infection and then to . for the rest of the infectivity period. the infectiousness of asymptomatic individuals was also assumed to be . and this applies to all infected individuals after the latent period but before onset of symptoms. the infection profile of a symptomatic individual was assumed to last for days as follows: a . day latent period (with inf(i i ) set to ) was followed by day asymptomatic and infectious, where inf(i i ) is set to . ; then days at peak infectiousness (with inf(i i ) set to . ); followed by . days reduced infectiousness (with inf(i i )set to . ). for an infected but asymptomatic individual the whole infectious period (of . days) was at the reduced level of infectiousness with inf(i i ) set to . . this infectivity profile is a simplification of the infectivity distribution found in a study of viral shedding [ ] . as reported below in the results section for the unmitigated no intervention scenario, these assumptions regarding the duration of latent and infectious periods lead to a mean generation time (serial interval) of . days which is consistent with that estimated for h n influenza [ , , ] . following infection an individual was assumed to be immune to re-infection for the duration of the simulation. we further assume that influenza symptoms developed one day into the infectious period [ ] , with % of infections being asymptomatic among children and % being asymptomatic among adults. these percentages were derived by summing the age-specific antibody titres determined in [ ] . symptomatic individuals withdrew into the home with the following probabilities; adults % and children %, which is in keeping with the work of [ , ] . the susceptibility parameter susc(i s ) is a function directly dependent on the age of the susceptible individual. it captures age-varying susceptibility to transmission due to either partial prior immunity or age-related differences in contact behaviour. to achieve a realistic age specific infection rate, the age-specific susceptibility parameters were calibrated against the serologic infection rates for seasonal h n in - in tecumseh, michigan [ ] . the resulting age-specific attack rates are consistent with typical seasonal influenz, with a higher attack rate in children and young adults (details of the calibration procedure may be found in [ ] ). the antiviral efficacy factor avf(i i ,i s ) = ( -ave i )*( -ave s ) represents the potential reduction in infectiousness of an infected individual (denoted by ave i ) induced by antiviral treatment, and the reduction in susceptibility of a susceptible individual (denoted by ave s ) induced by antiviral prophylaxis. when no antiviral intervention was administrated the values of both ave i and ave s were assumed to be , indicating no reduction in infectiousness or susceptibility. however, when antiviral treatment was being applied to the infectious individual the value of ave i was set at . , capturing a reduction in infectiousness by a factor of % [ ] . similarly, when the susceptible individual was undergoing antiviral prophylaxis the value of ave s was set to . indicating a reduction in susceptibility by a factor of % [ ] . this estimate is higher than most previous modelling studies [ , , ] , which assume an ave s of %. this common assumption appears to stem from an estimate made in [ ] based on - trial data. our higher value is based on a more comprehensive estimation process reported in [ ] , which also incorporated data from an additional study performed in - [ ] . it is also in line with estimates of %- % reported in [ ] . we examined a comprehensive range of intervention strategies including school closure, antiviral drugs for treatment and prophylaxis, workplace non-attendance (workforce reduction) and community contact reduction. these interventions were considered individually and in combination and social distancing interventions were considered for either continuous periods (that is, until the local epidemic effectively ceased) or periods of fixed duration ( weeks or weeks). antiviral drug interventions and social distancing interventions were initiated when specific threshold numbers of symptomatic individuals were diagnosed in the community, and this triggered health authorities to mandate the intervention response. this threshold was taken to be . % of the population. this threshold was chosen based on a previous study with this simulation model, which found that it represents a robust compromise between early, effective intervention and "premature" intervention, which can result in sub-optimal outcomes when limited duration interventions are used [ ] . it was assumed that % of all symptomatic individuals were diagnosed, and that this diagnosis occurred at the time symptoms appeared. for continuous school closure, all schools were closed simultaneously once the intervention trigger threshold was reached. for fixed duration (e.g. weeks or weeks) school closure, schools were closed individually as follows: for a primary school the whole school was closed if or more cases were detected in the school; in a high school only the class members of the affected class were isolated (sent home and isolated at home) if no more than cases were diagnosed in a single class; however if there were more than cases diagnosed in the entire high school the school was closed. note that these school closure policies were only activated after the community-wide diagnosed case threshold was reached; cases occurring in schools before this time did not result in school closure. this policy of triggering school closure based on epidemic progression avoids premature school closure which can reduce the effectiveness of limited duration school closure [ , , ] ; see [ ] for a detailed description of school closure initiation triggering strategies. two primary antiviral drug strategies have been examined; antiviral drugs used solely for treatment of symptomatic cases (strategy t), and treatment plus prophylaxis of all household members of a symptomatic case (strategy av). a further strategy was also examined, in which prophylaxis was also extended to the contact group (school or workplace contacts) of a symptomatic case (strategy t + h + e). due to the logistical resources required, it is unlikely that this extended strategy could be implemented throughout a pandemic, and we do not report the results of this strategy in the main paper; full results are however given in (additional file ). antiviral treatment (and prophylaxis for household or work / school group contacts) was assumed to begin hours after the individual became symptomatic. it was assumed that an individual would receive at most one prophylactic course of antiviral drugs. further details of antiviral interventions are given in [ , ] . workforce reduction (wr) was modelled by assuming that for each day the intervention was in effect, each worker had a % probability of staying at home and thus did not make contact with co-workers. community contact reduction (ccr) was modelled by assuming that on days when the intervention was in effect, all individuals made % fewer random community contacts. the most rigorous social distancing interventions considered in this study, which we denote as strict social distancing, involve the combined activation of school closure with workforce reduction and/or community contact reduction, and for this to occur for significant time periods; continuous and weeks duration were considered. in the present study we simulated a total of intervention scenarios (for each of three reproduction numbers . , . and . ). to simplify the results, we only present those interventions that reduce the unmitigated illness attack rate by at least %. we defined five severity categories based on those proposed by the cdc [ ] . the cdc pandemic index was designed to better forecast the health impact of a pandemic, based on categories having cfrs ranging from < . % to > = . %, and allow intervention recommendations to match pandemic severity. the discrete cfrs used are listed in table . we extend the cdc categories to further include rates of hospitalisation and icu treatment, as described below using data collected during the pandemic in western australia, by the state department of health. these data permit case hospitalisation (icu and non-icu) and case fatality ratios (cfr) to be related, as described below. the least severe pandemic considered (category ) has cfr of . % which is at the upper end of estimates for the pandemic. initially, the pandemic cfr was estimated to be in the range . % - . % [ ] ; however recent reanalysis of global data from suggest a cfr (for the - age group) in the range . % - . % [ ] . cost analysis results for a pandemic with h n characteristics using a similar simulation model to the one described here can be found in [ ] . calculation of costs arising from lost productivity due to death and from hospitalisation of ill individuals requires that individual health outcomes (symptomatic illness, hospitalisation, icu admission, and death) be estimated for each severity level. the pandemic data from western australia was used to provide this relationship between the mortality rate and numbers requiring hospitalisation and icu care. these data indicated a non-icu hospitalisation to fatality ratio of : and an icu admission to fatality ratio of : . these values align with those in a previous study by presanis et al. in [ ] , which estimated the ratios in the ranges - to and . - . to , respectively. the economic analysis model translates the age-specific infection profile of each individual in the modelled symptomatic infectiousness timeline . day latent (non infectious), day asymptomatic; days peak symptomatic; . days post-peak symptomatic [ ] asymptomatic infectiousness timeline . day latent; . days asymptomatic [ ] asymptomatic infectiousness . [ ] peak symptomatic infectiousness . post-peak symptomatic infectiousness . [ ] probability of asymptomatic infection . [ ] probability average school closure cost (per student per day) $ . [ ] average gp visit cost $ . [ ] average hospitalization cost (per day) $ [ ] average icu cost (per day) $ [ , ] population, as derived by the albany simulation model, into the overall pandemic cost burden. total costs involve both direct healthcare costs (e.g. the cost of medical attention due to a gp visit, or for hospitalisation) and costs due to productivity loss [ , ] . pharmaceutical costs (i.e. costs related to antiviral drugs) are also estimated. all costs are reported in us dollars using consumer price index adjustments [ ] . us dollar values are used to make the results readily convertible to a wide range of countries. age-specific hospitalisation costs are achieved by multiplying the average cost per day by average length of stay for each age group [ , ] . hospitalisation costs, including icu costs, those involving medical practitioner visits, and antiviral drug (and their administration) costs are taken from the literature and are presented in table [ , , ] . the antiviral costs include the costs of maintaining an antiviral stockpile. this was calculated by multiplying the antiviral cost per course (but not the dispensing cost per course, which was included separately) by the expected number of times each antiviral course would expire and be replaced between pandemics, assuming a mean inter-pandemic period of . years (based on the occurrence of pandemics in , , and ) and an antiviral shelf life of years [ ] . treatment costs, lengths of stay in hospital (both icu and non-icu), and other cost data used in establishing the overall cost of mitigated and unmitigated epidemics in the modelled community are given in table . productivity losses due to illness and interventions (e.g. necessary child-care due to school closure and workforce reduction) were calculated according to the human capital approach, using average wages and average work-days lost; the latter being determined from day-to-day outbreak data generated by the simulation model. assumed average wages are given in table . school closure is assumed to give rise to two costs. the first, following the work of perlroth et al. [ ] , is a $ per student school day lost. this is intended to approximate the cost of additional education expense incurred in the futurewhich might occur for example in the form of additional holiday classes. the second component is lost productivity of parents staying at home to supervise children. the simulation model calculates whether this occurs for every day for every household, based on what interventions are in force (school closure and/or workforce reductions), whether children or adults are ill, the number of adults in the household, whether it is a school day, etc., and accumulates the cost accordingly. indirect production losses due to death were also derived using a human capital approach, based on the net present value of future earnings for an average age person in each age group. this was calculated by multiplying the age-specific number of deaths due to illness by the average expectancy in years of future earnings of an individual by an average annual income [ ] . we assumed a maximum earning period up to age . productivity losses due to death were discounted at % annually, which is a standard discounting rate used to express future income in present value [ ] . to provide an alternative analysis, total costs were also calculated without this long-term productivity loss due to death component. overview figure presents the final attack rate (ar) and the total cost of the epidemic for each intervention strategy applied, for a pandemic with a basic reproduction number of r = . . although costs are calculated from the whole-of-society perspective, total costs are presented as a cost per person in the community, calculated by dividing the simulated cost of the pandemic by the population of~ , , in order to make the results more easily transferable to communities of various sizes. strategies are ordered from left to right by increasing effectiveness (i.e. their ability to decrease the attack rate), and only intervention strategies that reduce the attack rate by at least % are included. figure shows three distinctive features. firstly, for an epidemic with basic reproduction number r = . , no single intervention is effective in reducing the attack rate by more than %, and thus do not appear in figure . this finding is consistent with previous modelling studies which found that layering of multiple interventions is necessary to achieve substantial attack rate reductions [ ] [ ] [ ] [ ] [ ] [ ] , , ] . secondly, higher severity pandemics have higher total costs. total costs of unmitigated pandemics range from $ to $ per person for pandemics from category to category (see table ). thirdly, for high severity pandemics total costs are lower for the more effective intervention strategies. figure presents the constituent components that make up the total cost of each intervention and severity category, measured in terms of cost per person in the modelled community. three distinctive features can be seen in figure . firstly, for high severity pandemics costs are dominated by productivity losses due to death and health care costs. secondly, for low severity pandemics costs are dominated by social distancing and illness costs. thirdly, for all severity categories antiviral costs are comparatively low when compared with all other cost components of antiviral based intervention strategies. antiviral costs never constitute more than % of the total cost, and for all severity categories greater than (cfr > . %) antiviral costs are always the smallest cost component. below we report on effectiveness, total costs and cost components of interventions for pandemics with high and low severity. these cost data are presented in table . figure summarises the characteristics of key intervention strategies. for high severity pandemics (categories and , with case fatality rates above . %) the least costly strategy combines continuous school closure, community contact reduction, antiviral treatment and antiviral prophylaxis. at category this strategy has a total cost of $ , per person, a net benefit of $ per person compared to no intervention. this strategy is also the most effective intervention strategy, reducing the attack rate from % to . %. the results indicate that strategies with the lowest total costs are also the most effective. for a category pandemic the most effective strategies, all of which reduce the attack rate to less than %, have total costs ranging from $ , to $ , per person, which is less than one-third the cost of the unmitigated pandemic ($ , ), showing the substantial net benefit of effective interventions for high severity pandemics. these strategies all feature continuous school closure, with either continuous community contact reduction or antiviral treatment and prophylaxis. the ability of highly effective interventions to reduce the total cost of a high severity pandemic is due to the largest component of the overall cost being productivity losses arising from deaths. this is illustrated in figure which shows the cost components for each intervention. it can be seen that the majority of the cost for an unmitigated pandemic of severity category and is due to death-related productivity losses (shown in purple). although highly effective interventions incur large intervention-related productivity losses (shown in green), for high severity pandemics these intervention costs are more than outweighed by the reduction in medical costs and death-related productivity losses. the most costly intervention considered (i.e. which still reduced the attack rate by at least %) is continuous school closure combined with continuous workforce reduction, which costs $ , per person. for low severity pandemics (in category , having cfr < = . %) the intervention strategy with the lowest total cost considered is weeks school closure combined with antiviral treatment and prophylaxis, costing $ per person which represents a net saving of $ per person compared to no intervention. however, this strategy is not as effective as other intervention strategies, reducing the attack rate to only %. the most effective intervention (combined continuous school closure, community contact reduction, and antiviral treatment and household prophylaxis), which reduces the attack rate to . %, costs $ per person, a net benefit of $ per person compared to no intervention. figure shows that for category and pandemics, although highly effective intervention measures reduce medical costs and death-related productivity losses, they incur larger costs due to intervention-related lost productivity. the most costly intervention considered is continuous school closure combined with continuous workforce reduction, which costs $ , per person, a net cost of $ per person compared to no intervention. this is due to the large cost associated with % workforce absenteeism. an important subset of intervention strategies are those consisting of purely social distancing interventions. in the case that antiviral drugs are unavailable or ineffective, only these non-pharmaceutical interventions strategies will be available. the most effective non-pharmaceutical strategy is the continuous application of the three social distancing interventions, school closure, workforce reductions, and community contact reduction, which reduces the attack rate to %. this intervention has a total cost ranging from $ , to $ , per person for severity categories ranging from to respectively. the least costly non-pharmaceutical strategy omits workforce reduction, resulting in a slightly higher attack rate of %. this intervention has a total cost ranging from $ to $ , per person for severity categories ranging from to respectively. the costing model used for this analysis includes future productivity losses from deaths caused by the pandemic. this long-term cost is often not included in cost-utility analyses. the inclusion of death-related productivity losses greatly increases the total costs of severe pandemics. however, even if these costs are not included, medical costs (due to hospitalisation and icu usage) play a similar, although less extreme, role. if long-term productivity losses due to death are not included in the costing model, the total cost of the pandemic is not surprisingly lower. however the effectiveness and relative total costs of intervention strategiesthat is, the ranking of intervention strategies by total cost -remains the same whether or not death-related productivity losses are included (spearman's rank correlation coefficient r = . , p = . for a null hypothesis that rankings are uncorrelated). full cost results of an alternate analysis that omits death-related productivity losses is contained in an additional file accompanying this paper (additional file ), and is summarised below. for category , when death-related productivity losses are not included the total cost of intervention strategies ranges from $ to $ , . this range is much smaller than if death-related productivity losses are included, in which case total cost ranges from $ , to $ , . for lower severity pandemics with lower case fatality ratios, the contribution of death-related productivity losses is naturally smaller. for category , when death-related productivity losses are not included total cost ranges from $ to $ , ; with death-related productivity losses the range is $ to $ , . if death-related productivity losses are not included, social distancing and illness costs dominate the total cost of each intervention strategy for low severity pandemics, while health care costs dominate the cost profile for high severity pandemics. sensitivity analyses were conducted to examine the extent to which these results depend upon uncertain model parameters that may impact on the cost or effectiveness of interventions. the methodology adopted was to identify assumptions and model parameters known to have an effect on intervention outcomes, taken from previous studies with this simulation model [ , , , , , ] , and to perform univariate analyses on each, examining parameter values both significantly higher and lower than figure breakdown of pandemic cost components. breakdown of pandemic costs shown as horizontal bar, for each intervention strategy and each severity category. coloured segments of each bar represent cost components as follows: (blue) health care; (red) antiviral drugs, including dispensing costs; (green) productivity losses due to illness and social distancing interventions; (purple) productivity losses due to deaths. note that horizontal scale is different for each severity category. values are for a pandemic with unmitigated transmissibility of r = . . interventions abbreviated as: scschool closure; ccr - % community contact reduction; wr - % workforce reduction; , intervention duration in weeks; contcontinuous duration; avantiviral treatment of diagnosed symptomatic cases and antiviral prophylaxis of household members of diagnosed symptomatic cases. the baseline values. alternative parameter settings were analysed for transmissibility (as characterised by the basic reproduction number r ), voluntary household isolation of symptomatic individuals, antiviral efficacy, compliance to home isolation during school closure, degree of workforce reduction, and degree of community contact reduction. a common finding across all sensitivity analyses was that alternative parameter settings that rendered interventions less effective resulted in strategies that not only had higher attack rates, but also had higher total pandemic costs, with this effect being most pronounced for pandemics of high severity. further details and results of the sensitivity analysis can be found in an additional file accompanying this paper (additional file ). the need for an unambiguous, extended definition of severity has been noted in the world health organization report on the handling of the pandemic [ ] , which highlights the impact pandemic severity has on health care provision and associated costs. in the absence of such definitions, an extended severity metric is presented. this extends the case fatality ratio (cfr) severity scale devised by the cdc [ ] , with hospitalisation and intensive care unit (icu) data collected in australia during the pandemic. these data have been used to generate a more extensive notion of pandemic severity, relating actual age-specific attack rates with agespecific hospitalisation and mortality rates, thereby contributing to the realism of both the simulation model and the economic analysis. this pandemic severity scale together with a pandemic spread simulation model allows the calculation of the total cost of a pandemic, and to estimate the relative magnitude of all the factors that contribute to the pandemic cost, including not only pharmaceutical and medical costs, but also productivity losses due to absenteeism and death. the severity of a future pandemic is shown to have a major impact on the overall cost to a nation. unsurprisingly, high severity pandemics are shown to be significantly more costly than those of low severity, using a costing methodology which includes costs arising from losses to the economy due to death, in addition to intervention and healthcare costs. a key finding of this study is that at high severity categories, total pandemic costs are dominated by hospitalization costs and productivity losses due to death, while at low severities costs are dominated by productivity losses due to social distancing interventions resulting from closed schools and workplaces. consequently, findings indicate that at high severity, the interventions that are the most effective also have the lowest total cost. highly effective interventions greatly reduce the attack rate and consequently the number of deaths, which in turn reduces productivity losses due to death. although highly effective interventions incur significant intervention-related productivity losses, for severe pandemics having high cfr, these intervention costs are more than compensated for by the reduction in death-related productivity losses, resulting in lower overall costs. conversely, for low severity pandemics, although highly effective intervention measures do reduce medical costs and death-related productivity losses, these savings can be smaller than costs incurred due to intervention-related lost productivity, resulting in total costs that are higher than the unmitigated baseline. antiviral strategies alone are shown to be ineffective in reducing the attack rate by at least %. however, the addition of antiviral case treatment and household prophylaxis to any social distancing strategy always resulted in lower attack rates and lower total costs when compared to purely social distancing interventions. the cost of all antiviral interventions constitutes a small fraction of total pandemic costs, and these costs are outweighed by both the healthcare costs prevented, and productivity gained, by their use in preventing illness and death. it should be noted that the lowest severity category considered, pandemic category , has a cfr of . % which is at the upper end of cfr estimates for the pandemic, which has been estimated to have a cfr of between . % and . % [ ] . thus, the cost results are not directly applicable to the pandemic. vaccination has been deliberately omitted from this study. the effectiveness and cost effectiveness of vaccination will depend crucially on the timing of the availability of the vaccine relative to the arrival of the pandemic in the communityvaccination cannot be plausibly modelled without considering this delay, and how it interacts with the timing of introduction and relaxation of other, rapidly activated interventions. the examination these timing issues for realistic pandemic scenarios that include both vaccination and social distancing / antiviral interventions is an important avenue for future work. as they stand, the results of this study, specifically the "continuous" duration social distancing strategies, can be considered to be models of interim interventions to be used prior to a vaccination campaign. the results are based on the community structure, demographics and healthcare system of a combined rural and urban australian community, and as such may not be applicable to developing world communities with different population or healthcare characteristics. although the cost and effectiveness results are directly applicable to pandemic interventions in a small community of , individuals, we expect that the per-capita costs and final attack rate percentages derived in this study can be extended to larger populations with similar demographics, provided a number of conditions are met. for the results to be generalisable, it needs to be assumed that communities making up the larger population implement the same intervention strategies, and instigate interventions upon the arrival of the pandemic in the local community (according to the criteria described in the methods section). the assumption is also made that there are no travel restrictions between communities. it should be noted that the single-community epidemic results do not predict the overall timing of the pandemic in the larger population. the simulation model used in this study has been used in previous studies to examine various aspects of social distancing and pharmaceutical (antiviral and vaccine) pandemic influenza interventions [ , , , , , ]. this simulation model shares characteristics with other individual-based pandemic influenza simulation models that have been employed at a variety of scales, including small communities [ , , , , , ] , cities [ , ] , countries [ , , , ] and whole continents [ ] . several related studies which also used individualbased simulation models of influenza spread coupled with costing models are those of those of sander et al., perlroth et al., brown et al., and andradottir et al. [ , , , ] . the current study extends upon the scope of these studies in several ways: five gradations of pandemic severity are considered, more combinations of interventions are considered, social distancing interventions of varying durations are considered, and probabilities of severe health outcomes for each severity category are based on fatality, hospitalization and icu usage data as observed from the pandemic. also in contrast with those models, we have chosen to include a cost component arising from productivity loss due to death, though a similar costing without death-related productivity losses has been included in (additional file ). for a pandemic with very low severity, with a cfr consistent with mild seasonal influenza, and that of the pandemic, previous results with the simulation and costing model used for this paper coincide with the studies mentioned above [ ] . specifically, they showed that antiviral treatment and prophylaxis were effective in reducing the attack rate and had a low or negative incremental cost, and that adding continual school closure further decreased attack rates, but significantly increased total cost. for high severity pandemics the inclusion of productivity loss following death, as presented in this study, leads to a markedly different assessment of total costs when compared to the two studies quoted above that considered severe pandemics [ , ] . for example, perlroth et al. found that the incremental cost of adding continuous school closure to an antiviral strategy was always positive, even for pandemics with high transmissibility (r = . ) and a cfr of up to %, meaning that adding school closure always increased total costs. similarly sander et al. found that the addition of continuous school closure to an extended antiviral strategy also increased total costs, including pandemics with a % cfr. in contrast, we found that adding continuous school closure to an extended prophylaxis strategy reduced total costs where the cfr was . % or greater (i.e. category and above), for a pandemic with r = . . the study of smith et al. estimated the economic impact of pandemic influenza on gross domestic product for a range of transmissibility and severity values [ ] . consistent with our study was the finding that at low severity the largest economic impacts of a pandemic would be due to school closure (effective but costly) and workplace absenteeism (largely ineffective and costly). like the other two studies mentioned above, the study of smith et al. did not include future productivity losses due to death. as a result, in contrast to our findings, they did not find that, for severe pandemics, the high short-term costs of rigorous social distancing interventions were outweighed by future productivity of people whose lives were saved by the intervention. in this study we considered the case of a pandemic that infects a significant proportion of the population, and thus incurs significant direct costs stemming from medical costs and productivity losses. however, in the case of a pandemic perceived by the public to be severe, there are likely to be additional indirect macroeconomic impacts caused by disruption of trade and tourism, consumer demand and supply, and investor confidence [ , ] . in the case of a pandemic of high severity (i.e. high case fatality ratio) but low transmissibility, these indirect effects and their resulting societal costs may constitute the main economic impact of the pandemic, an effect seen with the sars outbreak in [ ] . the results of this study are relevant to public health authorities, both in the revision of pandemic preparedness plans, and for decision-making during an emerging influenza pandemic. recent modelling research has shown that combinations of social distancing and pharmaceutical interventions may be highly effective in reducing the attack rate of a future pandemic [ , , , , , , , , ] . public health authorities are aware that rigorous social distancing measures, which were used successfully in some cities during the pandemic [ , ] , when pharmaceutical measures were unavailable, would be highly unpopular due to resulting societal disruption, and costly due to associated productivity losses [ ] . the results of this study give guidance as to the pandemic characteristics which warrant the use of such interventions. the results highlight the importance of understanding the severity of an emergent pandemic as soon as possible, as this gives guidance as to which intervention strategy to adopt. in the likely situation where the severity of an emerging pandemic is initially unknown (but is suspected to be greater than that of seasonal influenza), the results indicate that the most appropriate intervention strategy is to instigate school closure and community contact reduction, combined with antiviral drug treatment and household prophylaxis, as soon as transmission has been confirmed in the community. if severity is determined to be low, public health authorities may consider relaxing social distancing measures. in the case of a category pandemic (cfr approximately . %), little is lost by the early imposition and subsequent relaxation of social distancing interventions: results indicate that even if schools are closed for weeks while severity is being determined, the total cost of the pandemic is lower than if no interventions had been enacted. if severity is determined to be high, extending the duration of social distancing interventions results in both net savings to society and reduction in mortality. anzic influenza investigators: critical care services and h n influenza in australia and new zealand europe's initial experience with pandemic (h n ) -mitigation and delaying policies and practices mortality from pandemic a/h n influenza in england: public health surveillance study analysis of the effectiveness of interventions used during the h n influenza pandemic developing guidelines for school closure 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and sensitivity analyses. "milne pandemiccostadditionalfile .doc". competing interests gjm has received a travel grant from glaxosmithkline to attend an expert meeting in boston, usa; mjp has received travel grants from glaxosmithkline and wyeth to attend expert meetings in reykjavik, iceland, boston, usa and istanbul, turkey. jkk and nh have no potential competing interests. key: cord- -dqqcajjd authors: smith?, robert j; gordon, richard title: the optaids project: towards global halting of hiv/aids date: - - journal: bmc public health doi: . / - - -s -s sha: doc_id: cord_uid: dqqcajjd nan we face a unique, transitory opportunity in the history of the hiv/aids epidemic, because we have collectively pooled money faster than the epidemic has grown [ ] . can we then seize the moment and halt this epidemic now? most scenarios for the future of hiv/aids project modest reductions spread out over decades [ ] . the very timescale of such projections, beyond the persistence time of all models, makes them unreliable [ ] . can we do better, quicker? the optaids project was conceived as a means to address this issue. its implementation thus far has been twofold: a workshop held in july and this supplement on the eradication of aids. the aims of the project are to address two questions: . can we optimally spend our way out of the hiv/aids epidemic? . can we work together to build a world halting aids model (wham) that would permit us to estimate the quickest way to halt hiv/aids, monitor our success, and adjust our strategy as we go? the optaids project grew out of a frustration with existing attempts to tackle the disease. aids exceptionalism means that hiv/aids is handled differently from other public-health epidemics, which has likely been detrimental [ , ] . consequently, much of the funding of hiv/aids efforts has been for qualitative observations of the expanding epidemic rather than quantitatively effective intervention. although fund accumulation has recently outpaced the epidemic, we argue that plans to spend donor money are too long range in the face of a growing epidemic [ ] . longrange scenarios have no reality to them, so that only shortterm solutions -those that fall within the persistence time of their models -have any possibility of being realistic [ ] . furthermore, disease is a global problem that is only tackled locally [ ] ; epidemics cross borders, whereas we fund mostly local or national "solutions". the optaids project was an outgrowth of the stop afghan aids project [ ] . this project was led by mathematical modellers planning to continuously adapt their models to new data and predicting what data should be collected. the stop afghan aids project showed how it should be possible to intervene quantitatively in an epidemic. the usefulness of modelling in complex systems is not new. mathematical models of the economy tell us whether a decrease in income tax will result in an increase in investment or an increase in imported consumer goods. mathematical models of the atmosphere tell us what the effects of carbon dioxide emissions or of nuclear wars may be. mathematical modelling is used routinely in such things as aircraft design and the design of traffic systems [ ] . so too, epidemics are quantitative creatures with predictable thresholds. models that can be adapted to new results and to changes in control policy have been identified as an integral part of disease-control programs [ ] . modelling-led interventions were instrumental in halting the foot and mouth outbreak in the uk [ ] . a mathematical model of the dynamics of measles in new zealand developed in successfully predicted an epidemic in and was instrumental in the decision to carry out an intensive immunisation campaign in that year. while the epidemic began some months earlier than anticipated, it was rapidly brought under control, and its impact on the population was much reduced [ ] . the west african onchocerciasis (river blindness) control program successfully used modeling to supplement intervention programs [ ] . by using clearly delineated endpoints, these models helped convince donors and the scientific community that the aims of the program were achievable [ ] . as a result, mathematical models have retained a role in subsequent policy discussions [ ] . insights from mathematical models during the sars epidemic helped determine how serious the epidemic might become, as well as the impact of proposed control measures. these models provided important guidance to public-health authorities at a critical time when little other information was available. insights from the models showed that, if unchecked, the virus could cause a significant epidemic, but that basic epidemiological control measures -patient isolation, contact tracing, etc -could have a substantial impact on the extent of the epidemic. subsequently, these control measures played a major role in limiting the spread of the epidemic [ ] . weather prediction models provide a workable analogy. such models consist of continually updatable inputs, that must adapt to an enormous array of incoming data [ ] . short-term predictions, especially those associated with discrete, extreme weather events such as floods and hurricanes, have proven useful in supporting emergency management strategies, unlike events such as earthquakes or acid rain, which have longer lead times [ ] . complex mediating models which themselves have explanatory power and which embody techniques of modeling can be refined and passed down to successor models [ ] . the virtue of mathematics in such a context is that it forces clarity and precision upon the conjecture, thus enabling meaningful comparison between the consequences of basic assumptions and the empirical facts [ ] . existing scenarios for hiv control have typically been spread out over two or more decades [ ] , which means that the reliability of their predictions is low. the basic concept of optaids is to spend more money up front, effectively, based on the best models and their parameters we can formulate, with the goal being a rapid halt to the epidemic with the fewest additional cases. this means that models can be shorter term and therefore more relia-ble, because we stay within the models' persistence time. optaids emphasises continuous monitoring to check the accuracy and adjust the parameters of the global model. mathematically, this is an optimal halting problem. the optaids workshop was the first of its kind: a scientific meeting held simultaneously in both a real world location and also second life ® http://secondlife.com, a virtual landscape that allows real-time communication. the broad topic was the eradication of aids using optimal spending models, but this encompasses an enormous number of issues surrounding the aids epidemic. topics covered included the impact of circumcision, the effect of traditional medicine, prevention strategies for countries with nascent epidemics and the difficulties of developing an hiv vaccine. mitacs http://www.mitacs.ca gave us a can$ , workshop grant for this meeting, which was held on july , . given that this amount would only cover a few airfares, we decided to allow people to participate via second life ® . second life ® allows the creation of avatars [ ] , so that users can participate in the world. within the virtual world, you can talk to other people's avatars, upload powerpoint slides and manipulate objects within the environment. twenty-two people convened over the day in toronto (figure ) , including ten presenters. the traffic count during the day indicated avatar arrivals in second life ® , four of whom were presenters. the workshop was advertised to pertinent groups in second life ® and open to the avatar public. the second life ® building includes a location where the original slide presentations can be viewed ( figure ). two screens were used in toronto, showing the slides and the audience (represented by avatars), while second life ® participants could lecture by having their avatar stand near a virtual screen in second life ® . everyone could hear everyone else. a second virtual screen showed a live camera view of the audience in toronto (figure ) . the all-day meeting had only a few short interruptions for technical reasons. a summary and follow-up discussion was presented at the annual meeting of the society for mathematical biology shortly afterwards. the four speakers presenting via second life ® were located in poland, seattle, denmark and los angeles. the technology allowed for interactive discussion, so speakers in toronto faced questions from second life ® participants all around the world, while second life ® speakers had their powerpoint presentations shown on a screen in toronto (operated by their avatars in second life ® and simultaneously by the organisers in toronto), and faced questions from toronto and other second life ® participants. the size of the turnout in second life ® demonstrated the effectiveness of virtual conferencing; many more people were able to attend the conference than would have been feasible otherwise. the event was covered by the national post, which reported on the innovative use of second life ® in an academic setting. all the presentations remain in second life ® http://slurl.com/secondlife/silver bog/ / / as posters that can be clicked on by anyone interested. speakers can be asked to show up personally as avatars to go over the slides. the aim of this supplement is to discuss aids as a global phenomenon and address issues surrounding its eradica-tion. due to the scale of the epidemic, a great number of sub-issues arise. in thinking of aids as a global pandemic, we need to tackle the disease from as many directions as possible. some of the articles involve mathematical models, others involve a thorough examination of the state of resources, or an understanding of the effect of the disease on society. this supplement comprises fifteen articles (including this introduction), divided into six themes: . history . resources . demographics . in-host models . computation . spending our way out of the epidemic theme comprises an introduction and overview of mathematical modeling [ ] , as well as a history of aids in africa and its effects on human development [ ] . theme is concerned with the various resources that comprise our intervention arsenal: the allocation of resources [ ] , cost-effectiveness of prevention [ ] , antiretroviral pricing [ ] , the effects of migration upon availability of health professionals [ ] , and the relation- ship between mathematical models and resource allocation [ ] . theme looks at the effects of demographic changes in china on hiv [ ] and the spread of hiv among men who have sex with men [ ] . theme examines in-host modeling -a crucial element in tackling the disease, often overlooked by epidemiologists -by proposing new methods for evaluating the efficacy of antiretroviral treatment [ ] and examining antioxidant supplementation as hiv therapy, with a focus on injecting drug users [ ] . theme looks at using virtual epidemics to understand real ones [ ] and develops an epidemic simulator of an agent-based, data-driven disease model [ ] . finally, theme examines the question at the core of the optaids project: spending our way out of the aids epidemic [ ] . the collection of articles in this supplement run the gamut of topics related to hiv/aids. they examine the disease from a global perspective, in an attempt to untangle many of the problems associated with the epidemic. however, we view this as a starting point: the next step is for policymakers and the donor community to embrace the idea of global eradication. only by working together can we combat this disease. aids is the fourth worst infectious disease of all time, resulting in more deaths per day over the past years than occurred on / / [ ] . over million adults are now infected with hiv, many in the developing world, where resources are scarce and infrastructure is struggling under the weight of this burgeoning epidemic. the hiv/ aids epidemic is often spoken of in terms of "reducing the spread" [ ] , or achieving "sustainable financing" [ ] however, this special issue demonstrates that, despite the immensity of the epidemic, eradication is not only possible, it is feasible. the time has come to stop thinking locally and to start acting globally. global health--the gates-buffett effect the case for expanding access to highly active antiretroviral therapy to curb the growth of the hiv epidemic useless arithmetic: why environmental scientists can't predict the future aids and the arrows of pestilence hiv testing, human rights, and global aids policy: exceptionalism and its discontents can we spend our way out of the aids epidemic? a world halting aids model why rich countries should care about the world's least healthy people aids , xvi international aids conference - mathematical models: questions of trustworthiness epidemiological modeling for onchocerciasis control. parasitology today the uk foot-and-mouth disease outbreak -the aftermath predicting and preventing measles epidemics in new zealand: application of a mathematical model the role of mathematical modeling in evidence-based malaria control neglected tropical diseases: infection, modelling and control final report of the conference on the eradicability of onchocerciasis the geographic spread of infectious diseases: models and applications princeton university press representing model uncertainty in weather and climate prediction prediction in science and policy uses and abuses of mathematics in biology aids in africa: three scenarios to avatars: exploring and building virtual worlds on the internet berkeley mathematical epidemiology is not an oxymoron the impact of hiv/aids on human development in african countries the past, present and future of hiv, aids and resource allocation hiv prevention cost effectiveness: a review of the literature factors influencing global antiretroviral procurement prices addressing the migration of health professionals: the role of working conditions and educational placements recommendations for increasing the use of hiv/aids resource allocation models population profiling in china by gender and age: implication for hiv incidences a sex-role preference model for hiv transmission among msm population quantifying the treatment efficacy of reverse transcriptase inhibitors: new analyses of clinical data based on within-host modeling reconciling conflicting clinical studies of antioxidant supplementation as hiv therapy: a mathematical approach halting hiv/aids with avatars and havatars: a virtual world approach to modelling epidemics epidemic modeling with discrete-space scheduled walkers: extensions and research opportunities reducing the spread of hiv infection in sub-saharan africa: some demographic and economic implications sixtieth session, agenda item . follow-up to the outcome of the twenty-sixth special session: implementation of the declaration of commitment on hiv/aids. scaling up hiv prevention, treatment, care and support we would like to thank natalie k. björklund- gordon the authors declare that they have no competing interests. rjs wrote the introduction, overview of the supplement and the conclusion. rg set the theme in the first draft and wrote the start of the introduction and the section on the workshop. both authors proofread and approved the final manuscript. key: cord- -axio zna authors: van, debbie; mclaws, mary-louise; crimmins, jacinta; macintyre, c raina; seale, holly title: university life and pandemic influenza: attitudes and intended behaviour of staff and students towards pandemic (h n ) date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: axio zna background: in a pandemic young adults are more likely to be infected, increasing the potential for universities to be explosive disease outbreak centres. outbreak management is essential to reduce the impact in both the institution and the surrounding community. through the use of an online survey, we aimed to measure the perceptions and responses of staff and students towards pandemic (h n ) at a major university in sydney, australia. methods: the survey was available online from june to september . the sample included academic staff, general staff and students of the university. results: a total of surveys were completed. nearly all respondents ( . %, / ) were aware of the australian pandemic situation and . % ( / ) reported either "no anxiety" or "disinterest." asian-born respondents were significantly (p < . ) more likely to believe that the pandemic was serious compared to respondents from other regions. . % ( / ) of respondents had not made any lifestyle changes as a result of the pandemic. most respondents had not adopted any specific behaviour change, and only . % ( / ) had adopted the simplest health behaviour, i.e. hand hygiene. adoption of a specific behaviour change was linked to anxiety and asian origin. students were more likely to attend the university if unwell compared with staff members. positive responses from students strongly indicate the potential for expanding online teaching and learning resources for continuing education in disaster settings. willingness to receive the pandemic vaccine was associated with seasonal influenza vaccination uptake over the previous years. conclusions: responses to a pandemic are subject to change in its pre-, early and mid-outbreak stages. lessons for these institutions in preparation for a second wave and future disease outbreaks include the need to promote positive public health behaviours amongst young people and students. in april , severe cases of pneumonia preceded by influenza-like illness were noted to occur in mexico and then north america. a novel influenza a (h n ) virus was identified as the cause and it rapidly evolved into a pandemic. cases of the strain were first identified in australia in early may and soon appeared across the country [ ] . as of february , there have been , confirmed cases and deaths in australia. while this pandemic has been moderate or milder than previous pandemics such as the spanish flu of - , similarities can be drawn between the two in regards to the median age of cases. in australia, the median age of confirmed cases is years [ ] universities therefore have the potential to become explosive, centrifugal outbreak centres due to their large young adult population, high levels of close social contact and permeable boundaries. during a pandemic or disease outbreak, the proportion affected may exceed the seasonal norm of one-third of the student population [ ] . as sites of transmission, they may have a negative impact on the larger communities in which they are embedded. additionally, student behaviour is often divergent from non-student adult populations [ ] . hence, understanding of and outbreak management in such institutions are essential to minimise the impact of pandemic influenza in both the institution and its surrounds. university settings are unique given the permeability of their boundaries and the groups, and the activities within the institution that affect social contact between its members. both of which have the potential to affect behaviours and perceptions. this survey was conducted to examine the understanding of and attitudes towards pandemic (h n ) amongst students and staff at the university of new south wales (unsw), sydney, australia and their behavioural intentions during this pandemic. the cdc recommends that institutions of higher education balance the goals to minimize morbidity and mortality from pandemic influenza with the goal of minimising educational and social disruption [ ] . between april th and september th , ten broadcast emails were sent out by the director of the university health service to staff and students. contained in the emails was information on the: ( ) h n situation; ( ) modes of spread and common symptoms; ( ) recommended health advice consistent with both the who and national recommendations; and ( ) contact information for the relevant health departments [ ] . posters developed by the commonwealth department of health and ageing and unsw were placed in high traffic areas and focused on: ( ) encouraging faculty, staff and students to stay at home if symptomatic (i.e. with a fever, cough, and runny nose) and to protect each other; ( ) cough/sneeze etiquette (i.e. "cover your mouth and nose when you cough and sneeze" and "dispose of used tissues in the bin) and ( ) hand hygiene (i.e. "wash your hands properly and regularly"). data was collected from the june - september, coinciding with the peak of the pandemic in australia. an anonymous online survey was designed to assess the knowledge, attitudes and perceptions of pandemic (h n ) , which was referred to by its vernacular alternative, "swine flu". the survey was piloted on june th with three students and three staff, representative of the members of the study population, and modified accordingly. the final version assessed: ( ) demographic characteristics; ( ) awareness, perceived personal risk and anxiety; ( ) recent influenza-related behaviours changes; ( ) intended behaviour in the event of various scenarios at unsw and ( ) compliance with different community interventions. in regards to the behaviour changes, we included four changes (cancelling social plans, avoiding busy public places, cancelling/postponing travel plans and not using public transport) that were related to avoidance behaviour and not recommended by the government and five changes (buying hygiene products, receiving the seasonal influenza vaccine, using online resources for teaching and learning and stockpiling necessities) that were related to recommended behaviours. the recommended behaviours questions were adapted with permission from a study undertaken by rubin et al [ ] . the sample comprised of both academic and non-academic staff (i.e. administration, it and other support staff) and students at unsw in sydney, australia. participants accessed the final questionnaire via a link on an online newsletter available to all unsw staff and students, and via an online information gateway. emails were also sent to the heads of each faculty, informing them of the survey. consent was implied upon completion and submission of the questionnaire. submitted surveys were collated in a directory and deidentified prior to analysis. participants were offered the chance to win a $ cash prize upon completing the survey. ethics approval was granted by the university of new south wales human research ethics committee. the quantitative data on the completed survey was collected in microsoft excel. openepi (version . ) was used to calculate [ ] , proportions, % confidence intervals and χ tests for significance. alpha was set at the % level. we used logistic regression to compute odds ratios to evaluate the association of demographic variables and attitudes and beliefs. a total of unsw staff and students aged ≥ years completed the online survey between the june and september . the overall response rate was . % ( / ) and most respondents were young ( - years, . %, / ) and born in australia ( . %, / ) ( table ). academic and general staff members were both overrepresented in our sample ( . %, / , x = . , p < . ; . %, / , x = , p < . respectively) compared to the actual proportions employed at unsw ( . %, / and . %, / respectively). students were underrepresented ( . %, / , x = , p < . ) compared to the proportion of internal students at unsw ( . %, / ). most respondents ( . %, / ) reported that they had heard about the australian pandemic situation. whilst . % ( / ) believed that it was serious, . % ( / ) said that they were "not anxious" (figure ) and a further . % ( / ) reported "disinterest". of the respondents who felt they were likely to contract pandemic influenza ( . %, / ), . % ( / ) believed the infection would adversely affect their health. towards the end of the survey period and the end of winter, the percentage reporting "no anxiety" increased and the proportion of respondents who believed that the pandemic was "serious" significantly decreased (or, . [ % ci, . - . ); p < . ) ( figure ). perceptions of susceptibility significantly decreased with the decline of laboratory-confirmed cases in australia (or, . [ % ci, . - . ]; p = . ). asian-born respondents were significantly more likely to believe that the pandemic was serious (or, universities are not immune to natural or manmade disasters, and past experience with these have illustrated the importance of continuity during and after these events [ , ] . in an influenza pandemic, such institutions must maintain a balance between academic continuity, with infection control and minimising morbidity [ ] . in contrast to pre-pandemic and early pandemic findings in australian communities [ , ] , most of the university population surveyed were not anxious about the australian pandemic situation nor did they think it was serious. younger respondents (aged - ) were most likely to believe they were not susceptible to pandemic h n , despite being the most affected group in previous influenza pandemics. following the resurgence of media coverage of "swine flu" in australia, we did measure a significant rise in anxiety, perceived susceptibility and seriousness. this however declined with the approach of spring and the decline of laboratory confirmed cases of influenza a (h n ) in nsw [ ] . this illustrates that public perception of a pandemic is unstable, especially when the severity and natural progression cannot be accurately predicted. if requested by authorities, most respondents in our cohort were willing to undergo isolation if suffering from influenza-like-illness (ili). of concern was the high proportion of students who indicated that they would still attend university with symptoms. in the event of an exam or assessment deadline, their proportion tripled. such behaviour is detrimental for both students and the community, for in addition to spreading the pandemic virus, students with ili are also likely have reduced academic performance by up - % [ ] . absenteeism from university was higher in respondents who had indicated making a lifestyle change, implying the practicality of encouraging general positive health behaviour in this population. along with encouraging students to self-isolate in the case of illness, there must be ongoing education about the importance of infection control, especially when anxiety rates and risk perceptions are low. health messages need to educate students about the impact of the illness on their studies, and universities should emphasise their illness/misadventure assessment policies during disease outbreaks. online resources such as lecture recordings and forum tutorials allow for off-campus education, and can provide continuity of learning for students undergoing isolation. however in our study, few respondents had adopted the use of online teaching or learning resources as a result of pandemic influenza (h n ). this may be due to a number of factors including: ( ) the apparent mildness of the pandemic; and/or ( ) the lack of promotion by the university to use these resources. it was encouraging to see that students were very willing to continue university schooling via online resources, indicating the potential for expanding the existing unsw online teaching resources. while it was encouraging that students would undertake online courses, we found very little support for an online teaching method among the academic staff members. reluctance to use online resources was associated with increased age, and may be due to unfamiliarity with or resistance to technology. in preparation for an outbreak, universities should focus on creating additional support for technologies that allow faculty and students to continue their teaching and learning activities which minimise disruption. online recordings, virtual learning environment, blogs, web conferencing and discussion forums should all be utilised to assist in the delivery of lessons. having a contingency and communication plan for teaching key sections may provide the needed continuity for students and faculty. training must be provided in the pre-pandemic periods to minimise disruption. we found that most respondents had not made any lifestyle changes or undertaken any specific behaviour change despite receiving information from the university. this may be attributed to the mildness of pandemic (h n ) . this finding supports both the pre-pandemic and post-sars findings on the dose-response relationship between outbreak severity and the responses to it [ , ] . of the respondents who did indicate behaviour change, increased hand hygiene was the most common. it would therefore be beneficial and at minimal cost for institutions such as universities to provide extra hand-washing facilities and posters encouraging compliance in communal areas and computer labs. universities could also boost hygienic practices by openly distributing small bottles of hand gels or tissue packets to staff and students on campus. close to % of our respondents stated that they were 'very willing' to receive a hypothetical pandemic vaccine. as the survey period ended before the vaccine became available, we were unable to follow up participants to ascertain if they did receive the vaccine. in australia, the h n vaccine was not released until september , by which time, virus activity was very low. a recent national survey [ ] , found that although % of the australian cohort was aware of an available pandemic vaccine, less than % had received the vaccine. we can therefore expect similarly low vaccination rates in our cohort. the survey also identified that uptake of the h n vaccine was three times as high in those aged years and over ( %) than in those aged - years ( %), with no statistically significant difference between males and females [ ] . we found that respondents who had received seasonal influenza vaccinations in the past were significantly more likely to accept the pandemic vaccine then their non-vaccinated counterparts. these findings are consistent with several recent studies on pandemic vaccine uptake [ , ] . providing the vaccine through clinics or university health facilities should help bolster vaccine uptake, especially for international students, who may not have access to free healthcare. of the participants surveyed, asian-born respondents were the most likely to be anxious about the australian pandemic situation, rate the situation as serious, undertake specific behavioural changes and comply with public health measures. it could be hypothesised that these respondents, their families, friends or members of their communities may have been exposed to previous infectious disease situations such as sars and avian influenza [ , ] . if not exposed, at the least these respondents have lived in countries where their governments have had to deal with these situations, leading to stricter infection control standards and higher levels of media exposure. interestingly, asian born respondents who have been settled in australia for longer periods were less likely to have made any lifestyle changes compared to their counterparts who have been in the country for only short amount of time. it would appear that living in australia dilutes the tendency to adopt behavioural changes, and it would be beneficial for future studies to identify aspects of australian culture which influence health behaviours. we acknowledge that this study has several limitations. these include: ( ) the survey was restricted to the unsw student, general and faculty staff, mostly highly educated sydney residents; ( ) the electronic format of the survey may have excluded persons without internet access; ( ) we did not defin what "requested by the authorities meant" so it was open to the respondents interpretation and ( ) the survey was not translated into other languages. however, english is the dominant language used in both teaching and communication and unsw relies heavily on electronic communication with its campus population to disseminate other unrelated information in english. there was no established measure of influenza protective behaviour, as most of the survey items were developed prior to the publication of the cdc guidance for responses to influenza for institutions of higher education [ ] . the declining number of participants who accessed the online survey towards the end of the survey period likely restricted analysis of how responses to the pandemic change over time. from the study results, several key messages should be drawn. firstly, risk perceptions and anxiety are low and will remain so unless there is a major shift in the virus. this will continue to impact on compliance or uptake of mitigation strategies. secondly, more effective health communication and management is needed to promote self-isolation and infection control in the event of illness especially amongst students. these students are unlikely to adopt behaviours that are unknown to them. therefore the focus should be on handwashing and cough etiquette. lastly, universities must invest in online teaching resources and training during inter-pandemic periods. there also needs to be greater recognition for the need for online assignment submission and examinations to ensure minimal disruption to the students. national centre for immunisation research and surveillance of vaccine preventable diseases (ncirs), the children's hospital at westmead and discipline of paediatrics and child health australian government department of health and ageing: pandemic (h n ) australian department of health and ageing: australian influenza surveillance report no colds and influenza-like illnesses in university students: impact on health, academic and work performance, and health care use on the use of college students in social science research: insights from a second-order meta-analysis cdc guidance for responses to influenza for institutions of higher education during the - academic year public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey openepi: open source epidemiological statistics for public health pandemic policy and planning considerations for universities: findings from a tabletop exercise. biosecurity and bioterrorism: biodefense strategy, practice, and science pandemic influenza in australia: using telephone surveys to measure perceptions of threat and willingness to comply the community's attitude towards swine flu and pandemic influenza australian government department of health and ageing: pandemic (h n ) predicting the anticipated emotional and behavioral responses to an avian flu outbreak longitudinal assessment of community psychobehavioral responses during and after the outbreak of severe acute respiratory syndrome in hong kong adult vaccination survey provisional topline results for h n vaccination uptake. canberra: australian government department of health and ageing acceptance of pandemic (h n ) pandemic influenza vaccination by the australian public does receipt of seasonal influenza vaccine predict intention to receive novel h n vaccine: evidence from a nationally representative survey of world health organisation: avian influenza: assessing the pandemic threat. world health organisation severe acute respiratory syndrome (sars) pre-publication history the pre-publication history for this paper can be accessed here submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution authors' contributions dv/hs participated in the design of the study and survey, undertook the distribution and collection, performed the analysis and drafted the manuscript. mlm participated in the design of the study and survey, assisted with the analysis and reviewed the manuscript. jc/crm participated in its design and coordination and helped to draft the manuscript. all authors read and approved the final manuscript. raina macintyre receives funding from influenza vaccine manufacturers gsk and csl biotherapies for investigator-driven research. these payments were not associated with this study. the remaining authors have no competing interests. key: cord- -seass p authors: li, xingming; huang, jianshi; zhang, hui title: an analysis of hospital preparedness capacity for public health emergency in four regions of china: beijing, shandong, guangxi, and hainan date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: seass p background: hospital preparedness is critical for the early detection and management of public health emergency (phe). understanding the current status of phe preparedness is the first step in planning to enhance hospitals' capacities for emergency response. the objective of this study is to understand the current status of hospital phe preparedness in china. methods: four hundred hospitals in four city and provinces of china were surveyed using a standardized questionnaire. data related to hospital demographic data; phe preparation; response to phe in community; stockpiles of drugs and materials; detection and identification of phe; procedures for medical treatment; laboratory diagnosis and management; staff training; and risk communication were collected and analyzed. results: valid responses were received from ( . %) of the hospitals surveyed. of the valid responses, ( . %) hospitals had emergency plans; . % had command centres and personnel for phe; . % included community organisations during the training for phe; . % could transport needed medical staff to a phe; . % had evaluated stockpiles of drugs; . % had evaluated their supply systems; . % had developed surveillance systems; and . % could monitor the abnormity(see in appendix). physicians in . % of the analyzed hospitals reported up-to-date knowledge of their institution's phe protocol. of the respondents, . % followed strict laboratory regulations, however, only about . % had protocols for suspected samples. furthermore, only . % could isolate and identify salmonella and staphylococcus and less than % could isolate and identify human h n avian flu and sars. staff training or drill programs were reported in . % of the institutions; . % periodically assessed the efficacy of staff training; % had experts to provide psychological counselling; . % had provided training for their medical staff to assess phe-related stress. all of the above capacities related to the demographic characteristics of hospitals and will be discussed in-depth in this paper. conclusion: our survey suggested that, at the time of the survey, hospital preparedness for phe in china was at an early stage of development. comprehensive measures should be taken to enhance hospital capacity in the prevention and management of phe. public health emergency (phe) is an event or events that cause or may cause harm to the health of a community or nation [ ] . to prevent and/or minimize the harm caused by phe, early detection and management are necessary. as hospitals are the main location for phe surveillance and treatment, their preparedness is critical for phe's early detection and management [ ] . evaluating the current status of phe preparedness within the hospital system is the first step in improving a nation's preparedness for a phe. yet, there is no national data on china's hospital phe preparedness capacity aside from two studies that addressed the issues at local level [ , ] . to understand the current status of hospital phe preparedness in china, a sample survey of hospitals in four representative city/ provinces were conducted between november and march . the survey used a cross-sectional study design to survey hospitals in different regions of china. respondents were all secondary and tertiary hospitals(the detail of hospital classification see in appendix) in the city of beijing and provinces of shandong, guangxi, and hainan. the selection of hospitals in these four regions is intended to represent a variety of regional economic status. broadly speaking, beijing and shandong are economically well developed, hainan moderately developed, and guangxi developing [ ] . according to the hospital classification method issued by the national bureau of statistics of china, the surveyed hospitals included general hospitals, hospitals of traditional chinese medicine (tcm), hospitals of integrated traditional chinese medicine and western medicine (tcm-wm), specialized hospitals, community health center, and medical emergency center (the definition of community health center and medical emergency center see in appendix) [ ] . four hundred secondary and tertiary hospitals were surveyed. the study was approved by the institutional review board (irb) of the school of basic medicine, peking union medical college in beijing, china. based on a literature and government document review, a detailed methodological approach for research framework and questionnaire development was followed to inform the development of this study [ ] . an indicator system framework was created and questionnaire designed based on the framework. the questionnaire consists of sections and items. the questionnaire and the survey protocol (including field work manual and quality control procedures) were tested by a pilot study. for the purpose of this study, we analyzed the data focused on the following nine areas of interest: ( ) hospi-tal's demographic data (including region, sars crisis experience, teaching function, hospital type, and number of medical staff in related departments); ( ) hospital phe preparation (emergency plans, response initiating time, accessibility, and revision and implementation of emergency plan); ( ) response to a community phe (cooperation with local organizations, relationship with the community phe network, medical treatment, and rescue work in the community); ( ) stockpiles of drugs and materials (stockpiles of drugs and other resources and personal protective equipment); ( )phe detection and identification (syndrome surveillance); ( ) procedures for medical treatment (protocol for diagnosis, treatment, and transfer of phe victims); ( ) laboratory diagnosis and management (laboratory regulation and management system, sample disposal and evaluation system, collection and disposal of suspected samples, and diagnosis of pathogen/etiology); ( ) staff training (organization of phe training, current training of medical staff, curriculum development and training effectiveness assessment); and ( ) risk communication (organization for communication of risk psychological counseling to victim and medical staff, and communication with public). excluding aspect , items - (covering survey questions) represent types of phe preparedness capacities. each answered item was scored for "yes" and for "no" or "unknown". item scores were calculated by adding together "yes" answers. items scores were used as a proxy for measuring phe preparedness in an institution. a total item score was measured by calculating the score across all items. the higher the total item score, the better the hospital phe preparedness capacity. further analyses were conducted to understand the correlation between preparedness capacity and demographic information. the distribution of the related preparedness capacities across categories of phe [ ] and types of etiology was also assessed. a computerized questionnaire stored in a cd was sent to the targeted hospitals accompanied by an official letter from each of the four city and provincial health departments stating the importance of the survey and requiring that each hospital designates a department director to be responsible for coordinating the completion of the questionnaire. each returned questionnaire was carefully reviewed for its completeness and consistency. for those questionnaires with incomplete and/or inconsistent responses, one or two follow-up telephone calls were made to ensure completeness and consistency. the data from returned questionnaires were then transferred into a database for analysis. a database was set up using microsoft excel . data was checked, cleaned, and analyzed using spss software version . . ninety-five percent confidence interval of means ( % ci) was used to describe phe preparedness capacities. categorical variables were analyzed with frequency and percentage. comparisons of mean score of each of eight phe preparedness capacities among different types of hospitals were performed with p < . as statistical significance using parameter test (independent-samples t test (two-tailed) or one-way analysis of variance) and/or non-parameter test (mann-whitney test or kruskal-wallis test) based on data distribution characteristics and homogeneity. four hundred hospitals responded, with a response rate of %. however, seventy-seven questionnaires were excluded from analysis due to one of the following reasons: ( ) if less than % of items in the questionnaire were not answered, or ( ) hospital did not meet secondary and/or tertiary hospital standard according to the hos-pital classification system. therefore, the valid response rate was . %. of analyzed hospitals ( ), . % were in beijing, . % in shandong, . % in guangxi and . % in hainan. in terms of hospital type, . % were teaching hospitals. the mean number of physicians and nurses per hospital was . , and the mean number of total medical staff per hospital was . . the mean number of physicians and nurses in emergency department and infectious-disease department were . and . , respectively. table shows the demographic characteristics of the analyzed hospitals. of hospitals, ( . %) had an emergency plan. among the hospitals that had an emergency plan, . % reported that the institution possessed a protocol to initiate the emergency plan, . % had a classification system for different phe events, . % had evaluated and revised their emergency plan at least once, and . % reported that their emergency plan was accessible to all and table . of all analyzed respondents, . % were designated as the local emergency hospital for phe patient admissions and . % of them were the designated hospitals to provide medical rescue services during a national disaster. of all analyzed respondents, . % could promptly transport needed medical staff to the phe field, . % reported that they were prepared to respond to the needs of vulnerable people (including women, children, pregnant women and the disabled) during a phe, however, only . % had evaluated their ability to increase beds and equipment for phe. when performing a phe preparedness drill, . % of respondents reported that they would invite relevant community organizations to participate. with regard to capacity comparison, the statistics test showed: the total item score of hospitals in beijing( % ci: . , . ) was lower than that of hospitals in shandong ( % ci: . , . ) and guangxi( % ci: . , . ); the score of teaching hospitals( % ci: . , . ) was higher than that of non-teaching hospitals( % ci: . , . ); and the score of tertiary grade a ( % ci: . , . ) and b ( % ci: . , . ) hospitals was higher than that of secondary grade b ones( % ci: . , . ), respectively. among all types of hospitals, community health center scored highest on this aspect. our results revealed that . % of respondents had evaluated their stockpiles of drugs, and . % had established a relationship with suppliers to provide emergency drug- supplies, however, only . % had signed written contracts with suppliers. of all analyzed respondents, . % had drug-distribution plans, and . % knew where the national or local pharmacy distribution centers were located. in regards to other medical materials, . % had stockpiles of materials for responding to phe. as for the stockpiles of drugs for infectious diseases, about . %, . % and . % of responding hospitals had drug stockpiles for treating infectious diarrhea, influenza and botulismo toxin, respectively. when hospitals were compared on this item, statistical analysis showed that institutions in beijing ( % ci: . , . ) had a higher score than that of shandong ( % ci: . , . ). tertiary hospitals generally had a higher score than secondary ones. among all the respondents, . % reported that they had developed syndromic surveillance systems for certain diseases and . % required that physicians on duty should report any abnormity to the hospital's presidents (the definition of abnormity see in appendix). abnormity in admission diagnosis, routine microbiological tests, emergency room patients, and death with unknown causes were systematically monitored by . % of institutions and . % of hospitals shared their surveillance information with the local health authority. there were statistically significant differences between tertiary grade hospitals (grade a % ci: . , . ; grade b % ci: . , . ) and secondary grade b hospitals ( % ci: . , . ) for this capacity, with tertiary hospitals scoring higher on their ability to detect and identify a phe. physicians in . % of the responding institutions reported being familiarized with the latest treatment protocol for a phe, . % could transfer phe victims to corresponding medical agencies for appropriate treatment, and . % could provide training on the protocol system. however, only . % had specific procedures for patient transfer in a phe. as for infectious disease treatment protocol, . % had protocols for sars, but only . % for brucellosis. with regard to the capacity comparison among all the respondents, . % reported that they had a training program for the following medical staff: infection managers ( . %); emergency department physicians and nurses ( . %); and infectious disease ward physicians and nurses ( . %). staff training was supervised by a designated person in . % of institutions and . % had training curriculums, . % of which was updated regularly. effectiveness of phe training was periodically assessed in . % of respondents. for this capacity, statistical significance indicated that respondents in shandong ( % ci: . , . ) scored higher than participating institutions in guangxi ( % ci: . , . ). serious phe concerns were raised in china during the sars crisis when it became apparent that hospitals possessed poor emergency preparedness [ ] . even the upcoming olympics game in beijing and the . earthquake disaster in china have dramatically evoked the awareness of phe preparedness capacity for hospital. based on the experience of the sars pandemic, all hospitals should possess fundamental phe programs, including preparedness of drugs, equipment, staff, emergency education and staff training [ , , ] , coordination with relevant community bodies [ ], medical treatment [ ] , early detection and warning [ ] , laboratory diagnosis [ ] [ ] [ ] and psychological intervention [ ] . since the sars crisis, the central chinese government has become more active in the construction of public health system, especially in regards to the medical emergency response system [ ] . one major effort involved a . billion rmb investment in local governments to initiate the construction of regional phe medical treatment systems [ ] . in order to offer some insight into the development of hospital phe preparedness capacity, this study examined the current status of hospital preparedness in beijing, shandong, guangxi, and hainan. emergency preparedness refers to the processes involved in ensuring an institution: ( ) has complied with the preventive measures; ( ) is in a state of readiness to contain the effects of a forecasted disastrous event in order to minimize loss of life, injury, and damage to property; ( ) can provide rescue, relief, rehabilitation, and other services in the aftermath of the disaster; and ( ) holds the capability and resources to continue to sustain its essential functions during a phe [ ] . an emergency preparedness systems primarily composed of emergency plans and organizational structures and lays the foundation for dealing with phe [ ] . emergency plans establish the protocol for operation under a phe [ ] . for a hospital to mobilize all phe resources in a short period of time, contingency plans must be issued in advance [ ] . in addition, periodic review and updating of emergency plans enhance an institution's emergency response capacity [ ] . our study showed that most hospitals had emergency plans and that these plans focused on infectious diseases control with less attention to preparedness for biological, nuclear radiation and other terrorism attacks. most of the hospitals had phe command departments and emergency response teams, however, only . % of hospitals with emergency plans reported they had evaluated and revised their phe systems. overall, tertiary hospitals performed better in phe preparation than secondary hospitals. meanwhile, no statistical significance was found between hospitals that had admitted sars patients and those that had not, suggesting that after the sars crisis, all hospitals raised awareness of emergency plans and implementation. no hospital or medical system can manage a public health emergency without community networks and public involvement. therefore, hospitals need to communicate and cooperate with other local health agencies, functioning as a networked public health provider. problems like lack of communication and coordination between hospital departments and inter-agency networks hinder the availability of resources in a community and limit timely forecasting, public communication and effective regulation of a phe [ ]. our survey revealed that if a phe occurred, most of hospitals reported that they could take responsibility for phe rescue service, transport the medical staff in a timely manner, and provide priority health services to vulnerable populations. yet, less than one third of respondents attended regulation and revision workshops for emergency plans for infectious epidemic control held by local agencies. this lack of cross-institutional interaction indicated that the ability of hospitals to coordinate with community agencies in preparation for, or in the event of a phe was generally poor. the survey showed that among all the types of respondents community health center were best able to respond to phe and the respondents with multiple functions performed better suggesting that communication and coordination between hospitals and community agencies should be strengthened. characteristics of a phe include suddenness and unpredictability [ ] . for most hospitals, medicine storage may be in great demand when faced with a sudden increase in patients. therefore, hospitals must have programs to ensure appropriate levels of emergency supplies including drugs, medical equipment, electricity, water and oxygen, disinfectant, etc. our survey suggested that most of the hospitals could establish an emergency-drug-supply system for most of the infectious diseases we addressed in the questionnaire except anthrax, brucellosis, botulism toxin poisoning and tetramine poisoning. for most of surveyed hospitals possessed emergency resource reserves, but less than half of them had corresponding drug distribution programs. in addition, hospital capacity was affected by economic level and classification of the hospital, suggesting that the importance of local economic development strengthens hospital ability to provide phe. early detection and identification of a phe are amongst the most important objectives for prompt and effective public health response to a phe [ ] as well as an essential precondition for selecting appropriate prevention and treatment measures. this study showed that most of the hospitals could regularly train medical staff on how to report and identify suspicious phe and that the institutions possessed surveillance systems to monitor various aspects of abnormity. approximately half of the respondents could share surveillance information with the local health authorities. there were statistically significant differences among various classification of the respondents, which demonstrated that after the sars crisis, hospitals at all levels attached high importance to phe monitoring and early warning system, however, the capacity was affected by the comprehensive strength of hospital. phe happens suddenly and its incidence rate is relatively low, which leaves most medical staff inexperienced and unprepared [ ] . therefore, it is important that hospitals develop emergency plans for phe treatment programs. in this survey, more than half of respondents showed that their physicians were aware of current phe protocols. most hospitals had transfer and treating procedures for infectious diseases, including sars, influenza, and infectious diarrhea, but less held these procedures for biochemical incidents, leakage of nuclear, and terrorist attacks. because they are easily used as biological terrorist attacks materials [ ] , therefore, the prevention and control of these emergencies become very important. our statistical analyses showed that tertiary-grade, teaching and tcm-wm hospitals performed better on medical treatment procedures preparedness, which might reflect the fact that different types of hospitals have different functions and mission in the community, however, for this capacity, the statistical significance among different regions showed the important role that economic factor plays. hospital laboratories not only have the task of clinical diagnosis, but take some responsibility in the surveillance of public health [ , ] . therefore, laboratory informa-tion plays an important role in detection of the phe [ , ] . detecting phe related pathogen/etiology can not only confirm clinical diagnosis, but also identify newly emerging infectious diseases [ , ] . the presence of sars in china in , and the slow response to its emergence, revealed that china's public health laboratory systems were weak [ ] . this survey indicated that many of the hospitals did not report adequate laboratory diagnostic capacities. although hospital laboratory regulations seemed relatively good, only one-third of hospital laboratories had programs for dealing with suspicious samples collecting, disposal and delivery. [ ] . when phe occurs, hospital medical staff are usually the first responders and information providers, therefore, education and training are key measures to enhance phe response [ ] . our survey suggested that after sars crisis, most hospitals re-evaluated the importance of medical staff training for phe. the majority of respondents offered training programs to their related medical staff. however, the effectiveness of these training programs needs to be periodically evaluated. phe can cause psychological as well as physical problems for the public and medical staff attending to victims [ , ] . in a public health crisis or emergency, effective risk communication can help people cope, make decisions, and return their lives to normal. crisis communication, as an important part of a phe response [ ] , is key to ensuring complete, transparent and prompt information exchange, and to help hospitals make timely responses and reduce the serious consequences [ ] . the results of this survey revealed that medical staff in . % of the hospitals underwent training for evaluation of phe-related stress and only one-third of respondents had specific programs and spokespersons for communicating critical messages and information to the media, public, governments and stakeholders. these results indicated that most of the surveyed hospitals do not understand the importance of psychological care in a phe emergency, do not have the resources to deal with it, or presume that it is not their place to do so. indeed, this capacity evaluation revealed that when a phe occurred, most hospitals' response plans focused on physiological medical treatment, but health education, psychological counseling, and crisis communication plans were rare. however, for this capacity, the statistical significance among different regions and levels showed the important role that economic factor and comprehensive level play. the study has several limitations. first of all, the surveyed hospitals were restricted to four city and provinces, even some types of hospitals were rare (the number of the surveyed community health center and emergency center was just one, respectively), therefore, the results may not fully represent the phe capacity of all hospitals in china. secondly, because of self-report method there may be a respondent reporting bias. the inclusion of official documents from respective health bureaus, for example, may have encouraged respondents to complete survey but have also been interpreted as an official assessment of capacity leading some hospital representatives to overestimate phe capacity. thirdly, only quantitative data were collected to measure certain capacities of phe preparedness. most questions required a "yes" "no" or "unknown" answer which restricts the collated data to these three categories. finally, this data set is not complete as some hospitals did not respond and others had to be excluded on the basis of incomplete answers or for ineligibility for hospital classification. to a certain extent, this loss of respondents caused a loss of information. after several years of construction and development, the capability of hospitals in china to deal with phe, in particular infectious diseases control, has improved greatly [ , ] . nevertheless, this research suggests that china has more progress to make before phe preparedness is satisfactory. to enhance hospital preparation for dealing with phe, governments at all levels should increase investment in the construction of infrastructure to create and sustain appropriate phe capacity. on the other hand, hospitals at all levels should enhance their management, including updating and revising of emergency plans; strengthening communication and cooperation with other local agencies; enhancing the capacity of abnormity monitoring and laboratory diagnostic capability for infectious diseases; improving the treatment program for various phe scenarios; and strengthening psychological intervention and risk communication capabilities. finally phe preparedness in relation to terrorism caused by nuclear radiation and biochemical substance was low in this study and should be further assessed for areas of need and improvement. the regulations on emergency public health events, decree no. the location of medical institutes in public health emergency response system an analysis of the current status of hospital emergency preparedness for infectious disease outbreaks in beijing an analysis of the current hospital emergency responding capacity in the province of heilongjiang c: health statistic yearbook of china in . beijing, peking union medical college press; . . national bureau statistics of china: hospital classification method accessed on mechanism of public health emergency response at the eighth meeting of the standing committee of the tenth national people's congress. gazette of the standing committee of the national people's congress of the people's republic of china song rl: the statute of public health emergency and procedures for infectious atypical pneumonia prevention. beijing: china legal publishing house national development and reform commission and ministry of health of the p.r.c: planing for construction of medical treatment system accessed on september meeting the challenge of bio-terrorism: lessons learned from west nile virus and anthrax the role that symptom surveillance plays in coping with public health emergency zhang hw: the survey for current status of public health laboratory of part provinces in china medical examiners and bio-terrorism the laboratory network building of infectious diseases surveillance. the journal of diseases surveillance draft capacity assessment guidelines & the program approach social development department of national development and reform commission of the people's republic of china: national debt project of medical treatment system business dictionary web site: the definition of emergency preparedness assessing levels of hospital emergency preparedness a manual for health emergency preparedness. beijing: people's medical publishing house bio-terrorism: implications for the clinical microbiologist which public health respond system should be built in china from sars crisis assessing hospital preparedness using an instrument based on the mass casualty disaster plan checklist: results of a statewide survey education is the key to defense against bio-terrorism who: community emergency preparedness: a manual for managers and policy-makers beijing. beijing, people's military medical publishing house hospital management. beijing, people's health publishing house we appreciate all hospitals who participated in this survey. specifically we would extend our thanks to the following persons who offered great assistants in the process of data collection, data analysis, and manuscript drafting. they are peng lv (beijing); lixin ma (shandong); faqing chen (guangxi); and wenli pan (hainan). abnormity: abnormity means the rapid increase of emergency room patients with acute asthma, flu, fever of unknown causes.hospital classification: according to "the hospital classification system" of the ministry of health of people's republic of china, all hospitals in china are classified into primary, secondary, and tertiary hospitals based on their functions in providing medical care, medical education, and conducting medical research. a secondary hospital is defined as a regional hospital that provides comprehensive medical care, medical education, and medical research for the region. a tertiary hospital is defined as cross-regional, providing comprehensive and specialized medical care with a high level of medical education and research functions. secondary and tertiary hospitals are further classified into subgroups: grade a, grade b, and grade c according to their service levels, size, medical technology, medical equipment, and management and medical quality [ ] .community health center: community health center is a kind of primary health care delivery in china, most of which are transferred from secondary grade hospitals, and provide preventive, curative care, maternal and child care, rehabilitation and health education to local inhabitants by general practitioners, community nurses and public health workers.medical emergency center: medical emergency center (first aid station) is a kind of emergency health care delivery in china, which provide emergency care, first aid, monitoring and treatment for all those patients with prehospital emergencies. the authors declare that they have no competing interests. jsh designed the study and developed the tools. hzh participated in design of the study and development of the tools, and supervised the data collection and data entry. xml performed data checkup, data analysis and drafted the manuscript. all authors participated in discussion, revision and approved of the final manuscript. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -up ii vw authors: schwind, jessica s; goldstein, tracey; thomas, kate; mazet, jonna ak; smith, woutrina a title: capacity building efforts and perceptions for wildlife surveillance to detect zoonotic pathogens: comparing stakeholder perspectives date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: up ii vw background: the capacity to conduct zoonotic pathogen surveillance in wildlife is critical for the recognition and identification of emerging health threats. the predict project, a component of united states agency for international development’s emerging pandemic threats program, has introduced capacity building efforts to increase zoonotic pathogen surveillance in wildlife in global ‘hot spot’ regions where zoonotic disease emergence is likely to occur. understanding priorities, challenges, and opportunities from the perspectives of the stakeholders is a key component of any successful capacity building program. methods: a survey was administered to wildlife officials and to predict-implementing in-country project scientists in participating countries in order to identify similarities and differences in perspectives between the groups regarding capacity needs for zoonotic pathogen surveillance in wildlife. results: both stakeholder groups identified some human-animal interfaces (i.e. areas of high contact between wildlife and humans with the potential risk for disease transmission), such as hunting and markets, as important for ongoing targeting of wildlife surveillance. similarly, findings regarding challenges across stakeholder groups showed some agreement in that a lack of sustainable funding across regions was the greatest challenge for conducting wildlife surveillance for zoonotic pathogens (wildlife officials: % and project scientists: %). however, the opportunity for improving zoonotic pathogen surveillance capacity identified most frequently by wildlife officials as important was increasing communication or coordination among agencies, sectors, or regions ( % of wildlife officials), whereas the most frequent opportunities identified as important by project scientists were increasing human capacity, increasing laboratory capacity, and the growing interest or awareness regarding wildlife disease or surveillance programs (all identified by % of project scientists). conclusions: a one health approach to capacity building applied at local and global scales will have the greatest impact on improving zoonotic pathogen surveillance in wildlife. this approach will involve increasing communication and cooperation across ministries and sectors so that experts and stakeholders work together to identify and mitigate surveillance gaps. over time, this transdisciplinary approach to capacity building will help overcome existing challenges and promote efficient targeting of high risk interfaces for zoonotic pathogen transmission. capacity building is an important tenet in the area of global health advancement [ ] . a conceptual approach that focuses on resource utilization and sustainability, capacity building is a term often used in international development where programs are implemented in developing countries with the overall aim to improve the population's skills, abilities, and organizational capabilities. in the public health sector, capacity building generally refers to improvement of a system's (e.g. country's) ability to increase the capability to conduct surveillance and monitoring of public health, perform medical research, improve health programs, and establish disease prevention/control measures. the process of building capacity using a one health approach may benefit public health and animal health by utilizing strategies that bridge health sectors and disciplines for improving infrastructure, personnel training, and surveillance networks [ , ] . in the past century alone, the number of emerging infectious diseases with international implications have increased [ ] . with globalization, local disease activity now has the potential for global consequences. recent outbreaks, such as sars and influenza, highlighted the basic need for in-country capabilities for disease recognition and identification at the source of emergence as a part of an early warning system for emerging and reemerging health threats [ ] . in , the united states agency for international development (usaid) launched an emerging pandemic threats (ept) program in order to address the threat to human health posed by emerging infectious diseases from wildlife. as one of the four projects in the ept program, the predict project was implemented in order apply a one health approach to monitor for and increase local capacity in 'geographic hot spots' so as to identify the emergence of potentially zoonotic pathogens in high-risk wildlife that could pose a major threat to human health [ ] . with approximately % of recent emerging infectious diseases being zoonotic and % of those originating in wildlife [ ] , improving viral surveillance in potential wildlife hosts was a critical component of the predict program. studies have shown that countries conducting wildlife pathogen surveillance are more likely to understand the disease dynamics within their borders and thereby may be better equipped to limit the risk of pathogen spillover across wildlife, domestic animal, and human populations [ , ] . a prominent example was the monitoring of wild bird populations in order to investigate the transmission of avian influenza viral subtypes across species [ ] . while some countries conduct wildlife disease surveillance as a part of routine management, most countries still only address events in post-outbreak scenarios. it is clear that successful capacity development requires the strengthening of local, regional, and global networks. for implementation, this goal may be best achieved once attitudes and perspectives regarding current capacity building efforts and priorities are adequately understood at each of these levels. within the predict project, 'rapid survey' questionnaires were designed to be used as a low cost and relatively quick method to examine the incountry teams' capacities, challenges, and opportunities for conducting zoonotic pathogen surveillance in wildlife. the aim of this study was to evaluate the similarities and differences between the perspectives of wildlife officials and predict's in-country project scientists regarding current priority interfaces, challenges, and opportunities for surveillance. data for this study were collected from predictparticipating countries in latin america, central/east africa, and asia/southeast asia, representing diverse regional perspectives on capacities for zoonotic pathogen surveillance in wildlife populations. respondents from out of invited countries where the predict program was active ( % participation) completed the questionnaire (rapid survey tool): cameroon, democratic republic of congo, republic of congo, gabon, rwanda, united republic of tanzania, and uganda in africa; bolivia, brazil, mexico, and peru in latin america; and bangladesh, cambodia, lao people's democratic republic, malaysia, and vietnam in asia/southeast asia. two predict countries did not submit completed surveys and three predict countries were not included because they were just beginning or ending their programmatic activities at the time of the survey. for each participating country, a lead predict project scientist with veterinary training and wildlife expertise was encouraged to complete the survey using individual knowledge and local resources regarding conditions observed in-country. following completion of their portion of the survey tool, each project scientist was then asked to interview at least one wildlife official within their country for completion of the stakeholder portion of the rapid survey tool. the rapid survey included questions regarding perspectives on priority interfaces, challenges, and opportunities for conducting wildlife zoonotic pathogen surveillance in each country (additional file ). for each of these categories, a list of choices was provided, with stakeholders instructed to rate their importance as important, unimportant, or unknown. project scientists were also asked to indicate the priority interfaces where the project was operational in each respective country. additionally, all stakeholders were asked about any knowledge of recent outbreaks involving wildlife. though beyond the scope of this publication, the rapid survey was also used internally to track in-country project progress, explore cooperation between health sectors, better understand organizational efforts for the improvement of wildlife health, and examine systematic improvements in wildlife pathogen surveillance occurring during the project timeline. baseline demographics of all participants (wildlife officials and project scientists) were compared, including the stakeholder region (latin america, asia/southeast asia, africa), gender (male, female), organization affiliation type (governmental, non-governmental, university) and reach (international, national, local). characteristics regarding the collaborating partner organizations that work alongside project scientists in-country were also noted. a combination of basic frequencies and percentages were utilized to evaluate wildlife surveillance efforts, including the priority interfaces, challenges, and opportunities for conducting wildlife pathogen surveillance in each country and region, from both the wildlife officials' and project scientists' perspectives. to determine how human-animal interface rankings compared to ongoing animal sampling efforts, the project scientists were asked to list the high-priority interfaces that were important for zoonotic pathogen surveillance in wildlife in each country. additionally, project scientists were also asked to indicate the interfaces where current predict surveillance efforts were operational. the percentage of stakeholders that identified each interface as important were compared to each other, as well as to the interfaces where predict's current surveillance efforts were focused, in order to identify disparities across groups. a list of global challenges and opportunities for conducting and improving surveillance for zoonotic pathogens in wildlife was also given to the wildlife officials to rate the importance of each challenge or opportunity. project scientists were asked to list the challenges and opportunities for building capacity in their respective countries to implement and sustain effective surveillance of zoonotic pathogens in wildlife populations. the project scientists' answers were coded into the same categories given to the wildlife officials, and then comparisons were made of the percentages of respondents who identified each particular descriptor as a challenge or opportunity in each stakeholder group. both the wildlife officials and project scientists were also asked about the occurrence of disease outbreaks in humans or livestock that may have originated from wildlife in recent years in order to determine the overlap between the two groups in their knowledge of outbreaks and the extent of predict involvement in each country based upon the identified outbreaks by each stakeholder group. associations between the stakeholder groups (wildlife official, project scientists) and the wildlife pathogen surveillance risk factors and outcomes (priority interfaces, challenges, and opportunities) were evaluated using contingency tables. a fisher's exact test was used for all categorical variables with cell frequencies less than , and a chi-square test was used for all categorical variables with cell frequencies of or more. all results were also stratified by global region (africa, america, asia) for the purpose of grouping similar countries in order to identify the characteristics of the region. the sub-group analyses utilized a fisher's exact test or chi-square test where appropriate. all analyses were conducted using stata™ (version . , statacorp, college station, tx) and a pvalue of ≤ . was regarded as significant. all research conducted was determined to be exempt from ethics review by the institutional review board at university of california, davis (# - ). twenty-two wildlife officials and project scientists completed the survey ( table ). the gender composition was an approximate : ratio of males ( , %) to females ( , %) among the wildlife officials, while the gender composition was a : ratio ( , %) among project scientists. of the wildlife officials, ( %) represented a governmental department with a national reach and ( %) with a local reach. thirteen ( %) project scientists were affiliated with non-governmental organizations and ( %) with universities, all with an international reach. a limited number of wildlife official surveys were completed through email ( , %) rather than by an inperson interview by the project scientist, due to time constraints and logistical limitations. key human-animal interfaces, areas where wildlife and humans were in close contact and thus potentially important for disease transmission, recognized by wildlife officials and project scientists, were compared to identify similarities and differences in perceived importance between the two stakeholder groups ( table ). the categories were also aligned with the interfaces where the predict project's efforts were currently focused in each country in order to identify potentially important areas for surveillance efforts. significant differences between the stakeholder groups, wildlife officials and project scientists, were seen at the human-animal interfaces of butchering wildlife (p < . ), wildlife-livestock interactions (p < . ), shared water sources (p < . ), and areas of land use change (p < . ), indicating categories with the greatest disparities and potential for education or programmatic improvement. at all interfaces, the overall percentage of wildlife officials that indicated the interfaces were important for zoonotic pathogen transmission was larger compared to the percentage of project scientists. stratification by global region revealed significant differences between the stakeholder groups on the importance of the interfaces for surveillance. in latin america, a higher percentage (p < . ) of wildlife officials ( %) indicated that shared water sources were an important interface for conducting surveillance for zoonotic pathogens in wildlife compared to project scientists ( %). in asia, a significantly higher (p < . ) percentage of wildlife officials ( %) indicated the areas where wildlife were butchered were an important interface compared to project scientists ( %). no statistically significant differences were observed between stakeholder groups in africa. to further understand where greater local capacity building efforts were needed, the percentage of high priority interfaces, where predict activities were focused, was evaluated. the majority ( %) of country teams were working in greater than % of the high priority interfaces. additionally, %, %, and % of country teams in asian, latin american, and african countries, respectively were working in % of their high priority interfaces. lack of sustainable funding and/or resources was the greatest challenge associated with conducting wildlife surveillance for zoonotic pathogens, as identified by both the wildlife official ( %) and project scientist groups ( %) (figure ). however, there was no agreement in the ranking of the other important challenges identified by both stakeholder groups. the second most important challenge as identified by project scientists was insufficient laboratory capacity ( %), whereas the second most important challenge identified by wildlife officials was the lack of existing government wildlife surveillance programs or wildlife policies ( %). when examined by global region, lack of sustainable funding was the challenge identified by most officials in all three areas (latin america: %; asia: %; africa: %). lack of existing government wildlife surveillance programs or wildlife policies and insufficient communication or coordination among agencies, sectors, or regions were also identified as important by at least % of wildlife officials in all three regions. when examining the differences between the two stakeholder groups, a significantly higher number (p < . ) of wildlife officials ( %) thought that insufficient human capacity (i.e. trained personnel) was a major challenge for effectively conducting wildlife surveillance for zoonotic pathogens compared to project scientists ( %). statistically significant differences between the two stakeholder groups were also observed with ranking the challenges of insufficient communication or coordination (wildlife officials: %, project scientists: %, p < . ), limited interest/awareness regarding wildlife disease (wildlife officials: %; project scientists: %, p < . ) and cultural acceptability in conducting wildlife surveillance for zoonotic pathogens (wildlife officials: %; project scientists: %, p < . ). overall for each challenge, a larger percentage of wildlife officials identified the descriptors as important when compared to project scientists. the top opportunity important for improving wildlife surveillance for zoonotic pathogens identified by wildlife areas of land use change* % ( ) % ( ) % ( ) note: these rankings are intended to be used as a comparison of stakeholder perspectives and do not represent the actual scientific importance of all possible interfaces or sampling situations encountered in zoonotic pathogen surveillance. *indicates a statistically significant difference (p < . ) between perspectives among two stakeholder groups. officials was increasing communication or coordination among agencies, sectors, or regions ( %) (figure ). however, the most important opportunities identified by project scientists were increasing human capacity, increasing laboratory capacity, and the growing interest or awareness regarding wildlife disease or surveillance programs (all %). opportunities for capacity building in wildlife pathogen surveillance identified as important by at least % of wildlife officials were explored by region. seven opportunities for conducting wildlife surveillance were identified in all three regions, which included increasing funding ( %), increasing human capacity ( %), increasing laboratory capacity from new/existing programs and facilities ( %), building on existing surveillance networks/programs ( %), collaboration with local/foreign programs or organizations ( %), growing interest or awareness regarding wildlife diseases or surveillance programs ( %), and increasing communication or coordination among agencies, sectors or regions ( %). significant differences in how the opportunities were ranked between stakeholder groups were identified. in all instances, a larger percentage of wildlife officials identified each opportunity as important for improving wildlife surveillance for zoonotic pathogens when compared to project scientists. knowledge of disease outbreaks that were thought to have originated from wildlife in recent years were reported, and five ( %) countries identified the same outbreaks by both stakeholder groups. in latin america, % of respondents indicated knowledge of at least one figure opportunities associated with conducting zoonotic pathogen surveillance ranked by wildlife officials and project scientists as 'important'. *indicates a statistically significant difference (p < . ) between perspectives among two stakeholder groups. outbreak thought to have originated in wildlife in recent years. the outbreaks reported by respondents in this region included avian influenza, hantavirus, leptospirosis, plague, rabies, rickettsiosis, and yellow fever. in asia/ southeast asia, % of wildlife officials compared to % of project scientists knew of at least one outbreak, with just one of the five countries having the same outbreak pathogens reported by both people. outbreaks thought to have originated in wildlife in this region included anthrax, avian influenza, influenza, leptospirosis, nipah virus, and sars. in central africa, % of wildlife officials reported disease outbreaks originating in wildlife compared to % of project scientists. the identified outbreaks included anthrax, arbovirus, avian influenza, ebola, hemorrhagic fever, lyssa virus, marburg, plague, rabies, and yellow fever. we present one of the first studies to compare the perspectives of wildlife officials and project scientists in the field of wildlife surveillance for zoonotic pathogens in an attempt to understand gaps in perceptions that could lead to differential investments of governments from those of international aid organizations and the private sector in pandemic prevention. findings from this research allow for a better understanding of key components (priority interfaces, opportunities, and challenges) associated with supporting surveillance programs on local, regional, and global scales in order to identify strengths, weaknesses, and future action areas related to implementing zoonotic pathogen surveillance in wildlife. this study was useful for implementation of predict project activities by not solely relying on the predict project scientists' perceptions so that a more balanced understanding of wildlife surveillance capacity in each country could be obtained, and will indirectly benefit wildlife even if originally motivated by public health needs. taking a one health approach further to assemble transdisciplinary working groups with common interests will allow constituents such as researchers, organizations, governments, and communities to focus on innovative capacity building activities. the global health community is increasingly recognizing the intrinsic importance of capacity development and assessment, consistent with the motivation for this study and for the predict project overall. in a study examining global trends in emerging infectious diseases from to , researchers found that the global resources needed to counteract disease emergence were disproportionately focused in regions where emerging disease events were least likely to originate, such as in the developed nations of europe, north america, australia, and parts of asia [ ] . due to factors such as globalization and urbanization, diseases that emerge in once isolated areas now have the ability to cause global health crises [ ] . this interconnectivity highlights the fact that any surveillance gaps at the individual country level can affect global health. recognizing this disparity across countries, numerous efforts to build and strengthen the capacity for disease detection and response in these 'hot spots'regions identified as likely for the emergence of novel pathogens from wildlife that affect human healthwere undertaken [ ] . the predict project, along with partner organizations in over developing countries, specifically concentrated on preventing future pandemics at potential sources through the promotion of increased capacity, enhanced surveillance programs in wildlife, and a better understanding of the drivers associated with emerging health threats [ ] . this study, conducted by predict's capacity tracking team, was just one area of focus in the larger effort for global pandemic surveillance, prediction, and prevention. study findings revealed differences and similarities regarding priorities, challenges, and opportunities for wildlife surveillance for zoonotic pathogens between the stakeholders. the wildlife official and project scientist groups both indicated the importance of working at key human-animal interfaces, such as the hunting locations, markets, wildlife near dwellings, wildlife-livestock interaction, captive wildlife, and extraction areas. discrepancies across stakeholder groups regarding the relative importance of other interfaces could have been due to differences seen in each organization's current focus or limitations in each individual's area of expertise. however, gaps in program presence at interfaces that were labeled as important by wildlife officials, such as areas where wildlife were butchered, shared water sources, and land use change, remain a key focus for program improvement and stakeholder education. it is essential to note that wildlife officials were not required to rank the relative importance of the interfaces, and thus could identify as many choices as 'important' as they thought appropriate. while the instructions to the project scientists were no different, the nature of their work required the prioritization and ranking of the relative importance of interfaces on a daily basis to decide how their financial and time resources would be spent. therefore, project scientists were more likely to have a larger spread in their rankings across categories than wildlife officials. both stakeholder groups agreed that the lack of sustainable funding was the greatest challenge facing wildlife surveillance for zoonotic pathogens today. however, different opportunities for improving wildlife surveillance for zoonotic pathogens were identified between the stakeholder groups. this could be due to the fact that most project scientists were representatives from non-governmental organizations or universities, whereas the wildlife officials were from governmental organizations, and as such, the opportunities familiar to the individuals within their respective organizations were likely specific to the chances to improve capacity provided to them within their organizational framework. discovering ways to collaborate and capitalize on these opportunities across sectors is an important step in building successful wildlife pathogen surveillance programs in each country. additionally, the fact that knowledge of outbreaks potentially originating in wildlife varied by global region suggests that there was a lack of sufficient communication across stakeholder groups and that there is a need to raise awareness among stakeholders on wildlife health issues in relation to public health. in addition to current high priority interfaces where predict surveillance efforts were targeted, additional key interfaces were identified as important from the majority of wildlife officials, such as shared water sources, and should be given consideration for future surveillance efforts. given limited resources, it was not surprising that all human-wildlife interfaces could not be addressed in the initial predict surveillance program. for example, shared water sources were a lower priority for surveillance because they represented primarily indirect opportunities for zoonotic pathogen transmission given the dynamics at play where humans and animals often utilize water sources at different times. on the other hand, areas where there were more direct interactions between wildlife and humans, and thus a greater potential for pathogen transmission, were targeted more often (e.g. markets). opportunities, such as a growing interest or awareness regarding wildlife disease or surveillance programs, could be used a starting point to obtain the funding needed to increase both human and laboratory capacity for wildlife pathogen surveillance. using stakeholders to identify and help to prioritize future research directions has long been recommended [ ] [ ] [ ] [ ] . the predict project has put this principle into action by placing in-country experts, who were also wildlife stakeholders, in key longitudinal programmatic positions and by using the rapid tool surveys as a way to reach out to incorporate input from external stakeholder groups, as well. from a global health perspective, this assessment was helpful in not only meeting a short-term goal of gaining perspectives of people both within and outside the project, but also a long-term goal of obtaining buy-in and input from stakeholders to promote project sustainability within and among the hotspot regions. this study was not without limitations, given that the field of wildlife pathogen surveillance and associated best practices continue to evolve. it was recognized that the interfaces, challenges, and opportunities listed were subjective, and there was often overlap among categories. however, the options given at the time of the survey represented the main themes encountered in wildlife surveillance. the survey also concentrated on the zoonotic transmission of pathogens at key human-animal interfaces and did not specifically focus on other pathogen transmission routes in ecosystems which are extremely important from a one health perspective, such as anthroponoses and pathogens solely transmitted in non-human animals. furthermore, this study consisted of a convenience sample of a limited number of wildlife officials chosen by the project scientists. the limited sample size restricted the generalizations that could be made beyond participating countries. however, similarities on the importance of the interfaces, associated challenges, and opportunities for conducting zoonotic pathogen surveillance in wildlife would likely be seen across global regions. a potential for information bias existed due to the fact that the survey administration was different between the two groups, as the project scientists filled out the survey as directed by their supervisors, whereas the wildlife officials were mostly interviewed by the project scientists and participated on a voluntary basis, providing the opportunity for interviewer bias to arise. however, the results still showed important differences even at the regional level, suggesting that different global regions may have unique issues that could relate to specific human-animal interactions in that region or to the varying level of infrastructure and development by region, for example the fact that the latin america region is considered more developed than the asia and africa regions may present different challenges and opportunities for wildlife surveillance. the rankings were derived from survey responses that indicated whether a stakeholder thought the priority interfaces, challenges, or opportunities were important to wildlife pathogen surveillance in his or her country specifically; therefore, it would be difficult to determine if a negative response was an indication that the descriptor was not applicable to the country, or if it was just simply not considered to be important by the respondent. future areas of research should include a greater number and range of stakeholders (i.e. varying level of professional titles, education) in order to better understand differences at local, national, and regional levels. this research would help to elicit the benefits of taking a topdown or bottom-up approach to capacity building across different regions. future surveys for capacity building and tracking should also aim to gain the perspectives of domestic animal health, public health, and environmental health professionals to truly build a one health approach to disease detection for the next emerging health threat. by using low cost, rapid methods for obtaining input from stakeholders on the ground, valuable cultural insights can be gained into local risk behaviors (i.e. wildlife hunting and trade), and awareness can be raised to facilitate country buy-in for project sustainability into the future. in this study, diverse perspectives were identified among key stakeholders as to the best strategies and interventions needed to strengthen capacity for public health/animal health programs aimed at combating emerging infectious diseases [ ] . given the range of participant perspectives, understanding key interfacesplaces of direct or indirect contact between animals and humans where disease transmission may occurby tapping into multiple experts within and across regions and sectors will help to gain consensus on priorities for improving zoonotic pathogen surveillance in wildlife. similarly, challenges and opportunities experienced by stakeholders varied across public and private sectors. therefore, a one health approach to capacity building that improves zoonotic pathogen surveillance in wildlife at local and global scales is greatly needed. this approach will include building bridges across ministries and sectors to enable sufficient manpower and funding mobilization to facilitate efficient targeting of high risk interfaces for zoonotic disease transmission. knowing the viewpoints of diverse stakeholders, the challenges they face, and the opportunities uniquely available to them will allow for optimal prioritization of recommendations for future capacity building and surveillance efforts going forward. building capacity in health research in the developing world public health: grand challenges in global health microbial threats to health: emergence, detection, and response global capacity for emerging infectious disease detection usaid launches emerging pandemic threats program global trends in emerging infectious diseases surveillance and monitoring of wildlife diseases. revue scientifique et technique-office international des epizooties human benefits of animal interventions for zoonosis control global patterns of influenza a virus in wild birds factors in the emergence of infectious diseases. emerg infect dis disease surveillance, capacity building and implementation of the international health regulations (ihr daszak p: prediction and prevention of the next pandemic zoonosis to strengthen consensus, consult the stakeholders the value of engaging stakeholders in planning and implementing evaluations engaging stakeholders to identify and prioritize future research needs innovative community-based approaches doubled tuberculosis case notification and improve treatment outcome in southern ethiopia surveillance, detection and response: managing emerging diseases at national and international levels capacity building efforts and perceptions for wildlife surveillance to detect zoonotic pathogens: comparing stakeholder perspectives we would like to thank all of the predict project scientists and research teams who assisted with data collection and conducted the interviews for this project. this study was made possible by the generous support of the american people through the united states agency for international additional file : rapid survey tool.abbreviations usaid: united states agency for international development; ept: emerging pandemic threats program. the author(s) declare that they have no competing interests.authors' contributions jss, tg, and wam designed the study and contributed to the writing of the manuscript. jss, tg, kt, and wam created the survey. tg, kt, jakm, and wam facilitated the data collection process, and pc performed the data collection. jss and kt performed statistical analysis. jss wrote the first draft, and jakm contributed to scientific review. all authors read and approved the final manuscript.authors' information predict consortium one health institute, school of veterinary medicine, university of california, davis, ca, usa website: http://www.vetmed.ucdavis.edu/ohi/predict/publications/ authorship.cfm key: cord- - oqv jom authors: rguig, ahmed; cherkaoui, imad; mccarron, margaret; oumzil, hicham; triki, soumia; elmbarki, houria; bimouhen, abderrahman; el falaki, fatima; regragui, zakia; ihazmad, hassan; nejjari, chakib; youbi, mohammed title: establishing seasonal and alert influenza thresholds in morocco date: - - journal: bmc public health doi: . /s - - -y sha: doc_id: cord_uid: oqv jom background: several statistical methods of variable complexity have been developed to establish thresholds for influenza activity that may be used to inform public health guidance. we compared the results of two methods and explored how they worked to characterize the influenza season performance– season. methods: historical data from the / to / influenza season performance seasons were provided by a network of primary health centers in charge of influenza like illness (ili) sentinel surveillance. we used the who averages and the moving epidemic method (mem) to evaluate the proportion of ili visits among all outpatient consultations (ili%) as a proxy for influenza activity. we also used the mem method to evaluate three seasons of composite data (ili% multiplied by percent of ili with laboratory-confirmed influenza) as recommended by who. results: the who method estimated the seasonal ili% threshold at . %. the annual epidemic period began on average at week and lasted an average of weeks. the mem model estimated the epidemic threshold (corresponding to the who seasonal threshold) at . % of ili visits among all outpatient consultations. the annual epidemic period began on week and lasted on average weeks. intensity thresholds were similar using both methods. when using the composite measure, the mem method showed a clearer estimate of the beginning of the influenza epidemic, which was coincident with a sharp increase in confirmed ili cases. conclusions: we found that the threshold methodology presented in the who manual is simple to implement and easy to adopt for use by the moroccan influenza surveillance system. the mem method is more statistically sophisticated and may allow a better detection of the start of seasonal epidemics. incorporation of virologic data into the composite parameter as recommended by who has the potential to increase the accuracy of seasonal threshold estimation. seasonal influenza epidemics result in considerable annual morbidity and mortality, with an estimated , to , deaths per year globally [ ] . associated with these seasonal epidemics are substantial economic losses due to absenteeism, lost wages and increased utilization of health care services [ ] . the influenza-associated respiratory annual mortality rate for people aged and older in morocco has been recently estimated by the us centers for disease control and prevention (us cdc) at . per , ( % credible interval of . - . ) [ ] . the risk of hospitalization due to influenza is to times greater in high-risk populations in morocco (e.g., the elderly and people with chronic disease) than in the general population [ ] . the most effective ways to prevent or mitigate these effects are through vaccination combined with appropriate clinical management of persons infected with influenza. optimal impact of vaccination campaigns is achieved by timing them prior to the beginning of the influenza season to ensure maximum coverage and protection among the population. likewise, a timely signal to healthcare providers that the influenza season is underway helps to guide their patient management decisions and to mitigate the effects of illness in the individual and in the community. local patterns of influenza virus circulation and seasonality may differ geographically, necessitating national estimates of seasonal influenza activity to inform public health guidance. national surveillance data is essential for understanding those patterns and establishing signals for the beginning of the influenza season and epidemic periods. establishing baseline activity, epidemic and alert thresholds is a useful tool to inform recommendations for timely influenza vaccination to lessen the burden of seasonal epidemics [ ] . while several statistical methods are commonly used, there is no gold standard for calculating influenza epidemic thresholds. the methods developed to date vary in their complexity and calculate either time-varying or fixed thresholds. the simplest ones use visual inspection of historical data to create a fixed threshold indicating the expected level of activity throughout the year [ , ] . statistical methods include regression models [ ] [ ] [ ] [ ] , time series methods [ ] , adaptation of industrial control processes such as shewart charts [ ] , cumulative sum (cusum) [ ] and rate difference models [ ] . methods that involve calculation of means and medians are of medium complexity but are practical as they may be simple to implement. the objective of this study was to evaluate the performance of two methods using means and medians to establish thresholds using data from the moroccan national influenza-like illness (ili) syndromic surveillance system. we compare the results of the world health organization averages method (who method) with the moving epidemics method (mem) which is recommended by both the who and the european centre for disease prevention and control (ecdc). as a complement to the thresholds using syndromic data, we also calculated a threshold using a composite parameter integrating both syndromic and virologic surveillance data. following these direct comparisons of the methodologies, we explored the best method for characterizing the / influenza activity. in , the epidemiology department of the ministry of health of morocco launched a year-round public sector syndromic surveillance system for ili comprised of primary health centers, with a catchment population of almost million people. sites report weekly ili activity to the regional and central levels, where health officials aggregate the surveillance data. a case definition similar to the who ili case definition recommended for public health surveillance, defined as "a sudden onset of fever, a temperature > °c and cough or sore throat in the absence of another diagnosis" was used from to [ , ] . in , morocco adopted the updated who standard ili case definition [ ] developed in as "an acute respiratory illness with a measured temperature of ≥ °c and cough, with onset within the past days" [ ] . reporting includes the total number of ili consultations aggregated by gender and age group, as well as total outpatient consultations. the proportion of ili visits among all outpatient consultations is used as a proxy for influenza activity. in , the moroccan national influenza center (nic) began a virologic surveillance system in both ambulatory and hospital sites to complement the syndromic system and provide data on laboratory-confirmed influenza activity [ ] . after an interruption in data collection beginning in , virologic surveillance was resumed in sentinel sites in . specimens were collected and characterized between september and june. enrolling patients from both out-and in-patient facilities allowed the integration of epidemiologic and virologic data representing the spectrum of illness from mild (ili) to severe (e.g. severe acute respiratory infection or sari) [ ] . we used seasons of syndromic surveillance data ( / to / , excluding the / pandemic year from analysis as influenza activity was not reflective of a typical season); this was described elsewhere [ ] . we compared two methodologies for establishing seasonal baseline activity and epidemic thresholds. we also compared the calculated thresholds with the observed weeks for the start and end of the / season. using three seasons of virologic ili surveillance data ( / to / ), we used the mem method to make calculations using the composite parameter recommended by who [ ] ; this method estimates the proportion of laboratory-confirmed influenza ili consultations among all outpatient consultations, or the product of weekly ili consultations of total outpatient visits and weekly percentage of influenzapositive specimens among respiratory tests. the methods discussed in order to standardize country information on influenza activity, have raised basic concepts summarized in table . the who global epidemiological surveillance standards for influenza (who manual) [ ] included a simple method to establish an average epidemic curve to identify the beginning of the influenza season using national influenza surveillance data. this method characterizes the intensity of influenza activity each year and may be used to describe the seasonality of influenza virus circulation. using ili as a proxy for influenza virologic activity [ , ] , we used weekly proportion of ili among all outpatient consultations as our indicator of influenza activity. with this method, we were able to produce an average epidemic curve. using data from the average epidemic curve, we used statistical measures of variance to establish an alert threshold. we determined the flat baseline for expected influenza activity throughout the year in order to develop an indicator for the onset of influenza season (seasonal threshold). sustained influenza activity (i.e., three consecutive weeks) above this baseline indicated the start of the influenza season or the epidemic period [ ] . in the final step, moderate, high, and extraordinary intensity thresholds were estimated as described in the who pandemic influenza severity assessment manual [ ] , (fig. ) . the moving epidemic method (mem) [ ] [ ] [ ] [ ] [ ] [ ] is an alternative tool developed to help model influenza epidemics also using retrospective national surveillance data. it may be described as a combination ratedifference model that uses cumulative differences in mem software produces an average curve, lower interval, and higher interval. calculate the mean and standard deviation (sd) of the average epidemic curve. for each week, the alert threshold is . sd above the weekly ili% mean. ili% > . sd indicates high ili activity or outbreaks and may be used to characterize a severe season. a graph consisting of the alert thresholds for each epidemic week. median weekly ili% over all weeks (i.e., the average epidemic curve is not used). indicates the level of influenza activity that signals the start and end of the annual influenza season(s). for prospective surveillance: upper limit of the % onesided confidence interval of the arithmetic mean of the highest pre-epidemic weekly ili% values. parameter value which marks the start of the epidemic period. for prospective surveillance: upper limit of the % onesided confidence interval of the arithmetic mean of the highest post-epidemic weekly ili% values. the third of three consecutive weeks with ili% above seasonal threshold. indicates that influenza activity occurs consistently. for retrospective analysis of individual season data: see "length of epidemic period". the third of three consecutive weeks with ili% below seasonal threshold for retrospective analysis of individual season data: see "length of epidemic period". weeks from epidemic start to end. for retrospective analysis of individual season data: mem software uses a "maximum accumulated proportions percentage (map)" algorithm to split the season into three periods: a pre-epidemic, an epidemic, and a post-epidemic period. proportion of total cases that occurred during the epidemic period upper % limit of -sided ci of mean of all peak values. upper % limit of the one-sided confidence interval of the geometric mean of the highest epidemic weekly ili% values. upper % limit of -sided ci of mean of all peak values. upper % limit of the one-sided confidence interval of the geometric mean of the highest epidemic weekly ili% values. upper . % limit of -sided ci of mean of all peak values. upper % limit of the one-sided confidence interval of the geometric mean of the highest epidemic weekly ili% values. rates to determine epidemic periods and intensity of activity [ , ] . using the free software r for statistical computing and graphics [ ] and its open source user interface rstudio [ ] , we uploaded our surveillance data via the mem application [ ] , and fit the model using three steps. we first visually compared activity over the seasons in order to compare the timing of peak activity and activity trends across seasons. the mem procedure has three main steps: first, the length, start and the end of the annual epidemics are determined, splitting the season in three periods: a pre-epidemic, an epidemic and a postepidemic period [ , ] . in the second step, we built the model by using retrospective data from all seasons. the mem app calculated the pre-epidemic threshold that marks the start of the epidemic period (analogous to the seasonal threshold in the who method). in the third step, medium, high, and very high intensity thresholds were estimated ( table ) . using the app, we produced graphs of each season showing the preepidemic, epidemic and post-epidemic periods (fig. ). in addition, as the assumption that ili activity is reflecting influenza virus circulation has limitations, we created a second seasonal threshold with this methodology using the composite parameter recommended by who for three seasons of virologic ili surveillance (fig. ) . lastly, we calculated indicators of performance of the app to detect epidemics, using values from the model for sensitivity, specificity, positive predictive value, negative predictive value, percent agreement and the matthew correlation coefficient ( table ). the application allowed us to optimize the model by searching the optimum slope of the map curve to optimize the goodness-of-fit of the model for detecting epidemics. the mem app calculates goodness-of-fit indicators in an iterative process using a cross-validation procedure [ ] . true positives (tp) were then defined as values of epidemic period above the threshold, true negatives (tn) as values of the non-epidemic period below the threshold, false positives (fp) as values of the non-epidemic period above the threshold and false negatives (fn) as values of epidemic period below the threshold. the process was repeated for each season in the dataset and all tp, tn, fp and fn were pooled. to measure the performance of the threshold, the following statistics and definitions were used [ ] : . sensitivity: the number of epidemic weeks above the pre-epidemic threshold and above the postepidemic threshold divided by the number of epidemic weeks (epidemic length). . specificity: the number of non-epidemic weeks below the pre-epidemic threshold and below the post-epidemic threshold divided by the number of non-epidemic weeks. . positive predictive value (ppv): the number of epidemic weeks above the threshold divided by the number of weeks above the threshold. the ili sentinel surveillance system is a public health activity organized by the ministry of health of morocco. personally identifiable data is excluded from this surveillance system; as a result, no request for authorization from the national ethics committees was required. indeed, the royal dahir n° - - dated august , , promulgating the law n° - relating to the protection of persons participating in biomedical research, provides for special provisions for non-interventional or observational researches as stipulated in its articles and . when applying the who method to our years of surveillance data, we estimated that the seasonal threshold was the point at which more than . % of outpatient consultations were due to ili (table ) . influenza activity crossed this threshold on average at week and the beginning of the epidemic period would be declared after three consecutive weeks of activity above this threshold, on average at week . the typical epidemic period lasted weeks, finishing at week , when activity was below the seasonal threshold for three consecutive weeks. the average peak activity occurred during week . seasons where ili activity regularly crossed the alert threshold may be characterized as severe ( fig. and table ). intensity thresholds were ili% of . , . and . % for moderate, high and extraordinary intensity thresholds) ( fig. and table ). the mem model produced an estimate that the average annual influenza epidemic period began on week , and that the epidemic period lasted on average weeks. the epidemic threshold (corresponding to the who seasonal threshold) was higher, at . % of ili patients among all outpatients. the average peak activity occurred during week , consistent with the estimate using the who method. intensity thresholds were of . , . and . % of ili patients among all outpatients for respectively medium, high and very high intensity thresholds ( fig. and table ). indicators related to the goodness-of-fit of the mem model for detecting the epidemics, using these retrospective data showed that the sensitivity of the mem epidemic threshold was . whereas the specificity was . . positive predictive value was . and negative predictive value was . (table ) . using three seasons of virologic data, we established a third seasonal baseline based on the composite parameter recommended by who, which integrated both laboratory-confirmed influenza and syndromic ili reporting (fig. ) . this method allowed us to compare the results of characterizing seasonality using these data types to identify the beginning of the influenza season. applying the mem methodology to our combined data, we determined that the average epidemic began at week , average peak activity occurred at week and the average epidemic period lasted weeks. using this method, medium, high and very high intensity thresholds were set at . , . and . % of laboratory-confirmed ili patients among all outpatients ( fig. and table ). goodness-offit indicators showed a sensitivity of %, specificity of %, positive predictive value of % and negative predictive value of % (table ) . ili data with the who/ ili data with the who thresholds, the curve overlapped the average epidemic curve and activity crossed the seasonal threshold during week of and was sustained after this time, confirming that this was the start of the epidemic period (fig. ) . the season peaked during the second week of , week earlier than the average identified by the who methodology (week ); we observed peak activity of . % of ili patients among all outpatients (fig. ) . when using the mem method with ili proportions, the epidemic period began at week , or the end of november . this finding indicated an early season, beginning weeks before the average epidemic start week of . the season peaked at week of (beginning of january), week before the average peak week determined by mem (week ), with peak activity above % of ili patients among all outpatients. this season was characterized as one of medium intensity (fig. ) . when considering the composite parameter, the mem method showed that the epidemic period began at week , or the end of november , with a sharp increase of the epidemic curve weeks prior to the average start (week ). the seasonal peak occurred at week of , week before the average peak week (week ), with peak activity above . % of confirmed ili patients among all outpatients. this season almost reached the threshold for high intensity (fig. ). the occurrence of the h n pandemic highlighted the need for a robust and standardized method to make timely assessments of the severity of influenza activity that may be used as an indicator of an unusual event. who developed and began implementing a framework on pandemic influenza severity assessment (pisa) [ ] in march . member states are encouraged to establish influenza baseline and epidemic alert thresholds from surveillance data and to monitor and describe the severity of each influenza season (seasonal, epidemic or pandemic influenza) using these thresholds. for this purpose, a simple method proposed by the who was used [ , , ] . who is now recommending mem, which is a more sophisticated method of reporting influenza activity adopted by the european centre for disease prevention and control [ ] [ ] [ ] [ ] and adopted by several countries from other regions [ , ] . the analysis using the mem application with seasons of syndromic surveillance data showed clear seasonality to ili activity and visual inspection of graphed data revealed a single seasonal peak per year. the data show seasonal peaks between december and march, varying by year, as described by barakat et al. based on visual analysis [ ] , matching trends observed in other northern hemisphere countries [ ] . the average seasonal peak in morocco occurs at week (mid-january) using either method. the seasonal threshold established using the method described in the who influenza surveillance guidelines was lower than the epidemic threshold calculated by the mem method when ili proportions are considered ( . % versus . % of ili patients among all outpatients). the average epidemic start week was estimated to be earlier when using the who method, with an average start at week versus week or by using respectively ili proportions or the composite parameter with the mem method. there is a three-to four-week difference between these methods when describing the typical start to a season; the optimal timing of a seasonal influenza vaccination campaign might vary accordingly. public health officials must weigh the costs and benefits of the optimal campaign period. influenza vaccine administration is ideally timed at least several weeks prior to influenza virus circulation as antibody response is achieved on average weeks post vaccination [ ] . the average epidemic period estimated by the who method was longer compared with the mem method ( weeks vs. or weeks respectively). there are few publications with estimates of the typical duration of an influenza season [ ] . according to the available evidence, the duration of the influenza season in the temperate zone of the northern hemisphere, ranges - weeks in europe [ ] . the goodness-of-fit calculations from the mem application indicate that the mem capacity for detecting epidemic activity had a sensitivity of % and a specificity of % when using ili proportions, implying that it is better for eliminating false signals than it is for detecting a true signal. our finding is similar to that of vega et al., who also found the sensitivity to be significantly lower than the specificity [ ] . using cambodian surveillance data, ly et al. [ ] also found that the who methodology appeared to have a higher sensitivity for detecting early epidemic activity, but a lower specificity than mem, implying a greater risk of signalling false starts to the season. timely detection of the start of seasonal epidemics may be important to alert health services and to mitigate morbidity, mortality and economic costs by allowing resource allocation and adjusting response measures to face the seasonal overload in the healthcare system. the public health implications for this difference between methodologies are that using the mem method without applying the seasonal threshold established using the who method, there is a risk of missing the beginning of the epidemic period and not providing timely guidance to clinicians to indicate influenza season has begun, and to manage patient treatment accordingly. using the lower who threshold for public health messaging regarding the beginning of the influenza season may pose the risk of a false alert and perhaps overprescribing antiviral medications. from another point of view, using a low seasonal threshold could influence decision-makers to recommend earlier vaccination. as our results showed that the seasonal threshold typically occurs between mid-november and mid-december in morocco, appropriate timing for vaccination could be about month before this date. of note, the us advisory committee on immunization practices (acip) recommends that vaccination should be offered by the end of october, considering the unpredictability of timing of onset of the influenza season and concerns that vaccineinduced immunity might wane over the course of a season [ ] . low seasonal thresholds may be crossed multiple times as was the case in our application of the who threshold for several seasons ( / , / , / , / and / [not shown]), due perhaps to variability in reporting by the surveillance sites. because of this variability, it is possible that declaring the start of the influenza season after two or three sustained weeks of activity above the threshold as recommended by who, is a prudent option for considering influenza transmission as epidemic. the mem methodology, however, calculates the length of the epidemic period during each season separately in order to determine the average length. thus, the epidemic threshold calculated with the mem method could be preferable to that established with the who method. mem was first used in in the who european region to estimate epidemic period and intensity using a minimum of five historical seasons for the calculations and the target season [ ] . despite the availability of only years of virologic data in morocco, we followed a who recommendation to use the composite parameter with mem [ ] . this allowed a clearer cut estimation of the beginning of the influenza epidemic period, characterized by a sharp increase in influenza-confirmed ili cases. when ili proportions are used, the two methods produce similar values for each intensity threshold considered in the pisa assessment of seasonal transmissibility; who has adopted the mem for this purpose. when comparing the highest weekly activity per season (the seasonal peak) to the intensity thresholds established by who and mem procedures, the / season was of moderate intensity ( figs. and ) . using the composite parameter, the / seasonal peak nearly reached the high intensity threshold, whereas this curve didnot cross the medium intensity threshold when using only ili proportions. our study has several limitations. first, the assumption that ili activity reflects influenza virus circulation is limited because of possible concurrent circulation of other respiratory viruses (e.g., rsv) [ , ] . who recommends using a composite parameter defined as the product of the ili or ari proportion and the percentage positive for the transmissibility indicator of the pisa tools [ ] . unfortunately, virologic data collected prior to was not consistently available for the period of our study as virologic surveillance was disrupted between and . despite this limitation, our laboratory-confirmed data showed something different than the syndromic data as the start of the virologic activity occurs suddenly and is therefore clearly identified. it is obvious that the inclusion of virologic data increases the specificity of seasonal threshold estimation. according to the who guidelines [ ] , "a combination of parameters may be preferable. for example, a seasonal threshold could be defined as the week in which the ili rate crosses a certain value and the percentage of specimens testing positive reaches a certain point". given the long life of our surveillance system, our data were limited by changes in data collection practices, inconsistency of reporting by surveillance sites, and variable access to primary health care. these problems are not unique to the morocco ili surveillance system, and we believe they are the nature of routine, sentinel surveillance. another limitation was the adoption of a new case definition in , at which point we also relaunched our surveillance system using a new protocol. these changes may have affected the trends that we observed in ili activity from that year forward. since both methods we used to establish thresholds recommend using a minimum of three to five seasons of data, we would not have enough data to run the models if we used only data from onward. determining a gold standard for influenza epidemic and intensity thresholds has been a long-standing research question for both international organizations and country-level public health authorities, and there is no consensus on the best method [ , , , , [ ] [ ] [ ] . both the who method and the moving epidemic method translate quantitative trend data into standardized qualitative intensity levels, which permit countries to determine if the current season is atypical or to assess country or regional differences in activity and intensity. both methods identified that the / season was the most active in morocco, excluding the / pandemic season according to non-published observations. both methods are coherent to identify excess activity or high intensity thresholds even though with adequate laboratory data mem with the use of the composite parameter, gives a theoretically better qualitative measure of the level of activity. this comparative study has shown that the threshold methodology presented in the who manual is simple to implement and easy to adopt for use by the influenza surveillance system in morocco or the national surveillance systems of other similar countries. mem is more statistically sophisticated and may provide a more accurate detection of the start of seasonal epidemics in temperate countries with clear seasonal circulation of influenza viruses, especially if virologic data are considered. whichever method is used, analysis of surveillance data will provide information about seasonal thresholds and epidemic curves that may help health care personnel in the clinical management of respiratory illness after the start of influenza season. establishing a seasonal threshold for influenza helps health authorities to identify suitable periods for annual vaccination campaigns and for health practitioners to administer influenza vaccines or prescribe influenza antiviral drugs. computerization of the influenza surveillance system improves timeliness and assessment of the intensity of the influenza epidemic early in its course will guide policymakers in ensuring the appropriate allocation of resources to control seasonal epidemics. estimates of global seasonal influenza-associated respiratory mortality: a modeling study influenza (seasonal) fact sheet epidémiologie de la grippe et facteurs de risque d'infection respiratoire aiguë sévère au maroc influenza seasonality: timing and formulation of vaccines world health organization. global epidemiological surveillance standards for influenza overview of 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outpatients and inpatients in morocco pandemic influenza a virus subtype h n in morocco, - : epidemiology, transmissibility, and factors associated with fatal cases world health organization. pandemic influenza severity assessment utilizing syndromic surveillance data for estimating levels of influenza circulation exploring a proposed who method to determine thresholds for seasonal influenza surveillance the moving epidemic method: the web mem application, technical manual v the moving epidemic method: guidelines to monitor influenza and other respiratory virus infections epidemics and pandemic the r project for statistical computing. the r foundation integrated development for r: rstudio influenza surveillance in europe: establishing epidemic thresholds by the moving epidemic method. influenza other respir viruses influenza surveillance in europe: influenza surveillance in europe: comparing intensity levels calculated using the moving epidemic method. influenza other respir viruses 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method establishing thresholds and parameters for pandemic influenza severity assessment evaluating tools to define influenza baseline and threshold values using surveillance data, egypt, season / seasonality, timing, and climate drivers of influenza activity worldwide kinetics and humoral antibody response to trivalent inactivated split influenza vaccine in subjects previously vaccinated for the first time influenza activity in europe during eight seasons ( - ): an evaluation of the indicators used to measure activity and an assessment of the timing, length and course of peak activity (spread) across europe prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices -united states, - influenza season influenza interaction with cocirculating pathogens and its impact on surveillance, pathogenesis, and epidemic profile: a key role for mathematical modelling possible interference between seasonal epidemics of influenza and other respiratory viruses in hong kong establishing thresholds for influenza surveillance in victoria european centre for disease prevention and control. indicators of influenza activity detecting the start of an influenza outbreak using exponentially weighted moving average charts publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank dr. amgad elkholy and dr. mohamed elhakim from infectious hazard management (ihm)/emro at world health organization and dr. henry laurenson-schafer for organizing training sessions on statistical methods for analyzing data provided by influenza surveillance systems as well as pr. abderrahmane maaroufi, former director of epidemiology at the ministry of health of morocco. a pilot study to assess the historical surveillance data of influenza in morocco and to compare the who method authors' contributions ar and ic designed the study. ic performed data analysis, interpretation of results and drafted the manuscript. mmc helped with study design, data analysis, interpretation of results, and drafting of the manuscript. ar and my assisted with study implementation and provided oversight of study personnel. ho, ab, fef, zr and hi assisted with access to and interpretation of laboratory testing results. st and he helped with data collection and study design and implementation. cn read and approved the final manuscript. all authors have read and approved the manuscript. none.availability of data and materials datasets were collected by each participating site including the national influenza center and gathered on a pooled database at the direction of epidemiology and disease control of the ministry of health of morocco. data cannot be publicly shared due to internal regulations of the ministry of health of morocco. the datasets analyzed during the current study could be available from the corresponding author on reasonable request and with special authorization of the ministry of health of morocco. the ili sentinel surveillance system is a public health activity organized by the ministry of health of morocco. personally identifiable data is excluded from this surveillance system; as a result, no request for authorization from the national ethics committees was required. indeed, the royal dahir n° - - dated august , , promulgating the law n° - relating to the protection of persons participating in biomedical research, provides for special provisions for non-interventional or observational researches as stipulated in its articles and . not applicable. the findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the us centers for disease control and prevention. the authors declare that they have no competing interests. key: cord- -skcaw ls authors: suwannarong, kanokwan; chanabun, sutin; kanthawee, phitsanuruk; khiewkhern, santisith; boonyakawee, paisit; suwannarong, kangsadal; saengkul, chutarat; bubpa, nisachon; amonsin, alongkorn title: risk factors for bat contact and consumption behaviors in thailand; a quantitative study date: - - journal: bmc public health doi: . /s - - -z sha: doc_id: cord_uid: skcaw ls background: bats serve as an important reservoir for emerging infectious diseases. bat contact and consumption, which persists in asia, poses risks for the transmission of bat-borne infections. methods: an analytical cross-sectional survey for risk factors associated with bat contact and consumption behaviors was conducted in ten provinces of thailand from may to december . a standardized questionnaire administered through face-to-face interviews was used to collect information from villagers who lived in or nearby areas of high bat density. the questionnaire contained independent variables related to sociodemographic, knowledge, attitudes, practices, and perceptions. results: the respondents (n = ) were females and males, mean age of respondents was . years-old and lived in rural setting. our results showed that . % of respondents (n( ) = ) in provinces reported bat contact during the past months. furthermore, . % of respondents (n( ) = ) in out of provinces reported of having consumed bat meat in the past months. risk factors for bat contact included sex (male) (or = . , % ci . – . ), educational attainment (lower than secondary school) (or = . , % ci . – . ), and the consideration of bats as being economically beneficial to the community (or = . , % ci . – . ), while agriculture-related occupation (or = . , % ci . – . ), knowledge that it is safe to eat bats (or = . , % ci . – . ), practice of allowing children to play with bats (or = . , % ci . – . ), and attitude of feeling safe in areas where bats live (or = . , % ci . – . ) were statistically significant protective factors against bat contact. risk factors for bat consumption included sex (male) (or = . , % ci . – . ) and educational attainment (lower than secondary school) (or = . , % ci . – . ), while knowledge of whether bats are safe to eat (or = . , % ci . – . ), knowledge of whether there are laws pertaining to hunting bats for consumption (or = . , % ci . – . ), and the practice of allowing children to play with bats (or = . , % ci . – . ) were statistically significant protective factors against bat consumption. conclusions: this study provides a better understanding of the sociodemographic factors, knowledge, attitudes, perceptions and practices that might influence bat contact and bat consumption behaviors. information on risk factors can be used for the development of appropriate education and communication interventions to promote proper knowledge, attitudes and practices regarding bats and bat-borne zoonotic diseases in thailand and other areas in the southeast asia region with similar environmental and cultural characteristics. the human and wildlife interface has been a global concern in the past decade due to several zoonotic disease outbreaks related to wildlife contact. pathogen transmission may occur through several routes, e.g., inhalation [ ] ; bites [ ] [ ] [ ] ; scratches [ ] ; hunting [ ] [ ] [ ] [ ] ; guano use as fertilizer [ ] ; food consumption [ , , ] ; handling, slaughtering and butchering; drinking water or food contaminated with saliva or feces [ ] ; and possible human-to-human transmission. bats are important reservoirs of several zoonotic pathogens. bat-borne diseases in humans have been reported worldwide and have been considered global concerns; these include the nipah virus [ , ] , the hendra virus [ ] , ebola [ ] , lyssaviruses [ ] , and severe acute respiratory syndrome coronavirus (sars-cov) [ , , ] . it has been documented that several factors influence human contact with bats. for example, previous studies in asia, and north america reported that sex [ ] , occupation [ ] , and locations of bat habitats [ ] influence human-bat interactions. bats play a cultural role in thailand including medicinal, religious, and culinary [ ] . a better understanding of human-bat interactions is critical to understanding zoonotic disease spillover and has been insufficiently studied [ ] . especially in thailand, the understanding of human-bat interactions and the epidemiological links involved in bat-borne disease and bat consumption is still insufficient. the objective of this study was to determine the factors associated with bat contact and bat consumption behaviors in ten provinces of thailand from may to december . our results will support the development of appropriate education and communication interventions to promote proper knowledge, attitudes and practices regarding bats and bat-borne zoonotic diseases in thailand and southeast asia. an analytical cross-sectional study was conducted to identify the factors associated with bat contact and bat consumption behaviors among persons who lived in or near areas of high bat density within at least months before the study. the questionnaire interviews were conducted from may to july . the chulalongkorn university institution review boards (irbs) and chiang rai provincial health office approved the human study (ref no . / and / ). this study obtained agreements from local administrative offices and the chiefs of villages to conduct data collection at the study sites. written informed consent forms were signed by the participants after they received information about the objectives of the study and prior to the interviews. different sampling methods were applied to select the study sites and study populations. the whole country was first stratified into four regions; central, northern, northeastern and southern thailand. provinces, districts and villages in each region were then purposively selected based on; ) a high density of bats in the villages/ study areas, ) a potential bat-human interface was observed by researchers during scoping visits, discussed with some villagers and/or local authorities, and ) information obtained from the relevant local and national authorities such as the ministry of natural resources and environment (mnre), and the ministry of public health (moph). lastly, a simple random sampling method (srs) was used to select respondents from official household registry records that were obtained from the local health promotional hospitals in the villages. in this study, provinces were selected as representatives of regions in thailand that have different living characteristics and practices. the provinces were ang thong, ayutthaya, lopburi and saraburi (central provinces); chiang mai and chiang rai (northern provinces); khonkaen and ubonratchathani (northeastern provinces); and krabi and surat thani (southern provinces) ( fig. and table ). bats from each study site were collected for species identification using physical characteristics and dna sequence variations in mitochondrial cytochrome-b (cytb) [ ] . the inclusion criteria for respondents were males or females between and years of age who had lived in the selected areas for at least months before data collection and were willing to participate in this study. the sample size calculation for this study was as follows: here, p = proportion of participants with bat contact. based on a previous study, . % of respondents reported bat consumption at some time in their lives [ ] . the variable p is . for this calculation, z = . ( % confidence interval), and d (margin of error) = %. therefore, the calculated sample size was . to increase the power, the sample size was elevated to . simple random sampling (srs) was used on the lists of the respondents retrieved from health promotional hospitals in the study areas. after srs of respondents was conducted, the participants were contacted by trained researchers for data collection. using a standardized questionnaire, a face-to-face interview was conducted with the respondents in a place that was not too secluded but still free from disturbances. a questionnaire was designed to collect information on bat contact and bat consumption behaviors. this questionnaire was modified from previous reports [ , , ] . the questionnaire interview was administered to collect information on sociodemographic factors, knowledge, attitudes, practices and perceptions for bat contact and bat consumption behaviors. the questionnaire was pretested with respondents in a district with the same environmental and population characteristics as the actual selected sites. the questionnaire was refined per the pretest results. field researchers were trained in its administration and in conducting questionnaire interviews with written informed consent forms obtained prior to the interviews. after the interviews, the information was checked for validity and precision before it was entered into spss software version (chicago, il). independent variables (n = ) were included in the analysis. the variables were based on previous relevant studies [ , [ ] [ ] [ ] [ ] [ ] . the independent variables, including the sociodemographic information, knowledge, attitudes, practices, and perceptions were as follows: -humans can get diseases from bats (true vs false) -there are no concerns about getting diseases from bats (true vs false) -bats can transmit diseases to humans (true vs false) -bats are economically beneficial to the community (agree vs disagree) -one can contract diseases if exposed to bats (true vs false) -one can contract diseases by drinking water from the same places as bats (true vs false) -one can contract diseases by eating fruits left by bats (true vs false) -bat guano is safe to use (true vs false) -it is safe to eat bats (true vs false) -there are laws related to hunting bats for consumption (true vs false) -children are allowed to play with bats (true vs false) -dead bats that are found are brought home for food (true vs false) -one feels safe in areas where bats live (true vs false) the dependent variable was a report of either one of bat contact experiences by the study respondents. list of bat contact experiences included the following: -found dead bat(s) in house -found live bat(s) in house, the community or tourist location -cleaned bat guano from house or the community -cleaned bat carcasses from house or the community -bat guano mining/collecting -use of bat guano -bitten by a bat -consumed bats for food -other activities, e.g., hunted bats, exposed to urine of bats the interviewed data were entered into and analyzed by spss software version (chicago, il). after data cleaning, the dependent and independent variables were assessed. data were analyzed in steps. first, bivariate analysis was performed, in which the degree of association of each variable was computed and each of the independent variables was analyzed separately. second, a stepwise logistic regression model was constructed including independent variables that had p values ≤ . results in bivariate analysis. this second step used p ≤ . as the cutoff point for identifying statistically significant variables. in this study, respondents participated in the questionnaire interview. these respondents from villages of districts in provinces in thailand ( fig. and table ). bats species from each study site were identified: chiang mai (scotophilus heathii and megaderma spasma), chiangxs rai (taphozous melanopogon), lopburi (taphozous melanopogon and chaerephon plicatus), khon kaen (chaerephon plicatus), and ayutthaya, ang thong, saraburi (pteropus lylei). of the respondents who participated in the questionnaire interview, ( . %) respondents from provinces reported having experienced bat contact during the past months before data collection. moreover, ( . %) respondents in out of provinces reported having consuming bat meat in the past months. the respondents were females and males. the mean age of the respondents was . years. approximately . % of respondents were aged > years. most of them lived in rural settings ( . %) and were married or cohabiting ( . %). respondents worked as farmers (rice, grains or vegetables) ( . %), followed by temporary employees ( . %), government officers ( . %), housewives ( . %), and shop vendors/owners ( . %). most of the respondents ( . %) had attained educational levels lower than secondary school, and . % had families composed of more than persons. most respondents had a monthly family income of ≤ , baht ( usd) ( . %). most respondents owned a motorcycle ( . %), while fewer owned a car ( . %). in this study, respondents in provinces reported a bat contact experience during the past months before data collection. among those respondents, . % reported encountering live bats in a house, the community or a tourist location, while . % reported eating bats for food, . % found bat guano in a house or the community, . % found dead bats in the house, . % participated in bat guano mining/collecting, . % cleaned bat carcasses from a house or the community, . % used bat guano as fertilizer, . % were involved in other contact activities (e.g., took bats from nets), and . % been bitten by a bat in the past months (table ) . in this study, the questionnaire interview contained sociodemographic questions and questions related to the knowledge, attitudes, practices and perceptions regarding bat contact experiences. bivariate analysis was performed to determine the associations between bat contact experiences and twenty-three independent variables. of the independent variables, variables had significantly associations in the bivariate analysis, using p ≤ . as a cutoff point: sex (male), age group (> years), occupation (agriculture-related occupation), educational attainment (< secondary school), family monthly income (< , baht), no concerns about getting diseases from bats, considered bats to be economically beneficial to the community, believed it is safe to eat bats, allowed children to play with bats, and felt safe in areas where bats live (table ). all variables were included in the stepwise logistic regression analysis for bat contact experiences. the results showed that sex (male) (or = . , % ci . - . , p = . ), educational attainment (< secondary school) (or = . , % ci . - . , p = . ), and considered bats to be economically beneficial to the community (or = . , % ci . - . , p < . ) were statistically significant associated with bat contact experiences, while occupation (agriculture-related occupation) (or = . , % ci . - . , p = . ), believed it is safe to eat bats (or = . , % ci . - . , p = . ), allowed children to play with bats (or = . , % ci . - . , p = . ), and felt safe in areas where bats live (or = . , % ci . - . , p = . ) were statistically significant protective factors against bat contact experiences (table ) . among the respondents, respondents ( . %; females and males) reported eating bats in the past months. of the respondents who reported contacts with bats, . % ( / ) reported eating bats in the past months. they also reported that bats were hunted, butchered, slaughtered, and cooked by several categories of persons (e.g., husbands, wives, neighbors, children, or hunters) in their communities. in this study, out of respondents ( . %) reported having eaten bats in their lifetime, of whom . % ( / ) reported consuming bats more than years ago, . % ( / ) who reported eating bats during the last - years, . % ( / ) who reported eating bats within the past months, . % ( / ) who reported eating bats in the past month, . % ( / ) who reported eating bats within week of data collection, and . % ( / ) who reported eating bats within the preceding week. of the respondents who reported eating bats, . % were male and . % were < years old (mean age of respondents . years old). most respondents were married or cohabiting ( . %) and had more than one child ( . %). the occupations of respondents were farmers (rice, grains or vegetables) ( . %), followed by temporary employees ( . %). most respondents had attained an educational level < secondary school ( . %) and had families composed of more than persons ( . %). most of the respondents ( . %) had monthly family income < , baht ( usd). some respondents owned a car ( . %), majority owned a motorcycle ( . %). of the respondents, those in the northern region, chiang mai ( . %) and chiang rai ( . %), reported more bat consumption than those in other provinces, including those in the northeastern region, ubon ratchathani ( . %), southern region, surat thani ( . %) and krabi ( . %). on the other hand, respondents in the central region reported less bat consumption (table ) . with regard to the details of bat consumption behaviors, we found that . % ( / ) of respondents reported killing bats themselves, followed by vendors ( . %), hunters ( . %), and neighbors ( . %). the participants reported that no children aged - years old killed bats. with respect to preparing and cooking bats for food, . % ( / ) of respondents prepared bat meat by themselves, followed by spouses ( . %), neighbors ( . %), and children ( . %). persons reported that the bats were eaten by spouses ( . %), neighbors ( . %), and children ( . %). most respondents reported eating cooked bat meat ( . %, / ), while only one respondent, a -year-old female from chiang rai province, reported eating raw bat meat. bats were obtained by hunting in caves ( . %), purchasing from local markets ( . %), hunting by themselves ( . %), and hunting by neighbors ( . %). dishes containing bat were "kang om" (spicy vegetable soup) ( . %), followed by spicy stir fry ( . %), "kua kling" (dry spicy fry with herbs), and deep-fried bat meat ( . %). the preferred recipes varied among provinces or regions; for example, people in the northern region, chiang mai, preferred to cook "kang om" while those in southern provinces, krabi, preferred spicy stir fry to other dishes. the field investigation showed that a typical bat preparation process included butchering the bats, selecting the parts for consumption, adding additional herbs for flavor, and boiling the ingredients in a large pot (fig. ) . in this study, variables (sociodemographic factors, knowledge, attitudes, practices and perceptions) were involved in the bivariate analysis, and eleven independent variables were eligible for the stepwise logistic regression analysis. these included sociodemographic variables (sex, educational attainment, owning a car, and owning a (table ). this is the first quantitative study regarding the risk factors for bat contact and bat consumption behaviors in thailand. our study showed that . % of respondents reported bat contact experiences during the past months. the respondents reported finding live bats in houses, the community or tourist locations; eating bats for food; cleaning bat guano from the house or community; finding dead bats in the house; participating in bat guano mining/collecting; cleaning bat carcasses from the house or community; using bat guano as fertilizer; participating in other contact activities; and having been bitten by a bat. this current study showed an incidence of bat contact experiences ( . %) that was higher than that reported in a study in canada [ ] , which showed that % of participants had direct contact with bats, and % found bats in their houses. however, the frequency of reports of being bitten by bats in the current study was lower ( . %) than that in the canadian study ( . %). interestingly, bat consumption behavior was shown in the second rank of frequent exposure behavior ( . %). from the stepwise logistic regression analysis on bat contact behavior, male, low education attainment and considering bats to be economically beneficial to the community were risk factors for contact with bats. in contrast, farming or agriculture-related occupations were a protective factor against contacting bats, which was different from a study in guatemala [ ] . this might be because other occupations, e.g., temporary workers, had more chances and/or free time to hunt or purchase bats. our results also showed inappropriate knowledge and attitudes with regard to feeling that it is safe to eat bats, allowing children to play with bats, and feeling safe in areas where bats live, which were influenced by the villagers' contact with bats. our observations agreed with the findings from a study in australia in which respondents had inappropriate perceptions that could lead to more bat contact/exposures [ ] . the consumption of wild animals, including bats, a product often called bushmeat, poses challenges for both wildlife conservation and human health [ ] . this study showed that ( . %) of the respondents reported bat consumption during the past months. however, respondents ( . %) in this study reported eating bats in their lifetime, which was higher than the studies in the republic of ghana ( . %) [ ] and madagascar ( . %) [ ] . thus, bat consumption incidences in thailand should be considered a matter for concern. this study showed that males reported more bat consumption behavior. our findings were comparable to previous studies in which males were more likely to consume wildlife in thailand and the lao pdr [ , ] . low education attainment was one of the risk factors that lead to bat contact and consumption. in addition, inappropriate knowledge and attitudes regarding whether it was safe to eat bats, legal to hunt bats, and safe to allow their children to play with bats could also be factors affecting bat consumption. among the provinces, the respondents from the northern region (chiang mai, and chiang rai) reported eating bats more than those in other regions. while, the central provinces reported less bat consumption due to their beliefs and social norms per the qualitative study results. regular law enforcement activities in the central provinces might be one of the contributing factors. in conclusion, this study has provided information related to sociodemographic factors, knowledge, attitudes, perceptions, and practices that may influence bat contact and bat consumption behaviors among thai villagers. the information from this study can be used in the development of communication interventions for zoonotic diseases related to bat contact and bat consumption behaviors in areas with similar environmental and cultural characteristics. supplementary information accompanies this paper at https://doi.org/ . /s - - -z. additional file . rodent-borne diseases and their risks for public health human-bat interactions in rural west africa cross sectional survey of human-bat interaction in australia: public health implications rabies-related knowledge and practices among persons at risk of bat exposures in thailand bushmeat hunting, deforestation, and prediction of zoonoses emergence characteristics and risk perceptions of ghanaians potentially exposed to bat-borne zoonoses through bushmeat bushmeat hunting and zoonotic transmission of simian tlymphotropic virus in tropical west and central africa factors determining the choice of hunting and trading bushmeat in the kilombero valley hunting, food preparation, and consumption of rodents in lao pdr bat consumption in thailand primates on display: potential disease consequences beyond bushmeat rodent consumption in khon kaen province transmission of human infection with nipah virus nipah virus infection outbreak with nosocomial and corpse-to-human transmission hendra virus: a one health tale of flying foxes, horses and humans fruit bats as reservoirs of ebola virus australian bat lyssavirus infection: a second human case, with a long incubation period a sars-like cluster of circulating bat coronaviruses shows potential for human emergence diversity of coronavirus in bats from eastern thailand a framework for the study of zoonotic disease emergence and its drivers: spillover of bat pathogens as a case study a test of the genetic species concept: cytochrome-b sequences and mammals knowledge, perceptions and attitude of a community living around a colony of straw-coloured fruit bats (eidolon helvum) in ghana after ebola virus disease outbreak in west africa analysis of patterns of bushmeat consumption reveals extensive exploitation of protected species in eastern madagascar uncovering the fruit bat bushmeat commodity chain and the true extent of fruit bat hunting in ghana importance of rodents as a human food source in benin conservation strategies for understanding and combating the primate bushmeat trade on bioko island, equatorial guinea wildlife trade and human health in lao pdr: an assessment of the zoonotic disease risk in markets the socio-economic drivers of bushmeat consumption during the west african ebola crisis children's traditional ecological knowledge of wild food resources: a case study in a rural village in northeast thailand bat rabies in the united states and canada from through : human cases with and without bat contact knowledge, attitudes and practices regarding rabies and exposure to bats in two rural communities in guatemala publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank dr. kallaya harnpicharnchai, mr. vichien patchamit, mr. buncha muankla, and mr. suphat hlikthuk for their support in the fields. we also thank the chief medical officers of the provincial health offices and their staff as well as the local authorities for their cooperation and assistance during research. we would also like to thank the department of natural parks, wildlife and plant conservation for their support on site and during the field bat sample collection. this research was supported by the chulalongkorn university, national research university fund, health research (nru - -hr). chulalongkorn university provided financial support to the center of excellence for emerging and re-emerging infectious diseases in animals and the one health research cluster. the thailand research fund provided financial support to the trf senior scholar to the corresponding author (rta ). we would like to thank the rachadapisek sompote fund and the second thailand. authors' contributions ks , pk, sk, pb, ks , cs, and nb conducted and coordinated the field study and questionnaire interviews. ks and sc conducted the data analysis. ks and aa drafted and revised the manuscript. aa supervised the study and served as principle investigator of the project and corresponding author of the manuscript. all authors read and approved the final manuscript. the first author (kanokwan suwannarong) is a postdoc associate at the center of excellence for emerging and re-emerging infectious diseases in animals, faculty of veterinary sciences, chulalongkorn university. she received the postdoctoral fellowship from the second century fund (c f), chulalongkorn university. her research interest is social epidemiology and community studies related to emerging infectious diseases and health managements. century fund (c f), chulalongkorn university for the first author's postdoctoral fellowship as well as for study designs, data collection and analysis of this project. all data generated or analyzed during this study are included in this published article and supplement tables.ethics approval and consent to participate the chulalongkorn university institution review boards (irbs) and chiang rai provincial health office approved this human study (ref no. / and / , respectively). this study obtained agreements from local administrative offices and the chiefs of villages to conduct data collection at the study sites. written informed consent forms were obtained after describing the objectives of the study to the participants and prior to the interviews. the faculty of veterinary science, chulalongkorn university's animal care and use committee, approved the animal study (iacuc no. and ) . the department of national park, wildlife and plant conservation, ministry of natural resources and environment approved the bat sample collection (no. ts . / ). not applicable. the authors declare that they have no competing interests. key: cord- -lrk ty authors: mohammed, abdulaziz; sheikh, taiwo lateef; gidado, saheed; poggensee, gabriele; nguku, patrick; olayinka, adebola; ohuabunwo, chima; waziri, ndadilnasiya; shuaib, faisal; adeyemi, joseph; uzoma, ogbonna; ahmed, abubakar; doherty, funmi; nyanti, sarah beysolow; nzuki, charles kyalo; nasidi, abdulsalami; oyemakinde, akin; oguntimehin, olukayode; abdus-salam, ismail adeshina; obiako, reginald o. title: an evaluation of psychological distress and social support of survivors and contacts of ebola virus disease infection and their relatives in lagos, nigeria: a cross sectional study − date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: lrk ty background: by september , an outbreak of ebola viral disease (evd) in west african countries of guinea, liberia, sierra leone, senegal and nigeria, had recorded over and probable or confirmed cases and deaths respectively. evd, an emerging infectious disease, can create fear and panic among patients, contacts and relatives, which could be a risk factor for psychological distress. psychological distress among this subgroup could have public health implication for control of evd, because of potential effects on patient management and contact tracing. we determined the prevalence, pattern and factors associated with psychological distress among survivors and contacts of evd and their relatives. methods: in a descriptive cross sectional study, we used general health questionnaire to assess psychological distress and oslo social support scale to assess social support among participants who survived evd, listed as evd contacts or their relatives at ebola emergency operation center in lagos, nigeria. factors associated with psychological distress were determined using chi square/odds ratio and adjusted odds ratio. results: the mean age and standard deviation of participants was +/ - . years. of participants, ( . %) were females, ( . %) had a tertiary education and ( . %) were health workers. most frequently occurring psychological distress were inability to concentrate ( . %) and loss of sleep over worry ( . %). losing a relation to evd outbreak (or = . , % ci, . – . ) was significantly associated with feeling unhappy or depressed while being a health worker was protective (or = . , % ci, . – . ). adjusted odds ratio (aor) showed losing a relation (aor = . , % ci, . – . ) was a predictor of “feeling unhappy or depressed”, loss of a relation (aor = . , % ci, . – . ) was a predictor of inability to concentrate. conclusions: survivors and contacts of evd and their relations develop psychological distress. development of psychological distress could be predicted by loss of family member. it is recommended that psychiatrists and other mental health specialists be part of case management teams. the clinical teams managing evd patients should be trained on recognition of common psychological distress among patients. a mental health specialist should review contacts being monitored for evd for psychological distress or disorders. the west african outbreak of ebola virus disease (evd) began in guinea in december [ ] . the outbreak involved sustained transmission in guinea, liberia, and sierra leone [ ] . by september , , the total number of probable and confirmed cases was , with deaths recorded from five countries in west africa namely, guinea, liberia, nigeria, senegal, and sierra leone [ ] . the first known case of evd was reported in nigeria on th july , through a man who travelled to lagos, nigeria, via lomé, togo and accra, ghana [ ] . as of th september , the total number of confirmed evd cases in nigeria was ( in lagos and in port harcourt) of which had survived and seven reported dead. four hundred and seventy contacts had completed days of follow up necessary to rule out evd infection. the news of evd spread into nigeria created widespread media attention, which initially focused mainly on the high infectivity and case fatality, with the potential to create fear and panic. also, the process of infection control and prevention necessary for the control of emerging infectious disease (eid) like evd involves the use of personal protective equipment, quarantine, and isolation [ ] , all of which may be associated with fear and anxiety. public apprehension of newly detected emerging infectious disease with high morbidity and mortality had been previously described. joffe et al. [ ] described pattern of public response to emerging infectious diseases like evd. this general public response pattern includes distancing the disease from self, blame of particular entities for the disease's origin and/or spread, and stigmatization of those who have contracted it and/or who are represented as having intensified its spread. the process may be driven by worry, fear and anxiety, which necessitate a psychosocial intervention as part of all outbreak response to eids like evd. in a study to assess the psychological impact of the outbreak of severe acute respiratory syndrome on hospital employees, about % of the respondents had experienced high levels of post-traumatic stress symptoms [ ] . researches conducted during evd outbreaks tend to focus on clinical manifestations and epidemiology of evd with little or no study on psychosocial impact or distress associated with evd. a study in democratic republic of congo described the feelings and experiences of survivors of ebola epidemic [ ] . they described psychosocial consequences among survivors to include fear of falling seriously ill, denial, fear of being accused by neighbors and shame. others included rejection by society, belief that the infection was a divine punishment, lack of income, and intense grief for colleagues who did not survive the epidemic. the previous study did not include use of a standardized instrument for evaluation of psychological distress and social support available to the respondents. no previous study that employed the use of standardized instruments like ghq or oss to measure psychological distress or social support among survivors and contacts of evd or their relatives was found after a literature review. we set out to determine the prevalence and pattern of psychological distress among the survivors, relatives and contacts of evd. we also assessed the social support available for the survivors, relatives and contacts of evd. finally, we determined factors associated with psychological distress. the study was conducted in lagos state. lagos state is located in the southwestern part of nigeria and has an estimated land area of km ( sq ml). the metropolitan area consists of islands, such as lagos island and extension into the adjacent mainland. the lagos international airport is the busiest of all the international airports in nigeria [ ] . we conducted a descriptive cross sectional study. the study population consisted of persons listed as survivors and contacts by the emergency operations center (eoc) for evd in lagos and a first-degree relation judged to be the primary care giver by the evd patient or contact. inclusion criteria survivors . persons confirmed as a case of evd in the present outbreak response and had been managed in the isolation ward of the response. . persons confirmed cured and discharged from isolation ward by case management team. persons determined by the contact tracing team to have been a contact of a known confirmed case of evd using standard protocol [ ] . . contacts who are being actively followed up or had completed the follow up period. . must be a first-degree relation (father, mother, spouse, child or sibling) who was adjudged to have actively supported the survivor during case management or contacts during contact tracing. . not currently living in lagos. we estimated that by interviewing a third of survivors and contacts in the line list of the contact tracing team as at the time of the evaluation and their relatives, we will be able to achieve the minimum sample size of calculated using the leslie and kish formula [ ] for estimating sample size for cross-sectional study. where: n = minimum sample size zα set at % significant level = . p = estimates of proportion of study population with psychological distress. we used the prevalence of % ( . ) psychological consequences of severe acute respiratory syndrome (similar eid to evd) among hospital workers in china. the calculated sample size was . the calculated sample size was adjusted for small population size (n = ) using the formula for finite population correction. where: n f = the desired sample size when population is less than , n = the desired sample size when the population is more than , n = the estimate of the evd survivors and contact or their relations ( ) as at the time of study for this study we targeted respondents we randomly selected the contacts for the study using the contact tracing team line list of all contacts with over people listed during the duration of the study. of the eight cases listed as survivors during the time of study, four were interviewed during the study period. for every contact or survivor selected for the study, we attempted to interview a first-degree relation (spouse, parent, child or full sibling) identified by the survivor/contact, if available and also meeting the case definition for a relation. we designed a socio-demographic questionnaire to collect information on the respondents' age, gender, marital status, local government area (lga) of residence, and level of education. we also asked if respondents had loss a relation due to the evd outbreak. the general health questionnaire -item version (ghq ) was used to assess psychological distress among the study participants. the general health questionnaire (ghq) is a screening questionnaire, designed for screening individuals with a diagnosable psychiatric disorder [ ] . the ghq does not generate specific psychiatric diagnosis but rather screens for individuals with possible disorders. in its original version, it had items (ghq- ), which were reduced to (ghq- ), and items (ghq- ) [ ] . the -item general health questionnaire (ghq- ) is the most extensively used screening instrument for common mental disorders in addition to being a more general measure of psychological wellbeing. the psychometric properties of ghq have been evaluated in several studies [ , ] . the oslo social support scale (oss) was used to assess patients' social support base during the period. the oslo -item social support scale provides a brief measure of social functioning and has been considered a good predictor of mental health [ ] . it covers different fields of social support, as it measures the number of people the respondent feels close to, the interest and concern shown by others, and ease of obtaining practical help. the oslo social support scale had been validated in nigeria [ ] . respondents who answered "difficult" or "very difficult" to the question "how easy can you get help from neighbors?" were defined as having difficulty getting help from neighbors during need. respondents who answered "none" or " - " to the question "how many people are close to you that you can count on if you have serious problems?" were defined as having less than people who they can count on for help for serious problem. finally those who answered "no", "little", or "uncertain" to the question "how much concern do people show in what you are doing", were defined as having people showing little concern in what they are doing. due to the interest in the pattern of psychological distress and social support among the respondents we analyzed each variable in the ghq and oss separately instead of using aggregate scores we recruited five resident doctors of the nigerian field epidemiology and laboratory training program [ ] as data collectors, who were part of the contact tracing team and had extensive experience with data collection from prior activities. they were trained for a period of days on the use of the study questionnaires and interview techniques prior to the onset of the study. data collection took place over a period of weeks and the average duration of each interview was min. data were entered into epi info . . , cleaned and edited for inconsistencies before analysis. we summarized our findings using frequencies, means (with standard deviation) and proportions. we used odds ratio (or) with % confidence interval ( % ci) to check for statistically significant associations and unconditional logistic regression to check for independent predictors of psychological distress. the evaluation was part of the evd outbreak response and was therefore exempted from ethical clearance by the evd emergency operation center in lagos. the evd emergency operation center however read and cleared the protocol before onset of the study. written informed consent was obtained from each participant after complete description of the study. as part of the response to evd, all the contacts, relatives and survivors who reported or had noticeable distress irrespective of whether they were part of this study or not, had access to counseling and other forms of treatment from the members of the psychosocial subgroup of the clinical management team. those found to have clinically significant psychological morbidity were counseled and all assessed to require specialist care were referred to the neuropsychiatric hospital, lagos. a total of interviews were conducted, of which three were disqualified because the interviews were not completed. the mean age of participants was +/ - . years, age range - years. of the participants, four ( . %) were survivors, ( . %) were contacts, ( . %) were contact relations and one ( . %) was a survivor relation (table ) . two thirds of the participants were females and ( . %) had a tertiary education. forty-five ( . %) were health workers and about half ( . %) resided in eti-osa local government area (lga) of lagos state ( table ) . the most frequently occurring psychological distress among all respondents were "not been able to concentrate on what you are doing" ( . %) and "lost much sleep over worry" ( . %). the least occurring psychological distress was "been thinking of yourself as worthless" ( . %). "not been able to concentrate on what you are doing" and "lost much sleep over worry" were the most frequently occurring psychological distress among survivors ( % and %, respectively) and among contacts ( . and . % respectively). only ( . %) of the participants reported "can count on less than people for help for serious problem" ( table ) . losing a relation to the evd outbreak (or = . , % ci, . - . ) was significantly associated with the psychological distress of "feeling unhappy or depressed" while being a health worker (or = . , % ci, . - . ) was protective. having no tertiary education (or = . , % ci, . - . ) was significantly protective against "not been able to concentrate", while living in eti-osa lga (or = . , % ci, . - . ) was significantly associated with "not feeling reasonable happy". all the four survivors reported they had, "not been able to concentrate" (table ) . losing a relation (aor = . , % ci, . - . ) remained an independent predictor of the psychological distress of "feeling unhappy or depressed". loss of a relation (aor = . , % ci, . - . ) remained an independent predictor of the psychological distress of "not been able to concentrate" while having no tertiary education (aor = . , % ci, . - . ) remained a protective factor against "not been able to concentrate" (table ). the most frequently occurring psychological distress among the respondents: inability to concentrate, losing much sleep over worry and being unhappy or depressed are key clinical features of anxiety, depression and post traumatic stress disorders (ptsd) as described in the diagnostic and statistical manual (dsm) of mental disorders [ ] . though the individual psychological distress does not amount to a neuropsychiatric disorder, it does indicate the presence of some psychological distress among the respondents that may have the potential to progress if not properly managed. evd can be perceived as a life-threatening event that meets a key diagnostic criterion of ptsd in dsm [ ] . the development of ptsd following life-threatening event has been demonstrated among nigerians [ ] and among health workers who had contact with severe acute respiratory syndrome (sars) [ ] . other less severe disorders caused by reaction to extremely stressful situations such as acute stress reaction and adjustment disorders could also present with the above psychological distress. the psychological distress of being unable to concentrate could be mistaken for cognitive impairment by the clinical management team if it occurs in a patient with evd, could be confused for viral encephalopathy or onset of brain damage secondary to evd infection. a case of adjustment disorder, in a survivor of the nigerian evd outbreak, initially diagnosed as having brain damage secondary to viral encephalitis is an example [ ] . losing a relation during this evd outbreak was significantly associated with being unhappy or depressed. this could be dismissed as a usual response to bereavement in people, but the feelings of depression (whether from normal grief or psychopathological) could have implication for the management of patients with evd or for the contact tracing team while monitoring contacts for clinical manifestation of evd. it could affect judgment and thus reduce cooperation with either the clinical management team or contact tracing team. feelings of depression could also cause patients or contacts of evd to tolerate emerging symptoms of evd thereby not reporting them to the management team. this could people show little or no concern in what you are doing ( . ) ( . ) ( . ) ( . ) complicate overall clinical impression of the patient or cause problems with determining the exact time of onset of clinical symptoms. the effect of an evd contact, with feelings of depression, failing to disclose important clinical symptoms may lead to delayed or failed recognition of evd onset with far reaching public health importance. the psychological stress of bereavement can mimic severe depression but also bereavement has long been described as a risk factor for development of depression [ ] . furthermore, it has been suggested that risk factors for common mental health problems arising from the evd outbreak such as witnessing and caring for individuals who are severely ill, perceived life threat, substantial mortality and bereavement, and the deaths of trained health care workers, in conjunction with the lack of well-trained mental health professionals in countries experiencing evd outbreak in west africa could amplify the risks of developing enduring psychological distress and progression to psychopathology by those affected [ ] . although the psychological distress the extensive social support base of the nigerian community, which is not limited to the immediate family members, may have helped the social support respondents had. poor social support was only a problem to less than a quarter of the respondents. this may have been due to the relatives not being aware of what the respondents were going through. overall, only few of the respondents demonstrated poor social support, respondents who had little or no interest shown in their activities were more likely to lack self-confidence. having no tertiary education, which was protective of inability to concentrate, may not be an entirely positive finding because it could reflect the lack of insight into the implication of an infection with evd by those without tertiary education. the study found loss of a relation to be an independent predictor of feelings of unhappiness or depression and inability to concentrate. contacts or survivors who have lost close relations should be considered at high risk of developing psychological distress or even psychological disorders. loss of a relation is a traumatic experience that has been shown to be a predictor of ptsd [ ] and depression [ ] among persons exposed to traumatic experience in nigeria. therefore the psychosocial response team for evd outbreak should prioritize this subgroup of contacts and survivors for special monitoring and evaluation. the contact tracing teams following up this subgroup of contacts should include a member of the psychosocial response team with training in detection of psychological distress/disorders. the findings of this study are subject to the following limitations. we only assessed for psychological distress and not disorders. only few survivors were sampled which limited the ability to independently look at the dynamics of psychological distress among them. the evaluation could not interview the anticipated number of relatives because some of the contacts did not inform their immediate family members about their status as evd contacts and therefore could not be interviewed. despite these limitations, we are confident the findings of this study reflect the possible psychological distress following being a survivor or contact of evd or a relation to any. we concluded that survivors and contacts of evd or their relatives develop psychological distress that could be predicted by loss of a relation and recommended that mental health specialists and social workers be part of the case management team of the response to evd outbreak. the clinical teams managing evd patients should be trained on recognition of psychological distress among the patients and recognition of common psychiatric disorders like depression that could follow evd infection, and special attention should be paid to those who have lost a relation. we also recommended the follow up of all survivors/contacts with increased risk of developing psychological distress or disorders for a minimum period of months by a mental health specialist for early detection of mental health disorders following evd. the findings of this study were shared with the ebola emergency operation center in lagos and the main findings were equally presented to the meeting of the association of psychiatrists and allied professionals in nigeria. 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meta-analysis of risk factors for depression in adults and children after natural disasters the ebola outbreak and mental health: current status and recommended response correlates of depression among internally displaced persons after postelection violence in kaduna, north western nigeria submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution submit your manuscript at www the authors declare that they have no competing interests.authors' contributions am conceived the study and developed the initial and subsequent drafts. key: cord- - qds e authors: richardson, katya l; driedger, michelle s; pizzi, nick j; wu, jianhong; moghadas, seyed m title: indigenous populations health protection: a canadian perspective date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: qds e the disproportionate effects of the h n pandemic on many canadian aboriginal communities have drawn attention to the vulnerability of these communities in terms of health outcomes in the face of emerging and reemerging infectious diseases. exploring the particular challenges facing these communities is essential to improving public health planning. in alignment with the objectives of the pandemic influenza outbreak research modelling (pan-inform) team, a canadian public health workshop was held at the centre for disease modelling (cdm) to: (i) evaluate post-pandemic research findings; (ii) identify existing gaps in knowledge that have yet to be addressed through ongoing research and collaborative activities; and (iii) build upon existing partnerships within the research community to forge new collaborative links with aboriginal health organizations. the workshop achieved its objectives in identifying main research findings and emerging information post pandemic, and highlighting key challenges that pose significant impediments to the health protection and promotion of canadian aboriginal populations. the health challenges faced by canadian indigenous populations are unique and complex, and can only be addressed through active engagement with affected communities. the academic research community will need to develop a new interdisciplinary framework, building upon concepts from ‘communities of practice’, to ensure that the research priorities are identified and targeted, and the outcomes are translated into the context of community health to improve policy and practice. the mandate of pan-inform is to develop knowledge translation methodologies with the aim of bridging the gaps between theory, policy, and practice [ ] . in a postpandemic workshop held in [ ] . pan-inform analyzed public health and clinical responses to the h n pandemic and found that canada's aboriginal (first nations, inuit, and métis) populations were disproportionately affected by the crisis. in fact, those living in first nations communities were . times more likely to be hospitalized after contracting the infection, with an intensive care unit admission rate times higher than non-aboriginal people [ ] . with a commitment to inform public health policies for the promotion of population health, pan-inform has prioritized initiatives to address the challenges of community health in protecting vulnerable populations from emerging infectious diseases. in order to identify the pertinent challenges, a public health workshop on "indigenous populations health protection" was held on may - , [ ] , at the cdm in york university. with the participation of key stakeholders from aboriginal health organizations, policy decision-makers, and representatives from the research community in canada, the workshop focused on public health responses, determinants of health, and the differential effects of intervention strategies in aboriginal populations. the presence of indigenous stakeholders was crucial in meeting the workshop objectives and providing a national forum to establish new partnerships, and foster research collaborations with aboriginal health organizations. modellers presented important research findings with relevance to indigenous health, and highlighted the importance of community-specific planning for vulnerable populations. from the standpoint of public health, the workshop uncovered some critical issues facing underserved communities in terms of access to healthcare services and program delivery. representatives from health departments shared their knowledge and experiences with addressing the disparities in healthcare access for many aboriginal communities across canada. through in-depth and collegial discussions, important inputs that must be encapsulated in modelling frameworks were identified, and the challenges that are involved in developing health policies were presented. aboriginal populations face different challenges during emerging infectious diseases. some of these challenges result from limited access to and the delivery of health services, particularly when some of canada's constitutionally identified aboriginal peoples have different levels of government responsible for the provision of healthcare. the federal government generally provides for first nations and inuit populations, whereas métis citizens generally fall under provincial health jurisdictions. what compounds this, however, is that first nations and métis citizens might live quite geographically close, but experience differential access to healthcare and noninsured health coverage. these differences can begin to be eliminated through collaborative multi-jurisdictional efforts designed to address the health needs of affected individuals, particularly those living in remote areas. aboriginal communities in the province of manitoba, especially in the northern region, were severely affected by the pandemic [ , ] . data for laboratory confirmed cases of h n infection and hospitalization collected during the first wave of the pandemic in the province of manitoba suggest significantly higher agespecific rates of incidence and hospital admission for first nations populations compared to non-first nations populations ( figure ). during outbreaks of the h n virus in manitoba, a tripartite table was established, which included representatives from the provincial and federal governments as well as representatives from first nations and métis self-governing organizations. the provincial minister of health liaised and dialogued regularly with the tripartite table to develop communication strategies for access to primary healthcare in northern manitoba. in addition, a table for 'equity and ethics' was established to collect feedback from communities and ensure that their respective citizens would receive equitable access to vaccine and other health resources. to facilitate responses, planning measures included the establishment of teams that were deployed to remote areas for the delivery of patient-care. patients with severe outcomes requiring hospitalization were transported to the southern part of the province for access to critical care. however, indigenous leaders stressed the importance of developing self-care systems. in response to this concern, manitoba health aided with the distribution of h n flu kits to communities where pharmacies and nursing stations were absent or not readily accessible. the provincial government also supported the use of traditional medicines and communicated the relevant information as to where such resources could be located. lessons learned from manitoba's experience during the h n pandemic included understanding that organizations and communities have developed their own plans for responding to emerging crises, and this underscores the necessity for effective communications at all levels of the healthcare system and community for the development of a coherent strategy [ ] . this was further highlighted by presenting the challenges that were encountered with the implementation of vaccination policies during the second wave, in particular with determining priority groups, eligibility criteria, and workforce requirements. pandemic prevention strategies included recommendations to adopt methods for the impact assessment of major decisions on health inequalities, to increase the engagement between services and communities, to strengthen the vital role of families and communities, to promote a more equitable distribution of the determinants of health, and to enhance prevention programs and encourage more outreach. several recommendations for enhancing pandemic preparedness at the provincial level were made, such as establishing recommended structures and elements for strategy development with an oversight body and a multi-stakeholder network. it was identified that there needs to be greater clarity in communicating policy guidelines, so that information is presented in a consistent and accurate manner to the public. to enhance the perspectives of northern communities, several impediments to adequate healthcare delivery during the h n pandemic in the territory of nunavut were discussed. cross-cultural barriers remain a key challenge in nunavut, as many of the healthcare professionals practicing in the territory are often considered outsiders. there is a general lack of orientation to the territory for outside staff, especially with regards to language training. the learning of nunavut's two languages is not mandatory and classes are limited to basic training. concerns regarding the potential to recruit and retain public health staff in nunavut remain unaddressed. nunavut still stores public health records in paper-based forms as opposed to electronic systems implemented in canada at large, which causes problems in maintaining accurate records and surveillance systems. although the need to generate and update these systems is known, vocalizing this concern has been limited. furthermore, regulations that have been put in place to protect public health are often rendered obsolete as few people are trained in policing these regulations. the lack of adherence to, or inadequate level of compliance with some regulations has resulted in an increased health burden in the inuit communities. the social determinants of health can be categorized as: distal (historic, political, social and economic contexts), intermediate (community infrastructure, resources, systems and capacities), and proximal (health behaviours, physical and social environment). colonization is a particularly important historical consideration, as are neocolonial policies because they perpetuate discrimination and social exclusion, even into the twenty-first century. these processes hinder the development of healthy identities and self-esteem, and are ultimately responsible for poor mental and physical health. chronic mental diseases affecting indigenous communities include schizophrenia, bipolar disorder and major depressive disorder, as well as post-traumatic stress disorder and addiction. most astounding is the suicide rate among first nations youth (aged [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , which is eight times the national average for females and five times the national average for males in canada [ , ] . other important social determinants of health include poverty, poor education, and overcrowded housing, which have a strong correlation to chronic and infectious diseases. the united nations' human development index has been applied to canada to understand the differences in quality of life and wellbeing between indigenous and non-indigenous populations [ ] . overall, canada has consistently ranked within the top five nations in the world but when the socioeconomic status of canadian aboriginal peoples is factored in, canada's ranking on the index drops significantly. many aboriginal peoples are essentially living in third world conditions within a first world country. geographic locale is a key factor in determining the level of access to healthcare, with the most underserved communities being those that are the most isolated and remote in the country. often these communities belong to indigenous groups living in the northern regions of the provinces and across the territories. approximately % of the inuit population lives in nunavut where resources pertaining to health practitioners and medical equipment are limited [ ] . geographic isolation complicates policy decisions, as the availability and lifespan of medicines need to be continually assessed to make accurate decisions about the shipment of medical supplies to remote communities. this was marked as one of the greatest challenges in serving these communities during the h n pandemic outbreaks. furthermore, the existence of multiple jurisdictions, each with differing policies concerning the health and wellbeing of first nations has led to a patchwork of polices. overlapping jurisdictions create conflicts in terms of identifying correct procedures to follow and assigning the responsibility for provision of care. currently, the provincial and federal governments share these responsibilities and there is little consistency in the modes for public health delivery between regions, especially between on-reserve and off-reserve indigenous populations. the outcome has been varying levels of healthcare delivery, number of personnel, and facilities available within each indigenous community. for relative infection (hospitalization) ratios, bar plots and % confidence intervals correspond to the age-standardized ratio of the proportion of infectious (hospitalized) cases in a given age group to the proportion of the population in the same age group [ ] . a relative ratio higher than indicates that the corresponding age group experienced a higher incidence of infection or hospitalization than the population as a whole. recognizing that limited access to healthcare acts as one of the perpetuating factors to increased rates of respiratory illness in aboriginal populations, a team of researchers has been conducting research to provide contrasting results if this limitation were removed [ , ] . the leading member of this research presented the findings specific to kahnawà:ke, an aboriginal reserve without any constraints in access to healthcare due to its close proximity to montreal, the largest urban centre in the province of quebec. data was collected on outpatient and emergency room visits between to for residents of both kahnawà:ke and montreal. analysis of such data, stratified by gender and age groups, indicates that the two regions had similar demographics, but the outpatient and emergency room visits were % higher for residents of kahnawà:ke compared to residents of montreal. when the access to healthcare factor was removed, questions arose about the reasons for the increased risk of vulnerability in residents of kahnawà:ke. although no conclusions have been drawn, data indicate that diabetes in first nations populations is % higher than the canadian national average; child obesity is % versus % in quebec; and smoking is % higher in quebec's first nations people compared to non-first nations. a constant annual pattern has been reported, linking the contributing factors, habitual smoking, and obesity to respiratory illnesses. although the link between social factors and health outcomes is strong, canada's approach to protecting vulnerable populations has focused on emergency services rather than prevention. a study conducted at york university's canadian homelessness research network analyzed how emergency response to homelessness impacts the vulnerability of homeless populations in the event of a pandemic, and how it presents impediments to effective pandemic planning [ ] . this study challenged key assumptions made about the resources available to homeless populations and raised important questions about system capacities in the homelessness sector. it also analyzed ethical considerations, noting that during emergency situations, there is a risk of compromising human rights for greater health and safety. it is common for difficult ethical questions about the prioritization and allocation of limited health resources to arise during these occasions, as well as concerns about the violation of individuals' autonomy through forced isolation or quarantine. the first wave of the h n pandemic exposed the vulnerability of aboriginal populations to poor outcomes, demonstrating the inefficacy of the polysaccharide vaccine that was in use at the time. this alerted health canada to fund a study that assessed the safety and immunogenicity of a new adjuvanted vaccine (arepanrix) in a sample of aboriginal adults [ ] . a leading member of the study team presented the results of this population-specific work. the study involved an open trial with participants, with first nations identity and métis, all from the winnipeg health region, which is the largest urban centre in the province of manitoba. the volunteers kept their daily symptom diaries for seven days following vaccination, including oral temperature measurements. there was a telephonebased safety interview on the seventh day, and an inperson review of adverse events on the twenty-first day. approximately % of the volunteers experienced adverse effects, although fever was not experienced and most general symptoms were abated by the end of the first week. the immune response assessment involved collecting blood samples at baseline, as well as to days post vaccination. sera were then tested for hemagglutination-inhibiting antibodies at the national microbiology laboratory in winnipeg. all of the patients had adequate antibody responses regardless of whether they were primed (previously exposed) or naïve (fully susceptible). results for the entire study, which examined , individuals across six projects, concluded that immunogenic responses to the vaccination in aboriginal adults exceeded those of non-aboriginal adults. workshop participants found the protocol completion rate impressive, with of the subjects present for the final blood draw, which was greater than the anticipated rate of participation by aboriginal people in the research. the safety profile of the adjuvanted vaccine was consistent with the projected rates. given the success of this study, it will be important in future work to determine if an equally satisfactory response follows the adjuvanted seasonal influenza vaccine. in the vaccine research domain, a study is currently being conducted for the development of a new vaccine candidate against heamophilus infuenzae type a (hia), which has emerged during the past decade in canadian aboriginal communities [ ] [ ] [ ] [ ] [ ] [ ] . the high prevalence of this infection, which manifests as meningitis, septicaemia, or bacteremic pneumonia, has prompted aboriginalspecific studies. invasive hia disease has become a major cause of severe outcomes in young children of several aboriginal populations in north america, with highest risk of contracting hia being reported in the navajo, white apache, alaskan natives, first nations, and inuit [ ] [ ] [ ] [ ] . in a study spanning the last decade, it was found that hia made up % of all serotyped isolates for heamophilus infuenzae [ ] . the emergence and high incidence of invasive hia disease in canadian aboriginal populations warrant further clinical and epidemiological studies, involving affected communities for the development of an effective hia vaccine candidate. helicobacter pylori (h. pylori), is yet another prevalent infection in canadian aboriginal populations [ ] . h. pylori is one of the most common pathogens affecting half of the world's population, particularly in developing countries. in canada, there are three identified groups, including aboriginal people, which are associated with higher risk of infection by h. pylori [ ] . the pathogen causes illnesses and conditions such as chronic gastritis and peptic ulcers, and increases the risk of gastric cancer [ ] [ ] [ ] . the current infection management strategies are based on antibiotic regimens. however, this treatment faces declining effectiveness, with rates dropping below % due to the emergence of drug-resistance. a team of canadian researchers has developed a new technology, which enables the formulation of a vaccine candidate against h. pylori. the leading member of the research team presented the results of this ongoing work that aims to analyze the characteristics of isolates from aboriginal populations. this analysis could identify the circulating strains in aboriginal populations, and determine the immune profiles of the affected populations. factors responsible for the increased vulnerability of these populations to h. pylori include crowded housing, poor sanitary conditions, and polluted water supplies, which underscore the importance of access to critical infrastructure in protecting and promoting community health. a major obstacle to developing appropriate health policies and responsive healthcare delivery is a lack of specific data. although data may be available for particular regions, there is a general lack of streamlining in data sets across multiple jurisdictions, as well as between hospital databases and public health surveillance systems in canada. as a result, public health professionals are often faced with a deficiency of information to make informed policy decisions. thus, incomplete data may be adapted or used out of the context in efforts to inform the development of programs and strategies. during the workshop, disease modellers discussed some key areas in which detailed population level data play a critical role in understanding the risk of infection and outcomes in different vulnerable groups. for example, the results of a study on comparative analysis of age distribution of infection and hospitalization during the h n outbreak, presented a marked difference in the risk of infection between first nations and non-first nations populations in manitoba [ ] . the study further discriminated between the first wave and second wave of the pandemic, and compared the incidence rates between on-reserve and off-reserve first nation communities, indicating that the risk for infection and hospitalization was significantly higher for the former. pre-school aged children in the first nation populations were at higher risk during the first wave, whereas school-age children were at higher risk of infection during the second wave. such comparative analysis was based on large databases created during the h n pandemic with stratification of health regions, age, gender, ethnicity, time for initial care, and the type and duration of health resources used for the management of infection. the need for detailed data is also important for the assessment of effectiveness and cost-effectiveness of intervention measures in the face of competing strategies. presented results of an ongoing research study highlighted the potential utility of an agent-based modelling approach to determine the most effective antiviral treatment and prophylaxis strategies for influenza infection control, and to evaluate the effect of limiting intervention duration [ ] . in summary, the preliminary findings suggested that a great deal of prophylaxis waste typically occurs at low treatment levels in early stages of the epidemic. the early administration of high treatment levels significantly reduces prophylaxis waste, but increasing prophylaxis coverage in some scenarios contributes to increased waste. limiting the duration of prophylaxis can reduce the waste for comparable outcomes. this work continues to investigate whether particular age groups contribute disproportionately to the waste of treatment resources, and during which stage of the epidemic the greatest amount of waste is created. the results of this study will be used to propose more specifically targeted interventions that can be tested in-silico using computer simulation experiments. workshop participants stressed the importance of developing relationships with aboriginal stakeholders to ensure that their voices are heard in policy-making, and their needs are addressed in strategy development and program delivery. yet, it can be difficult for researchers to honour all aspects of diversity in their work and use holistic and inclusive approaches, which equally weigh different systems of knowledge. to navigate these pertinent challenges, the use of a "communities of practice" (cop) model was presented. the cop model, defined as a group of people who have common concerns, a set of problems, and a passion about solving the problems [ , ] , consists of two core components: (i) the interrelationships formed around mutual trust, identity, and understanding; and (ii) the acknowledgement of differences in perception and understanding. there is a need to develop shared meanings through social engagements and interactions by working towards a common goal and communicating in an accessible jargon-free language [ ] . the concept of cop is best summarized by the term coined by mi'kmaw elder albert marshall, "two-eyed seeing," which refers to the ability to see with one eye from an indigenous perspective and with the other from a western perspective, learning to use both in tandem for the benefit of all. this creates a comprehensive approach to advancing aboriginal health objectives. within the context of cop, the director of the institute of aboriginal peoples' health (iaph) of the canadian institutes of health research (cihr) outlined the institute's two primary goals. first, the iahp aims to increase awareness, understanding, and appreciation of aboriginal beliefs, in addition to traditional knowledge among researchers, peer reviewers, and the canadian population by extension. second, the iaph places a high priority on recognizing, promoting, and incorporating the excellence and rigour of methodologies derived from indigenous norms. the objective is to have these methodologies incorporated into the way the iaph conducts its research, rather than remaining a mere side note. the iaph aims to increase the number of first nations, inuit, and métis researchers conducting aboriginal-related health research, as well as the number and quality of their research activities. the iaph also takes a grassroots approach in its support of community-based organizations that are eligible to receive and manage funds on behalf of the cihr, thereby increasing the communities' abilities to address their own health issues. the workshop highlighted three general areas of research that are neither discrete nor inclusive but can be labeled as instrumental, symbolic, or conceptual. instrumental research measures impact, symbolic research argues a position, and conceptual research evaluates whether the right questions are being formulated. each form of research has its own relevancy and can be more commonly associated with certain academic disciplines. for example, with respect to the topic of health risks among homeless populations, instrumental research may ask how shelters can be made more hygienic, while conceptual research would question whether it makes more sense to provide housing to homeless individuals rather than warehouse them in shelters. both types of research are important for public health and through interdisciplinary knowledge translation activities, the pertinent questions can be debated, re-framed and re-formulated so that they are meaningful and address public health concerns. the underlying process is complex and there will always be political challenges involved; however it is important that resources be marshaled to address these public health issues to produce maximum benefits to the communities at risk. with unique population characteristics that place some aboriginal communities at increased risk for adverse health consequences, it is imperative for public health authorities to identify vulnerable segments of the population, and in cooperation with local officials within the community, determine effective and feasible health responses. these responses must also take into account factors such as jurisdictional issues and the variability of aboriginal public health infrastructures. while effectiveness is a necessary criterion for the identification of optimal health responses, these factors must also be considered for assessing the feasibility of such responses in different community settings. taking into consideration these underappreciated aspects and realities of vulnerable populations, the workshop highlighted that modelling and simulations are invaluable tools that permit the rapid testing of hypotheses for the subsequent design and implementation of response strategies to address the needs of these populations. by permitting simultaneous observations of disease-related outcomes at multiple levels of communities and the healthcare system, models can inform the development of communitywide and specific contingency plans that incorporate the full spectrum of harms related to disease spread and benefits associated with response activities. the workshop was successful in bringing together key stakeholders, policy decision makers, and researchers from a wide array of disciplines, each with their own perspective but all with the common goal of improving the health status of canada's indigenous populations. during the preceding decade, canada has experienced the emergence of novel diseases that have caused tremendous public concern and economic consequences, including the sars epidemic and the influenza pandemic. the rapid containment of sars as the first major infectious disease threat of the st century was a public health success in the modern era [ ] , but also a warning that the global containment of emerging diseases may be much more difficult in this highly connected world, if not impossible. the influenza pandemic demonstrated this difficulty and incurred disproportionately large economic and political impacts, in addition to differential effects on many subpopulations including aboriginal peoples and underserved communities [ ] . while the focus here has been on first nations, inuit and métis people in canada, these experiences were similar to what happened for indigenous people living in the united states, australia and new zealand [ ] [ ] [ ] . the objectives of this networking event, and the spectrum of participants, attested to the fact that in the relatively short period of time since the inception of pan-inform, significant progress has been achieved through the hosting of bi-annual workshops of this scale. these networking activities have encouraged more intricate disciplinary dialogues, which challenge participants to re-evaluate their assumptions so that they are eventually resolved or dissolved. as a result of such interdisciplinary approaches, new and stronger links between theory, policy and practice have been forged. a strength of the workshop was the presentation of how appropriate use of data can lead to novel scientific findings that influence policy and practice. this is realized by involving the research community, affected populations, and policy makers in the interpretation and contextual use of data, which is becoming increasingly important as modellers aim to introduce ever more complex structures into the models such as social network patterns. public health challenges and research methods discussed during the workshop led to key recommendations outlined in table . presentations given during the workshop were evidence for the opening of a new chapter in canadian public health research and practice involving indigenous populations. ongoing studies for the development of vaccines for diseases to which aboriginal populations are prone, as well as projects that are population specific and function on community engagement are examples of movements towards addressing indigenous populations health protection. in moving forward, research should be integrated with planning, building capacity, and harmonizing response activities at all levels and across the healthcare system to help develop holistic policies that are context-specific and incorporate indigenous perspectives. pandemic influenza outbreak research modelling the first influenza pandemic of the st century: canada' s response, lessons learned, and challenges ahead public health agency of canada: statement on seasonal trivalent inactivated influenza vaccine (tiv) correlates of severe disease in patients with pandemic influenza (h n ) virus infection critically ill patients with influenza a(h n ) infection in canada statistical methods in medical research canada in the face of the h n pandemic suicide among aboriginal people in canada. ottawa: aboriginal healing foundation health canada: a statistical profile on the health of first nations in canada. ottawa: health canada state of the world' s indigenous peoples the nature of nursing practice in rural and remote canada increased influenza-related healthcare utilization among residents of an urban aboriginal community socioeconomic disparities and the burden of seasonal influenza: the effect of social and material deprivation on rates of influenza infection homeless youth's overwhelming health burden: a review of the literature. paediatr child health the responses of aboriginal canadians to adjuvanted pandemic (h n ) influenza vaccine invasive infections caused by haemophilus influenzae serotypes in twelve canadian impact centers invasive disease due to non-type b strains epidemiology of haemophilus influenzae serotype a invasive bacterial diseases in northern canada invasive haemophilus influenzae disease caused by non-type b strains in northwestern ontario invasive disease caused by haemophilus influenzae type a in northern ontario first nations communities helicobacter pylori infection in canadian and related arctic aboriginal populations canadian helicobacter study group participants: helicobacter pylori in first nations and recent immigrant populations in canada helicobacter pylori infection and the development of gastric cancer age distribution of infection and hospitalization among canadian first nations during the h n pandemic the impact of demographic variables on disease spread: influenza in remote communities situated learning: legitimate peripheral participation communities of practice communities of practice: learning, meaning and identity learning from sars: preparing for the next disease outbreak australian aboriginal and torres strait islander communities and the development of pandemic influenza containment strategies: community voices and community control the pandemic h n influenza and indigenous populations of the americas and the pacific differential effects of pandemic (h n ) on remote and indigenous groups indigenous populations health protection: a canadian perspective the workshop was supported by the canadian institutes of health research (dissemination event grant no. ), national collaborating centre for infectious diseases, mitacs and the centre for disease modelling. the funders had no role in writing this paper or making decision to publish it. the authors would like to thank all the participants for their significant contributions to the workshop. the authors declare that they have no competing interests.authors' contributions kr and sm wrote the first draft of this paper. md, np and jw contributed to the final version. all authors have read the paper and approved it. key: cord- -pdctikjg authors: delacy, jack; dune, tinashe; macdonald, john j. title: the social determinants of otitis media in aboriginal children in australia: are we addressing the primary causes? a systematic content review date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: pdctikjg background: aboriginal and torres strait islander children experience some of the highest rates of otitis media in the world. key risk factors for otitis media in aboriginal children in australia are largely social and environmental factors such as overcrowded housing, poverty and limited access to services. despite this, little is known about how to address these risk factors. a scoping content review was performed to determine the relationship between social determinants of health and otitis media in aboriginal and torres strait islander children as described by peer-reviewed and grey literature. method: search terms were established for location, population and health condition. the search terms were used to conduct a literature search using six health research databases. following the exclusion process, articles were scoped, analysed and categorised using scoping parameters and a social determinants of health framework. results: housing-related issues were the most frequently reported determinants for otitis media ( %). two articles ( %) directly investigated the impact of social determinants of health on rates of otitis media within aboriginal and torres strait islander children. the majority of the literature ( %) highlights social determinants as playing a key role in the high rates of otitis media seen in aboriginal populations in australia. there were no intervention studies targeting social determinants as a means to reduce otitis media rates among aboriginal and torres strait islander children. conclusions: this review identifies a disconnect between otitis media drivers and the focus of public health interventions within aboriginal and torres strait islander populations. despite consensus that social determinants play a key role in the high rates of otitis media in aboriginal and torres strait islander children, the majority of intervention studies within the literature are focussed on biomedical approaches such as research on vaccines and antibiotics. this review highlights the need for otitis media intervention studies to shift away from a purely biomedical model and toward investigating the underlying social determinants of health. by shifting interventions upstream, otitis media rates may decrease within aboriginal and torres strait islander children, as focus is shifted away from a treatment-focussed model and toward a more preventative model. otitis media (om) is one of the leading causes of disease among aboriginal and torres strait islander (hereafter referred to as aboriginal) children [ , ] . om refers to inflammation and infection of the middle ear and is classified as acute om, om with effusion or chronic suppurative om [ , ] . there are currently inadequate services to deal with ear and hearing health within aboriginal communities and high demand for services is expected to continue in coming years [ ] . the world health organisation have identified om in its various forms as a major health issue for aboriginal children, despite the fact that om is preventable and treatable, and is far less common for non-aboriginal children in australia [ ] . the gap in prevalence of om between aboriginal and non-aboriginal children has consistently been associated with social determinants, particularly housing-related issues [ ] [ ] [ ] [ ] [ ] [ ] [ ] . om can impact upon educational outcomes and employability for aboriginal people who are more likely to be socially and economically disadvantaged than non-aboriginal australians [ ] . key risk factors for om in aboriginal children include overcrowded housing, poor housing conditions, exposure to tobacco smoke, malnutrition, socioeconomic disadvantage and limited access to services [ ] [ ] [ ] [ ] [ ] [ ] [ ] . aboriginal children experience om at similar rates, frequency and severity as children living in developing nations, despite the overall high standard of living in australia [ , ] . the prevalence of om in some aboriginal communities is close to times higher than the % identified by the world health organisation as being a serious public health problem requiring urgent attention [ ] . this puts aboriginal children as one of the most at risk populations for om in the world [ , ] . significant health gaps have persisted in aboriginal populations since the british invaded australia in [ , ] . these health gaps are highlighted by the gap in lifeexpectancy between aboriginal and non-aboriginal australians, with aboriginal children born between and expected to live . years younger than non-aboriginal children [ ] . furthermore, social and economic disadvantage have been underscored as significant contributing factors to these poor health outcomes [ ] . therefore, social determinants of om in aboriginal children need to be better understood in light of evidence supporting the impact of poor housing, exposure to tobacco smoke and socioeconomic disadvantage on the prevalence and persistence of om in aboriginal children. this review aims to identify how social determinants are addressed in grey and peer-reviewed literature, regarding drivers of om and proposed interventions aimed at minimising the health burden of om among aboriginal children. this review aims to identify gaps in the literature and guide further research, policy development and service provision. given the broad nature of the research objective, a scoping content review was conducted to explore available research, to evaluate the need for further investigation, to describe key themes and to identify gaps in the literature. the framework proposed by arksey and o'malley [ ] for conducting a scoping content review was adapted for this study and is detailed below. initially, the research objective was established through preliminary review of the literature and discussion between the research team. following the establishment of the research objective, the search strategy was developed by implementing inclusion and exclusion criteria, and keywords (see table ). the location was limited to australia, the included literature was limited to english only and no time constraints were placed on the date of publication. the population of focus was established by two criteria: individuals of australian aboriginal identity and children aged years old or younger. health condition terms related to om and ear disease. literature type included peer-reviewed and grey literature. the literature search was conducted in april . keywords were established and agreed upon by the research team with the assistance of university library staff for the parameters: location, population and health condition. the selected databases were chosen upon consensus and the search was conducted independently by each research team member and the assisting librarian to limit bias. boolean operators were applied in the literature search within pubmed, proquest, scopus, informit, medline and google scholar. for the google scholar literature search, multiple searches were conducted due to search box restrictions (see table ). location keywords were substituted by selecting results from australia only and each of the om-related terms were searched for separately. the population keywords were searched with boolean operators consistent with other database searches and is detailed in table . the first step in selecting the literature was to exclude any duplicate papers. this was done using endnote (electronic referencing software). google scholar results were limited to the first two pages, given the large number of results yielded and time constraints for conducting the literature search. an excel spreadsheet was created to categorise the literature based on the following parameters: author, title, year, within australia, 'aboriginal-related term', 'omrelated term' and full text available. the literature was then systematically evaluated based on these criteria and included or excluded accordingly. where there was any uncertainty regarding the suitability of an article, consensus on whether to include the article(s) was reached by the research team. following selection of the included literature, two separate excel spreadsheets were created to analyse and report the results. one spreadsheet contained the peer-reviewed [ ] , as shown in fig. . the literature search was conducted using six specified databases and the exclusion process is detailed in fig. . the search yielded results, duplicates were excluded and a further articles were excluded based on location of the studies. articles were screened by title and article type, with excluded based on irrelevance of the title and one article was excluded due to the article type (unpublished thesis). following the screening process, articles were included in the study. of the included articles, were peer-reviewed and were grey literature articles. following the exclusion process, the included literature was evaluated by how om related social determinants were addressed. ( %) peer-reviewed and grey articles were identified as discussing social determinants, with ( %) discussing social determinants as a significant factor for driving the high rates of om and ( %) articles identifying the need to address social determinants to reduce the high rates of om in aboriginal children. of the articles that discuss social determinants as important for om management, articles did not discuss this in detail -these articles did not provide specific recommendation or evidence for further research and policy development. for example, sparrow et al. [ ] (p ) state "the key to improving chronic middle ear disease must be by addressing living standards and general health". although this type of statement is true and does acknowledge an important issue, the article does not pursue this theme further. further evaluation of the literature revealed that ( %) articles did not mention social determinants at all, with four articles ( %) providing analysis of social determinants of om. these four articles presented social determinants as key priority areas for future intervention and provided supported recommendations to help address social determinants linked to om. for example, jacoby et al. [ ] (p ) state "there is a need for more input by indigenous australians in developing programs, increased funding and improved access to nicotine replacement therapy". lastly, the most significant finding was that despite the majority ( %) of the literature discussing social determinants as impacting the presence of om in aboriginal children, there were no studies within the literature that proposed or investigated a social determinants-focussed intervention. in addition to the social determinants-related scoping criteria, the literature was comprehensively assessed using the 'social determinants framework for aboriginal and torres strait islander health'. [ ] the social determinants of health framework identifies three key areas of health for aboriginal populations, with the literature addressing 'housing, employment, education and income' most frequently ( %) in relation to high rates of om in aboriginal children. 'community involvement, social networks and family support' were discussed by few articles ( %) and even fewer mentioned 'culture, history and connection to land' ( %). moreover, over % of the peer-reviewed articles (n = ) did not address any of the three key areas of the social determinants of health framework. housing-related social determinants were reported most frequently within the literature, with ( %) reports of housing related risk factors for om ( specifically related to overcrowded housing). the next most frequently discussed social determinant was exposure to tobacco smoke, with articles ( %) discussing this as a significant determinant for om. low socioeconomic status, low income and poverty ( %), access to services ( %), hygiene ( %), and education of the primary caregiver ( %) were among the most frequently mentioned determinants. other reported determinants for om were employment status and employment opportunities ( %), nutrition ( %), community involvement in service provision and planning ( %), and cultural and language differences (n = ). sun et al. [ ] (p ) explain that improved housing for aboriginal populations is desperately needed, as "overcrowding is the single most important and most consistent risk factor for upper respiratory tract carriage (presence of bacteria), and consequently, the development of om in indigenous children". it is therefore important to note, that of the peerreviewed articles, only jacoby et al. [ ] examined overcrowded housing and its impact on om associated bacterial carriage. jacoby et al. [ ] provide thorough analysis on aspects of overcrowding, such as the number of adults, children and rooms within a household and its impact on om occurrence. more specifically, the greater the number of people, the greater the number of children and the fewer rooms within a house, the greater the risk of developing om [ ] . unfortunately, this article did not identify any means to address these issues and only highlights the seriousness of the housing problems faced by many aboriginal communities. a detailed analysis was performed on what recommendations were made in the literature (i.e. review of the recommended approaches to the management of om in aboriginal children). ( %) of the peer-reviewed and grey articles did not discuss social determinants in future directions at all. articles ( %) primarily recommended further research into antibiotic treatment and vaccine development, and the need for greater understanding of om associated bacterial carriage. five ( %) articles presented detailed recommendations for future research and policy development intended to address social determinants to reduce the high rates of om in aboriginal children. om is one of the leading causes of preventable disease amongst aboriginal children, and has been determined by the world health organisation to be a serious public health issue requiring urgent attention [ ] [ ] [ ] ] . om primarily occurs during developmental years and can drastically impact upon speech and language development, which is likely to influence educational outcomes and prospective employability-precursors to potentially life-long socioeconomic disadvantage and poverty [ ] . this study identifies how social determinants are addressed within grey and peer-reviewed literature, and summarises the primary determinants reported to be associated with om and management recommendations within the literature. this study highlights gaps between factors reported to be associated with om and recommended interventions within the literature. given the significance of this gap, further research aimed at understanding social determinants associated with om and identifying more effective management of the social determinants of om within aboriginal children is warranted. furthermore, the inter-related nature of the social determinants of health is emphasised throughout this paper and helps to underline the challenge that an exclusively biomedical model poses in addressing specific aetiology [ ] .(p - ) notably, a shift in approaches to manage om is desperately needed, in conjunction with further research to better understand the relationship between the social determinants of health and risk of om in aboriginal populations. this review demonstrates that there is an imbalanced research focus towards biomedical approaches in contrast to improving our understanding about how to address key social determinants contributing to high rates of om in aboriginal children. using the social determinants of health framework, this review has identified significant shortcomings within the literature and the current public health management of om in aboriginal children. the social determinants of health framework used within this study identifies three key areas of aboriginal health that are largely neglected by the available grey and peer-reviewed literature in relation to om management. although the literature mentions various social determinants that are consistent with the framework (e.g. housing, education, employment, community engagement, culture and history), none of the included articles evaluated these key areas of aboriginal health with the objective to establish effective social, environmental, political or cultural-focussed interventions for om. further, the key social determinants of om can be argued to stem from the persistent social, economic and cultural discrimination experienced by aboriginal populations. through evaluation using the social determinants of health framework, this review highlights the need to preserve aboriginal culture, strengthen aboriginal self-determination, respect and support aboriginal connection to land, empower aboriginal communities, improve education and employment opportunities for aboriginal people, and address poor housing conditions and overcrowding within aboriginal communities. importantly, one of the most significant and achievable goals should be to ensure the adoption of co-creation and a decolonised approach to ear health research, and health research more broadly, in aboriginal populations. aboriginal self-determination and services that are embedded within community are key to improving the management of om within aboriginal populations [ ] . such an approach is needed to help ensure success of public health programmes and services aimed at reducing the risk of om in early life, and consequently helping to eliminate the cycle of disadvantage that contributes to social determinants driving ill-health across the life-course. measurement of such targets should be done through formal and informal consultation with community at each step of the research process. there is growing acknowledgement within the literature that the current empirical research paradigm should adopt co-creation and qualitative research methods, in conjunction with quantitative methodology, to ensure successful research and research translation within aboriginal communities [ ] . furthermore, recognising aboriginal people as experts of their communities is vital to ensure successful planning, development, implementation and evaluation of health research and health approaches within aboriginal contexts. the most evident theme arising from this review was the importance of the home environment, with housingrelated determinants reported almost three times more than the next most frequently reported risk factor. despite acknowledgement of the association between housing and the prevalence of om in aboriginal children, there were no intervention studies within the reviewed literature that investigated how to effectively address the issue of housing in aboriginal populations. exposure to cigarette smoke and poor hygiene were not directly acknowledged as relating to housing within this review. however, these risk factors are likely to be influenced to some degree by the home environment, given the relatively high rates of smoking within the home in aboriginal populations [ , ] . it is therefore evident, that addressing the home environment is fundamental to adequately manage om in aboriginal populations. moreover, further research into housing as a determinant of om and as a means for intervention is desperately needed, given the lack of information available to adequately deal with this area of aboriginal health. addressing housing issues in aboriginal communities is a complex issue, particularly when considering the importance of connection to land in contrast with the importance of the physical structure itself. it can be said that the efforts of government housing programmes have been heavily focussed on the logistics. for example, funding and physical infrastructure, with little acknowledgement of the need to develop culturally appropriate housing policies and pathways [ ] . (p ) carson et al. [ ] (p ) stress the lack of intervention studies that link housing to aboriginal health outcomes and the ability to develop policy is limited as a result. the lack of intervention studies is also highlighted by this review, as no intervention studies looking at social determinants and aboriginal health outcomes were identified within the literature. intervention studies are crucial for policy development and although remoteness, and political and social barriers exist for improving housing and infrastructure in aboriginal communities [ ] , a shift in focus towards more culturally appropriate housing policy and provision is urgently needed. exposure to tobacco smoke is consistently reported as a key contributing factor for aboriginal children developing om. aboriginal children who are exposed to tobacco smoke in the home and who do not attend day-care have been suggested to be at greatest risk of developing om [ ] . this is not to say that home-care by parents and family is problematic. however, given the relatively high rates of smoking within the home environment [ ] , it is an important issue for consideration. jacoby et al. [ ] suggest that children who are exposed to tobacco smoke in the home who also attend day-care may be at lower risk of developing om, presumably because the time spent at daycare means less time exposed to tobacco smoke in the home. however, day-care attendance has previously been associated with a greater risk of om, and further research may help to explain this relationship. moreover, this inconsistent research helps to highlight the evident gaps within the literature resulting from the long-standing narrow lens of the biomedical focus of the existing research. furthermore, this supports calls for further investigation into the relationship of the social determinants of health and environmental factors with om risk in aboriginal children. education and employment of the primary caregiver is cited frequently as an important determinant for aboriginal children developing om. however, no paper within the reviewed literature discussed this any further than listing it as a significant contributing factor. it is important to highlight that low-level education and lack of employment opportunities consign many aboriginal people to levels of poverty [ ] . (p ) furthermore, education that excludes culture and native language has been demonstrated to adversely impact individuals by disempowering aboriginal communities and harming the cultural identity of these communities [ ] . moreover, hearing loss associated with om is likely to further disengage children within the classroom, and this is compounded by lack of engagement due to hearing loss being misconstrued as misbehaviour. it is therefore clear, that aboriginal children face significant barriers within the classroom and highlights the need for culturally appropriate schooling, accompanied by approaches to reduce rates of om and hearing loss. notably, there were no papers identified within this review that comprehensively evaluated the impact of om across the life-course, including the impact of om on speech, language and early childhood development, which may impact educational outcomes and long-term social and emotional wellbeing. aboriginal community involvement is an area that requires greater emphasis and encouragement from public health promoters, policy makers and service providers. programmes such as the 'healthy ears, happy kids', [ ] 'aboriginal otitis media project' [ ] , 'hearing, ear health and language services' ('heals') [ ] and 'deadly kids, deadly futures' [ ] help to draw attention from government and non-government organisations towards the seriousness of the burden of om in aboriginal communities. 'heals' and 'deadly kids, deadly futures' have helped to demonstrate priority areas for the public health management of om in aboriginal communities, in addition to recommendations about key research considerations when working with aboriginal communities. priorities include working towards improved coordination, access and delivery of services, enhancing capacity building within communities, and aboriginal control of research activities and translation [ , ] . furthermore, these programmes have helped to educate and empower aboriginal communities and health workers to manage om more effectively in a culturally safe way [ , , ] . given the historical marginalisation, neglect and subjugation of aboriginal populations, empowering aboriginal communities to manage health services, develop and implement research, and provide recommendations is essential to overcome issues of mistrust, and consequently, improve cultural access to essential services. importantly, 'deadly kids, deadly futures', which was not identified by the systematic literature search, provides a 'social determinants model of ear and hearing health' that highlights relevant social determinants of ear health for aboriginal children [ ] . this model may be useful to guide future research, policy development and the development of services. however, research focussing on how to best target these social determinants is lacking. therefore, further work is needed to advance these programmes and identify how to effectively target the underlying social determinants of om in aboriginal children. despite the lack of research about how to effectively target the social determinants of om, there is a growing body of research regarding diversifying health approaches to better address social determinants of health more broadly. the term 'integrated models of care' has emerged within the literature, which describes the integration of biomedical services with non-medical community services (e.g. housing, employment and food insecurity services) to provide a more comprehensive approach to target underlying risk factors for ill-health [ ] . using a similar approach, it is recommended that tools to screen for social determinants associated with om are developed. this will assist health workers to identify and target important social, environmental and cultural risk factors associated with om [ , ] . information obtained through this type of screening may provide health workers with relevant information to refer at-risk children to community services, in conjunction with traditional medical management, to help alleviate factors placing a child at heightened risk. this process has been referred to as 'social prescribing' and aims to broaden the often-narrow focus of biomedical intervention alone [ ] . therefore, it is recommended that future research looks at 'integrated models of care' and 'social prescribing', and how they can be incorporated into primary care management of om and ear disease. additionally, service coordination is key for successful navigation of healthcare systems and referral pathways, which are often complex. by integrating a wider variety of services in the primary care of om, such as housing or employment services, the need for coordination is particularly important to support the implementation of such models [ , ] . while this review presented a comprehensive analysis of both peer-reviewed and grey literature, this study excluded unpublished masters and doctoral theses. despite this, findings by vickers and smith [ ] following review of the cochrane library, found only one of systematic reviews included data from theses that could have significantly altered the conclusions of the reviews. moreover, there is limited benefit of including theses in systematic reviews, as they rarely influence the conclusions, and retrieving and analysing unpublished dissertations involves considerable time and effort [ ] . the timeframe of this project also limited the number of selected databases and consequently the number of papers that were included within the study. however, articles still provides comprehensive scope of the literature to enable thorough analysis, detailed explanation and well supported recommendations. using google scholar presented limitations in search function, as search box options within the database meant that a modified search was needed to fulfil the specified search strategy and to remain consistent with searches performed on the other selected databases. there is overwhelming consensus within the reviewed literature that aboriginal children experience disproportionately high rates of om when compared to non-aboriginal children. the high rates of om are linked to poor housing conditions, overcrowded housing, exposure to tobacco smoke, education, and overall social and economic disadvantage. furthermore, there is disparity between reported risk factors of om and current interventions aimed at reducing the burden of om in aboriginal populations. current interventions are primary focussed on biomedical approaches such as investigating vaccines and antibiotics. although vaccines and antibiotics are essential to the provision of high-quality clinical care for om, a broader public health lens is required to address the underlying social factors reported to be driving the gap in om rates between aboriginal and non-aboriginal children. it is important to mention that the aboriginal understanding of health includes "body, mind, spirit, land, environment, custom, socioeconomic status, family and community" [ ] . (p ) this understanding of health significantly differs from mainstream models of health, which typically involves the pursuit to merely limit ill-health within individuals without considering the context of their lives [ ] . therefore, policy and services founded upon this restricted understanding of health is likely to be restrictive in its ability to address the much more holistic aboriginal understanding of health, which includes how people live, work and interact with their environment, and the importance of community for the individual. in accordance with this notion, engaging communities in research design and implementation is fundamental to shift the current research paradigm. understanding the context of aboriginal lives is key for successful research and meaningful translation of research. further research into how social determinants contribute to om and what interventions may be beneficial to address om associated social determinants in aboriginal children is needed. intervention studies to evaluate the benefit of culturally suitable, accessible and safe housing on rates of om in aboriginal communities is vital. lastly, development of an aboriginal ear health framework is recommended. development of a comprehensive ear health framework requires further research, although should include information about social determinants of health screening, social prescribing, and coordinating the complex network of health and community services that may help to address underlying social determinants of om. research evaluating the association between social determinants of health and risk of om in aboriginal children what is known about health and hearing? in: australian indigenous healthinfonet review of ear health and hearing among indigenous australian household number associated with middle ear disease in urban indigenous health service: a cross-sectional study australian institute of health and welfare. ear and hearing health of indigenous children in the northern territory australian institute of health and welfare. ear disease in aboriginal and torres strait islander children otitis media in indigenous australian children: review of epidemiology and risk factors gaps in indigenous disadvantage not closing: a cencus cohort study of social determinants of health in australia, canada and new zealand from longtitudal analysis of ear infection and hearing impairment: findings from -year prospective cohorts of australian chidlren healthy ears, happy kids: a new approach to aboriginal child ear health in nsw health equity and the social determinants of health in australia the spectrum and management of otitis media in australian indigenous and nonindigenous children: a national study australian institute of health and welfare. the health and welfare of australia's aboriginal and torres strait islander peoples scoping studies: towards a methodological framework department of health and ageing. summary of aboriginal and torres strait islander health status do tissue spears used to clear ear canal pus improve hearing? a case series study of hearing in remote australian aboriginal children with chronic suppurative otitis media before and after dry mopping with tissue spears the effect of passive smoking on the risk of otitis media in aboriginal and non-aboriginal children in the kalgoorlie? boulder region of western australia association between early bacterial carriage and otitis media in aboriginal and non-aboriginal children in a semi-arid area of western australia: a cohort study crowding and other strong predictors of upper respiratory tract carriage of otitis media-related bacteria in australian aboriginal and non-aboriginal children environments for health: a salutogenic approach building trust and sharing power for co-creation in aboriginal health research: a stakeholder interview study social determinants of indigenous health. crows nest: allen & unwin australia indigenous australians and health: the wombat in the room ear infection ten times more likely in aboriginal children a case study of enhanced clinical care enabled by aboriginal health research: the hearing, ear health and language services (heals) project deadly futures: queensland's aboriginal and torres strait islander child ear health framework addressing social determinants of health: challenges and opportunities in a value-based model screening and referral for low-income families' socal determinants of health by us pediatricians social prescribing incorporating data from dissertations in systematic reviews publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors' contributions all authors have read and approved the final manuscript. jd: protocol development, literature search, data collection, data collation, data analysis, interpretation of results and was the major contributor to writing the manuscript. td: protocol development, literature search, interpretation of results, reporting of results and contributed to writing the manuscript. jm: literature search, interpretations of results, reporting of results and contributed to writing the manuscript. not applicable. data are available through the corresponding author.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord- - m psxri authors: park, hye yoon; park, wan beom; lee, so hee; kim, jeong lan; lee, jung jae; lee, haewoo; shin, hyoung-shik title: posttraumatic stress disorder and depression of survivors months after the outbreak of middle east respiratory syndrome in south korea date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: m psxri background: the outbreak of middle east respiratory syndrome (mers) in the republic of korea is a recent and representative occurrence of nationwide outbreaks of emerging infectious diseases (eids). in addition to physical symptoms, posttraumatic stress disorder (ptsd) and depression are common following outbreaks of eid. methods: the present study investigated the long-term mental health outcomes and related risk factors in survivors of mers. a prospective nationwide cohort study was conducted months after the mers outbreak at multi-centers throughout korea. ptsd and depression as the main mental health outcomes were assessed with the impact of event scale-revised korean version (ies-r-k) and the patient health questionnaire- (phq- ) respectively. results: . % of survivors reported ptsd (ies-r-k ≥ ) and . % reported depression (phq- ≥ ) at months post-mers. a multivariate analysis revealed that anxiety (adjusted odds ratio [aor], . ; %ci, . – . ; p = . ), and a greater recognition of stigma (aor, . , %ci, . – . ; p = . ) during the mers-affected period were independent predictors of ptsd at months after the mers outbreak. having a family member who died from mers predicted the development of depression (aor, . , %ci, . – . ; p = . ). conclusion: this finding implies that psychosocial factors, particularly during the outbreak phase, influenced the mental health of patients over a long-term period. mental health support among the infected subjects and efforts to reduce stigma may improve recovery from psychological distress in an eid outbreak. the outbreak of the middle east respiratory syndrome coronavirus (mers-cov) in the republic of korea had an enormous impact on medical, psychological, and social issues nationwide [ ] . the outbreak lasted from may to dec. and resulted in infected patients within the initial months, , officially isolated individuals, and an overall mortality of patients in a total of million population [ ] . acute infectious outbreaks of emerging infectious diseases (eids) are known to influence the physical as well as the mental health of affected patients, as observed during similar events such as the severe acute respiratory syndrome (sars) outbreak [ ] , which was associated with such issues during the acute phase [ ] and the long-term follow-up phase [ , ] . % of survivors expressed anxiety or depressive symptoms at -month post-sars in hong kong where citizens were infected, and its fatality was . % [ ] . in ninety survivors' cohort study for months in hong kong, post-sars cumulative incidence of psychiatric disorders was . %. the most common diagnoses were ptsd ( . %) and depression ( . %) [ ] . few studies have investigated the psychological impact of the korean mers-cov outbreak, but a survey conducted during this period found that % of the general public reported worrying about being infected by mers-cov and that % of this population experienced psychological distress [ ] . another study reported that . % of isolated individuals exhibited anxiety symptoms and that . % of this group reported feelings of anger during the isolation period [ ] . in contrast, anxiety was present in . % of mers patients [ ] , which was more prevalent than the rate of anxiety in isolated people without the mers-cov infection. compared to patients with other diseases, those with eids may experience greater suffering in terms of the physical and psychiatric symptoms of the infectious illness itself [ ] ; extreme fear and anxiety due to their unfamiliarity with the disease, which may be lifethreatening [ ] ; abrupt isolation from family and society during the illness [ ] ; stigma due to the infectious disease [ ] ; the unexpected death of a family member; and/or social impairments [ ] . given that some factors, such as grief or stigma, may be persistent following the mers illness, the suffering of afflicted individuals may negatively influence recovery in their daily lives during the acute outbreak period as well as the post-mers period. studies of sars survivors in hong kong and china reported persistent psychological burdens, including post-traumatic stress disorder (ptsd), in over % of the survivors after years [ ] . however, no studies have investigated the mental health status of mers survivors. thus, the present study explored mental health issues and related factors in mers survivors months after the outbreak to determine the long-term psychological outcomes of this population. the present study was part of a prospective nationwide cohort study of mers survivors conducted at multicenters in the republic of korea. for purposes of this study, a mers survivor was defined as a patient who was diagnosed with the mers-cov infection and then completely recovered, as confirmed by the korean government during the outbreak. of mers survivors who were eligible, consented to participate in the study initially when they were contacted by phone and mail at months post-mers (fig. ). of these participants, survivors completed the -month assessment that consisted of medical tests between june and august . among them, participants provided consent to participate in the psychological assessments in five tertiary hospitals: national medical center, seoul national university hospital, chungnam national university hospital, seoul medical center, and dankook university hospital. all subjects were older than years of age at enrollment, voluntarily participated in the study, and answered the questionnaires independently. written informed consent was obtained from all subjects, and the study was approved by the institutional review board of each study hospital. all subjects responded to self-report questionnaires assessing sociodemographic characteristics, previous history of medical illness or psychiatric visit, illness experiences during the mers-cov infection period, and psychological features. questions about mers-related illness experiences solicited information regarding status during infection, duration of hospitalization, presence of pneumonia, whether a ventilator or extracorporeal membrane oxygenation was applied, and whether a family member died from mers. to determine psychological outcomes, ptsd was assessed with the impact of event scale-revised korean version (ies-r-k) [ , ] , and depression was evaluated with the patient health questionnaire- (phq- ) [ , ] . the ies-r-k is a -item scale that assesses symptoms of intrusion, avoidance and numbing, and hyperarousal related to a particular life-threatening event (i.e., mers-cov infection in the present study). each item is rated on a scale ranging from to , and a total score ≥ is considered to be clinically significant [ ] . the phq- is a nine-item scale that assesses depression based on the symptoms of major depressive disorder included in the diagnostic and statistical manual of mental disorders-fourth edition (dsm-iv) [ ] . significant depression is considered to be present when the total score is > [ ] . current suicidality was assessed with the suicidality module of the mini-international neuropsychiatric interview (k-mini) [ , ] , which is composed of six weighted items rated as 'yes' or 'no': wish for death (weight of ), wish for self-harm (weight of ), suicidal thoughts (weight of ), suicide plan (weight of ), suicide attempt in the past month (weight of ), and lifetime suicide attempt (weight of ). the suicidality score is the sum of the weighted score of the six items, and a total score ≥ is considered to be above moderate degree of risk. anxiety was assessed with the generalized anxiety disorder- (gad- ) scale, which consists of seven items rated using a four-point likert scoring system [ ] . a total score ≥ is considered to be significant. the phq- and the gad- were administered additionally at two points, before and during infection with mers-cov, based on participant recall. insomnia was evaluated with the korean version of the insomnia severity index (isi-k) [ ] , a five-item measure relying on a five-point scale that assesses current sleep problems and interference with daily functioning; clinical insomnia was considered to be present if the total score was ≥ . mers stigma was assessed with an adjusted version of the -item berger human immunodeficiency virus (hiv) stigma scale [ ] and the -item short version of the hiv stigma scale [ ] . this questionnaire contains eight items rated on a four-point likert-type scale that ranges from "strongly disagree" to "strongly agree" and assesses the four domains of stigma: personalized stigma, disclosure concerns, negative selfimage, and concerns with public attitudes; the cronbach's α in the present study was . . the present study also included the brief cope, which is a -item questionnaire that uses a four-point likert scale to measure three distinctive coping strategies: emotionfocused, problem-focused, and dysfunctional [ ] . the social support systems of participants were assessed with the medical outcome study social support survey (mos-sss) [ ] , which includes items that are scored on a scale from to and assesses emotional/information support, tangible support, positive social interactions, and affectionate support. to examine the impact of social support on mental health in a regression analysis, poor social support was defined as a mos-sss score lower than that of the th percentile for all participants. the sociodemographic characteristics, mers-related clinical characteristics, and mental health status of the participants are presented as both numerical values and percentages. the present study placed a particular focus on ptsd and depression, which were the two most prevalent problems months post-mers in the descriptive analysis. accordingly, the subjects were divided into two groups based on the presence of significant ptsd or depression. independent t-tests were conducted to compare the mental health status between the two groups (p < . , adjusted for multiple comparisons), a stepwise regression analysis was performed to identify independent risk factors for ptsd and depression at months after the mers outbreak, and a univariate analysis was used to identify potential mediating factors associated with ptsd/depression (p < . ). subsequently, a backward multivariate logistic regression analysis was performed using variables identified as significant in the univariate analysis (p < . ). although depression during mers and current mers stigma were significant in the univariate analysis, these variables were not entered into the multivariate regression analysis due to multicollinearity with anxiety during mers (r = . , p < . ) and mers stigma during mers (r = . , p < . ), respectively. all data were analyzed with spss for windows version . (ibm corp.; armonk, ny, usa) except for the multivariate logistic regression analysis, which was performed with stata version . (stata; college station, tx, usa). the demographic characteristics of the subjects are presented in table . although more male (n = , . %) than female subjects were included in the study, the age distribution was relatively even (mean age: . years, standard deviation [sd]: . ). of the subjects, . % had a history of a visit to a psychiatric clinic prior to the mers outbreak. the distribution of respondents at the point of mers-cov infection was as follows: patients, . %; healthcare providers, . %; caregivers, . %; and those visiting the patients in hospitals, . % ( table ). the median length of hospitalization was overall, % of the subjects had at least one symptom of ptsd, depression, suicidality, or insomnia that was significantly above the clinical threshold. the mean total score on the ies-r was . (sd = . ), and . % of the subjects had significant ptsd ( table ). the mean score on the phq- was . (sd = . ) before infection with mers-cov, . (sd = . ) during the infection, and . (sd = . ) at months after the initial infection. moreover, % of the subjects had depression at months post-mers. most subjects had a minimum risk of suicidality, but . % showed at least a moderate degree of suicidal risk. of the survivors, % reported significant insomnia at months after the mers outbreak. during mers and months post-mers, all domains of ptsd, anxiety, and depression were more severe, and the quality of life was worse in survivors with current ptsd or depression compared to those without ptsd or depression (p < . ) (table s ). however, anxiety and depression prior to mers did not significantly differ in either comparison. survivors with ptsd reported higher scores for negative coping strategies compared to those without ptsd (p = . ). univariate and multivariate logistic regression analyses were performed to identify risk factors associated with ptsd or depression at months post-mers. the univariate analysis revealed that several factors were significantly associated with ptsd, including previous psychiatry history, having a family member who died from mers, depression and anxiety during the mersaffected period, greater perceived stigma currently and during the illness, and negative coping strategies (table s ) . depression was associated with gender, previous psychiatry history, anxiety before mers, having a family member who died from mers, and depression, anxiety, and greater stigma during the affected phase. neither the severity of mers nor complications, such as the development of pneumonia, use of a ventilator, or extracorporeal membrane oxygenation was associated with ptsd or depression. likewise, not having a spouse, living with a child, and poor social support were not associated with these outcomes. the multivariate logistic regression analysis revealed that previous psychiatric history (adjusted odds ratio [aor]: . , % confidence interval [ci]: . - . ; p = . ), anxiety (aor: . , % ci: . - . ; p = . ), and greater recognition of stigma (aor: . , % ci: . - . ; p = . ) during the mersaffected period were independent predictors of ptsd at months after mers (table ) . additionally, previous psychiatric history (aor: . , % ci: . - . ; p = . ) and having a family member who died from mers (aor: . , % ci: . - . ; p = . ) predicted the development of depression at this timepoint. the mers outbreak in is a noteworthy example of a national disaster that impacted most korean people. its early and rapid dissemination via hospitals concentrated in metropolitan areas [ ] , high fatality rate of nearly % [ ] , and unfamiliarity as a novel infectious disease [ ] may have led to high levels of anxiety and fear about being infected among the public and about death among affected people [ ] . the present findings confirmed high prevalence of mental health problems in survivors at the recovery phase after the outbreak. the prevalence of ptsd in survivors at months post-mers in the present study was comparable to the rate of . % observed in a study of sars survivors at months post-discharge from a hospital in singapore [ ] and higher or comparable to the rates of ptsd in patients with hiv ( - %), adult survivors of a human-made disaster ( - %) [ ] , and survivors of a stay in an intensive care unit ( - %) [ , ] . this indicates that an eid is not only a serious medical illness but also a psychologically traumatic experience for patients that can result in long-term psychological burdens. additionally, the result suggests that mental health adjusting for gender, presence of previous visit to psychiatric clinic, presence of a family member who died from mers, anxiety prior to mers (gad> = ), anxiety during mers (gad> = ), mers stigma during mers problems caused by an eid outbreak can continue for a long period. for example, another study showed that . % of sars survivors in hong kong still showed active psychiatric illnesses at years post-sars infection [ ] . furthermore, a second study demonstrated that % of chinese sars survivors still experienced ptsd at years post-sars [ ] . assuming that the experiences of the patients in the mers outbreak are similar in terms of eids, the mental health problems of the mers survivors in the present study may persist for longer than months. therefore, a study on mental health outcomes after months post-mers will be required. of the premorbid characteristics of the subjects, only a history of a visit to a psychiatric clinic was independently related to ptsd and depression at months post-mers, whereas demographic factors, such as gender, age, and level of education were not. on the other hand, high anxiety levels, perceived stigma about mers, and having a family member who died from mers predicted the development of ptsd or depression. these findings indicate that the psychological outcomes associated with an eid are mainly affected by factors during the outbreak period. furthermore, the presence of a physical illness prior to the mers-cov infection and the severity of mers were not associated with ptsd or depression. thus, psychosocial factors, rather than medical factors, may play an important role during mers-cov infection in terms of mental health status. these findings differ from those of a study investigating sars survivors at months post-infection, which found that the risk factors of ptsd included being female, the pre-sars presence of chronic medical illness, and the presence of complications caused by sars treatment [ ] . it is possible that the relatively small sample size of the present study was insufficient to statistically identify the influences of demographic characteristics and medical severity on adverse psychological outcomes. however, psychological burdens, such as widespread and extreme fear or feelings of isolation caused by mers [ ] , may have outweighed the possible contributions of these other factors. a previous report showing that only a history of mental disease and financial burden are related to anxiety in mers patients [ ] supports this assumption. the present findings suggest a need for appropriate psychosocial support during infectious outbreaks to reduce psychological distress in patients [ ] . therefore, healthcare professionals who treat these patients should be aware of the risk of developing adverse psychological outcomes during the acute stage of the illness as well as during the follow-up period. in particular, patients with a prior psychiatric history, high levels of psychological distress during the illness, or a negative perception about mers should be given more attention. interestingly, on our univariate analysis, we can assume that negative coping strategy such as denial, substance use, and selfblame may affect the development of ptsd. this relationship between negative coping style and ptsd is consistent with the previous findings in natural disaster and infectious disease [ , ] . it suggests that providing what is a useful coping strategy should be included in psychosocial support for survivors from eid. similarly, the governmental strategy for the management of eids should include psychosocial support based on group characteristics, risk factors, and severity of distress. the white paper, 'mers ,' issued by the korean government proposed that the national policy for eids should include content for "improving ethical problems and strengthening psychological support in eid control." [ ] the present findings suggest several considerations in this regard. in general, during the early outbreak phase, it is important that effective risk communication is incorporated into the overall strategy to reduce fear among the general public and quarantined people [ ] ; when developing such a strategy for this phase, it is also important to consider the ethical issues related to patients and quarantined people to minimize stigma [ ] . more specifically, due to the high prevalence of mental health problems, routine care for eid patients should include effective psychological support that reflects individual risk factors and the current level of distress. in fact, the central and local korean governments provided psychological support for quarantined people, patients, and families who had a member die from mers using designated public mental health care centers and telephone counseling during the outbreak [ ] . the core value associated with this program was adequate public accessibility; indeed, rather than rely on the passive provision of information, the program was implemented in a proactive manner [ ] . in addition, we should pay attention to stigma as a risk factor amenable to change rather than other psychosocial variables for ptsd in the study. in eid outbreak, the perspective is easily made that an infected patient is regarded as a dangerous vector or perpetrator to spread virus who should be isolated from the society [ ] . it can be maintained even after the outbreak [ ] . the stigma may produce discrimination and exclusion from a community regardless of medical indications. it would significantly threaten a patient's mental health and social relationship. consequently, their life could be influenced in a variety of domains such as residence, occupation and the use of healthcare for a long time [ ] . this study showed that reducing stigma can be an effective strategy to ameliorate psychological consequence after an eid. media and government should respect a patient or quarantined people as a citizen who are suffering and be sensitive to words or actions that might stigmatize a specific person or group. a community and healthcare service need to provide active support for an isolated patient to relieve their burden from the stigma [ ] . the present study has several limitations that should be noted. because this study assessed only % of the overall mers survivors, the results may not reflect the status of all survivors. however, the distributions of the demographic data on age, gender, and area of residence in the present study were similar to those in the official reports for all mers patients [ ] . second, psychological distress and stigma during the pre-mers period and during the mers-cov infection were evaluated based on participant recall and may not accurately represent the actual status of the subjects. additionally, the relatively small sample size may have limited the ability to identify risk factors due to low statistical power. however, given that . % of patients reported anxiety using the same scale in a previous study conducted during the isolation period [ ] , it can be assumed that the subjects in the present study were not likely to overestimate their symptoms during recall. finally, we assessed only with self-questionnaire that could be considered less accurate than the ratings of a clinician. our study showed that nearly half the assessed mers survivors experienced significant mental health problems, including ptsd and depression, at months post-mers. mers-specific psychosocial distress may influence long-term psychological sequelae. thus, efforts to control eids should include all levels of government and involve the implementation of effective strategies to reduce fear and stigma among the public; they should also enable the provision of adequate psychological support and hospital care for infected people. supplementary information accompanies this paper at https://doi.org/ . /s - - - . additional file table s . comparisons of mental health status and related factors between survivors with and without ptsd/depression in south korea. table s . univariate analysis assessing ptsd and depression and related variables months after the mers outbreak, in south korea. the mers outbreak in the republic of korea: learning from mers middle east respiratory syndrome coronavirus (mers-cov) outbreak in south korea, : epidemiology, characteristics and public health implications outcomes of sars survivors in china: not only physical and psychiatric co-morbidities psychological distress and negative appraisals in survivors of severe acute respiratory syndromes (sars) long-term psychiatric morbidities among sars survivors stress and psychological distress among sars survivors year after the outbreak the emotional distress and fear of contagion related to middle east respiratory syndrome (mers) on general public in korea mental health status of people isolated due to middle east 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development and validation of a structured diagnostic psychiatric interview for dsm-iv and icd- a brief measure for assessing generalized anxiety disorder validation of a korean version of the insomnia severity index measuring stigma in people with hiv: psychometric assessment of the hiv stigma scale psychometric properties of a short version of the hiv stigma scale, adapted for children with hiv infection you want to measure coping but your protocol's too long: consider the brief cope the mos social support survey middle east respiratory syndrome coronavirus (mers-cov) outbreak in south korea, : epidemiology, characteristics and public health implications quality of life and psychological status in survivors of severe acute respiratory syndrome at months postdischarge the epidemiology of post-traumatic stress disorder after disasters posttraumatic stress disorder following medical illness and treatment posttraumatic stress disorder and health-related quality of life in long-term survivors of acute respiratory distress syndrome mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up risk factors for chronic post-traumatic stress disorder (ptsd) in sars survivors post-traumatic stress disorder and coping in a sample of adult survivors of the italian earthquake post-traumatic stress disorder among recently diagnosed patients with hiv/aids in south africa worry experienced during the middle east respiratory syndrome (mers) pandemic in korea ethical perspectives on the middle east respiratory syndrome coronavirus epidemic in korea system effectiveness of detection, brief intervention and refer to treatment for the people with post-traumatic emotional distress by mers: a case report of community-based proactive intervention in south korea the patient as victim and vector: ethics and infectious disease the sars-associated stigma of sars victims in the post-sars era of hong kong the experience of sarsrelated stigma at amoy gardens stress and health: major findings and policy implications publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to acknowledge all the participants and researchers in the cohort study for mers survivors.authors' contributions shl and hss coordinated the overall study. hyp, shl, jlk, jjl, hl, and hss were involved in the concept and the design of the study. hyp and shl undertook the statistical analysis and drafted the manuscript. hyp, wbp, shl, jlk, jjl, hl, and hss contributed to the acquisition and the interpretation of the data, revised the manuscript and approved the article of its final version. the study was supported by a grant of the korea health technology r&d project through the korea health industry development institute (khidi), funded by the ministry of health and welfare, republic of korea (hi c ) and a grant from the korean mental health technology r&d project, ministry of health & welfare, republic of korea (hl c ). the funding bodies were not involved in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. the data obtained from the current study are not publicly available due to the sensitive nature of the study. not applicable. the authors declare that they have no competing interests. key: cord- -xjnbmah authors: van goethem, n.; struelens, m. j.; de keersmaecker, s. c. j.; roosens, n. h. c.; robert, a.; quoilin, s.; van oyen, h.; devleesschauwer, b. title: perceived utility and feasibility of pathogen genomics for public health practice: a survey among public health professionals working in the field of infectious diseases, belgium, date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: xjnbmah background: pathogen genomics is increasingly being translated from the research setting into the activities of public health professionals operating at different levels. this survey aims to appraise the literacy level and gather the opinions of public health experts and allied professionals working in the field of infectious diseases in belgium concerning the implementation of next-generation sequencing (ngs) in public health practice. methods: in may , belgian public health and healthcare professionals were invited to complete an online survey containing eight main topics including background questions, general attitude towards pathogen genomics for public health practice and main concerns, genomic literacy, current and planned ngs activities, place of ngs in diagnostic microbiology pathways, data sharing obstacles, end-user requirements, and key drivers for the implementation of ngs. descriptive statistics were used to report on the frequency distribution of multiple choice responses whereas thematic analysis was used to analyze free text responses. a multivariable logistic regression model was constructed to identify important predictors for a positive attitude towards the implementation of pathogen genomics in public health practice. results: out of the invited public health professionals completed the survey. % of respondents indicated that public health agencies should be using genomics to understand and control infectious diseases. having a high level of expertise in the field of pathogen genomics was the strongest predictor of a positive attitude (or = . , % ci = . – . ). a significantly higher proportion of data providers indicated to have followed training in the field of pathogen genomics compared to data end-users (p < . ). overall, % of participants expressed interest in receiving further training. main concerns were related to the cost of sequencing technologies, data sharing, data integration, interdisciplinary working, and bioinformatics expertise. conclusions: belgian health professionals expressed favorable views about implementation of pathogen genomics in their work activities related to infectious disease surveillance and control. they expressed the need for suitable training initiatives to strengthen their competences in the field. their perception of the utility and feasibility of pathogen genomics for public health purposes will be a key driver for its further implementation. sequence information from viruses, bacteria, and other infectious organisms can be used to identify a pathogen and its specific characteristics, and compare its genetic relatedness to other pathogens [ ] . advances in sequencing technologies, especially the shift to next-generation sequencing (ngs), have made it possible to analyze pathogen genomes in much greater detail. compared to sanger sequencing, ngs technologies allow a faster and cheaper way to sequence larger lengths of nucleotides. as such, ngs makes microbial pathogen whole-genome sequencing (wgs) accessible in high throughput within a matter of days [ ] . during the last decade, ngs has expanded beyond the research settings and is being rapidly applied into routine practice for public health and food safety [ ] [ ] [ ] [ ] [ ] [ ] . in public health, integrating pathogen genomics with epidemiology provides many opportunities for improving the population-level risk assessment and management of infectious diseases [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the main applications of wgs include ( ) retrospective (or near real-time) comparisons of pathogens' relatedness to test epidemiological transmission hypotheses of suspected outbreaks (i.e. outbreak investigations); ( ) wgs-based prospective surveillance by monitoring of cases generating alerts when clusters of pathogens with similar genomes are identified in a limited geographical area or time period or when virulent clones emerge (outbreak detection by control-oriented surveillance); and ( ) cross-sectional genomic epidemiology surveys to monitor long-term changes in epidemiology over larger geographic and population scales to inform prevention strategies (strategy-oriented surveillance) [ ] . the main added value of implementing wgs during surveillance activities or outbreak investigations is inherent in the higher resolution of the wgs output itself, leading to an increased sensitivity and specificity to identify transmission clusters compared to conventional subtyping methods [ ] . as such, there are numerous success stories of outbreak investigations applying wgs that were able to identify to the source of infection and implement targeted control measures to stop further spread, saving resources at the health protection and local authority level [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . other concrete examples of the utility of wgs for national surveillance and local infection control include the guidance of vaccination strategies [ ] [ ] [ ] [ ] and antibiotic stewardship [ , ] . besides transforming the public health approach to infectious diseases monitoring, analysis of pathogen genomics can advance the accuracy of infection diagnostics and guide the treatment of individual patients [ , [ ] [ ] [ ] [ ] [ ] [ ] . for several pathogens, ngs is able to replace current time-consuming and/or laborintensive conventional methods with a single, all-in-one diagnostic test [ ] [ ] [ ] [ ] . public health professionals play a key role in protecting the population against communicable disease threats. this requires them to give effective responses in a limited time frame, supported by adequate information resulting from applying the most appropriate tools adapted to the specific public health threat scenario. infectious disease surveillance systems build upon the cooperation between: clinicians, who are at the frontline through identification of infected patients; microbiologists, who are involved in testing specimens; molecular biologists, who study organisms at the molecular level; bioinformaticians, who develop computational approaches/algorithms to analyze genomic data; epidemiologists, who use the data to understand patterns in disease occurrence at the population level; infection control practitioners, who are responsible for local prevention and control of infectious diseases in the community; hospital hygienists, who are involved in the prevention and control of healthcare-associated infections; food safety inspectors, who monitor food products; etc. the activities of these public health experts operating at different levels in the information cycle will be impacted by the introduction of pathogen genomics as they are all connected to each other. this ranges from microbiologists adapting their laboratory workflows to epidemiologists rethinking their current data analysis approaches. typically, new laboratory technologies are adopted by data providers first, while data end-users might not be familiar enough with the new methods to effectively translate the output data into public health actions. expertise with pathogen genomics and its applications for public health practice might also differ between those in charge of national surveillance of infectious diseases and those involved in local infection control and patient management, as well as between different fields (i.e. human, animal, food, and the environment) within the one health spectrum [ , ] . differences in perceptions and needs between these different profiles should be taken into account before we can build a strategy that engages all the stakeholders in an effective collaboration. the key to success in translating pathogen genomics into public health practice is to demonstrate an added value by better addressing the needs and expectations of the whole range of public health experts. an effective exchange of expertise across disciplines (e.g., clinicians, microbiologists, epidemiologists, and bioinformaticians) is key for enabling the smooth implementation of ngs into routine public health activities. if such coordination of joint efforts cannot be accomplished, the technology shift, which is currently ongoing, might not realize its full potential [ , ] . previous surveys in the field of public health genomics focused on: human genomics [ ] [ ] [ ] ; specific aspects such as proficiency testing [ ] , the design of wgs clinical reports [ ] or data sharing [ ] ; or specific target groups such as national microbiology focal points [ ] or food safety laboratories [ ] . in this study, by organizing an online survey, we aimed to perform a wide landscape analysis of all potentially involved stakeholders in order to appraise the level of genomic literacy and to gather the opinions of public health experts and allied professionals working in the field of infectious diseases in belgium concerning the implementation of ngs in routine public health activities, in terms of its utility, feasibility, implementation, and translation into actionable results for public health decision making. an electronic questionnaire survey (see additional file ) was developed for this study using limesurvey (version . . ) [ ] for the collection of relevant information from public health professionals working in the field of infectious diseases in belgium. for the purposes of this study, a 'public health professional in the field of infectious diseases' was defined as a person with professional expertise in the field of infectious diseases and who directly or indirectly contributes to the population-level management of infectious diseases. to provide a complete picture of all involved stakeholders, the survey aimed to reach different subgroups based on professional qualification (i.e. microbiologists, molecular biologists, bioinformaticians, epidemiologists, clinicians, clinical biologists, infection control practitioners, and hospital hygienists), employing institution (i.e. governmental, private, hospital, and university), health field (i.e. human, animal, food, and environment), expertise in pathogens (i.e. bacteria, viruses, parasites, fungi, and yeasts), and level of action (i.e. national surveillance and local infection control). to identify all actors in the field of public health activities for infectious diseases, an overview was made of existing surveillance systems (i.e. data sources) in belgium (see additional file ). the set of questions was compiled based on the literature, including several review articles [ - , , , - , , ] . existing items from previous survey questionnaires [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] ] ) were used and adapted when relevant. most of the existing questionnaires from which some questions were adapted to be used for this survey were not validated, except for chow-white et al. as mentioned in the respective publication [ ] . the construction of the survey was discussed during several feedback rounds within a multidisciplinary team including epidemiologists, microbiologists, and molecular biologists. as a result, the survey instrument was vetted by subject matter experts. the questionnaire eventually contained eight main topics comprising background questions, general attitude towards pathogen genomics for public health practice and main concerns, genomic literacy, current and planned ngs activities, place of ngs in the diagnostic hierarchy of microbiology, data sharing obstacles, end-user requirements, and key drivers for the implementation of ngs. based on a filter question where participants indicated their level of familiarity with pathogen genomics, the respondents were redirected to different sets of questions with different levels of technicity and detail. the filter question gave access to a reduced version of the questionnaire for those participants judging themselves as not at all familiar with pathogen genomics. the responses were mainly collected as single/multiple options from a set of pre-defined answers, but also included the optional entry of free text. these qualitative open questions were included to add context to the quantitative responses. the survey tool was pre-tested by three researchers not directly involved in the development phase to ensure the acceptability and clarity of the questionnaire. participants were contacted individually by an email invitation containing a personal token to complete the survey. no monetary or other incentive was offered. the participant information statement at the beginning of the survey informed the respondents about the objective and design of the study and their rights before participation to the survey, and explained that responses are anonymized and will be kept confidential. the approval from an ethical committee was not considered necessary due to national regulations (legislation april ), as this study was not medical in nature and as participants were not subject to any actions and/or rules of conduct. the survey was available online during a two months' period during which three reminders were sent to those who had not yet responded. the first invitations were sent on the th of may and the survey remained active until the st of july . participants were invited to send any questions, feedback or comments for the survey to the organizers. only completed questionnaires were used for analysis. descriptive statistics were reported by analyzing categorical response frequencies. differences in viewpoints between the stakeholders were described using subgroup analyses and compared using a fisher's exact test. subgroups were compiled on the basis of the level of action (national vs. local), the position in the information cycle (data providers vs. data end-users), and the level of expertise in the field of pathogen genomics. the level of action was considered national when the main affiliation of the respondent concerned a national institute involved in national public health activities, whereas the local level included professionals who mainly operate at the community, hospital, or university level. subgroups based on the position in the information cycle were defined as data providers, defined here as experts in wet and dry lab procedures and (potentially) generating ngs data (including microbiologists, molecular biologists, clinical biologists, and bioinformaticians), and data endusers defined here as using ngs data to improve their activities and implementing infection control measures (including epidemiologists, local infection control practitioners, hospital hygienists, and clinicians). the level of expertise was categorized as high, middle or low, and was based on respondents' self-reported familiarity with pathogen genomics, training level, and current use of ngs. multiple logistic regression was performed to identify predictors of a positive attitude towards the implementation of pathogen genomics from a public health perspective. enthusiasm about public health agencies using genomics to understand and control infectious diseases was defined directly through a question with multiple options, each containing a clear statement (see additional file ). for the purpose of this analysis, the question asking about their enthusiasm originally consisting of multiple categories was collapsed into two levels: very enthusiastic versus all others. the following predictor variables were initially tested in the model: level of action; position in the information cycle; level of expertise; current use of ngs; institution; age group; years of professional experience; and position in their institution. model building involved a univariate analysis to select variables to be included in the multivariable model based on a χ -test (cut-off, p = . ), and variable selection from the multivariable model using backward stepwise regression based on the akaike information criterion (aic). adjusted odds ratios (ors) and % confidence intervals (cis) were calculated. quantitative analyses were performed using r software (r studio version . . ) [ ] . answers to open-ended survey questions were summarized and analyzed using nvivo qualitative data analysis software (nvivo version ) [ ] . this was done by identifying themes (codes) within the data, which were derived both deductively and inductively. following the thematic analysis framework, the text was compared and contrasted with the identified codes. the qualitative findings were summarized as a mind map linking the identified major and minor themes and a word cloud visualizing the word frequency from the qualitative responses. simultaneously, quotes were selected for the sake of illustration. out of the invited participants, did not respond at all, partially filled in the survey, and a total of participants delivered a completed survey which represents an overall survey response rate of % (fig. ). from these, participants continued after the filter question and delivered answers to all questions ( subject were redirected to a technical version of the survey and subjects to a basic version, based on the filter question). the data from the participants who preferred to quit after the filter question were only used to describe the background characteristics of the study population. the subjects who partially filled in the survey were dropped completely from the analysis. full responses to all questions as they appeared in the questionnaire are provided as an appendix to this report (see additional file ). background characteristics of the participants are presented in table . the majority of respondents had their main affiliation in the public sector ( %), followed by hospitals (including university hospitals) ( %), private sector ( %), and university ( %). the public sector was primarily represented by sciensano (belgian institute for health), comprising % of all survey participants ( / ). % of the respondents indicated that they had more than years of professional experience within the field of infectious diseases. the reported roles of respondents within their institutions included: microbiologists/molecular biologists/bioinformaticians/clinical biologists ( %); epidemiologists ( %); clinicians ( %); hospital hygienists/infection control practitioners ( %); and policy makers ( %). the survey respondents were asked to describe their level of familiarity with sequencing technologies and pathogen genomics using following classification: 'very -i am involved in the generation and/or use of ngs data' ( %), 'somewhat -i have a general sense of the applications of ngs' ( %), or 'not at all -i don't know anything about ngs and its applications' ( %). of those participants answering 'very familiar', most of them ( %; / ) indicated that they mainly used ngs in the context of wgs. of those 'not at all familiar', preferred to quit the survey and continued the survey to answer some general questions, leaving a total of participants for the remainder of the survey (fig. ) . subgroup analysis showed differences in familiarity with pathogen genomics between data providers and endusers (fig. ). data providers indicated significantly more frequently that they were 'very familiar' compared to data end-users (p < . ). the majority of respondents ( %; / ) indicated that they were very enthusiastic (i.e. 'we should be using genomics now') about public health agencies using genomics to understand and control infectious diseases, % ( / ) did not have an opinion or did not know enough of the topic to be able to give an opinion, and % ( / ) indicated that they did not see clear applications and/or an added value for public health. subgroup analysis pointed out differences in enthusiasm according to the level of expertise in the field of pathogen genomics ( fig. ). important predictors, as identified by the best fitting model, of a positive attitude related to the implementation of pathogen genomics from a public health perspective were the level of expertise, the level of action, and the position in the information cycle ( table ). participants classified as having a high level of expertise based on their self-reported familiarity with the topic, their training level, and/or the current use of ngs were significantly more likely to be enthusiastic about the implementation of pathogen genomics in a public health context compared to their peers with a low expertise (adjusted or = . , % ci = . - . ). further, public health professionals operating at the national level were more often 'very enthusiastic' about the implementation of pathogen genomics ( %) compared to those at the local level ( %). similarly, data providers were more often 'very enthusiastic' ( %) compared to data end-users ( %). a large majority of respondents considered the following public health activities as likely to be most impacted by pathogen genomics in the next five years: identifying an outbreak (clusters of related isolates) ( %; / ), nosocomial and food/waterborne outbreak investigations ( %; / ), and monitoring the spread of antimicrobial resistance ( %; / ). in contrast, only % ( / ) of respondents thought that pathogen genomics would have a major impact on making a diagnosis and selecting an appropriate treatment (individual patient management). other public health activities that will benefit from the implementation of pathogen genomics mentioned by the participants are presented in table . the most frequent concerns among participants being 'very' or 'somewhat' familiar with ngs technologies and pathogen genomics (n= ) regarding feasibility of its routine use for public health purposes, were the cost of sequencing technologies and the existing barriers to timely and open sharing of pathogen sequence data and accompanying metadata ( table ). all participants exclusively working with respiratory infections (e.g. influenza) and/or vaccine-preventable diseases (e.g. measles) (n= ) were very concerned about the cost, whereas this was only true for % of participants exclusively working with invasive bacterial diseases (e.g. neisseria meningitidis), food-and waterborne diseases (e.g. salmonella), and/or healthcareassociated infections (e.g. clostridium difficile) (n= ). further, other concerns shared by a large proportion of the participants were interdisciplinary cooperation, integration of pathogen sequence data with contextual data, access to bioinformatics expertise, and availability of typing schemes and databases. participants indicating to be 'not at all' familiar with pathogen genomics were mainly concerned about the cost of the sequencing technologies (see full responses in additional file ). other concerns provided by the participants as free text are presented in table . two-thirds of the participants ( / ) indicated that they had followed training in the fields of genomics/genetics/ molecular biology/bioinformatics. there were marked differences by position in the information cycle: % ( / ) of data end-users indicated that they had never followed any training in the field, whereas this was stated by only % ( / ) of data providers (p < . ). further breakdown of training experience by professional category is shown in fig. . the main reasons for not taking a training/course in this field (yet) were the lack of available and/or suitable trainings ( %; / ) and the lack of time ( %; / ). other reasons indicated as free text are presented in table . the vast majority of participants ( %, / ) indicated that they felt the need and/or would be interested in following (additional) courses/training/workshops covering a topic related to pathogen genomics. overall, % ( / ) participants being 'very' or 'somewhat' familiar with ngs technologies and pathogen genomics indicated that they are currently using or generating ngs data for at least one pathogen. differences between professional groups are presented in fig. . among the microbiologists, those from a national reference centre (nrc) were more likely to be currently using ngs ( / , i.e. %) compared to those from other laboratories ( / , i.e. %), however this difference was not significant (p= . ). from the public health professionals exclusively involved in human infectious disease activities, % ( / ) were currently using ngs technologies, whereas this was the case for % ( / ) of those exclusively involved in the food, animal or environmental sector (p= . ). looking forward, % ( / ) of participants indicated that they were planning to use or generate ngs data for any (additional) pathogen(s) within three years. details on the specified pathogens can be found in the appendix (see additional file ). reasons provided by participants indicating that they did not plan to implement pathogen genomics were mainly related to the cost and the lack of expertise. participants being 'very' or 'somewhat' familiar with ngs technologies and pathogen genomics (n= ) were asked to assign a score from to to the different criteria based on their increasing relative importance to decide whether or not ngs should be implemented for a particular pathogen (fig. ). clinical and/or public health significance of the pathogen were scored as the most important drivers. the different subgroups scored the different criteria similarly (see additional file ). comments provided by the participants to provide context to their scores are presented in table . centralization of sequencing and bioinformatics at nrcs organized per pathogen or per group of pathogens was most often ( %; / ) selected by respondents being 'very' or 'somewhat' familiar with pathogen genomics as the preferred wgs provision model in the belgian context. excluding participants working at nrcs slightly lowered this proportion to out of (i.e., %). there were no marked differences according to the level of action of the participants (fig. ) . illustrative quotes for the need for centralization are presented in table . public health activities, other than those provided within the survey, that will benefit from the implementation of pathogen genomics environmental monitoring "drinking water quality" "air quality, home environmental quality" metagenomics "metagenomics for patients with no identified cause of illness using conventional methods" "identification and characterization of new strains" "insights in dysbiosis" "microbiome analysis" other "discovery of a causal relation between a pathogen and a clinical disease (e.g. cancer)" "vaccine development" "phage therapy" "early diagnostics of diseases due to slow growing pathogens" "international tracking" "monitoring of antiviral resistance" concerns, other than those provided within the survey, related to the implementation of pathogen genomics for public health practice contextual data "harmonization of epidemiological datamost of the epidemiological data is very 'messy' or inconsistent, which makes systematic integration and surveillance unfeasible" "data collection is already limited so newer technologies will not automatically improve this process but be redundant if the basics are not met" "how to interpret the result at clinical level" "[…] they need to have a basic understanding (education) it order to understand and see cost/benefit of the whole picture" "appropriate training of personnel for execution and interpretation" "interpretation across sectors" "multidisciplinary knowledge" ethics "[…] healthcare workers integrity concerns" "in the hiv field, the phylogenetic analyses of virus permit to have an hindsight in paths of transmissionit is a very tricky topic in ethical and potentially legal aspects" other "does the identification prove that the pathogen poses a risk?" "the fear that some actors in the field will try to abuse their power and monopolize this new technologyto be really valuable to patient management and public health it is required to offer access to all laboratories" "high inter-laboratory variability" "[…] standardization and facilities for data sharing need to be improved" "the perceived utility and feasibility of pathogen genomics by public health practitioners is the biggest bottleneck of allall the other concerns listed above can be tackled given the drive within the field to solve them in the first place" reasons, other than those provided within the survey, for not taking a training/course in the field of pathogen genomics "lack of training adapted to public health needs" "not applicable for a clinician" "not my priority" "not relevant for my practice" "depends on the evolution in phenotypic typing" "[…] the main driver the pressure by ecdc rather than a real need for public health […] the first and main driver should be clinical significance: improve quality of care for the patient" "for bacteria, ngs will never fully replace classical methods for resistance testing, but would offer important complementary data" "cost-effectiveness (e.g. replacing multiple tests): not particularly true for viruses, but obvious for bacteria" centralization "[…] should be overall coordinated and controlled by the federal public health authority" "[…] in any scenario it will be important that sequence data are brought together in one databank for surveillance purposes" table . major themes identified within the qualitative data are utility (applications), feasibility (including capacity building, multi-disciplinary working, contextual data, costs, data sharing, ethics, timeliness, wet and dry lab), one health context, and routine implementation (including organization and translation into action). a mind map linking the identified major and minor themes is presented in fig. . a full list of identified themes and the coded text is available in the appendix (see additional file ), as well as a word cloud constructed based on the free text responses (see additional file ). this survey sought the opinion of belgian public health professionals working in the field of infectious diseases concerning the implementation of pathogen genomics in public health activities. to successfully translate pathogen genomics into public health practice, the needs and expectations of the different stakeholders should be taken into account. other questionnaire surveys related to knowledge and attitudes towards public health "the bureaucracy involved in the transmission of data" "the structure of public health in belgium will not help sharing data" "the required technical infrastructure" priority to publication "it is really a pity that priority to publication is an obstacle in the scientific world as it functions now" one health "a better collaboration between the veterinary and human side might increase the use of ngs on the veterinary side" "monitoring the emergence and spread of zoonotic pathogens has been impacted negatively, by the introduction of wgs at the human side only" genomics in specific health expert categories have been published [ , - , , , , ] . however, to the best of our knowledge this survey is the first that aimed to perform a wide landscape analysis of all potentially involved stakeholders. therefore, a strength of the current study is that it took into account a wide range of stakeholders with diverse backgrounds (epidemiologists, microbiologists, bioinformaticians, clinicians, infection control practitioners, etc.), health domains (human, food, environmental, etc.), pathogen expertise (bacteria, viruses, parasites, fungi, etc.), activity sectors (public, private, university, hospital, etc.), work positions (employee and lower/middle/high management), and degree of familiarity with genomics. besides seeking the general attitude of the participants towards the implementation of pathogen genomics in their professional activities and investigating the current and future use, this explorative study was able to touch upon multiple key topics, such as genomic literacy, data sharing obstacles, place of ngs in the diagnostic hierarchy of microbiology, and enduser requirements. familiarity with sequencing technologies and pathogen genomics varied between the different professional groups, with data providers being more familiar than data end-users. as shown before, one of the largest barriers to acceptability from the public health unit is the capacity to understand and use the data [ ] . possibly, there is a positive association between genomic literacy criteria could be assigned a score from to , or participants could indicate the 'i don't know' option. the boxplots show the median score and the interquartile range (grey boxes). the following criteria were included (top to bottom): clinical and/or public health significance, priority with respect to preventing the spread of antimicrobial resistance, local/national/international policy surveillance priorities or obligations, importance of prevention and control programs (e.g. vaccination), utility of wgs for diagnostics and/or treatment decisions (individual patient care), utility of increased resolution to infer relatedness that would not be obtained via conventional methods, availability of high-quality/complete/standardized epidemiological and/or clinical data to provide context to the wgs results, possibility to link genomic data from different sources (food-animalhuman-environment), cost-effectiveness (e.g. replacing multiple tests), time-saving compared to conventional testing methods, impact on outcomes for patients and populations (translation into actionable results), availability of wgs typing schemes and reference databases (e.g. for antimicrobial resistance), availability of validated (quality-controlled) wgs workflows (both wet and dry laboratory), availability of expertise to generate, analyze and interpret wgs data, and availability of the appropriate infrastructure (sequence technology, high-performance computing, data storage, etc.). having a high level of expertise, was the strongest predictor for a positive attitude, as was also shown in other surveys [ ] [ ] [ ] . epidemiologists and infection control practitioners should be informed about the benefits and limitations of ngs technologies in order to contribute in identifying tangible field application in public health, allowing the use of wgs output to appropriately guide public health actions [ , ] . another important challenge related to the interpretation of wgs data is the capacity to interpret signals, and thereby separating noise from public health events that require specific actions. consequently, integrating genomics into infection control and surveillance is critically linked to human resource development [ , ] . in the survey, the main reasons stated for not training in the field of genomics were lack of time or access to suitable trainings "…adapted to public health needs". however, the participants of this survey generally expressed a positive attitude towards following (additional) training courses, or workshops in pathogen genomics. educational workshops should be applied to a public health context and bring together the expertise of microbiologists, molecular experts, bioinformaticians, epidemiologists, infection control practitioners, and clinicians. the development of a new discipline called 'genomic epidemiology' integrating information on epidemiological and pathogen sequence characteristics by public health microbiologists, epidemiologists, and risk managers was recommended in the expert opinion on wgs for public health surveillance by the european centre for disease prevention and control (ecdc) in [ ] . ecdc has initiated public health genomics training workshops that bring together experts with epidemiology, microbiology and pathogen genomics backgrounds from european union (eu) member states with interest in implementing the technology in surveillance and outbreak investigations. besides, the zoonotic origin of many clinically relevant pathogens and antimicrobial resistance determinants stresses the importance of a cross-sectoral one health approach. the implementation of wgs should be synchronized and integrated between the human health and veterinary sectors [ ] allowing a better monitoring of the emergence and spread of zoonotic pathogens and antimicrobial resistance-related threats. lack of financial resources was often indicated as a principal reason for not using or planning to use wgs by the respondents of this survey, which was also reported by the european surveys conducted by ecdc [ ] and the european food safety authority (efsa) fig. mind map linking the major and minor themes identified in the qualitative responses, belgium, . codes were identified within the data deductively (i.e. themes that are expected and have been chosen in advance) and inductively (i.e. themes that are derived through analysis). during the thematic analysis the qualitative data from the survey was compared and contrasted with the identified codes. as such, the derived codes were assigned to the relevant text. next, the codes (plain boxes) were merged into categories (colored boxes). the following categories were identified: routine implementation (orange), one-health context (yellow), and feasibility (blue) [ ] . operational costs will be influenced by the processes used in current laboratory practice and differs between viruses and bacteria. whereas drug susceptibility testing and epidemiological typing are commonly performed for bacteria, this is often not the case for viruses detected in the routine laboratory [ ] . therefore, cost-effectiveness of ngs for many bacteria potentially follows from the replacement of conventional characterization methods, whereas for viruses ngs is considered as a tool providing additional complementary information without replacement of the existing methods. further, an important consideration is the added value of ngs for routine diagnostics. as long as ngs is more expensive than the conventional methods and when there is no direct benefit for the individual patient, it will not be used in routine. then the fields of application for surveillance purposes should be clearly defined to be able to justify the additional financial resources needed to perform wgs beside the diagnostic activities. to translate pathogen sequence data into truly useful and actionable information, it needs to be integrated with other types of information (i.e. clinical and epidemiological data). in belgium, most data end-users were concerned about the challenges encountered with the integration of pathogen sequence data with clinical and epidemiological data. indeed, the public health usability of any kind of lab results, including wgs data, is highly dependent on the cross-linkage with contextual epidemiological and clinical information [ , , ] . data integration is often hampered by the incomplete and/or unstandardized nature of the contextual data [ ] . the ongoing digitalization of health data such as laboratory and clinical records may represent an opportunity to review and upgrade traditional data collection processes for communicable disease surveillance. according to world health organization's (who) guidance on managing ethical issues in outbreaks [ ] , rapid data sharing is crucial during an unfolding health emergency. this suggests that pathogen sequence data should be rapidly and openly shared at the start of an outbreak, in many cases before scientific publication. however, many barriers for data sharing remain including authorship/attribution for publications, results dissemination, ethical considerations, data ownership, database access agreements, etc. [ ] . in our survey, practical barriers (lack of data standardization, poor data quality, missing metadata, etc.) seemed to be the major obstacles in belgium for sharing pathogen sequence data and associated metadata for public health purposes. participants mainly mentioned the lack of a central database and clear guidelines. this reflects a lack of information on the effective data sharing through eu-wide genomic surveillance and cross-border outbreak analysis systems managed by ecdc and efsa in support of the member states [ , , ] . finally, % of participants considered the priority to publication as a major bottleneck for sharing pathogen sequence data. publication priority is linked to the importance of guaranteeing reputational returns to research efforts [ , ] . the challenge here is to find a balanced arrangement that allows data sharing in real time and the acknowledgement of research work by giving to researchers who have been involved in data generation the possibility to use and publish their own results in priority. as the use of ngs shifts from research to routine laboratory practices, this data sharing barrier will slowly be alleviated. regarding expertise and availability of personnel, wet and dry lab experts were more concerned about the analysis of pathogen sequence data than the sequencing itself. as was mentioned in a review article of aarestrup et al. and documented in a recent european survey by revez et al., the most important limiting factor in many countries is the lack of access to bioinformatics expertise, especially when used as part of frontline diagnostics [ ] or national public health reference laboratory service [ ] . another point of discussion is the potential impact of ngs on the diagnostic microbiology pathway. traditionally, frontline clinical laboratories perform standard identification, antimicrobial susceptible testing and occasionally typing. isolates may then be referred to reference laboratories based on the need (e.g. diagnostic confirmation) or for surveillance purposes. these reference laboratories perform confirmation testing and advanced characterization. ngs was first implemented at the level of academic or reference laboratories, because of the need for investments, operational costs, and requirements for expertise [ ] while having limited added value for individual patient care. samples must be multiplexed (batching) for cost-effectiveness, which is easier to achieve in large reference laboratories with high volume of sample throughput [ , ] . however, processing delays may be present when samples are shipped to a reference center. these processing delays may result in longer turnaround times rendering this centralized approach inappropriate to support a fast response when needed. the reduced costs of sequencing facilitated the introduction of ngs technology to frontline clinical laboratories. this shift towards a decentralized use may reduce turnaround times, empower hospital-based microbiology, and strengthen local infection control efforts [ ] . this decentralized capacity will allow the inclusion of these data in the surveillance network coordinated by the epidemiologists what will compensate the reduced referral of isolates to reference centers. consequently, the implementation of ngs in routine labs is an important driver to reconsider the future role of nrcs. molecular typing for public health surveillance is undergoing a stepwise transition to ngs [ ] . current and future ngs activities represented in this national survey were mainly in the context of food-and waterborne outbreak detections and investigations, reflecting the priority for these diseases across europe and beyond [ , ] . several criteria should be considered in the process of integrating wgs in a routine laboratory setting [ ] in order to know in which situations and for which pathogens it is worthwhile to use ngs. identifying a set of key drivers that cover all aspects related to the implementation of ngs (utility and feasibility) can help to guide prioritization of pathogens and to efficiently allocate resources. clinical and/or public health significance of the pathogen was scored as the most important driver during the implementation of pathogen genomics in routine public health activities, followed by availability of expertise to generate, analyze and interpret wgs data, and priority of the pathogen with respect to preventing the spread of antimicrobial resistance. qualitative responses revealed the opinion of several participants that the assessment of the added value of new technologies for individual patient care is paramount. if pathogen genomics is routinely used to guide patient management (diagnosis and/or treatment options), the pathogen sequence data gathered for diagnostic purposes can be accumulated for public health activities [ ] . if there is no added value for routine diagnosis, the cost of wgs will have to be covered by limited public health budgets. as a limitation, the relatively low response rate induced a potential volunteer bias as those public health experts being more interested and/or experienced in the field could be more likely to participate in the survey. yet, % of the participants indicated that they were 'not at all' familiar with sequencing technologies and pathogen genomics. further, we noticed a possible underrepresentation of the food, animal and environmental field in comparison to the human field, as well as a low number of bioinformaticians in the survey. in addition, public health professionals from the belgian institute for health (sciensano) might be overrepresented. the majority of microbiologists participating in the survey are based in a nrc, emphasizing surveillance activities and hence less weight to routine diagnostics. given this potential imbalance, it is important to take into account the distribution of profiles within the study population while interpreting the results. however, it is difficult to ascertain the true underlying distribution of the different professional groups within the target population. another limitation of the study is that the specific terminology used in the questions may not have been uniformly understood or consistently interpreted by stakeholders with different professional backgrounds [ ] . public health professionals working in the field of infectious diseases in belgium were in general enthusiastic about public health agencies implementing pathogen genomics for the surveillance and control of infectious diseases. however, introducing genomic methods into public health practice is inevitably linked to the decrease in cost, the introduction in routine activities of frontline clinical labs, the identification of field applications in public health, and the necessary development of new competencies. the results of the survey confirm the need to increase genomic literacy by offering dedicated training opportunities among public health professionals, especially for the data end-users including epidemiologists, clinicians, and infection control practitioners, enabling them to critically assess the utility and feasibility of implementing pathogen genomics in their work activities. as such, those at the forefront (i.e. end-users) may act as "honest brokers" responsible for evaluating the added value of genomic application. in the end, the main driver for the advancement of pathogen genomics in public health practice depends on the added value of this information for the different clinical and public health needs. further, inter-disciplinary (between epidemiologists, microbiologists and bioinformaticians) and intersectoral (one health context) collaboration should be improved in the future to pool expertise and to ensure an integrated and cohesive system for the management of infectious diseases. in terms of feasibility, respondents in this survey were mainly concerned, like their peers in similar european surveys, about data integration, data sharing, and the cost of sequencing technologies. overall, this survey helps to better understand the perceived utility and feasibility of pathogen genomics according to public health professionals and can inform further guidance to facilitate its implementation in belgium. future challenges can be anticipated by performing a similar survey among public health experts based in a country that already progressed further in the process of implementing pathogen genomics within their public health surveillance system. supplementary information accompanies this paper at https://doi.org/ . /s - - - . additional file . "questionnaire". description of data: "list of questions included in the online survey". additional file . "selection of target groups for the survey". description of data: "an overview of existing surveillance systems to identify all public health professionals who (would potentially) generate or use ngs data for the surveillance of infectious diseases based in different institutes and organizations in belgium." additional file . 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human, animal, food, feed and food/feed environmental samples in the joint ecdc-efsa molecular typing database data sharing in genomics -re-shaping scientific practice impact of food and water-borne diseases on european population health world health organization. who estimates of the global burden of foodborne diseases real-time analysis and visualization of pathogen sequence data publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank all study participants who took the time to complete the survey and provided valuable insights to reach to objectives of our study. these include the scientists from the belgian institute for health (sciensano) and the federal agency for the safety of the food chain (fasfc) working in infectious disease departments; physicians and infection control practitioners of the regional infectious disease control teams from the three regions in belgium; microbiologists from national reference centers (nrcs) and from sentinel laboratories; members from the belgian society of infection specialists and clinical microbiologists (bvikm), the belgian antibiotic policy coordination committee (bapcoc), the belgian infection control society (bics), and the belgian society for food microbiology (bsfm); clinicians, clinical biologists and hospital hygienists participating in sentinel surveillance networks; and public health experts within the ministry of health. we also would like to thank jérome ambroise, jimmy van den eynden, and boudewijn catry for pre-testing the survey, and vera cantaert, yves dupont, chloé wyndham-thomas, and karl mertens for their contributions in recruiting participants. this research was supported by the .be ready project financed by sciensano. the raw data analyzed during the current study are available from the corresponding author on reasonable request. the first page of the questionnaire explained the purpose of the research, the measures taken to protect respondents' confidentiality and the voluntary nature of participation. questionnaire respondents were asked to tick 'agree' at the start of the questionnaire to indicate that they consented to take part in the study and were willing to complete an anonymized questionnaire. ethics approval was deemed unnecessary according to national regulations (law of april ; http://www.ejustice.just.fgov.be/mopdf/ / / _ . pdf#page ), as participation was anonymous and no medical data were processed. not applicable. the authors declare that they have no competing interests. key: cord- - rxhkg a authors: sun, xinying; shi, yuhui; zeng, qingqi; wang, yanling; du, weijing; wei, nanfang; xie, ruiqian; chang, chun title: determinants of health literacy and health behavior regarding infectious respiratory diseases: a pathway model date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: rxhkg a background: health literacy has been defined as the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions. currently, few studies have validated the causal pathways of determinants of health literacy through the use of statistical modeling. the purpose of the present study was to develop and validate a health literacy model at an individual level that could best explain the determinants of health literacy and the associations between health literacy and health behaviors even health status. methods: skill-based health literacy test and a self-administrated questionnaire survey were conducted among chinese adult residents. path analysis was applied to validate the model. results: the model explained . % of variance for health literacy, . % for health behavior and . % for health status: (gfi = . ; rmr = . ; χ( ) = . , p = . ). education has positive and direct effect on prior knowledge (β = . ) and health literacy (β = . ). health literacy is also affected by prior knowledge (β = . ) and age (β = - . ). health literacy is a direct influencing factor of health behavior (β = . ). the most important factor of health status is age (β = . ). health behavior and health status have a positive interaction effect. conclusion: this model explains the determinants of health literacy and the associations between health literacy and health behaviors well. it could be applied to develop intervention strategies to increase individual health literacy, and then to promote health behavior and health status. health literacy has been defined as the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions [ , ] .over the last decade, health literacy has become a hot spot of research [ , ] . with a deeper understanding of health literacy in academic circles, more and more researchers find that a lack of health literacy can cause some adverse effects for individuals and society. low literacy is associated with a variety of adverse health outcomes, including increased mortality, hospitalization, and in some cases poorer control of chronic health conditions [ ] [ ] [ ] [ ] [ ] . additionally, limited health literacy impacts on the prevention and screening of diseases, health behavior, the taking of patients' history and the interpretation of diagnoses [ ] [ ] [ ] [ ] [ ] . knowing little about preventive care, people with low health literacy tend to use more medicines and more expensive healthcare services, including hospitalization and emergency services [ , , ] . some investigators have elucidated explained the relationship of between limited health literacy and socioeconomic indicators, health behaviors, and health outcomes [ , ] . researchers have focused on explaining the potential mechanisms between these variables. aging, the language barrier, low education, bad socio-economic status and suffering from chronic diseases were all regarded as risk factors of limited health literacy [ , ] . though limited health literacy has been shown to be associated with worse health outcomes and some socioeconomic characteristics, the causal pathways are not entirely known. several researches have focused on explaining potential mechanisms. the conceptual model by baker illustrates these hypothesized relationships by highlighting individual capacities that are associated with literacy skill, the complexity of both printed and spoken health information and other factors such as cultural norms that are relevant to health outcomes [ ] . in , paasche-orlow and wolf proposed a conceptual causal model to explain associations between limited health literacy and health outcomes [ ] . in their model, socioeconomic indicators are the basic factors influencing health literacy. these include level of education reached, ethnicity, age, occupation and income. their model distinguishes three different types of health action that mediate the impact of health literacy on health: access to and utilization of health care, patientprovider interaction, and self-care. each of these domains is defined not only by patient factors but also by external factors that can be attributed to the health care provider or the health system. the pathways are particularly useful in highlighting the role of health actions and providing a useful taxonomy of behavioral domains. von wagner's review introduced a framework drawing on ideas from health psychology and proposing that associations between health literacy and health outcomes could be mediated by a range of health actions involving access to and use of health care, patient-provider interactions, and the management of health and illness [ ] . the framework outlines ways in which health literacy might affect either health actions themselves or their motivational and volitional determinants, which have been identified in social cognition models. mccormack established a conceptual framework for individual health literacy [ ] . the framework illustrates how health literacy functions at the level of the individual, while acknowledging that factors external to the individual (including family, setting, community, culture and media) influence all the relationships represented in the model. the framework is organized into four primary elements: ( ) health-related stimulus; ( ) factors that influence the development and use of health literacy skills, including socio-demographic characteristics, resources , prior knowledge and capabilities; ( ) health literacy skills needed to comprehend the stimulus and perform the task; and ( ) mediators between health literacy and health outcomes including motivation, attitudes, emotions, and self-efficacy. the health related outcomes include behaviors and status. although all these models or frameworks have given the relationship between socio-demographic characteristics, prior knowledge, health literacy, health behavior/action and health outcomes, they are all theoretical explanations. few studies have tried to validate them through the use of statistical modeling. so this study aimed to develop a health literacy model and to statistically validate it using path analysis. with the models of baker, paasche-orlow, von wagner and mccormack for reference, we proposed a health literacy model at an individual level. figure represents this model. in this model, socio-demographic indicators, including age, gender, level of education reached, occupation and income, are the basic factors influencing other variables. besides socio-demographic indicators, prior knowledge also influences the development of health literacy skills. then health literacy has direct effect on health behavior, meanwhile, as a mediator between prior knowledge and health behavior. finally, health behavior influences health status. the first part of the questionnaire was concerned with socio-demographic characteristics including age, gender, ethnicity, household registration status, marital status, education, occupation and income. the second part measured knowledge of infectious respiratory diseases, known as prior knowledge. questions were asked about the different types of infectious respiratory diseases and their prevention methods. the maximum possible score for this part of the questionnaire was . the third category asked about individual behaviors and actions including washing hands, wearing a face mask, sneezing, room ventilation and treatments for infectious respiratory diseases. the maximum possible score for the health behaviors category was . the last part of the questionnaire was concerned with individual health status. information sought included how frequently the subject fell sick, how often they saw a doctor, the degree of severity for each sickness as well as the duration of the sickness. this category was marked with a maximum score of . a skill-based health literacy instrument was established using ratzan and parker's ( ) definition of health literacy: "the degree to which individuals can obtain, process, understand, and communicate about healthrelated information needed to make informed health decisions [ ] .the instrument included sixteen stimuli materials involving the distribution of epidemics, immunization programs, early symptoms, means of disease prevention and individual's preventative behavior. the instrument included five different subscales: print-prose, print-document , print-quantitative, oral and internet. the print-prose scale measured the knowledge and skills needed to search, comprehend, and use information from texts that were organized in sentences or paragraphs, while the printdocument scale measured from non-continuous texts in various formats. the print-quantitative scale measured the knowledge and skills needed to identify and perform computations using numbers embedded in printed materials [ ] . mccormack developed a more comprehensive measure of health literacy, named the health literacy skills instrument (hlsi). similar to other studies, this instrument measures print literacy. however, it was innovative in that it also uses non-print stimuli and examines oral and internet-based information seeking skills [ ] . in this study, oral literacy was tested though six questions from three pieces of audio or video. we too used nonprint stimuli and measured oral and internet-based skills, but we did so using a series of questions to test the ability of internet-based information seeking rather than having the participants actually seek information online. the measurement instrument consisted of items ( table ) : five concerning print-prose literacy, eight for print-document literacy, six for print-quantitative literacy, six for oral literacy and five for internet-based information seeking literacy. the overall degree of difficulty and discrimination of the instrument were . and . respectively. the instrument demonstrated good internal consistency reliability with a cronbach's alpha of . . as for validity, confirmatory factor analysis showed that the items were grouped into five subscales representing prose, document, quantitative, oral and internet based information seeking skills. while the first three instruments pertained to print health literacy, the between may and december , surveys were carried out in beijing city (the capital of china), datong city (in shanxi province, north china) and shenzhen city (in guangdong province, south china). multi-stage sampling was employed. the target population was first stratified into residents from cities and residents from villages (living in cities at the time and having lived for more than months), with an equally divided sample size. they must be more than years old. then, based on the principle of balancing samples among factors like age and occupation, cluster sampling was conducted in six places where locals gather (including communities, factories, government organizations and other institutions), and six places where non-local residents gather (including hotels, building sites, assembly shops and employment medical examination centers). the sample size was calculated by the function n = z -a/ p ( − p)/d × deff. according to data obtained from the national health literacy survey in regarding health literacy towards infectious diseases, the expected percentage was % (p = . ) [ ] . the minimum sample size is . considering recovery rates and efficiency rates of the questionnaire, the actual sample size should be at least . in total, residents responded to the survey. the study received approval from the peking university institutional review board and the approval number is irb - . it was also accordance with helsinki declaration. the investigations were performed in large multimedia conference rooms. the survey was carried out by trained investigators. information about the study was provided by the investigators and informed consent was obtained from each participant. all participants were then instructed to answer the questions that related to audio & video materials. the rest of the questionnaire was answered by participants themselves. in order to ensure the quality of data, questionnaires with more than % of items unanswered were considered ineligible and removed before analysis. epi data . was used for data double entry and spss . for data analysis. descriptive statistics were employed to examine demographic characteristics. anova was applied to compare the differences among social demographic groups and the student-newman-keuls method was used to control the total α level. scale and factor analyses were conducted to verify the scale's reliability and construct validity. confirmatory factor analysis of a half randomly selected sample was implemented by the statistical analysis system (sas, version . ). path analysis was also implemented by sas. covariance analysis of linear structural equations (calis) was performed to examine the model. furthermore, maximum likelihood estimation was used to appraise the parameters with the covariance matrix. the path model was modified for several times until the main indexes of goodness of fit implied the final model fit the data well. generally, the α level was set at . . initial eigenvalue > was the criterion in the factor analysis. among respondents, . % of them were male and . % of them were female. the range of age was from to years and the average age was . ± . . the majority ( . %) of the respondents ware the han nationality. as for the marriage status, the proportions of single, married and other status were . %, . %, and . %, respectively. occupations of the respondents distributed across a number of fields, such as worker ( . %), service provider ( . %), office worker ( . %), farmer ( . %), retired ( . %) and others(including students, scientific and technical workers, teachers and doctors) ( . %). table shows other social demographic characteristics. table also shows the differences among age groups, education levels and income levels on prior knowledge about infectious respiratory diseases, health literacy, health behavior and health status. prior knowledge score and health literacy score increased as education levels and income rose, but tended to decline with increasing age. health behavior scores increased with higher levels of education and health status scores increase slightly with age. the effect of age on prior knowledge and health behavior had no linear trend. as seen in table , the correlations between demographic characteristics and various scores reflected the same characteristic with table . as for scores of prior knowledge, health literacy, health behavior, the correlations between each other were strong, while health status only has slightly strong correlation with health behavior. based on the proposed model on figure , a path model was tested and validated, seen as figure shows the determinants of health literacy and its effect on health behavior, even the relationship between health behavior and health status. the bold arrows show the strong effects among variables, especially "education", "prior knowledge", "health literacy" and "health behavior". education is the most important factor. it strongly and directly affects both prior knowledge and health literacy. the higher the level of education, the higher one tends to score in terms of prior knowledge and health literacy. prior knowledge is slightly affected by income, with those earning higher incomes possessing greater prior knowledge. health literacy is also affected by prior knowledge and age; the effect from prior knowledge is positive and that from increasing age note: ns, no significant difference; *, p < . ; **, p < . ; ***, p < . . the student-newman-keuls method was used to control the total α level. there were significant differences between §, †, ‡ and # groups, but no significant differences within each group. is negative. health literacy is a direct influencing factor of health behavior, but its effect is weaker than that of prior knowledge. the strongest influence factor for health status is age. with increasing age, health status is better. health behavior and health status have an interactional relationship, and the role of health behavior on health status is a little greater than that of health status on health behavior. this study established and validated a health literacy model at the individual level. this model included sociodemographic characteristics, prior knowledge, health literacy, health behavior and health status. it is a simple empirical model rather than a complicated conceptual model. in the model, socio-demographic characteristics are the basic factors. in this research, a number of sociodemographic factors were tested, such as gender, ethnicity, marital status, and occupation. there was no significant difference between genders and ethnic groups when it came to measurements of health literacy. the main reason is that the awareness of the public on the prevention of infectious respiratory disease has been greatly increased with various intervention activities being conducted after the outbreak of severe acute respiratory syndromes (sars) in and the outbreak of highly pathogenic avian influenza in in china. there was, however, a significant difference between the unmarried and married group, but the difference is explainable by age differences. in addition, there was a significant difference in health literacy across three categories of occupation. highest health literacy scores were seen among students, scientific and technical workers, teachers and doctors. office workers, service providers, general workers and other workers scored lower, while farmers and retired people scored lower still. due to the strong relationship between education level and subsequent occupation, the effect of occupation on health literacy reflected the effect of education on health literacy in a similar fashion. therefore, the model incorporated only three important factors: age, education and income. undoubtedly, educational background is the most important factor. in a structural equation, the coefficient of education background on health literacy was . , which indicates that with each level of education (classified as primary school, junior high school, senior high school, college and graduate students), participants score almost . points more in the health literacy test, which is roughly equivalent to understanding eight percent more health information in daily life. this indicates how important education is for the promotion of health literacy. education has the same strong effect on prior knowledge, and a further indirect effect on health literacy though prior knowledge. as an important social source of information, the effect of higher education levels on health literacy has been demonstrated in many studies [ , ] . in this study, we confirmed the quantitative relationship between education and health literacy, and the standardized coefficient (β)was . almost same with cho's study (β = . ) [ ] . age is the second important factor. through careful measurement, we find that prior knowledge and health literacy tend to increase slightly among younger age groups, but then decrease significantly with age among the older age groups. therefore, targeting the under- age group for the popularization and publicity of health literacy programwhen perception and behavior form and develop stablycan promote their health skills and knowledge, bringing them lifetime benefits. for those aged over , health communication and health education must be consolidated due to the downward trend of knowledge and health literacy with aging. conversely, the study found older age groups' health status was better than that of the younger groups, with the - age group as the dividing point. this finding is contrary to what other studies have measured. the main reason for this is that the health status category was only concerned with the frequency an individual got a cold and the severity of such sicknesses because it is relatively easier and more feasible to measure the frequency of catching a cold and its severity than other kinds of infectious respiratory diseases. as we know, older people have often developed stronger resistance to these illnesses than younger people. for example, kumar's review of h n flu shows that the virus is causing critical illnesses mostly in young adults. the researchers concluded that h n (swine flu) primarily affects young adults who are in relatively good health and free of underlying illnesses [ ] . income is the weakest of the three influencing factors in this study. it has only a slight effect on prior knowledge. usually, those of higher individual incomes own more sources of knowledge. therefore, the measured negative effect of income on health behavior is an unexpected phenomenon, though the standardized coefficient is very little and the t value of − . is only just significant. therefore, the relationship between income and prior health knowledge needs further research to confirm. in this study, prior knowledge is defined as an individual's knowledge at the time before reading, watching or listening to the health-related materials. baker's article cited the report of the institute of medicine's expert panel, and gave a more expansive definition of health literacy which included conceptual knowledge as part of health literacy [ ] . however, more researchers view conceptual knowledge or prior knowledge as a resource or a moderator that a person has, which facilitates health literacy, but does not in itself constitute health literacy [ , , , ] . this study finds that prior knowledge has a strong direct effect on health literacy. that is to say that a person with more health knowledge is better able to obtain, comprehend and use health information. in the model, we confirmed that health literacy and prior knowledge are the top two determinants of health behavior. prior knowledge's effect on health behavior stands to reason, for example in the kap model [ ] . health behavior and health status are interactional. in baker's model, health literacy is one of many factors that lead to the acquisition of new knowledge, more positive attitudes, greater self-efficacy, positive health behaviors, and better health outcomes [ ] . in von wagner's model, health outcomes depend on a range of mediating processes, most obviously actions to promote health, prevent disease, or comply with diagnosis and treatment, which the author calls health actions [ ] . in paasche-orlow and wolf's model, they proposed causal pathways between limited health literacy and health outcomes [ ] . their models distinguish three different types of health actions that mediate the impact of health literacy on health: access to and utilization of health care, patient-provider interaction, and self-care. in this study, health behavior mainly focused on self-care and utilization of health care, while health status reflected health outcome. however, health behavior and health status did not show a good relationship. the measurement of health status in this study was conditioned to respiratory infection due to the restriction of the project scope. it is obvious that respiratory infections are influenced by many things, not only individual behavior, but also a variety of biological and social factors. therefore, the relationship between health behavior and health outcomes, and the effect of health literacy on health outcomes though health behavior need further study to validate. this model explains the determinants of health literacy and the associations between health literacy and health behaviors well. education has positive, strong and direct effect on prior knowledge and health literacy. health literacy is also affected by prior knowledge and age, the effect from prior knowledge is positive and that from age is negative. health literacy is a direct influencing factor of health behavior. the most important factor of health status is age. health behavior and health status have a positive interaction effect. in this study, we focus on a health literacy model at the individual level. we should also try to highlight the importance of future research to extend the scope of health literacy beyond the individual. the research indicates that medical knowledge and health literacy are the main determinants of health behavior and health status, so health educators and health care providers should focus on developing culturally sensitive educational materials using a variety of media. increased staffing of health educators in clinical settings and community interventions would also help increase health literacy. we would like to develop an intervention that demonstrates how health literacy can be addressed to target community outcomes as opposed to individual outcomes. it is also important for this model to be testedand likely revisedso that intervention strategies to mitigate the impact of low health literacy are informed and conceptually driven. limited by the project's background, this study only measures health literacy where it concerns infectious respiratory diseases. therefore, the feasibility of the model should be tested in regards to other diseases and aspects of health. the study, participated in its design and coordination. all authors read and approved the final manuscript. introduction, in national library of medicine current bibliographies in medicine:health literacy health literacy: what is it? new directions in research on public health and health literacy the evolving field of health literacy research interventions to improve health outcomes for patients with low literacy: a systematic review literacy and health outcomes: a systematic review of the literature health literacy: a prescription to end confusion in search of 'low health literacy': threshold vs. gradient effect of literacy on health status and mortality association of age, health literacy, and medication management strategies with cardiovascular medication adherence health literacy and cancer communication understanding health literacy: implications for medicine and public health the evolving concept of health literacy the effect of health literacy on knowledge and receipt of colorectal cancer screening: a survey study health literacy in the field of infectious diseases: the paradigm of brucellosis centers for disease control and prevention: improving health literacy for old adults effects of health literacy on health status and health service utilization amongst the elderly an integrated model of health literacy using diabetes as an exemplar the development of health literacy in patients with a long-term health condition: the health literacy pathway model education, literacy, and health: mediating effects on hypertension knowledge and control the meaning and the measure of health literacy the causal pathways linking health literacy to health outcomes health literacy and health actions: a review and a framework from health psychology what is health literacy and how do we measure it the health literacy of america' s adults: results from the measuring health literacy: a pilot study of a new skills-based instrument survey on the status of health literacy of chinese residents in critically ill patients with influenza a(h n ) infection in canada health literacy, social support, and health: a research agenda an experimental evaluation of the kap model for he submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution this study was funded by china-us collaborative program on emerging and re-emerging infectious diseases ( u gghh - ). we would like to acknowledge the cdc china office and rti international for their support and valuable comments. we also thank all health care workers in beijing, shenzhen and datong for their help in data collection. we have no competing interests.authors' contributions xs participated in the design of the study, performed the statistical analysis and involved in drafting the manuscript. ys participated in the fieldwork of the study and interpretation of data. qz participated in the fieldwork of the study and analysis of data. yw participated in the fieldwork and involved in revising the manuscript. wd made contributions to design and participated in the fieldwork. nw conceived of the study and participated in its design. rx conceived of the study and participated in its design. cc conceived of key: cord- - hxrpi authors: nuzzo, jennifer b.; meyer, diane; snyder, michael; ravi, sanjana j.; lapascu, ana; souleles, jon; andrada, carolina i.; bishai, david title: what makes health systems resilient against infectious disease outbreaks and natural hazards? results from a scoping review date: - - journal: bmc public health doi: . /s - - -z sha: doc_id: cord_uid: hxrpi background: the – ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. important work has been done to describe the general attributes of a health system resilient to these crises, and the next step will be to identify the specific capacities that health systems need to develop and maintain to achieve resiliency. methods: we conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and any existing implementation frameworks that highlight these capacities. we also sought to identify the overlap of the identified themes and capacities with those highlighted in the world health organization’s joint external evaluation. sources of evidence included pubmed, web of science, oaister, and the websites of relevant major public health organizations. results: we identified themes of health system resilience, including: the need to develop plans for altered standards of care during emergencies, the need to develop plans for post-event recovery, and a commitment to quality improvement. most of the literature described the general attributes of a resilient health system; no implementation frameworks were identified that could translate these elements into specific capacities that health system actors can employ to improve resilience to outbreaks and natural hazards in a variety of settings. conclusions: an implementation-oriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. however, there remains a need to further refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies. health system resilience has been previously defined as "the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learnt during the crisis, reorganize if conditions require it" [ , ] . for many countries, the - ebola outbreak in west africa was a wake-up call regarding the critical importance of having resilient health systems. in each of the three countries most affected by ebola, a fragile health system was quickly overwhelmed by the complexity of tracking cases, the need to create and disseminate communication strategies, and the challenges of safely caring for a surge of critically ill patients. health workers were - times more likely to have been infected with the virus than members of the general public [ ] . sickened health workers could no longer care for ebola patients, and poor infection control in healthcare facilities contributed to nosocomial ebola transmission. in turn, heightened risks of nosocomial ebola infection increased public fear around hospitalization [ ] . rather than helping to contain ebola, health systems became an amplifier of disease, exacerbating the human, economic, and political toll of the outbreak. similarly, unprepared health systems across the world inadvertently contributed to disease transmission during recent epidemics of severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) [ ] . health systems that were unprepared for disasters were also unable to provide essential services, even in highly developed countries (e.g., canada during sars [ ] , korea with mers [ ] , and the us following hurricane sandy [ ] ). many countries have committed resources and efforts toward health system strengthening based on these recent disasters, but actionable plans and approaches to build resilient health systems have not yet achieved consensus. independent reviews of the global response to the - ebola outbreak have stressed the importance of establishing metrics to assess and monitor progress towards improving countries' capacity to respond to public health emergencies [ ] [ ] [ ] . in , the world health organization (who) created the international health regulations (ihr) joint external evaluation (jee) tool-a framework and process designed to measure countries' capacities to implement the requirements of the ihr, which include the ability to prevent, detect, and respond to public health emergencies of international concern [ ] . since its introduction, the jee has become an important tool used by countries to assess their capacities for infectious disease outbreaks and other public health emergencies. to-date, more than countries have conducted jee assessments [ ] . some countries that have undergone jee assessments have also begun to develop action plans to address gaps found in their jees. despite this progress, health facilities continue to be vulnerable to public health emergencies [ ] . important work has been done to describe the general attributes of a resilient health system [ , , [ ] [ ] [ ] . for example, kruk et al. describe a resilient health system as one that is "integrated with existing efforts to strengthen health systems," able to "detect and interpret local warning signs and quickly call for support," able to provide care for a diverse population, able to "isolate threats and maintain core functions," and is able to "adapt to health shocks" [ ] . however, as highlighted by turenne et al., there continues to be a lack of clarity around the conceptualization of health systems resilience [ ] . the aim of this scoping review was to draw from existing literature to characterize specific capacities required to build resilient health systems in the face of infectious disease emergencies and natural hazards, with an emphasis on highlighting potential efforts that health system actors (e.g. health facilities and health service delivery organizations that are not always well-integrated in government-led preparedness initiatives) could pursue to achieve desired health outcomes during health crises. we also sought to examine the extent to which capacities that are associated with resilient health systems are addressed by existing frameworks for measuring and motivating countries' health security, such as the jee. we searched the scholarly and grey-literature databases to identify which capacities should be included in a framework for assessing and improving health system resilience to infectious disease outbreaks and natural hazards. we also sought to determine whether there were existing frameworks that highlighted these capacities that could be used in low-, middle-, and high-income settings. for the purposes of our research, we used the who definition of health systems, defined as "all the activities whose primary purpose is to promote, restore, or maintain health" [ ] . specifically, we integrated literature in the following three areas: health security, health systems strengthening, and quality improvement. the aims of this research were to characterize the impacts that infectious disease outbreaks and natural hazards have on health systems; to identify challenges in maintaining health service delivery during outbreaks and natural hazards; and to identify strategies for effecting sustainable change in health systems-strengthening efforts. literature databases included pubmed, web of science, and oaister. key search terms were informed by, but not inclusive of, kruk et al.'s definition of a resilient health system, and included "health system," "health system strengthening," "resilience," "recover," "quality improvement," "infectious disease," "outbreak," "natural disaster," "global health security," "pandemic," "outbreak response," and "essential functions," as well as a variety of different pathogens responsible for recent infectious disease outbreaks (e.g., sars, ebola) and natural hazard types (e.g., cyclone, earthquake). see additional file : table s for the full electronic search strategy. additionally, we examined the websites of major relevant public health organizations (who, the rockefeller foundation, cdc stacks) to identify articles and frameworks not indexed in the aforementioned databases. all but one of the search results were filtered to include only those articles published during or after , to capture literature emanating in the wake of the sars epidemic, up until february , the end of the study period. however, one search term did included articles published during or after , to capture more broadly those resources that focused on essential health functions. only english-language articles were considered. we included documents if they described health system capacities that could potentially strengthen health system resilience to either infectious disease threats or natural hazards. documents were excluded if they described health capacities that were outside the aims of this research, as defined previously (i.e. articles that were purely about public health capacities that did not mention the relationship of these capacities to the healthcare system). for example, articles that described the importance of a trained epidemiologic workforce (a public health capacity) in outbreak identification and mitigation would be excluded. articles about the importance of engagement between ministries of health and the public would be excluded; however, articles about the importance of engagement between healthcare facilities and ministries of health would be included. documents were also excluded if the article described resilience in contexts outside of natural hazards and infectious disease outbreaks (i.e. armed conflict situations). each of the research team members ( in total) was assigned a set of articles to review. each article title was reviewed by the assigned researcher for relevancy using the previously mentioned inclusion and exclusion criteria, followed by a review of the abstract for those titles deemed relevant. all articles deemed relevant after title and abstract review were then read in their entirety by the assigned researcher, providing a final set of articles for analysis. article references were also reviewed to identify important literature not located in the primary search. articles were then thematically coded by the assigned researcher using qrs international's nvivo coding software [ ] and a qualitative coding instrument developed from a priori themes previously identified in other resilience checklists [ , , , ] . additional topics of interest that did not fit into the previously identified thematic rubric were coded as "other" for further review during data analysis. after completion of coding, through a process of inductive and deductive reasoning, the researchers identified a final list of themes and associated key literature that described the critical capacities necessary for health system resilience to infectious disease outbreaks and natural hazards. we then sought to identify areas of overlap between the health system resilience themes and capacities identified in our literature search, and the specific health security capacities that are the focus of the jee. the search yielded a total of articles after the removal of duplicates (additional file : figure s ). one hundred and fifty-eight articles were read in their entirety, of which were deemed to be relevant and underwent thematic coding. after the completion of coding, we identified key documents that described high-level themes of health system resilience, which are summarized in additional file : table s (see additional file : appendix a and appendix b for a comprehensive breakdown of sources organized by theme and author). thirty-nine papers focused primarily on infectious diseases, while another addressed natural hazards. the remaining papers were not threat-specific, but rather articulated general principles for strengthening health systems and described baseline capacities required for health system functioning. while the themes found in our search were consistent with the five elements of a resilient health system previously outlined by kruk et al. [ , ] , we also identified three additional themes not included in previous reviews, including the need to: develop policies for determining what level of care will be delivered when the level of demand exceeds existing resources; plan for post-event recovery; and commitment to quality improvement that ensures integration of lessons learned. for example, mehta et al. described the need to develop "altered standards of care" for responses to mass casualty events, which might include shifting resources to save as many lives as possible (i.e., triaging patients differently during emergencies as compared to normal operating conditions) and allowing for group isolation of patients that would normally be boarded in single rooms [ ] . the literature identified a number of issues that must be addressed during the recovery phase of a public health emergency, including the need for grief and psychological counseling [ ] , after-action assessment and revision of emergency response plans [ ] , and rebuilding of social cohesion and trust [ ] . a commitment to continuous quality improvement was also identified as an important component of resilient health systems, including making hospital performance ratings mandatory and publicly available to encourage peer competition with the primary goal being the overall improvement of hospital performance [ ] . in integrating literature across subject areas, we were able to identify multiple references to the capacities necessary to achieve the health system resilience attributes identified in our scoping review, which are summarized below (also see additional file : table s ). core health service capabilities: a resilient health system sustains baseline levels of routine healthcare delivery during a public health emergency [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . barriers to healthcare access: a resilient health system dismantles barriers to healthcare access so that the public accesses care during emergencies [ , ] . maintaining critical infrastructure and transportation: a resilient health system develops plans to weather interruptions in critical infrastructure and transportation [ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . timely and flexible access to emergency/crisis financing: a resilient health system has timely, flexible access to financing so that it can better prepare for and respond to public health emergencies [ , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . leadership and command structure: a resilient health system has a clear and flexible command structure that has been established prior to an event and is exercised frequently [ , , , [ ] [ ] [ ] [ ] [ ] [ ] . collaboration, coordination, and partnerships: a resilient health system collaborates and coordinates with partners within and outside of the health system [ , , , , , , ] . communication: a resilient health system has clear channels of communication between health system actors and other sectors, risk communication protocols, and robust engagement with patient populations [ , ] . flexible plans and management structures: a resilient health system has flexible plans and management structures to cope with rapidly evolving circumstances [ , [ ] [ ] [ ] . legal preparations: a resilient health system has made legal preparations to address challenges that may emerge during a crisis [ , , , , , , ] . surge capacity: a resilient health system is able to call on human and capital resources to "surge" the level of care during public health emergencies [ , ] . altered standards of care: a resilient health system has adaptable response plans to guide them in allocating scarce resources and healthcare services [ , ] . health workforce: a resilient health system has an adequate, trained, and willing work force [ , , , , , , , , ] . medical supplies and equipment: a resilient health system has access to medical supplies and equipment, including personal protective equipment, antivirals, and ventilators, during a crisis [ , , [ ] [ ] [ ] . infection prevention and control (ipc): a resilient health system has implemented strong ipc measures, including staff training, standardized protocols, a dedicated ipc focal point, and dedicated treatment units [ , , , , , , [ ] [ ] [ ] [ ] [ ] [ ] . commitment to quality improvement: a resilient health system requires a commitment to continuous quality improvement that promotes excellence and garners the trust of the community [ , , , , , , ] . plans for post-event recovery: resilient health systems have plans for post-event recovery that address a broad range of issues [ - , , , , , - ] . the capacities that we identified are associated with different actors in health systems. some of the capacities identified in our review could potentially be developed by individual health facilities. for example, kim et al. discussed one health system's plan to develop alternate care centers that could be deployed during an influenza pandemic, including the infrastructure that needs to be in place to ensure adequate functioning, such as transport of patients to the center [ ] . other capacities identified in the scoping review concerned the health system more broadly and would likely be addressed by national governmental authorities. for example, hanefeld et al. noted "the nature of the funding and financing mechanism as a core aspect enabling or hindering health systems' ability to respond to a shock" [ ] . no frameworks were identified in the search that translated these high-level themes into specific and actionable steps that health system actors can employ to improve and support health system resilience to both infectious diseases and natural hazards, and that can be undertaken in low-, middle-, and high-income settings alike. frameworks that did articulate specific capacities were either ) only applicable in the us context [ ] or ) did not cohesively address both infectious diseases and natural disasters [ ] . for example, meyer et al. created a checklist for health sector resilience to highconsequence infectious diseases [ ] , but the data for this checklist was informed by the us domestic response to the - west africa ebola outbreak. while some of the identified capacities may be generalizable to other countries, some are only pertinent in the us context. similarly, the hospital safety index, a tool developed by who, does identify capacities that are relevant to some health facilities, but the tool is largely aimed at evaluating the vulnerability of hospital infrastructure to natural hazards (an updated version includes limited consideration of the potential impact of infectious disease threats to hospitals) [ ] . only two of the health system resilience themes and capacities identified in our literature search directly overlapped with the specific health security capacities that are the focus of the jee-namely ipc and communication (see additional file : table s ). specifically, the jee indicator on antimicrobial resistance does address ipc, but only within the context of healthcareassociated infections and associated ipc programs [ ] . additionally, the literature we collected emphasized the importance of communication between health system actors, other sectors, and the community during outbreaks [ , ] . the jee contains a very detailed section on communication that specifically calls out for the need for communication and coordination between stakeholders, including healthcare workers; for systems for rumor management through healthcare workers; and for formal communication mechanisms with the hospital and healthcare sector [ ] . otherwise, health facilities are not directly addressed in the jee framework. there are some indicators in the jee that do address the themes identified in the literature review, but only within the context of public health. for example, the literature suggests that health facilities need access to financing during emergencies to cover the added costs of preparing for and responding to emergencies [ , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the jee indicator on national, legislation, policy and financing does address whether countries have the financing to fulfill their obligations under the ihr, which includes "regulations or administrative requirements, or other governmental instruments governing public health surveillance and response" [ ] . however, it does not specifically address financing within the context of health facilities, although countries could choose to include them in efforts to develop capacities in those areas. finally, some of the themes identified in our review could be leveraged through the development of other capacities that are the focus of the jee. for example, the jee does not explicitly assess how healthcare facilities should address barriers to healthcare access, such as long travel distances, the high cost of medical care, and public distrust. however, it does address the importance of risk communication and community engagement during an emergency. these relationships could potentially be leveraged by the healthcare system during an emergency to improve the public's trust in and subsequent use of the healthcare system. to date, much of the literature that specifically references health system resilience has focused on high-level attributes, rather than identifying specific capacities that health systems need to be resilient to infectious disease outbreaks and natural hazards. for example, kruk et al.'s five attributes of a resilient health system include a system that is "self-regulating," with the ability to "quickly identify and isolate a threat and target resources to it" [ ] . by integrating literature from across different disciplines, we were able translate these high-level themes into actionable corresponding capacities that health systems need to respond to infectious disease outbreaks and natural hazards. for example, the literature highlighted numerous ipc protocols and practices that are important for the control of infectious disease threats, including the need for front-line healthcare workers to conduct travel histories [ ] and the need to establish dedicated and multidisciplinary ipc committees to coordinate and guide healthcare staff on how to safely manage patients with infectious diseases [ , ] . an article by palagyi et al., published after this review was conducted, also highlights the importance of these capacities that we identified [ ] . additionally, the literature highlighted three themes not previously identified as attributes of a resilient health system, which warrant consideration in future efforts to define health system resilience. we present the capacities that we identified across the literature as merely the beginning of an effort to define capacities that health system actors need to be prepared for infectious disease outbreaks and natural hazards. further scholarship in these areas could support efforts to translate research findings into best practices in public health and healthcare practice and improve health outcomes following public health emergencies of all kinds. notably, the jee does identify the capacities necessary to implement the ihrs to protect against public health emergencies of international concern, but lacks guidance for health facilities at the patient-provider interface [ ] . moreover, many of the capacities assessed in the jee presume the existence and functioning of core health system capacities, yet these capacities themselves are not explicitly addressed in jee assessments. for example, while the presence of a national laboratory system-a jee indicator-is a critical capacity to have during an outbreak, it requires that healthcare providers and the proper supplies be available to collect patient samples (e.g., blood, sputum, etc.). ideally, efforts to improve health system resilience would complement and build upon those foundational capacities presumed by the jee process. the results of this literature review point to a need for increased integration of efforts to advance health security and health systems strengthening across the globe. several high-priority elements for health systems resilience likely exist at the nexus of health systems strengthening, health system resilience, and health security; further work is needed to determine the most effective co-investments in global health security and health system strengthening that enable more robust health system responses at the local, national, regional, and global levels during emergent crises [ ] . identifying those areas of overlap can help to actualize the jee's priority areas in health security, and also strengthen key components of national health systems such that their overall resilience is enhanced. while we strived to capture all relevant health systems literature, a potential limitation to our review is the lack of consistency and definitional clarity with which terms like "health system" and "resilience" are used throughout the medical and public health literature. it is possible that we may have missed relevant articles that describe these concepts using different terms. we also found in the literature an overrepresentation of papers detailing health system impacts of certain events and, thus, our findings may not include considerations from other events not represented in the literature. despite these limitations, we think our review serves to deepen the understanding of the specific capacities that health systems need to prepare for infectious diseases and natural hazards. the themes and capacities identified in our literature review provide an initial step in refining the concept of health system resilience to enable actors across the various sectors of the health system to take action to be able to respond and recover from infectious disease outbreaks and natural hazards. there remains a need to further define the concept of resilience so that health systems can simultaneously achieve sustainable transformations in public health practice and health service delivery as well as improve their preparedness for emergencies. in the same way that the jee tool has helped motivate countries to assess and improve their core public health capacities, an implementationoriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. moreover, such an effort may help to integrate foundational health system capacities into national efforts to improve core public health capacities. supplementary information accompanies this paper at https://doi.org/ . /s - - -z. additional file : table s . electronic search strategy. table s . summary of key themes and associated key evidence. table s . overlap of scoping review themes with joint external evaluation 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case studies of northern uganda and sierra leone vertical interventions and system effects; have we learned anything from past experiences? rebuilding transformation strategies in post-ebola epidemics in africa health system preparedness for emerging infectious diseases: a synthesis of the literature who | health security and health systems strengthening -an integrated approach publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. this research was supported by the rockefeller foundation. the rockefeller foundation had no role in the study design, data collection, data analysis and interpretation, in the writing of the report, or the decision to submit it for publication. key: cord- -tuyzhhwx authors: schmid, marc; lüdtke, janine; dolitzsch, claudia; fischer, sophia; eckert, anne; fegert, jörg m. title: effect of trauma-informed care on hair cortisol concentration in youth welfare staff and client physical aggression towards staff: results of a longitudinal study date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: tuyzhhwx background: professional caregivers working in child and youth welfare institutions are frequently faced with the complex mental health issues, emotional needs and challenging coping strategies of clients with cumulated traumatic experiences, leaving them prone to developing high levels of stress, burn-out and compassion fatigue. trauma-informed care (tic) is a milieu-therapeutic approach that aims to promote the self-efficacy and self-care of youth welfare staff by guiding them to a better understanding of their own and their clients’ stress symptoms and countertransference. despite increasing efforts to implement tic practices, and more widespread recognition of their value in youth welfare systems, there is a lack of studies evaluating the effectiveness of this approach. the aim of this study was to assess the effects of tic practices in youth welfare institutions on both the physiological stress of staff members and clients’ physical aggression towards their caregivers. . methods: data was obtained from a longitudinal study investigating the effectiveness of tic in residential youth welfare institutions. our sample consisted of youth welfare employees ( . % female) aged from to years (m = . , sd = . years). hair cortisol concentration (hcc) and occurrences of client physical aggression were assessed at four annual measurement time points (t to t ). results: participants in five institutions employing tic practices (intervention group) showed significantly lower hcc at t than staff members from institutions who did not receive training in tic (control group), indicating reduced physiological stress levels. at t , the intervention group reported significantly less physical aggression than the control group. conclusions: tic might be a promising approach for reducing the emotional burden of employees and institutions should invest in training their staff in tic practices. more research is necessary, to investigate the benefits and efficacy of tic, both to youths and staff members, and to foster a better understanding of which specific factors may contribute to stress reduction. many children and adolescents in the youth welfare system have experienced traumatic stress. they were witness to, and/or themselves victims of, child maltreatment and neglect, domestic violence, or emotional, physical, or sexual abuse. it is estimated that up to % of children and adolescents cared for by the youth welfare system had been exposed to traumatic events and % had experienced multiple traumatic events [ ] . youths with a trauma history, particularly those living in residential care, have an elevated risk of mental health problems such as anxiety, depression, externalising disorders, substance abuse, or risk-taking behaviour [ , ] . moreover, these traumatic experiences can have long-lasting effects on the young person's concept of self, cognitive control mechanisms and problem solving, relationships with others, and attachment to caregivers [ ] [ ] [ ] . in order to account for the maltreatment experiences and trauma-related needs of this highrisk population, efforts have been made to implement trauma-informed care (tic) practices in various psychosocial settings, especially youth welfare settings [ ] [ ] [ ] . but tic concepts should not be limited to residential group homes and youth welfare institutions [ ] . they are relevant for all psychosocial settings, such as juvenile justice institutions [ , ] , special needs schools, child and adolescent, as well as, adult psychiatric settings [ ] , paediatric health care networks [ ] , shelters for the homeless, refugee centres ( ) , rehabilitation and detox centres [ ] etc. a systematic review [ ] of tic literature on concepts with staff training reported implementation and evaluation studies. the conclusion is, that tic may improve clinical practice and can reduce trauma symptoms and the psychopathology of clients. due to the high prevalence of traumatic life events in young people living in out of home placement and the need of placement continuity, some countries have realized countrywide implementation processes [ ] [ ] [ ] . the challenge for youth welfare, juvenile justice, mental health institutions regarding the implementation process of tic is that lies in the process of organization development which includes fundamental changes in attitudes and key processes and scrutinizes established institutional practice and structures [ , ] . however, overall the implementation of tic is associated with higher staff satisfaction [ ] . branson [ ] describes, in his systematic review, different key variables of tic. the interventions described are very close to the tic concepts established in german speaking countries [ , ] . these concepts share many of the characteristic approaches and ideas with concepts established internationally, especially on the level of interventions. the approach practised in german-speaking countries, but also some other concepts, focus on the administrative, professional and emotional support of the staff and constructive structures for inner and outer safety on the entire milieu-therapeutic ward. tic is a conceptual framework and milieu-therapeutic approach "that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control, self-efficacy and empowerment" [ ] . tic conceptualises, and reframes, problem behaviour in the context of an individual's traumatic experience(s), and involves anticipating and avoiding institutional and individual practices that could increase the risk of traumatic re-enactment [ ] . besides addressing the needs of traumatised individuals, tic further aims to promote the self-efficacy and work related resilience of youth welfare staff, by guiding them to a better understanding of their countertransference and personal stress symptoms and by promoting their self-care [ , [ ] [ ] [ ] . continuous selfawareness and self-care may reduce stress and distress among social-service professionals, thereby enhancing work satisfaction and quality of care in the institution [ , ] . the ability of staff members, who interact with severely traumatised children, to cope with stress and apply self-efficacy, are key factors for alternative correctional experiences, the reorganisation of trustful relationships and positive attachment representations (f. ex. [ , , , ] ). youth welfare employees are continuously exposed to the traumatic experiences and challenging emotional and behavioural coping strategies of their clients and are at increased risk for developing burnout and secondary traumatic stress [ , , ] . furthermore, traumatic experiences of the children and adolescents may increase the risk of escalating interactions and physical violence against youth welfare staff [ , ] . much of the abundant literature on the association between traumatic experiences and auto-aggression has come to the conclusion that traumatic experiences in childhood are a prominent risk factor for aggressive behaviour and conduct problems throughout the course of a survivors' life [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the close correlation could be explained, for example, by the misinterpretation of specific social interactions [ ] [ ] [ ] [ ] [ ] , model learning, deficits in implicit and explicit emotion regulation [ ] , especially the selfregulation of aggressive impulses, deficits in the ability to mentalise and be empathic [ ] . since adverse childhood experiences are associated with an impaired ability to regulate or tolerate negative emotions, as well as externalising types of behaviour, affected youths may find themselves relying on counterproductive and detrimental coping strategies, such as opposition, aggression or delinquency when confronted with challenging emotions and situations (e.g., trauma triggers) [ ] [ ] [ ] [ ] . therefore, it is not surprising that frequent exposure to client aggression is a common reality in the professional life of social workers [ , , ] . alink et al. [ ] found that % of youth residential care staff experienced client aggression, and about half of them reported physical aggression, within the last year. another study reported that % of youth welfare staff experienced at least one type of verbal and physical aggression, with % reporting verbal threats and % experiencing physical violence in the past three months [ ] . a central aim of tic is to ensure internal and external safety for both social workers and their clients, including the prospective prevention of violent behaviour [ ] . however, the question whether implementation of tic is associated with a reduction in physical violence against youth welfare staff has barely been investigated. a review on effective strategies for implementing tic in youth psychiatric and residential treatment settings concluded that tic might lead to a decrease in client and staff injury rates [ ] . however, more longitudinal studies are needed, to demonstrate that tic significantly improves client and provider safety. while tic has proved beneficial to social functioning, emotion and behavioural regulation of children and adolescents served by the youth welfare system [ ] , studies on the effectiveness or benefits of tic on staff level are still lacking. one study reported that trauma-informed self-care strategies may increase compassion and job satisfaction, as well as reduce symptoms and burnout among youth welfare staff [ ] . although improving the stress management of employees is a central aim of tic [ , ] , no previous studies have investigated whether tic has an effect on stress levels among youth welfare staff. when the human body is under acute stress, the hypothalamic-pituitary-adrenal (hpa) axis releases the glucocorticoid cortisol, a central biomarker of stress that enables effective coping with stressors via the regulation of basal processes, such as inflammatory and immune responses [ ] [ ] [ ] . cortisol is traditionally measured in the blood, urine, or saliva, but these measurements only reflect short periods of time. in contrast, obtaining hair cortisol concentration (hcc) is a promising approach to measuring long-term cortisol release (for a review see [ ] ). a recent meta-analysis concluded that hcc is a valid indicator of stress. individuals with chronic stress exhibited a % higher hcc, and among those with ongoing stress, the increase in hcc was around % [ ] . since tic aims to reduce stress levels among professionals working with traumatised clients [ , [ ] [ ] [ ] , it is of great interest to compare whether there are long-term differences in hcc between youth welfare employees from institutions with and without tic practices. despite growing implementation efforts of tic practices and recognition of their value in youth welfare systems, there is a lack of studies evaluating the effectiveness of this approach [ ] . so far, this is the first longitudinal study investigating the influence of tic on hcc and physical aggression towards youth welfare employees. the aims of our longitudinal study were twofold. first, we wanted to examine whether the occurrence of physical violence towards youth welfare staff differs between staff members receiving training in tic practices and those providing the usual care. second, we aimed to investigate the longitudinal course of hcc among youth welfare staff with training in tic practices and providing usual care. our research aimed to answer the following questions: ( ) how high is the prevalence of physical aggression towards youth welfare staff? ( ) do youth welfare employees who received training in tic and those providing usual care differ with respect to the prevalence of physical aggression as assessed at four time points? ( ) do the two groups differ with respect to hcc over the course of the study? a total of youth welfare employees participated in the study. overall, participants had missing data with respect to hcc and physical aggression and were therefore excluded from the study (see table for missing data with respect to hcc and physical aggression across the four measurement time points). reasons for missing data were turnover, maternity leave, medical leave, a change of job within the institution, job loss and retirement. our analysis included participants who had complete hcc and physical aggression datasets for all four measurement time points (intervention group [ig]: n = ; control group [cg]: n = ). table shows the descriptive statistics for sociodemographic variables, occupation and professional experience. mean age of the final sample was . years (sd = . years), and . % of the population were female. . , p = . ). the majority ( . %) of participants were social education workers or social education workers in training with an average of . years (sd = . , range = - years) of professional experience in residential youth welfare institutions and having worked in the present institution for an average of . years (range = - years). groups were comparable across occupation and professional experience. the attrition was controlled. the statistical analyses show no significant differences between the analyzed sample and rest of the sample in regard with demographic variables like age, gender, and professional experience (p = . to p = . ), as well as physical aggression towards youth welfare staff (t -t ; p = . to p = . ), and cortisol-level (t -t ; p = . to p = . ). we obtained the data from a government-funded exploratory model project investigating the effectiveness of tic in residential youth welfare institutions, of which institutions received implementation of tic, conducted in the german speaking part of switzerland between and . we contacted all residential youth welfare institutions approved by the swiss federal office of justice, (sfoj) and invited them to participate in the model project. one recommendation of the sfoj was to include different categories of institutions in this project and open it to all institutions approved for by the sfoj. due to this recommendation, co-educative and institutions for male and female adolescents only were included in our study as well as one institution with a special needs school and one with an integrated job training programme. an advisory board, consisting of members of the sfoj, independent experts and the project team, who later conducted the tic trainings, selected suitable institutions among those, who were endorsed to participate in the project. we ran a naturalistic control group design and allocated the institutions to either of the two groups (ig or cg), carefully matching them in terms of comparable qualities of care (e.g., staff education, resident-staff-ratio, referrals). the selected institutions accommodate children, adolescents, and young adults between and years of age, characterised by high levels of traumatic experiences and clinically relevant internalising and/or externalising behaviour, with over a third of them having a criminal record or with symptoms of severe deficits in social behaviour [ ] . % of the children and adolescents in the institutions reported traumatic life events in the childhood trauma questionnaire (ctq) and % reached the clinical cut-off in the child behaviour checklist (cbcl total score). % were referred by penal law entities, % by civil law /child protection services and % attended special schools and working training voluntarily. the children in ig and cg do not differ significantly regarding age, psychosocial burden, traumatic life events, cbcl, maysi- scores. we used a longitudinal study design, to prospectively investigate changes in hcc and physical aggression towards youth welfare staff from each institution at four annual time points (t to t ). data collection comprised self-report questionnaires on sociodemographic variables and experience of aggression at the workplace, as well as hair samples for cortisol analyses. all participants received full information on the study aims and procedures and all gave written informed consent. the leading ethics committee of northwest and central switzerland (eknz), as well as the ethics committees of the cantons of bern, st. gallen, aargau, zürich, and ulm (germany), approved the study. implementation of tic practices in youth welfare institutions tic aims to transform an entire system of care by embedding an understanding of the dynamics and impact of trauma on youths and by creating a safe environment and culture of care, trust, choice, and collaboration [ , ] . in order to create such an atmosphere, it is crucial to address the security and self-efficacy of the residential staff as well as reorganise some key institutional processes. it is necessary that professionals on all levels of the organisation, including management, are committed to changing their existing attitudes and practices. therefore, the management staff and counsellors underwent a specific training in organisational development, supervision skills, and burnout prevention. implementation of tic requires a long-lasting commitment of the institutions to allocate resources and building capacity, to fully train the staff with respect to values and principles of tic, e.g., knowledge of neurobiological and behavioural sequelae of trauma, awareness of trauma triggers, intervening in a trauma-sensitive way, and attention to selfcare in response to working with traumatised clients [ , ] . apart from intensive training, the uptake of tic practices requires ongoing supervision as well as sufficient time for the transfer of knowledge and the consolidation of new strategies into institutional practice. for three consecutive years, experienced professionals conducted advanced training to implement and support tic in youth welfare institutions (six -day trainings for the management and counsellors, eight . -day trainings for the youth welfare staff). the training was mandatory for all the employees in the participating institutions. new employees in the intervention settings were included in the ongoing implementation process and received the respective training. in between trainings, institutions received ongoing supervision in implementing a trauma-informed philosophy and services, debriefing on critical incidents and support in promoting an organisational culture of well-being, permanency, safety, care, and respect towards clients and co-workers [ ] . at the third time point, i.e. by the end of the last training block, all key procedures must be fully implemented in the institutions on all levels of management. the implementation process includes new strategies for the supervision of challenging interactions [ ] between clients and staff, psycho educational sessions and so-called resilience hours in a one-to-one situation. the focus is on good, joy-filled interactions and includes some training in emotion regulation, mindfulness, mentalization and social problem solving skills. furthermore, institutions should revise, and if necessary improve, their key operational procedures (rules, documentation, admission, treatment planning), with a special focus on tic. the implementation process leads to a tic concept with the following characteristics, which must be implemented by the end of the last training (t ): concept of an internal (relationship, self-efficacy) and external (rules, crisis plan, room concept) safety place for staff and clients. special types of case supervision (at least once per month)including interaction analysis with a focus on security, self-efficacy and stress reduction of the staff [ ] . psychoeducation with every client about the link of adverse life events with emotion and anger regulation problems, dissociation and self-efficacy. regular (at least once per month) one to one situations with clients, with a special focus on positive interaction and resilience skills. group feedback sessions (at least one per month) with a focus on developing a positive peer culture. reflection of institutional procedures with regard to tic concepts and attitudes such as transparency, participation, good reason, respect for the individual needs of every client etc. at four annual time points (t = baseline, t = after months, t = after months, t = after months), the youth welfare staff completed several questionnaires covering sociodemographic variables, perceived collective efficiency, sense of coherence, self-care, job satisfaction, personal boundary violation, as well as symptoms of post-traumatic stress, secondary traumatic stress, and burnout. furthermore, hair samples were collected for hair cortisol analyses, and extensive qualitative interviews were conducted to evaluate the implementation process of tic. the implementation process completed after years. over the course of the study, none of the providers in the control group received training in tic, however providers in the control group received training in tic after the study was completed. a self-developed survey about personal boundary violations at the workplace [ ] assessed verbal and physical aggression by children and adolescents towards employees, aggression among children and adolescents, and self-injuring or suicidal behaviour of children and adolescents during the past three months. to address our research questions, only the items relevant to physical aggression by children and adolescents towards employees were analysed. participants were asked to indicate whether they had experienced physical aggression by clients in the past three months, e.g., getting kicked, getting bitten, or having objects thrown at them. hair was collected from the posterior vertex region [ ] . strands of hair ( . cm long) adjacent to the scalp were analysed. given an average hair growth rate of cm/ month [ ] the examination of a . cm hair segment allowed the assessment of cumulative cortisol secretion over the previous six weeks. hair cortisol was extracted as described by gao et al. [ ] . cortisol levels were determined using a commercially available, high-sensitivity (analytical sensitivity . μg/dl) salivary cortisol enzyme immunoassay kit (salimetrics europe, uk) according to the manufacturer's protocol. the intra-assay and inter-assay coefficients of variation of this assay are below %. samples were analysed in duplicate, and mean values of respective measurements were used in statistical analyses. all measures were done in a blinded fashion. values are expressed as pg cortisol/mg hair. descriptive statistics and group differences were calculated for the ig and cg. categorical variables were analysed using pearson's chi-square or fisher's exact test, and continuous variables were computed with student's t-test. hair cortisol data were positively skewed and therefore log-transformed. a one-way repeatedmeasures analyses of variance (anova) with hcc as within-subject factor and group (ig, cg) as betweensubject factor was conducted for testing differences in hcc. univariate anovas were further carried out, to separately compare hcc in the two study groups. age and gender were included as additional factors to control for possible confounding effects. means and standard deviations of hcc are provided in log-transformed units (pg/mg). statistical analyses were performed using spss for windows, version . table shows the prevalence of client physical aggression towards youth welfare staff over the four time points. across all four time points, . to . % of the total sample experienced physical aggression by clients. youth welfare staff in the cg were significantly more often exposed to physical aggression at time than youth welfare employees in the ig (cg: . %; ig: . %; p = . , fisher's exact test). no significant differences between the groups were found for the remaining time points. hair cortisol analyses figure shows the log-transformed hcc data at the four sampling time points in the ig and cg. a one-way repeated-measures mixed anova revealed no significant main effect of hcc (f [ , ] = . , p = . , η = . ); however, the interaction between hcc group was significant (f [ , ] = . , p = . , η = . ). table shows the means and sd for hcc in the two study groups. one-way anovas revealed a significant difference in hcc between groups at t (f [ , ] = . , p = . , η = . ), with the ig showing lower hcc than the cg (see table ). we investigated the impact of tic practices on hcc and occurrence of client physical aggression among youth welfare staff in a longitudinal study. our results showed a significant difference in hcc and client physical aggression between the two groups at t , with the ig showing lower hcc as well as reporting less physical client aggression than the cg. these results indicate that after implementation of tic, youth welfare staff in these institutions showed significantly reduced stress levels and experienced fewer client physical aggression compared to staff who did not receive training in tic. the significant reduction after t indicates that training and knowledge of psycho-traumatology are not enough to change institutional practice and reduce the stress level of staff [ , ] and that such implementation processes take time and the allocation of resources [ ] . it appears necessary to develop and implement tic key procedures in those institutional processes and structures focusing on client and staff safety and self-efficacy in interactions, towards a kind of supply chain in which the management supports staff and staff support clients. previous studies highlighted the benefits of tic practices such as increased compassion satisfaction and reduced symptoms of burnout among youth welfare staff [ ] . our study is the first to show a decrease in table prevalence of client physical aggression towards youth welfare staff in the intervention and control groups physiological stress among participants working in institutions with a tic approach. one reason for the stress decrease might be the focus of tic on establishing emotional safety by promoting self-care on a personal and institutional level [ , ] . for instance, traumainformed institutions may provide structures that allow their employees to institute support groups after critical incidents or difficult interactions, with the possibility to reflect on one's own feelings and motives in order to foster and maintain mental hygiene, coherence, mindfulness, and resilience of the staff [ , ] . we found rates of physical aggression towards youth welfare staff comparable to those reported in the literature, which illustrates that client aggression is a pressing concern that needs to be addressed [ , ] . however, it is noteworthy that at the last measurement time point, participants in the ig experienced significantly less client physical aggression than those in the cg. russell et al. [ ] showed that tic is associated with a decline in staff injury rates. exposure to client aggression is associated with impaired physiological and emotional well-being and may have implications for work satisfaction and quality of care [ , , ] . of course, this is a bidirectional association, which could lead to either a positive or a vicious circle: boundary violations against staff lead to insecurity and low self-efficacy, this induces reduced pedagogic presence and positive interactions, which can, in turn, enhance the risk of new boundary-violations [ ] . therefore, it is crucial to establish prevention and intervention standards to ensure the physical safety of employees. furthermore, from a perspective that regards aggression as a failure to regulate emotions in the face of threatening or frustrating situations [ , ] and through a trauma-sensitive lens, it might be helpful to create an atmosphere of shared decision-making with youths and thus promote their self-regulation and coping skills [ ] . the staff's ability to regulate and contain their own emotions in highly stressful interactions is of equal importance in order to recognise and adapt to the young people's needs [ ] . as noted above, client physical aggression is highly prevalent in residential youth welfare institutions and may be seen as an innate and unavoidable occupational hazard [ , ] . therefore, the staff should work within the framework of institutional structures that encourage communication and the sharing of note. hcc = hair cortisol concentration their concerns and highly emotional experiences in these challenging situations [ ] . the general mental health needs of children and adolescents cared for by the youth welfare system have been extensively studied [ ] [ ] [ ] , whereas knowledge about the professionals' experiences and psychological impact of this challenging area of work is limited. mcelvaney and tatlow-golden [ ] report that professionals working in the care and youth justice system describe themselves as feeling helpless, frustrated and incompetent in the face of the complex mental health needs of their clients. the authors conclude that the staffs own psychological response mirrors the traumatic response of their clients thus, the staff members feel traumatised themselves, thereby possibly contributing to further client traumatisation. high rates of traumatic stress and/or compassion fatigue are common among youth welfare staff and may lead to job burnout, work withdrawal, and turnover [ ] [ ] [ ] . three years after the beginning of the study, when the tic approach was fully adopted by the institutions, participants who received training in tic had significantly reduced hcc compared to the control group. moreover, tic-trained study participants' experienced significantly less physical client aggression than those who did not receive tic training at t . training of individuals to support the adoption of tic may be time-consuming and demanding and requires a long-term commitment of the institutions and their employees. however, our study suggests that implementing a tic approach may be beneficial in the long run. employees who feel less stressed and experience fewer physical assaults may be able to offer a better quality of care for their clients and remain in their jobs for longer, thereby fostering stability in the institution. several limitations of the current study have to be considered. as the data was taken from an exploratory study with longitudinal design, the final sample size was small, which might have precluded the ability to identify group differences. the complete set of measurements at the four annual time points was available for only % of the study population, which indicates a large participant drop-out rate due to turnover or other reasons. however, we have decided against an imputation of the missing values because participation in the entire implementation process is crucial for evaluating the effectiveness of tic. high rates of staff turnover are a common problem in social services [ ] [ ] [ ] and might have contributed to the small sample size in our longitudinal study. however, we controlled the attrition regarding different variables and could not find significant differences regarding psychosocial variables, hair cortisol concentration and burn out risk. the gender differences between ig and cg could be also a relevant limitation. some studies show, that female staff is at higher risk of boundary violations and sexual harassment at in the workplace [ , ] . we had very limited possibility to control and specify the correlation between violence against staff and gender in this small sample (we found no difference regarding hair cortisol concentration, tic and boundary violations p > . ). it will be necessary to prove the effect of gender in studies with greater samples that take into account the effect of gender on boundary violations and hair cortisol concentration, even if we could not observe such an effect in our study. notably, large sample sizes in longitudinal studies involving neurobiological measures are rare and difficult to obtain. to the best of our knowledge, this is the first longitudinal study assessing neurobiological variables in the youth welfare system. a further study limitation was the uncertainty on whether the tic concepts were implemented in a uniform way by the participating institutions. since all institutions had their established concepts, the degree of adherence to tic principles (i.e., frequency of performing the interventions, quality control) may have differed. given that institutions had unequal resources at their disposal for the implementation of tic, and that the tic approach tried to standardise highly heterogeneous concepts, employees at individual institutions may have encountered variable stress levels. it is possible that new employees in the intervention group have had training in tic in previous jobs, however there was no crossover of employees and the institutions participating in the study. finally, since the experience of client aggression was based on self-reports, a certain report and recall bias cannot be excluded. findings from the current study have important clinical implications. our results suggest that tic practices can successfully reduce physiological stress and client physical aggression among youth welfare employees working with traumatised children and adolescents. most notably, we used a biological measure of stress instead of subjective stress ratings, to assess the physiological changes after implementation of tic practices more accurately. the measured decrease in stress levels among the staff might be associated with the core principles of tic, such as fostering and maintaining mental hygiene, coherence, mindfulness, and resilience. by implementing operational procedures that guide the staff to a better understanding of their own stress symptoms and promoting self-care, they might be better equipped to recognise and adapt to the young people's needs and to avoid traumatic re-enactment. therefore, we suggest that institutions should invest in training their staff in tic practices and aggression de-escalation techniques. future research is needed to evaluate the effectiveness of tic in larger samples and other populations (e.g., child and adolescent psychiatry, forensic units, closed juvenile justice settings, settings for adults, homeless people etc.) -tic concepts are not limited to residential care or child and adolescent psychiatric settings, they have the potential to benefit practically all psychosocial settings. to what extent the results of these studies are transmittable to other psychosocial settings should be examined because, of course, boundary violations and high levels of stress in staff members are relevant in nearly all psychosocial settings. it is likely, that the consistent focus on the staff and the reduction of staff stress levels to enhance the capacities for correctional client-staff relationships, with lower arousal in the whole interaction, is the innovative aspect that differentiates our model [ , ] from other tic concepts (overview [ ] ). in addition, it would be of interest to investigate which component of tic is associated with the most marked decrease in physiological stress reactions. potential additional benefits of tic for employees and their clients should also be studied, and neurobiological changes induced by psychosocial interventions should be more fully understood. however, to the best or our knowledge, there are only few studies targeting individuals in residential care (e.g. [ ] ). our study shows that neurobiological research is feasible in this field and offers new insight into physiological changes that accompany tic. prevalence of maltreatment among youths in public sectors of care trauma experiences, maltreatment-related impairments, and resilience among child welfare youth in residential care 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among social workers in child welfare settings a pilot study of workplace violence towards paramedics violence in the workplace: gender similarities and differences hpa stability for children in foster care: mental health implications and moderation by early intervention publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank all subjects and caregivers who participated in this study, our colleagues who helped implement it and the swiss federal office of justice for providing the funding. authors' contributions ms, cd, sf, and jmf contributed to the design, patient recruitment, survey, data collection, and evaluation of the study. ms, jl, cd, sf, ae, and jmf completed data analyses and substantially contributed to the interpretation of data. ms and jl drafted the manuscript, and cd, sf, ae, and jmf revised it critically. all authors read and approved the final manuscript. this study was funded by the swiss federal office of justice. the funding agency was not involved in the study design, data collection, analysis, interpretation of the data, or manuscript preparation. the datasets used and analyzed during the current study are available from the corresponding author on reasonable request. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the helsinki declaration and its later amendments or comparable ethical standards. all participants received full information on the study aims and procedures and all gave written informed consent. the leading ethics committee of northwest and central switzerland (eknz), as well as the ethics committees of the cantons of bern, st. gallen, aargau, zürich, and ulm (germany), approved the study. this was not applicable. the authors declare that they have no competing interests. key: cord- -de aimuj authors: revere, debra; nelson, kailey; thiede, hanne; duchin, jeffrey; stergachis, andy; baseman, janet title: public health emergency preparedness and response communications with health care providers: a literature review date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: de aimuj background: health care providers (hcps) play an important role in public health emergency preparedness and response (phepr) so need to be aware of public health threats and emergencies. to inform hcps, public health issues phepr messages that provide guidelines and updates, and facilitate surveillance so hcps will recognize and control communicable diseases, prevent excess deaths and mitigate suffering. public health agencies need to know that the phepr messages sent to hcps reach their target audience and are effective and informative. public health agencies need to know that the phepr messages sent to hcps reach their target audience and are effective and informative. we conducted a literature review to investigate the systems and tools used by public health to generate phepr communications to hcps, and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective phepr communications. methods: a systematic review of peer- and non-peer-reviewed literature focused on the following questions: ) what public health systems exist for communicating phepr messages from public health agencies to hcps? ) have these systems been evaluated and, if yes, what criteria were used to evaluate these systems? ) what have these evaluations discovered about characterizations of the most effective ways for public health agencies to communicate phepr messages to hcps? results: we identified systems or tools for communicating phepr messages from public health agencies to hcps. few articles assessed phepr communication systems or messaging methods or outcomes. only one study compared the effectiveness of the delivery format, device or message itself. we also discovered that the potential is high for hcps to experience "message overload" given redundancy of phepr messaging in multiple formats and/or through different delivery systems. conclusions: we found that detailed descriptions of phepr messaging from public health to hcps are scarce in the literature and, even when available are rarely evaluated in any systematic fashion. to meet present-day and future information needs for emergency preparedness, more attention needs to be given to evaluating the effectiveness of these systems in a scientifically rigorous manner. public health emergency preparedness and response (phepr) involves activities directed at preventing possible emergencies and planning to ensure an adequate response and recovery if an emergency occurs. the public health system itself is a complex network of organizations and individuals that work together for the benefit of the public's health. these entities include public health agencies at local, state and federal levels, public safety agencies, emergency managers, academia, business, communities, the media, and the healthcare delivery system [ ] . as one component of the phepr system, information contributed by health care providers (hcps) to public health is aggregated, analyzed and used by public health agencies, in part, to inform early event detection and situational awareness [ ] . figure illustrates a simplified transfer of information from hcps to public health which is aggregated, analyzed and used to inform public health alerts and advisories which are sent to hcps. the importance of the transmission of hcp information to public health, particularly for notifiable condition reporting, has been well-documented [ ] [ ] [ ] [ ] . hcps serve a critical role in public health's recognition and control of communicable diseases as illustrated by west nile virus [ ] and sars [ ] ; influenza and influenza-like illness [ ] ; foodborne illnesses [ ] ; and illnesses associated with intentional release of biologic agents such as anthrax [ , ] . in public health responses involving bioterrorism, hcps have an especially important role since they will likely report such cases of unexplained or unusual illness to state and local public health officials who, in turn, may be able to conduct investigations and identify specific epidemiologic patterns or characteristics potentially indicative of bioterrorism [ ] . during an emergency situation health care providers (hcps) are depended on to prevent excess deaths, treat the injured, and mitigate suffering [ ] . to do this, and given that individuals will seek medical care in multiple locations during an emergency, hcps need to be aware of public health threats and emergencies, issue guidelines and updates, and facilitate surveillance [ ] . on september , , when telephone and paging systems failed, the new york city department of health and mental hygiene successfully used email and fax to distribute public health broadcast alerts to all nyc emergency departments, commercial and hospital laboratories, infection-control programs, and select providers [ ] . in an emergency, effective communication will not only depend on the information/message, but on the type of communication system or tool, the delivery format, and the robustness of the system. while timely, efficient, and effective communications between public health and hcps is an important part of public health emergency preparedness and response (phepr), most publications concerned with this exchange have emphasized the hcp-to-public health component. yet, it is well-established that the "return" of information to hcps is also significant. we conducted a systematic literature review to investigate the systems and tools used by public health to generate phepr communications to hcps, and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective phepr communications. three questions guided this literature review: what public health systems exist for communicating phepr messages from public health agencies to hcps? have these systems been evaluated and, if yes, what criteria were used to evaluate these systems? what have these evaluations discovered about characterizations of the most effective ways for public health agencies to communicate phepr messages to hcps? table lists the subject terms and keyword terms identified for key concepts for the search. to ensure retrieval of different types of phepr messages we included both health alerts (messages of the highest level of importance that warrant immediate action or attention) and health advisories (messages that provides key information for a specific incident or situation, such as a guideline change, and might not require immediate action). we also included as search terms any system, communication method or device that facilitated these communications. public health literature is reported to be poorly indexed in bibliographic databases and dispersed across a wide variety of journals and other sources, as well as across many disciplines [ ] . we included "grey" or non-peer-reviewed literature sources [ ] to ensure wide coverage of less accessible materials such as government reports and conference proceedings ( table ) . the exact search terminology used was tailored for each database as appropriate to its structure and thesaurus to ensure a high degree of sensitivity ( table ) . the web of science ® database was used to conduct cited reference searches of relevant articles. in addition, we hand-searched (known as snowball sampling) the reference lists of relevant articles and the tables of contents of the following journals: journal of homeland security and emergency management, disaster medicine & public health preparedness, and american journal of disaster medicine. the review was limited to publications in the english language and to materials published between / through / . all search strategies were recorded at each step. citations from database searches were downloaded into the endnote bibliographic reference program (http://www.endnote.com/) or manually entered as needed. duplicates were removed. figure illustrates the identification, screening, eligibility and inclusion numbers, and rationale for excluded materials in our search and selection process [ ] . articles were included if they described systems or tools for public health agencies to communicate phepr messages to hcps or included an evaluation of these systems or tools. data extracted from the articles included: purpose, location, organization or agency involved, hcp population, method(s) of communication, and type of evaluation performed, if conducted. if an evaluation was performed, the outcomes were extracted. of the initial set of full-text articles assessed for eligibility, were excluded once read as they only described systems that sent phepr messages to health departments (n = ) or were opinion articles (n = ). data extraction from the final articles resulted in identification of different systems, with one article describing more than one system. overall, the final articles contained information on the purpose of the system or tool ( %), location of the system ( %), public health organization or agency involved ( %), targeted hcp population ( %), and method(s) used by public health to communicate phepr messages to hcps ( %). eleven articles (covering systems) included a description of the evaluation used with the system. type of evaluations included comparative [ ] , interviewing [ ] , surveying [ , ] , retrospective [ , ] , formative [ ] , and an assessment following a simulation exercise [ ] . one article reported a causal relationship could be "inferred" between the dissemination of health advisories and hcp reporting and testing [ ] and two reported receiving feedback but did not detail method [ , ] . the remaining articles ( %) either did not mention an evaluation or did not contain enough information to determine if an evaluation had been conducted. of the systems and tools documented, the majority ( %) were north america-based. the location of the systems included: % state-level, % city-level, % country-level, and % regional, with one international system ( %). only one tool was designed to provide phepr messages to veterinarians; the remaining targeted hcps in hospitals, emergency departments and/or outpatient clinical settings. the majority of systems used email ( %) to deliver phepr messages. systems also delivered messages by phone, including cellular ( %); fax ( %); pager ( %); sms text messaging ( %); handheld devices such as pdas or blackberry ® ( %); other devices such as radios ( %); messaging through an electronic medical record "public health" pandemic "health alert" or "public health alert" veterinarians preparedness "health advisory" terrorism "preparedness message" surveillance "preparedness communication" system ( %); and "social media" ( %). some systems also posted the phepr message to a web site ( %) for passive consumption. a majority of systems used more than one method ( %) for delivering messages. only systems were described in sufficient detail to determine that each method was attempted sequentially as opposed to redundant messages being delivered through all devices and formats. table (additional file table s ) lists each messaging system or tool included in the final retrieval set and indicates type of evaluation conducted where applicable. after conducting a systematic search, we identified systems or tools currently being used to communicate phepr messages from public health to hcps. of the systems that reported an evaluation, only provided sufficient detail of methodology used. during a q fever outbreak, two public health alert faxes were sent asking physicians to submit serum samples on any patient meeting a clinical case definition of q fever and an association with the area where the outbreak occurred. by examining laboratory reports, van woerden et al ( ) found a statistically significant difference between the number of patients tested for q fever in the target population after the alerts had been sent as compared to a comparable two-week period one year before [ ] . another study retrospectively examined recommended public health agency actions communicated to hcps through a pop-up in an electronic health record in comparison with lab orders and treatment guidelines and found that a causal relationship "could be inferred" (although with no detail to document this inference) between the alert and a change in hcp behavior [ ] . other system evaluations lacked adequate detail to determine the extent of evaluation activities. prior to developing germwatch, a system focused on communicating advisories regarding respiratory viral pathogens and pertussis, gesteland et al ( ) conducted a formative evaluation of the feasibility and sustainability of the system [ ] . however, formative studies, though useful in the planning and early development phases of a system, need to be followed up with an evaluation focused on identifying changes in outcome or performance measures, results, or effectiveness criteria that can be confidently attributed to the system rather than other factors and conditions. while reports of retrospective evaluations of promed, a global outbreak surveillance system [ , ] , the messaging tools used in conjunction with a topoff exercise [ ] , and a survey of homeless service providers during the sars outbreak in toronto [ ] identify problems and propose measures to counteract problematic communications issues between public health and hcps, the reports lacked the detailed methodology or results that are needed to assess the rigor of these evaluations. ("public health") and (doctors or physicians or nurses or pharmacists or veterinarians or "healthcare providers" or "health care providers" or surveillance) and (communication or "emergency communication" or "disease event" or "health alert" or "public health alert" or "emergency alert") and (emergency or disaster or terrorism or pandemic or preparedness or response or "disease outbreak") medline inspec ("public health" or "emergency services" or "emergency preparedness" or "emergency planning" or "surveillance activity" or "emergency response") and alert web of science ("public health" and (doctors or physicians or nurses or pharmacists or veterinarians or "healthcare providers" or "health care providers" or surveillance) and (communication or "response capacity" or "emergency communication" or "disease event" or "health alert" or "public health alert" or "emergency alert") and (emergency or disaster or terrorism or pandemic or preparedness or response)) snowball technique hand-searching article references, related records, tables of contents of pertinent journals ahrq "public health" and "emergency preparedness" and alert cdc "public health" and "emergency preparedness" and "emergency communication" gpo access "public health" and providers* and communication and emergency "public health" and terrorism and alert nlm gateway "public health" and "bidirectional communication" and "health alert" rand "public health" and disaster and providers* and alert one of the most widespread strategies in the u.s. for public health agencies to communicate to hcps on both national and local levels is through the cdc's health alert network (han) program which communicates information about infectious disease outbreaks and public health implications of national disasters within its health alerts, advisories, and updates [ , , ] . given its wide coverage, we were surprised to find so few studies attempting to systematically verify that han messages are received, processed, and/or acted upon by the intended recipients outside of public health agencies. as a result, in part, of current studies of the h n outbreak, we are now learning that phepr messages may not be reaching their targeted audiences. for example, results of a cross-sectional survey of health departments, physicians, and pharmacists in kentucky regarding information dissemination and receipt during the early h n outbreak found that deficiencies exist in the effectiveness of public health phepr communications to hcps. while % of responding local health departments (lhds) rated their capacity to disseminate information to hcps as very good or excellent, only % of surveyed physicians and % of surveyed pharmacists reported receiving any information about h n from a lhd. seventy-four percent of pharmacists were not aware of their lhd's emergency plan in the event of an influenza outbreak [ ] . in conducting this review we discovered that there are multiple sources from which hcps may receive han communications. cdc not only sends messages to state and local public health agencies that then disseminate to hcps, but clinicians can also sign up to receive han messages directly through the cdc's clinician outreach communication activity (coca) as well as through any of the coca partner organizations that pass on or post coca-generated notices of new and updated cdc information on emerging health threats [ , ] . while any phepr situation presents challenges in communicating about uncertainties, collaborating across and within organizations, and communicating timely messages [ ] , every additional messaging source raises the potential for redundant and conflicting information. coca disseminates updates bi-weekly (more frequently when there is emergency information or event-specific updates). excluding han alerts, a tally of messages disseminated through coca from - yielded messages that each contain as many as topical messages. avoiding the communication of multiple and redundant messages that can engender "alert overload" in hcps is important, especially in a public health emergency situation. the han system allows hcps to set a preference for receiving messages but, as mentioned above, if the hcp is receiving messages from different sources the redundancy potential increases. staes et al ( ) presented an objective analysis of communication between public health agencies, health care organizations, and frontline hcps during the h n outbreak. the investigators conducted a cross-sectional survey to understand communication processes between public health and frontline hcps and found that hcps received redundant messages; were challenged to keep up with evolving and tailored messages from multiple organizations at a time when clinic volumes, patient concerns, and media exposure were increasing; and were overwhelmed by e-mail volume. the study suggests that phepr messages sent to hcps be concise and clearly identified [ ] . we found there are numerous formats (email, fax, etc) in which to deliver phepr messages to hcps. when more than one format was available it was not clear if hcps were given a choice between different ways to receive messages as opposed to receiving redundant messages in different formats or through different delivery systems. allowing hcps to set preferences for receiving phepr messages might improve response. our review has three main limitations: ) scope and search terms; ) access to full-text articles; and ) lack of data in the included articles. for practical reasons we limited ourselves to materials written in the english language. while we did not limit ourselves to u.s. systems or studies, it is possible that systems of phepr messaging to hcps developed in europe and asia may be written in other languages. it is also possible that our search strategy did not cast either a wide or targeted enough net to capture relevant literature. perhaps modifications to the terminology or concept operators would have yielded better retrieval sets. we were limited to resources accessible through our academic libraries and their inter-library partnerships so may have missed some material. another limitation is our elimination of articles missing or with uninformative abstracts. again, it is possible that this omitted key articles from our results. lack of data was an issue as many articles did not contain sufficient descriptive information. despite these limitations, our results show that detailed descriptions of phepr messaging from public health to hcps are scarce in the literature and, even when available are rarely evaluated in any systematic fashion. this review shows that little is known about the effectiveness of phepr communications from public health to hcps. we also found that by using multiple formats and delivery methods, current systems and tools may be increasing, rather than reducing, communication challenges for hcps with unnecessarily redundant messages; confusion due to messages that may reflect conflicting federal, state and local guidelines, information and concerns; alert "overload"; and lack of tailored preferences for receiving these important messages. much has been written about the "astute clinician" who noted an unusual clinical finding and set off the public health alarm concerning the first case of anthrax in palm beach county, florida in october [ ] . given the importance of hcps in phepr, more research needs to be done to further investigate how public health can communicate effectively with hcps. there are numerous questions about these systems and tools that need to be answered, some basic, such as: have phepr messages been successfully delivered? were they read and, if yes, can the date or time of their delivery and their content be recalled? is there an optimal frequency for sending phepr messages? what components of a message are most important for the message to be perceived as credible, authoritative, complete? what impact do phepr messages have on hcp behavior, surveillance or reporting of suspected or confirmed events of public health interest or phepr knowledge? one example of new research being conducted in this area is the reach trial in which the authors are using a randomized, community-based trial method to investigate the effectiveness of various message delivery systems (email, fax, and sms) for communicating phepr messages from public health agencies to hcps [ ] . the primary aim of reach is to determine the effectiveness of various message delivery systems (email, fax, and sms) for communicating phepr messages from public health agencies to hcps and to compare the effectiveness of communication methods between these two groups across diverse communities. this is however, only one effort. to meet present-day and future information needs for emergency preparedness, concentrated attention needs to be given to evaluating the effectiveness of phepr systems in a scientifically rigorous manner [ ] . additional file : table s : literature selected. iom: the future of the public's health in the st century will the nation be ready for the next bioterrorism attack? mending gaps in the public health infrastructure the bioterrorism preparedness and response early aberration reporting system (ears) evaluation of reporting timeliness of public health surveillance systems for infectious diseases syndromic surveillance using minimum transfer of identifiable data: the example of the national bioterrorism syndromic surveillance demonstration program the west nile virus encephalitis outbreak in the united states severe acute respiratory syndrome (sars) and coronavirus testing-united states outbreak of swine-origin influenza a (h n ) virus infection -mexico surveillance for foodborne disease outbreaks -united states emergency department visits for concern regarding anthrax-new jersey death due to bioterrorism-related inhalational anthrax: report of patients the role of an advanced practice public health nurse in bioterrorism preparedness bioterrorism preparedness and response: clinicians and public health agencies as essential partners the health alert network: partnerships, politics, and preparedness new york city department of health response to terrorist attack expert searching in public health the use of grey literature in health sciences: a preliminary survey preferred reporting items for systematic reviews and meta-analyses: the prisma statement using facsimile cascade to assist case searching during a q fever outbreak homelessness and the response to emerging infectious disease outbreaks: lessons from sars the novel influenza a h n epidemic of spring evaluation of promed-mail as an electronic early warning system for emerging animal diseases: to the internet and the global monitoring of emerging diseases: lessons from the first years of promed-mail informing the front line about common respiratory viral epidemics terrorism preparedness: web-based resource management and the topoff exercise using electronic health record alerts to provide public health situational awareness to clinicians local collaborations: development and implementation of boston's bioterrorism surveillance system novel h n and the use of hit within the chicago department of public health exemplary practices in public health preparedness. technical revere et al. bmc public health communication efforts among local health departments and health care professionals during the h n outbreak order out of chaos: the self-organization of communication following the anthrax attacks public health communication with frontline clinicians during the first wave of the influenza pandemic bioterrorism-related inhalational anthrax: the first cases reported in the united states. emerg infect dis improving public health to provider messaging: the reach project. joint conference on health iom: research priorities in emergency preparedness and response for public health systems: a letter report pre-publication history the pre-publication history for this paper can be accessed here public health emergency preparedness and response communications with health care providers: a literature review the authors would like to thank the bmc public health reviewers for their insightful comments and suggestions. this work was supported by the centers for disease control and prevention, grant no. p tp . its contents are solely the responsibility of the authors and do not necessarily represent the official views of the centers for disease control and prevention. authors' contributions dr conceived of and led the search, evaluation and synthesis components. kn participated in the database searches and retrieval set evaluation. dr authored the overall manuscript with contributions by kn, jb, as, ht and jd. all authors read and approved the final manuscript. the authors declare that they have no competing interests. key: cord- -p macofk authors: biezen, ruby; grando, danilla; mazza, danielle; brijnath, bianca title: visibility and transmission: complexities around promoting hand hygiene in young children – a qualitative study date: - - journal: bmc public health doi: . /s - - -x sha: doc_id: cord_uid: p macofk background: effective hand hygiene practice can reduce transmission of diseases such as respiratory tract infections (rtis) and gastrointestinal infections, especially in young children. while hand hygiene has been widely promoted within australia, primary care providers’ (pcps) and parents’ understanding of hand hygiene importance, and their views on hand hygiene in reducing transmission of diseases in the community are unclear. therefore, the aim of this study was to explore the views of pcps and parents of young children on their knowledge and practice of hand hygiene in disease transmission. methods: using a cross-sectional qualitative research design, we conducted in-depth interviews with pcps and five focus groups with parents (n = ) between june and july in melbourne, australia. data were thematically analysed. results: participants agreed that hand hygiene practice was important in reducing disease transmissions. however, barriers such as variations of hand hygiene habits, relating visibility to transmission; concerns around young children being obsessed with washing hands; children already being ‘too clean’ and the need to build their immunity through exposure to dirt; and scepticism that hand hygiene practice was achievable in young children, all hindered participants’ motivation to develop good hand hygiene behaviour in young children. conclusion: despite the established benefits of hand hygiene, sustained efforts are needed to ensure its uptake in routine care. to overcome the barriers identified in this study a multifaceted intervention is needed that includes teaching young children good hand hygiene habits, pcps prompting parents and young children to practice hand hygiene when coming for an rti consultation, reassuring parents that effective hand hygiene practice will not lead to abnormal psychological behaviour in their children, and community health promotion education campaigns. hand hygiene, including hand washing with soap and water, or the use of hand sanitizers, has been shown to reduce transmission of infectious diseases [ ] [ ] [ ] , especially gastrointestinal and respiratory tract infections [ ] . young children < years of age are most at risk, in particular those attending childcare or preschool [ ] [ ] [ ] . effective hand hygiene practice in community settings, has demonstrated a reduction of infections occurring in childcare [ ] [ ] [ ] [ ] , schools [ , [ ] [ ] [ ] , and in the home [ ] [ ] [ ] . according to aiello et. al's meta-analysis [ ] improvements in hand hygiene resulted in a % reduction in respiratory illnesses and a % reduction in gastrointestinal illnesses in community-based settings. the importance of hand hygiene practice in the prevention of infectious diseases was emphasized in all studies included in this meta-analysis. studies from europe, us, and the uk have also shown that hand hygiene interventions in the community can increase hand hygiene compliance among children [ ] [ ] [ ] . for example, interventions involving teacher modelling hand hygiene to school children [ ] , improving educator's knowledge and attitude towards hand hygiene [ ] , and the use of alcohol-based sanitizers [ , , ] have significantly reduced illness absenteeism in schools. however, factors such as lack of time to practice hand hygiene, poor adult modelling of regular hand washing, limited facilities including available sinks, soap and water, and the lack of knowledge regarding the importance of hand hygiene have hindered the compliance and sustainability of good hand hygiene practice [ , ] . despite wide promotion of hand hygiene in australia [ ] and good evidence that effective hand hygiene practice reduces infectious disease transmission, to date no studies have measured the efficacy and sustainability of hand hygiene practice in the australian primary care setting. thus, it is unclear whether primary care providers (pcps) and their patients follow recommended protocols to reduce infectious diseases, especially in young children. accordingly, the aim of this study was to explore the views of pcps and parents of young children regarding the practice of hand hygiene in the transmission of diseases in young children. data for this research were derived from a larger mixed methods qualitative study exploring pcps and parents' views, knowledge and attitudes towards their hand hygiene practice and reducing rti transmission in children < years of age. the methods applied have been previously described [ ] ; in summary, interviews were conducted with pcps and five focus groups with parents of young children (see table for schedules). pcps were defined as general practitioners (gps), practice nurses (pns), maternal child health nurses (mchns), and pharmacists (phs), and a diversified sampling strategy was applied to recruit them. the contact details of gps and pns were generated from an existing general practice database at monash university, victoria, australia. contact details for mchns and phs were generated from the maternal child health services directory [ ] and the local business directory respectively. recruitment was limited to one pcp per practice site across metropolitan melbourne, australia. purposive sampling via advertisements circulated to playgroups and mothers' groups was used to target parents and carers from the south east and east of melbourne, australia. five mothers' groups and play groups were initially approached to recruit the required number of parents and carers. if one site refused due to time or not enough willing participants then another would be approached until the total number of participants were reached. a total of five play groups (two accepted) and three mothers' group (all three accepted) were approached. interested participants were asked to contact the researcher (rb). all participants consented to up to an hour interview or focus group to explore their views, knowledge and attitudes towards management of respiratory tract infections, including prevention strategies such as influenza vaccination and hand hygiene in children < years of age. interviews and focus groups (each approximately h long) were conducted between june and july by rb. pcps' were interviewed at their work place or at a place convenient to them during practice hours; focus groups were conducted at play group centres or at scheduled mothers' group meetings. all participants gave written consent prior to data collection; pcps were provided with a aud$ and parents with a aud$ gift voucher upon completion. interviews and focus group discussions were digitally recorded and transcribed verbatim. data were analysed using a thematic approach [ ] to provide a flexible approach to identify, analyse and report themes or patterns within the data. initially, two researchers (rb and bb) read three transcripts independently to generate initial codes and themes, which were then compared and refined until consensus was reached. a further three transcripts were coded using the schemata and this process was repeated, three transcripts at a time, to incorporate emerging themes, until all transcripts were coded. data were managed using nvivo . study approval was obtained from monash university human research ethics committee (cf / - , , , ). a total of pcps ( females) and parents and carers ( females) participated in the study. the average years of experience for gps, pns, mchns and phs were . , . , . , and . years respectively. in the parents and carers cohort, % (n = ) were in the - years age group, with over % (n = ) having a graduate degree or higher. all participants revealed high levels of knowledge regarding hand hygiene and its importance. when asked, they gave their definition of hand hygiene, and discussed the importance of hand hygiene in reducing transmission of infection, including day to day practice. "washing hands frequently especially after sneezing, touching the nose, touching the mouth, coughing in the hands… the droplets in the transmission and what it means and even touching the handles of the doors, all of these can be a source of infection sometimes, and washing hands, i mean, they are important." gp "yeah i think it's [hand hygiene] quite important, because your hands touch anything. like your hands will touch the table and someone will come to the table your hands touched -without even realising, you're touching things. like you're touching your face all day. scratching your hair, everything, and then you go and touch things…" fg despite participants having good knowledge of hand hygiene, and recognising the importance in reducing disease transmission, many barriers such as variation in the practice of hand hygiene among pcps and parents, linking visibility to disease transmission, and doubts that hand hygiene practice was attainable in young children hindered good hand hygiene practice. we elaborate on these themes below. although pcps unanimously agreed that hand hygiene was important in reducing the transmission of diseases, there were large variations in practice. three types of hand hygiene practice were identified among gps and phs: some would wash hands between seeing patients irrespective of whether contact has been made, some would only wash hands if skin contact was made, while others would practice hand hygiene only if patients were visibly infectious. however, most gps commented that they would use alcohol sanitizers between patients if hand washing with soap and water was not possible. "… every time i examine the patient…" gp "not everyone, not if there's no skin contact…"gp "…if i'm handling something or i thought they are likely infectious..." gp "would be very rare. we don't try and touch… [we don't wash hands] not unless they are obviously sick…"ph pns on the other hand would often wash hands between patients as they were more likely to 'touch' patients during procedures, and rarely would mchns see babies/ children without skin contact. to the latter group, hand hygiene was habitual and 'routine'. alongside variations in hand hygiene practices among pcps, there were also divided views about whether to educate parents and patients on hand hygiene during a sick child consultation. some commented they would if time permitted; some would not as they assumed parents already had good knowledge of hand hygiene and transmission of infection. "i do talk to them and tell them it prevents a lot of cross infections…" gp "…it just doesn't come up, often there are other things to talk about, and we just don't have time." ph "look, parents… i don't know… but i can see most of the parents are quite… they know the hygiene.... they have the knowledge…" gp however, pcps commented they would not hesitate to discuss hand hygiene during a gastrointestinal tract infection consultation, but they did not always for an rti consultation. similar to pcps, parents also prioritised hand hygiene practice with gastrointestinal infections, which were seen as more infectious as they were more 'visible'. "just because i think of a cold as being non-severe… like, just a natural part of life. but gastro just would prefer to avoid." fg "gastro i would [discuss hand hygiene], but not respiratory tract infections." gp "but gastro, you're also vomiting and stuff, and go through places, institutions, like hospitals…" gp "… so when we triage… we do have a chat… like gastro… we have a chat to them about the transmission, and decreasing the spread of virus or whatever is causing the gastro, and what is going around..." pn "they [pharmacy staff] don't do it [wash hands] always, but if someone comes in with gastro, they would come straight up and (do the alcohol sanitising motion)…" ph pcps also commented that the interview process for this study gave them pause for thought making some gps realise that they need to talk to parents. while parents considered good hand hygiene as washing hands before meals, after meals and after going to the toilet, similar to pcps, parents also conflated 'dirt' with 'infectious' and dirt was a visual cue to prompt them to wash their hands. "just teaching her that if your hands are dirty you wash them, so even though i don't wash my hands every time i eat, i don't wash my hands if i've been out to the washing line, when she comes in [from outside] -"oh okay, we've got to wash our hands now"" fg "… if somebody has a cold or somebody has gastro or something like that then i'm really freaky about it and i clean everything within an inch of its life. but then other times, we're, kind of, more relaxed and pretty lazy about it." fg visual cues therefore determined behaviour such as when hands should be washed. gastrointestinal infections were seen as being 'visible' , therefore considered as more 'severe' than rtis, leading to the perception that disease transmission and infection control were visually based. although pcps demonstrated good knowledge of transmission of rtis -respiratory route and fomite transmissionthey still insisted that hand hygiene practice would not be effective in preventing or reducing rti transmission. "there is no prevention. i would have to stop sending children to crèche, and kinders, and schools because they get an infection … this is a part of life and growing up … it's not possible [to prevent]" gp pcps also believed that hand hygiene could not be achieved in young children as they presumed young children would not have hand hygiene awareness and good practice. in addition, prevention would not be achievable as parents and children have constant contact, especially as young children needed comforting when unwell. "yeah, well, probably not so much in the context of colds, kids are little anyway and they are not going to do it. i talk probably more in terms of gastro, we talk a bit about heightened domestic awareness and practice…" gp "they are going to kiss you, they are going to touch you… and they are going to kiss each other…" gp similarly, though parents acknowledged the importance of hand hygiene in reducing transmission of diseases, they also expressed reservations about 'over-surveying' their children and becoming 'germophobic'. over emphasising hand hygiene was perceived as leading to obsessive behaviours and psychological distress: "… i've actually had to pull it back because she was in there every five minutes… she got really quite ocd (obsessive compulsive disorder) about the whole thing…" fg "we sound like we're a bit paranoid… my daughter did say to me that i was turning her into a germ-a-phobe…" fg "i have seen a lot of quite obsessive hand washers at my new workplace." fg "i kind of figured i don't want to be too paranoid because you can't wipe your hand every two seconds…" fg while parents did not want to be 'paranoid' about being too clean and obsessive about hand hygiene, ultimately, they wanted to find that balance between good hand hygiene practice and not being paranoid about diseases. they did describe struggling to determine what was 'right' , the 'correct' hand hygiene practice, and what was considered as being 'too clean'. children being too clean was perceived as weakening immunity whereas being 'dirty' built immunity: "i also wonder about that whole cause [and] effect. because the people i know who wash their hands obsessively are always sick. and i just can't decide if they're always sick because they're obsessive hand washers or if they're obsessive hand washers because they're always sick…" fg "i worry about using the hand sanitiser too much… i don't know, i always think there's … almost too clean…" fg "i know some people that are clean, i don't know about too clean, but their kids get sick quite easily. i don't know whether it's because they're not getting immune to some dirt or something…" fg "we sound like we're a bit paranoid, but that's just us i think." fg even though barriers exist for both pcps and parents of young children when it came to good hand hygiene practice, they all agreed that hand hygiene training still needed to be taught early in life. "it really stems from the parents…"teaching hand hygiene when asked whose responsibility it was to teach hand hygiene practice to young children, pcps and parents commented that parents should be responsible. "… parents seem to talk to their kids about washing their hands…" gp "no, i haven't been telling them, no… i thought the mums would do it…" gp "so basically, it comes from the parents, if they set good examples…" fg the most effective approach to teaching young children good hand hygiene practice was identified by pcps and parents as role modelling. role modelling, the concept of washing hands in front of an audience so the behaviour can be imitated, was expressed as a good way to 'show' children how and when hands should be washed, allowing the behaviour to be 'copied'. hence developing their hand hygiene practice early in life, and eventually leading to sustained hand hygiene behaviour later in life. "i'm role modelling, so they can see me washing my hands… the most important thing i do (in the mother's group sessions)… that's hand hygiene." mchn "…having things down at the children's level, rolemodelling" fg this theme highlighted the general consensus that pcps and parents thought parents should be responsible for their children's hand hygiene practice, with prompting and role modeling as the most effective way to teach young children to start the good hand hygiene habit early in life. results from this study demonstrated the complex reasoning behind why a simple but important task such as hand hygiene is so difficult to consistently implement in everyday life. far from a benign, dispassionate process, there are inherent emotions invested in undertaking this task. while the world health organization 'my moments for health hygiene' recommends health-care workers to clean their hands before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings [ ] , factors such as the pcp's own habitual hand hygiene behaviour; the expectation that parents themselves have good hand hygiene practice; scepticism that hand hygiene is effective in reducing rtis or achievable in young children contributed to the large variation seen in pcps' recommendations to promote hand hygiene. for pcps and parents of young children, hand hygiene practices were centered on visual cues such as gastrointestinal infections and 'dirt' as being 'visible' , rather than the transmission of diseases. while coughing and sneezing can be quite 'visible' , it is often not associated with being 'dirty' , hence it is less likely to result in a reflexive action resulting in hand washing. the risk that promoting hand hygiene practice could result in paranoia and the effect of being 'too clean' were overriding concerns for parents more so than the message itself. variations in practice stemmed from personal attitudes, perceived behaviour, control and subjective norms [ ] , leading to the intent to wash hands. some pcps thought parents were knowledgeable in hand hygiene practice and therefore did not feel the need to mention hand hygiene during an rti consultation. a recent study by barroso et al. [ ] found a counterintuitive inverse relationship between knowledge and hand hygiene behaviour: where medical students reported high hand hygiene behaviour yet had lower knowledge as compared with medical residents, suggesting that factors other than knowledge were important in determining hand hygiene behaviour in this cohort. furthermore, many pcps said they would not wash their hands if there was no patient contact and if the patient was not visibly 'infectious'. whitby et al. [ ] , describe how inherent hand hygiene practice drives the community where visibly soiled, sticky, or gritty hands would prompt hand hygiene behaviour. this 'perceived susceptibility' or 'personal risk' was also described in a study from eight mediterranean countries [ ] , where they found health care workers' hand hygiene compliance was significantly higher after patient contact compared to before patient contact, implying that self-protection was a major driver of hand hygiene performance in this cohort. our results indicated that while the importance of hand hygiene was undeniable, hand hygiene practice and passing hand hygiene knowledge to parents of young children varied considerably within and across pcp groups. the diverse situations each pcp face in different scenarios such as whether patients were seen as 'infectious' , or whether they believed parents have the knowledge as to whether they needed to talk to them about hand hygiene were contributing factors to the variations seen in these groups. parents also relied heavily on visual cues such as 'dirty' and 'infectious' , to determine the need to hand wash, as they did not always remind their children to wash their hands. however, the 'awareness' of hand hygiene practice might also explain that hand hygiene was often taken for granted, and not 'thought about'. therefore, behaviour change interventions might need to be regular and applied in small incremental steps. raising awareness of possible personal risk could improve practice and sustainability when it comes to hand hygiene behaviour [ ] . additionally, parents were reluctant to encourage hand hygiene practices in their child for fear their children would be 'too clean' , and that they needed to be visibly 'dirty' or 'infectious' to build their own immunity. this belief needs to be directly challenged by pcps during discussion in an rti consultation, and further educating parents on good hand hygiene practice should therefore be considered. a more concerning theme that emerged from our study resulting from the discussions emanating from the parents focus groups was parents' fear of their child developing abnormal behavior such as ocd. although studies have shown strong links between people with ocd and feelings driving them to engage repeatedly and excessively in behavior such as hand washing [ , ] , there is no evidence suggesting that hand washing 'triggers' ocd. these studies found that ocd was characterized by the reduced ability to terminate an action, such as hand washing, rather than a response to a perceive threat i.e. perceived susceptibility or personal risk. therefore, parents' fear of excessing hand washing leading to ocd was not valid. however, the fear was enough for parents to be vigilant with children's hand washing practice, therefore an important area for further research. perhaps one of the biggest barriers to good hand hygiene practice in young children was the skepticism displayed by parents and pcps that good hand hygiene practice was achievable in young children, and almost not worth pursuing. thus, while the 'intent' was there regarding hand hygiene, compliance did not always follow. even though successful interventions incorporating hand washing in young children have shown to reduce absenteeism due to infection [ ] , a recent study of childcare centres in the netherlands [ ] found that while hand hygiene opportunities were readily available for children, overall adherence to hand hygiene guidelines was only % in participating day care centres, which supports the publicly held view that hand hygiene practice is not achievable in young children. however, participants in the study also believed that hand hygiene behaviour should start early in life. a study in seoul, korea [ ] , conducted in an elementary school setting with year students, showed parents' handwashing practice, parent and child bonding, and shared time have a significant correlation with children's hand hygiene practice. our study also suggested that both pcps and parents thought hand hygiene practice should start with good role modelling in the home, with frequent reminders. our study was not without limitations. first, the research was conducted in metropolitan melbourne, and therefore our results may be not generalisable to other areas such as rural or remote sites, or developing countries where there might be reduced access to hand hygiene products and handwashing facilities. second, pcps and parents of young children who participated in the study were very interested in this area, potentially introducing selection bias. third, providing incentives to participants may have led to a possible source of bias, although these incentives are aligned with similar work with estimated earnings and average australian wage [ , ] . currently little is known regarding young children's hand hygiene practice in the australian community. our study has taken the first step in exploring pcps' and parents' attitude, views and practice of hand hygiene practice, thereby identifying barriers to hand hygiene practice for pcps and parents of young children, which potentially impact hand hygiene habit and behaviour of young children. to overcome some of these barriers to good hand hygiene practice, the following interventions targeting pcps and parents may help increase awareness of the importance of hand hygiene and encourage effective hand hygiene behaviour: ) introduce health promotion that will educate and remind the public that diseases are not always 'visible' and that whether or not one appears dirty, transmission is still possible; ) good hand hygiene habits should be taught early in a child's life to sustain effective hand hygiene behaviour; and ) the importance of role modelling as a way to develop good hand hygiene habit in young children. in addition, pcps should at least encourage parents and young children to practice hand hygiene when coming for an rti consultation, which may reduce the transmission of rtis, reinforce the message of the importance of hand hygiene compliance and result in healthy hand hygiene practice in young children. finally, parents should be reassured that effective hand hygiene practice will not lead to abnormal psychological behaviour in their children and that hand washing will not reduce a child's immunity. this study demonstrated that on the surface, both pcps and parents of young children thought hand hygiene practice was important. however, dissonance emerged in practice because hand hygiene is implicitly tied to beliefs such as washing hands only when 'dirty'; concerns that children need to build their immunity and are already too clean; and skepticism that hand hygiene can be achieved in young children. pcps should be made aware that hand hygiene can be part of the habit of washing hands between patients, due to fomite transmission of diseases in practice. parental education around the importance of hand hygiene, focused on the 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evaluate the effect of a multimodal hand hygiene improvement strategy in primary care healthy hands: use of alcohol gel as an adjunct to handwashing in elementary school children factors influencing hand washing behaviour in primary schools: process evaluation within a randomized controlled trial hand hygiene of medical students and resident physicians: predictors of attitudes and behaviour welcome to hand hygiene australia (hha): hand hygiene australia why do we not want to recommend influenza vaccination to young children? a qualitative study of australian parents and primary care providers. vaccine maternal child health services: victoria state government using thematic analysis in psychology world health organization. my moments for hand hygiene. world health organization in the era of corona virus: health care professionals' knowledge, attitudes, and practice of hand hygiene in saudi primary care centers: a cross-sectional study behavioural considerations for hand hygiene practices: the basic building blocks self-protection as a driver for hand hygiene among healthcare workers using an analysis of behavior change to inform effective digital intervention design: how did the primit website change hand hygiene behavior across users? in the wake of a possible mistake: security motivation, checking behavior, and ocd when too much is not enough: obsessive-compulsive disorder as a pathology of stopping, rather than starting children's hand hygiene behaviour and available facilities: an observational study in dutch day care centres family factors associated with children's handwashing hygiene behavior general practice research. problems and solutions in participant recruitment and retention australian bureau of statistics. . -employee earnings and hours the authors would like to thank all the participants in this research. this study was part of a phd study, funded by the national health and medical research council (nhmrc), and the royal australian college of general practitioners (racgp). not applicable authors' contributions rb completed the background literature search and rb, bb, dg and dm contributed to the study design. rb conducted and transcribed all interviews. rb and bb performed the analysis of the data. rb drafted the manuscript. all authors revised all drafts and approved the final version of the manuscript.ethics approval and consent to participate all participants were provided with a plain language statement explaining the study and gave written consent prior to interview/focus group. the study was approved by monash university human research ethics committee (cf / - , , , ). the authors declare that they have no competing interest. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -qm a c b authors: des jarlais, don c; johnston, patrick; friedmann, patricia; kling, ryan; liu, wei; ngu, doan; chen, yi; hoang, tran v; donghua, meng; van, ly k; tung, nguyen d; binh, kieu t; hammett, theodore m title: patterns of hiv prevalence among injecting drug users in the cross-border area of lang son province, vietnam, and ning ming county, guangxi province, china date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: qm a c b background: to assess patterns of injecting drug use and hiv prevalence among injecting drug users (idus) in an international border area along a major heroin trans-shipment route. methods: cross-sectional surveys of idus in sites in lang son province, vietnam (n = ) and sites in ning ming county, guangxi province, china (n = ). respondents were recruited through peer referral ("snowball") methods in both countries, and also from officially recorded lists of idus in vietnam. a risk behavior questionnaire was administered and hiv counseling and testing conducted. results: participants in both countries were largely male, in their s, and unmarried. a majority of subjects in both countries were members of ethnic minority groups. there were strong geographic gradients for length of drug injecting and for hiv seroprevalence. both mean years injecting and hiv seroprevalence declined from the vietnamese site farthest from the border to the chinese site farthest from the border. . % of participants in china and . % of participants in vietnam reported crossing the international border in the months prior to interview. crossing the border by idus was associated with ( ) distance from the border, ( ) being a member of an ethnic minority group, and ( ) being hiv seropositive among chinese participants. conclusion: reducing the international spread of hiv among idus will require programs at the global, regional, national, and "local cross border" levels. at the local cross border level, the programs should be coordinated on both sides of the border and on a sufficient scale that idus will be able to readily obtain clean injection equipment on the other side of the border as well as in their country of residence. both injecting drug use and hiv among injecting drug users (idus) have become major international public health problems. hiv infection has been reported among idus in over countries [ ] . travel by idus, particularly along drug distribution routes, appears to be a major mechanism for the spread of both injecting drug use and hiv among idus. hiv spread north [ ] and south [ ] from new york city along the east coast in the u.s. stimson [ ] , and beyrer and colleagues [ ] have reconstructed the spread of hiv among idus in south east asia. beyrer et al. used molecular epidemiology (mapping the different subtypes of hiv) in their reconstruction. a recent study by kato and colleagues ( ) found patterns of hiv genetic subtyping consistent with cross-border transmission either from vietnam to china or from china to vietnam. while these regional and country level analyses have great value in understanding the worldwide spread of hiv among idus, they have important limitations with respect to hiv prevention efforts. reducing hiv spread by attempting to disrupt regional and country drug distribution routes may have the unintended consequence of displacing distribution to new routes, leading to additional spread of injecting drug use and hiv among idus. successful prevention efforts will be greatly facilitated by more detailed understanding of the spread of injecting drug use and transmission of hiv among idus within smaller geographic areas. understanding of hiv transmission across international borders is particularly important, as few hiv prevention programs are coordinated across such borders. we present here data on injecting drug use and hiv among idus in the adjacent border provinces of lang son, vietnam and guangxi, china. hiv among idus was noted in this area in [ ] and since then there has been substantial transmission among idus in both provinces. the present situation shows a clear geographic pattern, with the potential for additional spread across the border between the provinces and within each of the provinces. the data reported here were collected as part of baseline surveys of idus conducted before implementation of a cross-border hiv prevention intervention in lang son province, vietnam and-ning ming county, guangxi province, vietnam [ ] . figure shows a map of the area, with the project sites -in lang son province and in ning ming county. there is considerable official and entirely legal movement of commercial goods across the border in both directions. there are also semi-official and informal crossing points and pathways through the hills that permit local residents to cross the border with little or no regulation. crossing the border is a regular aspect of life for many people who live near the border, for example, to attend market days in the larger villages. drug dealers cross the border to sell drugs and drug users also cross to obtain drugs of higher purity and at better prices. the frequency of border crossing can vary, influenced by current price and purity of heroin, the ebb and flow of law enforcement activity and, factors such as the outbreak of severe acute respiratory syndrome (sars) in china. there is also substantial trade and migratory employment in the region. lang son city, aidian, and puzhai (near pingxiang) are bustling centers of legitimate cross-border trade, as well as drug trafficking and sex work. many people cross the border daily and seasonally to find work and many are employed as porters in the cross-border trade. the region is home to many ethnic minority groups (e.g., zhuang, tay, nung), some of whom live on both sides of the border (for example, the zhuang in china and the tay in vietnam are the same ethnic group but are known different names in the two countries). there is frequent intermarriage across the border, although this might be illegal and might lead to loss of nationality. kinship ties, like migratory employment and trade, result in additional cross-border movement. data collection methods for the idu surveys reported on here were essentially parallel in ning ming county and lang son province, with some variation in the community-based subject recruitment strategies used. the availability of large known drug use gathering places and of officially registered idus in lang son permitted greater use of probability-based methods in vietnam, while there was more reliance on peer recruitment in china. in ning ming county, a modified snowball/peer recruitment technique was used. the project peer educators sent recruiting letters to idus they knew personally, inviting them to come to a project center and participate in the survey. the idus who came to project centers for interviews were encouraged to recruit - additional participants. the research participants received chinese yuan (approximately $ . ) for the interview, yuan for each additional male respondent recruited, and yuan for each additional woman respondent recruited. the eligibility criteria were a minimum of years of age and recent (in the past months) drug injection. approximately one-half of the sample was based on individuals initially selected from the lists of known idus in the project sites. the other half was based on participants initially selected from idus present at gathering or shooting places mapped by project staff as part of the initial project implementation. for the half of the sample based initially on registered lists, clusters of individuals each were selected by probability proportional to size (pps) from the lists of idus in each commune. then four idus were picked at random from each selected cluster and these referred others until the quota for the commune was reached. for the portion of the sample selected initially at idu gathering or shooting places, sample quotas for these places were determined by pps based on the numbers of individuals observed at these places during the mapping phase. the interview team then revisited the selected places and chose four individuals at random from among those present at each place at that time (who were not necessarily those present during the mapping phase). the vietnamese participants were paid , vietnamese dong (approximately us$ ) for participating in the interview and hiv test. in vietnam, an oral informed consent was obtained for participation in the study, with the interviewer certifying that oral consent had been obtained. this procedure was requested by the institutional review board of the national aids standing bureau in order to provide more assurance of confidentiality to prospective participants. in china, standard signed informed consents were obtained from all participants. unique codes were constructed for geographic setting and map of project sites caoloc town each participant based on numeric date of birth and several letters representing, for example, the first letter of the mother's family name. (construction of the record number was slightly different in the two countries.) the objective was to have a unique identifier that the participant could readily reconstruct if he or she lost the project participation card. a structured instrument was used for the interviews, based on version b of the questionnaire being used in the world health organization's drug injection study, phase ii [ ] . trained interviewers, primarily staff of the local health departments, conducted the interviews. the questionnaire covered demographics, drug use, injection and sexual risk behavior, hiv testing history, hiv and hepatitis knowledge, and cross-border travel patterns. a question on the number of times the subject had crossed the border in the months prior to the interview was included. there are many factors which could influence the "ease/ difficulty" in crossing an international border, including distance to the border, cost of transportation, time needed to reach the border, and the need to have official papers for crossing. it was not practical to measure all such factors. instead, used simple physical distance (in kilometers) to the nearest border point. this gave five distance categories in vietnam and three distance categories in china. the baseline survey was conducted in july in vietnam and between july and september in china. the survey included hiv antibody testing. participants were given pre-test counseling and post-test counseling at local health centers. blood was drawn at the time of the interviews by trained phlebotomists from local health departments. participants were given a card with their unique identifier and returned to the local health center to receive their test results using this identification number. indeed, they could only retrieve their results by using this number since blood samples were not otherwise labeled. in china, testing was by double elisa (vironostika hiv-uni-form, organon (holland)) with confirmation of initial hiv-positive results by western blot (genelabs diagnostics). all testing was conducted at the laboratory of the guangxi center for hiv/aids prevention and control in nanning. in vietnam, testing was performed at the laboratory of the lang son provincial health services using the serodia sfd screening test (biorad {france}) and double elisa (genescreen, biorad (france); vironostika, organon [ ] ). this is the official protocol of the ministry of health in vietnam and the lang son laboratory is authorized to provide hiv testing according to this protocol by the ministry of health. data were entered and data sets were prepared in epiinfo, hiv prevalence against distance to border. the study was reviewed and approved by the institutional review boards (irbs) of the following institutions: guangxi center for hiv/aids prevention and control, the national aids standing bureau of vietnam, abt associates inc., and beth israel medical center. table shows selected demographic characteristics of the idu subjects recruited in china and vietnam. in both provinces, the subjects were primarily young males who had never been married. although there are known to be female idus on both sides of the border, the project has had difficulty inducing women to participate in the interventions and in recruiting them for the surveys. over twothirds of the subjects in china and one-half in vietnam belonged to ethnic minority groups (primarily zhuang in china and tay and nung in vietnam). the ethnic minority subjects tended to live closer to the border. table in this report, we present data on injecting drug use and hiv infection among idus in lang son province, vietnam and ning ming county, guangxi province, china from a baseline survey conducted before implementation of a peer-based cross-border hiv prevention intervention. several limitations should be noted. first, we were working with cross-sectional data, where longitudinal data from the initial spread of injecting drug use in the area would have certainly been preferable. second, there are measurement and sample size limitations. it would have been helpful to have a measure of ease of travel to the border rather than simple physical distance to the border. also it would have been helpful to have sufficiently large sample sizes so that the relationship between being a member of an ethnic minority group and being hiv seropositive could be examined within individual geographic sites. despite these limitations, there are very clear patterns in the data. there are similar gradients for mean length of injecting history and baseline hiv prevalence running in descending order from the vietnamese site farthest from the border to the chinese site farthest from the border. these patterns are consistent with the theory that both the practice of drug injection and the prevalence of hiv infection among idus spread from northern vietnam to southern china along a major heroin trans-shipment route [ ] . the patterns in our data suggest that, in some circumstances, it may be possible to reconstruct histories of the diffusion of injecting drug use and hiv among idus using cross-sectional data. there is clearly a potential for further cross-border transmission of hiv in both directions. our discussions with the peer educators in the cross-border hiv prevention project suggest three primary reasons for these idus crossing the border: . obtaining higher quality/lower priced drugs, . avoiding police pressure on drug injectors, which can be unpredictably variable and involves largescale periodic crackdowns, and . personal factors, such as migratory employment, commerce, and family ties. it would appear to be very difficult to reduce these reasons for idus crossing the border. because of the possibility of arrest, idus who cross the border are unlikely to carry needles and syringes with them, even if they are crossing the border at places without any supervision or inspection. prevention of risky injections among border crossing idus will require very good supplies of sterile injection equipment on both sides. if idus who crosses the border cannot readily access sterile injection equipment on both sides of the border, then their fellow idus will need to have sufficient supplies of sterile injection equipment for use by themselves and the idus who cross the border. this will require large-scale safer injection programs on both sides of the border. the majority of subjects in this study belong to ethnic minority groups, primarily zhuang in china and tay and nung in vietnam. ethnic minority idus were also overrepresented among the border crossers. the issues of ethnic minority status, injecting drug use, and hiv infection deserve much more research and policy development. ethnic minority idus are more likely to be infected with hiv in many places, from african-american and latino/a idus in new york city [ ] to roma in eastern europe [ ] to first nations in vancouver [ ] to vietnamese in australia [ ] to manipuris in india [ ] . as noted above, there was a strong relationship between ethnic minority status and hiv serpositivity in ning ming (or = . ( % ci . , . , p = . ) [ ] . social stigmatization of ethnic minority communities may make them more vulnerable to illicit drug use, including injecting drug use. employment discrimination against ethnic minority communities may increase the extent to which drug distribution occurs in these communities, and to which drugs are transported by minority community members. persons belonging to ethnic minority groups also may have important factors facilitating international travel, such as social support systems and persons that speak the same language on the other side of international borders. the data presented here illustrate many of the factors in the international diffusion of hiv among idus at modest geographic scale. (there is a total distance of kilometers between the two most distant sites in the study). these include gradients of length of injecting drug use and hiv seroprevalence across the international border, border crossing by idus and its association with hiv infection for those crossing from china into vietnam, overrepresentation of ethnic minority persons among the border crossers. both injecting drug use and hiv among idus are already well established among idus on the vietnamese side of the border and injecting drug use is well established on the chinese side of the border. hiv is present among idus on the chinese side of the border, but at lower seroprevalence levels than in lang son. there are multiple reasons that people cross the border in this area, and it would not appear to be possible to stop idus from crossing the border or from injecting drugs across the border. thus, hiv prevention goals must include increasing the safety of injections among border crossers (as well as reducing risk behavior among the idus who do not cross the border). this will require coordinated hiv prevention that increases the likelihood that idus will inject safely on both sides of the border. such a program has been implemented in lang son and guangxi provinces. it includes peer outreach, increased access to sterile injection equipment through syringe distribution and exchange and a pharmacy voucher program. idus may exchange used injection equipment for new needles/ syringes or for vouchers that can be redeemed at local pharmacies for needles/syringes, sterile water, and condoms. idus may also directly receive new needles/ syringes or pharmacy vouchers even if they do not return used equipment. the program also includes large-scale collection and safe disposal of used needles/syringes, general community education about drugs and hiv, and social support for people living with hiv or aids [ ] . reducing the international transmission of hiv among injecting drug users will require programs at the global, regional, national, and "local cross-border" levels. the local cross border programs will need to be coordinated on both sides of the border and on a sufficient scale that idus who cross the border will be able to readily obtain clean injection equipment on the other side of the border. the cross-border hiv prevention project currently being implemented in lang son province and ning ming county, guangxi offers an example of how such a coordinated approach can be implemented. evaluation data being collected in lang son and ning ming will be used to gauge the effectiveness of the interventions. global estimate of injecting drug use hiv seroprevalence among connecticut intravenous drug users in - : race/ethnicity as a risk factor for hiv seropositivity risk for htlv-iii exposure and aids among parenteral drug abusers in new jersey reconstruction of sub-regional diffusion of hiv infection among injecting drug users in south-east asia: implications for prevention overland heroin trafficking routes and hiv- spread in south and southeast asia a rapid assessment of hiv/ aids situation and vulnerabilities related to drug use in lang son development and implementation of a cross-border hiv prevention intervention for injection drug users in ning ming county drug injecting and hiv infection: global dimensions and local responses risk, power and the possibility of pleasure: young women and safer sex informed altruism" and "partner restriction" in the reduction of hiv infection in injecting drug users entering detoxification treatment le romes durvar" (god hits whom he chooses; the roma gets hit twice). an exploration of drug use and hiv risks among the roma of central and eastern europe risk factors for elevated hiv incidence among aboriginal injection drug users in vancouver crofts n: hiv, ethnicity and travel: hiv infection in vietnamese au with injection drug use organization naidsc: combating hiv/aids in india des jarlais dc: correlates of hiv status among injection drug users in a border region of southern china and northern vietnam the authors gratefully acknowledge all of the health department and clinic staff, other public officials, peer educators, and pharmacists in ning ming county, lang son province and guangxi province who are participating in and supporting this project. we would also like to acknowledge the support of the national institutes on drug abuse, u.s. national institutes of health. grant number r da . the author(s) declare that they have no competing interests. th conceived of the study, the study design and coordination and assisted in the drafting of the manuscript. dcd participated in the design of the study and drafted and edited the manuscript. th and dcd supervised the data analysis.pf, pj and rk performed the statistical analysis and participated in its design and coordination and participated in the writing and review of drafts of the manuscript.wl, yc & dm supervised the implementation of the project and data collection and processing for the chinese sites, and participated in the writing and review of drafts of the manuscript. dn, tvh, lkv, ndt & ktb supervised the implementation of the project and data collection and processing for the vietnamese sites, and participated in the writing and review of drafts of the manuscript.all authors read and approved the final manuscript. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /prepub key: cord- -pjvu c authors: xie, chaojun; zhao, hongjun; li, kuibiao; zhang, zhoubin; lu, xiaoxiao; peng, huide; wang, dahu; chen, jin; zhang, xiao; wu, di; gu, yuzhou; yuan, jun; zhang, lin; lu, jiachun title: the evidence of indirect transmission of sars-cov- reported in guangzhou, china date: - - journal: bmc public health doi: . /s - - -y sha: doc_id: cord_uid: pjvu c background: more than months have passed since the novel coronavirus disease (covid- ) first emerged in wuhan, china. with the migration of people, the epidemic has rapidly spread within china and throughout the world. due to the severity of the epidemic, undiscovered transmission of covid- deserves further investigation. the aim of our study hypothesized possible modes of sars-cov- transmission and how the virus may have spread between two family clusters within a residential building in guangzhou, china. methods: in a cross-sectional study, we monitored and traced confirmed patients and their close contacts from january to february , in guangzhou, china, including family cluster cases and residents within one residential building. the environmental samples of the building and the throat swabs from the patients and from their related individuals were collected for sars-cov- and tested with real-time reverse transcriptase polymerase chain reaction (rt-pcr). the relevant information was collected and reported using big data tools. results: there were two notable family cluster cases in guangzhou, which included confirmed patients (family no. : patient a, b, c) and confirmed patients (family no. : patient d, e), respectively. none of patients had contact with other confirmed patients before the onset of symptoms, and only patient a and patient b made a short stop in wuhan by train. home environment inspection results showed that the door handle of family no. was positive of sars-cov- . the close contacts of the patients all tested negative of sars-cov- and in good health, and therefore were released after the official medical observation period of -days. finally, according to the traceability investigation through applying big data analysis, we found an epidemiological association between family no. and family no. , in which patient d (family no. ) was infected through touching an elevator button contaminated by snot with virus from patient a (family no. ) on the same day. conclusions: contaminants with virus from confirmed patients can pollute the environment of public places, and the virus can survive on the surface of objects for a short period of time. therefore, in addition to the conventional droplet transmission, there is also indirect contact transmission such as snot-oral transmission that plays a crucial role in community spread of the virus. in late december , an outbreak of the novel coronavirus disease caused by the severe acute respiratory syndrome coronavirus (sars-cov- ) was reported by the local health facilities in wuhan, china [ , ] . the epidemic has been spreading to many other chinese cities [ ] [ ] [ ] . as the spread escalated, the world health organization (who) declared that the sars-cov- outbreak constitutes a "public health emergency of international concern" on january , , and the epidemic has escalated to a pandemic since march , . with the information from epidemiological investigation and clinical manifestation accumulating, evidence indicated that there existed person-to-person transmission of covid- [ , ] . in order to elucidate the reason for the rapid spread of the disease, the researchers examined whether the virus could survive in external environment and found detectable nucleic acid of sars-cov- in environmental sample gathered from south china seafood market in wuhan, the place where the virus first broke out. other studies also showed that the virus was also found in patients' feces and urine [ ] . the preexisting evidence suggests that contaminants from patients can pollute the environment of public places and indirectly indicates the possibility of contact transmission. due to the fact that the chinese government had invested a lot of resources and adopted various measures to manage the impact of the outbreak, the number of confirmed covid- cases and suspected cases has begun to decline slowly since february , and there has been no new cases for days in several provinces and cities [ ] . but the epidemic has not completely come to an end and we still need to remain vigilant continuously especially because of the migration of large populations and the gradual reopening of public places. new reports have shown that the virus continues to spread, yet we still have very few understandings of the characteristics of the virus, and therefore need further investigation. as reported in this study, there were two interesting family cluster cases reported in guangzhou, providing the evidence of snot-oral indirect transmission of sars-cov- . a cross-sectional study was conducted to investigate the possible modes of sars-cov- transmission between family clusters within the same residential building in guangzhou, china. between january , and february , , two family cluster cases included confirmed patients reported in one residential building. we investigated cases, close contacts, the residents,security guards and janitors of this building. on january , we sampled aerosol and surface samples from the elevator and the houses of the two families. on february , we sampled blood samples and throat swabs from the residents of this building, and throat swabs collected from the security guards and janitors. on february , , the second batch of surface samples from the elevator and the houses of the two families were collected. the environmental samples of the building and the throat swabs from the patients and their related individuals were tested with real-time reverse transcriptase polymerase chain reaction (rt-pcr) for sars-cov- . the relevant information was collected and analyzed using big data tools. all information of traceability investigation was collected using big data tools and reported by guangzhou center for disease control and prevention (guangzhou cdc), and the field epidemiological investigations were conducted by the staff of guangzhou municipal and baiyun district centers for disease control and prevention based on the "questionnaire on individual case of covid- cases" and the "questionnaire on individual case of suspected covid- cases". the pharyngeal swabs, blood samples, aerosol samples and surface samples were collected by medical staff in hospitals or during the field investigation, and safely sent to guangzhou centre for disease control and prevention. the real-time reversetranscriptase-polymerase-chain-reaction (rt-pcr) assay was performed to confirm the infection caused by the sars-cov- virus. the informed consent was obtained from each participant and this epidemiological study was approved by the ethical committee of guangzhou centre for disease control and prevention. the "big data tools" is a database containing information about monitored and traced cases and close contacts accumulated and managed by guangzhou cdc, from which we get the information of family cluster cases and residents of same residential building from january to february , in guangzhou, china. aerosol samples and surface samples were collected from the elevator and the houses of the two families. in addition to collecting throat swabs from confirmed patients, there were blood samples and throat swabs collected from the residents of this building, and throat swabs collected from security guards and janitors, as shown in table . laboratory confirmation of the sars-cov- by rt-pcr assay (shanghai biogerm medical biotechnology) was conducted in guangzhou center for disease prevention and control (guangzhou cdc). the rt-pcr assay was performed in accordance with the protocol established by the world health organization. sars-cov- nucleic acid testing was performed using rt-pcr assay according to the national health commission guidelines for laboratory testing of pneumonia with novel coronavirus infection [ , ] . the case is determined by a positive result by real-time reverse-transcriptase-polymerase-chain-reaction (rt-pcr) assay of the sars-cov- virus in patient's pharyngeal and anal swab specimens. only the laboratory-confirmed patients were included in the final analysis. an asymptomatic case is defined as someone who shows no clinical symptoms within days before the diagnosis, tests positive for sars-cov- on rt-pcr or serumspecific igm antibodies, and is identified through close contact screening, cluster epidemic investigation and traceback investigation. the exposure is defined as the following situations within days before the onset of illness applicable to individuals: ) traveling to or living in wuhan or other regions with severe epidemics abroad; ) having contact with sars-cov- infected individuals whose nucleic acid test was positive or with patients who had fever or respiratory symptoms coming from wuhan or other regions abroad that have been severely affected by the epidemic; ) having been to or more cases occurred fever or respiratory symptoms in a small area (such as home, office, school class, workshop, construction site, etc.). the cluster outbreak is defined as or more presumptive confirmed cases reported with fever or respiratory symptoms within days after having been in the same confined space (such as home, office, school class, workshop, construction site, etc.), which provides the possibility of interpersonal transmission and being infected due to co-exposure. close contact refers to an individual who has not taken effective protection when in proximity of suspected or confirmed cases days before the onset of symptoms or days before the collection of asymptomatic specimens. we setup the excel databases to include all questionnaires, clinic and laboratory data of two family covid- patients. the continuous variables were shown as medians and interquartile ranges (q -q ), median (iqr), or medians and ranges, median (min-max). the categorical variables were summarized as counts and percentages, no. (%). all the figures were drawn using graphad prism software, and all the analyses were performed using spss software (statistical package for the social sciences, version . ). in the cross-sectional study of covid- in guangzhou, we found that there were two notable family cluster cases, which included (family no. : patient a, b and c) and (family no. : patient d and e) cases of covid- patients, respectively. as listed in table , patient a was male and years old; patient b and c were female and were and years old. patient d was a year old female, and patient e was male and years of age. all patients had fever at onset, except for patient e, who was symptomless. patient a, years old, developed a fever at °c accompanied with runny nose on january th, , as shown in fig. . patient b, patient a's wife, developed a fever at . °c with an occasional dry cough on january th. patient c, their daughter, developed a fever at . °c without other symptoms on january th. on january th, the three patients visited jinshazhou hospital of guangzhou chinese medicine university for treatment. the chest ct of patient a showed bilateral lung inflammation and emphysema and blood test showed decreased lymphocyte count. the chest ct result of patient c also showed bilateral lung inflammation, while that of patient b was normal. on the night of the same day, they were admitted to the isolation ward of hospital as suspected cases of covid- . at : a.m. on january , their throat swabs were collected by guangzhou cdc and tested for sars-cov- virus nucleic acid test, all of which were reported to be positive on the same day, so they were immediately transported by ambulance to the designated covid- hospital for isolation treatment. these three patients were in mild severity. after isolation and treatment in the designated hospital, they were cured and discharged. a total of individuals were identified as close contacts of this family by guangzhou cdc and so far, all of them were healthy without any symptoms and thus are all relieved of medical observation. as described in fig. , patient d, a -year-old woman, experienced the onset of fever at . °c without other symptoms on january th, and went to jinsha street community health service center for treatment on january th. patient e, patient d's husband, without any respiratory symptoms, he went to jinshazhou hospital of guangzhou chinese medicine university with his wife on january th. the chest ct test of patient d showed bilateral lung inflammation and that of patient e showed inflammation in the upper lobe of the right lung. both patients were admitted to the isolation ward of hospital as suspected cases of covid- on the same day. on january th, the outcomes of virus nucleic acid test were both positive of sars-cov- so that they were transported by ambulance to the designated hospital of covid- for isolation treatment on january th. they were both mild patients in stable condition. after isolation and treatment in the designated hospital, they were cured and discharged. three other individuals were identified as close contacts of this family by guangzhou cdc and so far, all were in good health without any symptoms so that they were all relieved of medical observation. the results of viral nucleic acid test as presented in figs. , patients from the above two families were positive of sars-cov- , while the test results of throat swabs and blood samples collected from relevant individuals were all negative, as listed in table s and s . of all environmental samples, only the door handle of family no. tested positive of sars-cov- (shown in fig. ) , and the rest were negative that listed in table . all three members of family no. said that they had no contact with covid- patients nor individuals from hubei province. however, patient a and patient b had traveled to guangzhou by train from other province to visit their children (patient c). the train stopped in wuhan for several minutes. that stop was a crowded and compact hub where many passengers boarded the train. therefore, as shown in fig. , it was inferred that patient a and patient b were infected through close contact to passengers who might be unknown patients of covid- . later they passed on the covid- to their daughter (patient c) as close family contact. both members of family no. said that they had no contact with the patients in family no. or individuals from hubei province, and had no link to wuhan city. according to the traceability investigation through applying the big data tools, we found that patient a had a bad habit in personal hygiene that he often blew nose using his own hand, which was what he again did before touching the button of closing door in elevator. as shown in fig. , on january th, patient a blew nose using his own hand before touching the button of closing door in elevator, then min after patient a got out of the elevator, patient d entered the same elevator and touched the same button. the most important thing is that patient d immediately flossed with a toothpick after touching the elevator button. therefore, it was speculated that patient d (family no. ) was infected for covid- by means of snot-oral indirect transmission of touching the button of elevator contaminated by snot with virus from patient a (family no. ). although the epidemic of covid- has been going on for months, the epidemiological characteristics of the sars-cov- virus are not yet fully understood. with the import of covid- cases, there were many new local patients in the cities outside of hubei province [ , ] . some cities have a high proportion of clustering cases, such as beijing, where, as of february , a total of clustered cases involving patients accounted for % of a total of patients [ ] . a point worth noting about this epidemic is that some local cases have no clear source of infection in the cities outside of hubei province. recently, there were several reports that the new coronavirus could spread via droplets, contact and natural aerosols from human-to-human [ , , , ] , causing a high possibility of a pandemic. as more and more new cases with covid- are reported worldwide [ , ] , it seems to be a gloomy reality. to contain the spread of the covid- epidemic without delay, a deeper understanding of the sars-cov- virus should be presented [ ] . to reduce the impact and spread of the disease, it is essential to limit human-to-human transmission to reduce secondary infections among close contacts and health care workers. as reported in this study, we found two family clusters infected with sars-cov- in the same building in guangzhou, china. through testing the external environment samples, we found that the sample taken from door handle of family no. tested positive of sars-cov- , which indicated that contaminants with virus from confirmed patients can pollute the environment of public places. furthermore, the patient d of family no. was infected via the snot-oral indirect transmission, indicating that sars-cov- virus can survive in the environment for at least a short period of time. as previously reported by zou lr et al., higher viral loads were detected soon after symptom onset, with higher viral loads detected in the nose than in the throat [ , ] , which further demonstrated that indirect contact transmission by means of snot-oral transmission might be an effective way to spread the epidemic disease. for the surface survival of virus, sars-cov- can remain viable and infectious on surfaces up to days, so common surface transmission of the virus is highly possible [ ] . although the elevator buttons were detected as negative for viral nucleic acid, the possible reason is that the buttons have been used many times and the time interval from contamination to sampling is too long. during this period, the interior of the elevator has been disinfected several times. with the return to work and the gradual opening of public places, the migration of large population is a huge challenge for prevention and control of the epidemic. therefore, it is also still important for the prevention and control of the epidemic to pay attention to personal hygiene, taking measures such as wearing a facemask, washing hands frequently and not touching nose and mouth before washing hands and so on, as well as disinfection of public places in the coming time period. our study had some obvious limitations. first, on january , no samples were collected on the day of the elevator button pollution and our elevator button sampling took place on january . second, according to the weak positive test of patient a's home handle and his poor hygiene habits, it is our inference that the infection of patient d was caused by the transmission of the elevator button polluted by patient a's nose. third, we cannot exclude the possibility of transmission of the virus by unknown infected persons, such as asymptomatic carriers [ ] . in summary, this study provides direct evidence substantiating that sars-cov- can infect other individuals by means of snot-oral transmission as one mode of indirect contact transmission. this finding is of significance for the prevention and control of covid- and the formulation of the public health policies and measures. based on previous reports and the evidence provided in this study, it is important to pay attention to personal hygiene and disinfection in public places. supplementary information accompanies this paper at https://doi.org/ . /s - - -y. additional file : table s . the outcome of whole blood samples tested. table s . the outcome of throat swabs tested. local innovative and research teams project of guangdong pearl river talents program the funders had no role in study design, data collection and analysis early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a novel coronavirus outbreak of global health concern risk for transportation of coronavirus disease from wuhan to other cities in china characteristics of and public health responses to the coronavirus disease outbreak in china potential presymptomatic transmission of sars-cov- importation and human-to-human transmission of a novel coronavirus in vietnam a familial cluster of pneumonia associated with the novel coronavirus indicating personto-person transmission: a study of a family cluster cctv news national health commission of the people's republic of china. http:// wwwnhcgovcn clinical features of patients infected with novel coronavirus in wuhan clinical management of severe acute respiratory infection when novel coronavirus ( -ncov) infection is suspected: interim guidance clinical characteristics of imported cases of covid- in jiangsu province: a multicenter descriptive study clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china epidemiologic and clinical characteristics of novel coronavirus infections involving patients outside wuhan, china viral load kinetics of sars-cov- infection in first two patients in korea assessing the impact of reduced travel on exportation dynamics of novel coronavirus infection (covid- ) understanding of covid- based on current evidence sars-cov- viral load in upper respiratory specimens of infected patients false negative rate of covid- is eliminated by using nasal swab test aerosol and surface stability of sars-cov- as compared with sars-cov- covid- : asymptomatic carrier transmission is an underestimated problem publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank boqi rao, yingyi feng, yujie pan, zhi li, chun mao, wenhui lun, zeqin huang, and junyi ye from guangzhou medical university (guangzhou, china) for assisting with data collection. we thank boqi rao for his assistance in preparing the figures. we thank fuman qiu from guangzhou medical university (guangzhou, china) for his assistance in writing the manuscript. we are very grateful to all staff at guangzhou center for disease control and prevention for providing the data and all medical staff members and field workers who are working on the frontline of caring for patients and collecting the data. authors' contributions hz, lz and jl designed the study. cx, kl, zz, hp, dw, jc and xz collated the data. hz analyzed epidemiologic data. hz, cx, yg and jy contributed to interpreting the results. hz wrote the manuscript. xl, jl and lz revised the manuscript. all authors read and approved the final manuscript. this study was supported by the national natural science foundation of china. availability of data and materials the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.ethics approval and consent to participate this study was approved by the ethical committee of guangzhou center for disease control and prevention (no. gzcdc ). because of the urgent need to collect data on this emerging infectious disease, the requirement for written informed consent was waived. the oral informed consent was obtained from each participant and this form of consent was confirmed by the ethical committee. not applicable. the authors declare no competing interests. key: cord- -wisaamn authors: law, chi-kin; leung, candi mc title: temporal patterns of charcoal burning suicides among the working age population in hong kong sar: the influence of economic activity status and sex date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: wisaamn background: charcoal burning in a sealed room has recently emerged as the second most common suicide means in hong kong, causing approximately deaths each year. as charcoal burning suicide victims have a unique sociodemographic profile (i.e., predominantly economically active men), they may commit suicide at specific times. however, little is known about the temporal patterns of charcoal burning suicides. methods: suicide data from to on victims of usual working age ( – ) were obtained from the registered death files of the census and statistics department of hong kong. a total of cases of charcoal burning suicide were analyzed using a two-step procedure, which first examined the temporal asymmetries in the incidence of suicide, and second investigated whether these asymmetries were influenced by sex and/or economic activity status. poisson regression analyses were employed to model the monthly and daily patterns of suicide by economic activity status and sex. results: our findings revealed pronounced monthly and daily temporal variations in the pattern of charcoal burning suicides in hong kong. consistent with previous findings on overall suicide deaths, there was an overall spring peak in april, and monday was the common high risk day for all groups. although sex determined the pattern of variation in charcoal burning suicides, the magnitude of the variation was influenced by the economic activity status of the victims. conclusion: the traditional classification of suicide methods as either violent or nonviolent tends to elide the temporal variations of specific methods. the interaction between sex and economic activity status observed in the present study indicates that sex should be taken into consideration when investigating the influence of economic activity status on temporal variations of suicide. this finding also suggests that suicide prevention efforts should be both time- and subgroup-specific. temporal variation in suicide deaths is an important topic in suicide research worldwide. identifying the most probable timing of suicidiality will help to improve intervention and prevention efforts. charcoal burning in a sealed room has recently emerged as the second most common suicide method in hong kong [ ] [ ] [ ] [ ] [ ] . being a relatively painless and inexpensive method, charcoal burning has rapidly increased the suicide rates in the past few years [ ] . however, no prior research has examined the temporal pattern of suicides by charcoal burning. previous studies consistently showed asymmetrical distributions of suicide deaths. for both sexes, major peaks were found in late spring or summer ("spring fever") [ ] [ ] [ ] [ ] [ ] [ ] , whereas a nadir was noted in december (winter) [ ] . compared with monthly patterns, the daily (referred to as "weekday" or "weekly" in the literature) pattern of suicides is relatively under-researched, particularly in the hong kong context. notwithstanding the limited number of studies, the findings on the daily pattern of suicides were similar to those observed in the related studies, with marked peaks on mondays and nadirs on weekends [ , ] . thus, charcoal burning suicides may also have temporal variations if they follow a similar pattern. however, being a non-violent suicide method, charcoal burning is often assumed to have no obvious temporal patterns. in some seasonality studies, suicides by violent methods (e.g. jumping and hanging) showed more marked temporal variations when compared with nonviolent suicides (e.g. poisoning) [ , , ] . this may suggest that charcoal burning suicides do not have obvious temporal variations in either monthly or daily distributions. accordingly, the recent surge in suicides by charcoal burning would lead to a smoothing of the temporal variations in suicide in hong kong. the unique sociodemographic profile of the victims of charcoal burning suicide suggests that they may tend to commit suicide at specific times. charcoal burning suicide victims were more likely to be economically active and over-indebted than other suicide victims [ ] . although economic activity status had no influence on the monthly pattern of overall suicide deaths [ ] , its exact impact on the temporal patterns of charcoal burning suicides is unclear. it is reasonable to assume that the employed victims were particularly vulnerable to the fear of job loss, which has been found to significantly predict depressive symptoms and suicide mortality [ , ] . as the weekend represents a potential break from the stresses experienced during the work week, it is possible that suicide rates are lower during the weekend than during the work week. employed victims may also experience a greater fear of job loss during seasonal layoff periods and thus may be more inclined to commit suicide. the unemployed may also have a higher suicide risk at specific times as a result of the stress of job searching. some researchers have noted that during weekends, the unemployed tended to spend more time on socializing activities and significantly less time on job searching [ ] . consequently, unemployed people may be more likely to commit suicide during the week, as they experience higher levels of stress in relation to job searching during this period of time [ ] . the unemployed may also be more anxious about finding a job during recruitment seasons. nonetheless, community-based research in this area is lacking. the influence of economic activity status on the daily and monthly patterns of charcoal burning suicides is yet to be examined. in addition to economic activity status, sex difference may also influence the temporal pattern of charcoal burning suicides. in previous studies, a bimodal distribution of monthly suicide deaths was observed in women but not in men [ , ] . sex also interacted with the suicide method on the temporal patterns of suicide [ , ] . as the victims of charcoal burning suicide were predominately economically active men [ , ] , an interaction between sex and economic activity status on the temporal pattern of charcoal burning suicides is possible. however, this is yet to be investigated. the present study aims to fill these gaps in the existing research by examining the temporal asymmetries in the monthly and daily distributions of charcoal burning suicides in hong kong. in particular, the study will examine the temporal variations of charcoal burning suicides in relation to the economic activity status and sex of victims of usual working age ( - ). the present study covers the period, from to . suicide data were obtained from the registered death files of the census and statistics department of hong kong. following the th revision of the international classification of diseases and related health problems (icd- ), reportable deaths with an external cause code ranging from x to x are classified as suicide [ ] . a total of suicide cases were reported during the overall study period, with cases ( . %) involving victims of usual working age . of these cases, . % ( cases) were charcoal burning suicides (x ). all of the recorded suicides included information on the age, sex, and economic activity status (working versus non-working) of the victim, and the date of death and method used. to analyze the monthly and daily patterns, the data were divided into months of a year and days of a week, respectively. to examine the amplitude of temporal variation in suicides and its statistical significance, multinomial poisson regression analyses were conducted by fitting the number of suicides for each month/day of the week with the corresponding time variable [ , ] . given that the size of the usual working age population in hong kong increased by % during the study period, from . million in to . million in , the poisson regression is a more appropriate method than the chi-square test, which assumes that there has been no significant change in the size of the population. the poisson regression can also adjust for changes in regard to sex and economic activity status within the population over the study period. to adjust for differences in age and sex in the suicide rate and population structure, we included the age, sex, and economic activity status of the suicide victims, the year of incidence and the offset term of population size in the regression equation as the confounding variables. mathematically, the regression equation is written as follows: the temporal variation was modeled by comparing the actual frequencies of suicides with the expected values based on the assumption that the suicides are equally distributed. the exponential of the regression coefficient (β) represents the incidence risk ratio (irr), which describes the multiplicative effect of the corresponding independent variable on the risk [ ] [ ] [ ] . a significant irr indicates that there is a significant difference in the adjusted suicide risk between the corresponding month (or day of the week) and the reference period of time. in the present study, the suicide risks for december and saturday (which previous studies reported as being the periods of lowest risk [ ] [ ] [ ] ) were used as references to examine the respective monthly and daily patterns of suicide. in the present study, the seasons were defined as follows: spring (from march to may), summer (from june to august), autumn (from september to november) and winter (from december to february) [ ] . in all statistical analyses, a p-value smaller than % was considered to be statistically significant. all of the statistical work was performed using the sas statistical software package for windows, version . . of the charcoal burning suicide victims, . % (n = ) were men and . % (n = ) were women. the proportions of those who were working and non-working were . % (n = ) and . % (n = ), respectively. the economic activity status of the remaining . % (n = ) of victims was unknown. only those who were recorded as either working or non-working were included in the analyses. thus, a total of working men, working women, non-working men, and non-working women were included in the analysis of the influence of economic activity status and sex on the temporal variation in charcoal burning suicides. overall, moderate temporal variations were observed in the monthly patterns of charcoal burning suicides ( table ) . a peak was observed in april (spring) (irr = . , p = . ), but only among those who were working (irr = . , p = . ). significant sex differences were also observed. whereas men were less likely to commit suicide in summer (june: irr = . , p = . ; july: irr = . , p = . ), women were more likely to commit suicide in spring (april: irr = . , p = . and may: irr = . , p = . ), late autumn (november: irr = . , p = . ), and winter (january: irr = . , p = . ; february: irr = . , p = . ). the interaction of sex and economic activity status was also observed in the monthly pattern of charcoal burning suicides. although no monthly variation was observed in the suicide rate of working men, working women were more inclined to commit suicide in spring (april: irr = . , p = . and may: irr = . , p = . ) and winter (january: irr = . , p = . ). as for the non-working victims, men were less likely to commit suicide in summer (june: irr = . , p = . ), whereas women were more likely to commit suicide in late autumn (november: irr = . , p = . ). significant temporal variations were observed in the daily patterns of charcoal burning suicides ( table to our knowledge, the present study is the first to investigate the temporal patterns of charcoal burning suicide. as charcoal burning is a non-violent suicide method that requires planning to avoid rescue intervention [ ] [ ] [ ] , the temporal variations in suicide observed in this study contradict the findings of many published studies that suicide seasonality only exists in relation to violent methods [ , , ] . this suggests that the specific suicide method is an important factor of suicide seasonality, and that the simple differentiation between violent and nonviolent methods is not applicable to the interpretation of suicide seasonality in hong kong [ ] . in fact, a range of published studies have demonstrated that temporal variations in suicides are method-specific [ , , ] . future research on temporal patterns of suicide should be more method-specific. previous studies have attributed the monthly patterns observed in suicide rates to the influence of seasonalitylinked biological, psychosocial and meteorological correlates [ , , , ] . as the april peak in the seasonality of suicide has also been observed in other suicide methods, charcoal burning suicides may share some of the common causes of suicides by other methods. in addition to the presence of spring peak in april, it is observed that attempters were more likely to commit suicide by burning charcoal in the colder winter months. from a practical point of view, the sub-tropical climate of hong kong would implicitly discourage suicide attempters from burning charcoal in summer to take their own lives. by contrast, the cooler temperatures in winter would make charcoal burning a more acceptable option for suicide. however, the extent to which these explanations are able to account for the monthly pattern of charcoal burning suicides remains unclear. some studies suggest that the correlation between biological factors and seasonal variation is only observed in violent suicides [ , ] . furthermore, the findings on the effects of meteorological variables on suicide seasonality are rather inconsistent and have not been replicated in subsequent studies [ , ] . it is worth noting that only employed women tended to commit suicide by burning charcoal in spring (i.e., april). hence, the seasonal occurrence of particular mental disorders involving suicide ideation fails to explain the temporal variations in charcoal burning suicides. in fact, this is in line with the observation that charcoal burning suicide victims were less likely to be associated with psychiatric illness or substance abuse, compared with those who killed themselves using other methods [ ] [ ] [ ] [ ] [ ] . we expect that more detailed data on the events prior to the death of charcoal burning suicide completers, and on what the suicide attempters were thinking, will help us to explore this knowledge gap in future studies. the results confirm our hypothesis concerning the daily pattern of charcoal burning suicides. the risk of charcoal burning suicide was found to be higher on weekdays (i.e., monday, tuesday, and thursday) than on weekends. this is consistent with most of the other published findings, which report a peak at the beginning of the week [ , , , ] . as suggested by erazo et al. [ ] , a significantly higher rate of suicide on monday seems to be best explained in terms of socio-psychological variables. relatively speaking, a sense of personal failure and isolation is more likely to be triggered in a depressive person at the beginning of the working week, when their surroundings reflect their duties [ ] . a recent study on the relationship between the weekend, work, and well-being also indicated that both men and women tended to experience an enhanced sense of well-being during the weekend compared with working days [ ] . yet, the second peak on thursday observed in the present study is rather novel in the literature. further investigation of the relationship between weekdays and psychological stress is warranted. in line with our expectations, there were pronounced differences in the temporal patterns of charcoal burning suicides in relation to sex. the results identified marked peaks in the rates of charcoal burning suicide in spring and winter (january, february, april, may and november) for working-age women, a less obvious spring peak with a summer nadir was observed for working-age men. this seasonal difference in the magnitude of variation] may be further explained by gender differences in relation to thermal comfort. in an earlier physiological study, lan et al. [ ] found that chinese women were more sensitive to temperature differences than men and that women preferred a relatively warmer environment because they had a higher comfortable operative temperature. it can thus be expected that women are more inclined to burn charcoal in "cold months" and men are less likely to do so in "hot months". as our knowledge of the determinants of charcoal burning suicide remains scant, further research is needed to investigate the differential effects of charcoal burning on vulnerable men and women in terms of monthly patterns. it is worth noting that the influence of employment status on monthly and daily patterns of charcoal burning suicides differed considerably between men and women. according to our data, the monthly variations in suicide risk were more pronounced for non-working men and working women, whereas the daily variations were more apparent for working men and non-working women. it appears that economic activity status either strengthens or weakens the magnitude of the temporal variations in charcoal burning suicide, rather than serving as a determinant that alters the temporal distribution. this may indicate that active employment only serves as a stabilizing factor that protects individuals from various lifethreatening forms of behavior (e.g. alcohol consumption or misuse of illicit drugs) [ ] and thereby implicitly influences the timing of suicide among specific groups of individuals, but not the whole population. accordingly, the nature and magnitude of these effects should be recognized in future studies to develop a more effective approach to suicide prevention in hong kong. our findings contribute to the existing suicide research by extending our scientific knowledge of the temporal patterns of suicidal behavior. in practice, the results of this study may increase the awareness of clinicians, volunteers, and other stakeholders of the most probable timings of suicide, when at-risk individuals may be more vulnerable to suicidality [ , , ] . a greater understanding of the temporal patterns of suicidal behavior may contribute to establishing more effective suicide prevention strategies [ ] . in particular, the different patterns of suicide risk observed in each subgroup suggest that intervention practices for charcoal burning suicides should be more group-specific. several caveats on our findings need to be mentioned. first, the present study failed to separate the unemployed victims from the economically inactive victims due to the limited information available from the dataset. the employed and unemployed victims were expected to have similar variations in suicide risk, whereas the unemployed and economically inactive victims were likely to commit suicide at different times [ ] . future research should independently examine the temporal patterns of all three groups to gain a more comprehensive picture of the influence of economic activity status on suicide risk among charcoal burning victims. 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the netherlands sex-specific time patterns of suicidal acts on the german railway system: an analysis of cases weekends, work, and well-being: psychological need satisfactions and day of the week effects on mood, vitality, and physical symptoms investigation of gender difference in thermal comfort for chinese people employment status influences the weekly patterns of suicide among alcohol misusers temporal fluctuations and seasonality in attempted suicide in europe: findings from the who/ euro multicentre study on parasuicide seasons and meteorological factors in suicidal behaviour do weather, day of the week, and address affect the rate of attempted suicide in hong kong? mental disorders and comorbidity in suicide suicide as an outcome for mental disorders: a meta-analysis psychiatric illness and risk factors for suicide in denmark cite this article as: law and leung: temporal patterns of charcoal burning suicides among the working age population in hong kong sar: the influence of economic activity status and sex the authors are indebted to professor paul yip of the university of hong kong hkjc centre for suicide research and prevention, and the census and statistics department of hong kong who kindly shared the data necessary for our analysis. role of funding source. all authors declare that they have no competing interests. key: cord- -niurdu t authors: chern, jimmy ps; chen, duan-rung; wen, tzai-hung title: delayed treatment of diagnosed pulmonary tuberculosis in taiwan date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: niurdu t background: mycobacterium tuberculosis infection is an ongoing public health problem in taiwan. the national tuberculosis registry campaign, a case management system, was implemented in . this study examined this monitoring system to identify and characterize delayed treatment of tb patients. methods: records of all tuberculosis cases treated in taiwan from through were obtained from the national tuberculosis registry campaign. initiation of treatment more than days after diagnosis was considered a long treatment delay. results: the study included , patients. the mean day of delayed treatment was . days. most patients were treated immediately after diagnosis. the relationship between number of tb patients and days of delayed treatment after diagnosis exhibited a power-law distribution. the long tail of the power-law distribution indicated that an extreme number occur cannot be neglected. tuberculosis patients treated after an unusually long delay require close observation and follow up. conclusion: this study found that tb control is generally acceptabl in taiwan; however, delayed treatment increases the risk of transmission. improving the protocol for managing confirmed tb cases can minimize disease transmission. mycobacterium tuberculosis infection has long been a public health problem in taiwan. the annual incidence of tuberculosis in taiwan was . / , and . / , in and , respectively [ ] . in aboriginal mountainous areas, the reported incidence is even higher: . / , in . in a geographic analysis, yeh et al. reported that the incidence of tb cases in aboriginal populations in mountain areas decreased with distance from foci in mountain areas. the yeh study suggested that recent or new infections, not reactivation, explained the high incidence of tb in the general population of taiwan [ ] . a netherlands study estimated that the average patient with untreated smear-positive pulmonary tb infects more than ten patients annually during the natural course of the disease [ ] . however, identifying smear-positive tb cases through control programs and treatment with effective drug regimens can reduce the spread of infections. there-fore, timely and accurate diagnosis of tb and treatment are vital. delayed treatment can cause more infections per case [ ] . delays can be categorized as patient delays or health care system delays. identifying when delays occur and the factors related to types of delay can help tuberculosis control programs and medical providers improve diagnosis and treatment efforts [ ] . in taiwan, an aggressive case monitoring system has been in place since through the efforts of local public health administrations in cooperation with the taiwan centre for disease control (cdc). this monitoring system requires medical personnel to report all suspected and confirmed cases of tb to city or county local health bureaus. reliability of the reporting system is ensured by two policies: the no-report-no-reimbursement policy and the notification-fee policy [ ] . one policy stipulates that a medical facility failing to report a suspected case cannot receive reimbursement by the taiwan national health care system. the second policy financially rewards the medical facility for reporting suspected cases to local health administrations. this monitoring system collects data as of the dates the tb patient is diagnosed and treated. it provides a unique opportunity to study delayed treatment, defined as the length of time between initial diagnosis and initial treatment. therefore, this study identified and characterized tb cases with unusually long delays in treatment to evaluate the effectiveness of tb control in taiwan. data for all tuberculosis cases treated during - were obtained from the national tuberculosis registry campaign surveillance program. the tb surveillance program was established by the center for disease control (cdc, taiwan), taiwan department of health, and began collecting demographic, geographic, diagnostic and treatment data for all diagnosed tb cases since . this study enrolled only tb patients with sputum smear-and/ or culture-positive tb. treatment delays were measured as the time from the date of definite diagnosis (i.e., confirmation by laboratory findings) to the date of initial treatment for the disease. any treatment initiated more than seven days after diagnosis was considered delayed treatment. in taiwan, physicians are required to immediately treat patients with confirmed tb. physicians who lack sufficient expertise in treating tb must immediately refer the patient to a pulmonologist. this referral process is usually accomplished within a week. data for patients who experienced treatment delays longer than days were considered incorrectly managed and excluded from analysis. the annual distributions in days of delayed treatment were analyzed. differences between patients with tb infection were tested by independent t test and chi square test. we employed mantel-haenszel chi-square test for linear trend to examine whether the confirmed tb cases by laboratory diagnosis increased significantly over the four-year period of analysis [ ] . a p-value less than . was considered statistically significant. distribution-fitting and power function regression were performed to examine whether the days of delayed treatment was power-law distributed, which was determined by the following formula: where k represents the total days of treatment delay, and p(k) indicates the number of tb cases receiving delayed treatment. if the days of delayed treatment could be fitted by a power-law function with a high γ value (larger than ), the number of tb cases would sharply decrease, indicating that long delays are rare [ ] . most patients have experienced short delay, but a significant number of nodes have experienced a longer delayed treatment. the lotka was used to fit the power-law distribution [ ] multivariate logistic regression was employed to model the variables associated with long treatment delay. the dependent variable is a binary variable. patients with treatment initiated more than seven days after diagnosis was considered delayed treatment, coded as " ", otherwise, coded as " ". the study analyzed table ) . the distribution of treatment delays was skewed. mean treatment delay was . median and mode of treatment delay was during these years. in more than % of the patients, treatment commenced within days after laboratory-confirmed diagnosis; only . %- % had treatment delays longer than days (table ) . delayed treatment, defined as initial treatment seven or more days after diagnosis, was noted in , patients ( . % table ). the correlations between number of tb patients and days of delayed treatment after diagnosis were similar for each year ( fig. to fig. ). the days of delayed treatment of tb patients exhibited a power-law distribution with a % statistical significance, indicating that most patients were treated immediately after diagnosis. conversely, the absolute values of γ in power-functions ranged from . to . with r-square = . ( fig. to fig. ). this finding suggests that a small number of patients experienced treatment delays for a significant number of days. multivariate logistic regression results showed that gender, type of treatment facilities, and year were significantly associated with being long treatment delay. as compared to women, men were . times more likely to be in long treatment delay. patients treated in hospitals were also . times more likely to be in long treatment delay, compared to patients treated in clinics. yearly difference was also significant. the prevalence of long treatment delay in was % less than that in (the baseline), and the prevalence of long treatment delay in and were % and % respectively less than that in (as shown in table ). delayed diagnosis and treatment of active tuberculosis can be categorized as patient delay or health care system delay. in the health care system, most delays are caused by the diagnosing facility. such delays can be further categorized as delayed diagnosis or delayed treatment [ ] . regardless of cause, delayed diagnosis and treatment can be catastrophic to those exposed to infected patients [ ] , particularly medical personnel [ ] . for example, the large tb outbreak involving sixty healthcare workers in a taipei hospital was attributed to delayed diagnosis and treatment [ ] . minimizing delays in diagnosis or treatment can substantially improve tb prevention. previous studies measured patient and health care system delay [ , [ ] [ ] [ ] whereas the current study focused on treatment delays after definite diagnosis in a health care system. the intent was to focus on the severity of delays occurring. in taiwan, the the incidence of cases with definite diagnosis increased significantly during these years. mantel-haenszel chi-square for linear trend p < . . data are n, means ± sd, or n (%). number (n) of patients is given when the variable concerned is not measured in all patients. * chi-square tests p < . . incidence of laboratory-confirmed diagnoses increased gradually during these years. however, the incidence of tb remained relatively stable. the increased incidence of definite diagnosis may be attributable to improved accuracy of diagnosis by healthcare facilities. among these patients, most cases of tb infection in taiwan were males, which is consistent with previous studies. this gender difference may partly reflect epidemiological differences, including differences in exposure, infection risk, progression from infection to disease, socio-economic status, cultural factors and quality of health care received [ , [ ] [ ] [ ] [ ] [ ] [ ] . however, although a gender difference in incidence was noted, no gender difference was noted in number of days of delay after definite diagnosis. taiwan national health insurance was implemented in to provide universal health coverage. the national health insurance program provides accessibility to health care at reasonable cost [ ] . this might have increased utilization of medical care by both genders. additionally, taiwan also implemented a no-report-no-reimbursement policy in which penalizes medical facilities for not reporting possible tb cases by denying reimbursement. together, these measures may have helped improve the surveillance, diagnosis and time to treatment of tb in the overall population. however, this study revealed that more men than women experienced long delays in treatment. a study in yemen demonstrated that women were more likely than men to complete tuberculosis treatment [ ] , which suggests that women have shorter treatment delays than males and tend to receive treatment immediately after diagnosis. data are n, means ± sd, or n (%). number (n) of patients is given when the variable concerned is not measured in all patients. * chi-square test, p < . . ** t-test, p < . . however, a bangladesh study showed that women experience longer total delay, total diagnostic delay, patient delay and treatment delay (males . days, females . days) [ ] . these inconsistencies highlight the impact of different communities and cultures on gender differences in tuberculosis treatment delays. hence, a better understanding of the people and communities affected by tuberculosis is needed to provide consistent and high quality care [ ] . recent research indicates that many natural and socialeconomic phenomena, such as income, disease-related death and earthquake magnitude, follow a power-law distribution rather than a bell-curve distribution. this implies that small occurrences are common, and large instances are rare but possibly devastating [ , ] . our study also revealed a power-law distribution in tb treatment, suggesting that while most tb cases are controlled by public health authorities, the few patients who experience long delays in treatment can cause serious transmission. as can be seen in fig. to fig. , the tail of the powerlaw distribution has a much slower decay than other probability distributions, such as the poisson distribution. the probability that an extreme number will occur from a random sample cannot be neglected if we are dealing with power-law phenomena. it is worth noting that a powerlaw distribution in tb treatment, suggesting that while most tb cases are controlled by public health authorities, the few patients who experience long delays in treatment can cause serious risk for transmission [ , ] . as pastor-satorras and vespignani [ ] has revealed, in a power-law distribution, epidemics can reproduce with a considerably lower number of infected persons at each point in time, than other probability distributions. therefore, epidemics in a power-law distribution will not exhibit a threshold. it brings serious concerns for public health researchers working in the field of tuberculosis control. additionally, based on the data in this study, long delays in treatment usually occurred in hospitals (range: . % . %) rather than in primary-care clinics. the likely explanation is that not all physicians are familiar with treatment of tb, especially in hospitals with many specialists. chung et al. reported that physicians who are not pulmonologists are less effective in treating tb [ ] . we speculate that if the attending physician cannot explain the disease as convincingly as a pulmonologist, the patient may choose to visit another doctor for a second opinion or simply leave under the impression that the doctor is uncertain or is reluctant to disclose the tb findings because of the social stigma attached to the disease. to minimize treatment delays and disease transmission, the protocols for controlling tb at the hospital level must be strengthened. for example, nurses responsible for hospital tb control should be informed immediately after a laboratory diagnosis is confirmed. the nurse can contact the patient, inform primary doctor and arrange an immediate visit to a pulmonologist. nevertheless, this study bears the following limitations. first, the data analysis did not differentiate newly detected cases from relapses. second, global surveillance of drug resistance has shown that a substantial proportion of tuberculosis patients are infected with drug resistant mycobacterium tuberculosis strains [ ] . unfortunately, the possibility of multiple-drug resistant tb (mdr-tb) cannot be considered due to the lack of information in the data set. however, based on the report from chest hospital in taiwan, multidrug resistance occurred in . % of retreated tb patients, and . % of multidrug resistant isolates were found in new tb patients from january to june [ ] . a recent report in may revealed that, among patients with mdr-tb, . % ( / ) were fluoroquinolone-resistant [ ] . fluoroquinolones are widely used for the treatment of bacterial respiratory infections in taiwan. this treatment regimen of using fluoroquinolone before definite diagnosis of pulmonary tb might cause temporary symptom relief of the patient, and might eventually cause treatment delay and drug resistance [ ] . further studies are needed to examine the extent of fluoroquinolone-resistance in patients with long treatment delays. this study found that tb control is generally acceptable in taiwan; however, delayed treatment increases the risk of transmission. improving the protocol for managing confirmed tb cases can minimize disease transmission. mycobacterium tuberculosis in taiwan incidence of tuberculosis in mountain areas and surrounding townships: dose-response relationship by geographic analysis epidemiology of tuberculosis. the royal netherlands tuberculosis association patient and health care system delay in the diagnosis and treatment of tuberculosis patient and health care system delay in the start of tuberculosis treatment in norway the impact of national health insurance on the notification of tuberculosis in taiwan openepi: open source epidemiologic statistics for public health, version . . power laws, pareto distributions and zipf's law lotka: a program to fit a power law distribution to observed frequency data diagnostic and treatment delay among pulmonary tuberculosis patients in ethiopia: a cross sectional study diagnostic standards and classification of tuberculosis in adults and children tuberculosis among health care workers nosocomial transmission of mycobacterium tuberculosis found through screening for severe acute respiratory syndrome -taipei patient and health care system delay in queensland tuberculosis patients delay in tuberculosis case-finding and treatment in mwanza, tanzania patient and health system delay in the diagnosis and treatment of tuberculosis in southern taiwan the global burden of disease and risk factors in her lifetime: female morbidity and mortality in sub-saharan africa women and tuberculosis gender difference in delay to diagnosis and health care seeking behaviour in a rural area of nepal key p: women, health and development, with special reference to indian women. health policy and planning longer delay in tuberculosis diagnosis among women in vietnam the effect of universal health insurance on health care utilization in taiwan. results from a natural experiment gender and literacy: factors related to diagnostic delay and unsuccessful treatment of tuberculosis in the mountainous area of yemen gender differences in delays in diagnosis and treatment of tuberculosis the role of gender and literacy in the diagnosis and treatment of tuberculosis power-law distributions in empirical data scale-free networks epidemic spreading in scalefree networks sexual networks: implications for the transmission of sexually transmitted infections factors influencing the successful treatment of infectious pulmonary tuberculosis anti-tuberculosis drug resistance in the world report drug-resistant mycobacterium tuberculosis extensively drug-resistant tuberculosis the authors would like to thank the ministry of education of taiwan, "aiming for the top university and elite research center development plan" (no. hp ), and department of health of taiwan (doh -td-ph- ) for financial support. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -movbn dn authors: jahangiry, leila; bakhtari, fatemeh; sohrabi, zahara; reihani, parvin; samei, sirous; ponnet, koen; montazeri, ali title: risk perception related to covid- among the iranian general population: an application of the extended parallel process model date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: movbn dn background: the novel coronavirus disease (covid- ) has emerged as a major global public health challenge. this study aimed to investigate on how people perceive the covid- outbreak using the components of the extended parallel process model (eppm) and to find out how this might contribute to possible behavioral responses to the prevention and control of the disease. methods: this cross-sectional study was conducted in iran during march and april . participants were recruited via online applications using a number of platforms such as telegram, whatsapp, and instagram asking people to take part in the study. to collect data an electronic self-designed questionnaire based on the eppm was used in order to measure the risk perception (efficacy, defensive responses, perceived treat) related to the covid- . descriptive statistics, chi-square, t-test and analysis of variance (anova), were used to explore the data. results: a total of individuals with a mean age (sd) of . ( . ) years participated in the study. the results revealed significant differences in efficacy, defensive responses and perceived treat among different population groups particularly among those aged and over. women had significantly higher scores than men on some aspects such as self-efficacy, reactance, and avoidance but men had higher perceived susceptibility scores compared to women. overall . % of participants were engaged in danger control (preventive behavior) while the remaining . % were engaged in fear control (non-preventive behavior) process. conclusion: more than half of all participants motivated by danger control. this indicated that more than half of participants had high perceived efficacy (i.e., self-efficacy and response efficacy). self-efficacy scores were significantly higher among participants who were older, female, single, lived in rural areas, and had good economic status. the results suggest that socioeconomic and demographic factors are the main determinants of the covid- risk perception. indeed, targeted interventions are essential for controlling the pandemic. supplementary information: supplementary information accompanies this paper at . /s - - - . the novel coronavirus disease (covid- ) has emerged as a major global public health challenge [ ] . this potentially fatal infectious disease, which has affected most countries worldwide, is characterized by a steady speed of spread, leading to the world health organization (who) classifying it as a pandemic [ ] . in iran, apparently the two first cases of deaths related to covid- were reported on february , from qom, a city in the central part of the country. as of april , , iranian people have been infected with the covid- . in total, have died and , have recovered when we were carrying this study [ ] . the covid- is transmitted from human to human through respiratory droplets or direct contact. available findings show that avoiding exposure is the key to preventing covid- infection, which is why quarantining, physical distancing, and isolation have become the primary strategies for reducing covid- incidence and mortality. quarantine restricts the movement of people and reduces the infection rate for contagious diseases [ ] ; physical or social distancing involves staying at least two meters away from other persons; and isolation is the state of separating patients with covid- from otherwise healthy people [ ] . maintaining hygiene practices, such as proper hand washing, wearing a mask in crowded places, and staying at home, all are recommended for controlling the spread of the disease and breaking the transmission chain [ ] . during the early stages of the coronavirus pandemic in iran, several social media campaigns were launched to inform people about the risks of coronavirus and to persuade them to follow health care recommendations. therefore, providing necessary information about people's perception related to covid- is important for health policy makers in implementing effective and appropriate strategies in order to prevent and control of the disease. there are several factors that might affecting covid- response behaviors [ ] . multiple health models suggest that risk perception of the covid- is a vital component for any behavior change [ ] . of these, the extended parallel process model (eppm) is very relevant [ ] . according to the eppm, when people are exposed to a risky situation, they go through two cognitive appraisals: one related to the efficacy of the recommended advice and one related to the perceived threat [ ] . the eppm therefore indicates that the perception of a risk depends on efficacy, defensive response and perceived threat [ ] . thus, in order to influence people's behavior to follow the covid- health recommendations it is important to understand how people perceive the covid- pandemic, how they are assessing these risks, and how such assessments might lead them to change their behaviors. this study aimed to investigate on how people have perceived the covid- outbreak using the components of the eppm (efficacy, defensive responses, perceived treat) and how these might contribute to possible behavioral responses to the prevention and control of the disease. this was an online cross sectional study that was carried out in iran during march to april . data were collected using an electronic questionnaire via porsline. participants were recruited using online applications and posts on several platforms such as telegram, whatsapp, and instagram. we asked people for sharing the study announcements and to participate in the study. we also send several messages to significant others, virtual groups to share the study announcements. the posts asked people aged years and over to take part in a study that investigates on the covid- . those interested in participating were directed to complete the online questionnaire. the sample size for the study was estimated using the following formula [ ] : where z for % confidence interval is . , p = . (assuming that % of people would either be engaged in danger control or fear control processes), and d = . (precision = %). as such we estimated at least participants would be requiring for the study to have a power of % at % significant level. however, in practice individuals participated in the study. the risk-percept covid- was used to collect the data. this questionnaire was developed based on a literature review of the eppm-based risk perception assessments of other infectious diseases. the questionnaire was subjected to psychometric evaluation before the data collection and found to be a valid and reliable measure. the cronbach's alpha coefficients for the dimensions ranged from . to . , which indicated acceptable internal consistency for the questionnaire. in addition, the stability of the questionnaire as assessed by intraclass correlation coefficient (icc) showed satisfactory results (icc ranged from . to . ) among (n = ) same. the questionnaire was pilot tested with a sample of respondents. the final questionnaire consisted of items tapping into three pre-defined dimensions: each item was rated on a -point likert scale ( = strongly disagree, = disagree, = neutral, = agree, = strongly agree) giving an overall row score ranging from to . the rating for items belonging to defensive response were recoded so that to keep the direction of scoring as same as the other two dimensions (additional file ). also the following demographic data were collected for all participants: age, gender, education, marital status, economic status, history of coronavirus, family history of coronavirus, having chronic diseases, and living condition (urban vs. rural). . risk perception: using the following simple linear transformation [row scorethe lowest possible raw score/highest possible raw scorethe lowest possible raw score] × , the row scores were converted into a score of to where lower scores indicated lower risk perception and the higher scores indicated higher risk perception. . danger control and fear control: consistent with previous studies [ ] , we subtracted the perceived threat score from the perceived efficacy score (self-plus response-efficacy divided by two), resulting in a discriminating value. the discriminating value could be either positive or negative. a positive value meant that a person was engaging in danger control processes because their perceived efficacy was stronger than their threat perceptions. in other words, a person was likely to engage in some level of protective behaviors with regard to the specific health threat. a negative value meant that a person was engaging in fear control processes because their threat perceptions were stronger than their perceptions of efficacy. in these cases, a person was likely to engage in fear control processes and was probably not protecting himself or herself against the specific health threat. statistical analyses were performed using the statistical package for social science, version , for windows (spss inc., chicago, il, usa). the normality of the data was analyzed using a kolmogorov-smirnov test and the normal distribution of data was confirmed. the characteristics of the participants were summarized as demographic characteristics table shows the sociodemographic characteristics of the respondents ( male, and female). the mean age of the respondents was . (sd = . ) years. more than half of all participants ( %) were married. in all respondents ( . %) reported that they had coronavirus and ( . %) stated that they had a family member with a confirmed case of the disease. the majority of participants ( . %) lived in urban areas. the perceived risk for all participants based on sociodemographic characteristics are shown in table . the results by age revealed that as age increased, the significant progressive increase in perceived self-efficacy, avoidance response and perceived susceptibility scores were observed. this applied particularly for participants aged and over. there were no statistically significant differences between age groups for response efficacy, denial, reactance, and severity scores. women had higher but not significant scores than men for self-efficacy and response efficacy. men had higher perceived susceptibility scores for the covid- than women. the average scores across all dimensions showed significant increases as education levels increased, as well as for participants who were married or had good economic status. perceived risk scores showed that participants with confirmed coronavirus cases had significantly higher scores except for the perceived susceptibility scores. participants without any family history of coronavirus had higher perceived scores for response efficacy and selfefficacy. we found significantly higher scores for perceived risk among respondents with no chronic diseases (table ) . table shows the discriminating values indicating danger control and fear control scores based on different sociodemographic characteristics. a total of . % of participants were engaging in danger control processes and . % in fear control processes. the respondents in former group were more likely to engage in preventive behaviors while those in the latter group were more likely to delay recommended responses for preventing themselves from the covid- . there were significant differences in danger and fear control scores by age, gender, education, economic status, and having chronic diseases. this eppm-based study was conducted to assess the risk perceptions, overall perceived danger and fear control processes among iranian people during the early stages of the covid- pandemic. the study provides a timely assessment and initial evidence related to the risk perceptions and psychological responses of more than individuals across the country who took part in the study. in this study, the risk perception was evaluated through three dimensions of the eppm including efficacy (self-efficacy and response efficacy), defensive response (denial, reactance, and avoidance), and threat (susceptibility and severity). the study results showed that . % of respondents were motivated by danger control responses and . % by fear control responses. this indicates that more than half of all participants had high perceived efficacy (i.e., self-efficacy and response efficacy). according to the eppm, two cognitive appraisals might initiate after a person learns about a health risk: one related to the threat it poses and a second related to the efficacy to follow the recommended responses. when the threat of covid- is perceived to be more significant and efficacy is low, people are usually act to protect themselves from the fear rather than the danger itself (fear control process). conversely when perceived efficacy is significantly high, even if the perceived treat would be high, people usually are motivated to protect themselves from the danger and could manage the threat (danger control process) [ ] . self-efficacy scores were significantly higher among participants who were older, female, single, lived in rural areas, or had good economic status. self-efficacy is a positive mental state that is part of the cognitive appraisal process reducing stress and tension [ ] . a current study from china showed an association between self-efficacy and social support among patients who had been treated for coronavirus [ ] . this is inconsistent with our results, where it was found that participants with a history of coronavirus had lower selfefficacy scores. respondents who had a family member with coronavirus and those with three or more comorbidities had lower self-efficacy scores for controlling covid- . the results showed that respondents with high self-efficacy were better able to control their emotions. self-efficacy contributes to preventive behavior and the ability to conduct healthy behavior [ ] . in this regard, a study by liao et al. showed that self-efficacy was significantly associated with trust in government and media information on pandemic of a/h n influenza [ ] . we found that efficacy was significantly higher among respondents who were well-educated and had good economic status. it seems that these individuals believed that they can carry out the recommended responses to protect themselves from the covid- . individuals usually use psychological defense strategies to control their fears. these strategies include denial, avoidance, and reactance. our results showed that higher defensive response scores correlated with better responses from participants. defensive avoidance occurs when individuals block out feelings and thoughts about a threat or ignore further information about it, for example, switching the television channel or skipping covid- -related news. people in younger age groups had lower reactance scores and lower self-efficacy scores, indicating that younger people tended to take more risks and ignore health recommendations [ ] . the results also showed that respondents who were male, older, well-educated, and married had significantly higher perceptions of susceptibility. in fact, these individuals were simply thinking about the threat of the covid- and believed that the threat was relevant to them. according to the who, older people are at higher risk of contracting covid- [ ] . the iranian health care system and media provided significant coverage of the covid- pandemic, recommending that all people, especially older people take good care of themselves. this likely resulted in older people learning that they were more susceptible to the disease. however, some studies reported that after the initial stage of a pandemic the media attention to the topic declined and perceived susceptibility and severity declined accordingly [ ] [ ] [ ] . this study benefited from a relatively good sample size and using a theory based questionnaire for data collection was an advantage. the greatest strength of this study was its format. the online method allowed for the timely collection of information from a wide range of community groups. since the pandemic feature of the covid- made other data collection methods unsafe and difficult for both the researchers and the study participants, the online sampling method was particularly convenient. however, because of the online nature of the study, we were unable to reach people who did not have access to the internet or online applications. in addition, it is necessary to mention that online survey during the early stage of a pandemic was relatively new and therefore although some people received the invitation to participate, they did not attend to respond to the questionnaire. in fact, we could not identify none responders. furthermore, most participants were relatively well educated. thus the findings might not be generalized to all population. finally, the present study did not introduce the cut-off values for the three dimensions of the questionnaire. perhaps the future studies could indicate these values for screening proposes. more than half of all participants motivated by danger control. this indicated that more than half of participants had high perceived efficacy (i.e., self-efficacy and response efficacy). the results suggest that the risk perception of covid- differs by socio economic and demographic characteristics. indeed, the knowledge provided by the current study will likely contribute to the effectiveness of covid- control and prevention measures. supplementary information accompanies this paper at https://doi.org/ . /s - - - . additional file . the risk-percept covid- questionnaire. the file contains a -items questionnaire which was specially developed for the study. getting ready for the next pandemic covid- : why we need to be more prepared and less scared world health organization. coronavirus disease (covid- ) advice for the public. basic protective measures against the new coronavirus national committee on covid- epidemiology, ministry of health and medical education, ir iran. daily situation report on coronavirus disease (covid- ) in iran the psychological impact of quarantine and how to reduce it: rapid review of the evidence update: public health response to the coronavirus disease factors associated with adherence to infectious diseases advice in two intensive care units development of the perceived risk of hiv scale the extended parallel process model: illuminating the gaps in research the perception of risk messages regarding electromagnetic fields: extending the extended parallel process model to an unknown risk learning aids in singapore: examining the effectiveness of hiv/aids efficacy messages for adolescents using icts biostatistics: a foundation for analysis in the health sciences fear control and danger control: a test of the extended parallel process model (eppm) the dynamics of risk perceptions and precautionary behavior in response to (h n ) pandemic influenza the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china. medical science monitor the role of sociodemographic and psychological variables on risk perception of the flu. public health emerg collection situational awareness and health protective responses to pandemic influenza a (h n ) in hong kong: a cross-sectional study the effects of daily stress on positive and negative mental health: mediation through selfefficacy int: covid- situation in the region -total reports perceived risk, anxiety, and behavioural responses of the general public during the early phase of the influenza a (h n ) pandemic in the netherlands: results of three consecutive online surveys pandemic influenza in australia: using telephone surveys to measure perceptions of threat and willingness to comply monitoring of risk perceptions and correlates of precautionary behaviour related to human avian influenza during - in the netherlands: results of seven consecutive surveys publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we acknowledge the contributions of tabriz university of medical sciences, tabriz, iran for providing facilities to the study. our thanks go to all the respondents of the study for their valuable co-operation. the authors have agreed on the content of the manuscript. the authors declare no conflicts of interest. authors' contributions lj and am were responsible for the study design. lj did the analyses. lj and am were responsible for data interpretation. fb, pr, ss, and zs helped in the study design and data collection. kp and am helped in the drafting of the manuscript. am critically reviewed the manuscript and provided the final manuscript. all authors have read and approved the final manuscript. tabriz university of medical sciences supported this study and reviewed the study proposal. the questionnaires and datasets generated and/or analyzed during the current study are available from the corresponding authors on reasonable request. the study received ethical approval from the ethics committee of tabriz university of medical. sciences (no: ir.tbzmed.rec. . ). we obtained oral informed consent and parental consent from participants and participants aged - years, respectively. due to technical issues and since the data was collected during the pandemic, the ethics committee approved this procedure. key: cord- -lvn hqk authors: rosenkötter, nicole; clemens, timo; sørensen, kristine; brand, helmut title: twentieth anniversary of the european union health mandate: taking stock of perceived achievements, failures and missed opportunities – a qualitative study date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: lvn hqk background: the european union (eu) health mandate was initially defined in the maastricht treaty in . the twentieth anniversary of the treaty offers a unique opportunity to take stock of eu health actions by giving an overview of influential public health related eu-level policy outputs and a summary of policy outputs or actions perceived as an achievement, a failure or a missed opportunity. methods: semi-structured expert interviews (n = ) were conducted focusing on eu-level actions that were relevant for health. respondents were asked to name eu policies or actions that they perceived as an achievement, a failure or a missed opportunity. a directed content analysis approach was used to identify expert perceptions on achievements, failures and missed opportunities in the interviews. additionally, a nominal group technique was applied to identify influential and public health relevant eu-level policy outputs. results: the ranking of influential policy outputs resulted in top positions of adjudications and legislations, agencies, european commission (ec) programmes and strategies, official networks, cooperative structures and exchange efforts, the work on health determinants and uptake of scientific knowledge. the assessment of eu health policies as being an achievement, a failure or a missed opportunity was often characterized by diverging respondent views. recurring topics that emerged were the directorate general for health and consumers (dg sanco), eu agencies, life style factors, internal market provisions as well as the eu directive on patients’ rights in cross-border healthcare. among these recurring topics, expert perceptions on the establishment of dg sanco, eu public health agencies, and successes in tobacco control were dominated by aspects of achievements. the implementation status of the health in all policy approach was perceived as a missed opportunity. conclusions: when comparing the emerging themes from the interviews conducted with the responsibilities defined in the eu health mandate, one can identify that these responsibilities were only partly fulfilled or acknowledged by the respondents. in general, the eu is a recognized public health player in europe which over the past two decades, has begun to develop competencies in supporting, coordinating and supplementing member state health actions. however, the assurance of health protection in other european policies seems to require further development. the maastricht treaty from marked the beginning of the health mandate of the european union (eu) as enshrined today in article of the lisbon treaty (tfeu, treaty on the functioning of the european union) [ ] . the original eu health mandate focused primarily on stimulating cooperation between member states and supporting national actions (art. ( ), treaty of the european union (teu)) [ ] . it embodied the union with only limited legislative powers on health matters. although this initial mandate was enhanced through subsequent treaties, today article , still gives the eu relatively circumscribed power in areas of public health (art. ( ), tfeu). healthcare continues to remain a national competence and in this regard, the eu "shall respect the responsibilities of the member states for the definition of their health policy and for the organization and delivery of their health services" (art. ( ), tfeu). despite the restricted treaty-based mandate for health, the eu has a relevant role to play in national public health and health systems policies and has expanded its remit in areas beyond the treaty [ ] . areas affected by eu provisions are extensively described in the literature [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . to illustrate the main developments in the area of what can be called "eu health policy" a timeline is illustrated in table . however, because of its limited legal mandate, some eu legal initiatives were highly contested [ , ] . therefore, one can pose the question of what has been achieved over the last twenty years. it may be argued that, despite its narrow legislative scope, the health mandate has triggered important european actions in certain public health areas like tobacco control [ , ] , infectious disease control [ , ] , european guidelines [ ] [ ] [ ] and the development of an eu public health infrastructure [ ] . in recent years, the ec has summarized in annual reports a diverse nature of key public health achievements such as communications and recommendations, health policies, ec co-financed actions and established networks (e.g. high level groups, scientific committees, platforms) [ ] [ ] [ ] . however, stakeholders in the field provide examples indicating that public health relevant eu policies such as single eu policy assessments on the common agriculture policy (cap) [ , ] , pharmaceuticals [ ] , or the health in all policy (hiap) approach [ ] do not always meet the expectations of the public health community. in these papers the authors express concerns about potentially detrimental health effects [ , ] or disappointment about the support of the policies and approaches aimed at improving health in europe [ , ] . also, eu agencies such as the european centre for disease prevention and control (ecdc) are described as agencies with a limited legal mandate, competences and resources for eu public health but, at the same time, with promising prospects to develop as a renowned international player in the field [ ] . in addition, an evaluation of the eu health strategy acknowledges its status as a guiding framework for ec health policies and joint ec and member state actions table timeline of main developments in eu health policy year eu health policy developments before the introduction of a legal eu health mandate treaty of rome: health is not a priority. two aspects are considered: social security of cross-border workers and occupational health. on health but also identifies the missing impact of the strategy on other ec policies as well as on member state health policies and actions [ ] . evaluations of the eu public health programmes, which are one of the ec's financial instruments to implement its strategic health goals, criticize missing prioritization of topics, barriers for participation in projects for some member states and ineffective dissemination of project results [ , ] . hence, the available evidence of the impact of eu health policies, infrastructure, and actions is elusive, and the identification of the value of public health relevant eu-level actions across all policies is lacking. in this paper, we aim to explore and provide an overview of influential public health relevant eu-level policy outputs and a summary of policy outputs or actions perceived as an achievement, a failure or a missed opportunity by interviewing key experts in the field. by this, we intend to establish a qualitative indication of which eu health policies have contributed to the improvement of population health in europe. the study focused on the evolvement of the health mandate since , the year the maastricht treaty was signed. the study was carried out in two consecutive phases: ( ) qualitative interviews, suitable to identify expert perceptions, and ( ) voting on influential and public health relevant eu policy outputs and actions based on nominal group technique. the study adhered to the rats guidelines on qualitative research [ ] . experts were purposely selected to ensure heterogeneity of opinions. the selection was based on their individual profile and professional affiliation. we selected experts that were renowned in the field due to their current or former affiliation to specific eu-level bodies and institutions, research institutes with eu focus, or eu-level nongovernmental organization. selected experts were actively involved in public health research, policy-making, policy advice or advocacy performed at eu level, internally or externally. in addition, snowball sampling was applied until data saturation was reached. data saturation was assumed as soon as no new eu public health policy actions and their perceptions were mentioned during the interviews. the potential participants were contacted between december and march by a short information email to identify whether they were interested to participate in the interview study. of contacted experts, twenty participated in this study, one participant could not confirm participation due to time constraints and another did not respond to the invitation. of those twenty experts nine belonged to the initial purposively selected sample and eleven were identified during the snowball sampling procedure based on recommendations of already interviewed experts. the majority of experts was affiliated to an institution located in brussels (n = ). the composition of the study sample in terms of represented professional affiliations is outlined in table . upon agreement by the participant, an appointment for the interview was made and participants received an informative letter with more in-depth information about the goal of the study and an informed consent form in which the voluntary basis of the participation has been clarified and anonymized data handling was assured. interviews were conducted either face-to-face (n = ) or via telephone, or voice over ip (n = ) in the period between january and march and were held in english, dutch or german by one of the three principal investigators (nr, tc, ks). the interviews lasted from to minutes. all interviews were audio-recorded, transcribed verbatim and anonymized. the interviews were performed using a specifically designed semi-structured interview guide. the guide was developed on the basis of previous desktop research and an internal brainstorming session of an advisory research group consisting of the three principal investigators, four senior researchers, and one junior researcher of the department of international health at maastricht university to identify items relevant for investigating expert perceptions on european public health policy. during the course of this process, a list of public health relevant eu policy outputs, processes or procedures that were regarded as achievements, failures or missed opportunities were first gathered individually and then, following a group discussion, a common list was compiled. this output was used to construct the interview guide containing six guiding themes from which open-ended questions were formulated. the guiding themes included ( ) a description of the individual role of the expert in european public health, ( ) the individual definition of european public health, ( ) the assessment of public health relevant eu-level actions as being an achievement, missed opportunity or failure, ( ) the formulation of five influential european policy outputs, ( ) consequences of european health policy, and ( ) the policy process at the european level. the semi-structured interview guide was used as a framework for the interviews and allowed the interviewers to address other relevant topics that emerged during the interviews. after completion of interviews the three principal investigators initially performed an internal analysis of each separate interview and an analysis across interviews to identify the scope of eu-level actions and experts' perceptions of these actions as achievements, failures or missed opportunities [ ] . afterwards, a directed (or deductive) content analysis approach [ , ] was applied whereby the initially predefined coding scheme with the main categories of interest (achievement, failure, and missed opportunity) was used to summarize the respective topics and the reasoning that appeared during the interviews. topics that did not fit into one of these main categories were added as new codes and were organized into new categories. the analysis was jointly performed by the principal investigators using nvivo (qsr international pty ltd. version ). furthermore, the results of the content analysis on achievements, failures and missed opportunities were grouped according to the major common themes in a table to provide an overview of the perceptions of the key informants. prominent eu-level outputs or actions, which were discussed by almost all respondents, are described in more detail in the results section. where applicable, we used original quotes to illustrate the views and tendencies of experts' assessments. the professional profile and study id of respondents are indicated behind the respective quotes. quotes which were originally given in dutch or german were translated into english. a slightly adapted nominal group technique [ ] was used for triangulation purposes. during the interviews, the participants were asked for five influential policy outputs of european health policy-making. following the finalization of all interviews, all participant nominations were compiled in one list and reoccurring topics were removed. to ensure comparability of policy outputs and actions, we grouped the nominations into categories under the following headlines: (a) secondary legislation and court decisions; (b) soft laws, strategies, and programmes; (c) agencies, centres, organizations; (d) networks, policy platforms, cooperation; and (e) others. participants were asked in an online survey to select three outputs per category which were, according to their opinion, most influential. based on the participants' nominations, a ranking in terms of a frequency distribution of selected influential policy outputs for each category was determined. the online survey was completed by out of participants who took part in the interviews. the design and analysis of the study was guided by applying guba and lincoln's test for trustworthiness [ ] . credibility and dependability have been ensured by enlarging the sample until saturation was reached in terms of the identification of eu policy actions and their perceptions. moreover, three researchers in the primary research group in combination with an internal advisory research group were involved with the aim of reflecting upon the study design and critically questioning the findings. additionally, the primary research group met regularly during the interview period to exchange initial findings and experiences on the interview process. the members of the internal advisory research group were experienced in eu public health policy research or qualitative research methodologies. the confirmability was strengthened by the use of several investigators both in the data collection process and in the analysis phase, combined with the use of triangulation, where interview participants were also asked to participate in the ranking exercise. the medical ethical committee of the university hospital maastricht and university maastricht declared that no ethical approval was required for this type of research. all participants were informed about their role and rights as study participant prior to their interview participation. all participants provided written or audio-recorded informed consent to be interviewed. overall, respondents consistently mentioned that, during the twenty-year history of the eu health mandate, specific initiators induced change in european public health policy. the most important identified initiators included the maastricht treaty with its later amendments, the health-related rulings of the european court of justice, and the health crises such as boviene spongiforme encefalopathie (bse) and severe acute respiratory syndrome (sars). in addition, the internal market provisions with the foreseen free movement of goods, people, services and capital, initiated change with both negative and positive public health impact. additionally, a set of conditions was identified in the interviews that described and advanced the role of eu health policy as a reference point for public health. these conditions under which eu health policy made progress during the past twenty years were (i) the regulatory power at the eu-level, (ii) eu-led facilitation of cooperation and comparisons across member states; along with (iii) increased capacity building on eu issues and on eu-level (e.g. professionalization, development of interest groups, associations). the ranking of influential policy outputs of eu-level health policy-making is provided in table . in the category "secondary legislation and court decisions", the patients' rights decisions made by the european court of justice (n = ) were chosen by most of the respondents as influential policy output, followed by the directive on the application of patients' rights in cross-border healthcare [ ] (n = ) and the directive on advertising and sponsorship of tobacco products [ ] (n = ). in the category entitled "soft laws, strategies, and programmes", the first and second eu public health programmes [ , ] (n = ) were selected most frequently, followed by the - health strategy "together for health" [ ] (n = ). the third rank is shared by three policy outputs: the "framework for action in the field of public health" [ ] (n = ) which is the commission's first proposal setting out eu-level public health after the introduction of the health mandate in the maastricht treaty, the council conclusions "towards modern, responsive and sustainable health systems" [ ] (n = ), and the current over-arching european strategy "europe " [ ] (n = ). in the third category on "agencies, centres and organizations", the european medicines agency (ema, n = ) ranked top, followed by the ecdc (n = ) and the european food safety authority (efsa, n = ). among "networks, policy platforms and collaborations", the european presidencies (n = ) were selected most often by the respondents, followed by the collaboration of the european commission (ec), the world health organization regional office for europe (who-eur) and the organization for economic co-operation and development (oecd) (n = ). moreover, the three entries on the third rank include the eu health policy forum (n = ), the network on epidemiological surveillance and control of infectious diseases (n = ), and the network on health technology assessment (n = ). the fifth category was not topic specific therefore, work on european level health determinants (n = ), the exchange of best practices (n = ), and published scientific reports which influenced eu policy-making (n = ) were ranked on the first three positions. at a glance, the label "achievement" was allocated to the public health mandate as it is laid down in the treaties, the establishment of eu-level agencies dealing with public health topics and successes in smoking prohibition, food safety and infectious disease control. the label "missed opportunity" was allocated to the insufficient degree to which the hiap approach is implemented and the ways in which health promotional aspects of alcohol and nutrition were handled. the label "failure" was less often assigned with the missing integration or link to social policies appearing in some interviews under this heading as well as the strength of the internal market which annulled national protective alcohol legislations in some member states. in table , we provide the full list of eu-level outputs or actions which, based on the content analysis and the identified thematic categories, were mentioned as achievements, missed opportunities or failures by the key informants. due to a broad and divergent spectrum of perceptions, topics almost always shared aspects of achievements, missed opportunities or failures. in the following section, we focus on those eu-level outputs or actions which were mentioned by the majority of respondents during the interviews and allowed us to draw a comprehensive picture on the breadth and the diversity of expert perceptions. an assessment of the general value of eu-level public health actions over the last twenty years resulted in mainly ambivalent judgments. on the one hand, many relevant activities were performed at an eu-level and the existence of a health mandate contributed to an eu social model. on the other hand, its dependence on political will and economic circumstances influenced the development of eu-level public health policy and led to the perception that more should or could have been achieved within and beyond the possibilities of the current health mandate. the establishment of the directorate general for health and consumers (dg sanco) in as an independent, formal structure for eu health policy was generally discussed as an achievement. the formation of dg sanco, and thus, the political decision to separate the health dossier from dg v, the former dg with the responsibility for health policy as well as a focus on employment and social policies, was controversially perceived. the establishment of dg sanco led, on the one hand, to a more mature health policy field. "…the dg v was a big dg and then dg sanco became separate from that. health had its own commissioner, its own opportunity to protect itself and public health benefits." (# , public health advisor/advocate) on the other hand, aspects of failure were mentioned regarding the detachment of health and social policy at eu-level. according to the respondents being separated led to a loss of collaboration for more holistic health policies and actions in health systems and healthcare at eu-level. a following the formation of dg sanco, it was seen as a beneficial way forward for the dg to shift its sectorial policy approach from a focus on specific topics such as cancer, drug dependence, health monitoring, accidents and injuries, or pollution-related diseases, to a horizontal one with the formulation of the first health strategy with three cross-cutting objectives: health information, health threats and health determinants [ ] . "and this was an important moment in time where the sectorial approach to aids, cancer and other issues has been reduced gradually and that more the integral horizontal approach, which was applied at that time already in all member stateshence europe was running behind in that sense, but ultimately was embraced and taken as guideline for the framing of all sorts of public health actions. "(# , eu/national civil servant) since it fostered more visibility of the public health field and closer cooperation by financing projects, joint actions and research across europe, the public health programme of dg sanco was commonly discussed as being supportive to the development of european public health and the mobilization of the public health community. aspects of missed opportunity became relevant when assessing the representation of health in other eu policies. "i don't know what exactly the reason is, but they [dg sanco] are not strong enough to push for health in [the other] dgs. the obvious example is the latest eu strategy, you cannot find reference to health anywhere it's really a disaster, because of [the] weak dg sanco. health is not among the headline targets, it's not among the flagships." (# , public health advisor/advocate) while the cooperation with other dgs was recurrently discussed as problematic, the potential for the "partnership on active and healthy ageing" under the european innovation union appeared as a unique theme and was regarded as an achievement for strengthening health policy on the general eu policy agenda. ecdc profile should cover also non-communicable diseases and sdoh. coordination of the approval of efficacy, safety and quality of drugs. cost-effectiveness of pharmaceuticals is not taken into account. problem of not being able to tackle pharmaceutical pricing. reversal of the approval of already approved drugs not handled on eu-level. control of health claims of food products. efsa mandate should include/be stronger on health promotion aspects of nutrition (e.g. regulation of advertisement of unhealthy food products). food safety directive. health mandate assures that health protection should be guaranteed in all eu policies. hiap and health impact assessment have never been implemented fully (tick box exercise). leads to the discussion of health in other sectors. control; tobacco product-; tobacco advertising directive). the tobacco regulations could have been designed stronger (e.g. more harmonized realisation of smoking prohibition on public places). tobacco regulation has some aspects of failure since a strict, general ban is not reached. food safety measures and regulations on health claims. missing political will to tackle obesity and related life style factors like unhealthy food products. health research programme eu health research budget and outcomes of the programme. missing integration of the research programme and eu health research outcomes in public health. health research budget. the use of structural funds for investments in health ( ) ( ) ( ) ( ) ( ) ( ) ( ) . internal market rules as source for legislation should be more attentive to health concerns. internal market provisions cause problems if member state regulation is more protective regarding health threats than eu regulation. the patients' rights directive in general. negotiations on patients' rights directive failed to include a strong emphasis on the development of common standards. effect on cross-border cooperation. gives legal certainty to policy makers. policy field which starts to recognize health, e.g. in its white paper on the cap after ( / (ini)). unrecognized potential for health of the cap by public health sector. health life years as indicator in the lisbon strategy. missing health information system. lack of morbidity data. different public health topics health inequalities ec communication: solidarity in health: reducing health inequalities in the eu. strengthening of the hta approach in the eu. coordinating cross-country level health technology assessments. coordinated management of rare diseases. existing drug resistance of tuberculosis as indicator for lacking disease management. health of minorities (e.g. roma) as part of the european agenda. social care is hardly seen as eu competence. environmental standards set by the eu. missing follow-up process on the environment and health action plan ( ) ( ) ( ) ( ) ( ) ( ) ( ) . blocking of direct to consumer advertising of prescription-only pharmaceuticals. white paper on governance ( ) increased transparency. more standardisation of methods (evaluation of indicators, outcomes, policies) and common language. increased understanding of the public health community about the impact of eu policies on public health. cooperation with industry influences the health research agenda and policy-making. evidence-based policy-making: the interest of the industry is against public health. and that's a good sign, if we can get more of those sorts of partnerships on specific policies, then i think, we'll get a better understanding."(# , eu/national politician) with regard to assessing the status of dg sanco cooperation with other international policy actors, respondents had mixed perceptions. whereas some argued that dg sanco's collaboration with international organizations like the who-eur or the oecd is improving and therefore, can be considered as an achievement, others asserted that this collaboration was not sufficiently established and can therefore be categorized as a missed opportunity. the establishment and the work of eu public health agencies like the ema, the ecdc, the efsa, and the european monitoring centre for drugs and drug addiction (emcdda) were regarded as an achievement and as an important step forward towards the strengthening of the european dimension in health. the work and the scope of the agency mandates was a recurring topic and subject to diverging perceptions. as an example, in the case of the ecdc, its development was assessed as an achievement whilst its scope was considered a missed opportunity. the bioterrorism attacks on the united states of america in and the sars crisis led to calls for better international coordination of infectious disease surveillance and the establishment of ecdc in [ ] . hence, the setting up of ecdc was commonly perceived as an achievement, since it gave preceding eu actions in infectious disease control a formal structure and maintained actions in the field. also, the close collaboration with the respective national public health agencies during outbreaks and in negotiating and developing common guidelines for infectious disease control were regarded as an important task of the ecdc. however, a number of respondents were critical of the scope of the ecdc mandate and thus, looked at this as a missed opportunity. questions were raised on whether the ecdc's responsibility in surveillance, risk assessment and training are sufficient or if additional responsibilities in risk communication and management were needed to assure full stewardship during and in the prevention of health crises. "i suppose the flu epidemic […] . that should be put on the table not only as a missed opportunity, big failure, having put ecdc at the center of the development, but the ecdc is not authorized to risk communicational management as you know. so, in that sense, it is a failure that member states were not able to coordinate in this very important public health area and use the eu institution, either ecdc or who to do that." (# , public health advisor/advocate) moreover, interview participants reported tensions between member states and eu agencies regarding the transfer of responsibilities from national to eu-level. "and the member states are very reluctant to hand over power regarding public health to the commission, or to brussels. now if you focus on infectious diseases, that is much better because they understand that there is a need, but again it is not easy." (# , eu/national civil servant) since the largest burden of disease in the eu is caused by non-infectious rather than infectious diseases, a call was put forward to further increase the mandate of ecdc to all public health relevant aspects and not focus only on infectious diseases. the hiap approach was generally assessed as an achievement regarding its potential to address health determinants outside the health sector. "[the article on the health mandate] is very important, because thereby a mandate is created that the commissioner for health and consumer affairs […] approaches his colleagues whenever they make new legislation to ensure that the health protection dimension is guaranteed; it gives partly a mandate to break into the policy and law development in sectors which in principle do not have any links with public health. […] this is very difficult. but its potential is very strong." (# , eu/national civil servant) however, in regard to its degree of implementation participants commonly perceived hiap as a missed opportunity. health impact assessment, the implementing tool to hiap, was regarded as a "tick box exercise" (# , # , both public health advisor/advocate) rather than a thorough consideration of health in other policies areas. explanations given during the interviews demonstrated that conditions to achieve hiap seemed not to be established yet and that there seems to be difficulty in bringing dg sanco interests in line with the interests of other dgs without over-emphasizing the health aspect. political assertiveness in convincing other commissioners and dgs about the relevance for intersectoral cooperation was perceived to be lacking, even though an inter-service group on public health with the participation of more than twenty ec departments was established for this purpose. generally, the work regarding tobacco was regarded as an achievement of how european health policy-making effectively addressed a life style risk factor for health. "the progress around tobacco [directive on tobacco advertising, directive on tobacco products, transparency register], the fact that we have a piece of international law on tobacco [who framework convention on tobacco control] is massive and that was european led." (# , public health advisor/advocate). this quote echoed the perception of the majority of respondents who emphasized the leading role of the eu regarding the support and commitment to the who framework convention on tobacco control. moreover, it was argued that the achievements regarding the regulation of tobacco advertising and smoking prohibition in public places would not have been achieved by single member states independently and thus this was a common achievement initiated and supported by european cooperation. nevertheless, aspects of a missed opportunity or even failure were mentioned in this regard since some would have appreciated stronger legislative measures to achieve a more harmonized realization of smoke-free legislation across the eu. it was considered that the achievements recognized in eu tobacco legislation were missed in the regulation of other health-related life style factors such as nutrition and alcohol. whilst regulations in the area of food safety were generally acknowledged as an achievement by preventing food-borne health threats; a potential mandate to address the composition of food and thereby, prevent, inter alia obesity or non-communicable diseases seemed to be neglected and was labeled as a missed opportunity. "…food safety has been majorly put forward over the last twenty years, in the sense that we know that the food will not be contaminated. but then it is a missed opportunity in the sense that beyond food safety there is health promotion and then one wanted the union to have more powers to regulate issues on the content of saturated fat for instance or the percentages of sugar and so on." (# , public health advisor/advocate) with regard to governmental activity on these issues, the eu platform for action on diet, physical activity and health was named as an example of an achievement as well as a failure. "i think the diet platform […] can be seen as a failure and opportunity. […] if we had not created that platform then arguably the issue wouldn't have been tackled at all. and in a way that has been really brought some issues of complexity to the political discussion around issues around marketing of food, around self-regulation, reformulation, some of the initiative like salt in diet has come as a commitment from that platform."(# , public health advisor/ advocate) the failure aspect of the eu platform for action on diet, physical activity and health was related to the perception that a platform is a rather weak policy instrument and that more political will to tackle these issues with stronger eu policy or legal instruments would have had more impact. additionally, the lack of timely cooperation of public health professionals with other sectors such as agriculture was raised as missed opportunity. it was illustrated that agriculture policy has public health relevant links regarding affordability, accessibility, and the availability of food. however, it was also argued that this cooperation has been developed further over the recent years. "and it is correct, that the common agriculture policy has not been taken up health in the beginning, but by now they are doing this very consciously. […] thus, i really see an improvement; i actually do not see a situation anymore in which health was influenced really negatively [by the common agriculture policy]." (# , eu/national civil servant) internal market provisions were perceived as ambivalent by the respondents. the eu is based on internal market rules that also affect eu health policy. "the engine of european health policies is still the market."(# , academia) however, the influence of eu market regulations, for example on alcohol policies, was perceived as a failure when member states had more protective and stricter national legislation as was the case in the nordic countries. respondents claimed that eu internal market regulations that are more attentive to health issues would be appreciated in this case. moreover, the potential given by articles and of the tfeu, which put limitations on the single market, was mentioned and it was perceived as a missed opportunity that this potential had not been fully taken up by public health experts: "[…] the public health aspect, which is written into article [now article , tfeu] on the internal market, you can put limits on the internal market on the grounds of public safety, public morality and public health, is almost never used. what if dg internal market was turned into our greatest weapon?" (# , public health advisor/advocate) this was positively exemplified by the case of tobacco control which applied internal market rules for public health purposes to assure harmonized labeling, packaging, nicotine content, etc. across the eu. however, the application of the health argument to put limitations on the internal market rules was also perceived as being negatively connoted by non-public health experts: "if you just go to the dg internal market and grab the first person you see and ask them what public health means, they will tell you it's the exception member states use to defend local weird monopolies on peculiar alcohol, or something like that. it's an exception to a rule." (# , academia) the recent eu patients' rights directive in cross-border healthcare [ ] was mainly regarded as an important achievement. this assessment was not necessarily driven by satisfaction with the scope of the directive but, instead, because it is the first eu secondary legislation ever enacted specifically on healthcare. "[…] the cross-border directive will turn out to be incredibly important. particularly because it is so symbolic important if you like because it does represent really the first time that the eu has got any concrete in relation to healthcare as opposed to public health. the consequences of this remains to be seen." (# , eu/national civil servant) "therefore, i see the patients' directive as a true success from a legislative perspective" (# , academia) the achievement aspect was supported by perceptions that the directive will lead to more cross-border cooperation and will have an impact on quality of care as well as on priority setting in healthcare and the packaging of healthcare services. thereby, it was expected that the directive will not only influence people who seek healthcare services in other countries but also those who seek services in their home country. in this regard, some expected that the directive would also ultimately empower patients as consumers of healthcare services. "the cross-border directive […] will have consequences of more consumer empowerment, consumer rights, patient rights, more consumer participation and more literacy,…"(# , public health advisor/advocate) however, there were also critical voices that interpreted the directive, as targeting a limited segment of the european population and hence, potentially increasing health inequalities. these respondents also questioned the willingness of the general population to seek healthcare treatment outside their home country. furthermore, respondents were critical of the extent to which more eu involvement in healthcare of member states would lead to quality assurance in general: "it is positive in the way people can be treated where they want, but it is still my point of view that we […] want to have our own level of quality and we don't want others to decide what level it should be. perhaps, because we have a very high quality […] . but of course we don't mind to tell others about it, we don't mind others to come in, we don't mind to help others to get the same standard -that is cooperation, so i always say i love cooperation but i do mind the harmonization.". (# , eu/national politician) this study provides an overview of public health relevant eu-level actions of the past twenty years. we outlined the diverse nature of expert perceptions on key developments in the field and provided a ranking of the most influential achievements. the assessment of outputs or actions being an achievement appeared across and within interviews along with assessments of outputs or actions being a missed opportunity and less often a failure. thereby, it turned out that the eu public health field has significantly developed its organizational structures (dg sanco, supranational agencies dealing with public health) and incorporated public health topics like infectious disease control and tobacco control, whereas the hiap approach still included untapped potential. this finding confirms "the challenge of implementation" [ ] of the hiap concept in the eu [ , ] . given the fact that according to article and article ( ),tfeu [ ], a high level of human health protection should be ensured within all eu policies and actions, it was seen as a weakness that the uptake of health consideration in the general eu policy-making process was low [ ] . ollila described the importance of communication and cooperation strategies for a successful realization of the hiap approach [ ] . the deficiency of these strategies was raised during the interviews which indicated that the performance of eu health players is perceived to be particularly poor in this regard. concordance of interview responses with tasks formulated in the health mandate of the eu interestingly, the study indicated that the treaty-based tasks such as support of cooperation between member states, development of guidelines and indicators, best practice exchange, and periodic monitoring and evaluation on eu-level public health to ensure 'a high level of human health protection' [ ] were only partially perceived as fulfilled or acknowledged by the interviewed experts. thematic discussions on actions or policies related to the development of guidelines and indicators appeared with regard to infectious disease surveillance and management of rare diseases but were not a major theme across interviews. the eu-level task to promote best practice exchange among member states was regarded as influential, which is represented by a top position in one of the rankings presented in this paper. with regard to the task of establishing monitoring and evaluation structures, some respondents perceived the status of the eu health information system rather as a failure. this corresponds to observations in the literature indicating that although ground work such as the development of a common eu health indicator set is acknowledged [ , ] further efforts are needed to implement and maintain health indicators [ ] and to develop a permanent and sustainable eu public health monitoring and reporting infrastructure that supports decision making in public health on eu level [ , ] . respondents agreed that cooperation in the area of public health between member state representatives and experts as well as with other stakeholder groups has increased and has been facilitated by the eu through various projects, networks, forums, and platforms. this trend was mainly positively perceived since it supported eu-level public health policy by accumulating and exchanging knowledge, generating public support and a legitimacy to act on certain fields [ ] . this finding is corroborated by the literature on the potential of new governance instruments for health-and social policy-making at eu-level [ , [ ] [ ] [ ] . however, these new governance instruments can also be regarded as a rather strategic investment of the ec to keep topics on the agenda until a political window of opportunity opens but as an ineffective policy tool to enforce and implement action in due course [ ] . the collaboration of a diverse set of stakeholders as it is the case for example in the eu platform for action on diet, physical activity and health can lead to actions that constitute rather a compromise of various interests. consequently, the results might be disappointing from the viewpoint of public health experts [ , ] . a final judgment on the impact of facilitating collaboration is to be awaited and may only be made in the long term future. it will require different ways of measuring 'impact' compared to the analysis of domestic adaptations when implementing eu hard law [ ] . the assessments of ec tasks for public health policy making have been influenced by characteristics like the subsidiarity principle throughout several interviews. on the one hand some participants were in favor of more eu influence on health policies and their implementation. in their view integration and harmonization of health policy did not reach far enough and hence their perception of actions was dominated by the category 'missed opportunity'. on the other hand some experts were in favor of keeping certain health issues like health care as national responsibility which led to a perception of too much eu involvement and a negative perception of the evolvement of the health mandate. public health has a cross-cutting nature and cooperation across dg's often poses difficulties. therefore, convincing evidence is required to demonstrate the health impact of policies outside the health domain and strong partnerships are needed to counter strong industrial lobbying groups [ , , ] . the ease of cooperation and the potential to achieve policy coherence between dg sanco and dgs with stronger regulatory competences like the internal market (e.g. regarding tobacco, pharmaceuticals) or agriculture policy (regarding food safety, subsidies of unhealthy versus healthy food products) represented another characteristic that influenced the individual perception of eu public health policies. experts who assessed the value of eu health policy actions under the reality of a rather weak health mandate were more likely to perceive eu actions as achievements. this was in contrast to others who strove for more appreciation of social and health matters in eu policies and who perceived a lot of missed opportunities or failures in this regard as the power of the eu was too weak to realize change and to fulfill the objective of the health mandate to ensure human health protection for citizens in the eu. in summary, underlying themes such as cooperation among european public health professionals, increasing institutionalization, and characteristics such as the issue of subsidiarity or the possibilities to cooperate across eu policy domains influenced experts' perceptions throughout the topics presented in this paper. these conditions and characteristics are part of what lamping called the "chaordic dynamics" of european integration in the field of health policies [ ] . as our study demonstrated eu health policy does not demonstrate a clear-cut success since the logic of action in the field can involve diverging interests. nevertheless, the eu public health has quite systematically developed in terms of scope and impact beyond the original mandate. the ranking of influential policy outputs provided indications on important developments in eu public health policy. however, even though we categorized the outputs, they sometimes differed in character and power which might have led to imbalanced judgments. additionally, we received different reasons for labeling eu-level actions or policies as achievements, missed opportunities or failure for public health. some were identified because they increased the strength or value of eu-level public health policy, whereas, others were identified because they impacted the health of the european population. the findings of the study may not be empirically generalizable since they were closely linked to qualitative individual perceptions and the settings that participants belonged to. however, we are confident that the broad range of profiles of the experts has ensured the diversity of perceptions on the topics varying from achievement to missed opportunity and failure. moreover, given that participants were generally active in health policy at eulevel and mainly positive about the eu, this could also have influenced the obtained results to some extent. eu public health policy is subject to divergent perceptions of how successful or unsuccessful specific topics have been tackled and how far european integration in public health policy should go. from the findings, it is unequivocal that the eu has strengthened its role over the past twenty years in supporting, coordinating, and supplementing member states' actions on public health issues as laid down in article ( ), tfeu. the eu is now a recognized player in public health in europe. however, when it comes "to the promotion of a high level of […] protection of human health […]in defining and implementing its policies and activities" (article , tfeu), further work is needed to achieve the full potential of the eu health mandate. endnote a also several eu member states disconnected on national level the ministry of health from social affairs. at the time of writing only seven out of eu member states organized health and social affairs within one ministry (spain, france, sweden, finland, estonia, greece, the netherlands). regulation (eec) / on the application of social security schemes to employed persons and their families moving within the community (accompanied by implementing ec launches the action programme maastricht treaty: the legal basis for undertaking actions in the field of public health is defined in article year eu health policy developments after the introduction of a legal eu health mandate by the maastricht treaty the european agency for the evaluation of medicinal products (emea), now european medicines agency (ema), has been formed in london. treaty of amsterdam: health impact assessment is implemented directorate general for health and consumers (dg sanco) is established lisbon agenda recognizes health protection as a prerequisite for economic growth measured with the indicator healthy life years the european food safety authority (efsa) has been established in parma first programme of community action in the field of public health the tobacco advertising directive / /ec is adopted after the first version has been annulled by the european court of justice commission decision to set up an executive agency for the public health programme. it has the task to manage community action in the field of public health the european centre for disease prevention and control (ecdc) in stockholm is operational white paper: together for health: a strategic approach for the eu decision for a second programme of community action in the field of health directive / /eu on the application of patients' rights in cross-border healthcare has been adopted. abbreviations aspher: association of schools for public health in the european region boviene spongiforme encefalopathie; dg: directorate general; dg connect: directorate general for communications networks, content and technology; dg sanco: directorate general for health and consumers emcdda: european monitoring centre for drugs and drug addiction; eu: european union; gats: general agreement on trade in services; heidi: health in europe: information and data interface; hia: health impact assessment; hiap: health in all policies; hta: health technology assessment; oecd: organization for economic cooperation and development; sars: severe acute respiratory syndrome; sdoh: social determinants of health; tfeu: treaty on the functioning of the european union; who-eur: world health organization-regional office for european union: the maastricht treaty. the treaty on the european union (teu). maastricht: european union european union and health policy: the "chaordic" dynamics of integration the impact of the eu law on health care systems eu law and the social character of health care health law and policy in the european union the politics of european union health politics health systems governance in europe -the role of european union law and policy health law and the european union health governance in europe -issues, challenges and theories european union public health policies -regional and global trends european policymaking on the tobacco advertising ban: the importance of escape routes patient's rights: a lost cause or missed opportunity? in health care and eu law european parliament and council of the european union: directive on the approximation of the laws, regulations and administrative provisions of the member states relating to the advertising and sponsorship of tobacco products ( / /ec) european parliament and council of the european union: directive on the approximation of the laws, regulations and administrative provisions of the member states concerning the manufacture, presentation and sale of tobacco products ( / /ec) european parliament and council of the european union: decision setting up a network for the epidemiological surveillance and control of communicable diseases in the community ( / /ec) european commission: commission decision / /ec on the early warning and response system for the prevention and control of communicable diseases under decision no / /ec european guidelines for quality assurance in colorectal cancer screening and diagnosis european guidelines for quality assurance in cervical cancer screening european guidelines for quality assurance in breast cancer screening and diagnosis eu regulatory agencies and health protection. in health systems governance in europe public health and risk assessment directorate: key achievements public health and risk assessment directorate: key achievements directorate general for health and consumers (dg sanco): health in the eu. what is in there for you? recent achievements cap on health? the impact of the eu common agricultural policy on public health. london: faculty of public health estimating the cardiovascular mortality burden attributable to the european common agricultural policy on dietary saturated fats regulating medicines in europe: the european medicines agency, marketing authorisation, transparency and pharmacovigilance is health recognized in the eu's policy process? an analysis of the european commission's impact assessments the european centre for disease prevention and control: hub or hollow core? j health polit policy law public health evaluation and impact assessment consortium: mid-term evaluation of the eu health strategy - -final report. bologna: public health evaluation and impact assessment consortium european court of auditors: the european union' s public health programme public health evaluation and impact assessment consortium: mid-term evaluation health programme ( - ) -final report. bologna: public health evaluation and impact assessment consortium how to peer review a qualitative manuscript qualitative data analysis: an expanded sourcebook beltz: weinheim three approaches to qualitative content analysis consensus methods for medical and health services research naturalistic inquiry european parliament, council of the european union: directive on the application of patients' rights in cross-border healthcare council of the european union: decision on adopting a programme of community action in the field of public health council of the european union: decision on establishing a second programme of community action in the field of health ( - ) ( / /ec) together for health: a strategic approach for the eu - (com( ) final). brussels: commission of the european communities european commission: commission communication on the framework for action in the field of public health (com( ) final). brussels: commission of the european communities council conclusions: towards modern, responsive and sustainable health systems ( /c / ). off j eur union european commission: communication on europe . a strategy for smart, sustainable and inclusive growth (com( ) final). brussels: european commission european union: communication from the commission to the council, the european parliament, the economic and social committee and the committee of the regions on the health strategy of the european community (com( ) final) european union: regulation of the european parliament and of the council. establishing a european centre for disease prevention and control the state of health in all policies (hiap) in the european union: potential and pitfalls health in all policies: from rhetoric to action european union health information infrastructure and policy. in european union public health policy regional and global trends public health indicators for the eu: the joint action for echim (european community health indicators & monitoring). archives of public health = archives belges de sante publique the weakness of strong policies and the strength of weak policies: law, experimentalist governance, and supporting coalitions in european union health care policy the hard politics of soft law: the case of health. in health systems governance in europe the open method of co-ordination in action: the european employment and social inclusion strategies collaboration and consultation: functional representation in eu stakeholder dialogues europeanization: new research agendas buchner b: nutrition, obesity and eu health policy a european alcohol strategy submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution the paper was partly presented at a symposium held on th june in brussels, belgium, the european public health conference on th november in malta, and a conference on the th anniversary of the eu health mandate on nd may in maastricht, the netherlands. we would like to express our sincere thanks to the experts who invested their time and participated in the interviews. their views and perceptions on european public health policy were highly valued. we would like to thank wilco tilburgs and hassan el fartakh for their support in transcribing the interviews and ann borg for her support and helpful recommendations during the final editing process. we also appreciate the support of our colleagues at the department of international health at maastricht university; in particular kasia czabanowska, matt commers, kai michelsen, christoph aluttis and beatrice scholtes gave advice in setting up and designing the study, questioning the results, or reviewing the manuscript. the authors declare that they have no competing interests. all authors were involved in setting up the study. nr and tc coordinated the study. nr, tc and ks carried out the interviews, performed the analysis, and interpreted the results. nr drafted the manuscript. all authors revised the manuscript and approved the final version. key: cord- -alyyju x authors: james, peter bai; wardle, jonathan; steel, amie; adams, jon title: an assessment of ebola-related stigma and its association with informal healthcare utilisation among ebola survivors in sierra leone: a cross-sectional study date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: alyyju x background: we examined the magnitude and correlates of ebola virus disease (evd)-related stigma among evd survivors in sierra leone since their return to their communities. in addition, we determined whether evd-related stigma is a predictor of informal health care use among evd survivors. methods: we conducted a cross-sectional study among evd survivors in five districts across all four geographic regions (western area, northern province, eastern province and southern province) of sierra leone. ebola-related stigma was measured by adapting the validated hiv related stigma for people living with hiv/aids instrument. we also measured traditional and complementary medicine (t&cm) use (as a measure of informal healthcare use). data were analysed using descriptive statistics and regression analysis. results: evd survivors report higher levels of internalised stigma ( . ± . ) compared to total enacted stigma ( . ± . ). social isolation ( . ± . ) was the highest reported enacted stigma subscale. ebola survivors who identified as christians [aor = . , %ci: . – . , p = . ], who perceived their health to be fair/poor [aor = . , %ci: . – . . p = . ] and who reside in the northern region of sierra leone [aor = . , %ci: . – . , p = . ] were more likely to experience internalised stigma. verbal abuse [aor = . , %ci: . – . , p = . ] and healthcare neglect [aor = . , %ci: . – . , p = . ] were independent predictors of t&cm use among evd survivors. conclusion: our findings suggest evd-related stigma (internalised and enacted) is prevalent among evd survivors since their return to their communities. religiosity, perceived health status and region were identified as independent predictors of internalised stigma. verbal abuse and healthcare neglect predict informal healthcare use. evd survivor-centred and community-driven anti-stigma programs are needed to promote evd survivors’ recovery and community re-integration. the - ebola virus disease (evd) outbreak in west africa is considered the largest and unprecedented public health emergency in the history of the disease [ ] . as at the th march , the morbidity and mortality figures due to evd were estimated at , and , respectively [ ] . the west african ebola outbreak also recorded the highest number of survivors, and current estimates put the number of evd survivors at more than , [ ] . many evd survivors are known to be suffering from short and long-term physical symptoms and mental complications as a result of surviving evd [ ] [ ] [ ] . psychosocial consequences of evd survivorship can be traumatic, due to the adverse psychological experiences of individuals with evd had to grapple with during infection, treatment and post-discharge. these adverse experiences includes various forms of psychosocial challenges such as depression, anxiety and grief due to loss of loved ones and stigma [ ] . stigma constitutes negative attitudes and beliefs that discredit an individual or group of individuals leading to prejudice and societal exclusion [ ] . stigma can lead to experiences and feelings of blame, shame, worthlessness, loneliness, isolation, social exclusion and discrimination in accessing social amenities and healthcare services [ , ] . socially undesirable manifestations (prejudice and discrimination) expressed against those with the stigmatizing attributes are known as enacted stigma whereas the feeling of shame, guilt or worthlessness experienced as a result of having the stigmatising attribute is referred to as internalised stigma [ ] . evd-related stigma is largely based on community fear that evd survivors are still contagious [ ] . such fear is profound if evd survivors experience post-ebola sequelae [ , ] or are aware that the ebola virus can be present in certain immune-protective parts of the body after convalescence (for example, the semen, breast milk, ocular (eye) fluid, and spinal column fluid) [ , ] . evd-related stigma has led to evd survivors being mocked by their communities [ , ] , being evicted from their homes by their property owners [ , ] , losing their former jobs [ ] and being divorced by their spouses [ , ] . some evd survivors have been prevented from visiting public places such as public toilets and have experienced difficulty in trading commodities at their local market due to a community reluctance to touch their items or money [ , ] . evd-related stigma has been reported by evd survivors and their communities in dr congo ( %), guinea ( %) and liberia ( %) [ ] [ ] [ ] , and may be more common among female rather than male evd survivors [ ] . other factors, which have been reported as predictors of evd-related stigma, are age, level of education, and having accessed medical care [ ] . liberian research also suggests evd survivors are reported to be more likely to experience stigma compared to their close contacts who were not infected with evd virus [ ] however the degree of evd-related stigma may decline among survivors over time [ , ] . in sierra leone, stigmatisation is reported in approximately one third of evd survivors [ , ] . stigma associated with infectious disease has been linked to poor adherence to conventional treatment and the utilization of informal or non-integrated forms of health care such as traditional and complementary medicine (t&cm) [ , ] . t&cm refers to a number of health systems, products and practices considered to be predominantly outside conventional medical practice and the medical curriculum [ , ] . in sub-saharan africa, an average of % of the general population is estimated to use t&cm products and % consult t&cm practitioners [ ] . the key reasons for t&cm use in africa have been attributed to its low cost, easy accessibility, the alignment between t&cm philosophy and local cultural and religious values, perceived safety and efficacy, and dissatisfaction with conventional medicine [ ] . in sierra leone, t&cm utilisation is common especially among hypertensive, pregnant women, infertile women, and lactating mothers and in the management of malaria and diarrhoea [ ] [ ] [ ] [ ] [ ] [ ] . studies have reported individuals with hiv/aids or mental health diagnoses that experience stigma are more likely to access t&cm services [ , ] . this pattern of use is reportedly due to the users' perception of t&cm as less stigmatizing than conventional medicine, partly justified by the view that these t&cm approaches are deeply rooted in the local cultural and traditional practices [ , ] . among sars survivors, t&cm was reported to be useful in overcoming sars-related stigmas by creating new social support networks and counteracting potential future stigmatization and discrimination [ ] . most studies on stigma among evd survivors have focussed on its magnitude and nature both immediately following and over a number of years after discharge from an ebola treatment centre [ - , - , , , ] . although recent studies have reported the use of informal healthcare services among evd survivors [ , ] , globally, no study to date has reported whether evd-related stigma is associated with t&cm utilisation among evd survivors. in addition, none of the published studies in sierra leone on evd survivors has explored the sociodemographic and health-related factors associated with evdrelated stigma. such associations are important, as they will inform the design and implementation of future antistigma interventions. therefore, we examined the magnitude and the sociodemographic and health related correlates of enacted and internalised stigma among evd survivors in sierra leone since their return to their communities. in addition, our study determined whether enacted and internalised stigma are possible predictors of informal healthcare service utilisation (t&cm use) among evd survivors in sierra leone. we conducted a cross-sectional questionnaire study between january and august among evd survivors across all four geographic regions (western area, northern province, eastern province and southern province) of sierra leone. participants in this study were adult evd survivors aged years and older experiencing post-ebola sequelae. we excluded evd survivors whose physical and psychological health limited them from providing information, such as those survivors with memory loss, hearing loss, high fever and bleeding or those experiencing acute emotional distress. a sample of evd survivors was determined using a sample size formula for cross-sectional studies (n = z pq/ d ). we increased our sample to to make up nonresponses. multistage sampling method was used to recruit participants across the country. data was collected from the four geographic regions of sierra leone (western area, northern province, southern province and eastern province). five districts were purposefully selected to cover all four geographic regions of the country. the location of the five districts in sierra leone are shown in fig. . the five districts are western area urban and western area rural districts (both in the western area), bo district (southern province), kenema district (eastern province) and bombali district (northern province). these five districts were chosen based on the epidemiological profile of the total confirmed ebola cases and because they are host to the highest number of ebola survivors in sierra leone. we randomly sampled the required number of evd survivors in all five districts based on proportional representation using the national list of registered ebola survivors obtained from the sierra leone association of ebola survivors (slaes). survivors who were randomly chosen were invited to participate in the study via telephone. the survey instrument measures evd demographics such age, sex, marital status, educational status, religious affiliation, employment status, financial status, place of residence (urban/rural), geographical region (north, south, east regions and western area) and time (months) since post-discharge. perceived health status was measured using a five-point likert scale that ranged from "excellent" to "poor". evd survivors were asked if they had been diagnosed with any chronic condition prior to being infected with evd virus. the ebola-related stigma instrument was adapted from the hiv-related stigma for people living with hiv/aids (hasi-p). the hasi-p is a validated -item scale that measures stigma among hiv/aids patients in the past months [ ] . this instrument was validated among hiv/aids patients in five african countries: lesotho, malawi, south africa, swaziland and tanzania. it consists of the following subscales and this includes verbal abuse (eight items, α = . ); healthcare neglect (seven items, α = . ); social isolation (five items, α = . ); fear of contagion (six items, α = . ); and workplace stigma (two items, α = . ) all of which measures enacted stigma. the final subscale called negative selfperception (five items, α = . ) measures internalised stigma [ ] . we decided to use hiv/aids related stigma scale (hasi-p) because hiv/aids patients share similar psychosocial challenges with evd survivors in terms of social isolation, fear of contagion and family and community stigma and discrimination [ ] . in addition, there is widespread misinformation about hiv/aids and evd. for instance, evd and hiv/aids only affects certain groups of people in society (the poor for evd and promiscuous adults or homosexuals for hiv/aids) and the unfounded community fear of being infected with the virus through means that have not being scientifically proven [ ] . to adapt to our setting, the hasi-p was reviewed by two experts in sociology and evd as well as piloted among evd survivors. based on their feedback, we decided to remove the two items that measure workplace stigma since the majority of evd survivors did not have any paid job before or after evd. we also removed the statement "at the hospital, i was left in soiled bed" from the healthcare neglect subscale since majority of survivors were not admitted at the clinic/hospital. in addition, the wording of some statements were changed to fit the local evd survivorship context. further, we decided to assess stigma experienced by evd survivors since their discharged from ebola treatment centre instead of the past months, as was the case when the instrument was validated among hiv/aids patients [ ] . the final adapted hasi-p instrument used in our study is attached as an additional file . evd survivors were asked about their health care utilisation, including whether they have used t&cm treatment (products and practitioners) since their discharge from the etc. the common t&cm modalities considered in our study were informed by studies undertaken previously in sierra leone [ - , , - ] and across africa [ ] . we considered t&cm in our study to include biological based therapy (herbal medicine and animal extract), spiritual therapy (prayer/faith healing), alternative medicine systems (chinese herbal medicine, and acupuncture), and physical therapy/body manipulations (massage therapy, traditional bone setting). trained data collectors obtained the relevant information from evd survivors using self-administered or interviewer-administered (for illiterate participants) formats. the university of technology sydney human research ethics committee (uts-hrec-eth - ) and the sierra leone ethics and scientific review committee granted ethical clearance. a participant information sheet, explaining the purpose and scope of the study, as well as the option to opt out, was given or read (illiterate) to evd survivors before seeking their consent to participate. survivors signing or thumb printing the consent form was interpreted as their willingness to participate. survivors who signed or thumbed printed (for illiterate participants) the consent form were then given the questionnaire to fill or to be interviewed(for illiterate participants).three hundred and fifty eight evd survivors consented and completely filled the questionnaire and were included in the data analysis. we collected our data between may and august and it was done either at the regional office of evd survivors or their homes or the village courtyard. we used ibm spss statistics version to perform all analyses. each of the stigma items was assigned a score of to ( = never, = once or twice, = several times and = most of the time). for each participant, we summed the scores and divided by the number of items to get the mean score for each of the factors/subscales. to obtain the overall total stigma mean score, we summed up the mean scores of each of the factors and divided by . stigma was analysed as a binary variable (yes/no). mean stigma score of zero means that none of the items (experiences) in each of the subscales (internalised stigma, verbal abuse, healthcare neglect, fear of contagion and social isolation) occurred since discharged from the etc. a mean stigma score greater than zero indicated that at least one of the items in each of the subscales occurred once or twice or several times or most of the time. as a binary variable, mean score of zero was taken as the absence of stigma and greater than zero was taken present of stigma. we employed chi-square and fischer exact two tailed tests to determine the association between stigma subscales and sociodemographic and health related variables. we conducted a backward stepwise regressions analysis to establish the most parsimonious model that determines the sociodemographic and health related predictors of internal and enacted stigma. we also used backward stepwise regressions analysis to establish the most parsimonious model that predicts whether internal and enacted stigma is an independent predictor of informal healthcare use (t&cm use). to determine the independent association between evd -related stigma and t&cm use, all of the sociodemographic (age, sex, marital status, religious affiliation, employment status residence etc.) and health related (perceived health status, duration(years) since discharged from etc, known chronic disease) variables were taken as potential cofounders and were adjusted for in the regression analysis. probability less than . was as statistically significant for all inferential statistical analyses. out of the survivors invited to participate in the study, of them agreed to take part in the study. however, failed to completely fill the questionnaire. thus, complete data on evd survivors were analysed. table gives a summary of evd survivors' sociodemographic and healthrelated characteristics. more than half (n = , . %) of survivors were within the ages of - years and close to two-thirds (n = , . %) were females. also close to three -fourths (n = , . %) of survivors perceived their health to be fair/poor. based on the calculated mean scores, evd survivors reported higher levels of internalised stigma ( . ± . ) compared to enacted stigma ( . ± . ). among the enacted stigma subscale, social isolation ( . ± . ) and healthcare neglect ( . ± . ) were the highest and least respectively. we categorised stigma scores into (yes /no) as there was little variability in stigma scores. in general, majority of ebola survivors endorsed at least one item exploring internalised stigma (n = , . %) and any of the three subscales measuring enacted stigma (n = , %). verbal abuse (n = , . %) and fear of contagion (n = , . %) were the highest and least reported enacted stigma subscales respectively (see table ). association between stigma and sociodemographic and health related variables among ebola survivors table summarises the comparison of internalized and enacted stigma with sociodemographic and health related variables among ebola survivors. religious affiliation (p = . ) and perceived health status (p = . ) were associated with internalised stigma. none of the sociodemographic and health related variables was associated with table ). no sociodemographic and health related variables predicted total enacted stigma. association between t&cm use and internalised and enacted stigma this is the first nationally representative study to determine the prevalence of stigma, its sociodemographic correlates and association with informal and nonintegrated forms of health care such as t&cm use among evd survivors in sierra leone. one key finding from our study is that evd survivors report high levels of internalised and enacted stigma since discharge from an ebola treatment centre which is in line with findings from a longitudinal liberian study that reported high levels of stigma at baseline but lower levels at subsequent follow-up visits [ , ] . our finding also resonates with similar short term and smaller sample size cross-sectional studies in sierra leone [ , , ] , liberia [ ] , guinea [ ] , and dr congo [ , ] ,which reported that evd survivors experience several forms of internalised and enacted stigma. our result identifies higher occurrence of internalised stigma when compared with the occurrence of total enacted stigma experienced by evd survivors. our result contrasts to findings reported in a liberian longitudinal cohort study that employed a different stigma instrument [ ] but is in line with a south african study that employed the same stigma tool to measure stigma among hiv/aids patients to that employed in our study [ ] . the higher frequency of internalised stigma (negative self-perception) among evd survivors in our study is a cause for concern and warrants further research attention as it can lead to low self-esteem, low self-efficacy, loss of hope for the future and can interfere with life goal achievement [ ] . the findings for evd studies appear to be similar to some other infectious diseases. for example, similar sequelae have been reported among hiv/aids patients in hong kong [ ] and uganda [ ] , in which hiv/ aids patients reported to feel less worthy of themselves, guilt, shame and self-blame for having hiv/aids. the common types of enacted stigma faced by evd survivors in our study were social isolation, verbal abuse and fear of contagion, all of which are congruent with the common forms of stigma reported by evd survivors in the wider literature [ ] . these findings may be applicable to other emerging infectious disease survivors more generally, as similar forms of stigma from the public and healthcare staff have also been reported among sars survivors in hong kong [ ] . social isolation, verbal abuse and fear of contagion can lead to increased levels of psychological distress, delayed access to medical care, low adherence to medical therapy and reduced quality of life as it has also been reported among hiv/aids and mental health patients [ , ] . drawing from lessons learnt from hiv/aids-related stigma, several evd survivor-centred and community-driven strategies have been suggested that could contribute to evd survivors' recovery and community re-integration. these include community long-term psychosocial counselling for evd survivors to enhance their coping skills, community education and social support programs for evd survivors, recruitment and training of trusted opinion leaders that can spread accurate de-stigmatising messages within communities, minimising social isolation and promoting economic empowerment of evd survivors and evd affected communities [ , ] . the mental health impact of surviving ebola is enormous, and previous studies have reported that psychological distress, anxiety and depression are widespread among ebola survivors [ , ] . although the impact of ebola -related stigma on mental illness among ebola survivors is not well understood, stigma induced psychological distress and anxiety have been found to be associated with adverse mental health outcome among hiv/ aids patients [ ] . since hiv/aids and ebola virus disease share similar stigmatizing attributes [ ] , it is possible that ebola -related stigma maybe contributing to the mental health complications among ebola survivors. thus, it likely that stigma reduction strategies will help reduce the mental health burden among evd survivors. evd survivors in our study who identified as christians and reside in the northern region were more likely to experience internalised stigma. the reasons for the high levels of internalised stigma among christians remain unclear. going forward, an in-depth ethnography study would be required to explain the high levels of internalised stigma amongst christians compared to muslims that was observed in our study. our study findings also reveal that evd survivors who perceive their health to be fair/poor are more likely to experience internalised stigma than those who perceive their health to be good. in hiv/aids patients, the link between stigma and perceived poor health status is postulated to be because stigma is known to promote poor adherence to treatment, lowers emotional coping and social support networks and reduces access to and usage of health and social services leading to poor health outcomes [ , ] . the similarity of our findings suggest that similar concerns may be present for evd survivors. further studies are needed to explore the link between internalised stigma and religiosity as well as perceived poor health status among evd survivors in sierra leone. nonetheless, our results have revealed that religiosity, perceived health status and spatial location are potential predictors of internalised stigma among evd survivors and, that healthcare provider and social workers should consider these characteristics as possible risk factors for internalised stigma among evd survivors in sierra leone. further analysis of the enacted stigma subscales revealed verbal abuse was more likely to occur among evd survivors residing in urban locations when compared to those living in rural areas. our finding may be explained by the fact that adherence to local bylaws to prevent stigma and discrimination by the community was more prevalent in rural areas compared to urban areas [ ] . also, previously identified urban-rural community differences in knowledge and perception of, and attitude towards, evd may also explain our finding [ ] . our study also revealed that evd survivors who are unemployed were more likely to be socially isolated by their communities than their counterparts who were employed. such a finding maybe explained given that unemployed evd survivors are likely to be economically and socially dependent on their families and their communities for their wellbeing and, as such are more likely to experience stigma in the form of isolation from their families and communities compared to employed evd survivors [ , ] . evd survivors who experienced healthcare neglect in conventional healthcare settings in our study were more likely to use t&cm. our finding is not surprising given that healthcare neglect (negative attitude of healthcare providers, long waiting time or being the last person to be seen by the doctor) leads to patient's dissatisfaction with conventional healthcare -a key driver for t&cm use in the general and sub-health populations in africa [ ] . thus, it is important for policy makers and health providers to bear in mind that, like other sub-health populations, evd survivors will likely seek informal healthcare options if they feel neglected by the conventional health system. at policy level, laws are needed that allow evd survivors to receive appropriate care in a safe environment without being stigmatised or discriminated. in addition, educational interventions to change the negative attitude towards evd survivors among health providers are required. however, there were also positive attributes identified for t&cm use. the high rate of t&cm use among evd survivors who experienced enacted stigma (healthcare neglect and verbal abuse) maybe related to the notion that t&cm may serve as a stigma reduction strategy. for instance, t&cm has been used by patients to resist the terminal understanding of hiv/aids and believing that hiv/ aids is chronic rather than a terminal illness [ ] . also, hiv/aids patients and sars survivors have used t&cm practices such as yoga and tai chi to create social support groups as people in such settings are less likely to act differently to each other since they share similar health status and experiences [ , ] . drawing from the experiences of hiv/aids patients and sars survivors in using t&cm in managing stigma, it is possible that evd survivors will be using t&cm not only to address their physical health needs but also to as a coping mechanism against the stigma they are experiencing in their communities and at healthcare facilities. as such, there may be a role for integration of some t&cm where appropriateto help improve conventional health options for evd survivors. going forward, welldesigned qualitative research is required to have a deeper understanding of the meanings of t&cm practice in the everyday lives of evd survivors. the following limitations must be considered when interpreting our findings. first, our study may suffer from recall bias as we relied entirely on self-reported data. second, our study employed a cross-sectional design and, therefore we cannot infer causality between independent and outcomes variables. third, we adapted the hiv/aids-related stigma scale (hasi-p) [ ] to measure evd related stigma among evd survivors, as there is no detailed or validated tool exist for evd related stigma. we decided to use hiv/aids related stigma scale (hasi-p) because hiv/aids share similar characteristics with evd in terms of social isolation, fear of contagion and family and community stigma and discrimination [ ] . finally, our findings are only applicable to evd survivors in sierra leone and may not be representative of evd survivors in other neighbouring evd affected countries. nevertheless, the national nature of this survey represents one of the most representative samples of stigma in evd survivors. the majority of evd survivors in sierra leone experience both internalised and enacted ebola-related stigma although internalised stigma was the most common in terms of occurrence. to reduce evd related stigma, and the impacts of such stigma on evd survivors' health and wellbeing, evd outbreak responses should include evd survivor-centred and community-driven interventions that can help contribute to evd survivors' recovery and community re-integration. evd survivors appear drawn to informal and non-integrated care (t&cm) via both push (i.e. dissatisfaction with conventional care) and pull (i.e. empowerment and social commitments from t&cm). future research is needed to have a deeper insight of the meanings of t&cm practice in the everyday lives of evd survivors. supplementary information accompanies this paper at https://doi.org/ . /s - - - . additional file . ebolarelated stigma questionnaire. abbreviations etc: ebola treatment centre; evd: ebola virus disease; t&cm: traditional and complementary medicine we want to extend our thanks and appreciation to the ebola survivors who consented to take part in this study. we also want to extend our appreciation to the staff of the sierra leone ebola survivors association and staff of the ebola clinic at military hospital wilberforce freetown as well as all data collectors for their support during data collection.. we also extend our thanks to the faculty health, university of technology sydney to help fund the field work for this study. in addition, we extend our thanks and appreciation to dean and staff of the faculty of pharmaceutical sciences, college of medicine and allied health sciences, university of sierra leone. the authors thank mr. john alimamy kabba for helping in creating the map used in this manuscript. authors' contributions pbj and jw conceived of the study while, pbj, jw, as & ja contributed in designing the study. pbj analysed the data and wrote the initial draft of the manuscript. jw, as and ja supervised the process and contributed to the intellectual content of the manuscript. all authors read and approved the final version of the manuscipt. the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. availability of data and materials due to confidentiality and privacy concerns, and given the sensitivity surrounding stigma and discrimination among ebola survivors, our study did not receive approval from the university of technology sydney human research ethics committee and the sierra leone ethics and scientific review committee to publicly share the raw data. also, ebola survivors consented to participate in the study on the basis that their data would not be shared with anyone except members of the research team (my supervisors and i). the raw data informing the findings of this study are stored privately at the university of technology sydney data storage platform called cloudstor. however, upon reasonable request, the anonymised raw data underlying the findings of this study can be made available through the following persons not applicable. the authors declare that they have no competing interest. exposure patterns driving ebola transmission in west africa: a retrospective observational study ebola situation report who: clinical care for survivors of ebola virus disease. interim guidance neuropsychological longterm sequelae of ebola virus disease survivors -a systematic review sequelae of ebola virus disease: the 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reintegration experience of ebola survivors in guinea: a cross-sectional study publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -oo wler authors: chung, pak-kwong; zhang, chun-qing; liu, jing-dong; chan, derwin king-chung; si, gangyan; hagger, martin s. title: the process by which perceived autonomy support predicts motivation, intention, and behavior for seasonal influenza prevention in hong kong older adults date: - - journal: bmc public health doi: . /s - - -x sha: doc_id: cord_uid: oo wler background: this study examined the effectiveness of a theoretical framework that integrates self-determination theory (sdt) and the theory of planned behavior (tpb) in explaining the use of facemasks to prevent seasonal influenza among hong kong older adults. methods: data were collected at two time points in the winter in hong kong, during which influenza is most prevalent. at time , older adults (n = ) completed self-report measures of sdt (perceived autonomy support from senior center staff, autonomous motivation for influenza prevention) and tpb (attitude, subjective norm, perceived behavioral control, and intention for influenza prevention) constructs with respect to facemask used to prevent infection. two weeks later, at time , participants’ acceptance of a facemask to prevent influenza in the presence of an experimenter with flu-like symptoms was recorded. results: path analysis found that perceived autonomy support of senior center staff was positively and significantly linked to autonomous motivation for facemask use, which, in turn, was positively related to intentions to wear facemasks through the mediation of attitude, subjective norm, and perceived behavioral control. however, the effect of intention on facemask use was not significant. conclusions: results generally support the proposed framework and the findings of previous studies with respect to intention, but the non-significant intention-behavior relationship may warrant future research to examine the reasons for older adults not to wear facemasks to prevent seasonal influenza despite having positive intentions to do so. seasonal influenza is an acute epidemic of the influenza virus that quickly and easily spreads from person to person [ ] . annual seasonal epidemics peak during the winter months in temperate regions such as hong kong. epidemics cause mild-to-severe illness and can be fatal in vulnerable groups such as the elderly [ ] . everyday preventive actions, such as facemask wearing, play an important role in the prevention seasonal influenza epidemics [ , ] . this is because the main route of human-to-human transmission of the influenza virus is via respiratory droplets when an individual is close contact with someone who has the influenza virus and displays influenza symptoms [ ] . in community settings, wearing a facemask is an effective means to minimize transmission of influenza, particularly in areas of high population density. in order to promote the adoption of behaviors like facemask use to prevent seasonal influenza infection, previous research has demonstrated that psychological factors such as motives and intentions are likely play a key role [ , ] . researchers have attempted to predict and understand health behavior using behavioral theories and models adopted from social psychology [ ] . among the models that have been applied to understand influenza prevention behaviors, most have adopted a social-cognitive approach, in which preventive behaviors such as vaccination and facemask wearing are viewed as intentional behaviors based on beliefs and expectancies [ , , ] . prominent among these social cognitive approaches is the theory of planned behavior (tpb) [ ] . according to the theory, intention, defined as the extent to which individuals will invest effort in pursuit of an action, is the most proximal predictor of behavior. intention is the function of attitude (i.e., personal evaluation of how good, useful, valuable, and pleasant the behavior is), subjective norm (i.e., beliefs that the behavior is consistent with the expectations of significant others), and perceived behavioral control (i.e., beliefs in the availability of sufficient personal resources, in relation to barriers or risk factors, to execute the behavior). the tpb has been widely applied and tested in health-related behavioral contexts with meta-analytic studies supporting its effectiveness in predicting various health behaviors [ , ] . the predictive efficacy of the tpb with respect to influenza prevention has also been supported in research on influenza vaccination behaviors [ , ] . apart from the tpb, another important theory in social psychology that has been frequently applied in health contexts is self-determination theory (sdt) [ , ] . sdt makes the distinction between different forms of motivation based on its quality rather than quantity: autonomous motivation, controlled motivation, and amotivation. autonomous motivation is the most self-determined form of motivation. autonomously motivated individuals perform behaviors for the intrinsic value of the behavior, or to attain personally-important values or goals that represent their true sense of self. in contrast, individuals experiencing actions as controlled motivated engage in behaviors due to external pressures or externally-referenced obligations. amotivation represents a lack of motivation such that individuals do not know why they engage in their actions at all. individuals experiencing actions as controlled motivated will only perform an action when the external demands or controlling contingencies are present and the actions will cease once the contingencies are no longer present. of the three types of motivation identified in sdt, autonomous motivation is proposed to be more favorable to behavioral persistence and well-being because the individual is motivated for self-referenced reasons and in the absence of external reinforcement or contingency [ ] . consistent with the need to promote autonomous motivation toward health behaviors, according to the sdt, creating a context or 'environment' that cultivates autonomous motivation is an effective means to promote autonomous motivation and change behavior [ , ] . in an influenza prevention context, interventionists may capitalize on autonomy support techniques as a means to promote autonomous motivation [ ] . for communitydwelling older adults, their senior center serves as an important vehicle to present autonomy-supportive messages to promote behaviors that could enhance health and wellbeing, including preventive behaviors to reduce the transmission of potentially life-threatening infections [ ] . recent approaches have attempted to integrate concepts from the tpb and sdt in a unified model to explain health behavior. the integrated model proposes that the motivational variables from sdt are distal predictors of the social cognitive variables from tpb, which are, in turn, considered the proximal antecedents of action [ , ] . the rationale for the integration arises from a key tenet of sdt that individuals who perceive their reasons for acting autonomously should view their behavior as one they should approach. in order to enact the behavior, the individual should align his or her beliefs regarding future engagement in the behavior to be consistent with their motives (i.e., to form positive beliefs about the behavior and form intentions to engage in it). promoting autonomous motivation, therefore, may be a means to promote behavioral engagement through the enhancement of positive beliefs regarding the behavior and the formation of intentions to engage in the behavior in the future. the model has been tested in many health contexts including physical activity, binge drinking, injury management, sugar consumption, and myopia prevention [ ] [ ] [ ] [ ] [ ] [ ] . although a recent study also applied the integrated model to predict behavior in the context of h n pandemic, participants were presented with a hypothetical situation and were not actually facing an actual pandemic and no actual facemask wearing behavior was assessed. [ ] . even though intention is theoretically the most proximal predictor of behavior, there has been growing number of concerns about the differential predictive power of intention on health behavior, and the so-called intention-behavior gap has raised concerns over the adequacy of intentions in explaining future behavior [ ] [ ] [ ] . it is, therefore, important that test of the integrated model include prospective measures of actual behavior, particularly in influenza prevention contexts. the purpose of the current study was to examine the efficacy of an integrated model based on sdt and tpb to predict facemask wearing to prevent seasonal influenza in a sample of hong kong older adults. we adopted a two-week prospective correlational design during hong kong's winter, the peak season for seasonal influenza, and we included an actual measure of the target behavior. specifically, we measured the motivational and social cognitive variables from the integrated model at time (baseline) and followed that up two-weeks later at time with an assessment of actual facemaskwearing behavior. building on the integrated model, it was hypothesized that: ( ) perceived autonomy support from senior center staff for facemask wearing would be positively and directly related to autonomous motivation (hypothesis a) and positively and indirectly related to attitude, subjective norm, and perceived behavioral control via the mediation of autonomous motivation (hypothesis b); ( ) autonomous motivation would be positively and directly related to attitude, subjective norm, and perceived behavioral control (hypothesis a) and positively and indirectly related to intention via the mediation of attitude, subjective norm, and perceived behavioral control (hypothesis b); ( ) attitude, subjective norm, and perceived behavioral control would be positively and directly associated with intention (hypothesis a) and positively and indirectly related to actual facemask wearing behavior via the mediation of intention (hypothesis b). participants ethical clearance was granted by the committee of research ethics and safety (hasc) at hong kong baptist university. we obtained approval and on-site assistance to recruit participants from one senior center in hong kong using convenience sampling. this center has over registered chinese-speaking community-dwelling hong kong older adults aged years and older. a total of older adults expressed an interest in participating to senior center staff and members of the research team. of these eligible participants, agreed to participate and signed consent forms (response rate = . %). the sample comprised of males and females (m age = . , sd = . , range to ) participated the study at time . at time , participants ( males, females; m age = . , sd = . ) remained in the study (retention rate = . %). data were collected at two time points with a two-week interval in the november of . at time , during the peak season of winter influenza in hong kong, participants completed survey measures of study variables under the supervision of researchers following an introductory session in which the purpose and procedure of the study was explained and written informed consent obtained. the surveys took to min to complete. senior center staff were not present during the completion and were not able to see participants' responses. at time , participants were invited to a face-to-face interview in a private room to ostensibly assess their knowledge of h n . the true purpose of the interview was to assess participants' facemask wearing behavior for influenza prevention. during the course of the interview, the interviewer wore a facemask and feigned influenzalike symptoms (e.g., coughing, sneezing). before the start of the interview, the interviewer told the participants in an offhand manner that he/she had caught "the 'flu", and that surgical facemasks were available at the desk that they could take and use for free. this allowed the interviewers to record participants' facemask-wearing behavior. on completion of the interview, participants were debriefed regarding the cover story and informed that the interviewer had feigned influenza symptoms and worn the facemask as a prop to model the behavior. perceived autonomy support perceived autonomy support from staff of senior center was measured using the six-item health care climate questionnaire (hccq) [ ] . participants were provided with a common stem: "when the staff at the senior center asks me to wear a facemask in an enclosed public place…" followed by the six items (e.g., "i feel that he/ she has provided me choices and options"). responses were made on a -point scale anchored by ("not at all true") and ("very true"). the chinese version of the hccq has demonstrated sufficient validity and reliability [ ] . the six-item autonomous motivation subscale from the treatment self-regulation questionnaire (tsrq) [ ] was used to measure autonomous motivation. the stem of tsrq items was modified to refer the specific behavior of interest (i.e., "i want to wear a facemask in an enclosed public place because …"). participants responded to items on -point likert scales with ("not at all true") and ("very true") as scale anchors. the chinese version of tsrq has demonstrated sufficient validity and reliability [ ] . measure of the tpb variables were based on ajzen's guidelines [ ] . measures of subjective norm ( items; e.g., "it is expected of me to wear facemask in an enclosed public place in the forthcoming month."), perceived behavioral control ( items; e.g., "it is possible for me to wear facemask in an enclosed public place in the forthcoming month."), and intention ( items; e.g., "i intend to wear facemask in an enclosed public place in the forthcoming month.") were rated on -point likert scales with ("strongly disagree") and ("strongly agree") as anchors. attitudes were measured using items preceded by a common stem, "for me to wear facemask in an enclosed public place in the forthcoming month would be …" followed by a series of -point semantic differential scales: extremely harmful-extremely beneficial, extremely unpleasant-extremely pleasant, extremely worthless-extremely valuable, extremely badextremely good, and extremely unenjoyable-extremely enjoyable. facemask-wearing behavior was assessed at time during the face-to-face interview. the interviewer disclosed in an offhand manner that they had caught influenza and feigned influenza symptoms. participants were made fully aware of the availability of facemasks and that they were free to use. the interviewer was trained to observe and record the correct use of the facemasks according to world health organization guidelines (i.e., complete coverage of mouth and nose) [ ] . the interviewers recorded a ("yes") when participants took and used the facemasks correctly and otherwise recorded a ("no"). control variables included past facemask-wearing habit (i.e., whether or not they had worn facemasks previously; item), knowledge of the benefits of facemask wearing (i.e., knowing that facemask wearing can prevent influenza; item), frequency of influenza infection during the past months ( item), and perceived susceptibility. perceived susceptibility (e.g., "i have an increased risk of falling ill with influenza"; items) was rated on a point likert scale with ("strongly disagree") and ("strongly agree") as scale anchors [ ] . given that the time facemask wearing behavior was a categorical variable (yes/no), the proposed integrative model (see fig. ) was tested using path analysis (i.e., observed variables) with a variance-adjusted weighted-least squares (wlsmv) estimation method using the mplus . [ ] . variables including facemask wearing habit, knowledge of facemask wearing benefits, frequency of influenza during the past months, and perceived susceptibility were included as control variables. adequacy of the fit of the proposed model with the data was based on multiple criteria for assessing goodness of fit including the comparative fit index (cfi), the root-mean-square error of approximation (rmsea) and the weighted root mean square residual (wrmsr). values exceeding . for the cfi and less than . and . for the rmsea and wrmsr [ , ] , respectively, indicate good fit. for our tests of mediated effects, mediation was confirmed when the indirect effect of a predictor variable (e.g., autonomous motivation) on an outcome variable (e.g., intention) via a mediator (e.g., attitude) was statistically significant and the confidence interval of the effect size did not include zero. in terms of the facemask wearing habit, most of the participants reported wearing facemasks previously (n = ), while a small number of them reported that they did not been used to wearing facemasks previously (n = ). with respect to knowledge of the benefits of facemask wearing, most of the participants reported knowing facemask wearing can prevent flu (n = ), while a small number reported they did not know facemask wearing can prevent flu (n = ). with regards to the frequency of influenza during the past months, most of the participants reported that they had not caught influenza (n = ). in comparison, only participants reported that they caught influenza once, seven participants reported they had had the flu twice, and only three participants reported catching influenza three times. missing data analysis revealed no significant pattern (missing data = . %) and the small number if missing cases was replaced using mean substitution. descriptive statistics and intercorrelations of the study variables are presented in table . the model exhibited adequate fit with the data, χ ( ) = . , p = . , cfi = . , wrmr = . , rmsea ( % ci) = . (. , . ). direct, indirect, and total effects of the path estimates of the integrated model are presented in table and fig. . effects of the control variables were not significant except the effect of frequency of influenza over the previous six months on autonomous motivation (β = −. , %ci [−. to −. ], p = . ), and they are not, therefore, displayed in fig. . focusing on the effects encompassed by hypothesis , we observed a statistically significant and positive effect of perceived autonomy support on autonomous motivation consistent with our hypothesis (hypothesis a). the indirect effects of perceived autonomy support on attitude and subjective norm were statistically significant as hypothesized (hypothesis b), although the direct effects were not. as predicted, the total, direct, and indirect effects of perceived autonomy support on perceived behavioral control were also statistically significant (hypothesis b). statistically significant and positive associations were observed for autonomous motivation on attitude, subjective norm, and perceived behavioral control, as hypothesized (hypothesis a). the indirect effects of autonomous motivation on intention mediated by attitude, subjective norm, and perceived behavior control were all statistically significant, consistent with predictions (hypothesis b). we found statistically significant and positive effects of attitude, subjective norm, and perceived behavioral control on intention, as predicted (hypothesis a). however, contrary to predictions, the effect of intention on our measure of facemask wearing was small and not statistically significant (hypothesis b). building on an integrated model of sdt and tpb [ , , ] , we tested effects among perceived autonomy support, autonomous motivation, attitudes, subjective norms, perceived behavioral control, intention, and behavior for facemask wearing during peak influenza season among elderly people in hong kong. consistent with our hypotheses, we found statistically significant and positive effects of ( ) perceived autonomy support on autonomous motivation, attitude, subjective norm, and perceived behavior control; ( ) autonomous motivation on attitude, subjective norm, and perceived behavioral control, and intention; and ( ) attitude, subjective norm, and perceived behavioral control, on intention. there were also significant and positive indirect effects of perceived autonomy support on attitude, subjective norm, and perceived behavior control via autonomous motivation, and of autonomous motivation on intentions via attitude, subjective norm, and perceived behavior control. however, we found no effect of intention on our measure of actual facemask wearing, and, consequently, no indirect effects of the motivational and social-cognitive variables on behavior mediated by intention. our findings, therefore, suggest that the motivational and social-cognitive constructs outlined in the integrated model are effective in predicting intentions to wear a facemask during the peak winter season, but, critically, intentions were not predictive of individuals' actual engagement in facemask wearing behavior. [ , ] . the finding is also consistent with the findings of a previous study on facemask wearing [ ] . the results suggest that establishing an autonomy supportive environment or 'motivational climate' toward influenza prevention behaviors such as facemask wearing will be effective in fostering autonomous motivation toward the behavior. consistent with previous studies of influenza prevention behaviors such as facemask wearing and vaccination using the tpb [ , , ] , attitudes, subjective norms, and perceived behavior control had positive, significant, and medium-to-large associations with the intentions of wearing facemasks in hong kong older adults. among these three variables, perceived behavioral control had the strongest effects relative to attitudes and subjective norms. it was also the most prominent variable in the transmission of indirect effects of autonomous motivation on intention. given that the tpb is, by and large, an integration of the personal (i.e., attitude) and social (i.e., subjective norm) antecedents of intention from the reasoned action approach [ , ] , and the self-efficacy related component from social cognitive theory [ ] , the increase of older adults' personal resources (e.g., selfefficacy) and the decrease of the hindrance from barriers (e.g., easy access to facemasks when needed) seem to be most efficacious in accounting for variance in intentions to engage in the focal health behavior. current findings provide formative evidence to support interventions to facilitate greater confidence in wearing facemasks and to overcome barriers to doing so. the significant and positive direct effects of perceived autonomy support on attitude and perceived behavioral control indicated that a supportive motivational climate may affect the belief-based tpb variables. this is in line with previous studies [ , , , ] and it further corroborates the integrated model [ , ] . that is, autonomous motivation from sdt underpins the belief-based social cognitive variables of tpb, and the current study extends this to facemask wearing to prevent influenza transmission. the prominent role of control-related beliefs for this health behavior, and its mediating role in translating autonomous motives into intentions, is consistent with other theories which feature self-efficacy as a prominent component [ ] . it is also consistent with previous research that has adopted the integrated model and demonstrated that perceived behavioral control is a key predictor and mediating factor of the influence of autonomous motivation on intentions [ ] . the intentions of facemask wearing alone may be insufficient or unimportant when it comes to engaging in this particular behavior. in a post hoc analysis, we found that the majority of participants ( . %) scored above the mid-point on the intention scale but only two fifths of them chose to wear the face masks ( . %) in our scenario. considering these data, it would be reasonable to assume that the majority of participants should be considered inclined abstainers or unsuccessful intenders [ , ] , or have weak or unstable [ ] [ ] [ ] intentions. given that older adults' facemask wearing habits, knowledge of whether wearing facemasks can prevent influenza, frequency of influenza over the previous months, and perceived susceptibility to influenza were controlled for, it is reasonable to conclude that the current findings are consistent with the well-documented intention-behavior gap. a number of factors may account for this 'gap'. first, it emerged from the qualitative debriefing session conducted after the study had been completed that many of the participants chose not to wear a facemask because the interviewer was wearing a facemask, and they believed that they were, therefore, safe. others reported that they were put off wearing facemasks themselves because it would make it difficult or uncomfortable to breathe, a notable barrier. as this is anecdotal evidence rather than a formal assessment, it may be important in future research to examine participants' specific beliefs regarding the behavior, rather than global or direct measures of attitudes and perceived behavioral control. such an approach may identify the influential behavioral (e.g., beliefs that people with illnesses will wear facemasks to reduce risk to others) and control (e.g., wearing masks makes it difficult or uncomfortable to breathe) beliefs that may influence the formation of intentions. omission the beliefs that precede intentions aside, it may also be important to study the underlying volitional mechanisms from dual-phase models of action like the model of action phases [ ] and the health action process approach [ ] that determine the enactment of intentions. incorporation of volitional components like implementation intentions, action planning, and coping planning into the study of facemask wearing may assist in identifying the possible moderators of the intention behavior relation. similarly, it may also be important to look at the implicit, non-conscious or 'automatic' influences on action. research has indicated that self-reported habit predicts behavior as do implicitly measured attitudes and motives [ ] [ ] [ ] . such influences likely account for action independent of the intentional route to behavior, and therefore determines action beyond an individual's awareness. the likely process involved is that the implicit beliefs are associated with schema, or memory structures, which outline patterns of action which have been well learned and reinforced over time. such patterns are activated when the implicit belief or attitude is cued, and, as a consequence, an individual's behavior is initiated automatically [ , ] . this does not mean that individuals act like 'automatons' , blindly carrying out actions. the actual behavior may involve considerable planning and effort, it is just that the behavioral pattern is set in motion in a quick, efficient manner making the behavior subjectively very easy to enact. implicit beliefs are also more likely to facilitate the enactment of the intended action, or failing to do the action, if it is either rewarding or relatively easy to do. future research should examine individuals' implicit beliefs toward illness and implicit beliefs toward the behavior, with respect to facemask wearing and assess their contribution to action. this would be consistent with further integrated models that have attempted to incorporate implicit components alongside motivational and volitional components of action in a unified framework [ ] . the current study has numerous strengths including a focus on an important health-related behavior aimed at preventing influenza infection in a vulnerable population and has the potential to save lives, recruitment of a hard-to-reach population of older adults, adoption of an integrated theoretical model that has shown efficacy in predicting health behavior, and the use of valid and reliably instruments and a prospective design, and the use of an externally-verified observational measure of behavior instead of self-reports which have inherent biases. although our findings offer insight into the motivational processes that relate to facemask use in hong kong older adults to prevent influenza transmission during peak season, a number of limitations of the study should be identified and discussed. first, participants in the current study were ethnically and geographically homogeneous since they were recruited from the same senior center. all participants were hong kong chinese, and most of them were female. in future, it would be important to replicate the findings in more diverse sample of older adults to provide further evidence on the validity and generalizability of study findings. secondly, inference of causal relations among variables in the integrated model cannot be made even with the adoption of a prospective design. the causal direction of effects in the model can only be inferred from the theory rather than the data [ ] , it is, therefore, imperative that researchers also adopt experimental paradigms to manipulate key variables in the nomological network proposed by the theory and observe their effects on outcomes. finally, the current study did not conduct an a priori statistical power analysis and adopted a manifest rather than latent variable approach given the relatively small sample. future research should seek to conduct a power analysis beforehand, collect data from a larger sample and use a latent variable modeling approach which would control for measurement error [ ] . in conclusion, findings of the current study provided support for the motivational aspects of the integrated model to the wearing of facemasks to prevent seasonal influenza in a sample hong kong older adults. however, our research did not support the link between intentions to wear facemasks and a situated decisional measure of facemask wearing in a real-life context. further examination of the potential alternative processes and moderators of the link between intentions and behavior in this context may provide insight on contexts in which intentions to wear facemasks lead to actual facemask wearing behavior, and the processes involved. abbreviations cfi: comparative fit index; hccq: health care climate questionnaire; rmsea: root-mean-square error of approximation; sdt: self-determination theory; tpb: theory of planned behavior; tsrq: treatment self-regulation questionnaire; wlsmv: variance-adjusted weighted-least squares; wrmr: weighted root mean square residual world health organization. influenza (seasonal) seasonal influenza in adults and children-diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the infectious diseases society of america facemasks and intensified hand hygiene in a german household trial during the / influenza a (h n ) pandemic: adherence and tolerability in children and adults mathematical modeling of the effectiveness of facemasks in reducing the spread of novel influenza a (h n ) advice on the use of masks in the community setting in influenza a(h n ) outbreaks psychosocial factors influencing the practice of preventive behaviors against the severe acute respiratory syndrome among older chinese in hong kong decision on influenza vaccination among the elderly: a questionnaire study based on the health belief model and the multidimensional locus of control theory. scand j prim health care theoretical frameworks in exercise psychology meta-analysis of the relationship between risk perception and health behavior: the example of vaccination determinants of influenza vaccination among healthcare workers from intentions to actions: a theory of planned behavior prospective prediction of health-related behaviours with the theory of planned behaviour: a metaanalysis theory of planned behavior and adherence in chronic illness: a meta-analysis determinants of older adults' intentions to vaccinate against influenza: a theoretical application factors affecting intention to receive and self-reported receipt of pandemic (h n ) vaccine in hong kong: a longitudinal study intrinsic motivation and self-determination in human behavior the "what" and "why" of goal pursuits: human needs and the self-determination of behavior motivational predictors of weight loss and weight-loss maintenance a meta-analysis of the effectiveness of intervention programs designed to support autonomy preventing the spread of h n influenza infection during a pandemic: autonomy-supportive advice versus controlling instruction senior citizens centers: what they offer, who participates, and what they gain integrating the theory of planned behaviour and self-determination theory in health behaviour: a meta-analysis an integrated behavior-change model for physical activity myopia prevention, near work, and visual acuity of college students: integrating the theory of planned behavior and self-determination theory autonomous forms of motivation underpinning injury prevention and rehabilitation among police officers: an application of the trans-contextual model theoretical integration and the psychology of sport injury prevention predicting sugar consumption: application of an integrated dual-process, dual-phase model perceived autonomy support in physical education and leisure-time physical activity: a cross-cultural evaluation of the trans-contextual model predicting alcohol consumption and binge drinking in company employees: an application of planned behaviour and self-determination theories how big is the physical activity intention-behaviour gap? a meta-analysis using the action control framework time to retire the theory of planned behaviour bridging the intention-behaviour gap: planning, self-efficacy, and action control in the adoption and maintenance of physical exercise validating the theoretical structure of the treatment self-regulation questionnaire (tsrq) across three different health behaviors constructing a tpb questionnaire: conceptual and methodological considerations mplus user's guide goodness of fit evaluation in structural equation modeling evaluating cutoff criteria of model fit indices for latent variable models with binary and continuous outcomes self-determination theory applied to health contexts a metaanalysis predicting and changing behavior: the reasoned action approach mind the gap: bringing our theories in line with the empirical data -a response to commentaries social foundations of thought and action: a social-cognitive theory modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors the trans-contextual model of autonomous motivation in education: conceptual and empirical issues and meta-analysis inclined abstainers': a problem for predicting health related behaviour temporal stability as a moderator of relationships in the theory of planned behaviour goal conflict and the moderating effects of intention stability in intention-behavior relations: physical activity among hong kong chinese mediator of moderators: temporal stability of intention and the intention-behavior relation thought contents and cognitive functioning in motivational and volitional states of mind a review and analysis of the use of 'habit' in understanding, predicting and influencing health-related behaviour investigating the predictive validity of implicit and explicit measures of motivation on condom use, physical activity, and healthy eating cognitive control and the non-conscious regulation of health behavior what measures of habit strength to use? using metaanalytic path analysis to test theoretical predictions in health behavior: an illustration based on meta-analyses of the theory of planned behavior manifest variable path analysis: potentially serious and misleading consequences due to uncorrected measurement error not applicable. this study was funded by faculty research grant (frg), hong kong baptist university (grant number frg - - - ). all data supporting our findings will be shared upon request. all authors were involved in the design of the study protocol. pkc, cqz, jdl, and dkc were involved in the data acquisition. pkc and cqz conducted all analyses and wrote the first draft. pkc, cqz, dkc, and msh contributed to the interpretation of the results. all authors critically reviewed the manuscript and approved the final version.ethics approval and consent to participate the current study involves human participants and the research protocol had been approved by the committee of research ethics and safety (hasc) at hong kong baptist university. all participants provided written informed consent to participate. not applicable. the authors declare that they have no competing interests. key: cord- -k wrory authors: prieto, diana m; das, tapas k; savachkin, alex a; uribe, andres; izurieta, ricardo; malavade, sharad title: a systematic review to identify areas of enhancements of pandemic simulation models for operational use at provincial and local levels date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: k wrory background: in recent years, computer simulation models have supported development of pandemic influenza preparedness policies. however, u.s. policymakers have raised several concerns about the practical use of these models. in this review paper, we examine the extent to which the current literature already addresses these concerns and identify means of enhancing the current models for higher operational use. methods: we surveyed pubmed and other sources for published research literature on simulation models for influenza pandemic preparedness. we identified models published between and that consider single-region (e.g., country, province, city) outbreaks and multi-pronged mitigation strategies. we developed a plan for examination of the literature based on the concerns raised by the policymakers. results: while examining the concerns about the adequacy and validity of data, we found that though the epidemiological data supporting the models appears to be adequate, it should be validated through as many updates as possible during an outbreak. demographical data must improve its interfaces for access, retrieval, and translation into model parameters. regarding the concern about credibility and validity of modeling assumptions, we found that the models often simplify reality to reduce computational burden. such simplifications may be permissible if they do not interfere with the performance assessment of the mitigation strategies. we also agreed with the concern that social behavior is inadequately represented in pandemic influenza models. our review showed that the models consider only a few social-behavioral aspects including contact rates, withdrawal from work or school due to symptoms appearance or to care for sick relatives, and compliance to social distancing, vaccination, and antiviral prophylaxis. the concern about the degree of accessibility of the models is palpable, since we found three models that are currently accessible by the public while other models are seeking public accessibility. policymakers would prefer models scalable to any population size that can be downloadable and operable in personal computers. but scaling models to larger populations would often require computational needs that cannot be handled with personal computers and laptops. as a limitation, we state that some existing models could not be included in our review due to their limited available documentation discussing the choice of relevant parameter values. conclusions: to adequately address the concerns of the policymakers, we need continuing model enhancements in critical areas including: updating of epidemiological data during a pandemic, smooth handling of large demographical databases, incorporation of a broader spectrum of social-behavioral aspects, updating information for contact patterns, adaptation of recent methodologies for collecting human mobility data, and improvement of computational efficiency and accessibility. results: while examining the concerns about the adequacy and validity of data, we found that though the epidemiological data supporting the models appears to be adequate, it should be validated through as many updates as possible during an outbreak. demographical data must improve its interfaces for access, retrieval, and translation into model parameters. regarding the concern about credibility and validity of modeling assumptions, we found that the models often simplify reality to reduce computational burden. such simplifications may be permissible if they do not interfere with the performance assessment of the mitigation strategies. we also agreed with the concern that social behavior is inadequately represented in pandemic influenza models. our review showed that the models consider only a few social-behavioral aspects including contact rates, withdrawal from work or school due to symptoms appearance or to care for sick relatives, and compliance to social distancing, vaccination, and antiviral prophylaxis. the concern about the degree of accessibility of the models is palpable, since we found three models that are currently accessible by the public while other models are seeking public accessibility. policymakers would prefer models scalable to any population size that can be downloadable and operable in personal computers. but scaling models to larger populations would often require computational needs that cannot be handled with personal computers and laptops. as a limitation, we state that some existing models could not be included in our review due to their limited available documentation discussing the choice of relevant parameter values. conclusions: to adequately address the concerns of the policymakers, we need continuing model enhancements in critical areas including: updating of epidemiological data during a pandemic, smooth handling of large demographical databases, incorporation of a broader spectrum of social-behavioral aspects, updating information for contact patterns, adaptation of recent methodologies for collecting human mobility data, and improvement of computational efficiency and accessibility. the ability of computer simulation models to "better frame problems and opportunities, integrate data sources, quantify the impact of specific events or outcomes, and improve multi-stakeholder decision making," has motivated their use in public health preparedness (php) [ ] . in , one such initiative was the creation of the preparedness modeling unit by the centers for disease control and prevention (cdc) in the u.s. the purpose of this unit is to coordinate, develop, and promote "problem-appropriate and data-centric" computer models that substantiate php decision making [ ] . of the existing computer simulation models addressing php, those focused on disease spread and mitigation of pandemic influenza (pi) have been recognized by the public health officials as useful decision support tools for preparedness planning [ ] . in recent years, computer simulation models were used by the centers for disease control and prevention (cdc), department of health and human services (hhs), and other federal agencies to formulate the "u.s. community containment guidance for pandemic influenza" [ ] . although the potential of the exiting pi models is well acknowledged, it is perceived that the models are not yet usable by the state and local public health practitioners for operational decision making [ , [ ] [ ] [ ] . to identify the challenges associated with the practical implementation of the pi models, the national network of public health institutes, at the request of cdc, conducted a national survey of the practitioners [ ] . the challenges identified by the survey are summarized in table . we divided the challenges (labeled a through a in table ) into two categories: those (a through a ) that are related to model design and implementation and can potentially be addressed by adaptation of the existing models and their supporting databases, and those (a through a ) that are related to resource and policy issues, and can only be addressed by changing public health resource management approaches and enforcing new policies. although it is important to address the challenges a through a , we consider this a prerogative of the public health administrators. hence, the challenges a to a will not be discussed in this paper. the challenges a through a reflect the perspectives of the public health officials, the end users of the pi models, on the practical usability of the existing pi models and databases in supporting decision making. addressing these challenges would require a broad set of enhancements to the existing pi models and associated databases, which have not been fully attempted in the literature. in this paper, we conduct a review of the pi mitigation models available in the published research literature with an objective of answering the question: "how to enhance the pandemic simulation models and the associated databases for operational use at provincial and local levels?" we believe that our review accomplishes its objective in two steps. first, it exposes the differences between the perspectives of the public health practitioners and the developers of models and databases on the required model capabilities. second, it derives recommendations for enhancing practical usability of the pi models and the associated databases. in this section, we describe each of the design and implementation challenges of the existing pi models (a -a ) and present our methods to examine the challenges in the research literature. in addition, we present our paper screening and parameter selection criteria. design and implementation challenges of pandemic models and databases validity of data support (a ) public health policy makers advocate that the model parameters be derived from up to date demographical and epidemiological data during an outbreak [ ] . in this paper we examine some of the key aspects of data support, such as data availability, data access, data retrieval, and data translation. to ensure data availability, a process must be in place for collection and archival of both demographical and epidemiological data during an outbreak. the data must be temporally consistent, i.e., it must represent the actual state of the outbreak. in the united states and other few countries, availability of temporally consistent demographical data is currently supported by governmental databases including the decennial census and the national household travel survey [ ] [ ] [ ] [ ] . to ensure temporal consistency of epidemiological data, the institute of medicine (iom) has recommended enhancing the data collection protocols to support real-time decision making [ ] . the frequency of data updating may vary based on the decision objective of the model (e.g., outbreak detection, outbreak surveillance, and initiation and scope of interventions). as noted by fay-wolfe, the timeliness of a decision is as important as its correctness [ ] , and there should be a balance between the cost of data updating and the marginal benefits of the model driven decisions. archival of data must allow expedited access for model developers and users. in addition, mechanisms should be available for manual or automatic retrieval of data and its translation into model parameter values in a timely manner. in our review of the existing pi models at provincial and local levels, we examined the validity of data that was used in supporting major model parameters. the major model parameters include: the reproduction number, defined as the number of secondary infections that arise from a typical primary case [ ] ; the proportion of the population who become infected, also called infection attack rate [ ] ; the disease natural history within an individual; and fractions of symptomatic and asymptomatic individuals. the first row of table summarizes our approach to examine data validity. for each reviewed pi model, and, for each of the major model parameters, we examined the source and the age of data used (a a, a b), the type of interface used for data access and retrieval (a c), and the technique used for translating data into the parameter values (a d). public health practitioners have emphasized the need for models with credible and valid assumptions [ ] . credibility and validity of model assumptions generally refer to how closely the assumptions represent reality. however, for modeling purposes, assumptions are often made to balance data needs, analytical tractability, and computational feasibility of the models with their ability to support timely and correct decisions [ ] . making strong assumptions may produce results that are timely but with limited or no decision support value. on the other hand, relaxing the simplifying assumptions to the point of analytical intractability or computational infeasibility may seriously compromise the fundamental purpose of the models. every model is comprised of multitudes of assumptions pertaining to contact dynamics, transmission and infection processes, spatial and temporal considerations, demographics, mobility mode(s), and stochasticity of parameters. credibility and validity of these assumptions largely depend on how well they support the decision objectives of the models. for example, if a model objective is to test a household isolation strategy (allowing sick individuals to be isolated at home, in a separate room), the model assumptions must allow tracking of all the individuals within the household (primary caregivers and others) so that the contact among the household members can be assigned and possible spread of infection within the household can be assessed. this idea is further discussed in the results section through an analysis of some of the model assumptions regarding contact probability and frequency of new infection updates that were made in two of the commonly referenced pi models in the pandemic literature [ , ] . it has been observed in [ ] that the existing pi models fall short of capturing relevant aspects of human behavior. this observation naturally evokes the following questions. what are the relevant behavioral aspects that must be considered in pi models? are there scientific evidences that establish the relative importance of these aspects? what temporal consistency is required for data support of the aspects of human behavior? the third row of table summarizes our plan to examine how the existing models capture human behavior. for each reviewed pi model, we first identify the behavioral aspects that were considered, and then for each aspect we examine the source and the age of data used, the type of interface used for data access and retrieval, and the technique used for translating data into model parameter values (a a-d). we also attempt to answer the questions raised above, with a particular focus on determining what enhancements can be done to better represent human behavior in pi models. public health practitioners have indicated the need for openly available models and population specific data that can be downloaded and synthesized using personal computers [ ] . while the ability to access the models is essential for end users, executing the pi models on personal computers, in most cases, may not be feasible due to the computational complexities of the models. some of the existing models feature highly granular description of disease spread dynamics and mitigation via consideration of scenarios involving millions of individuals and refined time scales. while such details might increase credibility and validity of the models, this can also result in a substantial computational burden, sometimes, beyond the capabilities of personal computers. there are several factors which contribute to the computational burden of the pi models, the primary of which is the population size. higher population size of the affected region requires larger datasets to be accessed, retrieved, and downloaded to populate the models. other critical issues that add to the computational burden are: data interface with a limited bandwidth, the frequency of updating of data during a pandemic progress, pre-processing (filtering and quality assurance) requirement for raw data, and the need for data translation into parameter values using methods, like maximum likelihood estimation and other arithmetic conversions. the choice of the pi model itself can also have a significant influence on the computational burden. for example, differential equation (de) models divide population members into compartments, where in each compartment every member makes the same number of contacts (homogeneous mixing) and a contact can be any member in the compartment (perfect mixing). in contrast, agentbased (ab) models track each individual of the population where an individual contacts only the members in his/her relationship network (e.g., neighbors, co-workers, household members, etc.) [ ] . the refined traceability of individual members offered by ab models increases the usage of computational resources. further increases in the computational needs are brought on by the need for running multiple replicates of the models and generating reliable output summaries. as summarized in the last row of table , we examine which models have been made available to general public and whether they are offered as an open or closed source code. we also check for the documentation of model implementation as well as for existence of user support, if any. in addition, we look for the ways that researchers have attempted to address the computational feasibility of their models, including data access, retrieval and translation, model execution, and generation of model outputs. the initial set of articles for our review was selected following the prisma reporting methodology, as applicable. we used the pubmed search engine with the keyword string "influenza" and "pandemic" and "model" in english language. a total of papers were found which were published between and . we filtered those using the following selection criteria (also depicted in figure ). -articles that evaluate one or more strategies in each of the mitigation categories: social distancing, vaccination, and antiviral application. we limited the paper (by excluding models that do not consider all three categories) to contain the scope of this review, as we examined a large table plan for examination of the design and implementation challenges of the existing pi models design and implementation challenges validity of data support (a ) for model parameters for each pi model and for each of the major model parameters (e.g., reproduction number, illness attack rate) examine: a a. data source for parameter values (actual, simulated, assumed) a b. age of data a c. type of interface for data access and retrieval (manual, automatic) a d. technique to translate raw data into model parameter values (e.g., arithmetic conversion, bayesian estimation) credibility and validity of model assumptions ( body of related papers from which our selected articles drew their parameters (see additional tables). -articles with single-region simulation models. we defined single-region for the purpose of this review as either a country or any part thereof. models presenting disease spread approaches without mention of any regional boundary were included, as these approaches can directly support decision makers at provincial and local levels. there exists a significant and important body of literature that is dedicated to global pandemic influenza modeling that aims at quantifying global disease spread [ ] [ ] [ ] [ ] , assessing the impact of global vaccine distribution and immunization strategies [ ] [ ] [ ] and assessing the impact of recommended or self-initiated mobility behaviors in the global disease spread [ , ] . as these overarching aims of the global models do not directly impact operational decisions of provincial and local policy makers during an evolving pandemic, we have not included them in our final selection of articles. -articles that include data sources for most model parameter values and, when possible, specify the methods for parameter estimation. we included this criterion in order to evaluate models with respect to the challenge of "validity of data support." see table where we outline our evaluation plan. clearly, models not satisfying this criterion would not support our review objectives. using the above filtering criteria, an additional snowball search was implemented outside pubmed, which yielded additional eligible papers [ , [ ] [ ] [ ] [ ] and bringing the total number of papers reviewed to twentythree. we grouped the twenty-three selected articles in eleven different clusters based on their model (see table ). the clusters are named either by the name used in the literature or by the first author name(s). for example, all three papers in the imperial-pitt cluster use the model introduced initially by ferguson et al. [ ] . in each cluster, to review the criteria for the design and implementation challenge (a ), we selected the article with the largest and most detailed testbed (marked in bold in table ). as stated earlier, credibility and validity of model assumptions (a ), were examined via two most commonly cited models in the pandemic literature [ , ] . the challenges a -a were examined separately for each of the selected articles. out of the ten model clusters presented in table , eight are agent-based simulation models, while the rest are differential equation models. also, while most of the models use purely epidemiological measures (e.g., infection attack rates and reproduction numbers) to assess the effectiveness of mitigation strategies, only a few use economic measures [ , , ] . in our review, we examined epidemiological, demographical, and social-behavioral parameters of the pandemic models. we did not examine the parameters of the mitigation strategies as a separate category since those are functions of the epidemiological, demographical, and social-behavioral parameters. for example, the risk groups for vaccine and antiviral (which are mitigation parameters) are functions of epidemiological parameters such as susceptibility to infection and susceptibility to death, respectively. another example is the compliance to non-pharmaceutical interventions, a mitigation strategy parameter, which can be achieved by altering the social behavioral parameters of the model. in this section, we present the results of our review of the models that evaluate at least one strategy from each mitigation category (social distancing, vaccination and antiviral application). we also identify areas of enhancements of the simulation based pi models for operational use. our discussion on validity of data support includes both epidemiological and demographic data. additional file : table s summarizes the most common epidemiological parameters used in the selected models along with their data sources, interface for data access and retrieval, and techniques used in translating raw data into parameter values. additional file : table s presents information similar to above for demographic parameters. the most commonly used epidemiological parameters are reproduction number (r), illness attack rate (iar), initial set of articles filtered from pubmed using keyword search (n = ) remaining articles (n = ) exclusion of articles that do not examine pandemic influenza spread under a comprehensive set of mitigation strategies (n = ) exclusion of articles that examine global pandemic spread (n = ) remaining articles (n = ) remaining articles (n = ) inclusion of articles that meet the above criteria but are obtained using snowball search outside pubmed (n = ) exclusion of articles that do not provide a comprehensive support for data collection and parameterization methods (n = ) articles reviewed (n = ) figure selection criteria for pi models for systematic review. disease natural history parameters, and fraction of asymptomatic infected cases. in the models that we have examined, estimates of reproduction numbers have been obtained by fitting case/mortality time series data from the past pandemics into models using differential equations [ ] , cumulative exponential growth equations [ ] , and bayesian likelihood expressions [ ] . iars have been estimated primarily using household sampling studies [ ] , epidemic surveys [ , ] , and case time series reported for h n [ , ] . the parameters of the disease natural history, which are modeled using either a continuous or phase-partitioned time scale (see additional file : table s ), have been estimated from household random sampling data [ , , ] , viral shedding profiles from experimental control studies [ , , , ] , and case time series reported for h n [ , ] . bayesian likelihood estimation methods were used in translating case time series data [ , ] . fraction of asymptomatic infected cases has been estimated using data sources and translation techniques similar to the ones used for natural history. recent phylogenetic studies on the h n virus help to identify which of the above epidemiological parameters need real-time re-assessment. these studies suggest that the migratory patterns of the virus, rather than the intrinsic genomic features, are responsible for the second pandemic wave in [ , ] . since r and iar are affected not only by the genomic features but also by the migratory patterns of the virus, a close monitoring of these parameters throughout the pandemic spread is essential. real-time monitoring of parameters describing disease natural history and fraction of asymptomatic cases is generally not necessary since they are mostly dependent on the intrinsic genomic features of the virus. these parameters can be estimated when a viral evolution is confirmed through laboratory surveillance. estimation methods may include surveys (e.g., household surveys of members of index cases [ , ] ) and laboratory experiments that inoculate pandemic strains into human volunteers [ ] . current pandemic research literature shows the existence of estimation methodologies for iar and r that can be readily used provided that raw data is available [ ] . there exist several estimators for r (wallinga et al. [ , ] , fraser [ ] , white and pagano [ ] , bettencourt et al. [ ] , and cauchemez et al. [ ] ). these estimates have been derived from different underlying infection transmission models (e.g., differential equations, time since infection and directed network). with different underlying transmission models, the estimators consider data from different perspectives, thereby yield different values for r at a certain time t. for example, fraser [ ] proposes an instantaneous r that observes how past case incidence data (e.g., in time points t- , t- , t- ) contribute to the present incidence at time t. in contrast, wallinga et al. [ , ] and cauchemez et al. [ ] propose estimators that observe how the future incidences (e.g., t + , t + , t + ) are contributed by a case at time t. white and pagano [ ] considers an estimator that can be called a running estimate of the instantaneous reproduction number. further extensions of the above methods have been developed to accommodate more realistic assumptions. bettencourt extended its r estimator to account for multiple introductions from a reservoir [ ] . the wallinga estimator was extended by cowling [ ] to allow for reporting delays and repeated importations, and by glass [ ] to allow for heterogeneities among age groups (e.g., adults and children). the fraser estimator was extended by nishiura [ ] to allow the estimation of the reproduction number for a specific age class given infection by another age class. the above methods for real-time estimation of r are difficult to implement in the initial and evolving stages of a pandemic given the present status of the surveillance systems. at provincial and local levels, surveillance systems are passive as they mostly collect data from infected cases who are seeking healthcare [ ] . with passive surveillance, only a fraction of symptomatic cases are detected with a probable time delay from the onset of symptoms. once the symptomatic cases seek healthcare and are reported to the surveillance system, the healthcare providers selectively submit specimens to the public health laboratories (phl) for confirmatory testing. during the h n pandemic in , in regions with high incidence rates, the daily testing capacities of the phl were far exceeded by the number of specimens received. in these phl, the existing first-come-first-serve testing policy and the manual methods for receiving and processing the specimens further delayed the pace of publication of confirmed cases. the time series of the laboratory confirmed cases likely have been higher due to the increased specimen submission resulting from the behavioral response (fear) of both the susceptible population and the healthcare providers after the pandemic declaration [ ] . similarly, time series of the confirmed cases likely have been lower at the later stages of the pandemic as federal agencies advocated to refrain from specimen submission [ ] . the present status of the surveillance systems calls for the models to account for: the underreporting rates, the delay between onset of symptoms and infection reporting, and the fear factor. in addition, we believe that it is necessary to develop and analyze the cost of strategies to implement active surveillance and reduce the delays in the confirmatory testing of the specimens. in our opinion, the above enhancement can be achieved by developing methods for statistical sampling and testing of specimens in the phl. in addition, new scheduling protocols will have to be developed for testing the specimens, given the limited laboratory testing resources, in order to better assess the epidemiological parameters of an outbreak. with better sampling and scheduling schemes at the phl, alterations in the specimen submission policies during a pandemic (as experienced in the u.s. during the outbreak) may not be necessary. the above enhancements would also support a better real-time assessment of the iar, which is also derived from case incidence data. our review of the selected pi models indicates that currently all of the tasks relating to access and retrieval of epidemiological data are being done manually. techniques for translation of data into model parameter values range from relatively simple arithmetic conversions to more time-consuming methods of fitting mathematical and statistical models (see additional file : table s ). there exist recent mechanisms to estimate incidence curves in real-time by using web-based questionnaires from symptomatic volunteers [ ] , google and yahoo search queries [ , ] and tweeter messages [ ] and have supported influenza preparedness in several european countries and the u.s. [ , ] . if real-time incidence estimates are to be translated into pi models parameters, complex translation techniques might delay execution of the model. we believe that model developers should consider building (semi)automatic interfaces for epidemiological data access and retrieval and develop translation algorithms that can balance the run time and accuracy. additional file : table s shows the most common demographic parameters that are used in the selected models. the parameters are population size/density, distribution of household size, peer-group size, age, commuting travel, long-distance travel, and importation of infected cases to the modeled region. estimation of these parameters has traditionally relied on comprehensive public databases, including the u.s. census, landscan, italian institute of statistics, census of canada, hong kong survey data, uk national statistics, national household travel survey, uk department of transport, u.s. national centre for educational statistics, the italian ministry of university and research and the uk department for education and skills. readers are referred to additional file : table s for a complete list of databases and their web addresses. our literature review shows that access and retrieval of these data are currently handled through manual procedures. hence, there is an opportunity for developing tools to accomplish (semi)automatic data access, retrieval, and translation into model parameters whenever a new outbreak begins. it is worth noting that access to demographic information is currently limited in many countries, and therefore obtaining demographic parameters in real-time would only be possible for where information holders (censing agencies and governmental institutions) openly share the data. the data sources supporting parameters for importation of infected cases reach beyond the modeled region requiring the regional models to couple with global importation models. this coupling is essential since the possibility of new infection arrivals may accelerate the occurrence of the pandemic peak [ ] . this information on peak occurrence could significantly influence time of interventions. some of the single region models consider a closed community with infusion of a small set of infected cases at the beginning [ , , ] . single region models also consider a pseudo global coupling through a constant introduction of cases per unit time [ , ] . other single region models adopt a more detailed approach, where, for each time unit, the number of imported infections is estimated by the product of the new arrivals to the region and the probability of an import being infected. this infection probability is estimated through a global disease spread compartmental model [ , ] . the latter approach is similar to the one used by merler [ ] for seeding infections worldwide and is operationally viable due to its computational simplicity. for a more comprehensive approach to case importation and global modeling of disease spread, see [ ] . recall that our objective here is to discuss how the credibility and validity of assumptions should be viewed in light of their impact on the usability of models for public health decision making. we examine the assumptions regarding contact probability and the frequency of new infection updates (e.g., daily, quarterly, hourly) in two models: the imperial-pitt [ ] and the uw-lanl models [ ] . choice of these models was driven by their similarities (in region, mixing groups, and the infection transmission processes), and the facts that these models were cross validated by halloran [ ] and were used for developing the cdc and hhs "community containment guidance for pandemic influenza" [ ] . we first examine the assumptions that influence contact probabilities within different mixing groups (see table ). for household, the imperial-pitt model assumes constant contact probability while the uw-lanl model assumes that the probability varies with age (e.g., kid to kid, kid to adult). the assumption of contact probability varying with age matches reality better than assuming it to be constant [ ] . however, for households with smaller living areas the variations may not be significant. also, neither of the papers aimed at examining strategies (e.g., isolation of sick children within a house) that depended on age-based contact probability. hence, we believe that the assumptions can be considered credible and valid. for workplaces and schools, the assumption of % of contacts within the group and % contacts outside the group, as made in the imperial-pitt model, appears closer to reality than the assumption of constant probability in the uw-lanl model [ ] . for community places, the imperial-pitt model considered proximity as a factor influencing the contact probability, which was required for implementing the strategy of providing antiviral prophylaxis to individuals within a ring of certain radius around each detected case. we also examined the assumptions regarding the frequency of infection updates. the frequency of update dictates how often the infection status of the contacted individuals is evaluated. in reality, infection transmission may occur (or does not occur) whenever there is a contact event between a susceptible and an infected subject. the imperial-pitt and the uw-lanl models do not evaluate infection status after each contact event, since this would require consideration of refined daily schedules to determine the times of the contact events. instead, the models evaluate infection status every six hours [ ] or at the end of the day [ ] by aggregating the contact events. while such simplified assumptions do not allow the determination of the exact time of infection for each susceptible, they offer a significant computational reduction. moreover, in a real-life situation, it will be nearly impossible to determine the exact time of each infection, and hence practical mitigation (or surveillance) strategies should not rely on it. the above analysis reveals how the nature of mitigation strategies drives the modeling assumptions and the computational burden. we therefore believe that the policymakers and the modelers should work collaboratively in developing modeling assumptions that adequately support the mitigation strategy needs. furthermore, the issue of credibility and validity of the model assumptions should be viewed from the perspectives of the decision needs and the balance between analytical tractability and computational complexity. for example, it is unlikely that any mitigation strategy would have an element that depends of the minute by minute changes in the disease status. hence, it might be unnecessary to consider a time scale of the order of a minute for a model and thus increase both computational and data needs. contact rate is the most common social-behavioral aspect considered by the models that we have examined. in these models, except for eichner et al. [ ] , the values of the contact rates were assumed due to the unavailability of reliable data required to describe the mobility and connectivity of modern human networks [ , , ] . however, it is now possible to find "fresh" estimates of the types, frequency, and duration of human contacts either from a recent survey at the continental level [ ] or from a model that derives synthetic contact information at the country level [ ] . in addition, recent advances in data collection through bluetooth enabled mobile telephones [ ] and radio frequency identification (rfid) devices [ ] allow better extraction of proximity patterns and social relationships. availability of these data creates further opportunity to explore methods of access, retrieval, and translation into model parameters. issues of data confidentiality, cost of the sensing devices, and low compliance to the activation of sensing applications might prevent the bluetooth and rfid technologies from being effectively used in evolving pandemic outbreaks. another possibility is the use of aggregated and anonymous network bandwidth consumption data (from network service providers) to extrapolate population distribution in different areas at different points in time [ , ] . other social-behavioral parameters that are considered by the reviewed models include reactive withdrawal from work or school due to appearance of symptoms [ ] , work absenteeism to care for sick relatives or children at home due to school closure [ , , , ] , and compliance to social distancing, vaccination, and antiviral prophylaxis [ , ] . once again, due to the lack of data support, the values of most of these parameters were assumed and their sensitivities were studied to assess the best and worst case scenarios. existing surveys collected during the h n outbreak can be useful in quantifying the above parameters [ , ] . recent literature has explored many additional socialbehavioral aspects that were not considered in the models we reviewed. there are surveys that quantify the levels of support for school closure, follow up on sick students by the teachers [ ] , healthcare seeking behavior [ ] , perceived severity, perceived susceptibility, fear, general compliance intentions, compliance to wearing face masks, role of information, wishful thinking, fatalistic thinking, intentions to fly away, stocking, staying indoors, avoiding social contact, avoiding health care professionals, keeping children at home and staying at home, and going to work despite being advised to stay at home [ ] . there are also models that assess the effect of selfinitiated avoidance to a place with disease prevalence [ ] , voluntary vaccination and free-ride (not to vaccinate but rely on the rest of the population to keep coverage high [ ] . other recognized behaviors include refusal to vaccinate due to religious beliefs and not vaccinating due to lack of awareness [ ] . we believe that there is a need for further studies to establish the relative influence of all of the above mentioned social-behavioral factors on operational models for pandemic spread and mitigation. subsequently, the influential factors need to be analyzed to determine how relevant information about those factors should be collected (e.g., in real-time or through surveys before an outbreak), accessed, retrieved, and translated into the final model parameter values. it is important to mention very recent efforts in improving models for assessment of relevant social behavioral components including commuting, long distance travel behavior [ , , ] , and authority recommended decline of travel to/from affected regions [ ] . for operational modeling, it would be helpful to adapt the approaches used by these models in translating massive data sets (e.g., bank notes, mobile phone user trajectories, air and commuting travel networks) into model parameter values. in addition, available new methodologies to model social-behavior that adapts to evolving disease dynamics [ ] should be incorporated into the operational models. with regards to accessibility and scalability of the selected models, we first attempted to determine which of the simulation models were made available to general public, either as an open or closed source code. we also checked for available documentation for model implementation and user support, if any. most importantly, we looked into how the researchers attempted to achieve the computational feasibility of their models (see additional file : table s ). three of the models that make their source codes accessible to general public are influsim [ ] , ciofi [ ] and flute [ ] . influsim is a closed source differential equation-based model with a graphical user interface (gui) which allows the evaluation of a variety of mitigation strategies, including school closure, place closure, antiviral application to infected cases, and isolation. ciofi is an open source model that is coupled with a differential equation model to allow for a more realistic importation of cases to a region. flute is an open source model, which is an updated version of the uw-lanl [ ] agent-based model. the source code for flute is also available as a parallelized version that supports simulation of large populations on multiple processors. among these three softwares, influsim has a gui, whereas ciofi and uw-lanl are provided as a c/c++ code. influsim's gui seems to be more user friendly for healthcare policymakers. flute and ciofi, on the other hand, offer more options for mitigation strategies, but requires the knowledge of c/c++ programming language and the communication protocols for parallelization. other c++ models are planning to become, or are already, publicly accessible, according to the models of infectious disease agent study (midas) survey [ ] . we note that the policy makers would greatly benefit if softwares like flute or ciofi can be made available through a cyber-enabled computing infrastructure, such as teragrid [ ] . this will provide the policy makers access to the program through a web based gui without having to cope with the issues of software parallelization and equipment availability. moreover, the policy makers will not require the skills of programming, modeling, and data integration. the need for replicates for accurate assessment of the model output measures and the run time per replicate are major scalability issues for pandemic simulation models. large-scale simulations of the u.s. population reported running times of up to h per replicate, depending on the number of parallel threads used [ ] (see additional file : table s for further details). it would then take a run time of one week to execute replicates of only one pandemic scenario. note that, most of the modeling approaches have reported between to replicates per scenario [ , [ ] [ ] [ ] [ ] [ ] [ ] , with the exception of [ , , , ] which implemented between to replicates. clearly, it would take about one month to run replicates for a single scenario involving the entire u.s. population. while it may not be necessary to simulate the entire population of a country to address mitigation related questions, the issue of the computational burden is daunting nonetheless. we therefore believe that the modeling community should actively seek to develop innovative methodologies to reduce the computational requirements associated with obtaining reliable outputs. minimization of running time has been recently addressed through high performance computing techniques and parallelization by some of the midas models (e.g., epifast) and other research groups (e.g., dicon, gsam), as reported in [ ] . minimization of replicates can be achieved by running the replicates, one more at a time, until the confidence intervals for the output variables become acceptable [ , ] . in addition to the need of minimizing running time and number of replicates, it is also necessary to develop innovative methodologies to minimize the setting up time of operational models. these methodologies should enable the user to automatically select the level of modeling detail, according to the population to mimic (see a discussion of this framework in the context of human mobility [ ] ), and allow the automatic calibration of the model parameters. there exist several simulation models of pandemic influenza that can be used at the provincial and local levels and were not treated as part of the evaluated models in this article. their exclusion is due to their limited available documentation discussing the choice of demographic, social-behavioral or epidemiological parameter values. we mention and discuss their relevant features in this manuscript, whenever applicable. for information about the additional models, the reader is referred to [ , , ] . there also exist a body of literature evaluating less than three types of mitigation strategies that were not considered as part of the review, as we discussed in the methods section. this literature is valuable is providing insights about reproduction patterns [ , ] , effect of cross-immunity [ ] , antiviral resistance [ ] , vaccine dosage [ , ] , social-distancing [ ] and public health interventions in previous pandemics [ , ] . though the literature on pandemic models is rich and contains analysis and results that are valuable for public health preparedness, policy makers have raised several questions regarding practical use of these models. the questions are as follows. is the data support adequate and valid? how credible and valid are the model assumptions? is human behavior represented appropriately in these models? how accessible and scalable are these models? this review paper attempts to determine to what extent the current literature addresses the above questions at provincial and local levels, and what the areas of possible enhancements are. the findings with regards to the areas of enhancements are summarized below. enhance the following: availability of real-time epidemiological data; access and retrieval of demographical and epidemiological data; translation of data into model parameter values. we analyzed the most common epidemiological and demographical parameters that are used in pandemic models, and discussed the need for adequate updating of these parameters during an outbreak. as regards the epidemiological parameters, we have noted the need to obtain prompt and reliable estimates for the iar and r, which we believe can be obtained by enhancing protocols for expedited and representative specimen collection and testing. during a pandemic, the estimates for iar and r should also be obtained as often as possible to update simulation models. for the disease natural history and the fraction of asymptomatic cases, estimation should occur every time viral evolution is confirmed by the public health laboratories. for periodic updating of the simulation models, there is a need to develop interfaces for (semi)automatic data access and retrieval. algorithms for translating data into model parameters should not delay model execution and decision making. demographic data are generally available. but most of the models that we examined are not capable of performing (semi)automatic access, retrieval, and translation of demographic data into model parameter values. examine validity of modeling assumptions from the point of view of the decisions that are supported by the model. by referring to two of the most commonly cited pandemic preparedness models [ , ] , we discussed how simplifying model assumptions are made to reduce computational burden, as long as the assumptions do not interfere with the performance evaluation of the mitigation strategies. some mitigation strategies require more realistic model assumptions (e.g., location based antiviral prophylaxis would require models that track geographic coordinates of individuals so that those within a radius of an infected individual can be identified). whereas other mitigation strategies might be well supported by coarser models (e.g.,"antiviral prophylaxis for household members") would require models that track household membership). therefore, whenever validity of the modeling assumptions is examined, the criteria chosen for the examination should depend on the decisions supported by the model. incorporate the following: a broader spectrum of social behavioral aspects; updated information for contact patterns; new methodologies for collection of human mobility data. some of the social behavioral factors that have been considered in the examined models are social distancing and vaccination compliance, natural withdraw from work when symptoms appear, and work absenteeism to care for sick family members. although some of the examined models attempt to capture social-behavioral issues, it appears that they lack adequate consideration of many other factors (e.g., voluntary vaccination, voluntary avoidance to travel to affected regions). hence, there is a need for research studies or expert opinion analysis to identify which social-behavioral factors are significant for disease spread. it is also essential to determine how the social behavioral data should be collected (in real-time or through surveys), archived for easy access, retrieved, and translated into model parameters. in addition, operational models for pandemic spread and mitigation should reflect the state of the art in data for the contact parameters and integrate recent methodologies for collection of human mobility data. enhance computational efficiency of the solution algorithms. our review indicates that some of the models have reached a reasonable running time of up to h per replicate for a large region, such as the entire usa [ , ] . however, operational models need also to be set up and replicated in real-time, and methodologies addressing these two issues are needed. we have also discussed the question whether the public health decision makers should be burdened with the task of downloading and running models using local computers (laptops). this task can be far more complex than how it is perceived by the public health decision makers. we believe that models should be housed in a cyber computing environment with an easy user interface for the decision makers. additional file : additional file : table s epidemiological parameters in models for pandemic influenza preparedness. the excel sheet "additional file : table s " shows the epidemiological parameters most commonly used in the models for pandemic influenza, the parameter data sources, and the means for access, retrieval and translation. additional file : table s demographic parameters in models for pandemic influenza preparedness. the excel sheet "additional file : table s " shows the demographic parameters most commonly used in the models for pandemic influenza, the parameter data sources, and the means for access, retrieval and translation. additional file : table s 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real-time estimation of the serial interval and reproductive number of an epidemic real time bayesian estimation of the epidemic potential of emerging infectious diseases estimating in real time the efficacy of measures to control emerging communicable diseases the effective reproduction number of pandemic influenza. prospective estimation estimating reproduction numbers for adults and children from case data pros and cons of estimating the reproduction number from early epidemic growth rate of influenza a (h n ) global infectious disease surveillance and health intelligence monitoring influenza activity, including using internet searches for influenza surveillance detecting influenza epidemics using search engine query data the use of twitter to track levels of disease activity and public concern in the u.s. during the influenza a h n pandemic the role of the airline transportation network in the prediction and predictability of global epidemics social contacts and mixing patterns relevant to the spread of infectious diseases little italy: an agent-based approach to the estimation of contact patterns -fitting predicted matrices to serological data reality mining: sensing complex social systems dynamics of person-to-person interactions from distributed rfid sensor networks cellular census: explorations in urban data collection. pervasive computing mobile landscapes: using location data from cell-phones for urban analysis. environ and planning b: plann and des social and economic impact of school closure resulting from pandemic influenza a/h n compliance and side effects of prophylactic oseltamivir treatment in a school in south west england using an online survey of healthcare-seeking behaviour to estimate the magnitude and severity of the h n v influenza epidemic in england behavioural intentions in response to an influenza pandemic modelling the influence of human behaviour on the spread of infectious diseases: a review the scaling laws of human travel understanding individual human mobility patterns adaptive human behavior in epidemiological models stochastic modelling of the spatial spread of influenza in germany simple models of influenza progression within a heterogeneous population planning for the next influenza h n season: a modelling study a populationdynamic model for evaluating the potential spread of drug-resistant influenza virus infections during community-based use of antivirals optimizing the dose of pre-pandemic influenza vaccines to reduce the infection attack rate finding optimal vaccination strategies for pandemic influenza using genetic algorithms living with influenza: impacts of government imposed and voluntarily selected interventions public health interventions and epidemic intensity during the influenza pandemic the effect of public health measures on the influenza pandemic in the us cities the authors wish to thank doctor lillian stark, virology administrator of the bureau of laboratories in tampa, florida, for providing valuable information on the problems faced by the laboratory during the h n pandemics. the authors also wish to thank the reviewers of this manuscript for providing valuable suggestions and reference material. we appreciate the support of dayna martinez, a doctoral student at usf, in providing some literature information on social-behavioral aspects of pandemic influenza. authors' contributions dp conducted the systematic review and analysis of the models. td and as guided dp and au in designing the conceptual framework for the review. all three jointly wrote the manuscript. ri and sm provided public health expert opinion on the conceptual framework and also reviewed the manuscript. all authors read and approved the final manuscript. the authors declare that they have no competing interests. key: cord- -yw rzrb authors: prateepko, tapanan; chongsuvivatwong, virasakdi title: patterns of perception toward influenza pandemic among the front-line responsible health personnel in southern thailand: a q methodology approach date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: yw rzrb background: thailand has joined the world health organization effort to prepare against a threat of an influenza pandemic. regular monitoring on preparedness of health facilities and assessment on perception of the front-line responsible health personnel has never been done. this study aimed to document the patterns of perception of health personnel toward the threat of an influenza pandemic. methods: q methodology was applied to a set of health personnel in charge of influenza pandemic preparedness in the three southernmost provinces of thailand. subjects were asked to rank statements about various issues of influenza pandemic according to a pre-designed score sheet having a quasi-normal distribution on a continuous -point bipolar scale ranging from - for strongly disagree to + for strongly agree. the q factor analysis method was employed to identify patterns based on the similarity and dissimilarity among health personnel. results: there were three main patterns of perception toward influenza pandemic with moderate correlation coefficients between patterns ranging from . to . . pattern i, health personnel, which we labeled pessimistic, perceived themselves as having a low self-efficacy. pattern ii, which we labeled optimistic, perceived the threat to be low severity and low vulnerability. pattern iii, which we labeled mixed, perceived low self-efficacy but low vulnerability. across the three patterns, almost all the subjects had a high expectancy that execution of recommended measures can mitigate impacts of the threat of an influenza pandemic, particularly on multi-measures with high factor scores of in all patterns. the most conflicting area was vulnerability on the possible impacts of an influenza pandemic, having factor scores of high ( ), low (- ), and neutral ( ) for patterns i, ii, and iii, respectively. conclusion: strong consistent perceptions of response efficacy against an influenza pandemic may suggest a low priority to convince health personnel on the efficacy of the recommended measures. lack of self-efficacy in certain sub-groups indicates the need for program managers to improve self-confidence of health personnel to participate in an emergency response. an influenza pandemic is a significant natural health threat that has periodically occurred over the past years [ ] . its severe impacts to global human health, healthcare service, society, and economy were evidently documented during the previous pandemics [ , ] . for a coming one, influenza experts have agreed that this threat is inevitable and possibly imminent [ ] . if the next pandemic occurs, it is expected that % of the global population will become ill, nearly million will be hospitalized and a quarter of these would die within a few months of its attack [ ] . to mitigate the impacts of this threat, the world health organization (who) has recommended that all countries should consider this threat as very important and urged them to make preparations a high national priority. thailand occasionally has had serious outbreaks of avian influenza a (h n ) since early , in both poultry and humans. in response to these outbreaks and a possible future influenza pandemic, the national committee on avian influenza control and influenza pandemic preparedness has issued a national strategic plan for influenza pandemic preparedness. beyond preparedness, the perception of each individual is also a fundamental factor that contributes to the spread, prevention, and control of infectious diseases. for example, during the severe acute respiratory syndrome (sars) epidemics, the perceptions toward this disease had an effect on the preventive health behaviors (e.g., hand hygiene, mask wearing) and that consequently contributed to containing the outbreaks [ ] [ ] [ ] . for a current threat of an influenza pandemic, sporadic perception surveys among health workers have been done in developed countries [ ] [ ] [ ] [ ] . yet this issue has not been explored in developing countries, particularly in the southeast asian region where it is more likely to be a source of the next pandemic [ ] . southern thailand experienced a probable sars case in , but there has been no reported case of avian influenza a (h n ) in both poultry and human. however, the region faces a serious problem of ethnic violence. this unrest has led to the loss of over , lives and more than , injuries in the past years. it is possible that the local health systems may have deteriorated due to the unrest leading to loosening of preparedness against the threat of an influenza pandemic. we have therefore conducted a study to investigate the preparedness. the current report is confined to perceptions related to the threat of an influenza pandemic with the objective to document the patterns of perception of health personnel toward this threat in southern thailand. as health personnel are key persons for influenza pandemic preparedness and con-trol, it is hoped that understanding their patterns of perception will allow control programs to properly improve the training. it may also be useful for other developing countries where an influenza pandemic is a serious threat, but the personnel are not fully prepared. q methodology, which basically originated from the theory of factor analysis [ ] was applied. while conventional factor analysis is used in scale development and tries to group items or variables, q method tries to group subjects. therefore, people of the same group or having the same factor will have a similar pattern of chosen statements. the implication would be that it would be easy to put people of the same factor into the same intervention program. this method was taken into our study because this is a scientific and systematic study of human subjectivity, involving perceptions, attitudes, and opinions [ , ] . furthermore, it is also unique since it mixes the strong points of both qualitative and quantitative research techniques, compared to traditional surveys [ , ] . in doing q, the flow of communication surrounding the study topic (concourse) is firstly formed to get a wide range of ideas toward that topic. this is generally collected from various sources (e.g., scientific papers, books, news, interviews, focus group discussions, etc.). it is commonly presented in the form of statements. afterward, a q sample (a representative set of statements) is selected from the concourse and developed to be more meaningful, which represents various issues of the study topic and eventually is compiled into the instrument. the study subjects are then asked to rank the representative statements and place them into a score sheet, which is designed in a continuous scale ranging from strongly disagree to strongly agree, following a standardized instruction based on the judgment of each subject. this is known as the q sorting procedure. the sheets that are completely ranked by each subject (qsort) are finally correlated and analyzed by q (subjectwise) factor analysis, and the factors are then interpreted. in our study, statements on various issues of an influenza pandemic were initially gathered from scientific articles, newsletters, and books to form a concourse. the protection motivation theory (pmt) was used as a basis for grouping and developing the statements into four domains: perceived severity, perceived vulnerability, perceived response efficacy, and perceived self-efficacy, by refining, clarifying, and combining the raw statements to be more meaningful and more understandable. to catch various aspects of an influenza pandemic and keeping the total number of the statements suitably manageable by our subjects, we included eight refined statements in each of such four domains with one additional item added to make the total number of the statements equal (qsample). these statements were then placed into the score sheet (figure ), and forced to follow a quasi-normal distribution, that is, - - - - - - - - . the reliability of this instrument was tested with cronbach's alpha. each statement was randomly assigned a number from to for the subjects to arrange and place into the score sheet. to get more understandability, the statements were pilottested with health personnel and were then revised as appropriate before the study. the study was conducted in the three southernmost provinces of thailand: yala, pattani, and narathiwat, during april to october . apart from the problems of ethnic violence, the area is in a remote part of the country where the logistic problems will be easily visible. the area is also close to malaysia, so cross-border diseases have a high chance of spread due to the movement of populations. the research protocol was approved by the ethics committee of the faculty of medicine, prince of songkla university, prior to conducting the study. a list of all health facilities in the study area was obtained from the local health offices. health personnel designated by each facility to be responsible for influenza pandemic preparedness were identified. these included a numbers of doctors, nurses, pharmacists, laboratory personnel, public health specialists, public health administrators, and junior health workers. all were invited to participate in the study. the selected personnel were sent a set of documents, which included a cover letter, an overview describing the study importance and objective, a set of statements (q sample), a standardized step-by-step set of instructions for responding to the study, and a score sheet. following the initial mailing, two phases of follow up were performed: a sequence of telephone calls at one month, with nonresponders contacted by the first author after three months. each consenting subject was asked to rank the statements about different issues concerned with an influenza pandemic into the levels of agreement and disagreement based on their own judgments. each participant was requested to place two statements in the columns of strongly disagree (- ) and strongly agree (+ ), three in disagree (- ) and agree (+ ), four in - and + , five in - and + , and five statements in the neutral response column ( ). however, if they thought that our distribution did not represent their real perceptions, they were encouraged to sort such statements accordingly. each q-sort was considered as complete if all statements were placed into the score sheet without repetition of the statements. the data from each completed score sheet were entered and analyzed in pqmethod . (free software). betweensubjects correlation matrix was computed and a q (subject-wise) factor analysis by principle components analysis (pca) method was performed using a varimax rotation technique. factors that could explain more than % of the variance were adopted and retained into the final solution. a participant who had absolute factor loadings of larger than ± . , which suggests high significance (p < . ) with the group, was included into that particular factor. in each factor, the ascending sorted normalized scores (z-scores) of assigned number of each statement were returned into the score sheet from right to left order (figures , , and ) . each final score sheet thus displays the pattern of the defined factor. comparisons among patterns were based on the factor scores and the mean values of the domain of the statements. for visualization of the patterns, the domains of each statement were linked to different colors or grey shadings in the final q-sort models that are shown in figures , , and . since the cells in the extreme score regions reflect strong perceptions in the domains, they are the primary target for comparing similarity and dissimilarity of each group of health participant score sheet figure participant score sheet. strongly agree [ ] [ ] [ ] [ ] [ ] pattern i. pessimistic with perceived low self-efficacy figure pattern i. pessimistic with perceived low self-efficacy. personnel's perceptions on the threat of an influenza pandemic. after consultation with an expert in instrument development, statements listed in table of a total health personnel, ( %) persons completed the score sheet. there were no statistically significant differences between responders and non-responders in terms of gender, age, religion, educational level, total period of working, job classification, experience of getting training on influenza pandemic preparedness and perceived levels of knowledge about an influenza pandemic, public health measures against an influenza pandemic and impacts of an influenza pandemic. however, the nonresponders had a lower educational level than those of the responders ( % vs. %, respectively). the basic characteristics of the respondents are presented in table . q factor analysis gave three factors that met our criteria with the percentages of explained variance being . %, . %, and . %, respectively. after varimax rotation, subjects were classified into factor i (in other words, the first pattern composites of health personnel), into factor ii, and into factor iii. the other subjects were not classified into any factor because all their loading values were less than . or had high loading on more than one factor. the composite reliability of each factor was . , with the corresponding standard errors of factor scores being . , . , and . . the correlation coefficients between the three factors were . (factor i vs. ii), . (factor i vs. iii), and . (factor ii vs. iii), indicating a moderate similarity among the patterns. the three patterns had scores for each specific statement distributed into the q-sort model or composite factor array and are displayed in figures , , and . the same information is displayed in table . factor scores of statement were , - , and - as shown in the first row of table . in the q-sort model, statement is in column + of figure , and column - of figure , and column - of figure . from table , statement number has a common factor score of for all three patterns. this indicates that all three patterns of health personnel strongly perceived that multimeasures must be performed during an influenza pandemic. statement number was also in columns + of figures and , and + of figure , which is related to response efficacy on multilevels of responsibility for preparedness against the threat. in contrast, statement was the most dissenting issue with factor scores of , - , and . health personnel classified as pattern i quite strongly perceived that thailand will have possibly high impacts from an influenza pandemic if and when one occurs, but those classified in pattern ii strongly disagreed, and those in the remaining group were neutral. the right extremes of all three q-sort models are consistently filled with three black cells (statements , , and ) out of cells of that region. this indicates that all three pattern ii. optimistic with perceived low severity and low vul-nerability figure pattern ii. optimistic with perceived low severity and low vulnerability. pattern iii. mixed with perceived low self-efficacy but low vulnerability figure pattern iii. mixed with perceived low self-efficacy but low vulnerability. means of factor scores for each component of the pmt are displayed in table . all groups had positive perceived response efficacy of the measures. patterns i and iii, however, perceived low self-efficacy, in contrast to high perceived self-efficacy of pattern ii. optimistic personality of pattern ii was also expressed as perception of low severity and low vulnerability where the pattern i has isolated neutral perception of severity with a moderate level of perceived vulnerability. finally, more mixed appraisal is found in pattern iii, the group who perceived a low level of vulnerability but a very high level of severity. we identified three main patterns of health personnel in southern thailand based on the perception toward a threat of an influenza pandemic. pattern i was pessimistic (strongly perceived response efficacy, but perceived low self-efficacy). pattern ii was optimistic (strongly perceived response efficacy, but perceived low severity and low vulnerability). pattern iii was mixed (strongly perceived response efficacy, but perceived low vulnerability and low self-efficacy). a high perception on response efficacy was predominantly found in all health personnel groups. perceptions on vulnerability were more varied. the majority of our health personnel perceived low selfefficacy toward an influenza pandemic. self-efficacy is one important component of coping appraisal of the pmt [ ] . it has powerful influence on human's feeling, thinking, motivation, and behavior [ ] [ ] [ ] . previous metaanalyses provided evidence for self-efficacy having the largest effect size and was the strongest predictions of protection motivation [ , ] . people with low self-efficacy usually believe that tasks are harder than they can handle. this can lead to limit task planning, increase stress, reduce the low level of attempt, and having a tendency to avoid duties and activities [ ] [ ] [ ] . balicer et al. reported that nearly a half of local health workers may be unwilling to report to duty during a pandemic event [ ] . however, that study did not identify different patterns of health workers as our study has done. another conventional survey conducted among a general population (rather than health workers) in developed countries of europe and asia on avian influenza risk perception showed a similar result. the level of self-efficacy among the respondents was also low and the authors concluded that a low level of self efficacy may obstruct any interventions [ ] . the most dissenting issue among our health personnel toward this threat was on vulnerability of possible impacts in the country (statement number ). naturally, the occurrence and severity of an influenza pandemic cannot be predicted [ ] . fifteen per cent of our health per- showed that more than half did not consider that the risk of an imminent influenza pandemic was more than a possibility [ ] . both perceived severity and perceived vulnerability are components of threat appraisal of the pmt [ ] . perception of low level of severity and vulnerability or low levels of appraised threat of an influenza pandemic may inhibit motivation of health personnel to engage in protective behavior [ , ] . however, the effect sizes of such two components in previous meta-analyses were small to medium and barely predicted of protection motivation and behavior compared to the components of coping appraisal (response efficacy and self-efficacy) [ , ] . perception of response efficacy was stronger than other domains. this may be influenced by past experiences of the country, which after employing on multi-sectors and multi-measures could successfully suppress avian influenza a(h n ) [ ] . this study used a wide range of front-line health personnel responsible for influenza pandemic preparedness. thus, it may reflect the problems specific to this area with acceptable accuracy. the study was confined to the three southernmost provinces of thailand where avian influenza a (h n ) has never occurred. our study subjects might be different from those in other regions of the country where the infected cases of that avian influenza in both humans and poultry have been reported, and intensive avian influenza controls have been fully activated. the study subjects were also predominated by personnel from health centers and community hospitals in rural areas. the threat of a pandemic may be less compared to in urban areas. the study was based on q methodology which had never been employed among local health workers; thus, the data have to be interpreted with caution. approximately % of the respondents were not able to be classified into any of the three groups determined by our factor analysis. the patterns are therefore far from ideal. the statements about influenza pandemic that were used in our study should be improved to be more specific for health workers in future work. despite the above limitations, this study highlights important findings. strong consistent perceptions of implementing recommended measures against an influenza pandemic can remove or mitigate impacts of this threat, and may suggest a low priority to convince health personnel on the efficacy of the measures. perception of low self-efficacy in certain subgroups who gave low scores on the statements related to self-efficacy on an influenza pandemic indicates the need to improve self-confidence of health personnel to participate in an emergency response by the control program. potter cw: a history of influenza seasonal and pandemic influenza preparedness: a global threat influenza pandemics of the th century are we ready for pandemic influenza? will vaccines be available for the next influenza pandemic? sars transmission, risk factors, and prevention in hong kong sars-related perceptions in hong kong. emerg infect dis monitoring community responses to the sars epidemic in hong kong: from day to day local public health workers' perceptions toward responding to an influenza pandemic physicians' perception of pandemic influenza perception in relation to a potential influenza pandemic among healthcare workers in japan: implications for preparedness koh d: concerns, perceived impact and preparedness in an avian influenza pandemic -a comparative study between healthcare workers in primary and tertiary care capacity of thailand to contain an emerging influenza pandemic doing q methodology: theory, method and interpretation a primer on q methodology q methodology-a journey into the subjectivity of human mind q methodology: definition and application in health care informatics cognitive and physiological processes in fear appeals and attitude change: a revised theory of protection motivation self-efficacy: toward a unifying theory of behavioral change human agency in social cognitive theory self-efficacy: the exercise of control a meta-analysis of research on protection motivation theory prediction and intervention in health-related behavior: a meta-analytic review of protection motivation theory avian influenza risk perception blaser mj: pandemics and preparations protection motivation theory effects of components of protection motivation theory on adaptive and maladaptive coping with a health threat grotto i: a systematic analytic approach to pandemic influenza preparedness planning this study was part of the first author's thesis to fulfill the requirement for phd in epidemiology at prince of songkla university (psu). we sincerely acknowledge all health personnel who participated in the study. appreciative thanks to the graduate school, psu, and the disease control department, ministry of public health, thailand for supporting the study. we also wish to thank dr. alan geater, dr. vorasit sornsrivichai, mr. edward mcneil, the epidemiology unit, faculty of medicine, psu, and mr. darrell beng, adelaide, south australia. the authors declare that they have no competing interests. tp designed this study, was the principal investigator of the project, performed data analysis, and drafted the manuscript. vc provided supervision, suggestion, and development on manuscript writing. all authors have contributed to revision of the draft version and have read and accepted the final version of this manuscript. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -bq p gs authors: alrubaiee, gamil ghaleb; al-qalah, talal ali hussein; al-aawar, mohammed sadeg a. title: knowledge, attitudes, anxiety, and preventive behaviours towards covid- among health care providers in yemen: an online cross-sectional survey date: - - journal: bmc public health doi: . /s - - -y sha: doc_id: cord_uid: bq p gs background: the growing incidence of coronavirus (covid- ) continues to cause fear, anxiety, and panic amongst the community, especially for healthcare providers (hcps), as the most vulnerable group at risk of contracting this new sars-cov- infection. to protect and enhance the ability of hcps to perform their role in responding to covid- , healthcare authorities must help to alleviate the level of stress and anxiety amongst hcps and the community. this will improve the knowledge, attitude and practice towards covid- , especially for hcps. in addition, authorities need to comply in treating this virus by implementing control measures and other precautions. this study explores the knowledge, attitude, anxiety, and preventive behaviours among yemeni hcps towards covid- . methods: a descriptive, web-based-cross-sectional study was conducted among yemeni hcps. the covid- related questionnaire was designed using google forms where the responses were coded and analysed using the statistical package for the social sciences software package (ibm spss), version . . descriptive statistics and pearson’s correlation coefficient test were also employed in this study. a p-value of < . with a % confidence interval was considered as statistically significant. the data collection phase commenced on nd april , at pm and finished on th april at am. results: the results indicated that from the hcps participating in this study, . % were male, and % were aged between and years with a mean age of . ± . . most ( %) held a bachelor’s degree or above having at least years of work experience or less ( . %). however, while . % of the respondents obtained their information via social networks and news media, a further . % had never attended lectures/discussions about covid- . the results further revealed that the majority of respondents had adequate knowledge, optimistic attitude, moderate level of anxiety, and high-performance in preventive behaviours, . , . %, . and . %, respectively, towards covid- . conclusion: although the yemeni hcps exhibited an adequate level of knowledge, optimistic attitude, moderate level of anxiety, and high-performance in preventive behaviours toward covid- , the results highlighted gaps, particularly in their knowledge and attitude towards covid- . a cluster of pneumonia cases of unknown origin or causes was reported in wuhan, china, on th december [ ] . among the initial cases reported, most originated from vendors and dealers working in the huanan seafood market in wuhan [ ] . the world health organisation (who) and the chinese authorities identified the causative agent as a new strain of coronavirus (sars-cov- ), named at that time as a coronavirus disease , commonly referred to after that as covid- [ ] . initially, sars-cov- quickly spread within china before dramatically spreading to other countries on a global scale [ ] . on th march , who declared the outbreak of covid- as a global pandemic [ ] . since th september , the virus has infected over , , people, causing , deaths in countries worldwide [ ] . in yemen, the fight against covid- began on th april resulting from the initial case confirmed in ash shihr, the hadramout province, southern yemen. on th april , five more cases of covid- were confirmed and registered in aden city, the temporary capital of yemen. after that, the cases started to increase in other cities daily. since th september , cases of covid- have been reported in the republic of yemen, of which cases have since recovered, resulting in deaths. however, the number of covid- cases is anticipated to be much higher than these figures, particularly given the transparency and the inability to effectively track and control the spread and number of cases reported in north yemen [ ] . at present, the exact dynamics and transmission of the virus have not been determined. however, according to who, the virus can be transmitted via air-droplets and fomites during close and unprotected contact between an infected person and a healthy person [ ] . according to the centre for disease control and prevention (cdc) sars-cov- is transmitted from person to person through close contact (within ft); from an infected person via respiratory droplets during coughing or sneezing or when touching a surface or an object that is contaminated with the virus, including touching one's eyes, nose or mouth [ ] . in most cases, those infected with covid- experience none or mild to moderate symptoms that are alleviated within several weeks of isolation. however, in contrast, it can cause severe respiratory syndrome or death, particularly in older people or patients with chronic health diseases [ ] . similarly, healthcare providers (hcps) as the front line defence in treating patients with covid- are more susceptible to this spreading infection [ ] . the who on th july , estimated that close to % of all covid- cases globally, which accounts for nearly . million cases, were related to hcps. however, this figure is possibly underestimated, as, at that time, no systematic reporting or other measures were in place [ ] . indeed, information released by the international council of nurses (icn), reported that until june , nearly , hcps worldwide had acquired covid- , with over nurses dying [ ] . in the context of yemen, at present, the ongoing war and civil unrest over the past six years within the country has severely impacted or destroyed the much of the country's infrastructure, with only % of the country's health facilities remaining in operation [ ] . this consists of two testing centres and ventilators for a population of nearly million people. further, the country continues to suffer from limited testing capacity, critical shortage in health care supplies, including basic personal protective equipment (ppe) and other measures, limited by the ability to track the spread of the virus, especially, given the similarity covid- symptoms with other diseases that already prevail in the country [ ] . all these factors place the country sadly in a unique if not, an uncompromising and dangerous position should covid- spread uncontrollably within the community, adding further burdening hcps' in the country. however, viewing this situation from a wider perspective, the rapid spread of covid- globally has caused considerable level anxiety, fear and panic among the population in countries worldwide, especially given that fact that hcps and the elderly are most vulnerable to the risk of infection [ ] . according to who, the shortage of appropriate ppe and other preventive measures directly endangers hcps and represents a major cause of concern for countries [ ] . likewise, the availability and correct use of ppe is critical in order to protect and safeguard frontline workers such as hcps in coping with though, what is of prime importance at this stage, is for hcps to adhere to applying these preventive measures, which largely depend on their knowledge, attitude, and practice in addressing this highly contagious virus [ ] . nevertheless, yemeni hcps have been facing a double battle even before this pandemic eventuated given that yemen, according to who, is more than % below the basic health services global benchmark concerning the coverage of health care services. furthermore, while there are a limited number of skilled hcps in the country, they have not received salaries for nearly five years. surprisingly, the proportion of medics in yemen has been calculated as medics to every , of the population, notwithstanding that the number of nurses and midwives that are available remains inadequate to fill this shortage. these issues are further compounded by the 'brain drain' in the country of people seeking better opportunities offshore and weakening medical health education [ ] . therefore, to ensure the protection of hcps and safeguard yemen from covid- , there is an urgent need to upskill and enhance the understanding and awareness of covid- among hcps. this study aims to assess the knowledge, attitude, fear, and anxiety, as well as the preventive behaviours of hcps towards covid- . study area, study design, and study period a descriptive, web-based cross-sectional survey was conducted among yemeni hcps between nd april , pm and th april , am. all hcps who provided direct healthcare services to patients were invited to participate in the study. the questionnaire developed and used in this study was adapted from previously published studies based on the authors' permission [ , ] . the questionnaire consisted of items that sought to collect information on the respondents' knowledge, attitude, anxiety, and preventive behaviours toward covid- . the questionnaire comprised of five parts. part ( ) the socio-demographic characteristics such as age, sex, occupation, education level, years of working experience, and sources of covid- related knowledge. part ( ) the respondents' knowledge ( -items). part ( ) the respondents' attitude ( -items) and part ( ) the respondents' anxiety ( -items). part ( ) included questions on the respondents' preventive behaviours ( -items). scoring of knowledge, attitude, anxiety, and preventive behaviours the scoring system that was used in this study was adapted from the work of taghrir et al. [ ] and roy et al. [ ] . the -items related to knowledge were assessed with either a "yes" or "no" response in which each correct response was awarded a score of one ( ), while a zero ( ) score was assigned to an incorrect response. the scores ranged between (no correct answers) and (all answers are correct). a score of less than was considered as having inadequate knowledge, and between and , the scores were considered as having moderate knowledge, while a score of and above was considered as having adequate knowledge. similarly, the -items signifying the respondents' attitudes were evaluated with a "correct" or "incorrect" response. the scores ranging between zero ( ) and seven ( ) were considered as acquiring a negative attitude, while the scores between eight ( ) and ten ( ) were considered as having a positive attitude. the -items related to anxiety were assessed via a -point likert scale, in which a score between = "never" to = "always". the total cumulative score ranged between and . here, scores between and were considered as "low anxiety", and those scores ranging between and were considered as "moderate anxiety", while those ranging between and were considered as "high anxiety". the -items related to preventive behaviours were assessed with a "yes" or "no" response. a score between zero ( ) and seven ( ) was considered as "low performance", while a score between eight ( ) and ten ( ) was considered as "high-performance". three experts with a background in infectious disease and epidemiology (one specialist in infectious disease and two epidemiologists) were invited to participate in assessing the content validity of the questionnaire items. the reliability of the questionnaire items was based on a pilot study that included participants, and the reliability was tested using a cronbach's alpha test with the results showing . for the knowledge part, . for the attitude part, . for the anxiety part, and . for the preventive behaviours part. at present, due to the outbreak of covid- and the specific preventive precautions and measures recommended by the ministry of health and population in yemen, an electronic web-based self-reported questionnaire was designed to comply with the recommendations. the internet link was distributed to the hcps via email, whatsapp, telegram, and other forms of social media. the criteria of the hcps to participated in the study needed to be living in the republic of yemen, regardless of gender, aged years or older, was aware of the covid- outbreak, and who had signed a consent form to participate in the study. although participation in the study was voluntary, personal details of the participants were not recorded on the questionnaire. the respondents in receipt of the questionnaire were encouraged to forward the survey to other colleagues who may be interested in participating in the study as well. approval of the ethics committee of al-razi university was obtained before conducting the study. the respondents needed to confirm their willingness to participate on a voluntary basis by answering a "yes or no" question on a written informed consent form before being allowed to complete the online self-reporting questionnaire. the statistical package for social sciences (ibm spss), version . was used in the administration and analysis of the collected data. descriptive analyses using mean values and standard deviations for continuous variables and the count and percentages for the dichotomous or categorical variables were used in describing the data. the relationship between the study variables was assessed using pearson's correlation coefficient test. a pvalue of < . (two-tailed) with a % confidence interval was reported as significant for the correlation analysis. the respondents' socio-demographic data are presented in table below. as shown in the table, over half ( . %) of the hcps were male, with more than ( %) of respondents were aged between and years with a mean of . ± . . regarding the occupation of respondents, . % were physicians, followed by pharmacists ( . %), laboratory technicians/workers ( . %), and nurses ( . %). regarding their education and working experience, . % of respondents held a phd, . % held a board position with . % of all respondents having years or less of working experience. concerning covid- related information sources, social media was highlighted as the main source ( . %) followed by news media ( . %). around . % of respondents were aware of covid- , with a further . % having never attended lectures or discussions on covid- . the level of knowledge among healthcare providers regarding the covid- pandemic is presented in fig. below. twenty-one items within the questionnaire instrument having a "true" or "false" response choice was used to assess the extent of the respondents' knowledge regarding covid- . as shown in fig. , the majority of hcps ( . %) were believed to have acquired an adequate level of knowledge regarding covid- , while . % had moderate knowledge, and only . % were considered to have inadequate knowledge. the lower percentages were attributed to four ( ) statements that discussed the importance of wearing face masks, the need to wear n face masks only during intubation, suction, bronchoscopy, and cardiopulmonary resuscitation, in treating the disease by usual antiviral drugs and antibiotics as the first-line (of defence) treatment, that scored . , . , . , and . %) respectively. the level of attitude of yemeni hcps towards the covid- pandemic is shown in fig. below. the respondents' attitude towards the covid- pandemic was assessed using ten ( ) items with a "yes" or "no" response choice. as shown in fig. , the findings indicate that the majority of respondents ( . %) had a positive attitude, while . % had a negative attitude towards the covid- pandemic. however, although the vast majority of respondents exhibited a high degree of optimism and attitude towards the pandemic, . % still believed that they would not contract the disease, and almost . % were willing to move to other locations within the country to be safe and secure during the pandemic. the level of anxiety among yemeni hcps toward the covid- pandemic is illustrated in fig. below. the level of anxiety among hcps was assessed using -items, with the answers rated against a -point likert ranging between = "never" to = "always". as shown in fig. , the findings indicate that just of half of the respondents had a moderate level of anxiety towards the pandemic, . % had a high level of anxiety, and . % had a low level of anxiety towards the covid- pandemic. healthcare providers' self-reported preventive behaviours toward the covid- pandemic ten-items each requiring a "yes" or "no" response was used to assess the respondents' level of self-reported preventive behaviours towards covid- . five ( ) items were to avoid or reduce visiting public places in their daily life. one item was related to preventive behaviour such as coughing/sneezing, two items were related to hand washing and frequently disinfecting surface areas on a frequent basis, and one item was related to talking with family and friends about preventive measures associated with of covid- . as can be seen in fig. , the vast majority ( . %) of respondents exhibited sufficient preventive behaviours, while only . % demonstrated low preventive behaviours. the lowest score ( . %) was related to cancelled or postponed activities and events such as eating out, sporting activities, and meeting with colleagues. association between the respondents' socio-demographic characteristics and their knowledge, attitude, anxiety, and preventive behaviours the association between the respondents' sociodemographic characteristics and their knowledge, attitude, anxiety, and preventive behaviours towards the covid- pandemic are reflected in table below. as the correlation between hcps knowledge, attitude, anxiety, and preventive behaviour scores is shown in table below. the correlations were divided into four ( ) levels based on the following criteria: weak = - . , fair = . - . , good = . - . , and excellent = . or greater [ ] . as shown in table , there was a significant positive linear correlation between knowledge-attitude (r = . , p < . ), knowledge-anxiety (r = . , p < . ), knowledge-preventive behaviours (r = . , p < . ), attitude-anxiety (r = . , p < . ), attitude-preventive behaviours (r = . , p < . ) and anxiety-preventive behaviours (r = . , p < . ). accordingly, the results indicate the relationship between knowledge, attitude, anxiety, and preventive behaviours towards the covid- pandemic. since the first confirmed case announced in yemen on th april , in ash shihr, (a port city in the hadhramaut province of southern yemen), rising fear and anxiety extended to other provinces from the possibility of contracting covid- and its outbreak. the hcps as the front line of defence and older people were the most vulnerable in contracting covid- that the majority of other people. during this time, there was also a critical shortage of ppe given the current conflict in the region, and civil unrest in the country [ ] . equally important was the need during this period to understand the level of preparedness of hcps' in order to cope with the outbreak of covid- in the country. this fact motivated the need to undertake the current study aiming to explore the level of knowledge, attitude, anxiety, and preventive behaviours among hcps towards the outbreak of covid- in the country. the findings have shown that while the majority of respondents ( . %) had never attended covid- training courses with respect to covid- , most ( . %) had acquired an adequate level of knowledge about the outbreak of the virus. on the other hand, the four ( ) statements reflecting the importance of wearing face masks in the community, having to wear n face masks only during intubation, suction, bronchoscopy, and cardiopulmonary resuscitation, the possibility to treat the disease using antiviral drugs and antibiotics as first-line treatment scored the lowest at . , . . and . %, respectively. this result possibly highlights the need to direct more attention toward developing educational courses and programmes related to covid- . likewise, the adequate level of knowledge among the respondents could be attributed to their educational level since most ( . %) of respondents held a bachelor's degree or higher, (i.e. a master's degree). accordingly, an educated professional group such as this could help to collect knowledge of covid- from a variety of % of hcps seemed to use social media and news media as the main source of information, which is a significant concern given the reliability of this information. this is because utilising such media can mislead hcps by spreading fabricated and unverified information. it is also worth highlighting that the respondents' level of knowledge was only statistically significantly different according to their age, occupation, and educational level. furthermore, these results are consistent with the results of a previous study [ ] which reported that the level of knowledge towards covid- differs significantly across different age groups, educational levels, and levels of different professions. the results are also in line with the results of giao et al. [ ] and saqlain et al. [ ] regarding the difference in the level of respondents' anxiety based on their profession. concerning the level of respondents' attitude, it was found to differ based on the participants' occupations significantly. this corroborates with a study by giao et al. [ ] , which reported a significant association between respondents' attitude and their occupation. however, in contrast, the result seems in differ from the results of saqlain et al. [ ] and rahman and sathi [ ] , who stated that a positive attitude toward covid- did not significantly vary nor differ across different occupations. equally, the results revealed that the respondents' level of anxiety was significantly different based on their gender and educational levels. these results support the findings reported by al-hanawi et al. [ ] that respondents' level of worry or concern attributed to covid- differs significantly across gender and educational level. this result is also in line with previous studies [ , ] carried out in china, indicating that females have higher levels of anxiety compared to males. similarly, the respondents' level of self-reported preventive behaviour significantly differed according to their gender, occupation, years of working experience, and educational level. these results are in agreement with the results by rahman and sathi [ ] on the variation of respondents' preventive behaviour according to different age groups, al-hanawi et al. [ ] regarding the gender of respondents, saqlain et al. [ ] regarding the respondents' years of working experience and khasawneh et al. [ ] about the respondents' educational level. with respect to the attitude of the respondents', the result showed that . % of respondents had an optimistic attitude towards covid- , though unfortunately, the findings also revealed that . % believe that they avoid infection, and close to . % of respondents were willing to relocate to protect themselves from covid- . this result suggests that most of the respondents were either confident of protecting themself from the virus or unaware about the nature of covid- how contagious it is. similarly, one-third of respondents would look to leave their work and relocate for fear of infection, which contributed to the shortage of hcps if the situation was to become more serious, i.e. rising infections. accordingly, based on the results and the information presented above, it is imperative given the seriousness of the issue that training courses and awareness programmes be created on covid- and disseminating such information via official websites. regarding the high level of optimism and attitude of respondents in the current study, this could also be explained, at this stage, by the limited number of cases reported in yemen, and the adequate level of knowledge they had gained since the outbreak of the virus, and until this research study was conducted. according to roy et al. [ ] , adequate awareness often leads to optimistic attitudes, which could positively affect the preparedness of hcps to address pandemic issues. furthermore, the results of the current study showed a positive correlation between the respondents' knowledge and their attitude, which could support this conjecture. moreover, the findings of the current study are consistent with a study by giao et al. [ ] , that healthcare workers had a high level of knowledge and a positive attitude towards covid- . these findings are also in line with the results of a cross-sectional study conducted among saudi health college students [ ] , which revealed that more than half of the students had a positive attitude towards mers-cov. concerning the respondents' level of anxiety, the results indicated that nearly half ( %) of the respondents had a moderate level of anxiety and . % had a high level of anxiety regarding the covid- outbreak. according to roy et al. [ ] , fear and anxiety within a population are usually expected given the significant impact of the pandemic on the community, which could also affect the mental well-being of people and influence their behaviour in the wider community. in this study, only . % of the respondents exhibited a high level of anxiety concerning covid- , which could possibly be attributed to their level of knowledge given they were still experiencing the first wave of the virus covid- . interesting, the current study indicated lower anxiety level results compared to other studies that were carried out during the outbreak as reported by huang and zhao [ ] on chinese healthcare workers and nemati et al. [ ] on iranian nurses. in these studies, the results showed that the level of anxiety among healthcare workers was higher compared to other people. the high anxiety level among the hcps could be attributed to the uncontrolled nature of the pandemic and concerns of becoming infected, particularly given the shortage of healthcare institutions and ppe. concerning the self-reported preventive behaviours, it was found that the majority ( . %) of respondents had a high-performance level of preventive behaviours towards covid- , which could be attributed to the having an adequate level of knowledge and awareness among the respondents towards covid- . as reported in a previous study, those who had acquired adequate knowledge exhibited optimistic attitudes and appropriate, it not proactive practices toward covid- [ ] . another study revealed that the level of good or sound knowledge in a given population about covid- is significantly reflected in their behaviour and attitude [ ] . however, the findings from the current study were seemingly lower than a study conducted during covid- by taghrir et al. [ ] on medical students in iran finding that . % of the respondents showed relatively high-performance in preventive behaviours toward covid- . according to the results of this study, females were found to exhibit a higher-performance-level in preventive behaviours compared to their male counterparts, possibly due to their better compliance in preventive measures towards covid- . this result is consistent with the result by taghrir et al. [ ] that females demonstrated more precautionary behaviours compared to males. notwithstanding, another key result in this study was of the positive linear correlation between knowledge-attitude, knowledge-anxiety, knowledgepreventive behaviours, attitude-anxiety, attitudepreventive behaviours, and anxiety-preventive behaviours. this result confirms the relationship between the respondents' level of knowledge and their level of anxiety, attitude, and preventive measures towards covid- . such a correlation could be explained by the theory of reasoned action (tra) [ ] , which states that a person's intention to carry out a specific behaviour is determined by their attitude towards this behaviour. in the current study, the findings are in line with the results of other studies [ , , ] showing that acquiring a good level of knowledge of covid- is correlated with optimistic attitudes and proper practices towards covid- . however, in contrast, the results of this study disagree with the results by nemati et al. [ ] in which they found that most iranian nurses displayed their anxiety and that of their families as a result of covid- though the knowledge they had acquired about covid- to be sufficient. lin et al. [ ] found that the level of knowledge of covid- did not influence anxiety levels. however, they found that higher levels of attitude were highly associated with high levels of anxiety. furthermore, in a study carried out in hong kong by leung et al. [ ] , the results revealed that the level of anxiety during the sars outbreak was highly associated with behavioural responses such as wearing face masks. in a separate study by roy et al. [ ] , they revealed that people's level of anxiety correlated with their behaviour. the results showed that under the effect of rumours, people tend to modify their behaviour positively compared to an undesirable one. reuben et al. [ ] also reported the relationship between respondents' attitudes and their preventive behaviours. regarding the relationship between the respondents' attitudes and their preventive behaviour, rubin et al. [ ] conducted a study during the swine flu outbreak, reporting a significant association between the respondents' attitude and their behavioural change (e.g. performing one or more avoidance behaviours). nevertheless, several limitations were inherent in this study which should be addressed for future research. the first limitation concerns the nature of collecting the data. the data in this study were collected via a webbased survey since it was not possible to conduct a faceto-face survey among yemeni hcps during given the uncertainty surrounding the outbreak of the virus and level of contagious. therefore, the data may be seen as being less reliable having less accountability compared to face-to-face interviews and the lack of a trained interviewer. secondly, collecting the data was challenging, given the availability of respondents and cooperation. thirdly, the exclusiveness of the study to hcps. therefore, future research should involve a more diverse community or population, employing a community-based study design. the results of this study have demonstrated that the majority of hcps in yemen had acquired an adequate level of knowledge of covid- . however, their level of knowledge concerning situations that require wearing n masks and the possibility of using current antiviral drugs and antibiotics as the first-line of treatment for covid- could be improved through training and other programmes. the moderate anxiety level, as revealed in this study, would undoubtedly increase, particularly if the prevalence curve of the outbreak of covid- elevated, and the situation became much worse. therefore, implementing preventive measures and regulation strategies to control the emotional status among hcps is recommended. in addition, organisations such as who and the ministry of public health and population in yemen must continue to provide updated information regarding covid- to warrant better control concerning covid- . a novel coronavirus from patients with pneumonia in china study of knowledge, attitude, anxiety & perceived mental healthcare need in indian population during covid- pandemic covid- ) and the virus that causes it accessed who declares covid- a pandemic who: director-general's opening remarks at the media briefing on covid- who: coronavirus disease (covid- ) situation reports geneva: world health organization cdc: interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease (covid- ) in healthcare settings knowledge and attitude toward covid- among healthcare workers at district hospital clinical characteristics of hospitalised patients with novel coronavirus-infected pneumonia in wuhan, china who: coronavirus disease (covid- ): situation report, . . . icn calls for data on healthcare worker infection rates and deaths accessed covid- in humanitarian crisis: a double emergency covid- in yemen: preparedness measures in a fragile state the psychological impact of quarantine and how to reduce it: rapid review of the evidence shortage of personal protective equipment endangering health workers worldwide health care workers face a double battle -covid- in a conflict zon covid- and iranian medical students; a survey on their related-knowledge, preventive behaviours and risk perception statistical power analysis for the behavioral sciences: jacob cohen knowledge, attitude, and preventive practices toward covid- among bangladeshi internet users. electronic electron knowledge, attitude, practice, and perceived barriers among healthcare workers regarding covid- : a cross-sectional survey from pakistan psychological distress amongst health workers and the general public during the covid- pandemic in saudi arabia psychological health, sleep quality, and coping styles to stress facing the covid- in wuhan knowledge, attitudes, impact, and anxiety regarding covid- infection among the public in china attitude and practice toward covid- among the public in the kingdom of saudi arabia: a cross-sectional study medical students and covid- : knowledge, attitudes, and precautionary measures. a descriptive study from jordan. front public health knowledge and attitude toward middle east respiratory syndrome coronavirus among heath colleges' students in najran, saudi arabia generalised anxiety disorder, depressive symptoms, and sleep quality during covid- epidemic in china: a web-based crosssectional survey. medrxiv preprint assessment of iranian nurses' knowledge and anxiety toward covid- during the current outbreak in iran knowledge, attitudes, and practices towards covid- among chinese residents during the rapid rise period of the covid- outbreak: a quick online crosssectional survey understanding and promoting aids-preventive behavior: insights from the theory of reasoned action attitudes and practices towards covid- : an epidemiological survey in north-central nigeria longitudinal assessment of community psychobehavioral responses during and after the outbreak of severe acute respiratory syndrome in hong kong public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank all the healthcare providers who agreed to participate in this study and for their support in distributing the link to the questionnaire to other colleagues to participate.authors' contributions gga, taha, and msaa were involved in the inception of the idea and study design. taha and msaa were responsible for data collection. gga supervised, and taha performed the data analysis. gga drafted and finalised the manuscript. all the authors contributed to the interpretation of the data, reviewing, and drafting the manuscript, and approving the final manuscript. this study did not receive any form of grants or financial support. data are available from the corresponding author on a reasonable request. this study obtained ethical approval from the ethics committee for research of al-razi university. the participants provided their consent to participate voluntarily through answering a "yes or no" question in the online written informed consent form before they were allowed to complete the questionnaire. not applicable. the authors declare they have no competing interests. key: cord- -agzb aac authors: montgomery, joel m.; woolverton, abbey; hedges, sarah; pitts, dana; alexander, jessica; ijaz, kashef; angulo, fred; dowell, scott; katz, rebecca; henao, olga title: ten years of global disease detection and counting: program accomplishments and lessons learned in building global health security date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: agzb aac nan worldwide, infectious diseases continue to emerge at an alarming pace, due to numerous factors including microbial adaptation, increasing human population migration, urbanization, conflict and instability, intensified animal-human interface, and habitat perturbation [ ] [ ] [ ] [ ] [ ] [ ] . the litmus test for an effective national public health program is its ability to be ready to initiate an effective response for an unknown emerging or re-emerging infectious disease or public health event. the most impactful global health programs are built with the understanding that they must be able to help countries strengthen core public health capacity so that new threats can be detected and contained before they become international crises that increase morbidity and mortality, adversely impact the health and livelihoods of individuals and populations, disrupt travel, interfere with global trade and economies, or even lead to political destabilization [ , ] . this is the basis for all global health security work and has been the mission of cdc's global disease detection (gdd) program since its inception in . as one of the first steps through which cdc systematically approached global health security, the gdd program was designed to bring resources together to promote a broader approach to preparing countries for any infectious disease threat that could occur [ ] . today, after more than a decade of partnerships in groundbreaking science, disease detection, and response to the world's most urgent public health threats, lessons from the gdd program as a precursor to global health security offer the global health community one model for collective success. this supplement is dedicated to highlighting a sample of successes achieved and lessons learned through the gdd program throughout its + years of implementation. the idea for the gdd program took shape against the backdrop of the - severe acute respiratory syndrome (sars) epidemic, which affected more than people in countries and cost the world more than $ billion us dollars [ , ] . in , the u.s. congress authorized funding for cdc to establish the gdd program [ ] . using existing research infrastructure developed as part of cdc's international emerging infectious diseases program, the gdd program was developed to "promote global health security by building capacity to rapidly detect and contain emerging health threats [ , , ] . since its inception, the gdd program has held a broader more cross -cutting mandate than previous cdc programs. rather than focusing on a single disease or issue, the gdd program helps prepare countries for any emerging or reemerging infectious disease outbreak or significant public health event. to fulfill its mission, the gdd program uniquely established a network of regional centers (gdd rcs) to help countries rapidly and effectively address public health threats. these international centers formed a worldwide base of health security through scientific evidence-based capacity building and creating strong, trusted ties with partner countries (fig. ) . the mandates of the gdd rcs were to help develop a strong workforce of epidemiologists and laboratorians; enhance or promote the one health concept [ ] by encouraging multi-sectoral collaborations between ministries of health and ministries of agriculture; and build and expand state-of-the-art laboratory capacity for detection of newly emerging infectious diseases in addition to strengthening basic laboratory diagnostic capabilities. to date, gdd rcs have provided expert consultations, supported outbreak response, and offered epidemiology and laboratory training in more than countries. ten gdd rcs existed (fig. ) as of january , representing the americas, africa, and asiaincluding the indian subcontinent and southeast asia. selection of countries for placement of gdd rcs was based on a number of factors, including: ) country interest in hosting a gdd rc, including track-record of previous successful collaborations with us government agencies ) high burden or perceived high burden of infectious diseases in the country or region, ) potential for infectious disease emergence, and ) a need to strengthen or improve public health infrastructure to detect and respond to infectious disease outbreaks. an early insight was that the baseline public health infrastructure varied from country to country. at a minimum, all were in need of workforce development (i.e. trained field epidemiologists, public health laboratorians, data analysts and health communicators), improvements in the ability to develop complex laboratory diagnostics, and creation or improvement of disease surveillance, including specimen transport systems and integration of laboratory and surveillance data into an adequate response system [ ] . to meet this variety of needs, cdc placed experienced medical epidemiologists, laboratorians, veterinarians, and public health specialists in a number of the gdd rcs [ ] . the work of the gdd rcs has been guided by two overarching objectives or principles: ) to conduct cutting edge public health science, including original research, and to generate solid data to inform public health policy decisions, and help guide public health capacity building, and ) to have forward-deployed assets or pre-positioned staff, equipment and supplies to map of gdd regional centers (gdd rcs) and outbreak support provided by the gdd rcs from to . color corresponds to the gdd rc that provided support, while size corresponds to the number of outbreaks supported in each country. note: outbreaks responded to in the home country of each gdd rc were not included in this map rapidly support the host country government's ability to respond to outbreaks and prevent further spread of disease within and outside the borders of the country. global health preparedness is a priority worldwide, as evidenced by the adoption of the international health regulations (ihr) in , and the subsequent work of over nations, the u.s. government, cdc, the world health organization (who), to advance the global health security agenda (ghsa) [ ] . ghsa, launched in february , is a commitment between countries to marshal resources, expertise, and technical assistance to build core public health infrastructure around the world and monitor progress using specific metrics and targets. the ultimate goal of the ghsa is to better prepare for epidemics and pandemics and to help countries meet their commitments to the who ihr, [ ] and the world organization of animal health's (oie) performance of veterinary services pathway [ ] . the gdd program's value in helping countries achieve ihr goals was solidified in december , when the programalthough a relatively small program with a modest budget was designated by who as a collaborating center for implementation of ihr national surveillance and response capacity [ ] . the gdd program contributes to global health security efforts in much the same way as ghsa by strengthening the world's core public health capacity, ultimately helping countries achieve ihr compliance. the program serves the countries in which it resides, as well as neighboring countries, with the expertise and support needed to prevent, detect, and respond to any public health threat. a look at the data: gdd program activities and accomplishments the gdd program has collected data for both quantitative and qualitative indicators to monitor and evaluate the progress and effectiveness of its regional centers since , with some additional indicators added in and . these indicators cover multiple topic areas including consultations, outbreak investigations, trainings and workforce development, pathogen discovery, new diagnostic testing capacity, surveillance, networking, and publications. data associated with each gdd rc capture both efforts and outcomes in country and support to other nations. additional cdc datasets with information on human assets deployed during the ebola epidemic and data sharing during the zika epidemic were also included in these analyses. the three datasets (gdd program indicators [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , ebola, and zika) were analyzed using tableau software, version . . . findings were validated with targeted outreach to cdc personnel. from to , gdd rcs responded to outbreaks around the world. each outbreak response corresponded to a specific event regardless of the number of cases identified during the outbreakfor example, a single case of rabies and an outbreak of dengue resulting in cases were both considered single outbreak events. outbreaks also included events in animals, such as h n in poultry, west nile virus in horses, and rabies in dogs, as well as responses related to the environment such as pesticide poisonings and natural disasters. one quarter ( of ) of all outbreaks that gdd rcs responded to between and occurred outside of the gdd rcs' countries of origin (fig. ) . among one of the most important contributions of the gdd rcs have been responses during the recent who-declared public health events of international concern (pheics). shortly after the april declaration of h n as a pheic, gdd rcs in egypt, guatemala, kazakhstan, kenya, and thailand partnered with countries to improve and/or establish diagnostic laboratory capacity to detect h n (fig. ) ; of these ( %) partnerships or interactions occurred from may -june , . during the - ebola outbreak in west africa, all gdd rcs, as well as cdc headquarters in atlanta, deployed gdd program personnel to aid in the response effort (fig. ). in total, individuals associated and stationed within the gdd rcs were among the first responders to be deployed; of these individuals deployed to liberia, guinea, and sierra leone, while others deployed to the republic of congo, guinea-bissau, drc, nigeria, benin, and switzerland. in addition, of the ( %) individuals deployed were host country nationals or locally employed staff. gdd rcs not only directly supported ebola response efforts but also prepared their respective and neighboring countries for possible importation and spread of the virus within their borders. using an assessment tool developed by cdc, gdd guatemala conducted an ebola preparedness assessment for latin american nations, while gdd egypt trained participants from jordan, morocco, lebanon, tunisia, and egypt on ebola preparedness. gdd bangladesh collaborated with a large number of non-governmental private sector groups to develop standard operating procedures for ebola case management and response; similarly, gdd thailand collaborated with health ministers from countries to develop a strategic framework for enhancing partnership on ebola preparedness and response. laboratory testing capacity for ebola was increased by gdd india, and airport screening protocols and border security were improved by gdd kenya. meanwhile, gdd rcs in south africa and china focused on increasing communication platforms for the dissemination of information concerning ebola. furthermore, the chinese field epidemiology training program (fetp) deployed current and former trainees for the first time and u.s. cdc locally engaged country staff were deployed to sierra leone to help transfer laboratory technology to the chinese laboratory in-country. the gdd rcs were well poised to act during the - zika epidemic. using a combination of funding sources, including zika supplemental funding provided through partnership with the us agency for international development and gdd core funding, eight of the gdd rcs (guatemala, kenya, thailand, south africa, india, bangladesh, china, and egypt) were able to use their existing acute febrile illness surveillance systems to implement a global, network-wide surveillance activity to examine the global distribution of zika virus. the timely introduction of zika testing into existing gdd supported surveillance platforms allowed for the rapid identification and characterization of some of the first zika cases in guatemala and india [ ] . the guatemala, kenya, and thailand rcs were also able to quickly design and implement studies to examine the effect of zika virus infection in pregnant women and their babies, and the guatemala rc was able to initiate activities to examine potential long-term outcomes of infection. leveraging existing platforms allowed for faster implementation of activities. it also generated important lessons for future responses, such as the need to map showing the deployment of regional center staff to countries in west africa and geneva, switzerland from cdc's regional centers around the world and from cdc's headquarters in atlanta, ga in response to the ebola epidemic. note: map does not include multiple deployments consider how differences among protocols can affect comparability of results across countries, and highlighted the potential benefits of centralized coordination of surveillance and research. one of the strengths of the gdd rcs has been their ability to increase laboratory capacity for identification of threats, including identifying new pathogens to the world or pathogens new to a region. of the outbreak responses, the gdd rcs provided laboratory support in ( %). of these laboratory-supported outbreak responses, ( %) resulted in a confirmed etiology or cause of the outbreak. in the same -year period, pathogen-specific tests were newly established or updated by gdd rcs in countries through a program of deliberate technology transfer. examples included tests for pathogens of international concern or pandemic potential (e.g. h n , h n , h n , mers coronavirus, chikungunya, and ebola), respiratory pathogens (e.g. adenovirus, rhinovirus, coronavirus, and rsv), acute febrile illness pathogens (e.g. q fever/coxiella burnetii, leptospirosis, brucella, rickettsia, and west nile virus), food and waterborne pathogens (e.g. escherichia coli, salmonella, shigella, listeria, and campylobacter), and others (e.g. bartonella species, botulinum neurotoxins, arboviruses, arenaviruses). in collaboration with local and international partners, gdd rcs conducted groundbreaking work on organisms during - , including detecting organisms new to their respective regions, discovering organisms and pathogens new to the world, and identifying pathogens with a new mode of transmission ( [ , ] , and bacterial and parasitic pathogens (q fever/coxiella burnetii, leishmania species, and legionella longbeacheae) [ ] . in , the gdd program began collecting data on the number and type of surveillance platforms and the number of people enrolled or captured in active or passive disease surveillance systems. gdd rcs' activities currently cover more than , , people through various types of surveillance platforms. gdd rcs have established more than unique surveillance sites monitoring disease syndromes and specific illnesses such as acute febrile illness, respiratory disease, japanese encephalitis, and nipah virus. the syndrome most commonly responded to by gdd rcs from to was gastrointestinal illness (diarrhea, vomiting), followed by influenza-like illness (ili) and acute/undifferentiated febrile illness (a/ufi). increased ili cases in were due to the pandemic of h n and outbreaks of h n , while increased gastrointestinal illnesses in corresponded to cases of cholera in kenya, and increased a/ ufi in correlated with the dengue and chikungunya outbreaks in east africa. the types of disease surveillance platforms implemented via the gdd rcs include event-based, sentinel, facility-based, and population-based surveillance. the ability to conduct population-based surveillance is particularly important because it often provides the most accurate information on the burden of infectious disease syndromes, as it allows for the calculation of their incidence, which is the number of cases among a known population size during a standard period of time. gdd rcs in china, egypt, guatemala, india, kenya and thailand have conducted population-based surveillance over the course of the -year period [ ] [ ] [ ] [ ] [ ] [ ] . the incidence rates generated via these platforms are important measures of disease burden because they can be compared across different locales. examples of uses of data derived from population-based surveillance include the comparison of rates of disease in rural areas with rates in urban areas and the monitoring of impact of interventions or control strategies. the gdd program recognizes that a strong workforce lies at the core of effective emergency response. from to , the gdd rcs trained more than , multi-disciplinary public health professionals through unique training sessions. the subject matter experts from across cdc headquarters, as well as highly trained medical epidemiologists, laboratorians, veterinarians, and public health specialists stationed within the gdd rcs lead formal training programs, such as the field epidemiology training program (fetp), offer informal on-the-job-training and provide mentorship to local counterparts [ ] . in addition to leading training opportunities such as tabletop exercises and data analysis workshops, gdd rcs capitalize on cdc subject matter expertise around the agency to provide disease-specific guidance and training. this development of workforce capacity at the local level is integral to identifying and containing public health threats at their source. the graduates of fetps in gdd rcs from to responded to many of the outbreaks recorded, leading to proper identification of the source for many of the outbreaks, detection of additional cases/determining the full scope of the outbreaks, and classification or discovery of existing or novel risk factors of disease transmission. more often than not, these graduates continue to practice public health in-country after graduating [ ] . gdd rcs served as the platform for subject matter experts and researchers across cdc and through their effort provided a total of public health consultations from to . consultations varied widely in scope, type of collaborators, and length of partnership. for example, gdd kenya regularly provided consultations on health issues affecting refugees in kenya, ethiopia, uganda, and tanzania, while gdd india teamed up with the national institute of mental health and allied sciences (nimhans) to work on an acute encephalitis syndrome network. regional centers such as gdd egypt, gdd kazakhstan, and gdd georgia conducted laboratory assessments at laboratories and hospitals, recommended laboratory equipment for national blood banks, and advised on infection control procedures, respectively, with subject matter expertise support from cdc headquarters. furthermore, the gdd rcs supported the use of technology by collaborating with provincial satellite tv channels to communicate risks such as hand, foot, and mouth disease (hfmd) and h n in vietnamas was the case with gdd chinaand by providing technical support for an electronic surveillance platform in panama, coordinated out of the gdd rc in guatemala. finally, gdd rcs worked with a number of collaborators (i.e., gdd south africa with national park staff, gdd bangladesh with live-bird market workers, and gdd thailand with veterinarians) on a variety of one health projects. the gdd program collaborates with experts across cdc, maximizing the subject matter expertise residing in the agency, and with ministries of health and international partners. from to , gdd rc staff authored or co-authored a total of peer-reviewed articles and other significant documents, such as policy documents, position papers, and training manuals. these publications address disease-specific outbreaks and emergencies, surveillance and laboratory science, and cross-cutting priorities related to disease threats. these publications show the diversity and strong scientific foundations of gdd's work. the original overarching goal and purpose of the gdd program was to improve global capacity within partner nations to prevent emerging infectious disease threats at the site of origin, rapidly detect disease events, and respond to outbreaks to mitigate the consequences to the population. the accomplishments of the gdd rcs highlight examples of many firsts: diseases detected before they became significant threats; additions of new laboratory tests to identify the cause of illness; vital workforce training programs begun and expanded; as well as faster, smarter response to outbreaks because of the capacity the program helped build in-country. as previously noted, the gdd program offered an early strategic approach to global health security efforts as countries worked to meet their obligations under the ihr [ ] . when the ihr [ ] were adopted in , the gdd program was uniquely positioned to help close the critical gap between global public heath capacities defined in the ihr [ ] and the ability of many member states to meet these requirements. over a decade after implementation of the ihr [ ] more than countries have extended their commitment to strengthening global public health capacity through the ghsa [ ] . the gdd program again offered a framework forand experience inimplementing the cross-cutting public health systems needed to meet the targets set forth by both ihr and ghsa. the gdd program exemplifies the work that cdc has done to improve global health outcomes and enhance global health security specifically as part of the core functions of the organization. the gdd program unites the resources of the united states and its international partners to provide technical assistance, logistical support, and funding through regional networks and intergovernmental organizations. through this work, we have increased the capacity of the global public health workforce to identify and contain threats. it is critical to note that the value of the in-country work done by the gdd program extends beyond stopping outbreaks. partnerships and relationships formed through the program have contributed to health diplomacy abroad. these critical ties extend our ability to respond in times of crisis, and play an additional role in strengthening other initiatives and programs that protect public health. public health programs like gdd have served as inroads to connection in fragile areas, such as those facing political instability and conflict, because they remove barriers to collaboration by addressing universally acknowledged health needs. the gdd program's efforts over the last decade to improve global public health capacity have, indeed, moved us forward. measurable progress has been made within a focused, but limited, scope. for progress to continue, however, cdc and the global health community must go beyond our initial efforts and work more broadly to confront challenges and embrace opportunities that arise. the gdd program has given us the following important lessons that can inform our next steps: ) create multiregional connectivity. strong networks can harness a variety of strengths, share resources, and connect across disciplines toward common goals. a major success of the gdd program has been to create regional platforms where subject matter experts can engage with one another and programs can break free of their silos. moving from siloed to shared approaches also enhances collaboration on science and research, thereby strengthening the foundation for public health action. global networks have been created by gdd, and more recently with ghsa, in recognition that shared risk means shared responsibility, and the best way to achieve success is by working together to ensure our collective health, safety, and security. ) adopt consistent goals and measures. from the beginning, the gdd program has applied a consistent set of goals and metrics to track progress over time and across programs. the world's global health security efforts are also seeing the benefits of instituting consistent targets, as well as frameworks for measuring success against those targets. over the past few years, the who joint external evaluations have become a valuable tool to track progress on global health security initiatives, both past-to-present and country-to-country [ ] . evaluation is a key part of recognizing accomplishments and is critical to finding gaps we must still address. only once we know where we stand can we take action to implement successful programs and point them in the right direction to reduce our identified vulnerabilities. ) deploy the power of science and data. cutting-edge scientific research has always been at the core of the gdd program's mission. scientific data are the tool we use to detect, respond, and to halt or prevent outbreaks and to inform policy changes that protect public health globally. scientific research helps partners make evidence-based decisions and implement effective local solutions that eliminate outbreaks at their source. additionally, taking an active role in teaching others how to capture, analyze, and effectively use public health data creates a workforce capable of rapidly recognizing and responding to threats. future scientific progress will require not only improved connection across scientific disciplines, but also sustained and dedicated commitment to a unified scientific strategy. ) build trusted partnerships. the gdd program's success has relied on strong partnerships. the program's longstanding presence in regions across the globe has proven that in-country engagement leads to trust. this trust becomes particularly valuable in outbreak response, as global partners rely on cdc data and expertise as a resource that saves lives. strong partnerships at all levels are critical to global health security, and the process of creating gdd rcs has formed and strengthened partnerships at all levelsgovernment-to-government relationships, collaboration with other organizations and non-governmental organizations (ngos), and local and personal connectionsthat can be leveraged to address critical public health priorities. ) build for flexibility. cross-cutting public health programs give us the ability to respond to any crisis, regardless of cause. strong core systems and connected resources can pivot when needed to address emerging or reemerging threats. as threats change, and as science changes, funding tied to a single disease may prove limiting in its scope. conversely, investment in core public health capacity ensures that a single mission does not dictate the longevity or capacity of a program, and that we can continue to maintain and grow our valuable resources, expertise, and connections. flexible, nimble systems are our best answer to an unpredictable future. while there have been many successes and substantial impacts made by gdd rcs, there have also been significant challenges recognized. some of these have impacted the ability of the gdd program to accomplish one of its primary goals: helping countries achieve ihr compliance. despite the global prominence of infectious diseases, there are few rigorous and precise estimates of the burden and etiology of key infectious disease syndromes in developing countries [ , ] . some of the problems in measuring the burden of these diseases in developing countries have included poor access to the clinical facilities, lack of accurate or available laboratory diagnostics, and absence of population-based surveillance systems needed to accurately assess incidence rates. accurate information on burden of the most important infectious disease syndromes is needed by ministries of health and public health policy decision-makers to set current priorities for optimal use of limited resources for public health programs. efforts to assist our partner countries in building national laboratory and surveillance systems have been significantly hampered by insufficient resource allocationboth financial and staff time. this has led to a greater recognition of the actual time and money required to develop and maintain such systems. another challenge has been the need for better coordination and communication of a unified mission and objective that is supported, fully adopted and implemented in all of the gdd rcs. in some instances, lack of clarity on adopting and implementing a unified mission led to a divergence of operations and a mixture of activities driven, in many cases, by individual investigator interests and expertise in country. the inability to have every kind of public health expertise represented among country-based staff highlights the need for sustained and active scientific engagement across the agency. the public health science conducted through such activities has been commendable; however, the data generated has not always been completely successful in informing policy for ministries of health (i.e., vaccine coverage, educational campaigns targeting high-risk populations, improvement or development of vector-control programs). more needs to be done to ensure that data are applied to their full potential in improving the health of the populations served. finally, although there have been some cross gdd rc projects (e.g., use of a multipathogen taqman array card to identify the etiology of community-acquired pneumonia, c. van beneden pers com), overall, it has been a challenge for the gdd rcs to link across a network of regional offices or platforms to implement unified protocols or projects (i.e. estimating burden of a specific disease, measuring the effect of a specific medical countermeasure, etc.) in multiple countries, throughout multiple populations, in diverse ecologies, and among unique cultural settings. building the capacity to do this could strengthen the overall goals of global health security to prevent, detect and respond to health threats. the gdd program is part of a long and significant history at cdc of protecting health globally, ranging from smallpox eradication, polio elimination, hiv, malaria, and cholera control to emergencies including sars, h n , ebola, and zika. as this history shows us, global health is never static, and the work is not finished. as we look to the future, our biggest challenge remains the unknown. health threats will continue to take us by surprise. the nature of disease means that we cannot always predict what the next outbreak will be, or where and how it will spread. ever-increasing interconnection across the globe means that when the next outbreak does take hold, it will be capable of spreading rapidly. to stop it, we will need systems in place that are sensitive enough to signal a new health threat, specific enough to pinpoint problems and focus resources, and flexible and connected enough to protect the world's economic and social wellbeing. we must recognize that global health security begins locallyif there are gaps anywhere in the system, disease will find it. lessons learned through the lens of the gdd program can offer us a way forward. more than a decade of successes and failures has given us information and evidence-based strategies essential to developing core public health capacities around the world. these strategies include increasing coordinated, multi-center scientific collaboration across nations to strengthen the global network; increasing the number of public health professionals trained; broadening and strengthening global partnerships; and reducing gaps in global preparedness for emerging health threats. as the global health community looks for the best ways to operate in our changing world, lessons from the gdd program will continue to inform our work. we have an obligation to keep our nation and our world safe, healthy, and secure. we must therefore continue our effortsand commit to doing much moreto improve what we can, where we can, on a continual basis. we can afford nothing less. risk factors for human disease emergence ecology of zoonoses: natural and unnatural histories factors in the emergence of infectious diseases urbanization and disease emergence: dynamics at the wildlife-livestock-human interface human-livestock contacts and their 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ethiopia epidemiology of severe pneumonia caused by legionella longbeachae, mycoplasma pneumoniae, and chlamydia pneumoniae: -year, population-based surveillance for severe pneumonia in thailand surveillance for respiratory infections in low-and middle-income countries: experience from the centers for disease control and prevention's global disease detection international emerging infections program incidence of pneumococcal pneumonia among adults in rural thailand, - : implications for pneumococcal vaccine considerations incidence and clinical features of respiratory syncytial virus infections in a population-based surveillance site in the nile delta region national surveillance of health care-associated infections in egypt: developing a sustainable program in a resource-limited country surveillance for hospitalized acute respiratory infection in guatemala the substantial hospitalization burden of influenza in central china: surveillance for severe, acute respiratory infection, and influenza viruses building global epidemiology and response capacity with field epidemiology training programs monitoring and evaluation framework committee on emerging microbial threats to health in the st century public health surveillance and infectious disease detection we thank alexis adams for leading efforts to compile and review the contents of this supplement; radha friedman for the collection and review of the gdd program indicator data; past and present us government and locally employed staff of the gdd regional centers for their work on the activities described; cdc technical experts that provide assistance for the activities at the gdd regional centers; and the over government, ministries of health, ministries of agriculture, academic institutions, research institutions, and other partners that continue to work with cdc to enhance public health and improve global health security. the findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the centers for disease control and prevention. publication costs are funded by the u.s. centers for disease control and prevention.about this supplement this article has been published as part of bmc public health volume supplement , : th anniversary of the centers for disease control and prevention -global disease detection program. the full contents of the supplement are available online at https:// bmcpublichealth.biomedcentral.com/articles/supplements/volume- supplement- .authors' contributions jmhelped conceptualize manuscript, supervised data analysis and was the primary author of the manuscript. awanalyzed and co-drafted manuscript. shhelped conceptualize manuscript, supervised data analysis and codrafted the manuscript. dphelped conceptualize manuscript and co-drafted the manuscript. ohorganized framing of and co-drafted manuscript. jaco-drafted manuscript. kiprovided early leadership towards the development and implementation of the gdd program and contributed towards the writing, editing, formatting of the manuscript. fareviewed and edited manuscript. sdreviewed and edited manuscript. rkhelped conceptualize manuscript and supervised data analysis. all authors have read and approved the final manuscript. the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.author details key: cord- - gqn z authors: watkins, rochelle e; cooke, feonagh c; donovan, robert j; macintyre, c raina; itzwerth, ralf; plant, aileen j title: influenza pandemic preparedness: motivation for protection among small and medium businesses in australia date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: gqn z background: community-wide preparedness for pandemic influenza is an issue that has featured prominently in the recent news media, and is currently a priority for health authorities in many countries. the small and medium business sector is a major provider of private sector employment in australia, yet we have little information about the preparedness of this sector for pandemic influenza. this study aimed to investigate the association between individual perceptions and preparedness for pandemic influenza among small and medium business owners and managers. methods: semi-structured face-to-face interviews were conducted with small and medium business owners or managers in new south wales and western australia. eligible small or medium businesses were defined as those that had less than employees. binomial logistic regression analysis was used to identify the predictors of having considered the impact of, having a plan for, and needing help to prepare for pandemic influenza. results: approximately per cent of participants reported that their business had a plan for pandemic influenza, per cent reported that they had not thought at all about the impact of pandemic influenza on their business, and over per cent stated that they required help to prepare for a pandemic. beliefs about the severity of pandemic influenza and the ability to respond were significant independent predictors of having a plan for pandemic influenza, and the perception of the risk of pandemic influenza was the most important predictor of both having considered the impact of, and needing help to prepare for a pandemic. conclusion: our findings suggest that small and medium businesses in australia are not currently well prepared for pandemic influenza. we found that beliefs about the risk, severity, and the ability to respond effectively to the threat of pandemic influenza are important predictors of preparedness. campaigns targeting small and medium businesses should emphasise the severity of the consequences to their businesses if a pandemic were to occur, and, at the same time, reassure them that there are effective strategies capable of being implemented by small and medium businesses to deal with a pandemic. since late the risk of pandemic influenza and the need for preparedness have featured reasonably frequently in the news media in australia, often associated with overseas reports of large outbreaks of infection among birds or small clusters of infection among humans. strategic plans have been prepared for an outbreak of pandemic influenza associated with human avian influenza infection at national and global levels [ , ] . many of these plans include mechanisms to facilitate and manage community-wide responses in recognition of the likelihood that pandemic response requirements will exceed the response capacity of health authorities and governments. preparation by the business community for an influenza pandemic is encouraged by governments, but much of the onus is on businesses to inform themselves about the threat posed by pandemic influenza and develop their own plans. as such, large corporations often have detailed plans, but less is known about pandemic preparedness in small and medium sized businesses. small and medium businesses are a major employer in australia, accounting for approximately half of all private sector employees [ ] . small businesses, which include businesses with less than employees, were alone estimated to employ almost . million people in australia in [ ] . pandemic influenza is likely to have a major impact on businesses, yet little is known about the needs and preparedness of small and medium sized businesses. government and health authorities in australia and overseas have recommended that businesses, community organisations and individuals implement a range of strategies to prepare for pandemic influenza, and an increasing number of resources are being produced to provide guidance on pandemic preparedness and business continuity planning [ ] [ ] [ ] [ ] . a resource specific to pandemic preparedness planning among small businesses in australia is also available [ ] . pandemic planning resources generally describe the nature of the anticipated threat, highlight the role of government and health authorities, outline essential business continuity planning and response requirements, and describe specific measures that may be implemented to limit or prevent disease spread. specific strategies recommended to limit disease spread within the workplace include promoting improved hygiene and infection control practices, using social distancing measures and flexible work arrangements to minimise contact between individuals within the workplace and the community, using personal protective equipment, restricting workplace entry and isolating individuals who may be infectious [ ] . a greater understanding of the factors associated with planning for pandemic influenza among small and medium businesses is required to inform communication strategies that promote improved preparedness for a pandemic. protection motivation theory [ ] is a commonly used framework for fear-appeal research [ ] . protection motivation theory conceptualises an individual's acceptance of advice on how to protect themselves from a health threat as primarily a function of four specific beliefs: the perceived severity or seriousness of the threat and the likelihood of the threat occurring (which together constitute 'threat appraisal'); and the perceived effectiveness of actions to avoid the threat and the individual's perceived self-capacity to implement those actions (which together constitute 'coping appraisal'). if a sufficient level of threat is perceived to exist, and coping appraisal is high, then the individual will take appropriate action. however, where a threat appraisal is high but coping appraisal is low, the individual is unlikely to take appropriate action. protection motivation theory suggests that campaigns using threats must include information about how to avert the threat, and ensure that members of the target audience have the skills and resources necessary to adopt the recommended actions. investigations of the effectiveness of health threat communications are supportive of the protection motivation theory framework [ ] , finding that communication effectiveness is associated with the extent to which the communications present real but controllable threats [ ] . the health belief model [ , ] also conceptualises behaviour as dependent upon individual perceptions including the perceived likelihood and severity of the potential health threat, and the perceived effectiveness of responses to the threat. similarly, research has supported the importance of health belief model constructs in behaviour change [ ] , particularly where illness avoidance and perceived threat are of central importance [ , ] . among health behaviour theories that identify similar constructs as important determinants of health behaviour, current research provides no clear indication of the superiority of any single approach [ ] . guided by the concepts considered to be of importance in these health behaviour theories, and the protection motivation theory framework in particular, we aimed to investigate the association between selected beliefs and preparedness for pandemic influenza among small and medium business owners and managers. between may and july , structured face-to-face interviews were conducted with either the owners or managers of small or medium businesses in australia. eligible businesses were defined as businesses which have less than employees [ ] . participating businesses were recruited from new south wales ( ) and western australia ( ), with approximately per cent of the sample in each state being selected from businesses located in the capital cities (n = ), per cent being recruited from large satellite cities (n = ), and the remaining per cent from rural centres (n = ). participating businesses in western australia were randomly sampled from a membership database of businesses obtained from the local chambers of commerce and industry. in new south wales businesses were randomly sampled from a purchased list of businesses stratified by industry type. in both instances the lists of businesses were checked to ensure that the sampling frames included only businesses which operated in the eligible study areas prior to recruitment. a flow chart was used to guide the recruitment of interviewees in both states to ensure recruitment processes were standardised, including gaining confirmation that the business had less than employees, ensuring that a minimum of three attempts were made to establish contact with each business to be recruited, and ensuring that an appropriate person was interviewed. face to face interviews with business owners or senior managers were administered by trained interviewers from a market research firm in new south wales, and by trained interviewers contracted by the local chambers of commerce and industry in western australia. prior to the study interview verbal consent to participate was obtained following the provision of, and discussion of, a study information sheet. study procedures were approved by the human research ethics committee of curtin university of technology. focus group discussions with business owners and managers in perth and sydney were used to inform and develop the structured interview schedule. the interview schedule was pre-tested among a small sample of business owners to ensure the questions were acceptable, understandable, unambiguous, and that open ended questions elicited the expected type of response. basic characteristics of the participating businesses assessed included the job classification of the interviewee (owner, chief executive officer/managing director, senior manager), main business location (capital city, satellite city, rural centre), industry type, business size (number of employees), average number of customers per day, and the educational level of employees (proportion of employees who attended university). the response categories for industry type were pre-coded based on the divisions in the australian and new zealand standard industrial classification [ ] . for analysis purposes, businesses operating in the primary and secondary industry sectors (i.e., businesses engaged in production and manufacturing) were aggregated; and classifications for tertiary industry businesses (i.e., businesses operating within the service sector) were aggregated according to the following three industry type categories: property and business services; retail trade; and other tertiary. the following beliefs about pandemic influenza were each assessed by a single question: the perceived severity of the threat; the risk of the threat; and the ability to respond effectively to the threat. the general belief about the severity of the threat was operationalised as the perceived proportion of people that could become sick if pandemic influenza were to affect the local community. the perceived risk of the threat was operationalised as the likelihood that pandemic influenza would become a significant health issue in australia in the near future, and assessed on a four point scale (very unlikely, unlikely, likely, very likely). an additional business-specific indicator of risk, the perceived level of risk that pandemic influenza poses to the interviewee's business, was also rated on a four-point scale (no risk, some risk, moderate risk, high risk). a dichotomous indicator of coping appraisal was derived from the open-ended question: "can you think of any steps you can take to protect your business from pandemic influenza?" responses were independently reviewed by two coders, and participants who were unable to identify any potentially useful steps that could be taken to protect their business or limit disease spread were classified as having low coping appraisal. a small proportion of participants nominated the responses 'don't know' and 'no idea' to represent their beliefs about the risk and severity of pandemic influenza (table ) . when dichotomous indicators of risk and severity were used in the analysis, these responses were aggregated with the other low risk or low severity responses for analysis purposes on the basis that these responses indicated an absence of perceptions of high risk or high severity. this coding did not significantly affect the findings of the analysis. three dependent variables in the analysis provide different indicators of engagement in adaptive processes associated with the threat of pandemic influenza. participants were asked "before being contacted about this study, how much have you thought about the impact of pandemic influenza on your business?" (not at all, a little, a lot). the need for help with planning for pandemic influenza, which can be considered an indicator of an adaptive response to the threat of pandemic influenza, was assessed using the following open-ended question: "is there anything you need to help you prepare for pandemic influenza?" responses were dichotomised into a variable which indicated whether help was or was not required. lastly, the presence of a plan for pandemic influenza was assessed by the single question "has your business made any specific plans should pandemic influenza arise?" (yes, no, unsure). the chi-square test of independence was used to test for associations between categorical study variables, and the independent samples t-test was used to test for differences between groups on continuous variables. phi, which is a measure based on the chi-square test of association, is used to assess the strength of association between two dichotomous variables, and indicates the amount of total variance explained by the association between the variables. binomial logistic regression analysis was used to identify the significant independent predictors of the health behaviour theory-based belief variables and the three main dependent variables: having considered the impact of, hav- ing a plan for, and needing help to prepare for pandemic influenza. dependent variables were dichotomised for analysis due to skewed distributions and the small sample size. initial model development included entry of variables into a forward stepwise model, with the probability criterion for entry set at . and exit at . . the final models were developed manually to allow exploration of alternative model forms. a main effects model was initially determined. effect modification was also explored, and the inclusion of interactions was determined by the significance of the change in log likelihood of the model. crude odds ratios (cor), adjusted odds ratios (aor) adjusted for the other variables in each model, and % confidence intervals ( %ci) are used to summarise the magnitude of association found between variables. all analyses were performed using spss version . (spss inc., ) and the significance level was set at p ≤ . . in total, eligible businesses were contacted and interviews were completed, producing an overall response rate of per cent. the response rate of per cent ( / ) for new south wales (nsw) was considerably lower than the per cent ( / ) achieved for western australia (wa), but consistent with the different sampling methods used. there was no significant difference between participating and non-participating businesses in wa according to business size (p = . ) or industry type (p = . ). similar data on the characteristics of non-participating businesses in nsw were not available for analysis. nonparticipation was most frequently associated with the business owner or manager being either too busy or unavailable during the interview period, explaining per cent and per cent of refusals in the wa and nsw samples respectively. the characteristics of participating businesses are summarized in tables and by state. most participating busi-nesses had less than employees and more than half of the individuals interviewed were business owners. business owners were significantly more likely to be interviewed in wa than nsw ( table ) . most of the participating businesses operated within the tertiary or service sector. the representation of businesses from different industry types was significantly different by state, with the wa sample having a higher proportion of retailers (table ) and reporting a significantly lower proportion of university educated staff compared with the nsw sample (table ) . approximately per cent of participants believed that pandemic influenza was likely or very likely to become a significant health issue in australia in the near future (table ) , and, on average, participants believed per cent of people in affected communities would become sick ( table ). around per cent of participants reported that they had not spent any time thinking about the impact of pandemic influenza on their business, and over per cent could not identify any steps that they could take to protect their business (table ). only per cent of participants reported having a pandemic influenza plan for their business ( per cent were unsure), and over per cent of participants reported needing help to prepare for pandemic influenza (table ) . beliefs about the risk and severity of pandemic influenza and the amount of time spent considering the impact of pandemic influenza on the business did not differ significantly between states. beliefs about being able to respond to the threat and perceptions about the need for help did differ between states, with businesses in wa having a significantly lower level of response efficacy and being less likely to need help to prepare than businesses in nsw (table ) . businesses in nsw were also significantly more likely to have a plan for pandemic influenza than businesses in wa (table ) ; however, the difference in response rate for the two states renders the generalisability of such differences as tenuous. beliefs about the perceived severity of pandemic influenza and the perceived risk of pandemic influenza to the business were not significantly associated with any business characteristics. business characteristics which were significant predictors of beliefs about the perceived risk of pandemic influenza and coping appraisal are summarized in table . the perceived risk of apandemic in australia was significantly associated with the role of the person interviewed, with non-owners being about twice as likely to consider pandemic influenza as a likely or very likely risk than business owners. both state and the role of the individual interviewed were significantly associated with response efficacy, with businesses in nsw and non-owners being about twice as likely to be able to identify actions which could protect their business in the event of a pandemic than businesses in wa and owners. each of the significant predictors of beliefs identified only explained a small proportion (less than per cent) of the overall variance associated with the belief variables. bivariate associations between beliefs and the dependent variables (table ) indicate that almost all beliefs and dependent variables assessed were significantly associated. the high correlation between the general belief about the risk of pandemic influenza and the specific belief about the risk of pandemic influenza to the business, which explained over per cent of the total variance in responses (equivalent to a pearson correlation coefficient of approximately . ), was among the strongest associations found. there was no significant association between having a plan and the need for help, and coping appraisal was independent of perceptions of severity. logistic regression models were used to determine the significant independent predictors of having considered the impact of, having a plan for, and needing help to prepare for a pandemic. all models were tested for interaction terms and no significant effect modification was found. the significant independent predictors of dependent variables, based on the inclusion of both belief variables and business characteristics, are summarised in table . thinking a lot (versus a little or not at all) about the impact of pandemic influenza on the business was most strongly associated with the perceived risk of pandemic influenza, with participants who perceived a pandemic as likely or very likely to be a health issue in australia in the near future being approximately times more likely to have reported thinking a lot about the impact of a pandemic on their business. businesses that were located in the capital city were about three times more likely to have spent a lot of time thinking about the impact of a pandemic compared with businesses in satellite city or rural locations. these same factors were also significant predictors of having considered the impact of a pandemic on the business when this variable was dichotomised as thought at all (a little or a lot) versus not at all. the perceived need for help was most strongly associated with the perceived risk of pandemic influenza to the business, with participants who perceived the risk of a pandemic to the business as moderate or high being approximately times more likely to report needing help to prepare. state was a significant independent predictor of the perceived need for help, with businesses in nsw more likely to report needing help than those in wa. the perceived need for help was also significantly associated with industry type, with businesses in the property and business services and retail trade sectors being significantly less likely to need help than other service sector businesses. industry type was not significantly associated with perceptions about the risk or severity of a pandemic, but was significantly associated with coping appraisal (χ = . , p = . ), with per cent of retailers unable to think of steps to protect their business as opposed to per cent of other service sector businesses and per cent of production and manufacturing businesses. the presence of a specific plan for pandemic influenza was significantly and independently associated with both perceived severity of a pandemic and coping appraisal. participants who believed that per cent or more of the local community would become sick were over times more likely to have a plan, and participants who were able to identify steps that could be taken to protect their business were over times more likely to have a plan for pandemic influenza. there is a lack of empirical data to inform public health response strategies for pandemic influenza. to our knowledge this study provides the first systematically collected information on preparedness among small and medium businesses in australia, and is among only a few studies in the field worldwide. we found that only a small proportion of businesses studied had thought a lot about how pandemic influenza may impact on their business, that few had made any specific plans to protect their staff or their business in the event of pandemic influenza, and that over per cent state they need help to prepare for pandemic influenza. these findings suggest that additional strategies are required to promote increased awareness of the threat of pandemic influenza in the community, to promote the resources available to assist with preparedness, and to facilitate engagement in preparedness planning. behaviour change is a process, and time is required to initiate and establish new behaviours. according to the protection motivation theory, coping appraisal responses which lead to the establishment of protection motivation occur after the threat-appraisal process, as a threat needs to be identified before coping options can be evaluated [ ] . as such, and as has already been highlighted by others, occasional media reports are insufficient to adequately inform individuals about pandemic influenza, and interventions are required before a pandemic occurs to improve public awareness, build mutual trust, promote effective coping responses and assist in the successful implementation of plans when they are required [ ] . national influenza plans require collective communitywide efforts for an effective response to pandemic influenza. however, they lack information relating to strategies to enable the effective dissemination of this information beyond the availability of these plans on websites [ ] . given that the strategy for response to pandemic influenza in australia is based on containment and reducing transmission of the virus [ ] , and that key response strategies such as isolation, social distancing, and improved personal hygiene which have been supported by mathematical modelling studies [ ] depend on community-wide behaviour modification, additional strategies are required to enable an effective shared response. our findings suggest that the beliefs of small and medium business owners and managers are likely to have important consequences for preparedness. beliefs about the risk of and severity of pandemic influenza were the most important independent predictors of having thought about, and having a plan for pandemic influenza respectively. the perceived risk of pandemic influenza to the business was also the most important predictor of needing help to prepare. these findings are consistent with the relationships proposed by prominent theories of health behaviour, including the protection motivation theory [ , ] , and suggest that these theories provide a useful model for understanding preparedness behaviours among small and medium businesses in australia and elsewhere. protection motivation theory and health belief model concepts have been found to be valuable for understanding and promoting a variety of health-related behaviours [ , , , ] , including the performance of protective behaviours during the outbreak of the severe acute respiratory syndrome in hong kong [ ] . the importance of perceptions about risk and severity in understanding preparedness behaviour suggests that health behaviour theories provide a useful framework for the design of communication strategies that aim to promote preparedness for pandemic influenza among the business community. based on the temporal relations identified in these theoretical frameworks, our results suggest that communications containing information about risk and severity are likely to promote both threat appraisal and coping appraisal processes, and can motivate protective behaviours given a perceived ability to implement recommended actions. promotion of the ability to respond effectively to the threat of pandemic influenza appears to be an important factor associated with protective responses to the threat of pandemic influenza. this finding is consistent with research findings based on other health threats which indicates that low levels of self efficacy and response efficacy provide a barrier to action [ , ] . the high proportion of participants reporting needing help with preparation indicates that self efficacy may be an important factor limiting planning for pandemic influenza, which is consistent with the findings of recent research in europe and asia [ ] . individual business characteristics were relatively unimportant among the predictors of having thought about or planned for pandemic influenza. apart from beliefs about risk, the only other significant predictor of having considered the impact of pandemic influenza on the business was whether the business operated within or outside a capital city. it is possible that this association reflects a factor which can modify the perceived threat of pandemic influenza based on understandings about population density and the probability of exposure to infection. in contrast, individual business characteristics were more important predictors of needing help to prepare, with industry type and state being significant predictors in addition to beliefs about risk. retail traders and businesses that provide property and business services were less likely to report the need for help. differences in the need for help by industry type, given the significant association between industry type and coping appraisal, suggests that some businesses may have difficulty identifying effective protection strategies that are appropriate for specific high-risk business environments, such as retail outlets. this finding highlights the importance of providing support to identify effective response strategies and overcome response difficulties within all business environments. furthermore, our finding that the need for help was not significantly related to whether a plan for pandemic influenza exists appears to highlight the difficulties associated with planning for pandemic influenza, even among those businesses that have already made specific plans for pandemic influenza. our finding of a difference in the need for help by state is likely to be associated with the different sampling and recruitment processes used in the two study locations. in wa the local chambers of commerce was directly contracted to supply the business contact details and conduct the interviews. thus, the existing relationship with the businesses sampled is likely to explain the higher response rate in wa, why a higher proportion of owners were interviewed, and provide a sample which may be less biased in terms of either having a specific interest in pandemic influenza or time or resource pressures than the nsw sample. selection bias associated with the different recruitment strategies may explain why participants from nsw were more likely to have a plan, were more likely to need help and reported lower response efficacy. alternatively, these findings may be due to real differences in beliefs and behaviour between states, which may for example be associated with differences in media exposure or other local influences. regardless of the cause, these differences did not significantly influence the associations found between beliefs and preparedness. due to the cross-sectional study design we are limited in the type of conclusions that we can draw about causality based on the associations observed. for example, having prepared a pandemic influenza plan is likely to result in improved levels of coping appraisal. however, experimental research [ ] has provided support for the impact of beliefs on protection motivation and current behaviour. the associations found in this study explained a low proportion of variance in preparedness behaviour, although the magnitude of the associations found is similar to those reported for protection motivation theory concepts and other health-related behaviours [ , ] . several factors could have contributed to the low explanatory power in the present study, including the assessment of a limited number of theory-based belief constructs, the use of single-item and thus limited operationalisations of the key belief and outcome variables which have unknown reliability, and the use of dichotomous indicators due to the small sample size. also we did not assess behavioural intentions. further work is required to extend the scope of this study and considered other relevant constructs including social norms and response costs. the non-random nature of the sampling frames used to recruit study participants and the small scale of the study limits the generalisability of the study findings. it is also likely that response bias associated with the low response rate may have resulted in an overestimation of the proportion of businesses that have a plan for pandemic influenza, particularly in nsw. the use of financial or other incentives for participation is recommended in future studies to facilitate improved response rates, particularly where industry partners are not used. the findings of this study may also be limited in that self-report methods were used to assess whether the business had a pandemic influenza plan. responses may have been biased in favour of reporting the presence of a plan or having considered the impact of pandemic influenza on the business associated with social desirability bias. there is a shortage of data available to guide public health policy and practice in pandemic influenza planning and response [ ] . current guidance for pandemic influenza preparedness appears to have had little impact on preparedness among the small and medium business sectors in australia. our findings suggest that further investment by governments is required to improve both the specification of and utilisation of available planning resources, as has been highlighted previously [ ] . further work is required to underpin both the design of communication strategies to promote behavioural change, as well as the feasibility and effectiveness of strategies for disease control, which also support beliefs about being able to respond effectively to the threat of pandemic influenza. the findings of this study should be interpreted alongside more in-depth knowledge about the beliefs of business owners and managers that underlie the protection motivation theory constructs, as has been illustrated elsewhere [ ] . in this way, a greater understanding about beliefs to be reinforced or changed, and responses to specific strategies can be gained, helping to promote improved effectiveness of the communication strategies developed. also, particularly in the small and medium business sectors that may have significant resource constraints, the presence of alternative adaptive responses to the threat of pandemic influenza require further investigation. we found that only a small proportion of small and medium sized businesses in australia have made formal plans to guide their response in the event of pandemic influenza. effective communication strategies and support structures to promote preparedness for pandemic influenza are essential to facilitate large-scale community involvement in response efforts. findings from this study provide knowledge which can be used in the preparation of strategies to enable the effective delivery of information on preparedness for businesses. our results indicate that to motivate improved planning among the small and medium business sector, campaigns targeting small and medium businesses should emphasise the severity of the consequences to their businesses if a pandemic were to occur, and, at the same time, reassure them that there are effective strategies capable of being implemented by small and medium businesses to deal with a pandemic. world health organization: epidemic and pandemic alert and response: avian influenza the australian response: pandemic influenza preparedness australian government department of industry tourism and resources: business continuity guide for australian businesses australian government department of health and ageing: australian 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influencing the practice of preventive behaviours against the severe acute respiratory syndrome among older chinese in hong kong health behaviour theory and cumulative knowledge regarding health behaviors: are we moving in the right direction? australian bureau of statistics: australian and new zealand standard industrial classification (anzsic) preparing for an influenza pandemic: ethical issues using mathematical models to assess responses to an outbreak of an emerged viral disease. final report to the department of health and ageing. canberra, national centre for epidemiology and population health effects of a psychosocial intervention on breast self-examination attitudes and behaviours adolescents' cognitive appraisals of cigarette smoking: an application of the protection motivation theory avian influenza risk perception prediction and intervention in health-related behaviour: a meta-analytic review of protection motivation theory people at risk of flooding: why some residents take precautionary action while others do not world health organization writing group: nonpharmaceutical interventions for pandemic influenza, national and community measures managing fear in public health campaigns: a theory-based formative evaluation process the research was funded by the national health and medical research council of australia (project grant number ) and the australian biosecurity cooperative research centre for emerging infectious disease. the authors would also like to thank the local chambers of commerce and industry in east victoria park for their assistance with and support of the research. the author(s) declare that they have no competing interests. ajp, rew and crm conceived, designed and supervised the study; fcc and ri entered the data; rew and fcc analyzed the data; rew drafted the manuscript; and rjd, ajp, crm and fcc provided feedback on the interpretation of results and editorial comments on the manuscript. we wish to dedicate this paper to the memory of our colleague and much loved friend professor aileen joy plant who died suddenly on the th of march while on an avian influenza mission for the world health organization. this work would not have been possible without her leadership. her outstanding vision for and contribution to the advancement of global public health will be greatly missed. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -enoyoorn authors: shu, yuelong; song, ying; wang, dayan; greene, carolyn m.; moen, ann; lee, c. k.; chen, yongkun; xu, xiyan; mcfarland, jeffrey; xin, li; bresee, joseph; zhou, suizan; chen, tao; zhang, ran; cox, nancy title: a ten-year china-us laboratory collaboration: improving response to influenza threats in china and the world, – date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: enoyoorn the emergence of severe acute respiratory syndrome (sars) underscored the importance of influenza detection and response in china. from , the chinese national influenza center (cnic) and the united states centers for disease control and prevention (uscdc) initiated cooperative agreements to build capacity in influenza surveillance in china. from to , cnic and uscdc collaborated on the following activities: ) developing human technical expertise in virology and epidemiology in china; ) developing a comprehensive influenza surveillance system by enhancing influenza-like illness (ili) reporting and virological characterization; ) strengthening analysis, utilization and dissemination of surveillance data; and ) improving early response to influenza viruses with pandemic potential. since , cnic expanded its national influenza surveillance and response system which, as of , included laboratories and sentinel hospitals. with support from uscdc, more than public health staff from china received virology and epidemiology training, enabling > % network laboratories to establish virus isolation and/or nucleic acid detection techniques. cnic established viral drug resistance surveillance and platforms for gene sequencing, reverse genetics, serologic detection, and vaccine strains development. cnic also built a bioinformatics platform to strengthen data analysis and utilization, publishing weekly on-line influenza surveillance reports in english and chinese. the surveillance system collects , – , specimens and tests more than , influenza viruses annually, which provides valuable information for world health organization (who) influenza vaccine strain recommendations. in , cnic became the sixth who collaborating centre for influenza. cnic has strengthened virus and data sharing, and has provided training and reagents for other countries to improve global capacity for influenza control and prevention. the collaboration’s successes were built upon shared mission and values, emphasis on long-term capacity development and sustainability, and leadership commitment. the chinese national influenza center of the chinese center for disease prevention and control (china cdc) and the influenza division of the united states centers for disease control and prevention first discussed influenza virological surveillance in china in . in , cnic and uscdc signed agreements that enabled uscdc to provide technical and financial support for influenza surveillance in china and laid the foundation for future collaborations between the two agencies. initially, uscdc provided funds directly to cnic for laboratory training and specimen sharing; later, funding was provided through who headquarters, and subsequently through the who western pacific regional office. between and , cnic and uscdc staff traveled through who. between and , cnic and uscdc staff traveled to each other's agencies for training and collaborative studies. in , china enhanced earlier influenza surveillance efforts by establishing an influenza-like illness (ili) and virological surveillance system to report ili cases and isolate viruses for seasonal influenza vaccine strain recommendations. the surveillance system, including network laboratories and sentinel hospitals, did not capture the diversity of influenza activity and viruses circulating throughout the country. in addition, china recognized that the poor quality of the data with respect to completeness, timeliness and accuracy, limited the system's capacity to contribute to public health practice. the emergence of sars in [ ] and avian influenza a (h n ) virus in in mainland china [ ] underscored china's role as a potential source for emerging novel influenza viruses, due to its large human population, extensive and rapidly expanding poultry and swine production, cultural practices that increase exposures at the human-animal interface, and consumer preference for live poultry [ ] . recognizing the importance of high-quality influenza surveillance in china, from , china cdc and uscdc established influenza and global disease detection (gdd) cooperative agreements to improve the ili and virological surveillance system in mainland china, and to expand cnic's role from contributing to seasonal influenza vaccine strain recommendations to conducting early detection and response to novel influenza viruses with pandemic potential. in this report, we review the china-us laboratory collaboration on influenza from to , to share best practices and lessons learned, and to assess how this collaboration builds capacity in the prevention and control of influenza in china and globally. building upon existing technical exchanges and training programs, cnic and the influenza division of the uscdc signed a bilateral cooperative agreement in to develop and build the capacity of the influenza surveillance laboratory networks in china. in , china cdc and uscdc signed an additional cooperative agreement on emerging and remerging infectious diseases which was funded by the uscdc gdd program that allowed for enhanced collaborations with cnic in the field of influenza. the objectives for these collaborations were: ) to improve and expand the influenza surveillance system in china; and ) to build capacity for early detection and response to seasonal influenza, avian influenza and other influenza viruses with pandemic potential. in september , the uscdc deployed the first influenza assignee to china and established a uscdc program team in china, comprised of both a uscdc staff member from the united states and one to three locally-employed staff, to ensure effective communication and cooperation between cnic and uscdc. members of the uscdc team in country and colleagues from the influenza division in atlanta worked closely with cnic on a routine basis and contributed to numerous accomplishments including: ) developing human technical expertise in virology and epidemiology in china; ) improving the quality and function of the influenza surveillance system in china; ) strengthening the analysis, utilization and dissemination of surveillance data; and ) improving early response to avian influenza and other influenza viruses with pandemic potential. the following collaborative activities were identified to meet these priorities: ) training and enhancing human workforce development in cnic and network laboratories across the country; ) strengthening quality improvement activities including a) improving the quality of influenza virological surveillance through nucleic acid detection, virus isolation in embryonated eggs, genetic and antigenic characterization, and receptor-binding specificity characterization; b) strengthening quality assurance of network laboratories by conducting annual laboratory quality assessments; c) initiating the iso accreditation program; and d) introducing new technology including nucleic acid sequence based amplification (nasba), multi-plex pcr, and deep sequencing in cnic; ) adding new functions to the influenza surveillance system including: drug resistance surveillance; monitoring serologic status among occupationally exposed groups; conducting environmental sampling surveillance; and using multi-pathogen detection platforms for the surveillance of other respiratory viruses; ) establishing an influenza information system to integrate epidemiology and laboratory data and to promote timely data analysis and sharing; and ) promoting international collaborations in the form of information exchanges and virus-sharing during the influenza pandemic and the influenza a(h n ) outbreaks. from to , cnic staff received training in cdc atlanta, from one month to . years in length, on topics including influenza surveillance and laboratory management, reverse genetic techniques, serological techniques, pathology, antigenicity characterization, and drug resistance surveillance. cnic provided lecture-based training to staff from network laboratories and sentinel hospitals, and hands-on training to lab specialists on cell culture, virus isolation, and serology testing and gene sequence analysis with uscdc support. during this timeframe, china also expanded its ili and virological surveillance network. in , the network increased from to network laboratories and to sentinel hospitals, primarily supported with funds from the chinese government, with supplemental project-based financial support from uscdc and who. during the influenza a(h n ) pandemic period, the chinese government expanded the network further to include laboratories and sentinel hospitals (fig. ) . the china-us collaboration, complementing the national program, aimed to strengthen capacity by providing training, strengthening laboratory quality assessment and accreditation, and establishing new laboratory testing technologies. from to , provincial influenza labs were certificated by cnic as provincial influenza reference centers. the number of network laboratories capable of performing nucleic acid detection increased from in to in , and more than % of all network laboratories were capable of performing virus isolation (fig. ) . similarly, the number of network laboratories with capacity to conduct virus isolation in eggs to support the selection of vaccine viruses increased from in to in . from to , the network laboratories substantially increased the number of specimens processed annually from , to , , the number of specimens tested for influenza viruses by real-time rt-pcr from to , , and the number of influenza viruses isolated from specimens collected within the influenza surveillance system from to , (fig. ) . over the ten-year period, cnic conducted full genome sequencing on influenza viruses, the number of viruses sequenced per year increased from in to in . with technical support from uscdc, cnic established surveillance for anti-viral drug resistance in . a total of , viruses of different types/subtypes were analyzed during the ten years, and the number of strains tested for drug susceptibility increased over -fold, from in to in [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . from to , cnic conducted annual quality assessments to monitor the quality of specimen collection, storage, transportation and testing of the network laboratories. the proportion of network laboratories capable of achieving % correct test results for rt-pcr and real-time rt-pcr increased from % in to % in (table ). in addition, cnic participates in who's annual external quality assurance program (eqap), and has received % accurate results since . a year after who's assessment of cnic in , the chinese ministry of health submitted an application for cnic to become a who collaborating centre (who cc) for reference and research on influenza. cnic implemented performance improvement measures based on who requirements, and launched a one-year assessment in november . in october , cnic was officially designated as the world's sixth who cc for influenza, joining laboratories in australia, japan, the united kingdom and the united states. as the ili surveillance system expanded in size and capacity, its function also expanded to the early detection of emerging novel influenza viruses. built on the existing influenza surveillance network, cnic developed an influenza identification platform which can detect all types/subtypes of influenza viruses including zoonotic infections. this system allowed cnic to confirm china's first human infections from starting in , the national assessment only included one network laboratory from the provinces designated as provincial reference centers; the remaining laboratories within these provinces participated in the provincial assessments (not shown here) [ ] [ ] [ ] . cnic developed an information system with three online components: the influenza surveillance information system, the infectious disease surveillance platform and the influenza prediction and early warning platform. local cdc users across china can access this system to: ) report cases of ili, pneumonia of unknown etiology, and severe acute respiratory infection (sari); and ) upload laboratory testing results. the infectious disease surveillance platform also collects test results from environmental surveillance and serologic studies of groups with occupational exposure to poultry. with support from the collaboration with uscdc strengthened data analysis and, since , has generated online weekly influenza reports to share when, where and which influenza viruses are circulating in china. the weekly reports, in both chinese and english, are emailed to key stakeholders and are also made available on the cnic website [ ] . since , cnic also has reported influenza surveillance data to who flunet [ ] . during the influenza a(h n ) virus outbreak, cnic detected and reported the first case of human infection with a(h n ) virus to who on march , within one week of receiving the specimen. the first paper describing this case was published in the new england journal of medicine days after case confirmation [ ] . subsequently, cnic has published more than additional peer-reviewed papers on a(h n ) virus infections in humans to describe the virological characteristics of a(h n ) virus [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for the international public health audience, and to inform a(h n ) outbreak response efforts. during the early stages of the h n pandemic, uscdc and china cdc established routine conference calls between directors and experts of the two centers. uscdc shared the genetic sequence of the pandemic virus with cnic, allowing cnic to rapidly develop nucleic acid detection kits which were transported to national influenza network laboratories and other laboratories across the country. the availability of testing reagents ensured accurate estimates of the magnitude of the pandemic in china and allowed the chinese government to coordinate an appropriate response. in addition, the uscdc country team in beijing worked closely with china cdc experts on pandemic risk assessment and response. in , cnic shared novel avian influenza a (h n ) viruses from human infections with who collaborating centers and other qualified laboratories worldwide. cnic also worked with who, uscdc and other international laboratories to modify serological protocols for influenza a (h n ) virus detection [ ] . international collaboration for the first human outbreak of avian influenza a (h n ) virus was exemplified by a joint mission of chinese and international influenza experts to beijing and shanghai from to april . team members included representatives from china's national health and family planning commission (nhfpc), china cdc, international influenza experts from australia, europe, hong kong (china), the us, and who. the mission report, covering recommendations for ongoing surveillance and investigations, information sharing and collaboration, and preparedness and response, was released and shared through who and nhfpc websites. in addition, two uscdc epidemiologists from traveled to china, to work with china cdc experts to analyze surveillance data, design case control and serologic study protocols, and discuss response measures. at the same time, two cnic senior staff spent months at us cdc's influenza division to receive training on deep sequencing of influenza a(h n ) viruses. as a new who collaborating centre for influenza, cnic not only increased influenza control and prevention capacity throughout china, but also throughout the region. in recent years, cnic, with chinese government support, has provided hands-on laboratory training to neighboring countries, such as from the association of southeast asian nations (asean). more specifically: in , cnic provided avian influenza laboratory diagnostic training to trainees from asean countries; during the pandemic, cnic provided free test kits to countries and training on biosafety and laboratory diagnosis of a(h n pdm ) virus for participants from asean countries; and in , cnic conducted training on serological detection of avian influenza a(h n ) virus for participants from indonesia, laos, malaysia, mongolia, philippines, thailand and vietnam. further, cnic shared serological and nucleic acid testing protocols with who and provided diagnostic kits for pandemic h n to brunei, cambodia, cuba, indonesia, laos, malaysia, mongolia, papua new guinea, philippines, singapore, thailand and vietnam, and seasonal influenza surveillance-related reagents and consumables to dpr korea. in the last decade, the cnic-uscdc collaboration has built capacity in seasonal and novel influenza prevention and control in china and beyond. the workforce of the influenza surveillance network, both within cnic and within network laboratories and sentinel hospitals throughout china, is now well developed. the influenza surveillance system expanded in size, capacity, and function, and improved the quality of its testing and use of data. no longer focused on seasonal influenza alone, the ili surveillance network detected the first human infections with influenza a (h n ) virus, a (h n ) virus, a (h n ) virus and other novel avian influenza viruses. the collaboration promoted timely data analysis and sharing, including the development of an on-line influenza weekly report for early case reporting and information sharing. in addition, the collaboration enabled cnic to provide technical assistance in the field of influenza laboratory diagnostics to numerous countries in the region. one challenge faced by the cnic-uscdc collaboration during the past decade was the limited effective coordination with animal health sectors in the field of avian influenza in china. in the future, the two agencies plan to strengthen avian influenza collaborations within a one-health approach that promotes a multi-sectoral response to emerging influenza threats. a major contributor to the success of this collaboration was that it complemented the existing national influenza program, in addition to the chinese government's commitment to developing an extensive and robust influenza surveillance system. in , the chinese government invested the equivalent of million us dollars to expand the network. all collaborative efforts were designed to support the successful expansion of the network. for example, to ensure the quality of the new system, the cnic-uscdc collaboration provided training for laboratory specialists within the new network laboratories and sentinel hospitals and improved quality assessment of the system. the collaboration also supported the establishment of new components of the surveillance system, such as antiviral resistance surveillance and environmental surveillance. at the outset, cnic and uscdc agreed that these new components would soon be fully incorporated and maintained by the national program. in this way, the collaboration maximized existing government investments in influenza surveillance. further, the collaboration demonstrated the importance of influenza surveillance during response efforts to the pandemic and the a(h n ) outbreak, ensuring continued government commitment to the influenza surveillance system in the future. the cnic-uscdc collaboration was strengthened by the two agencies' shared mission and values. long before the launch of the official cooperative agreement in , both agencies recognized the importance of improving influenza surveillance in china; the recent a(h n ) and sars outbreaks highlighted china as a potential source for emerging novel respiratory viruses with pandemic potential. further, uscdc's strategic priorities at the time included increasing global surveillance and response capacity to strengthen global health security and china, the most populous country in the world, played a critical role. in this way, the collaboration between cnic and uscdc was founded on a joint mission and mutual, well-defined priorities. another factor contributing to the success of the collaboration was its commitment to capacity building. cnic plays a key role managing and developing the influenza surveillance network in china, and therefore, cnic staff members who received training at uscdc and other international organizations played a vital role during the responses to both the a(h n ) pandemic and the - a(h n ) outbreaks in terms of early virus identification, deep gene sequencing, vaccine development, and serving as trainers in both domestic and international settings. finally, this cnic-uscdc collaboration would not have thrived without the shared vision and commitment of the leaders within the two agencies. fortunately, the formal cooperative agreement was built upon the foundation of a long-term collaboration between cnic and uscdc. in the decades prior to , influenza experts from both agencies had developed strong professional respect for one another, as they shared a profound interest and commitment to preventing and controlling influenza illness around the globe. the leadership's respect and trust for one another likely facilitated the rapid joint responses to emergencies, which included data and virus sharing, technical exchanges, and joint manuscripts in the peer-reviewed literature. in the past decade, china rapidly expanded its capacity to detect and respond to seasonal influenza and novel influenza viruses with pandemic potential. the - china-us collaboration in the field of influenza demonstrates how two public health agencies worked together to expand a disease surveillance system, and ultimately improved the prevention and control of both seasonal and novel influenza viruses in china and the world. eepidemiological study on severe acute respiratory syndrome in guangdong province the first confirmed human case of avian influenza a (h n ) in mainland china. zhonghua liu xing bing xue za zhi = zhonghua liuxingbingxue zazhi risk-based surveillance for avian influenza control along poultry market chains in south china: the value of social network analysis characteristics of oseltamivir-resistant influenza a (h n ) 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humanisolated h n influenza virus in ferrets and pigs dual e k and d n mutations in the pb protein of a(h n ) influenza virus increased its virulence in mammalian models biological characterisation of the emerged highly pathogenic avian influenza (hpai) a(h n ) viruses in humans monitoring avian influenza a(h n ) virus through national influenza-like illness surveillance the authors thank jackie katz, xin liu, mei shang, and the many other dedicated members of the chinese national influenza center, chinese national influenza surveillance and response system, china cdc, us cdc, who and who ccs who contributed to the success of this international collaboration. the findings and conclusions in this report are those of the authors and do not necessarily represent the views of the us centers for disease control and prevention or the chinese center for disease control and prevention. this work was financially supported by the us centers for disease control and prevention cooperative agreements (grant numbers: u /ccu , key: cord- -yxhk qm authors: podin, yuwana; gias, edna lm; ong, flora; leong, yee-wei; yee, siew-fung; yusof, mohd apandi; perera, david; teo, bibiana; wee, thian-yew; yao, sik-chi; yao, sik-king; kiyu, andrew; arif, mohd taha; cardosa, mary jane title: sentinel surveillance for human enterovirus in sarawak, malaysia: lessons from the first years date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: yxhk qm background: a major outbreak of human enterovirus -associated hand, foot and mouth disease in sarawak in marked the beginning of a series of outbreaks in the asia pacific region. some of these outbreaks had unusually high numbers of fatalities and this generated much fear and anxiety in the region. methods: we established a sentinel surveillance programme for hand, foot and mouth disease in sarawak, malaysia, in march , and the observations of the first years are described here. virus isolation, serotyping and genotyping were performed on throat, rectal, vesicle and other swabs. results: during this period sarawak had two outbreaks of human enterovirus , in and . the predominant strains circulating in the outbreaks of , and were all from genogroup b, but the strains isolated during each outbreak were genetically distinct from each other. human enterovirus outbreaks occurred in a cyclical pattern every three years and coxsackievirus a co-circulated with human enterovirus . although vesicles were most likely to yield an isolate, this sample was not generally available from most cases and obtaining throat swabs was thus found to be the most efficient way to obtain virological information. conclusion: knowledge of the epidemiology of human enterovirus transmission will allow public health personnel to predict when outbreaks might occur and to plan interventions in an effective manner in order to reduce the burden of disease. hand, foot and mouth disease (hfmd) is a common acute viral illness that primarily affects infants and young children, and often occurs in clusters or outbreaks. it is characterized by rapid onset of fever and sore throat, accompanied by vesicles and ulcers on the gums, tongue, buccal mucosa and palate. punctate and usually transient skin lesions appear on the palms, soles and occasionally on the buttocks, knees or other areas. while the fever and rash may subside rapidly, the mouth lesions may last more than a week, and virus may continue to be shed for several weeks [ ] . in temperate countries hfmd occurs during the summer but in the tropics hfmd can occur at any time during the year. the major causative agents of hfmd are coxsackievirus a (cva ), human enterovirus (hev ) and coxsackievirus a (cva ) of the genus enterovirus in the family picornaviridae [ ] . other enteroviruses isolated from hfmd cases are the other species a human enteroviruses such as coxsackievirus a (cva) , cva , cva and cva , and coxsackievirus b (cvb) , cvb , cvb and cvb [ ] [ ] [ ] . unlike other aetiological agents of hfmd that normally cause mild disease, hev infection has been reported to cause neurological disease manifesting as aseptic meningitis, encephalitis or poliomyelitis-like acute flaccid paralysis [ ] . first isolated from a child suffering from encephalitis in california in , hev was further isolated from cases with severe neurological disease in california during the next three years [ ] . historically, hev -associated outbreaks have been reported in australia in [ ] , japan in and [ ] , bulgaria in [ ] and hungary in [ ] . in the past decade, countries in the asia-pacific region have experienced an increased occurrence of hev -associated hfmd outbreaks [ ] . hev outbreaks have been reported in sarawak in , taiwan in , perth in , then in singapore, korea, malaysia and taiwan in [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in an outbreak of hev in in sarawak, a state of malaysia on the island of borneo, a cluster of unusual paediatric deaths due to encephalitis and cardiac failure was observed [ , ] . this raised a lot of fear and anxiety and because of the heightened concern about hev in sarawak, we implemented a sentinel surveillance programme for hfmd beginning in march . this programme was set up as part of the operational functions of the sarawak health department and was approved by the director of health. the principles of the helsinki declaration were followed throughout the surveillance operation. our aims were to investigate the epidemiology of this common childhood disease in sarawak, and to determine if there were any differences in the patterns of transmission of hev , cva and other aetiological agents of hfmd. it was also the aim of this programme to provide data of practical value for doctors and public health personnel with a view to efficient and effective virological surveillance of hev , in particular, to provide an early warning system for hev outbreaks. this paper describes the preliminary observations from our surveillance programme from march through june . in early after discussion with a number of community paediatricians, our team set up a protocol for a sentinel surveillance programme for hfmd. the doctors who had consented to actively participate were provided with a standard reporting and specimen collection form, sterile swabs and virus transport medium, a telephone number for obtaining assistance for transport of specimens to the laboratory and a facsimile number to report cases to the health department. all sentinel clinic doctors obtained parental consent before swabs were taken. sentinel clinic doctors were provided with feedback on viruses isolated from their patients and contact was maintained through both outbreak and inter-outbreak periods to assure doctors that the surveillance programme was active and ongoing. data obtained in this manner were expected to provide accurate information about disease trends and molecular epidemiology of the relevant viruses. three specialist paediatric clinics located in the towns of kuching and sibu in the state of sarawak actively participated in this study from march . in we included a fourth specialist clinic in sibu. two government polyclinics in kuching and sibu also participated as sentinel clinics. all children presenting to the sentinel clinics with a history of oral or other skin lesions typical of hfmd were enrolled into the surveillance study, and throat and rectal swabs were obtained from each child enrolled in the first months. where possible, swabs were also obtained from mouth ulcers, vesicles and other skin lesions. after a preliminary analysis of data from the first months, the protocol was modified to require only throat swabs from sentinel clinics. rectal swabs were optional and doctors were requested to provide vesicle swabs whenever possible. specimens were to be transported on ice to the laboratory in ml of viral transport medium (vtm) where they were vortexed, freeze-thawed and aliquoted. since the primary objective of programme was a sentinel surveillance system for hev hfmd, we inoculated specimens into human rhabdomyosarcoma (rd) cells susceptible to both cva and hev . it was not a particular objective of this exercise to identify the minor causative agents known to be associated with hfmd and hence we did not include multiple cell lines as part of our virus isolation protocol. rd cell cultures normally showed the characteristic enterovirus cpe in to days and were harvested after the monolayer showed extensive cpe. a blind passage was done with all cultures showing no cpe after to days. rna was extracted from all culture harvests using tri reagent ls (molecular research centre, cincinnati, oh, usa) according to the manufacturer's instructions. the dry rna pellet was dissolved in μl of sterile ultra high quality rnase-free water and stored at - °c until use. the presence of enterovirus rna in culture fluids was determined by a previously described pan-ev rt-pcr method [ ] with some modifications. the duration of all the steps in the pcr was reduced to one minute and the final extension was reduced to minutes. from through , specimens positive using the pan-ev primers were tested for the presence of hev genome by rt-pcr using the primers s and a, which anneal to the vp gene of hev . dr. mark pallansch (centers for disease control, atlanta) generously made the primer sequences available to us prior to publication [ ] . all pcr products were sequenced to confirm the identification. in , we changed our protocol for identification of hev due to problems of misidentification of local strains of cva as hev using the primer set s/ a [ ] . currently, hev specific primers designed in-house are used for specific identification of hev [ ] . all primers used are listed in table . sequencing reactions were performed using the big dye terminator cycle sequencing kit version . or . (applied biosystems, foster city, ca, usa). molecular serotyping of non-hev enteroviruses isolated was carried out using the methods and sequences published by oberste and colleagues [ ] and chu, ishiko and colleagues [ , ] . prior to , serotyping of selected non-hev enteroviruses was performed exclusively according to oberste's method. when ishiko's method [ ] was published in , we made a comparison of the methods by serotyping new isolates using both methods. we determined that for human species a enteroviruses circulating in our region, ishiko's primers gave identical serotype identification to that obtained using oberste's method [ ] . since there was no discrepancy between the methods, we modified ishiko's primers to convert the method from a semi-nested to a non-nested method for ease of use. our modifications were verified and described by cardosa and colleagues [ ] . we then retrospectively retested all non-hev enteroviruses isolated prior to using the modified method. a subset of isolates identified by sequencing of vp were subjected to confirmation by using vp specific primers and dna sequencing of the pcr products, as described previously [ ] . dna sequences of vp and vp gene products generated by rt-pcr from isolates were used in this analysis essentially as previously described [ ] . the software package clustalx [ ] was used for alignment and to generate a bootstrapped phylogenetic tree using the neighbour joining method according to saitou and nei [ ] .primers and dna sequences ttccaataccaccccttggatga antisense ( - ) hev vp gene. [ ] acyatgaaaytgtgcaagg sense ( - ) hev vp gene. [ ] ccrgtaggkgtrcacgcrac antisense ( - ) hev vp gene. [ ] ctgggacatagayataacwgg sense ( - ) hev vp gene. np a [ ] gciccicaytgitgiccraa antisense ( - ) hev vp gene. mas s [ ] ataatagcaytrgcggcagccca sense ( - ) partial vp gene. mas a [ ] agagggagrtctatctcycc antisense ( - ) partial vp gene. md [ ] cctccggcccctgaatgcggctaat sense ( - ) partial utr. md [ ] attgtcaccataagcagcca antisense ( - ) partial utr. *position relative to the genome of hev strain -ms- (genbank accession number u ) all primers used in the methods described above are listed in table . all new dna sequences used in the phylogenetic analysis but hitherto unpublished have been deposited in genbank and have the accession numbers ay , ay , ay to ay . all other sequences used are from previous publications by our own as well as other groups [ , , [ ] [ ] [ ] ] . detailed protocols, sample collection methods and other practical information have been placed in the public domain through our apnet (the asia-pacific enterovirus surveillance network) website [ ] . statistical analysis was performed using the software package jmp statistics version . (sas institute inc., usa) and prism for macintosh (graphpad software, inc., usa). the first provisional protocol we provided to the sentinel clinics for the collection of specimens required both throat and rectal swabs and vesicle or ulcer swabs where possible. results from virus isolation studies of specimens obtained from both sentinel clinics as well as hospitals during this period were used to review the protocol that was originally implemented. a total of specimens from children with a clinical diagnosis of hfmd were received during the -month period from march through august . the age of the children ranged from months to years, with ( . %) males and ( . %) females. all specimens received were subjected to virus isolation. fifty specimens from children, of a total of ( . %) specimens, were too heavily contaminated with bacteria. twenty four of the contaminated specimens were rectal swabs, were throat swabs and were from various skin lesions. all remaining uncontaminated cell culture harvests were tested for enteroviruses by using the pan-ev set of primers and of the ( . %) specimens tested yielded an enterovirus, but only of the ( . %) enteroviruses were hev . these specimens were from children and an enterovirus was isolated from ( . %) children. only ( . %) of the children had hev . from this early set of specimens, we were able to isolate an enterovirus from % of the throat swabs, % of the rectal swabs, % of the mouth ulcers and % of the vesicle swabs. clearly vesicle swabs are very useful specimens, but only % of the children had had vesicle swabs taken because not all children presented with skin lesions filled with abundant fluid. since throat swabs provided a reasonably high yield of enterovirus isolates, we made the decision in , to require throat swabs as the primary specimen from the sentinel clinics, with vesicle swabs where possible, while rectal swabs were not required. this served to reduce the laboratory workload during an outbreak. our laboratory received specimens from children from march through june , with a male to female ratio of . : . the histogram in the top panel of figure shows the distribution of hfmd cases seen in our sentinel clinics during this period. there have clearly been two large outbreaks of hfmd in and (bottom panel of figure ), with some sporadic activity between these peaks. the dominant enterovirus serotype isolated during both the outbreaks was hev as shown in the middle panel of figure . cva was always isolated during hev outbreaks as well but was also isolated in interoutbreak periods. other species a human enteroviruses such as cva , cva , cva , cva and cva were also isolated in inter-outbreak periods. phylogenetic analysis of the hev strains isolated in sarawak from to show that both genogroup b and genogroup c strains circulated in sarawak during this period (see figures and ) . we have used both vp and vp genes in the phylogenetic analysis in order to be certain that there is no major discrepancy in genotyping associated with using vp and vp gene regions. furthermore, we wish to provide both options to other groups who may wish to compare their data with ours since it is known that many groups may still use vp sequencing as a first step in molecular identification of human enteroviruses. although both genogroup b and genogroup c hev strains co-circulated in sarawak, the predominant genogroup in both the hev outbreaks of and was genogroup b. besides co-circulating with genogroup b strains during outbreaks, genogroup c viruses also appeared sporadically between outbreaks along with other species a human enteroviruses. we never isolated a genogroup b hev in non-outbreak periods. the distribution of genogroup b and genogroup c hev strains during the surveillance period is shown in the bottom panel of figure . the phylogenetic trees in figures and the hfmd epidemiological curves for the outbreak years and were plotted according to epidemiological week ( figure ) and show clearly that the first hfmd cases began to be seen early in the year. by week a clear rise in the number of cases was seen. this early rise in cases differs from the summer outbreaks seen in temperate countries, and we suggest that the hev outbreaks in sarawak preceed the summer outbreaks of countries in the northern hemisphere in each year. in the hfmd outbreak stretched to the end of the year, peaking between phylogenetic tree generated from the vp gene, showing relationships between hev isolated in different years figure ). in , the number of hev cases declined sharply by the end of april (by week ) and were no longer detected by the end of june, coinciding with the last hfmd cases seen that year. interestingly this outbreak coincided with the sars outbreak in the region and the public health measures put into place during this time evidently served to control the transmission of enteroviruses as well. a detailed analysis was done on data collected from two sentinel clinics, coded s and s , which had sent samples to our laboratory consistently and reliably throughout the seven-year study period. a total of specimens were collected from cases during the years. of the cases, specimens from ( %) were subjected to virus isolation. a total of specimens were subjected to virus isolation, thus ensuring that the majority of specimens from the majority of cases were tested ( . % of specimens from % of cases). an analysis of the proportion of the different types of specimens and the virus yield obtained is shown in table . more than specimens from outbreak and nonoutbreak periods were tested from to . enteroviruses were grown from . % of those tested. throat swabs comprised . % of the total number of specimens tested and . % of these yielded enteroviruses. detailed information about the enterovirus serotypes isolated during this surveillance programme is also provided [see additional file ] . although on the whole, the virus isolation success rate was much lower than anticipated from the results for the first months, it remained the case that throat swabs were more useful than the rectal swabs which yielded non-polio enteroviruses in only . % of the samples tested. it should be noted however, that the first months of the study coincided with an inter hev epidemic period, with mostly cva and non-hev species a human enteroviruses causing hfmd. we have compared the virus isolation yields during hev outbreak ( and ) years with the yields during an hfmd outbreak caused by non-hev enteroviruses ( ) and we found that we successfully isolated virus from % of specimens collected in but only % of viruses during the hev outbreak years, suggesting that hev is more difficult to isolate than cva and other species a enteroviruses. the virus isolation rate in the first months ( %) is therefore comparable to that obtained later, when hev was not circulating. there were children from whom a non-polio enterovirus was isolated. of these, were excluded from the analysis because of missing information on their age at presentation. the children ranged in age from days to months, with a mean of . months and a median of . months. there were dominant serotypes of enteroviruses isolated from these children and we asked the question if different serotypes of enteroviruses caused infection in children of different ages. table shows the mean ages of the children who had cva , hev and cva infection. comparison of means for each pair using an unpaired t test at an alpha of . , showed that there was no significant difference in the mean ages of the children in the different groups (cva versus cva : p = . ; cva versus hev : p = . ; cva versus hev : p = . ). following the outbreak of ev associated hfmd in sarawak, malaysia, the health department installed a sentinel surveillance programme with the expectation that we would be able to study epidemiological trends and begin to predict when to expect outbreaks with sufficient accuracy in order to implement public health interventions to reduce the burden of the disease. although the surveillance programme is still ongoing in sarawak, we have sought to glean some preliminary information from the data generated over the first years of the programme. two hev outbreaks. a recent report on a similar surveillance programme in yamagata prefecture in japan ( ) ( ) ( ) ( ) ( ) ( ) suggests that in yamagata there is frequent importation of hev from surrounding countries seeding the clusters of cases seen annually in this community [ ] . the hev strains in this study were isolated from small clusters of cases that tended to be seen in the summer months while in our situation we observed outbreaks of hev every years with cases being seen much earlier in the year, well before the northern summer. in both sarawak and yamagata experienced a large outbreak and in both situations, a genogroup shift from c to b was noted. it is interesting that in sarawak, of the genogroup c viruses, only genogroup c strains have been observed, while genogroup b viruses appear to be changing from outbreak to outbreak, suggesting that it is likely that genogroup b viruses are evolving within borneo and that the outbreaks we have experienced are being seeded from within rather than from imported viruses. since the outbreaks in sarawak typically begin early in the year, it is also possible that genogroup b strains generated in sarawak may seed hev outbreaks in the region, which typically occur later than the sarawak outbreaks. this temporal sequence of regional outbreaks is also true of those occurring in singapore and in peninsula malaysia. the data we have obtained through years of our sentinel surveillance programme for hfmd in sarawak have provided useful clues to understanding the epidemiology of hev in the state. it is clear that the appearance of hev associated hfmd in sentinel clinics signals the start of an outbreak, but the rise in the number of cases is so rapid that this approach is not a suitable early warning system. in there were only weeks between the time the first hev cases were seen and the peak of the outbreak. clearly this could be explained by rapid and effective response by the public health teams, but we have no way to know. alternatively, the -year cycle of hev outbreaks we have observed could, if verified in the coming years, provide public health officials with the relevant information to plan and to implement their intervention programmes to reduce the disease burden in the years when an hev outbreak is expected. although this is not expected to prevent the outbreaks entirely, effective public health measures put into place early enough can limit the spread, reduce mortality and reduce the burden on the community and the health system. it is important to note that epidemiological curves showing hfmd alone, without distinguishing the infecting agent for each case, can stretch broadly over many months, with non-hev enteroviruses continuing to be isolated after cessation of hev activity. this was especially evident in , when hev associated fatal cases were reported in neighbouring singapore in september and october [ ] , and the media attention surrounding these events generated a high index of suspicion in sarawak as well. no hev was isolated in sarawak after august that year, but numerous cva continued to be isolated until the end of . thus even though sociological factors affect the shape of the hfmd epidemiological curves in sarawak, epidemiological curves specifically showing genogroup b strains of hev were consistently sharp and well defined in and . the mean and median age of children with hfmd was months and months respectively, but the mean ages did not differ between the groups infected with the different serotypes. it is thus intriguing that hev has caused much larger and sharper outbreaks than either cva or cva . this suggests that hev has the capacity to spread rapidly through the susceptible population and then become quiescent in the community. in the third year after any hev outbreak, the whole cohort of children under years of age has not been exposed to hev and all of these children are then susceptible, providing the conditions for another sweeping transmission of hev through the community. the annual birth cohort in sarawak is to thousand and thus in years there are up to , susceptible children in the state. according to the trends we have reported, we expect that the next outbreak of hev in sarawak will be in . at the time of writing we have already begun to pick up hev cases in our sentinel programme and from past experience, an outbreak in sarawak is often followed by outbreaks in other countries in the region. we have therefore decided to put our data into the public domain in order that other public health practitioners in the asia pacific region may benefit from this experience and prepare for a spread of hev in the region once again in the months to come. the main conclusions arising out of this preliminary report are described below: a. hev outbreaks have occurred every years in sarawak starting in . all the outbreaks ( , and ) have been caused by genogroup b viruses and furthermore, each of the outbreaks has been associated with genogroup b viruses that are genetically distinct from each other. b. hev of subgenogroup c has been isolated throughout the years of the surveillance programme and are closely related to each other and to genogroup c viruses isolated elsewhere. sarawak has so far not experienced large hfmd outbreaks caused by hev of genogroup c . indeed hev of subgenogroup c behave much like other species a enteroviruses, occurring sporadically throughout the surveillance period. c. in sarawak, occurrence of hev genogroup b infections is tightly clustered, with cases rising and falling very rapidly. oxford textbook of medicine edited by: weatherall dj, ledingham jgg and warrell da enteroviruses: polioviruses, coxsackieviruses, echoviruses and newer enteroviruses. in field's virology an apparently new enterovirus isolated from patients with disease of the central nervous system hand, foot and mouth disease associated with coxsackievirus group b enterovirus infections and neurologic disease--united states, - enterovirus type infection in melbourne outbreaks of hand, foot, and mouth disease by enterovirus . high incidence of complication disorders of central nervous system enterovirus isolated from cases of epidemic poliomyelitis-like disease in bulgaria virological diagnosis of enterovirus type infections: experiences gained during an epidemic of acute cns diseases in hungary in frequent importation of enterovirus from surrounding countries into the local community of yamagata enterovirus from fatal and nonfatal cases of hand, foot and mouth disease epidemics in malaysia, japan and taiwan in - isolation of subgenus b adenovirus during a fatal outbreak of enterovirus -associated hand, foot, and mouth disease in deaths of children during an outbreak of hand, foot, and mouth disease in sarawak, malaysia: clinical and pathological characteristics of the disease. for the outbreak study group an epidemic of enterovirus infection in taiwan. taiwan enterovirus epidemic working group phylogenetic analysis of enterovirus strains isolated during linked epidemics in malaysia neurological manifestations of enterovirus infection in children during an outbreak of hand, foot, and mouth disease in western australia change of major genotype of enterovirus in outbreaks of hand-foot-andmouth disease in taiwan between and pcr detection of the human enteroviruses serotypespecific identification of enterovirus by pcr incorrect identification of recent asian strains of coxsackievirus a as human enterovirus : improved primers for the specific detection of human enterovirus by rt pcr typing of human enteroviruses by partial sequencing of vp molecular epidemiology of enterovirus in taiwan molecular diagnosis of human enteroviruses by phylogeny-based classification by use of the vp sequence molecular epidemiology of human enterovirus strains and recent outbreaks in the asia-pacific region: comparative analysis of the vp and vp genes the clustal_x windows interface: flexible strategies for multiple sequence alignment aided by quality analysis tools the neighbor-joining method: a new method for reconstructing phylogenetic trees molecular epidemiology of enterovirus infection in the western pacific region this is a web resource for surveillance of hev epidemic hand, foot and mouth disease caused by human enterovirus this study was supported by operational funds of the sarawak health department, ministry of health, malaysia and by grants from the ministry of science, technology and innovation, malaysia: - - - and - - - btk/er/ . in the final year of this study, some of this work was supported by a wellcome trust/nhmrc, australia international collaborative research grant gro aia. the author(s) declare that they have no competing interests. all the virology and molecular biology was conducted by the team from universiti malaysia sarawak. members of the sarawak health department provided logistic support in the collection of specimens and data from the community, and also in the communication of trends and public health measures to the primary care doctors. the surveillance system was conceived of by mta, planned and executed by mjc, fo and ak. bt and tyw were key players in the primary healthcare setting. all authors have read and approved this manuscript. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -w catjj authors: degeling, chris; johnson, jane; kerridge, ian; wilson, andrew; ward, michael; stewart, cameron; gilbert, gwendolyn title: implementing a one health approach to emerging infectious disease: reflections on the socio-political, ethical and legal dimensions date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: w catjj background: ‘one health’ represents a call for health researchers and practitioners at the human, animal and environmental interfaces to work together to mitigate the risks of emerging and re-emerging infectious diseases (eids). a one health approach emphasizing inter-disciplinary co-operation is increasingly seen as necessary for effective eid control and prevention. there are, however, socio-political, ethical and legal challenges, which must be met by such a one health approach. discussion: based on the philosophical review and critical analysis of scholarship around the theory and practice of one health it is clear that eid events are not simply about pathogens jumping species barriers; they are comprised of complex and contingent sets of relations that involve socioeconomic and socio-political drivers and consequences with the latter extending beyond the impact of the disease. therefore, the effectiveness of policies based on one health depends on their implementation and alignment with or modification of public values. summary: despite its strong motivating rationale, implementing a one health approach in an integrated and considered manner can be challenging, especially in the face of a perceived crisis. the effective control and prevention of eids therefore requires: (i) social science research to improve understanding of how eid threats and responses play out; (ii) the development of an analytic framework that catalogues case experiences with eids, reflects their dynamic nature and promotes inter-sectoral collaboration and knowledge synthesis; (iii) genuine public engagement processes that promote transparency, education and capture people’s preferences; (iv) a set of practical principles and values that integrate ethics into decision-making procedures, against which policies and public health responses can be assessed; (v) integration of the analytic framework and the statement of principles and values outlined above; and (vi) a focus on genuine reform rather than rhetoric. the recent ebolavirus (ebov) outbreak in west africa and continuing human infections with a novel h n influenza a virus in mainland china are salient reminders of how human and nonhuman health are inextricably linked. nonhuman animals are the source of % of emerging and re-emerging infectious disease (eid) threats to human health [ ] , and more than half of all established human pathogens [ ] . the threats posed by eids are dynamic. eids are caused by pathogens that can change their behaviour over timeeither through genetic modification or through changes in the patterns and pathways of transmission [ ] . social, economic and political systems can either promote or inhibit pathogen transfer, and the incidence and pathogenicity of the disease [ ] . while a lack of data makes quantitation difficult, eids and zoonoses account for a significant proportion of the global disease burden [ ] . eids and emergence of zoonotic pathogens, including human immunodeficiency virus (hiv), are direct causes of an estimated million deaths worldwide each year [ ] . a one health approach is increasingly considered to be the most effective way of managing eid threats [ , ] because it represents an acknowledgement of certain facts about the nature of disease, which are then deployed to structure the response. one health is grounded in a recognition that human, animal and environmental health are interdependent [ ] , that animal species provide a shared reservoir for pathogen exchange and spread, and that many eids are driven by varied and dynamic human-animal interactions [ , ] . the response one health offers is to deconstruct the disciplinary silos [ ] which have separated biomedical and social sciences devoted to the study of human disease from those devoted to nonhuman disease and ecological concerns [ , ] . inter-disciplinary research is called for and required, as is interventionist practice at local, national and international levels involving: policymakers, planners, regulators, physicians, veterinarians, ecologists, public and animal health officials, environmental health officers, microbiologists, and other allied natural and social scientists [ , ] . although principally associated with eid prevention and control, one health is also relevant to prevention and control of endemic and zoonotic animal diseases, as well as securing food safety [ , ] . considering the magnitude and complexity of global issues surrounding infectious disease and food security, the one health approach has the potential to provide the creative, effective and sustainable solutions required. despite its strong motivating rationale, implementing a one health approach can be challenging. dealing with eids in an integrated and considered manner can be highly problematic, especially in the face of a perceived crisis. in this paper we examine the socio-political, ethical and legal considerations implied by a one health approach to eids. first we describe how a one health approach could galvanise and enhance current capacity in eid prevention and control. making reference to case examples, we then identify and characterise sociopolitical, ethical and legal concerns that have the potential to limit the effectiveness of one health interventions. finally, we draw on this data to provide guidance as to how these concerns and issues might be addressed, and point to remaining challenges to the likely success of the one health approach to eid control and prevention. in order to explore the broader implications of a one health approach we employed philosophical and qualitative methods to map existing and potential scientific, ethical and political responses to eids in australia and our region. the overarching philosophical approach is that of developing sustained arguments that critically analyse the existing literature and reconceptualise or refine key concepts. this conceptual information is often observed in exemplars and paradigm cases. in particular we focused on materials pertaining to the social, political and ethical consequences of responses to the risks posed to human health and wellbeing by hendra virus [hev], nipah virus [niv] and rabies virus [rbv] in australasia, and compared them with international responses to canonical examples of pandemic and food borne zoonoses severe acute respiratory syndrome (sars) [ ] and bovine spongiform encephalitis/variant creutzfeldt jacob disease (bse/vcjd), respectively. a synopsis of the characteristics and burdens of these diseases and the pathogens that cause them are outlined in boxes and . because our aim was to generate inductive insights and develop a robust set of argumentsrather than a comprehensive catalogue of every case example or publicationthe sample evolved iteratively from searches of textual sources such as publicly available international (e.g. who) and government reports; academic databases (e.g. pubmed); online/print news services (factiva); organizational newsfeeds (centers for disease control); and the websites of major one health collaborations [ ] . materials in the sample were read and qualitatively reviewed through an iterative process of testing, revising and refining our definitions, principles and theoretical generalisations [ , ] against the emerging conceptual map and feedback from the research team. led by the first author, this cycle of searching, mapping and critical analysis continued until a period where new textual materials were not providing substantive new insights and the team was confident that a position of conceptual saturation had been achieved. in what follows we draw on these analyses and reflections to describe the content, context and nature of the challenges that need to be faced for the effective implementation of a one health approach to eid control and prevention. findings eid prevention and control strategies require a one health approach one health is a holistic approach that emphasizes, but is not restricted to, the need to understand and regulate the environmental context (human-animalecosystem interface) of disease emergence and expression [ ] . eids are characterized by their complexity and uncertainty as to their causes, consequences and likely solutions [ ] . in broad terms, the occurrence and cross-species transmissibility of many emerging pathogens, like ebolavirus (ebov) and h n , arise from human activities such as changes in land use, growth in global trade and travel and intensification of animal husbandry practices [ ] [ ] [ ] . the speed with which our understanding of the biology and epidemiology of h n has developed demonstrates how much our ability to respond to new eid threats has improved over the last few decades. yet despite advances in immunobiology and genomics that have contributed to diagnostics, therapeutics, and vaccine development, the threat of eids to human health and community wellbeing persists. part of the reason why eid threats remain in spite of scientific advances, are that eid events are not simply about pathogens jumping species barriers. the threats posed by eids are comprised of complex and contingent sets of relations that involve socioeconomic and sociopolitical drivers and consequences, with the latter extending beyond the impact of the disease. the social, cultural and economic impacts of zoonoses are significant. the examples contained in tables and demonstrate the difficult balance between the human health risks and socioeconomic and cultural costs of eid control [ , ] . policy decisions should be based on sound evidencebut it is often the case in dealing with eids that the evidence required is absent or fluid. eid events are often dynamic situations that are characterised by uncertainty. as events unfold new evidence is created. consequently decisions made on the basis of present data can be seen as wrong in the future, as more evidence and a better understanding emerges. official reviews of canonical eid events such sars [ ] and bse/vcjd [ ] share two key findings: (i) that actions to reduce risk should not be predicated on scientific certainty; and (ii) that policies to deal with the risks and effects of an eid need to be founded on widely held values, so that people understand, in advance, the kinds of choices that will have to be made. this suggests that the one health approach needs more than inter-sectoral collaboration and robust health legislation, as the unique nature of eids critically limits the effectiveness of scientific, top-down and technocratic approaches to governance [ ] . hendra virus infection is endemic among at least two species of flying fox in australia and causes rare, but catastrophic, human infection [ ] . loss of habitat has led to increasingly intense incursions of flying foxes into populated rural and peri-urban areas and promoted the 'spill-over' of hendra virus into horses and then to people [ ] . hundreds of people have been directly exposed to hendra virus, with seven confirmed human infections and four deaths since . with over one hundred dead horses and persistent risk, the emergence of hendra has had significant impact on equine and tourist industries in north eastern australia, diverted major research resources and caused significant distress and controversy in the broader community [ , ] . nipah virus, a close relative of hendra, is endemic in east asian flying fox populations. in , after a program of deforestation and agricultural development in eastern malaysia it spread to pigs then humans and other animals, causing respiratory disease and severe encephalitis [ ] . it subsequently was reported in india and bangladesh. humans can be infected directly from bats, by ingestion of contaminated food and from other humans. among confirmed human cases, the overall mortality was greater than % [ ] . nipah control programs devastated malaysia's pig industry and caused high unemployment and dislocation of rural populations, at a cost of more than us$ billion to the national economy [ ] . nipah virus has been identified by who as a likely cause of future pandemics. rabies virus infects the central nervous systems of people, wildlife and domestic mammals. the disease is transmitted by bites from infected animals and once it becomes symptomatic, it is virtually always fatal. , people die and . million receive post exposure prophylaxis annually, costing $ billion [ ] . rabies is endemic in much of south east asia but its range is expanding. focusing on australia, the continent is free from rabies, but the current expansion of the disease in indonesia [ ] is a genuine threat to northern regions. although likely controllable in domestic dog populations [ ] , if rabies were to become endemic amongst wild or feral animals in this setting, current modelling indicates it would be almost impossible to eradicate [ ] . table significant historical (i.e. effectively eradicated) eids severe acute respiratory syndrome (sars) is a human respiratory infection, caused by a coronavirus isolated from chinese horseshoe bats [ ] . it was first reported in asia in and, within a few months, spread to thirty seven countries in the americas, europe and asia. it affected more than people and caused deaths, before being successfully eliminated by concerted international efforts. the outbreak and fear that another pandemic could occur are estimated to have cost canadian and east asian economies us$ billion [ ] . bovine spongiform encephalitis/variant creutzfeldt jacob disease (bse/ vcjd) is a rare but fatal human neurodegenerative condition, caused by consumption of bovine products contaminated with the prions that cause bse. since vcjd was first identified in , cases have been reported in the uk and forty nine elsewhere. the world bank estimates that the direct costs of vcjd/bse to date exceed more than us $ billion. infected herds and the control measure imposed to prevent further infections devastated agricultural communities. the impacts of the emergence of a new zoonotic disease amongst the british public were far broader than agriculture, including the cessation of uk plasma production because of potential iatrogenic infection. with an estimated one in uk residents carrying vcjd, the burdens will continue well into this century [ ] . the success of one health depends on more than scientific knowledge and technical achievement because some of the issues that arise in addressing eid risks are socalled 'wicked problems' [ ] . when a new eid threat emerges there are rarely ready-made solutions and health policymakers and practitioners are often forced to make tragic choices that may contravene widely held values. considerations must include the need to protect public health and the wider social, economic and environmental impacts of proposed interventions. economic and political interests can complicate the decisionmakers' motives and decision-maker uncertainty is compounded by policy decisions becoming entangled in political, ethical and legal considerations [ ] [ ] [ ] . as events surrounding the ebov outbreak in west africa illustrate, the importance placed on a specific eid threat at any one time also depends on who is setting the agenda [ ] . therefore to be successfully implemented, the one health approach must address a range of socio-political, ethical and legal challenges that arise as a consequence of the spread of infection within and between species. most of these challenges are not unique to one health, but are shared by any approach to addressing eids. however these challenges frequently go unrecognized. in the following section we will clarify the nature of these issues so they can be addressed later in the paper. ( )socio-political challenges a focus on individualism, perceptions, short term solutions, populism and avoiding controversy are features of political life, which can prove challenging for eid policy and work against developing effective strategies for addressing eids. policy responses to eid events such as nipah and hendra virus infections (outlined in box ) tend to focus on necessary and proximal causes (what individuals do to put themselves at direct risk from an infectious pathogen) because the science about other aspects of eids is often complex, uncertain and lacking a clear narrative. compounding this, our moral psychologies have evolved to respond to direct harmsnot indirect distal causal stories. many people in liberal democracies believe that they are entitled to rights and freedoms that cannot be sacrificed merely for the marginal gains of others. as the discourse surrounding climate change and other wicked problems illustrates, this promotes technological solutions because they do not require substantive changes in human behaviours and underlying values systems. [ ] the net result is that the policy focus for eid prevention and control tends to remain on individual behaviours rather than the structural drivers of emergence and transmissiona case example being the focus on vaccine development and the husbandry practices of horse owners in response to the zoonotic risks of hendra virus [ , ] .. the political impetus for action in response to many eids is not necessarily scientific evidence but societal perceptions. indeed, in the face of scientific uncertainty and ethical ambiguity, ideological perspectives and short-term political considerations often supplant efforts to devise effective long-term interventions [ , ] . political imperatives to avoid, or at least minimise, public concern whilst dealing with eids can also prove challenging. in the case of bse, powerful interests dominated early government responses, leading policymakers to make decisions that avoided public controversy, but had major economic consequences. as the crisis unfolded, expertise became politicized leading to conflict between agencies and policy inconsistency between health communication strategies and the measures being taken to minimize the risks to human health [ ] . even when the link between bse and vcjd became clear, existing feed bans were poorly enforced and risk communication was dominated by fear of public panic [ ] ; even as the decision was made to remove all potential sources of human infection from the uk food supply, messages were confused and policy implementation impeded by poor co-ordination between agencies [ ] . a common but problematic response to eid threats has been to invoke the precautionary principle. roughly speaking, the precautionary principle can be applied in situations where human activities create a scientifically plausible, but uncertain, risk of significant harm. in response the principle advocates that actions ought to be taken to avoid or reduce the harm, and that these actions need to be proportionate to the seriousness of the potential harm. in other word, in the absence of evidence take a conservative approach. however applying the precautionary principle to eids in an attempt to protect the public can result in what, in retrospect, amounts to an excessive response. this occurred with attempts to control nipah infection, where significant damage was inflicted on industry, livelihoods and the economy. similarly, experience with highly pathogenic avian influenza (hpai) h n in china and se-asia showed that overzealous policy responses can destroy livelihoods and threaten food supplies [ , ] . in vietnam alone, almost million birds were culled in in an attempt to eradicate hpai. although many birds were owned by large commercial operations, others were kept by 'backyard' farmers and villagers. mass culling of poultry appears decisive, but places excessive burdens on vulnerable populations, is ineffective in the context of extensive 'backyard' poultry farming and can, in fact, promote the spread of disease [ ] . a similar scenario is currently playing out with rabies control in bali. unfortunately, the precautionary principle and analytic tools and concepts appealed to in this domain, fail to deliver what is required at times of eid outbreaks since they do not advance public engagement or help resolve disagreements in times of uncertainty [ , ] . philosophical critiques of the precautionary principle applied to eids have also shown its limitations, including that defining criteria by which to judge a threat as plausible and a response proportionate, often will only substitute one uncertainty for two others [ ] . ( )ethical challenges the effectiveness of an eid control policy will depend on the context of its implementation and particularly its alignment with stakeholder and public values [ , ] . in modern liberal democracies at least some consensus over what is in the public interest and an understanding of the values which support it, is therefore required for the successful implementation of eid responses. yet this is precisely what has been lacking in outbreaks where fracture lines, differences and value conflicts have become apparent. when the stakes are high, evidence and the implications of actions are uncertain, the situation is complex and resources may be limited but where decisions need to be made, differences are exposed. such differences could be around beliefs about how to deal with ecological and environmental issues, which may conflict with the importance people attach to public goods, protection of individual autonomy and animal welfare [ ]. these conditions of crisis and division are conducive to undesirable consequences including public fear, mistrust, misinformation and non-compliance with public health directives. for example in canada during the sars crisis, leaders were unprepared for the range of ethical conflicts that arose, including those over: individual freedom versus the common good; healthcare workers' safety versus their duty to care for the sick; and economic costs versus the need for containment [ ] . as indicated in box , both the outbreak itself and fear that another outbreak could occur had significant economic consequences. any approach which hopes to successfully respond to eid threats, including a one health approach, needs to address the ethical concerns articulated above. to this end, potentially conflicting values and logic must be negotiated to realise effective, sustainable and just solutions. prioritisation and resource allocation require political processes based on fundamental ethical questions about what is valuable, what is to be protected and, ultimately, what is dispensable. to be effective, public policy must be consistent with the values of citizens to whom it is applied, otherwise it can become mired in controversy about whose values should prevail [ , , ] . therefore, one of the first and most important tasks of policy work is to establish how the public interest is best defined. ( )legal challenges the legal environment in which eid policy is made and in which responses to outbreaks occur, presents its own set of challenges. the law surrounding eid responses in most jurisdictions is diffuse, complicated and often subject to re-interpretation on the basis of whose interests are given primacy at the time decisions are made. moreover, in many countries different approaches by state/provincial and local authorities, overlaid by federal/national powers, complicate regulation so much that 'hard law' is often replaced by resort to 'soft law' of executive and administrative powers and international instruments, such as the international health regulations (ihr) [ ] . this may add complexity and confusion to the eid regulatory structures, rather than facilitating public health responses to a new threat. such confusion provides a salient reminder that even in 'global law' approaches to eids, the sovereign state remains the institution responsible for regulation and control [ ] . public health law responses to eids tend to be oriented towards controlling cross-border pathogen transfer and community outbreaks rather than the underlying deficiencies and structural conditions from which the threats emerge. other laws, such as environmental law, may be more useful in addressing structural conditions for emergence. changes in land use and agricultural intensification in developing societies are major drivers of eid. however, the cost of laws that restrict development may be greater global health inequities, with consequential effects for health outcomes. in order to clarify eidrelated legal tensions between economic development and health security, a more explicit recognition is needed of who are the primary beneficiaries and who bears the costs of a one health approach to eids [ ] . legal clarity around the frameworks designed to protect populations from eids is critical to providing an enabling infrastructure to co-ordinate and support the one health-based work of policymakers, development planners, human and animal health-workers and biosecurity agencies. the health of humans, animals, and ecosystems are interconnected. a one health approach promises a better understanding of how to prevent and control eids at the human-animal-ecosystem interface. however the socio-political, ethical and legal challenges of eids illustrated above highlight how responses to infectious disease threats are intrinsically value laden. when a new infectious pathogen such as hendra or nipah virus first appears, or a known threat such as rabies or ebola encroaches on a new setting, there is limited scientific evidence or past experience to guide decisions or determine whether a planned response will be proportionate. vastly different interpretations of eid events and their likely outcomes might be supported by the available data. policymakers and practitioners therefore have little guidance as to what they should do when faced with a nascent infectious disease threat, only what they can do. as others [ ] [ ] [ ] have cogently argued, they must therefore ask themselves: whose health is being prioritized; which public and which good are we seeking to protect? notwithstanding recognition of a need for complementary work on values-based questions that inevitably surround eid risks and eid control, the adoption of the one health approach, so far, has not included development of a comprehensive, ethically-informed policy and implementation framework; this has limited its practical utility [ , ] . despite rhetorical and some financial support for one health as the guiding ethos by which to address interconnected human, animal and environmental health issues, its impact will be minimal unless implications of uncertainty on, and potential conflicts between, human values and political processes are recognised and articulated. any attempt to address these ethical and normative dimensions must take into account the dynamic nature of eid risk management. a policy that seems reasonable today may be inappropriate tomorrow, in light of new evidence. and when situations are uncertain, decision-makers inevitably fall back on their values. therefore, a solid framework based on shared values is needed to support decision-making surrounding eids when "evidence" isor may beunreliable, and rapidly changing or fluid. what is needed to guide a one health approach to eids? to successfully meet the challenges described above, particularly the necessity to align eid policy with public values, a one health approach needs to engage in the following. (i) social science and economic research to help catalogue and describe the drivers, mechanisms and social and political configurations through which eids become threats to human, animal and ecological health [ , ] . the complex connections between individual social needs and the local socioeconomic context of affected or at-risk communities, need to be understood and addressed by policymaking processes. this should ensure that manifest injustice, livelihood-based decisions and other social and cultural factors do not undermine the effectiveness of favoured control measures. without adequate knowledge of specific local arrangements, there is a danger that insufficiently nuanced or unified approaches to eids will actually undermine the heterogeneous relationships and contingent practices that make health possible in circumstances of structural disadvantage [ , ] . the social sciences are analytically broader and more policy focussed than the natural sciences. whereas the natural sciences tend to frame infectious disease threats narrowly as matters of biological integrity and security, such that barrier technologies and hygiene practices dominate the logic of interventions [ ] , social science approaches go beyond this. building social scientific evidence for use in conjunction with natural scientific evidence about eids aligns with the growing realization that eid emergence is as much about the social and economic configuration of capital flow as it is about the biological features of host-pathogen interactions. current approaches to the economic and structural drivers of eid emergence still presume that state and market neoliberalism is part of the natural order, even as evidence is mounting that these systems of development are central to the problem [ , ] . moreover, the current emphasis on microbiology and focus on newer molecular techniques to characterise pathogens, is drawing attention away from developing better understandings of the environmental, economic and social drivers of eids. while this is understandable given the desire for vaccines and drugs to solve eids, if one health researchers and practitioners broaden their approach to causality to include upstream, social and economic systemic causes, questions and issues that have been traditionally bracketed or thought best avoided will become central to the cross-sectoral collaboration implied by one health. framework (ohaf) needs to be pursued. such a framework would catalogue case-based experiences and reflect the particular dynamics of specific eids, and promote inter-sectoral collaboration and knowledge synthesis, including integration of information about social, cultural and economic impacts, control measures and uncertainty [ , ] . the framework would serve as a prompt to ensure that minority perspectives are represented and all relevant concerns are considered. an ohaf could provide a rubric for comparisons between outbreaks. this would allow the inherent complexities of economic and societal responses to eids to be compared, to inform policy processes. it is vital for discussions about eid prevention and control to have this kind of sound empirical foundation, because uncertainty and media coverage have the potential to drive bad policy. development of an ohaf could be facilitated by adopting well established and methodically rigorous processes such as framework analysis, produced by the national centre for social research (uk) [ ] , or multi-criteria decision analysis [mcda] developed within the field of decision science [ ] . in the first instance framework analysis would allow for systematic incorporation of the perspectives and contributions of different scholarly disciplines and expert stakeholders. framework analysis facilitates movement between different datasets, thematic areas, theoretical resources, and levels of abstraction without loss of conceptual clarity [ ] . the framework method is used to organize and manage research and interpretation through the process of summarization, which is codified into a robust and flexible matrix that allows the policymaker/researcher to analyze data both by case and theme. it is commonly used in areas such as health research, policy development and program evaluation. equally, mcda methods offer an alternative and potentially complementary approach to ohaf development. comprised of a suite of analytic strategies, mcda have been shown to be valuable tools for prioritization and decision-making in animal and human health [ ] . mcda provides a framework to compare policy alternatives with diverse and often intangible impacts, which can be particularly useful in determining and justifying the prioritization and mobilization of limited research and public health resources [ , ] . (iii)genuine processes of public engagement across the developed and developing world are also essential to a successful one health approach. these processes are not so much about engaging in deliberative democracy for policy decision-making, as about defining the principles and values that should guide decision-making. this means procedural inclusiveness alone is not enough to ensure transparency and reflexivity, to capture people's preferences and to effectively communicate with the public [ ] . the successful implementation of the one health approach to eids will depend on public trust and cooperation. public support for unpalatable measures is more likely if citizens understand the issues, and policy implementation reflects community values and preferences. to this end, citizens' juries have been employed in the uk, australia, the us and elsewhere [ ] [ ] [ ] [ ] to explore similar issues and identify citizens' preferences. they represent informed public opinion better than other social research methods (e.g. surveys or focus groups) because they give participants factual information, bring them into a structured and constructive dialogue with experts, provide them with time to reflect and deliberate, and allow them to represent their views directly to policymakers. to be successful, one health needs to be about more than disease prevention and control. the dynamic, unpredictable effects and risks to peoples' lives of eids necessitate a public health and biosecurity infrastructure equipped to address the ethical problems that arise. eid management must therefore be based on normative principles as well as local knowledge, operational experience and disease-specific scientific and economic evidence. this means that governments and policy-makers need to explain and justify the values that underlie decision-making and engage the public in discussions about ethical choices, so that when difficult decisions arise in the face of uncertainty, they will be accepted as fair and essential for the public good [ ] . this necessitates that the guiding values and likely ethical choices need to be articulated in a formal statement in advance, as in the heat of emerging health threat, decision makers will be under pressure from many sources to 'do something quickly'. (v)integration of an ohaf and spv with the ihr and relevant national health and biosecurity legislation is essential so that policymakers and practitioners can dynamically test their decision-making. our response should of course be based on the best scientific evidence, but eids are not just scientific issues, they also have significant social, ethical and animal rights dimensions. experiences of infectious disease threats such as bse/vcjd and sars indicate that there have been problems combining evidence and human values at both local and policy levels [ , ] . the communicability of diseases between species raises social, ethical and legal issues that have not been clearly elucidated or adequately addressed. our response to nonhuman animal disease is not determined solely by bio-scientific knowledge; the way people and animals live with and amongst each other is also shaped by social norms, economic imperatives and human values. in matters of public health it is no longer sufficient to ask what works and what is the strength of the evidence; we also need to ask ethical questions about how we should seek to live, and what is the right thing to do [ ] [ ] [ ] . consensus about the best approaches to eid control and prevention are not always possible, however an agreed set of guiding principles and values can be a means to ensure dialogue, if not always agreement. the development of an ohaf and spv will also promote clearer communication about public risk. significant eid threats have major implications for distribution of scarce resources, access to and regulation of health services and maintenance of social order. as described above it is also clear that policy and legal responses to eid threats are often highly politicised and compromised by failure to communicate clearly with the public. policymakers responsible for responding to disasters such as eids typically find that there is a dissonance between transparency that may appear alarmist versus withholding information to avoid panic. regardless of advice, people will make their own decisions based on their interpretation of available information, from formal and informal channels. so public communication, before and during a public health emergency, is frequently as important as political decisions and regulatory changes [ , ] . this means that, to be effective, a one health approachlike any eid policymust deal with scientific uncertainty, whilst addressing the socio-political, ethical and legal dimensions of effective health communication and intervention strategies [ ] . by exposing decision-making processes to reveal the scientific and normative uncertainties and ethical complexities, the introduction of an ohaf and a spv into one health theory and practice may incorporate iterative deliberation and learning into eid policy processes. (vi)finally, one health must be about genuine reform rather than merely rhetoric. a one health approach rests on the assumption that the cross-sectoral integration of expertise, research methodologies and public health infrastructure will inevitably improve capacity for disease-risk prediction and effective intervention. however, calls for increased intersectoral co-operation by public health practitioners, clinicians, scientists and policy-makers are not a new phenomenon. for example in the s advocates of "new public health" called for health authorities to turn their attention to the social, economic and environmental factors that affect healthrequiring the realignment and policy integration of health departments with other government agencies [ , ] . unfortunately in this case as others, attempts at promoting inter-sectoral approaches rarely move beyond rhetoriceven when driven by the best intentions and supported by substantial resources [ ] [ ] [ ] . the problem is that arguments that promote the need for greater co-operation between sectors tend to focus on the likely benefits of collaboration rather than what reform would entailthat is, what needs to be done organisationally and politically to achieve the desired outcomes [ ] . established 'sectors'whether orientated towards human or animal health, agriculture or the environmenthave genealogies, traditions and rationalities of "what we are here for" that have been shaped by social, political and administrative processes [ ] . as institutions, they are philosophically and structurally resistant to change that diverts resources and re-orients practices away from their own sectoral priorities [ ] . in essence, they have their own constituencies to serve. as a consequence, establishment and implementation of mechanisms that enhance information-sharing, collaboration and inter-sectoral co-operation, such as working groups and interdepartmental committees, have rarely delivered the outcomes promised in the past. responses to bse/vcjd in the uk [ ] , hpai in south east asia [ ] , and recent case studies of one health programs in uganda [ ] , suggest that more work is needed to coordinate implementation and overcome sectoral interests. the complexity of the problems posed by eids mean that organising effective control and prevention programs will require genuine cross-sectoral integration and, potentially, re-sectoring of some institutional and professional responsibilities [ ] . and as the recent ebolavirus disease outbreak illustrates, there must also be sustained social and political willingness to achieve control. if one health is genuinely the way forward, as we believe it is, then we should do more than talk about its potential benefits. without genuine cross-sectoral reform and a radical broadening of the scope of its inquiry into how specific social, cultural and spatial configurations promote the risks of eid emergence, one health is in danger of becoming merely a rhetorical strategy to avoid conflict between its core disciplines, whereby practitioners, researchers and policymakers will espouse the methodological and moral case for interdisciplinary collaboration yet remain in their silos [ ] . even if these barriers are overcome the one health approach will only succeed if it explicitly acknowledges local contingent and contextual dimensions of disease risk and disease expression and the political impacts of scientific uncertainty, while also seeking to accommodate the values and preferences of 'at risk' and affected individuals. further, we suggest that decision making around eids requires an ethical framework that reflects the values of affected and 'at risk' communities, privileges justice, takes account of human flourishing, protects animal health and welfare and is developed in consultation with relevant stakeholders and the public. eid risk management is a major global public health issue to which one health represents a promising approach, but its potential benefits have not been fully realised [ , ] . despite recognition that the social and cultural dimensions are critical to the success of one health, social scientists are yet to play a central or substantive role in shaping research programs and interventions [ , ] . at the same time as the literature on the ethics of pandemic responses and preparedness continues to grow, the one health approach to eids has received little formal ethical consideration. even the most ethically attuned existing frameworks for biosecurity and infection prevention and control provide only general operational principles that do not guide actions in times of uncertainty. if one health is to be meaningful − let alone successful − more attention must be paid to how these different types of knowledge are brought together and brought to public attention. effective responses to eids are likely to be delayed or precluded unless all the socio-political, ethical and legal implications are articulated, publicly 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a framework for health promotion does health promotion need a code of ethics? early response to the emergence of influenza a (h n ) virus in humans in china: the central role of prompt information sharing and public communication the new public health what is the "new public health joining up or pulling apart? the use of appraisal to coordinate policy making for sustainable development what's new about the "new public health"? learning lessons from past mistakes: how can health in all policies fulfil its promises? the significance of 'sectors' in calls for urban public health intersectroralism: an australian perspective one world-one health and neglected zoonotic disease: elimination, emergence and emergency in uganda ecological aspects of hendra virus cross-species virus transmission and the emergence of new epidemic diseases the hendra virus report: an investigation into agency responses to hendra virus incidents between new directions in conservation medicine: applied cases of ecological health henipaviruses: unanswered questions of lethal zoonoses the nipah virus outbreak and the effect on the pig industry in malaysia the cost of canine rabies on four continents review of rabies epidemiology and control in south, south east and east asia: past, present and prospects for elimination development of a novel rabies simulation model for application in a non-endemic environment australian veterinary emergency plan (ausvetplan) review of bats and sars an update on the assessment and management of the risk of transmission of variant creutzfeldt-jakob disease by blood and plasma products the work was funded by nhmrc grant # and seed funding from the marie bashir institute for infectious disease and biosecurity and the school of public health at the university of sydney. the funding source has had no involvement in how the paper was interpreted or written. the authors declare that they have no competing interests.authors' contributions cd led the conceptualization, review, critical analysis and drafting of the article. jj, gg, ik, aw, mw, and cs all made significant contributions to the critical analysis and drafting of the paper. jj and cd led the final preparation of the paper for submission. all authors read and approved the final manuscript.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord- -ou wj rz authors: hwang, stephen w; cheung, angela m; moineddin, rahim; bell, chaim m title: population mortality during the outbreak of severe acute respiratory syndrome in toronto date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: ou wj rz background: extraordinary infection control measures limited access to medical care in the greater toronto area during the severe acute respiratory syndrome (sars) outbreak. the objective of this study was to determine if the period of these infection control measures was associated with changes in overall population mortality due to causes other than sars. methods: observational study of death registry data, using poisson regression and interrupted time-series analysis to examine all-cause mortality rates (excluding deaths due to sars) before, during, and after the sars outbreak. the population of ontario was grouped into the greater toronto area (n = . million) and the rest of ontario (n = . million) based upon the level of restrictions on delivery of clinical services during the sars outbreak. results: there was no significant change in mortality in the greater toronto area before, during, and after the period of the sars outbreak in compared to the corresponding time periods in and . the rate ratio for all-cause mortality during the sars outbreak was . [ % confidence interval (ci) . – . ] compared to and . [ % ci . – . ] compared to . an interrupted time series analysis found no significant change in mortality rates in the greater toronto area associated with the period of the sars outbreak. conclusion: limitations on access to medical services during the sars outbreak in toronto had no observable impact on short-term population mortality. effects on morbidity and long-term mortality were not assessed. efforts to contain future infectious disease outbreaks due to influenza or other agents must consider effects on access to essential health care services. in march , the health care system in toronto, canada, was confronted with an outbreak of severe acute respiratory syndrome (sars), a highly contagious and severe atypical pneumonia. [ ] [ ] [ ] the infection control measures employed in response to this crisis were extraordinary and unprecedented. actions to control sars in the greater toronto area included the closure of four hospitals, the cancellation of all non-emergency surgical services, an almost complete curtailment of inter-hospital patient transfers, and the postponement of most hospital-based outpatient clinics. [ , ] moreover, access to physicians, hospital laboratories, imaging studies, and other hightechnology services was limited by infection control procedures. [ ] the effect of these measures on access to health care was underscored by media reports of inappropriate delays for cancer therapy and the inability to perform urgent surgeries, sometimes resulting in death. [ ] [ ] [ ] [ ] the effects of widespread limitations of access to medical services have been studied from different perspectives. studies of influenza outbreaks from the early th century provide insight into healthcare restrictions and are applicable to the sars experience because both are contagious respiratory illnesses with high mortality rates that are largely controlled through isolation procedures. previous work has documented increased cardiovascular and other non-influenza related deaths during influenza outbreaks. [ ] [ ] [ ] however, these increases were likely related to the effects of the infection itself rather than limited access to care. [ ] [ ] [ ] [ ] [ ] studies of diminished health care access due to withdrawal of medical services during physicians' strikes have documented significant alterations in health service utilization, intermediate outcomes, and various health-related processes of care. [ ] [ ] [ ] however, no rigorous study has examined the effects of physician job action on overall population mortality. [ ] while there is little debate regarding the necessity of a concerted response to control the sars outbreak, the delivery of health care to the general population was clearly reduced. evidence suggests that in toronto more essential services were less affected than services for lowacuity conditions. [ ] an important question is whether sharply curtailed access to health care had an impact on population mortality due to causes other than sars. this issue will be highly relevant in the event of a future infectious disease emergency, such as a recurrence of sars, a highly virulent influenza epidemic, avian flu, the emergence of a new infectious organism, or a bioterrorist attack with an agent such as smallpox. we therefore sought to determine if the infection control measures undertaken during the sars outbreak in toronto were associated with a change in overall population mortality. in early march , a toronto resident returned from hong kong infected with sars. she died at home but spread the virus to her family members, who initiated the outbreak when they were admitted to hospital. however, since our intent was to estimate the effect of the public health containment measures on the overall population, we defined the period of the sars outbreak as beginning on march , (the th week of the year). [ ] on this date, the province of ontario declared a state of emergency and issued special directives to all hospitals in the greater toronto area (city of toronto, york region, durham region, peel region, halton region, and simcoe county) instructing them to curtail inter-hospital transfers, elective surgery, and outpatient services. [ ] as a result, health care utilization in the greater toronto area decreased significantly. [ ] inpatient procedures such as abdominal aortic aneurysm repairs, cholecystectomies, and joint replacement surgeries decreased by - %. cardiac surgeries and percutaneous coronary interventions decreased by about %. outpatient procedures such as breast biopsies, chemotherapy infusions, and vasectomies decreased by - %. outpatient diagnostic tests such as mri and ct scans decreased by - %. outpatient physician visits decreased by % overall, and emergency department visits decreased by %. in contrast, medical care in the area of ontario outside of the greater toronto area had increased infection control measures but comparatively little restriction of clinical services. we defined the end of the sars outbreak as july , (the th week of the year), because this was the date that the world health organization removed toronto from its list of sars-affected areas. death certificate data for the years , , and were obtained from the provincial death registry. all deaths in ontario are recorded in this registry. data obtained from each death certificate included the decedent's date of birth, sex, place of death, and date of death. because our goal was to examine the indirect effects of sars through its impact on the health care system, we subtracted the deaths in ontario due to sars from the death certificate database before performing further analyses. we combined death certificate and census data to calculate weekly age-specific mortality rates in the greater toronto area and the rest of ontario. because the beginning of the sars outbreak (as defined for the purpose of this study) occurred weeks after the beginning of the year, we compared mortality rates for the -week period before the beginning of the outbreak, the outbreak period, and the -week period after the end of the outbreak. mortality rates were calculated for the corresponding weeks in and . rates were expressed as deaths per week per , population. the two prespecified primary analyses were based on total mortality in males and females of all ages, and total mortality in males and females age years and over. these rates were not age-or sex-standardized because the age and sex structure of the population did not change significantly during the study period. we used two statistical approaches, poisson regression and interrupted time series analysis. poisson regression was used to compare weekly mortality rates in with corresponding weekly mortality rates in and . the dependent variable was the log of the rtio of the observed to expected mortality rates. generalized estimation equations were used to adjust for possible serial correlations. we used interrupted time-series analyses to test for effects of the sars outbreak on mortality rates. [ , ] timeseries analysis consists of several techniques for modeling autocorrelation in temporally sequenced data. [ ] the holt-winters forecasting method was used to predict the mortality rate per , person-years during and after the sars outbreak. this method takes into account both time trends and seasonal fluctuations within timeseries data. the % confidence intervals for predicted mortality rates were generated using this method and then compared to observed mortality rates. our primary analysis tested for a pulse-function effect with a delay of four weeks in the onset of changes in mortality rates at the beginning and end of the sars outbreak. the four week delay was chosen as a best estimate of the lag between the beginning of the sars emergency and onset of overall health effects. sensitivity analyses were performed by varying the lag period from two weeks to six weeks. all statistical analyses were performed using sas figure . figure shows observed mortality rates in the greater toronto area in . the % confidence intervals are displayed for the expected mortality rate after the start of the sars outbreak, based on the holt-winter method. the interrupted time series analysis found no significant change in mortality rates in the greater toronto area associated with the period of the sars outbreak in , as indicated by the fact that the observed rates remained almost entirely within the % ci for the predicted rates. the poisson regression analysis found no significant change in mortality before, during, and after the period of the sars outbreak in compared to the corresponding time periods in and ( we examined overall mortality for the region most affected by the extraordinary infection control measures taken to contain the toronto sars outbreak in . despite a prolonged period of intense clinical service restrictions, we found no significant change in mortality rates compared with corresponding periods in previous years. the widespread limitation of access to medical serv-ices did not appear to have any short-term effects on deaths within the population. did the infection control measures and policies employed to control the sars outbreak produce collateral damage to the delivery of health care to the population? the containment strategy did result in dramatic decreases in nonurgent inpatient and outpatient procedures and surgeries, outpatient diagnostic tests, and overall physician visits. [ ] although overall emergency department visits declined substantially during the sars outbreak, this decline apparently reflected significant reductions in the volume of patients with low-acuity complaints. [ , ] hospitalizations in toronto during this period were % lower than expected, representing a relatively modest decrease. [ ] studies conducted in other jurisdictions suggest that the changes in health care delivery and care-seeking behavior associated with the sars outbreak may have had negative health effects. in taiwan, use of ambulatory care fell by %, inpatient care decreased by %, and childbirths shifted from larger medical centers to less well-equipped district hospitals and clinics. [ , ] in hong kong, the number of individuals diagnosed with active tuberculosis decreased significantly during the outbreak, suggesting that the population's avoidance of medical care led to delays in diagnosis. [ ] on the other hand, another study conducted in hong kong found that the proportion of positive samples for influenza and respiratory viruses other than sars decreased significantly during the sars outbreak, a change that the investigators attributed to the population's heightened attention to respiratory hygiene. [ ] because these acute viral infections can lead to serious complications among individuals with chronic medi- weekly mortality rate per , population in the greater toronto area figure weekly mortality rate per , population in the greater toronto area. dashed lines indicate the beginning and end of the sars period. observed mortality rates are indicated by squares and circles. solid lines indicate the forecasted mortality rate and % confidence intervals. cal conditions, this trend may have had a beneficial effect on the overall mortality rate. our data are consistent with the assertion that patients with severe illnesses retained the ability to access life-saving services during the sars outbreak in toronto. fortunately, the outbreak was relatively short-lived and limited in scope. future outbreaks of influenza or other emerging infectious diseases may be much more severe and prolonged. the establishment of data capture and reporting systems in advance of such an event would provide decision-makers with timely information on possible increases in morbidity and mortality attributable to impaired health care access, in addition to data on the direct effects of the outbreak itself. this information could be used to determine which services should be prioritized during a period of severely restricted health services. this work has certain limitations. first, our study was designed to detect increases in short-term mortality that would constitute an immediate health challenge, but not longer-term effects. although such delayed consequences are not implausible, they would be difficult to identify and attribute to impaired access to care during the sars outbreak. second, our study did not consider outcomes such as health status, quality of life, or other measures of morbidity that may have been affected by sars-related infection control measures. instead, we focused on mortality, an outcome that is both readily measured and of unquestioned importance. future studies are needed to assess the effects of extraordinary infection control measures on morbidity. third, we chose a clinically plausible lag of four weeks before the onset of change in mortality rates for our interrupted time-series analysis. the selection of a different lag period might have resulted in slightly different findings, although our results were corroborated by the poisson regression analysis. finally, this study examines a "natural experiment" in which restrictions on health care services were not applied uniformly, instantaneously, or in a randomized manner. nonetheless, our use of a control group consisting of the population of ontario outside the greater toronto area, which was not affected by severe restrictions on access to hospital-based care, serves to minimize this potential bias. a coordinated response to severe infectious disease outbreaks requires an approach that balances an infection control mandate with the need to preserve access to essential health services. in the situation of a widespread disease outbreak, health care decision-makers understandably concentrate upon the immediate threat of the infectious disease. the sars experience in toronto suggests that the preservation of the delivery of health care for other urgent conditions is equally important. this con-cept is particularly relevant because future infectious disease outbreaks, such as avian influenza or a bioterrorist attack, could limit access to health care resources to a much greater extent than did the sars outbreak. further research is needed to examine the possible effects of such events on cause-specific mortality rates and on health outcomes other than mortality. clinical features and short-term outcomes of patients with sars in the greater toronto area identification of severe acute respiratory syndrome in canada public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto national advisory committee on sars and public health: learning from sars: renewal of public health in canada ottawa utilization of ontario's health system during the sars outbreak. toronto: institute for clinical evaluative sciences sars causes critical delays for cancer operations. the globe and mail the collateral damage of sars. the globe and mail :a -a clement feared system may snap clement feared health system would collapse. the globe and mail a study of excess mortality during influenza epidemics in the united states, - excess mortality from epidemic influenza selwyn collins d: excess mortality from causes other than influenza and pneumonia during influenza epidemics patient safety: infection control -a problem for patient safety influenza vaccination is not associated with a reduction in the risk of recurrent coronary events association of influenza vaccination and reduced risk of recurrent myocardial infarction influenza vaccine pilot study in acute coronary syndromes and planned percutaneous coronary interventions: the flu vaccination acute coronary syndromes fluvacs) study myocardial infarction, stroke, and sudden cardiac death may be prevented by influenza vaccination effects of the israel doctors' strike on hypertension control in ashdod doctors' strike: non-availability of drugs: activation of seizures perinatal outcome following physicians' strike of mortality in jerusalem during the doctor's strike public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto a change in level of a non-stationary time series intervention analysis with applications to economic and environmental problems econometric models and economic forecasts boston: irwin/mcgraw-hill the impact of sars on a tertiary care pediatric emergency department surge capacity associated with restrictions on nonurgent hospital utilization and expected admissions during an influenza pandemic: lessons from the toronto severe acute respiratory syndrome outbreak the impact of the sars epidemic on the utilization of medical services: sars and the fear of sars the immediate effects of the severe acute respiratory syndrome (sars) epidemic on childbirth in taiwan lowered tuberculosis notifications and deterred health care seeking during the sars epidemic in hong kong infections during sars outbreak the author(s) declare that they have no competing interests. swh conceived of the study, participated in its design and coordination, and drafted the manuscript. amc conceived of the study, participated in its design, and participated in the revision of the manuscript. rm performed the statistical analyses and participated in the revision of the manuscript. cmb conceived of the study, participated in its design and coordination, and drafted the manuscript. all authors read and approved the final manuscript. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /prepub key: cord- - gzi fo authors: davies, jane; bukulatjpi, sarah; sharma, suresh; davis, joshua; johnston, vanessa title: “only your blood can tell the story” – a qualitative research study using semi- structured interviews to explore the hepatitis b related knowledge, perceptions and experiences of remote dwelling indigenous australians and their health care providers in northern australia date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: gzi fo background: hepatitis b is endemic in the indigenous communities of the northern territory of australia and significantly contributes to liver-related morbidity and mortality. it is recognised that low health literacy levels, different worldviews and english as a second language all contribute to the difficulties health workers often have in explaining biomedical health concepts, relevant to hepatitis b infection, to patients. the aim of this research project was to explore the knowledge, perceptions and experiences of remote dwelling indigenous adults and their health care providers relating to hepatitis b infection with a view to using this as the evidence base to develop a culturally appropriate educational tool. methods: the impetus for this project came from health clinic staff at a remote community in arnhem land in the northern territory, in partnership with a visiting specialist liver clinic from the royal darwin hospital. participants were clinic patients with hepatitis b (n = ), community members (n = ) and key informants (n = ); were indigenous individuals. a participatory action research project design was used with purposive sampling to identify participants. semi-structured interviews were undertaken to explore: current understanding of hepatitis b, desire for knowledge, and perspectives on how people could acquire the information needed. all individuals were offered the use of an interpreter. the data were examined using deductive and inductive thematic analysis. results: low levels of biomedical knowledge about hepatitis b, negative perceptions of hepatitis b, communication (particularly language) and culture were the major themes that emerged from the data. accurate concepts grounded in indigenous culture such as “only your blood can tell the story” were present but accompanied by a feeling of disempowerment due to perceived lack of “medical” understanding, and informed partnerships between caregiver and patient. culturally appropriate discussions in a patient’s first language using visual aids were identified as vital to improving communication. conclusions: having an educational tool in indigenous patient’s first language is crucial in developing treatment partnerships for indigenous patients with hepatitis b. using a culturally appropriate worldview as the foundation for development should help to reduce disempowerment and improve health literacy. significant health disparities exist between indigenous and non-indigenous australians resulting in a [ ] [ ] year average reduction in life expectancy for an indigenous child born between and [ ] . liver disease is the third largest contributor ( %) to this gap in life expectancy with chronic hepatitis b (chb) contributing significantly, in the form of liver cirrhosis and hepatocellular carcinoma (hcc). chb is endemic in the indigenous communities of the northern territory (nt) of australia with prevalence rates estimated to be between . % [for children born in the universal vaccine era ( onwards)] and . % (for adults born pre universal vaccination) [ ] [ ] [ ] [ ] [ ] [ ] [ ] , this is compared to % in australia as a whole [ ] . despite the availability of effective, government subsidised treatments only an estimated % [ ] of all people living with chb in australia are receiving appropriate management for their infection. this disparity in rates of hepatitis b and low uptake of treatment is also seen in other indigenous populations across the world [ , ] . the barriers to people accessing care for chb are multifactorial but among indigenous australians, include gaps in knowledge, low health literacy and challenges in accessing the appropriate care [ ] . both a recent situational analysis [ ] and a qualitative study [ ] in the torres strait region of australia identified low levels of knowledge about chb both in health care providers and indigenous australian patients with chb. christie et al. [ ] have explored views of health literacy in the particular cultural context of remote indigenous communities in the nt, as well as carrying out a scoping study looking at ways to improve health literacy in this region. suggests that "effective health literacy is largely to do with effective communication" (p. ). based on their research, they argue that building on an individual's existing knowledge using a culturally appropriate approach (i.e. a relevant respectful partnership which is mindful of language, worldview, existing knowledge and beliefs) to achieve a shared understanding of the issue at hand is more beneficial than attempts by health practitioners to simply 'transfer' biomedical knowledge to their patients [ ] . although many health promotion or information resources exist for hepatitis b [ ] , all the above [ ] [ ] [ ] [ ] [ ] studies as well as the australian national hepatitis b strategy [ ] highlight the lack of culturally appropriate resources, in particular visual and multimedia resources, available to facilitate shared understandings of hepatitis b and strengthen health literacy. in the context of the nt indigenous population, english is usually a second (or even third or fourth) language; therefore, achieving effective cross cultural or "culturally safe" communication can be challenging, as has been extensively documented in health care settings over the last decade [ ] [ ] [ ] . miscommunication between health providers and patients has been reported to be pervasive, however using interpreters and translators is perceived to be only part of the solution [ ] . different worldviews and knowledge systems that exist among indigenous australians, including alternative concepts of physiology, pathology and disease causation also contribute [ ] . an often misinformed assumption by health providers of shared understandings [ ] , along with the absence of opportunities and resources to construct a body of shared understanding perpetuate this miscommunication. two specific factors, culture and worldview, are increasingly acknowledged as important antecedents contributing to health literacy [ ] [ ] [ ] [ ] . there are a myriad of different definitions of culture; when referring to culture in this paper we use the broad definition of the culture of a society as "… the totality of its shared beliefs, norms, values, rituals, language, history, knowledge and social character" [ ] . participatory projects working with indigenous communities in the design and development of health education resources have been successful in improving health literacy and participation in healthcare in other disease areas [ , ] . the aim of this research project was to explore the knowledge, perceptions and experiences of remote dwelling indigenous adults and their health care providers relating to hepatitis b infection. we also aimed to gauge interest among indigenous participants in further knowledge of this disease and gain perspectives on how and in what format people could best acquire the information they needed. this was the first stage of a wider participatory action research (par) project with the intention of using the results as the evidence base to inform development of a culturally appropriate hepatitis b educational resource. this project was undertaken in northern australia between july and december . it was based at the health clinic of a remote community in arnhem land, km northeast of darwin (the capital of the nt). this community has a population of , with an average age of years; % are indigenous australians and only . % of the population speak english as their first language. there is an average of . people per available bedroom and % of households are considered to be overcrowded. there are three general stores, a school, a library, a health clinic as well as a police station and a community church. the overall project design was based on par principles; specifically, ongoing consultation, reflection and discussion with the community throughout each iterative cycle. jd (a female non-indigenous researcher and clinician with experience in working in a cross cultural environment) and sb (a female indigenous researcher and health worker in the remote community) worked alongside each other in constructing the interview schedule, recruitment, data collection, analysis and interpretation. this paper reports the results of the first part of this project which was the first formal par cycle and provides the evidence base for the development of a culturally appropriate educational tool for hepatitis b, the second phase of the project (details not presented here). however prior to this project informal discussions regarding the issues facing the community with respect to the burden of disease produced by hepatitis b, the lack of community understanding and the difficulties health workers have in explaining hepatitis b to community members had been discussed within clinic meetings and with the visiting liver clinic service. the impetus for the project came from the community clinic. their enthusiasm for the project led to the development of a collaborative research partnership between the community clinic, the royal darwin hospital liver clinic and menzies school of health research and establishment of the formal par process. ethical approval for the study was obtained from the human research ethics committee of the northern territory department of health and menzies school of health research (hrec) as well as miwatj health aboriginal corporation (an aboriginal-controlled health service representing communities across east arnhem land) and charles darwin university. semi-structured interviews were carried out with groups of people; key informants (health clinic staff, community health educators, liver clinic staff -both urban and remote, − and doctors and nurses, indigenous and non-indigenous), indigenous people living with chb and indigenous community members. interviews explored the background of the individual, their hepatitis b knowledge, their experience of health communication/education about hepatitis b, available resources and their perspectives about potentially useful educational tools. all participants were shown two existing resources; an animation about the liver and its function (chosen as it was part of an electronic education package targeted at indigenous australians) and a flip chart, (developed in victoria, australia, intended for use in the clinic setting and aimed mainly at asian individuals) about hepatitis b and asked to comment on them as a way of generating ideas/preferences for any future educational tool. patient and community member interviewees were also asked from where they acquired their knowledge about hbv, what influenced their current understanding, and barriers to understanding (table ) . jd and sb recruited participants into the study and carried out the interviews; both had received specific training in interview techniques prior to the commencement of the project. all patients were given the option of an accredited interpreter in their first language if this was not english both for the process of obtaining written informed consent and the interview itself. a mixture of purposive (non-probability sampling in which the researchers suggest who to approach to be included in the study based on them possessing certain characteristics [ ]) and network (using existing participants to suggest other people to approach [ ] ) sampling was used to recruit individuals from a range of different backgrounds with a proportionate mix of gender, age and hepatitis b status. the majority of participants were recruited through the community clinic and the hospital liver clinic; however some individuals were recruited through the social and professional networks of the research team. interviews were carried out in numerous settings ranging from the community clinic, our hospital clinic, our research institution, individuals' homes and gardens, under trees and at an international conference ( th australasian viral hepatitis conference, auckland, september ). interviews were audio recorded and ranged in duration from to minutes. information collected in yolŋu matha was translated into english in real time by the accredited interpreter and meaning and understanding clarified by sb (bilingual researcher present at all interviews carried out in yolŋu matha) as part of the recording. transcription of the interviews was in english. an audio diary of the real time experience and reflections on the interviews was kept by jd and sb and included in the data analysis. all participants were offered an aud$ electricity voucher in recognition of their time and effort in contributing to the study. in the process of exploring patients' and providers' knowledge, experiences and perceptions of hbv, data emerged on the potential impact of low levels of health literacy on healthcare interactions and therefore future health outcomes as well as the pathways through which this may occur. as such, we have used paasche-orlow & wolf's model [ ] figure of the pathways that exist between low levels of health literacy and poor health outcomes as an organising model for our data analysis. data analysis was carried out by jd and sb, with input from vj and jsd. it commenced with the first interview and was continuous throughout the project. data immersion consisted of carrying out the interviews, reading the transcripts and listening to the audio recordings multiple times on multiple occasions dispersed over time. sections of text were organised into codes based both on the categories covered in the interview schedules and also inductively as the text was digested and understood. codes were also reflected upon with reference to the passche-orlow & wolf model in particular with regard to the similarities and differences in using this model in this particular cultural context (yolŋu people) for this particular disease (hepatitis b). concurrently and inductively the codes were organised into broader categories and themes. on multiple occasions clarification was sought regarding the cultural context of specific terms and ideas from sb. sb returned to individual participants to verbally clarify findings on a number of occasions however transcripts were not routinely returned to participants for checking. data were organised and managed in nvivo (qsr international pty ltd, victoria, australia). jd, sb, ss & jsd are all clinical care providers as well as researchers and acutely aware of the ethical implications of this within this project particularly for those individuals interviewed who were hepatitis b patients. careful explanation of the fact that the research project and an individual's clinical care are completely separate and mutually exclusive was undertaken with the hepatitis b patient group in particular. care was taken to conduct the interviews completely separately in both time and location from any clinical care so as to maintain this separation. we adhered to the rats guidelines in reporting this project. thirty two semi-structured interviews were carried out between july and september . participants consisted of clinic patients with hepatitis b ( ), other community members ( ) and key informants ( ) . twenty-four ( %) were indigenous people. median age of participants was years (iqr - ) and ( %) were female. highest level of education attained was junior school for one individual ( %), secondary school for ( %) and tertiary education for ( %). all participants had the opportunity to use an interpreter; interviews were carried out using a yolŋu matha interpreter (the principal indigenous language spoken in the community). the remainder were carried out in english. knowledge about hepatitis b: "only your blood can tell the true story" there was a distinct lack of biomedical knowledge regarding chb, especially in the people living with chb group, and even among those who had been previously reviewed in the liver clinic and/or were currently on oral antiviral treatment for chb. people living with chb and community members generally acknowledged that they did not know or have any understanding of what hepatitis b was and were commonly unable to attempt any explanation on direct questioning. however, when contextual translation was provided in yolŋu matha some understanding often emerged: "something like that person will get that virus inside the body. sometimes he [the virus] will be gone and sometimes will stay there for bit long. that's the story i know". "when i see people with hepatitis they have a yellowish thing -eye -you know just around the eye balls and that thing to me, it tells me that the person either have a hepatitis or kidney failure". the word "germ" and an understanding of germs being micro-organisms that required a microscope to visualise them was recurrently touched upon, with specific reference to previous education programmes and research projects carried out in the community both by the aboriginal resource development service (ards) in darwin and menzies school of health research. these experiences appeared to have led to an increased understanding of biomedical concepts around infectious diseases in general and were discussed in a positive light. despite this many misconceptions about hepatitis b from a biomedical perspective were identified, particularly around causation and transmission. in particular the ideas that chb can be caused by smoking, lifestyle factors, diet and lack of exercise were frequently reported by community members: "maybe because i was washing myself too much in cold water it may have caused the sickness or me sleeping outside". "when you smoke you get the sickness in the lungs and in the liver". this was also reflected in comments made by numerous people that before "western influences" chb didn't exist as a problem; it was a "new" sickness that people did not really know much about and could be prevented by reverting to a more traditional lifestyle. many people reported that their underlying beliefs about health and disease are based on traditional medicine including sorcery as causation of disease and traditional plant-based remedies as treatments. although there were no bush medicines reported that can be used to specifically treat chb, a remedy made from paper bark trees was described as being used and felt to be effective for liver sickness in general. the biomedical or "balanda" (white person) version of hepatitis b was very much seen as an alternative explanation; new information that didn't exist in previous generations. there was also some confusion surrounding human immunodeficiency virus (hiv) and chb. some community members reported that the two diseases were one and the same sickness. this misunderstanding appeared to contribute significantly to the sense of stigma or shame around a diagnosis of chb, and that it had to be kept a secret because of what it might reveal about sexual orientation or partner preference. as well as this, the opinion that an individual patient may be to blame in some way for acquiring chb, which appeared to be centred on awareness that chb could be sexually acquired, was recurrently voiced. this lack of biomedical knowledge was not confined to the patient and community members. some key informants, both indigenous and non-indigenous, also acknowledged that they found it a difficult area to understand clearly themselves. multiple health professionals reflected on the role of working in an endemic setting seeing a high volume of people living with chb as necessary to achieve true competency in the management of chb, stating that prior to this, their understanding was more superficial. the topic of hepatitis b is part of the routine curriculum studies undertaken by aboriginal health workers (ahw) and this appeared to be the origin of knowledge for this group, as similar concepts and responses were reported. the concepts of mother to child transmission, sexual acquisition and the infectiveness of blood and other body fluids were expressed by several ahws; however they were less clear about the natural history of the disease, the interpretation or meaning of blood test results, and the potential for treatment or intervention. perceptions of hepatitis b: "it's like a silent killer; i can drop dead anywhere so i take my tablets and pray" people living with chb and community member perceptions about chb tended to portray the disease in a negative light, describing it as a "scary sickness", a "serious infection", a "big sickness". people living with chb in particular described fear as a motivating factor for their actions and behaviours, which either pushed them to take their tablets to prevent imminent death or made them too afraid to attend the clinic, so acting as a barrier to receiving any care. within the key informant group there was recurrent reference to the many more urgent competing health priorities in remote communities, such as ischemic heart disease, diabetes and renal disease. chb, owing to its long term, insidious or asymptomatic nature, in combination with the lack of appropriate resources, resulted in it being neglected and often not adequately addressed. multiple logistical issues were also felt to contribute to an almost fatalistic view of what was achievable, such as: the remote and dispersed nature of the patient population; the difficulty accessing secondary care physicians and investigations, especially liver ultrasound; the turnover of health care professionals, and lack of continuity of care. in the context of these factors it was perceived that chb is just too complex a problem to tackle. it was also noted that even where good quality educational resources are available for other diseases, they are rarely used in clinical practice. instead, they sit on a shelf gathering dust or the technology to use them is either not there or does not work. it is not clear if this is because they are not useful, did not have community input into their development or have not been well implemented or evaluated. "people (with hepatitis b) tend to be asymptomatic for long periods in contrast to chronic diseases like ischemic heart disease, chronic airways disease, chronic kidney disease, diabetes, and day to day problems that people can identify as being directly linked to the condition so it tends to be way down the list of priorities". non-indigenous health worker "the system relies on people being involved for the long haul and yet there's not a single clinic where we were outlasted by the clinic or the nurse manager of the clinic or the gp where we were there for longer than anyone else in all of the east arnhem clinics". non-indigenous health worker "i think, i mean working in the top end i've seen a lot of really nice materials that have been developed educationally and flip books and things. in my experience they're rarely used". among non-indigenous key informants there was a perception that it was not possible to translate certain key words such as 'liver' and 'kidney' accurately into yolŋu matha and hence adequate explanations of hepatitis b were challenging to achieve even with a translator. an indigenous community member working as a translator, however, said that this was not true. "most of the time by and large yolŋu are hunter gather people. they can cut up a kangaroo, wallabies; they can identify those things [liver and kidney] pretty well, they can make that distinction. it is common knowledge to be able to identify them, there are clear words for them [liver and kidney] and they are different". non-indigenous individuals in the study (all key informants) tended to significantly overestimate the depth of shared understanding between themselves and indigenous individuals when discussing chb. when reviewing existing resources with the non-indigenous health workers there was recognition that there were too many medical terms and a feeling that they were too detailed in content. however, the general concepts that were explained in these resources were felt to be appropriate. indigenous participants also described an excess use of jargon but also reported that the concepts used were foreign and difficult to relate to. he is saying he's been to the clinic, they have explained several times. sometimes he doesn't understand [what they are saying], especially the doctors. this lack of shared understanding was also touched upon when discussing the use of ahws as translators in the context of clinic consultations about chb. although a few of the doctors with extensive experience of working in a remote community environment had good insight into the difficulties ahw may face in explaining biomedical concepts, there was a general feeling that having an ahw with them during a consultation to translate their biomedical explanation was adequate to achieve a shared understanding. in stark contrast to this, ahw participants reported finding this expectation overwhelming as they did not feel sufficiently equipped to be able to facilitate a satisfactory explanation due to their lack of understanding of what was being said. if i don't understand the message then how am i gonna convey it. multiple patients voiced the concern that they were asked to have many blood tests related to their diagnosis of chb, without receiving adequate explanation of their purpose, and that there was a lack of follow up to receive and discuss the results. this lack of understanding and communication left them feeling worried, angry and frustrated and in several cases like the clinic staff were purposely hiding something from them, resulting in a lived experience of disempowerment and inferiority. "i hold my temper at that time, when i don't get my results back i feel like i need, i want to do something, like smash windows or something here at the hospital". "i figured there was something wrong with me when they kept on requesting more and more bloods from me". "that's one of the things. sometimes doctors hide something to the patient and they don't want to tell straight". the results described so far highlight factors which all contribute to the patient-provider aspect of the paasche-orlow & wolf model (figure ). as well as clearly impacting on an individual's hepatitis b specific health literacy these factors appear to shape healthcare interactions, potentially representing a foundation step in the pathways that exist between low levels of health literacy and poor health outcomes in indigenous australians. indigenous participants across all groups overwhelmingly cited language as the single most important feature of any potential educational resource and also as the most significant barrier to achieving effective cross cultural communication. "she's saying, she doesn't understand, it's not much meaningful. the words are big words, the numbers are not good, and the words are not good. should be in language". on multiple occasions through the process of interviewing (at the request of individuals normally in the patient group), we used a trained interpreter to provide a brief clinic style explanation of chb, and this appeared to be able to significantly increase an individual's understanding of their illness. it was however emphasised repeatedly that the translation process was not simply a case of turning the english into yolŋu matha and that multiple steps were needed; to ensure the individual translating has adequate understanding, to allow/enable contextual translation, to communicate the message via the interpreter in the appropriate language, to check understanding in language, to ask the interpreter to back translate the participant's understanding and to clarify any miscommunication, as well as great care not to simplify the message too much such that the detail was lost. indigenous participants perceived that the best path is to remove all medical jargon and acronyms and translate the simple english into yolŋu matha, using accurate but "culturally safe" concepts. the value and preference for visual aids, again of a culturally safe and accurate nature, was a predominant comment. it became apparent over the duration of the project that there was a lack of shared understanding of the word "silent" between non-indigenous key informants (health workers) and patients in the context of hepatitis b. whereas the non-indigenous health care professional may use the word 'silent' to describe the immune tolerance (early stage chb when viral load is high but minimal liver damage is occurring) or immune control phase (later stage chb following e antibody seroconversion where viral load is low and minimal liver damage is occurring) of hepatitis b, a yolŋu patient or ahw may interpret this to mean that the sickness is brought about by sorcery a , with negative connotations of retribution or punishment. although not held by all, this was a commonly held belief voiced amongst the indigenous people interviewed. culturally important relationships between certain individuals, which health care providers may not be aware of, were seen as a barrier to effective communication. for example; a well-respected senior male elder in the community may feel uncomfortable with having a younger female interpreter in a medical consultation, as it would infer something negative about his knowledge of the subject or ability to understand the health care worker and so decline the assistance of an interpreter altogether. this can then result in the individual having an inadequate understanding of the information presented to them. the importance of gender sensitivity, not only in a clinical scenario but also in any potential educational resource was touched on by individuals in all groups. the ability for people to speak honestly and in detail about hepatitis b was felt to be culturally difficult between individuals of different gender. patients and community members felt this to be more important if the gender mismatch was between two indigenous individuals and not as significant if the second individual was a non-indigenous individual or a health care professional. however some non-indigenous health care professionals felt that consultations between a health worker and patient of the same gender tended to result in improved cross cultural communication and improved rapport. motivation to understand more about hepatitis b: "we want to learn more about this sickness" despite a lack of biomedical knowledge, indigenous participants passionately voiced a desire to understand more about hepatitis b. the importance of telling the full and true story was emphasised, in not missing out the details, but finding a culturally appropriate contextual translation to allow a shared understanding of the important information. indigenous participants were enthusiastic about spreading this knowledge to all to whom it may be relevant in order to allow them to make choices about seeking management. both indigenous people living with chb and community members perceived that the moral and ethical obligation was on "us", the health care providers, the ones giving injections (vaccination) and taking blood tests to ensure patients were appropriately informed. this understanding was felt to be very powerful in facilitating autonomy and respect, as well as being vital to a respectful patienthealth care professional relationship. "she's saying she wants to learn more about this hepatitis b so she can pass the story to her people, to her family. and to encourage them to come to the clinic and have a check-up". a culturally appropriate education resource: what we need… when discussing educational resources, non-indigenous key informants reported that an analogy with hepatitis b using a local animal (e.g. a crocodile or snake) to represent how the virus can lie dormant in the liver and then suddenly attack resulting in serious health consequences would be culturally appropriate. by contrast, indigenous participants generally preferred more medical imagery requesting to see a real human-like figure with a real liver, and a story based in a culturally appropriate setting. one participant remarked that the majority of local animals are hunted as food by community members, so it would be counterproductive to use them to explain a human sickness -people would then think they could get the disease from the animal. a strong desire to understand the detail about hepatitis b was recurrently expressed but the need for contextual translation done in a culturally appropriate way was stressed. in general, indigenous participants reported a preference for an electronic format with an emphasis on interactive pictures and less text. if text is utilised, it was clear from participants that it must be in yolŋu matha and spoken as well as written. there was a recurrent specific request for a separate "women's business" section to speak about the issues specifically related to pregnancy. figure summarises the important aspects from the results which have been taken forward into the process of developing a culturally appropriate tool to aid in the development of effective treatment partnerships for indigenous patients with chb. in light of our results we have adapted paasche-orlow & wolf's model figure to highlight how the relationships between health literacy and poor health outcomes may operate for indigenous australians with respect to hepatitis b. this study documents low levels of biomedical knowledge about hepatitis b which appear to be influenced by a multitude of factors including culture, gender, competing health priorities and a lack of shared understanding. pessimistic almost fatalistic perceptions of the disease predominated across all groups of individuals interviewed. in terms of experiences the major theme identified was communication particularly the importance of having information available in an individual's first language to aid in effective cross cultural communication. indigenous individual's repeatedly expressed a desire for increased knowledge and insight into the ability of this knowledge to reduce disempowerment and improve hepatitis b specific health literacy. ideas as to how to best enable this to happen included using visual aids, electronic formats, simple language and the absolute requirement for information to be available in yolŋu matha. knowledge and beliefs are important patient factors in the patient-provider interaction component of paasche-orlow & wolf's model linking low levels of health literacy and poor health outcomes. a lack of biomedical knowledge about hepatitis b was identified in indigenous individuals across all groups interviewed. this is consistent with data from indigenous individuals in the torres strait [ ] as well as non-indigenous australians from culturally and linguistically diverse backgrounds [ ] . lack of knowledge and erroneous beliefs about hepatitis b, as well as contributing to low levels of health literacy, may lead to a reduced ability or willingness to participate in decision making about management plans. this in turn may influence adherence with the plan and subsequent necessary self-care activities. multiple factors affecting the provider side of the patient-provider interaction were also identified. communication skills to allow shared understandings to be developed as well as insight into how best to achieve this are crucial in our context, where there are multiple competing priorities; however lack of these skills is identified in our results as an ongoing barrier to achieving shared understandings. in the context of australian indigenous peoples where english is not the first language and culture and worldview are very different we would suggest that the patient-provider interaction not only significantly contributes to health literacy but is a pre-requisite to allowing access & utilisation of care and self-care to occur and so ultimately influencing health outcomes ( figure ) . as well as the patient-provider factors described above, extrinsic factors such as support technologies, health education and resources are identified as key factors to allow optimisation of self-care. the wider project that this research is part of was initiated due to a lack of culturally appropriate resources about chb for use in clinical practice. our data identified a real desire for more knowledge and understanding around chb for all in the community to motivate and empower people living with chb and community members, which in turn should increase selfmanagement in relation to chb. our results identify a clear ambition by community members and people living with chb towards 'critical health literacy' as defined by nutbeam et al. [ ] as the tertiary level of health literacy encompassing not only communication of information and development of personal skills but also personal and community empowerment. there is now increasing experience with the use of innovative, interactive, internet, mobile phone and tabletbased resources to improve health literacy in other settings [ , ] . in the context of indigenous australia, several groups have produced apps in the area of mental health [ ] but robust evaluation of their value is still awaited. in northern australia, christie's research group has proposed a tablet-based, easily transportable, touch pad body resource, which does not contain any embedded health messages, but rather focuses on aspects of a healthy body. their vision is that this could be used as the foundation for a further discussion about the impact of chronic diseases on the body and how treatments act to return the body to a healthy state [ ] . the evidence derived from this project that will be taken forward to phase of the par process and used to guide the development of a culturally appropriate educational tool about hepatitis b is summarised in figure . effective communication is not only central to improving health literacy [ ] , it is a crucial element in achieving culturally safe healthcare, which in essence can be defined as "shared respect, shared meaning, shared knowledge and experience of learning together" [ ] . more recently, research suggesting that some indigenous patients believe that health care workers deliberately withhold information from them highlights the extreme lack of trust that can develop as a consequence of ineffective communication [ ] . as communication transcends all aspects of health literacy, hence "culturally safe communication" at both a system and individual level is clearly integral to its improvement. culturally safe communication has also been suggested as being important in reducing ethnic and racial disparities in healthcare [ ] . specifically in the australian aboriginal context, involvement of the local community in developing and implementing health education programmes, so they are culturally safe, has been shown to directly influence their effectiveness [ , , ] and attention to worldview and language are argued to be integral to achieving improvements in health education [ ] . it is therefore disappointing that more than a decade after the publication of cass et al's [ ] paper documenting the pervasive nature of miscommunication between indigenous people and their health care professionals, our results show the major barrier to achieving critical health literacy is still poor cross-cultural communication. consistent with the view of vass et al. [ ] who suggest "the health literacy of indigenous australians can be improved by promoting the oral use of the peoples' first language in the health sphere" indigenous participants anticipate they will better understand and be able to process and act on information given to them in their own language. our results also provide further insight into the complexity of achieving effective and culturally safe communication in this setting, when, for example, the lack of a shared understanding of one word -"silent"which is used so commonly in clinical practice with hepatitis b patients can lead to such significant misunderstanding. we have also highlighted the potential for miscommunication to be perpetuated in health settings when communities are not adequately consulted about health education and health promotion resources. the well-meaning but mistaken beliefs among non-indigenous key informants in this study about the appropriateness of using animal analogies when discussing how hepatitis b affects the liver or the mistaken belief that the lack of a direct translation of a word prohibits meaningful translation of key messages, are two examples from our data. the negative perceptions and fear of hepatitis b as a disease may originate from the low levels of health literacy documented and contribute to stigma and potential non-disclosure of diagnosis as well as having implications for individual clinical care and the success of public health interventions. this pessimism may have been confounded by the lack of shared understanding and different health beliefs about causation in the context of provider-patient interactions. additionally, the non-indigenous key informants in this study perceived that there are multiple logistical barriers and competing priorities to providing effective and appropriate long term care for people living with chb and felt overwhelmed by the task. this negativity is likely to adversely influence an individual's access and utilisation of care and so contribute to the relationships between limited health literacy with inequitable health outcomes as per paasche-orlow & wolf's model. our study is limited by the fact it only included one community and because of multiple previous education and research projects in this community in the discipline of infectious disease, it is likely that this community has higher health literacy that most regarding infectious diseases specifically. cultural practices, traditions and world view may be totally different to other australian indigenous peoples; however, our findings about the importance of communications and shared understandings are likely to transcend region and apply to all indigenous australians. this view is supported by the similarities between our findings, and those of preston-thomas et al., who investigated hbv knowledge in a completely different group of indigenous australians -torres strait islanders. although not directly translatable to other cultures, it is likely that the modified factors highlighted in figure will be of greater importance to those people living with chb from culturally and linguistically diverse backgrounds, particularly if they are receiving care in a country where the language of health care is not their own first language. although low levels of biomedical knowledge about chb are clearly a significant barrier and an important influence on health literacy our findings resonate more clearly with christie et al's [ ] definition of health literacy. in this context, what is really critical to improving health literacy is developing a shared understanding between patients and providers, which hinges on effective communication. if we can use the insight we have gained from this study and work with the people who provided it to develop an educational tool grounded in their culture, in their first language and make it easily accessible, that would be a first step to improving health literacy about chb. qualitative research using a participatory approach holds promise of breaking cross-cultural barriers in health communication and health care. we acknowledge that there will also need to be appropriate implementation and evaluation of the resulting resource to ensure its success. biomedical knowledge about hepatitis b is low in this indigenous community in the northern territory, experiences and perceptions about chb are in general negative and at times nihilistic. however there is a strong desire for increased knowledge and evidence of increased understandings with contextual translation of information. patient provider interactions leading to the development of shared understandings between indigenous people living with chb and the health care professionals looking after them are the foundation for improving health literacy and so health care outcomes related to chb. language and using a culturally appropriate worldview are crucially important in developing an educational resource to aid in developing treatment partnerships for indigenous patients with chb. maintaining a participatory approach to development should help to reduce disempowerment and overcome some of the barriers to its implementation and success. endnote a sorcery as a cause of disease is a commonly held belief in indigenous communities in arnhem land particularly where a death is sudden, unexplained or happens to someone who is seen outwardly as healthy. it can be a form of retribution or punishment but is not always viewed in this way. closing the gap key facts hepatitis b in australian aborigines and torres strait islanders: georgraphical, age and familial distribution of antigen subtypes and antibody hepatitis b virus markers in children and staff in northern territory schools establishment of a surveillance system (utilising midwifes data collection systems) for monitoring the impact of hepatitis b vaccination on the population prevalence of chronic hepatitis b virus infection in australia hepatitis b prevalence and prevention: antenatal screening and protection of infants at risk in the northern territory screening for hepatitis b in east arnhem land: a high prevalence of chronic infection despite incomplete screening incomplete protection against hepatitis b among remote aboriginal adolescents despite full vaccination in infancy the end of the australia antigen? an ecological study of the impact of universal newborn hepatitis b vaccination two decades on the burden of chronic hepatitis b virus infection in australia a national health system response to chronic hepatitis b: using population data to define gaps in clinical care provision distribution of viral hepatitis in indigenous populations of north america and the circumpolar arctic the new zealand hepatitis b screening programme: screening coverage and prevalence of chronic hepatitis b infection responding to australia's national hepatitis b strategy - : gaps in knowledge and practice in relation to indigenous australians a situational 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end confusion. washington dc: the national acadamies the sage dictionary of sociology participatory action research in indigenous health health promotion resources for aboriginal people: lessons learned from consultation and evaluation of diabetes foot care resources network sampling. encyclopedia of survey research methods health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the st century ugandan youth preferences for content in an internet-delivered comprehensive sexuality education programme community desires for an online health information strategy the effectiveness of a suicide prevention app for indigenous australian youths: study protocol for a randomized controlled trial the evolving concept of health literacy cultural safety -what does it mean for our work practice? can cultural competency reduce racial and ethnic health disparities? a review and conceptual model culturally appropriate methods for enhancing the participation of aboriginal australians in health-promoting programs health literacy and australian indigenous peoples: an analysis of the role of language and worldview submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution we would like to thank all participants and local health clinic staff who all so generously gave their thoughts and time to contribute to this study. key: cord- -nz uc sl authors: abou-abbas, linda; nasser, zeina; fares, youssef; chahrour, mohammad; el haidari, rana; atoui, rola title: knowledge and practice of physicians during covid- pandemic: a cross-sectional study in lebanon date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: nz uc sl background: as the coronavirus disease (covid- ) pandemic continues to evolve, physicians must be equipped with adequate knowledge, skills on the prevention measures, and confidence in diagnosing and treating covid- patients. therefore, it is of great interest to assess the knowledge and practices of physicians to identify existing gaps and improve occupational safety and viral surveillance. methods: a cross-sectional study was conducted in lebanon between th march and th april . data was collected through an online survey that included information on socio-demographic characteristics, knowledge, practice, physicians fear towards covid- as well as their perceptions regarding actions/policies implemented by the ministry of public health (moph) and their health care facilities. multivariable logistic regression analyses were carried out to identify the factors associated with good knowledge of covid- and good practice toward its prevention. adjusted odds ratio and their % confidence intervals were reported. results: our survey revealed that the majority of lebanese physicians had good knowledge about the disease ( . %) while approximately half of the respondents adopted good preventive practices ( . %). the odds of having good knowledge was . times higher among physicians aged and above (adjusted or = . with a % confidence interval (ci) of . to . ) compared to their counterparts aged less than years old. our results also showed that the odds of good practice was times higher among frontline compared to the second line workers (adjusted or = . with % ci of . to . ). physicians with an experience of years and above were . times more likely to have good practice compared to their counterparts (adjusted or = . with % ci of . to . ). finally, participants with good knowledge of covid- were . times more likely to have a good practice (or = . with % ci of . to . ). conclusion: lebanese physicians revealed a good level of knowledge; however, they had limited comprehension of the precautionary measures that protect them from this virus. our findings have important implications for the development of strategies suitable for improving the level of practice among physicians and enhance prevention programs. novel coronavirus disease (covid- ), which first emerged in china in december , has turned into a worldwide disaster affecting at a rapid pace all the countries over the world [ , ] . the latest figures, at the time of writing, show more than . million cases worldwide with a death toll exceeding . [ ] . given the nature and burden of covid- pandemic, unprecedented challenges have faced governments, communities, and health care systems. physicians, who are directly engaged in the diagnosis, treatment, and care of covid- patients, are exposed to infection from aerosol and droplet contamination [ ] and at high risk for nosocomial infections [ ] . as covid- pandemic continues, the death of physicians has been increasingly reported worldwide. a recent cross-sectional study published in april showed that medical doctors have died due to covid- ; in italy, in china, in france, in the united kingdome (uk), the united states of america (usa), and spain and in south korea [ ] . lebanon, a small arab country, is taking part in the global fight against the covid- pandemic. the first case was detected on february , , in a traveler who had returned from iran. as per august st, , the ministry of public health (moph) announced that the number of cases has reached [ ] . during this outbreak, health care workers (hcws) of which physicians had contracted the infection in their health care facilities. most of the cases occurred in the early period of the outbreak due to misdiagnosis of the cases and the inadequate preventive practices. thus, a preparedness of frontline physicians should be the main priority of all lebanese health care settings to function properly and competently combat covid- . they should be equipped with adequate knowledge, skills on the prevention measures, and confidence in diagnosing and treating covid- patients. as part of an epidemic preparedness plan, it is of great interest to assess the knowledge and practices of physicians to identify existing gaps and improve occupational safety and viral surveillance. thus, this study was conducted in the early stage of the covid- outbreak in lebanon to assess the knowledge and practices of physicians regarding covid- . also, we sought to evaluate their fear towards covid- and their perceptions regarding policies/actions implemented by the moph and their health care settings in handling covid- pandemic. a cross-sectional study, using an online survey, was conducted during the early phase of the covid- epidemic in lebanon between th march and th april . as the lebanese government recommended the public to minimize face-to-face interaction and isolate themselves at home, potential respondents were electronically invited to participate. thus, an online questionnaire using a google form was distributed through "whatsapp" groups and social media using a snowball technique. all physicians, working in hospitals or medical centers in different regions in lebanon and who agreed to participate in the study, were included. no exclusion criteria were applied. participants were identified via professional groups and academic institutions. the sample size was calculated using the online rao-soft sample size calculator designed specifically for population surveys. based on an estimated population of , physicians [ ] , an anticipated response of %, a confidence level of % and a % margin of error, the required sample size would be at least . a structured questionnaire was initially developed and designed by the authors in the english language to cover important aspects of knowledge and practice towards covid- among physicians (additional file ). core dimensions and items content of these two domains were identified through a review of the published literature on middle east respiratory syndrome coronavirus (mers-cov) [ ] [ ] [ ] [ ] in addition to the most recent available information on covid- from the world health organization (who) and the centers for disease control and prevention (cdc) websites up to th march . content validity of the resulting version was assessed by a panel of three experts with expertise in implementing infection control procedures and emergency preparedness. they were asked to evaluate the relevance of the items in assessing the knowledge and practices of physicians towards covid- . a consensus was reached after omitting four items that were rated irrelevant also minor linguistic edits were made. then, the items were translated and adapted to the arabic language by three translators. a final questionnaire was generated and was divided into five sections: -socio-demographic information including age, gender, marital status, specialty, place of work, and clinical experience. participants were also asked whether they were directly engaged in providing care to suspected, probable, or confirmed covid- cases. those who responded "yes" were considered as frontline physicians. physicians, who answered "no" were considered as second-line workers. -knowledge section: six dimensions with a total of items were designed to measure physician's knowledge about nature of the disease ( items), the transmission of the disease ( items), actions in dealing with suspected, probable and confirmed cases ( items), precautionary measures by health care providers ( items), and treatment of the disease ( items). all the items were answered on a true/false basis and an additional "do not know" option. a correct answer was assigned point and an incorrect/ unknown answer was assigned points. the total knowledge score, obtained by the sum of the scores, ranged between and . based on bloom's cut off point, physicians' overall knowledge was categorized as good if the score was above % (≥ points) and poor if the score was less than % (< points) [ ] . a question exploring the source of their knowledge concerning covid was also added to this section. on this question, multiple responses from the participants were allowed. -practice sections: seven questions were used to evaluate the uptake of various preventive measures. the items were answered "always", "occasional" and "never" respectively. the answer (always) was assigned point while answers (occasional and never) were assigned points. the overall practice score, obtained by the sum of the scores, ranged between and . practice levels were defined as "good" or "poor" based on bloom's cut off point. physicians with scores ≥ % (≥ points) were classified as having a good practice, while those with scores < % (< points) were considered having poor practice [ ] . -physicians' fear towards covid- was assessed by items (i am afraid of working in places where patients suspected of covid- are admitted/cared for, i am afraid of treating a patient with covid- ) on a -point likert scale ( -agree, -neutral, -disagree). a point of was given to agree to answer while disagree or neutral responses were given a point. -physicians' perceptions regarding policies/actions implemented by the ministry of public health (moph) and their health care settings in handling the covid- epidemic ( -appears in disarray/disorganized, -insufficient, -acceptable/appropriate, -excessive and unnecessary. the survey was pilot tested in a sample of physicians to check the clarity and readability of all items. physicians did not report any problems in understanding the questionnaire. on average, the survey was completed within approximately min. the data of the pilot study was removed from the final analysis. data was collected using an online survey. an invitation letter, including a link to the web survey platform, requesting lebanese physicians to participate in this survey was prepared. the invitation letter includes information describing the survey and asking for voluntary participation of physicians as well as declarations of confidentiality and anonymity, and instructions for filling in the questionnaire. this letter was sent to approximately physicians through professional groups and academic institutions. statistical analysis was carried out using the statistical software spss (statistical package for social sciences), version . . descriptive statistics were reported using means and standard deviations (sd) for continuous variables and frequency with percentages for categorical variables. both bivariate and multivariable logistic regression analyses were performed to identify associated factors of good knowledge and good practice. the variables in bivariate analysis with p-value < . were entered into multivariable logistic regression. adjusted odds ratio and their % confidence intervals were reported. the final logistic regression model was reached after ensuring the adequacy of our data using the hosmer and lemeshow test. the statistical significance level was set at p-value < . (two-sided). a total of physicians participated in the survey among them . % were males. the mean age was . (sd = . ) ranging from to years. the majority of the participants were specialists ( . %) and . % of respondents were frontline workers who were directly engaged in taking care of suspected, probable, or confirmed cases of covid . almost half of the physicians ( . %) had been practicing medicine for years or longer. the summary of characteristics is shown in table . out of the physicians, the majority of ( . %) had good knowledge. assessment of physicians' fears towards covid- the majority of participants ( . %) declared that policies/actions implemented by the ministry of public health are adequate (fig. ) , whereas only . % revealed that the policies/actions implemented by their health care facilities were adequate in fighting covid- (fig. ). results of the bivariate and multivariable analysis showed that only age was significantly associated with good knowledge at p-value < . . the odds of having good knowledge was . times higher among physicians aged and above (adjusted or = . with a % ci of . to . ) compared to their counterparts aged less than years old (table ) . factors associated with good practice toward covid- prevention since the declaration of the first case on february st, , a great public health concern emerged in lebanese public and governmental institutions. until this date, no definitive treatment was recommended, and physicians are expected to play an important role in the detection and management of cases of covid- . in addition, they are carrying the burden to prevent further spreading of the disease. thus, lack of their knowledge regarding transmission and clinical manifestations of the disease as well as inadequate preventive practices could lead to misdiagnosis of the case and increase the risk of infection. this study was conducted during the early stage of the covid- outbreak in lebanon to provide insight into the knowledge and practices of physicians. results of our survey revealed that the majority of lebanese physicians had good knowledge about the disease while only half of the respondents adopted good preventive practices. our results also showed that frontline physicians who had been practicing medicine for more than years, and with a good level of knowledge had good practice compared to their counterparts. our finding of a good level of knowledge among physicians is in line with that of minghe zhou et al., who reported that . % of hcws have sufficient knowledge regarding covid- with doctors showing higher scores compared to nurses and paramedics [ ] . when looking at the dimensions of knowledge, we found that most participants were aware of the nature of the disease ( . %) and its treatment ( . %). however, a poor level of knowledge was clearly shown in response to the questions regarding the transmission of the disease ( . %), similarly for the actions when dealing with covid- cases ( . %) and precautionary measures by health care providers ( . %). consistent with our findings, akshaya srikanth bhagavathula et al., [ ] reported a poor level of knowledge among hcws concerning the transmission of the disease ( %). this could be attributed to the scientific dilemma proposed by the experts regarding this topic. logistic regression analysis showed that the age of the participants was the only significant predictor of good knowledge. this comes inconsistency with the study conducted in pakistan to evaluate knowledge, attitude, practice, and perceived barriers among hcws regarding covid- by saqlain et al. [ ] . we also found that physicians used official international and governmental websites such as who ( . %), moph ( . %), cdc ( . %), and (idsa) ( %) as main sources of information about covid- . this indicates that physicians utilize reliable sources to acquire information regarding covid- and reflect their good level of knowledge. it is also worth mentioning that some physicians used tv ( . %) and facebook ( . %) as sources of information. although these platforms provide an easy way to get the information, they can also be a source of fake news. thus, it is highly recommended for physicians to seek information from scientific and authentic platforms. concerning practice, approximately half of the respondents ( . %) followed infection control practices. these include regular hand hygiene ( %), wearing a face mask ( %), and gloves ( %). only half of our participants can maintain a social distancing of at least . m from colleagues ( %). this could be to overcrowding or small surfaces in health care settings. in addition, only . and . % of the physicians were aware of the proper donning and doffing ppe. a recent study conducted in pakistan showed that . % of physicians had good practices in following precautions to avoid covid- [ ] . limited resources in the institution, the lack of experience, the poor level of knowledge regarding mode of transmission of the disease, actions are taken when dealing with cases and precautionary measures could partly explain the poor preventive practices of physicians. the lebanese order of physicians (lop), the syndicate of hospitals, and the scientific societies have conducted many online training sessions for hcws mainly physicians. in addition, several protocols and memo regarding sars-cov- were issued. despite all of this, a significant number of hcws have been infected due to misdiagnosis of the cases and inadequate preventive practices. thus, continued professional education and training are advised to empower physicians by supporting their ability to acquire and use evidence-based information. this imposes an action plan from lop and syndicate of hospitals to enhance the actions and preventive measures that should be implemented when confronting a novel virus. similar to the findings of zhang et al., [ ] , results of our survey showed that frontline physicians who results are expressed in terms of frequency and percentage had been practicing medicine for more than years had better practice compared to their counterparts. this indicates that frontline physicians' with more than years of experience had skills to deal with public health emergencies and are confident in their ability to defeat the virus. a finding of considerable concern in this survey is that more than % of the respondents expressed their fear towards treating a patient with covid- which in turn was associated with poor practice. indeed, sars-cov- is highly contagious which could explain the reluctance of physicians to treat patients with covid- . thus, psychological interventions to improve physicians' mental health and to enhance confidence in their ability to treat patients are needed. with a deeper understanding of covid- , we believe that physicians' fear will decrease and the number of physicians who are willing to treat these patients would gradually increase. interestingly, the majority of participants ( . %) declared that the policies/actions implemented by the moph are adequate. the lebanese governments have set early lockdown measures such as the closure of all educational institutions, international airport, and its sea borders in addition to the nighttime curfew. all these measures have contributed, till the time of the writing, to the success in slowing the pace of covid- progression. however, only . % revealed that the policies/actions implemented by their health care facilities were adequate in fighting covid- . this could be due to the poor infection control practices implemented in the health care facilities and the shortage of available ppe for all hcws. thus, increasing the preparedness of all health care facilities is vital to increase the confidence of physicians so to improve their work. the findings of the present study should be considered in light of several limitations. firstly, no validated tool for the assessment of the knowledge and practices of hcws was available. we have adapted and modified tools used for the assessment of knowledge, attitude, and practice toward mers-cov [ ] [ ] [ ] [ ] in addition some items were formulated from who and cdc guidelines. secondly, due to the lockdown, we did not design the sample to statistically represent the lebanese population of physicians and make rigid extrapolations, but to offer for the first time, useful insights of the knowledge and practices towards covid- . thirdly, only physicians who publicly shared their phone numbers were eligible to participate; this could have led to selection bias. therefore, assessment of knowledge and practices of a significant proportion of physicians and their opinions might be missed in this analysis. fourth, some participants might have provided socially desirable responses rather than their actual opinions. this study offers useful insights into the knowledge and practices of lebanese physicians towards covid- . lebanese physicians revealed a good level of knowledge; however, they exhibit poor preventive practices. as the global threat of covid- continues to emerge, there is . ( . - . ) † others included single, widowed, and divorced, *p-value< . is considered significant a clear need for further education and training, particularly on disease transmission, actions in dealing with covid- cases, and preventive measures. this should, in turn, improve their confidence and relief their fears towards getting infected by covid- cases. severe acute respiratory syndrome coronavirus ; covid- : coronavirus disease ; hcws: health care workers; nhcprc: national health commission of the people's republic of china; cdc: centers of disease controlled and prevention board; zhumc: al zahraa hospital university medical center who: world health organization; spss: statistical package for social sciences; sd: standard deviations; ci: confidence interval; idsa: infectious diseases society of america; tv: television; lop: lebanese order of physicians; ppe: personal protective equipment references . (who) who. pneumonia of unknown cause -china emergenciespreparedness, response, disease outbreak news, world health organization (who)-march : who the epidemiological characteristics of novel coronavirus diseases (covid- world heath organisation. who coronavirus disease (covid- ) dashboard modes of transmission of virus causing covid- :implications for ipc precaution recommendations death from covid- of health care workers in china characteristics of doctors' fatality due to covid- in western europe and asia-pacific countries epidemiological surveillance program. surveillance of covid- in lebanon characteristics of physicians practising in lebanon: a survey knowledge and attitude of healthcare workers about middle east respiratory syndrome in multispecialty hospitals of qassim, saudi arabia attitude and practices of healthcare providers towards mers-cov infection at makkah hospitals, ksa knowledge and attitude towards the middle east respiratory syndrome coronavirus among healthcare personnel in the southern region of saudi arabia the perceived effectiveness of mers-cov educational programs and knowledge transfer among primary healthcare workers: a cross-sectional survey knowledge and attitudes towards middle east respiratory sydrome-coronavirus (mers-cov) among health care workers in south-western saudi arabia knowledge, attitude and practice towards covid- among chronic disease patients at addis zemen hospital, northwest ethiopia knowledge, attitude, and practice regarding covid- among healthcare workers in henan novel coronavirus (covid- ) knowledge and perceptions: a survey of healthcare workers knowledge, attitude, practice and perceived barriers among healthcare professionals regarding covid- : a cross-sectional survey from pakistan knowledge, attitude, practice and perceived barriers among healthcare workers regarding covid- : a cross-sectional survey from pakistan publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to thank dr. mohammad obeid, dr. georges maalouf, and mr. mario baakliny for their help during the data collection. the authors are also grateful to all physicians who accepted to be part of this study. authors' contributions laa and ra developed the project idea. mc and rh formulated the questionnaire. laa and zn organized and analyzed the survey. laa, zn, and ra drafted and critically reviewed the paper. yf reviewed the manuscript for important intellectual content. all authors read and agreed on the final version. no funding was received.availability of data and materials data are available from the corresponding authors upon reasonable request. the study was initially approved by the scientific research committee of the neuroscience research center, faculty of medical sciences at the lebanese university (reference # / ), and then by the institutional review board (irb) of al zahraa hospital university medical center zhumc (reference # / ). participation in the study was voluntary. all the necessary measures to safeguard participants' anonymity and confidentiality of information were respected. written informed consent was obtained from all the participants. not applicable. the author(s) declare that they have no competing interests.author details key: cord- -sig h authors: yeung, may ps; ng, stephen kam-cheung; tong, edmond tak fai; chan, stephen sek-kam; coker, richard title: factors associated with uptake of influenza vaccine in people aged to years in hong kong: a case–control study date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: sig h background: in hong kong, people aged – years were added as a recommended priority group (recommended group) for influenza vaccination by the department of health (dh) starting from / onwards. the coverage rate of influenza vaccination for this age group was suboptimal at . % in / . this study investigates the factors associated with the uptake of influenza vaccination among adults in hong kong aged – years. methods: a case–control study was conducted in communities by street intercept interviews from july to august . cases were adults aged – years who had received the influenza vaccine in / or / , while controls were the same as the cases, except they had not received the influenza vaccine in / or / . multiple logistic regression analysis was performed on the data to explore the associations between vaccination status and the variables. results: six hundred and four respondents in total were interviewed and included in the analysis. there were cases (vaccinated) and controls (non-vaccinated), with a case-to-control ratio of : . . the following were strongly associated with vaccination compared to other factors: ‘eligible for free government vaccine’ (or . , % ci, . - . , p < . ); ‘willing to receive flu vaccination for free’ (or . , % ci, . - . , p < . ); ‘perceived having severe or moderate symptoms when contracting flu’ (or . , % ci, . - . , p = . ), and ‘convenient to reach a vaccination location’ (or . , % ci, . - . , p = . ). the majority of the cases ( . %) and controls ( . %) were not aware that they belonged to a recommended group for influenza vaccination and most (> %) were willing to be vaccinated if it was free. conclusions: factors related to free and convenient vaccination, the perception of the severity of symptoms when contracting influenza had a comparatively strong association with influenza vaccination uptake amongst – year olds, compared to other factors. seasonal influenza vaccination (referred to as 'influenza vaccination' , 'vaccination' or 'vaccine' , below) remains an effective measure to protect individuals and communities from severe morbidity and mortality induced by influenza. to mitigate the disease burden of influenza, many developed countries recommend vaccination for high-risk groups. some exceptions are the united states (us), austria and estonia, which have universally recommended people aged months or above to receive influenza vaccination [ ] [ ] [ ] . few european countries, such as belgium and ireland, included those aged - years in their recommended groups [ ] . although the vaccine did not provide an overall economic benefit in some communities, it yielded significant health benefits by reducing severe complications from influenza [ , , ] . meta-analysis and literature reviews demonstrated that the influenza vaccine had a moderate effect in reducing the clinical symptoms of influenza in healthy people from to years [ , ] . many middle-aged adults have undiagnosed medical conditions, such as diabetes mellitus, and are at higher risk of severe influenza-related complications [ , ] . in hong kong, people aged - years were added as a recommended priority group (recommended group) for influenza vaccination by the department of health (dh) starting from / [ ] . the major driver behind this inititiative was a real increase in influenzaattributed intensive care unit (icu) admissions and deaths among the middle-aged group in / , [ ] plus an anticipated increase in the years to come when the influenza a(h n )pdm strain was predicted to circulate in the population. after this new vaccination policy was launched, however, the vaccine was not well received and the vaccination coverage in this new target group was very low at . % [ ] . no free or subsidised influenza vaccination service was provided by the government to this group, except those who already belonged to the other free or subsidised recommended high-risk groups and those with financial difficulties, i.e., comprehensive social security assistance (cssa) recipients. healthy - year olds, without other risk indicators, had to pay if they wanted to be vaccinated. this study aimed to find out which factors were associated with the low uptake of influenza vaccination among people aged - years in hong kong. a survey was conducted in a community setting in hong kong from july to august , following which a case-control analysis was used to investigate the study hypothesis. street intercept interviews were undertaken in districts (out of a total of in the territory). cases were (i) those who received the influenza vaccine in / or / , i.e., from september to august ; (ii) aged - years in - ; and (iii) citizens who were resident in hong kong. controls were the same as the cases in (ii) and (iii), except they had not received the influenza vaccine in / or / influenza seasons. some controls had received the influenza vaccine before september . they were classified as control because they were not included as the recommended group in / and before. the sample size was calculated with a significance level of . (two-sided) and a power level of . . the calculation of the sample size was done by the fleiss formula for unmatched case-control studies with dichotomous exposure variables. a minimum sample size of was required with a case-to-control ratio of : [ ] . the interviewers were assigned a random time slot, covering weekdays, weekends, office and non-office hours. the questionnaire was conducted in summer before the next influenza vaccination season, which usually begins in september of each year. primary data were collected by four trained research interviewers who were fluent in chinese and english. the interviewers were stationed in areas of high pedestrian traffic, such as near underground train stations and shopping malls, during the assigned random time slot. this research had been approved by the human subjects ethics sub-committee of the hong kong polytechnic university and the ethics committee of the london school of hygiene and tropical medicine. before each interview, the interviewer would inform the respondent about the nature and purpose of the study and invited their voluntary participation. interviewees were asked to respond only after informed consent was obtained. no incentive was given. the hypothesis of this study was there were differences in associated factors (variables) between those hong kong residents aged - years who received the influenza vaccine in / and / , and those who did not. the null hypothesis assumes no such association. the questionnaire was designed with reference to past vaccination questionnaires from health authorities [ , ] and relevant studies [ ] [ ] [ ] . the draft questionnaire was then sent for comment to a multi-disciplinary team, comprised of an infectious disease specialist, an epidemiologist and general practitioners. the questionnaire was in chinese and english and had questions including on demographic data and covering the factors (variables) to be examined. statistical analyses were performed using the software sas . . categorical demographic data and variables were compared using the pearson chi-square test, crude and adjusted odds ratios (ors) with corresponding % confidence intervals (cis) and p-values. multiple logistic regression analysis was performed. any variables with p values < . and those with important associations demonstrated in the literature were selected for regression analysis (backward stepwise regression algorithms). the regression model is a built-in formula in the sas software. all statistical tests were two-tailed and variables were considered significant at a significance level of . . the study included cases (vaccinated) and controls (non-vaccinated), with a case to control ratio of : . . this sample size reached the required range in the sample size calculation. the average interview time was min (standard deviation ± min) for each questionnaire, and the response rate was . %. during street intercept interviews, there were more non-vaccinated individuals (controls) than vaccinated ones (cases). after the required number of non-vaccinated was recruited, the excess approached by the interviewers were counted as non-responders. in total man-hours were spent on the interviews. the differences between baseline demographic data of cases and controls were statistically insignificant regarding sex, ethics, education level, employment status, personal monthly income, current smoking and drinking status. the demography of cases and controls are shown in table . there was no apparent discrepancy in the sample and the target population. one exception was in the sampled respondents; there were proportionally higher numbers of females than males (m:f = : . ), while the overall ratio in the target community was : . other demographic parameters of the sampled population, such as the age proportion between groups, education level, ethnicity, and the percentage of those in employment, were comparable to the target population (i.e., hong kong general population aged - years). the majority of the respondents were chinese, and there were more female than male respondents ( . % vs . %). most ( . %) of those who were in employment were aged years or below. overall, half of the respondents ( . %) had no income. one in four ( . %) was a housewife and one fifth ( . %) was retired. the majority of them ( . %) had received at least years of education up to secondary level. the majority of all the cases ( . %) and controls ( . %) were not aware that the health authority had recommended vaccination against influenza. however, the cases were more aware of the recommendation for influenza vaccination than the controls, (or . , % ci . - . , p = . ). there were health knowledge differences between the cases and controls in all the questions asked on knowledge, including government vaccination services, vaccine reduction in influenzarelated hospital admission, and vaccine protection for healthy adults. however, these associations were statistically insignificant after the or was adjusted ( table ) . when compared to the controls, more of the cases had chronic diseases; more frequently 'visited doctors in the past months' and 'lived with children below years or elders above years'. however, none of these associations was statistically significant after the or was adjusted. there was no association between vaccination and smoking/drinking. most cases ( . %) stated that they were likely or very likely to receive the vaccine in / , compared to only . % among the controls. this implies those who had previous vaccinations in / and / would choose to be vaccinated again in the future. in general, more cases perceived there to be a higher risk of contracting influenza in the next months and/ or having severe influenza or moderate symptoms when there were no associations between differences in response to the government telephone reminder service for vaccination, if there was one. in respect of vaccination, the cases were more heavily influenced by others' opinions and actions than were the controls. when compared, more cases would 'accept advice from health professionals' (or . , % ci . - among the controls (i.e., never received vaccination or received vaccine on or before / ), . % of them had previously received the vaccine. the following were common reasons given by the controls for not receiving a vaccine: considered vaccination unnecessary ( . %); believed they were not in a high-risk group ( . %); and concerns about side effects of vaccination ( . %). of the controls that had previously been vaccinated, % had received the vaccine at a public clinic. a subgroup analysis was performed on those who received influenza vaccination but did not know they were recommended group by the department of health (dh). there were cases (who were vaccinated) and among them answered yes to "knowing oneself to be in the recommended group for flu vaccine" and answered no. in these people the five commonest reasons for vaccination were: advice from healthcare professionals ( . %), vaccine was useful in protect oneself against flu ( . %), flu shot had additional benefits, e.g. protect family member ( . %), perception of not having very good or good health ( . %) and eligible for free government vaccine ( . %). more than half ( %) of these people received their influenza vaccine at government public clinics, and most of the remaining ( %) at private general practitioners. this is a case-control study with vaccination status as the 'outcome' and personal or external environmental factors as 'exposures'. a case-control study design was chosen because of a low prevalence of eligible cases. a street intercept interview method enabled the interviewers to screen and approach a larger number of people, according to the outward appearance of their age. this probably lowered the rejection rate and enabled a greater control in completing the questionnaire. it was estimated that a larger number of people would have had to be approached should a telephone or postage survey been used. the low response rate ( . %) was attributable to the difficulty in finding cases, as the excess controls approached by the interviewers were counted as non-responders. moreover, the interviews were conducted in summer time when the street temperature was > °c, the streets were crowded and no incentive was offered. multi-dimensional factors have contributed to people's choice of whether or not to receive vaccination. these factors comprise of social, environmental and economic dynamics in a specific context. the factors were put in a multiple logistic regression model and statistically adjusted for age, employment status, in receipt of social security, and all independent variables. before statistical adjustment, most of these factors had statistically significant crude odds ratios. the variables affected each other and many became non-significant after adjustment. there would be a confounding effect between variables. the majority of the cases ( . %) and controls ( . %) were not aware that they were in a group recommended by the health authority to receive influenza vaccination. among the controls, a higher percentage ( %) deemed vaccination to be 'unnecessary'. this revealed a failure of dh and health professionals in communicating the message that 'vaccination is recommended' to this age group. given that there was an association between 'knowing oneself to be in the recommended group for flu vaccine' and vaccination, better communication of the risks might have improved the vaccination rate. a health promotion strategy on empowerment and enhancement of knowledge on this issue needs to be planned and supported by health-care policy. studies suggested that previous influenza vaccination was a predictor for subsequent vaccination (or . - . ) [ ] [ ] [ ] [ ] . however, past behaviour does not provide an insight into the reasons why a person chooses to be vaccinated. the vaccination coverage rate is price sensitive. this was demonstrated in this study and in countries which provided vaccine reimbursements to users [ , ] . to receive influenza vaccination, most ( %) people aged - years in the general hong kong population had to pay out-of-pocket. in this study, the odds of the cases being 'eligible for free government vaccine' were . times the controls. among the cases, half ( %) of them attended a private clinic or hospital and paid the vaccination fee. many study cases and controls expressed they were willing to receive the vaccine if it was free or subsidised. such a vaccination service could possibly increase the vaccination rate. there was only a mild association between chronic disease(s) and vaccination and the association was insignificant after the or was adjusted (or . , % ci . - . , p = . ). this result contradicted the findings of many studies that indicated that the presence of chronic diseases was one of the most persistent factors associated with vaccination [ , , [ ] [ ] [ ] [ ] [ ] [ ] . ' accept advice by health professional' was moderately associated with vaccination (or . , % ci . - . , p = . ). several other studies have shown that doctors' and health professionals' advice was associated with influenza vaccination [ , ] . health professionals had a duty to recommend vaccination to high-risk groups in order to protect them from influenza and severe complications. 'had family member received flu vaccine' was associated with people's uptake of the vaccination, but 'accept advice from relatives and friends' was not. in japan, advice from health professionals, family and/or close friends was strongly associated [ ] . in the usa and other western countries, advice from family and/or close friends was not a significant factor in acceptance of influenza vaccination [ , ] . this could possibly be due to the differences in cultural backgrounds between individuals in these countries. this study showed no association between vaccination and smoking and drinking. it is uncertain whether people were consistent in their health behaviours. studies have proven that smoking is not associated with vaccination [ , ] . no data was found on other health behaviours, such as drinking or frequent exercise, having a link to vaccination. given past experiences of infectious disease epidemics in hong kong, people may be more inclined to receive vaccination to protect themselves in anticipation of the occurrence of a disease epidemic such as sars or swine influenza. previous research has suggested that newly issued recommendations are not quickly embraced by the majority of citizens. in the us, government national health interview survey data did not show a marked increase in vaccination rates among adults aged - and - years after the us advisory committee on immunization practices expanded its recommendations to these subgroups in and , respectively [ , ] . this vaccination policy limited the government vaccination free service to those suffering economic hardship and chronic diseases among - year-olds. although the price of receiving an influenza vaccination constitutes a minute percentage of monthly income, this does not necessarily mean socio-economically deprived groups who are ineligible for free vaccination would be willing to pay for the vaccine. subsidised vaccination would attract those who are willing to pay at a discounted price. health providers could be engaged, with or without incentives, to promote the benefit of vaccination. in addition, dh should consider health promotion messages addressing factors with strong associations to encourage payment by the individual. these factors included 'the perception of having severe or moderate symptoms when contracting flu' , 'knowledge of being in the recommended group for flu vaccine' and 'good vaccine protection for healthy adults'. a case-control design enabled the measurement of many different exposures at once and for the combined effects of exposures to be examined. in addition, data were collected within a short time-frame. one of the important limitations of this case-control was the temporal sequence and reverse causality. it is difficult to interpret the time sequence of the exposures and the outcomes. for example, it is uncertain whether perception of the safety of the influenza vaccine was a cause or a consequence of vaccination. other limitations of this casecontrol include the information and recall bias of the respondents, and the inability to estimate the coverage of vaccination in this age band. one limitation of using the street-intercept method would be the possibility that the interviewers approached those who looked - years and, potentially missed a number of younger and older looking individuals; the extent of this bias is difficult to assess. another bias would be due to the sampling of respondents from different locations, e.g., on public and private estates, in train stations and shopping malls. a comparison of the demographic characteristics of the samples collected in different locations, and those of the relevant population, would be useful to identify potential bias. the study results have important implications for the general population aged - years in hong kong. there would be considerable differences between cultures, beliefs, norms and external environments -such as health systems and service provision -which have to be taken into consideration when applying the results to other populations. further studies on the local vaccination policy and the views of health professionals would provide a comprehensive account of the low vaccination coverage in this age group. factors related to free and convenient vaccination, perception of the severity of symptoms when contracting influenza had a comparatively strong association with influenza vaccination uptake among - year olds, compared to other factors. differences in national influenza vaccination policies across the european union, norway and iceland risk groups and other target groups -preliminary ecdc guidance for developing influenza vaccination recommendations for the season - prevention and control of seasonal influenza with vaccines. recommendations of the advisory committee on immunization practices-united states influenza vaccination in austria from to : a country resistant to influenza prevention and control the effectiveness of vaccination 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patient's perceptions and information provided by the public health service are predictors for influenza vaccine uptake factors influencing acceptance of influenza vaccination given in an ed predictors of flu vaccination among urban hispanic children and adults influenza vaccination coverage against seasonal and pandemic influenza and their determinants in france: a cross-sectional survey healthy young and middle age adults: what will it take to vaccinate them for influenza? vaccine patient acceptance of influenza vaccination compliance with influenza vaccination. its relation with epidemiologic and sociopsychological factors no intention to comply with influenza and pneumococcal vaccination: behavioural determinants among smokers and non-smokers behavior and beliefs about influenza vaccine among adults aged - years we would like to thank the interviewers from the hong kong rehabilitation power; cathel hutchison for providing the language editing service; and ss lee, nguyen-van-tam and mark jit for their invaluable expert opinions. authors' contributions mpsy was the principal investigator and generated the research framework and methods, collected, analysed, interpreted the data and drafted the manuscript. skcn and etft contributed to the study methodology, analysis and revision of the manuscript. sskc contributed to the questionnaire design and statistical analysis. rc contributed to the conception, design, analysis and interpretation of the study, and critically revised the manuscript. all authors read and approved the final manuscript. key: cord- -velir gb authors: hickey, jason; gagnon, anita j; jitthai, nigoon title: pandemic preparedness: perceptions of vulnerable migrants in thailand towards who-recommended non-pharmaceutical interventions: a cross-sectional study date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: velir gb background: non-pharmaceutical interventions (npis) constituted the principal public health response to the previous influenza a (h n ) pandemic and are one key area of ongoing preparation for future pandemics. thailand is an important point of focus in terms of global pandemic preparedness and response due to its role as the major transportation hub for southeast asia, the endemic presence of multiple types of influenza, and its role as a major receiving country for migrants. our aim was to collect information about vulnerable migrants’ perceptions of and ability to implement npis proposed by the who. we hope that this information will help us to gauge the capacity of this population to engage in pandemic preparedness and response efforts, and to identify potential barriers to npi effectiveness. methods: a cross-sectional survey was performed. the study was conducted during the influenza h n pandemic and included migrant participants living in border areas thought to be high risk by the thailand ministry of public health. data were collected by migrant community health workers using a -item interviewer-assisted questionnaire. univariate descriptive analyses were conducted. results: with the exception of border measures, to which nearly all participants reported they would be adherent, attitudes towards recommended npis were generally negative or uncertain. other potential barriers to npi implementation include limited experience applying these interventions (e.g., using a thermometer, wearing a face mask) and inadequate hand washing and household disinfection practices. conclusions: negative or ambivalent attitudes towards npis combined with other barriers identified suggest that vulnerable migrants in thailand have a limited capacity to participate in pandemic preparedness efforts. this limited capacity likely puts migrants at risk of propagating the spread of a pandemic virus. coordinated risk communication and public education are potential strategies that may reduce barriers to individual npi implementation. we have recently seen the emergence of two new pathogens that are being closely monitored by public health agencies due to their pandemic potential. one is a new avian influenza a (h n ) virus in china that has developed the ability to transmit from human-to-human. the other is the middle east respiratory syndrome coronavirus with mortality rates above %. discovery of these pathogens highlight the importance for public health officials worldwide to continue pandemic preparedness efforts. one key strategy employed during the previous influenza a (h n ) pandemic was the use of non-pharmaceutical interventions (npis). examining and enhancing individuals' attitudes towards npis is one important area of preparation for a new pandemic. this paper presents data collected during the pandemic about the perceptions of migrants in thailand towards npis and their ability to implement these npis. many potential barriers were identified. non-pharmaceutical interventions such as personal hygiene, cough etiquette, social distancing and border measures constituted the principal tools employed in global efforts to mitigate the influenza a (h n ) pandemic. npis were heavily relied upon during the early stages of the pandemic to slow disease transmission, while work was undertaken to understand the virus and develop a vaccine [ ] . antivirals were available in many countries but potential development of resistance presented a major concern [ ] , highlighting the importance of npis to reduce reliance on antivirals. during future pandemics it is likely that npis will again constitute our principal set of tools to reduce transmission, gain time to put response measures into place and work towards vaccine development. thailand is an important point of focus in terms of global pandemic preparedness and response due to its role as the major transportation hub for southeast asia, the endemic presence of multiple types of influenza, and its role as a major receiving country for migrants. certain groups of migrants may be particularly vulnerable to pandemic influenza due to traditions in raising poultry and swine, poor personal hygiene and sanitation, low levels of health knowledge and awareness, and limited access to health care [ ] [ ] [ ] [ ] . some migrant populations in thailand share these characteristics [ ] . furthermore, migrants' proximity to international borders may increase likelihood of cross-border disease communication and occurrence of future pandemics [ ] . thailand's ministry of public health (moph) works collaboratively with the international organization for migration (iom) to improve the health and well-being of potentially vulnerable migrant groups. iom's work is focused in 'priority provinces' that have been designated as such, based on the high concentration of migrants and frequency of cross-border communication (i.e., movement of individuals and goods). the proportions of migrants compared to thai people living in border areas vary widely and depend on how one defines "migrants". in this context, we define it as any individuals that do not have a thai citizenship, regardless of their places of birth or immigration status. the two studied provinces are among the top five in the country regarding the size of migrant populations. there are an estimated two and a half million migrants providing unskilled labour in thailand, nearly one and a half million being undocumented [ ] . thailand's past experience with avian influenza outbreaks meant that pandemic preparedness guidelines and policies had been put into place prior to the influenza a (h n ) pandemic [ ] . npis, including hand hygiene, social distancing, face masks and border measures were all included in the guidelines, were widely promoted and implemented during the pandemic [ ] . thailand's first case of a (h n ) pdm was reported in early may, . in total, , confirmed cases and resultant deaths were reported [ ] . failure of npis to prevent widespread transmission of influenza a (h n ) pdm highlights the need to identify factors that may reduce the effectiveness of npis during a pandemic. several studies have demonstrated that individual characteristics of non-migrant populations are closely linked to npi adherence [ , ] . an anonymous telephone survey of adults in hong kong revealed perceived efficacy of hand washing and face mask use to be 'quite effective' in nearly % of respondents [ ] . positive perceptions were linked to higher levels of hand-washing and face mask use. another telephone survey of individuals in england, scotland and wales found that perceived efficacy toward disinfection measures and hand washing were quite high (more than % answered 'tend to agree' or 'agree') but was lower towards social distancing, face mask use, and avoiding hospitals [ ] . this study also found an association between perception and npi adherence. both studies highlight the importance of assessing and addressing individuals' perceptions of npis. during the influenza a (h n ) pandemic, iom and the mcgill university school of nursing undertook a study to identify influenza knowledge, attitudes, and practices among migrants in thailand. one assumption guiding a subset of questionnaire development was that it is ultimately an individual decision to adhere to npi recommendations. in addition, the most recent revision of the who guidance document on pandemic preparedness incorporates a more explicit and active role for communities, individuals and families [ ] . the guidance document suggests that respiratory hygiene, hand washing and voluntary isolation of cases may help limit the spread of influenza, but it does not address individuals' willingness or ability to undertake these actions. our aim was to collect information about vulnerable migrants' perceptions of and ability to implement npis proposed by the who. we hope that this information will help us to gauge the capacity of individuals within the vulnerable migrant community to participate in pandemic preparedness and response efforts, and to identify potential barriers to npi effectiveness. study participants (n = ) were recruited from two provinces in northern thailand adjacent to the myanmar and laos borders, chiang rai and tak. participants were sampled from all known migrant-populated communities within these provinces. first, maps created by migrant community health workers (mchws) during a previous iom/moph project that outline the number and locations of households within each community were used to randomly select households. the number of households chosen from each map was based on the proportion of migrants in that village compared to the rest of the province. a web application, research randomizer [ ] was used to randomly generate the specific household numbers to sample. second, data collectors approached members of the selected households and requested a volunteer from each household to complete the survey. the decision to seek volunteers from each household was made after extensive consultation with iom and mchws as the most ethically and culturally appropriate method in this context. consideration was given to sampling the household heads, but it was felt that this would have turned our sample into a predominately male one and put unintended pressure on this person to participate. random selection of individuals was also considered, but it was likely that this method would have been culturally offensive to some groups. data collectors attempted to recruit equal numbers of male and female migrants by requesting a female volunteer from the first household, a male from the second household, a female from the third, and so forth. it was requested that volunteers be between the ages of and without any known psychological disability that would prevent them from completing the survey. interviewer-assisted questionnaires were administered between september and november, by mchws employed by the moph. mchws travelled to the communities where they are known to the migrant population and familiar with the culture and language(s) spoken. participants spoke a range of ethnic languages so mchws were selected who had fluency in one or more of these languages. interviews were conducted in the participant's primary language, in thai, or in a mixture of both, depending on participant's preferences and language abilities. most mchws had been involved in previous health promotion activities and data collection and were familiar with negotiating this communication process. mchws were responsible for describing the purpose of the study, the risks and benefits of participation, obtaining informed consent, and collecting data. all mchws received training on research methodology, survey administration and research ethics prior to data collection. this study received ethical approval from the mcgill university research ethics committee and underwent review by iom for cultural appropriateness prior to recruitment. the subset of data presented in this paper contains information on socio-demographic factors and perceptions and practices relating to the following who-defined categories of npis: measures to reduce risk that cases transmit infection, measures to reduce risk that contacts transmit infection, measures to increase social distance, disinfection measures, and border measures [ ] . a -item interviewer-assisted questionnaire was used to collect data. this instrument was revised from a previous iom influenza questionnaire to incorporate key components of the who's global influenza preparedness plan, pandemic preparedness checklist [ , ] and related themes from the literature [ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . pandemic preparedness 'experts' working with iom provided their feedback on the revised version and it was adjusted accordingly. it was then translated from english into thai using two independent translation services. each translation was subjected to review by one author (nj) and the one judged to be superior was blind backtranslated [ ] . the back-translation was compared to the original english version and necessary adjustments were made. mchws provided further feedback on the questionnaire during training sessions and revisions were made to ensure cultural appropriateness. the questionnaire was then piloted with non-study participants and revised one final time for clarity. interpretation of the thai questionnaire into the primary languages of the participants was rehearsed extensively during training to ensure accuracy and equivalency between mchws. the subset of results reported in this paper include, socio-demographic variables and measures to reduce risk of disease transmission. these data were collected using closed-ended questions. one to two days of data collection were observed in each province by one author (jh) to ensure quality and consistency of questionnaire administration. additionally, each data collector's first three interviews were audiorecorded and reviewed for consistency. mchws were required to review completed questionnaires for missing or unclear responses and to resolve these before leaving the participant's home. questionnaires were reviewed for completeness and logical data checks were made prior to computer data entry. questions arising were resolved with the mchw. the first questionnaires from each province that were entered by the data-entry clerk were reentered by one author (jh) in their entirety to assess for errors. if errors were discovered, feedback was given to the data-entry clerk and/or mchws, the error corrected, and the next records examined similarly. a % random sample of questionnaires was later re-entered to confirm data quality. univariate descriptive analyses were conducted and frequency tables were created using microsoft excel. questionnaires with incomplete response sets for this data subset (n = ) were omitted from analysis. data from both provinces were combined to provide a broad assessment of migrants' practices and perceptions that could be used by iom and the moph to implement policies and programs at a national level. the response category of 'unsure/declined to answer' was included as a valid response for the purposes of data analysis. previous work at iom has shown that this category of response is typically high among this population as migrants are careful to avoid giving answers that may be viewed negatively by health/governmental authorities. it is an important response item in terms of analysis because it helps us gauge migrant's uncertainty about the survey questions as well as their comfort level with participation. results were summarized within each category of npi. data collectors were able to enroll a volunteer from each household selected for sampling. a total of participants were included in analyses, from tak province and from chiang rai province. forty-nine percent were between to years of age. fifty-one percent were female. education levels were low, % having no formal education, and only % having completed more than six years. seventy-five percent were able to have at least a basic conversation in thai. over one in five were unemployed and of those employed, the most common job reported was daily labourer ( %). median family income was usd (thb ) per month and supported an average household of . family members (sd . , range - ). only % of participants responded that they would agree to stay inside their homes if sick with an influenza-like illness during an outbreak. the majority ( %) were unsure what action they would take or declined to answer the question. hospital ( %) was the preferred location for confinement, followed by the home ( %). one quarter of respondents had used face masks in the past when sick. slightly less ( %) said they would agree to use a face mask if sick in the future and over half ( %) said they would not wear a face mask. only one third believed that wearing a mask could prevent the transmission of illness. further results are presented in table . the majority of respondents ( %) said that if they were sick with an influenza-like illness they would agree to tell health authorities so that contacts could be located. most ( %) would feel more comfortable giving this information to a mchw. less than half ( %) reported that they would be able to check their own temperature at home; the most common barriers to doing so were not owning a thermometer ( %) and not knowing how ( %). participants were given a scenario in which they had been in contact with someone sick with influenza. in response, just over half ( %) would agree to take preventative medicine and avoid travelling to places with no signs of outbreak. when given a hypothetical of a disease outbreak or pandemic, nearly half ( %) said they would remain in their community. some said they would move to another community in thailand ( %) and a few said they would move back to their home country ( %). if official border crossings were closed, some participants would travel through other routes ( %). just under half of respondents ( %) agreed that banning cross-border travel during a pandemic could help prevent the spread of disease. further results are presented in table . respondents were asked whether they thought various social distancing measures would be effective at reducing the spread of illness during periods of disease outbreak. avoiding gatherings of five or more people received the most positive responses ( %), followed by avoiding places of entertainment ( %), avoiding department stores, supermarkets and minimarts ( %), avoiding restaurants ( %), limiting contact with family and friends ( %), avoiding public transportation ( %), keeping children from school ( %), avoiding the workplace ( %), avoiding the hospital ( %), and avoiding the public health centre ( %). further results are presented in table . less than half of all respondents ( %) said they would increase hand washing frequency during an outbreak or pandemic. among those who would increase hand washing % do not use any form of soap. less than half ( %) agreed that hand washing can reduce the transmission of illness during periods of disease outbreak. like hand washing, only % of those who would increase disinfection frequency during a pandemic ( %) would use some form of soap. further results are presented in table . the vast majority of respondents ( %) said they would agree to truthfully answer questions about their current health at a border crossing. more than nine in ten would truthfully tell health workers if they were feeling sick ( %) and allow health workers at the border to take their temperature ( %). most ( %) would agree not to cross the border if sick after leaving an area with disease outbreak. further results are presented in table . we conducted a cross-sectional survey among vulnerable migrants in northern thailand to gain a better understanding about their perceptions of, and ability to implement, various npis proposed by the who. with the exception of border measures, to which nearly all participants reported they would be adherent, attitudes towards recommended npis were generally negative or uncertain: measures to reduce risk that cases transmit infection would be implemented only by a minority; perceptions towards implementing measures to reduce the risk that contacts transmit infection were somewhat better, but still a cause concern; perceived efficacy of social distancing measures was low; and, less than half of participants thought that disinfection measures could reduce the spread of influenza during a pandemic. these results demonstrate the existence of potential barriers to npi implementation during a pandemic, suggesting that vulnerable migrants in thailand have a limited capacity to participate in pandemic preparedness efforts. in addition to negative perceptions towards npis, we also identified several other barriers: most had never worn a face mask before when sick, so are unlikely to know the correct way to do so if necessary in the future; many reported being unable to monitor their own temperatures, mainly due to not owning a thermometer and not knowing how to use a thermometer; and, most use clean water only for hand washing and disinfection, implying either a lack of knowledge about adequate disinfection or a lack of materials (e.g., soap or disinfectant). our results differ with those of lau et al. [ ] who found that . % of people surveyed in hong kong surveyed would comply with quarantine measures. only % and % of participants in this study would agree to home or hospital isolation, respectively. social distancing could be seen as another form of quarantine. results on social distancing in our study were somewhat comparable to a study of indians recruited from hospitals, factories, markets, and office in udaipur province, india [ ] . the authors found that the majority of participants did not adhere to the recommended social distancing measures. we did not measure behaviour, but the negative or uncertain attitudes in our sample suggest that adherence rates would be similar. not being able to go to work and not having access to basic necessities are two potential explanations why individuals would not want to be isolated [ ] . current results also differed from lau et al.'s [ ] sample on face mask use and hand washing. the authors comment that wearing masks is an "established practice in hong kong" (p. ), which might explain why the vast majority of participants had worn face masks in the past even though only about a quarter perceived them to be 'very effective'. a similar finding was noted for hand washing. perceptions were comparably low in our sample, but fewer participants agreed they would employ these measures. the one area where our results matched those of lau et al. [ ] was in peoples' willingness to tell border officials if they were feeling ill. nearly all participants from both studies agreed they would do so. we were unable to find any comparable literature related to other border measures, or about peoples' attitudes towards contact tracing. there is a need to educate vulnerable groups about npis during inter-pandemic and pandemic periods. the who technical consultation on public health measures during the influenza a (h n ) pandemic highlights the need for risk communication materials to be "adapted, tested and approved for local use ahead of time" ([ ], p. ). during the a (h n ) pandemic in thailand risk communication was undertaken through television, radio and printed materials. however, coordination of these efforts was not always well managed and messages were sometimes inconsistent and inaccurate [ ] . a better understanding about individuals' perceptions of npis could help to highlight areas in which public health officials should focus risk communication and other educational activities. ongoing risk communication should be used to increase local knowledge. public education campaigns have increased among migrants in thailand since the bird flu in , but knowledge levels remain low (hickey j, gagnon aj, jitthai n: knowledge about pandemic influenza preparedness among vulnerable migrants in thailand, submitted). the gap between public education efforts and results highlight the inherent challenges in bringing health education to vulnerable migrant populations. many of the migrants in this study live in remote, hard to access areas and belong to diverse cultural and linguistic groups. migrants may also have limited experience applying recommended guidelines [ ] and undocumented migrants may avoid contact with public health officials due to fear of deportation. for risk communication to be effective, it must address these challenges and incorporate a component designed to improve people's perceptions of npis. widespread implementation of npis will be unlikely if public perceptions remain low [ , ] . future research efforts should continue to assess the perceptions and ability of diverse populations relating to implementation of npis. these data could provide valuable information to public health agencies with regard to planning for future outbreaks and pandemics and assessing risk communication and public education activities. in the current inter-pandemic period, it would also be beneficial to develop and test measures to improve perceptions towards and understanding of npis, particularly among potentially vulnerable populations. ongoing efforts to systematically assess and standardize public education campaigns and risk communications for consistency and effect should also continue, as should the development of culturally and linguistically appropriate materials. this study has several limitations. translation of some concepts (e.g., pandemic) into migrant languages was sometimes difficult. this difficulty was addressed by working with mchws to determine acceptable translations. because this was a cross-sectional study with data collected at one time point only we were not able to measure potential changes in behaviour resulting from npi recommendations. as such we are not able to say with certainty that our results are associated with decreased capacity to enact npis, though based on the literature presented it seems likely that this would be the case. our results provide a baseline that may be useful in assessing future public education efforts. external validity in this study was reinforced by random sampling of households and high participation rates. validity may be threatened by our decision to request an individual volunteer from each randomly selected household. census data is not available for this population, but comparison with socio-demographic data from relevant studies [ , ] suggests that we obtained a representative sample. we were able to enroll a volunteer from each household that was sampled, but despite attempts to ensure completeness, participants had to be excluded from data analysis due to missing answers. internal validity was strengthened by the incorporation of existing questionnaires and concepts into an adapted tool, expert review of the adapted tool, rigorous translation, and extensive cultural review and pretesting of the final instrument. we did not conduct a factor analysis due to time/resource constraints. who pandemic guidance documents propose that individuals have a role to play in pandemic preparedness. however, if these individuals do not know how to fulfill that role or do not believe that certain interventions will be effective, they are unlikely to take part in the role that has been proscribed to them. results from the current study suggest that vulnerable migrants in thailand have a limited capacity to participate in pandemic preparedness efforts due to negative or uncertain attitudes towards npi effectiveness and an inability to enact certain npis. this limited capacity likely puts this population of migrants at risk for contracting and transmitting influenza during periods of outbreak and pandemic. current results highlight the need for ongoing, culturally-appropriate, multi-lingual risk communication and public health education. research into the appropriate use of risk communication during inter-pandemic and pandemic periods, combined with ongoing education at the community level, could potentially strengthen individuals' capacity to participate in pandemic preparedness efforts. world health organization: public health measures during the influenza a (h n ) oseltamivir resistance -disabling our influenza defences ministry of public health: the second national strategic plan for the prevention and control of avian influenza and preparedness for influenza pandemic. bangkok: ministry of public health pandemic preparedness among sudanese migrants in greater cairo. geneva: international organization for migration bangkok: southeast asia regional inter-agency information sharing/coordination meeting on ahi practices and behaviour survey to inform the avian and human influenza prevention and containment. serbia: unicef migration and hiv/aids in thailand: triangulation of biological, behavioural and programmatic response data in selected provinces. bangkok: international organization for migration a standardized health information system for refugee settings: rationale, challenges and the way forward bangkok: international organization for migration lessons learned from influenza a(h n )pdm pandemic response in thailand public perceptions, anxiety, and behavioural change in relation to the swine flu outbreak: cross sectional telephone survey prevalence of preventive behaviors and associated factors during early phase of the h n influenza epidemic world health organization: pandemic influenza preparedness and response: a who guidance document. geneva: world health organization world health organization: who global influenza preparedness plan: the role of who and recommendations for national measures before and during pandemics. geneva: world health organization world health organization: who checklist for influenza pandemic preparedness planning. geneva: world health organization knowledge and concern about avian influenza among secondary school students in taif, saudi arabia. east mediterr health j a survey of knowledge, attitudes and practices towards avian influenza in an adult population in italy rothberg mb: patient knowledge and attitudes about avian influenza in an internal medicine clinic influenza pandemic: perception of risk and individual precautions in a general population: cross-sectional study. bmc pub health anticipated and current preventive behaviours in response to an anticipated human-to-human h n epidemic in the hong kong chinese general population knowledge, attitudes, and practices regarding avian influenza (h n ) poultryhandling practices during avian influenza outbreak back-translation for cross-cultural research changes in knowledge, perceptions, preventive behaviours and psychological responses in the pre-community outbreak phase of the h n epidemic public knowledge, attitude and behavioural changes in an indian population during the influenza a (h n ) outbreak the community's attitude towards swine flu and pandemic influenza pandemic influenza preparedness and response among immigrants and refugees assessment of mobility and hiv vulnerability among myanmar migrant sex workers and factory workers in mae sot district. tak province, thailand: international organization for migration submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution the authors declare that they have no competing interests.authors' contributions jh contributed to project development, led implementation, and was responsible for leading data analysis and manuscript publication. ag and nj contributed to project development, supported implementation, and guided data analysis and manuscript drafting. all authors read and approved the final manuscript. nigoon jitthai is the former employee of the international organization for migration (iom). key: cord- -lhn tc authors: tracy, c shawn; rea, elizabeth; upshur, ross eg title: public perceptions of quarantine: community-based telephone survey following an infectious disease outbreak date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: lhn tc background: the use of restrictive measures such as quarantine draws into sharp relief the dynamic interplay between the individual rights of the citizen on the one hand and the collective rights of the community on the other. concerns regarding infectious disease outbreaks (sars, pandemic influenza) have intensified the need to understand public perceptions of quarantine and other social distancing measures. methods: we conducted a telephone survey of the general population in the greater toronto area in ontario, canada. computer-assisted telephone interviewing (cati) technology was used. a final sample of individuals was achieved through standard random-digit dialing. results: our data indicate strong public support for the use of quarantine when required and for serious legal sanctions against those who fail to comply. this support is contingent both on the implementation of legal safeguards to protect against inappropriate use and on the provision of psychosocial supports for those affected. conclusion: to engender strong public support for quarantine and other restrictive measures, government officials and public health policy-makers would do well to implement a comprehensive system of supports and safeguards, to educate and inform frontline public health workers, and to engage the public at large in an open dialogue on the ethical use of restrictive measures during infectious disease outbreaks. long considered an anachronism from a bygone era, quarantine has re-emerged in the st century as an important (albeit controversial) tool in the battle against infectious disease. prior to the outbreak of severe acute respiratory syndrome (sars), it had been more than years since mass quarantine measures had been invoked in north america [ ] . the sars containment measures imposed in canada and asia, and on a lesser scale in the u.s., provoked a heated debate within the public health community regarding the ethics and legality of quarantine [ ] [ ] [ ] [ ] [ ] [ ] . likewise, the sars experience has sparked a renewed research interest in the ethics and effectiveness of quarantine. the findings of two recent retrospective studies of the spanish flu pandemic strongly suggest that it was non-pharmaceutical inventions such as quarantine and other social distancing measures that were most effective in slowing the rate of spread and minimizing the rate of death [ , ] . and data from sars-affected regions have pointed to the enduring value and effectiveness of quarantine and other restrictive measures [ , ] . in contrast, there are those who argue that the use of quarantine during sars was both ineffective and inefficient [ , ] . the advent of advanced statistical modelling has added a new dimension to this long-running debate [ , ] . toronto experienced the largest outbreak of sars in north america, with investigation of , potential cases and identification of , contacts of sars patients who required quarantine [ ] . post-sars investigations have detected myriad adverse effects among those quarantined: significant feelings of uncertainty, anxiety, and isolation [ ] ; experience of stigma, fear, and frustration [ ] ; symptoms of depression and post-traumatic stress disorder [ ] ; and loss of anonymity [ ] . despite the long and controversial history of quarantine, little is known about lay perceptions of and attitudes toward its modern-day use. in view of the evidence of potential adverse effects on individual well-being and psychosocial health, and owing to the critical necessity of high compliance in the event of a major infectious disease outbreak, it is increasingly important to understand how quarantine is perceived by the general public. therefore, the objective of the present study was to determine prevailing public attitudes toward the use of quarantine as a means of infectious disease control. the study was conducted in two regions of the greater toronto area (gta), specifically the city of toronto proper and the regional municipality of york located directly to the north of toronto. the gta is among the largest metropolitan areas in north america with a population exceeding . million [ ] . as the urban centre of the gta, the city of toronto is a densely-populated, cosmopolitan city (population estimate: , , ; population density: , /km ; visible minority population: %). in contrast, york is a much less-densely populated suburban region comprised of several small cities and towns (population estimate: , ; population density: . /km ; visible minority population: %). the study sample was stratified to include an equal number of participants from toronto and york. there was no age or gender stratification. all participants provided verbal consent over the telephone prior to the survey interview. research ethics approval was obtained from the university of toronto, toronto public health, and york region public health unit. the survey instrument was developed by toronto public health for use in a telephone survey of the general public following the sars outbreak. the data reported in this paper are derived from a subset of survey items specifically designed to measure public attitudes towards the use of quarantine during infectious disease outbreaks. these items addressed issues ranging from the legality of restrictive measures, the perceived effectiveness of quarantine, and the supports that should be supplied to those affected by quarantine orders. respondents were asked to indicate their level of agreement/disagreement with each item; the response format was a -point likert-type design ( = "strongly disagree"; = "somewhat disagree"; = "neutral"; = "somewhat agree"; and = "strongly agree"). after the response format was explained and before the first survey item was asked, all participants were provided standardized definitions of 'quarantine' ["quarantine means that you must stay in a separate area away from others because you were around someone with a serious illness and so you might have it, too."] and 'infectious disease' ["infectious disease means a sickness that you can catch from another person, like the flu or tuberculosis.]. at the conclusion of the survey, respondents were asked to supply general demographic information. data collection occurred between april , and may , . the survey was administered using computerassisted telephone interviewing (cati) technology. the interviewers received training in advance and worked with the assistance of two project supervisors. potential participants were screened for eligibility at the beginning of each call. inclusion criteria included the following: minimum age of years, primary residence located within the study area during the sars outbreak, english comprehension skills, and ability to provide informed consent. those who did not meet the minimum age criteria were asked if another member of the household aged or above was available to participate in the survey. a final sample of individuals was achieved through standard random-digit dialing. the survey response rate varied slightly by study region. excluding calls to ineligible participants (i.e., did not meet inclusion criteria) and disqualified numbers (e.g., not in service, wrong number, fax/computer/business line), the final response rate was % for the city of toronto and % for york region. a factor analysis using varimax rotation with kaiser normalization was performed on the data yielding four factors. composite index scores were then computed for each factor by summing the responses on items loading on the respective factors. thus, if a factor comprised five items then individual composite scores for that index could range from to . bi-variate and multivariate analyses were performed to investigate the inter-relationships among variables. all analyses were performed using spss . for windows. no statistical weighting of the data was performed. a total of participants were administered the subset of survey items on quarantine. table presents a summary of the demographic characteristics of this sample. the majority were middle-aged ( %) and female ( %). within this sample, % of participants were personally impacted by quarantine during the sars crisis (i.e., either they or someone else in their home was ordered into quarantine). table presents the distribution of responses for each of the likert-type survey items (from "strongly agree" through to "strongly disagree"). in the table, the wording of the individual items is precisely as appeared on the survey instrument; however, for the purposes of presentation, the items are clustered according to the findings of the factor analysis (as described below). as there were no significant differences between respondents from toronto versus york, the overall results are shown. the vast majority of respondents indicated agreement (either "strongly agree" or "somewhat agree") that sufficient justification exists for the use of quarantine during infectious disease outbreaks. similarly, most respondents agreed that public health authorities and government officials should endeavour to lessen the burdens endured by those ordered into quarantine. likewise, there was majority support for the use of various legal sanctions, penalties, and/ or coercive measures in order to maximize compliance with quarantine orders. and, finally, the vast majority of respondents were in favour of safeguards against unwarranted and/or inappropriate use of quarantine. while these high percentages suggest a certain degree of convergence of opinion, it is important to note that the proportion of respondents indicating "strongly agree" versus "somewhat agree" varies significantly across the items, as indicated in table . finally, survey participants were asked to indicate, by way of forced choice, their response to this statement: "breaking or not obeying a quarantine order is most like which of the following [choose only]: (a) parking in a no-parking zone; (b) driving way above the speed limit on a busy street; or (c) physical assault." fully % responded that breaking quarantine is most like 'physical assault,' whereas % selected 'driving above the speed limit' and % chose 'parking in a no-parking zone' ( % did not answer). principal components factor analysis of the survey data yielded an underlying factor structure of four independent factors. based on a subjective analysis of the content of items loading on each individual factor, the four factors were labelled as follows: 'justification,' 'sanctions,' 'burdens,' and 'safeguards' (as shown in table ). four sub-scales were computed by summing scores for the items within each of the factors identified in the factor analysis. in addition, a total composite index was computed by summing scores across the four sub-scales. scores on the four sub-scales and composite scale were submitted to age, gender, and regional analysis. analysis of variance testing revealed a number of statistically significant age and gender differences. on the 'justification' sub-scale, female respondents scored significantly higher than males [f = . (df = ), p < . ], thereby indicating greater agreement that the use of quarantine is justified in the context of an infectious disease outbreak. with respect to age, older respondents (> yrs) indicated greater agreement that use of quarantine is justified than did the young ( - yrs) [f = . (df = ), p < . ]. also, older respondents agreed more strongly that the use of sanctions for quarantine absconders is appropriate when compared both with the young and with the middle-aged ( - yrs) [f = . (df = ), p < . ]. there were no significant differences by region. the quarantine of exposed persons (along with the isolation of infected persons) has been properly described as the most complex and most ethically and legally controversial intervention within the jurisdiction of public health [ ] . complexity and controversy notwithstanding, the present data indicate a very high rate of public acceptance of quarantine as a means to control the spread of infectious disease. indeed, the vast majority of respondents indicated strong support for the use of quarantine in an infectious disease outbreak, for legal penalties against absconders, for social supports for those affected, and for public safeguards against potential inappropriate use. data on public attitudes toward quarantine in the wake of sars are scarce. public opinion polls have indicated high levels of acceptance of quarantine among samples of toronto-area residents ( %) and us citizens ( %) [ ] . these findings are supported by an observed non-compliance rate of only . % among torontonians requiring quarantine during sars [ ] . a qualitative study of factors influencing compliance with quarantine in toronto identified 'protection of the health of the community' as a prominent motivating factor. the authors of the study concluded that "while the overall compliance rate among residents of the gta appears to have been high, the influence of 'civic duty' and social responsibility may not be as significant in other countries and cultures" [ ] . comparative data from international studies do lend support to the theory that cultural values and societal norms impact upon quarantine compliance rates. researchers at the harvard school of public health and the u.s. centers for disease control and prevention surveyed residents of hong kong, taiwan, singapore, and the u.s. and found significant regional variability [ ] . the proportion of survey respondents favouring the quarantine of persons suspected of having been exposed to a serious contagious disease was as follows: % in the u.s., % in hong kong, % in singapore, and % in taiwan. by way of comparison, in the present study, % of respondents agreed that quarantine is a good way to stop the spread of infectious disease outbreaks. interestingly, in our study, significantly fewer ( %) agreed that public health officials should be able to detain those who fail to obey quarantine orders. likewise, in the harvard study, the proportions favouring the use of quarantine decrease significantly if people could be arrested for refusing (to a low of only % in the u.s. to a high of % in taiwan). the authors partially attributed the observed differences to prior experience with infectious disease outbreaks in which quarantine and other restrictive measures were implemented [ ] . in view of this inter-region variability, it is not surprising that the global community of public health experts is itself conflicted about the use of quarantine and other restrictive measures that impinge upon the intrinsic rights of individuals. those who favour the consideration of quarantine during infectious disease outbreaks maintain that it is prudent public health policy [ ] , whereas those in opposition argue that quarantine is inherently paternalistic and an unnecessary breach of basic human rights [ ] . despite the difference of opinion, however, there does appear to be general agreement on this: "ultimately, public health must rely not on force but on persuasion, and not on blind trust but on trust based on transparency, accountability, democracy, and human rights" [ ] . with a view to fostering further deliberation and constructive debate, we are proposing a conceptual framework for the ethical use of restrictive measures in public health emergencies (see figure ). building upon previous theoretical work on the justification for public health intervention [ ] , our model is designed to reflect the dynamic interplay among theory, empirical evidence, and policy/ practice that is inherent to public health. to that end, we have incorporated the empirical data from the public opinion survey described in this paper. the model explicitly contemplates the four primary functions of public health as regards the use of restrictive measures in infectous disease outbreaks, namely, response, enforcement, support, and oversight. for instance, with respect to the enforcement of quarantine orders, the model illustrates how the specific function of enforcement aligns with the ethical principle of the 'least restrictive means' and is likewise concordant with empirical evidence indicating strong public support for the use of sanctions to promote compliance with quarantine orders (survey data reported here). this conceptual framework for the ethical use of restrictive measures in public health emergencies should be considered provisional and, as such, is open to further testing and refinement. much has been learned from the unexpected arrival of sars in the spring of [ , ] . likewise, we continue to learn from historical analyses of the influenza pandemic, with one recent study providing strong support for the hypothesis that early implementation of public health measures such as quarantine can significantly reduce influenza transmission [ ] . given the current threat posed by pandemic influenza, it is incumbent upon the public health community-including ethicists and legal experts-to delineate both the limits to individual liberty and the obligations of public health authorities in the context of an infectious disease outbreak. it is noteworthy that the concept of 'voluntary quarantine' features prominently in many of the current plans for pandemic influenza. as contrasted with the classic quarantine order, which is typically enforceable by law, voluntary household quarantine refers to compliance based on the individual's own free will without legal compulsion. owing to the global threat of pandemic influenza, considerable planning and preparation for infectious disease outbreaks has been undertaken [ ] . there remains a pressing need, however, to engage the citizenry more fully in the process of preparedness planning in order to ensure that the plans reflect the common will and that the policies serve the common good [ ] . in this regard, the continuing growth in interest and activity in the subfield of public health ethics is certainly welcome and holds greats promise. while we believe the data reported here contribute to the goal of better planning and better preparedness, the present study is limited by its sample of respondents who were drawn only from the greater toronto area. our goal was to assess the attitudes and perceptions of those living in an area significantly impacted by the sars outbreak, but further research is now required to determine the generalizability of the present findings to other geographic regions and other populations. also, our survey was conducted after the conclusion of the outbreak; it is conceivable that public perceptions and attitudes toward the use of restrictive measures could be different during the course of an outbreak. finally, a relatively small proportion of our survey respondents were directly affected by quarantine during sars, which precluded any analysis of differences between those who were directly affected and those who were not. the use of restrictive measures such as quarantine draws into sharp relief the push and pull of opposing forces that characterize the dynamic interplay between the personal autonomy of the citizen on the one hand and the collective rights of the community on the other. as bensimon and upshur [ ] have argued, justification for quarantine cannot be founded upon scientific evidence alone; rather, the decision to implement quarantine should be equally an emerging conceptual framework for the ethical use of restrictive measures figure an emerging conceptual framework for the ethical use of restrictive measures. ii. iii. iv. informed by the values, preferences, and practices of the affected communities. the present findings indicate strong public support for the use of quarantine in the context of an infectious disease outbreak and for serious sanctions against those who fail to comply. our data further suggest, however, that public support for quarantine is contingent on the implementation both of legal safeguards to protect against inappropriate use and of psychosocial supports to provide for individuals who are adversely affected. this tension between individual rights and the greater public good is precisely the challenge that infectious disease presents to public health ethics. in order to engender strong public support for the use of quarantine and other restrictive measures, government officials and public health policy-makers would do well to implement a comprehensive system of supports and safeguards, to educate and inform frontline public health workers, and to engage the public at large in an open dialogue on the ethical use of restrictive measures during infectious disease outbreaks. sars epidemic unmasks age-old quarantine conundrum public health vs. civil liberties evidence and effectiveness in decision-making for quarantine public health and ethical considerations in planning for quarantine balancing public health and civil liberties severe acute respiratory syndrome: did quarantine help? is the quarantine act relevant? nonpharmaceutical interventions implemented by u.s. cities during the - influenza pandemic public health interventions and epidemic intensity during the influenza pandemic evaluation of control measures implemented in the severe acute respiratory syndrome outbreak in beijing public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto when is quarantine a useful control strategy for emerging infectious diseases? impact of quarantine on the sars outbreak: a retrospective modeling study risk perception and compliance with quarantine during the sars outbreak the psychosocial effects of being quarantined following exposure to sars: a qualitative study of toronto health care workers sars control and psychological effects of quarantine one-year outcomes and health care utilization in survivors of severe acute respiratory syndrome annual demographic estimates: census metropolitan areas, economic regions, and census divsions, age, and sex public health strategies for pandemic influenza: ethics and the law the public's response to severe acute respiratory syndrome in toronto and the united states factors influencing compliance with quarantine in toronto during the sars outbreak attitudes toward the use of quarantine in a public health emergency in four countries ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats bioterrorism, public health, and human rights upshur re: principles for the justification of public health intervention public health law and ethics: lessons from sars and quarantine ethics and sars: lessons from toronto stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza upshur r: public engagement on social distancing in a pandemic: a canadian perspective this article is dedicated to the memory of dr. sheela basrur, who served so many so well as medical officer of health for the city of toronto during the sars outbreak, and then later as chief medical officer of health and assistant deputy minister of public health for the province of ontario. the authors declare that they have no competing interests. cst performed the statistical analysis of the survey data, drafted the first version of the manuscript, and contributed to subsequent revisions. er initiated the study, participated in the design of the survey instrument, and contributed to the revising of the manuscript. regu participated in the statistical analysis, contributed to the revising of the manuscript, and will act as guarantor. all authors have read and approved the final version of the manuscript.publish with bio med central and every scientist can read your work free of charge the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -mi gcfcw authors: davis, mark d m; stephenson, niamh; lohm, davina; waller, emily; flowers, paul title: beyond resistance: social factors in the general public response to pandemic influenza date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: mi gcfcw background: influencing the general public response to pandemics is a public health priority. there is a prevailing view, however, that the general public is resistant to communications on pandemic influenza and that behavioural responses to the / h n pandemic were not sufficient. using qualitative methods, this paper investigates how members of the general public respond to pandemic influenza and the hygiene, social isolation and other measures proposed by public health. going beyond the commonly deployed notion that the general public is resistant to public health communications, this paper examines how health individualism, gender and real world constraints enable and limit individual action. methods: in-depth interviews (n = ) and focus groups (ten focus groups; individuals) were conducted with community samples in melbourne, sydney and glasgow. participants were selected according to maximum variation sampling using purposive criteria, including: ) pregnancy in / ; ) chronic illness; ) aged years and over; ) no disclosed health problems. verbatim transcripts were subjected to inductive, thematic analysis. results: respondents did not express resistance to public health communications, but gave insight into how they interpreted and implemented guidance. an individualistic approach to pandemic risk predominated. the uptake of hygiene, social isolation and vaccine strategies was constrained by seeing oneself ‘at risk’ but not ‘a risk’ to others. gender norms shape how members of the general public enact hygiene and social isolation. other challenges pertained to over-reliance on perceived remoteness from risk, expectation of recovery from infection and practical constraints on the uptake of vaccination. conclusions: overall, respondents were engaged with public health advice regarding pandemic influenza, indicating that the idea of public resistance has limited explanatory power. public communications are endorsed, but challenges persist. individualistic approaches to pandemic risk inhibit acting for the benefit of others and may deepen divisions in the community according to health status. public communications on pandemics are mediated by gender norms that may overburden women and limit the action of men. social research on the public response to pandemics needs to focus on the social structures and real world settings and relationships that shape the action of individuals. conclusions: overall, respondents were engaged with public health advice regarding pandemic influenza, indicating that the idea of public resistance has limited explanatory power. public communications are endorsed, but challenges persist. individualistic approaches to pandemic risk inhibit acting for the benefit of others and may deepen divisions in the community according to health status. public communications on pandemics are mediated by gender norms that may overburden women and limit the action of men. social research on the public response to pandemics needs to focus on the social structures and real world settings and relationships that shape the action of individuals. the re-emergence of infectious diseases is a leading public health problem. pandemics and epidemics [ ] including avian influenza, sars, ebola, and pandemic influenzaand the rise of anti-microbial organisms [ ] now threaten the health of populations around the globe. it has been argued that the re-emergence of these diseases marks the end of the golden age of medicine and the dawning of a period where health and security will be undermined by resurgent infectious diseases [ ] . pandemic influenza stands out in this situation because: it spreads quickly around the globe affecting many millions of people; it is associated with, potentially, high mortality, and; the world experienced a highly publicised, though ultimately mild for most, pandemic influenza in / . it is believed that another, more serious influenza pandemic is inevitable, though no-one, as yet, can predict when it will occur. for these reasons, explaining infectious diseases threats to the general public and encouraging them to adapt their health behaviours is high on the public health agenda. in relation to pandemic influenza, public communications feature in preparedness and response planning which requires that members of the general public adopt measures during a public health emergency, including: hygiene (e.g., covering the mouth and nose when sneezing or coughing, washing hands, keeping surfaces clean, avoiding sharing personal items) and the avoidance of close contact with others [ ] . understanding how populations respond is also crucial for the science that supports response planning. for example, mathematical models, which underpin pandemic response planning, factor in biological, psychological and sociological assumptions of how populations respond to infectious diseases [ , ] . effective communications with the general public and understanding how they respond, therefore, have a pivotal role to play in the management of pandemic influenza, in particular, and in the area of emerging infectious diseases, in general. however, knowledge of how to best communicate on pandemics with the general public and how they take up these messages is an emerging field with some inconsistencies [ ] . evaluations of the public health response to the / pandemic influenza claim that public communications were largely successful in preparing and reassuring publics during the emergency [ , ] . these findings need to be read against the fact that the pandemic was a short-lived and ultimately mild public health emergency for most people. there is a view, also, that members of the general public are resistant to pandemic risk messages. some commentary has suggested that the general population is increasingly resistant to public policy on global threats, including climate change and emerging infectious diseases [ ] . surveyswhich dominate the social scientific view on public responsesconducted during the pandemic indicate that populations in the uk and australia were complacent with regard to h n and reported insufficient behavioural responses [ ] [ ] [ ] [ ] [ ] . broad brush, risk communication research has identified that material circumstances and symbolic framing of risk [ ] , inequalities in education and access to media [ ] , (mis)trust in media and governmental advice [ , ] , all shape how members of the general public respond to communications on pandemics. close-focus, qualitative research offers the view that while the general public endorses governmental advice, in the circumstances of the / pandemic they were also unlikely to act in the ways advised by governments [ , ] . there are additional explanations for the apparent resistance on the part of the general public. for example, because they are bombarded with so many messages, including those pertaining to pandemics, members of the general public may by subject to 'health threat fatigue' [ ] . this is not the same as resistance. it is, instead, a dulling of alertness seated in screening out of overwhelming and competing risk messages. members of the general public appear to digest and critically reflect on risk communications messages [ ] , and tailor risk reduction strategies to their personal circumstances [ ] . it is also argued that the general public is only too aware of the 'boy who cried wolf ' syndrome [ ] , where too frequent assertion of danger leads publics to dismiss public health warnings. in addition, audience reception of communications on health is framed by the historic rise of individualism in society [ ] and health systems [ ] . individualism implies that members of the general public take on the view that responsibility for their health is a matter of personal volition and effort. this view is often utilised in health communications that call on people to take care of themselves, but it is a perspective that can obscure factors that are not within the control of the individual. it is also an approach to risk that has a moral loading and therefore a negative effect for those who are unablethrough choice or otherwiseto avoid health harms. exactly how individualism plays out in relation to pandemic influenza warrants further inquiry. because it is so vital that public health authorities communicate with members of the general public as effectively as possible and as there are competing explanations and routes of inquiry available in the literature, it is necessary to re-examine the apparent resistance to communications and advice on the part of the general public. a central challenge is to get beyond prevailing assumptions and build up a theory of public engagement informed by the life worlds of the general public [ ] . understanding why populations fail to sufficiently enact precautions must involve taking account of how lives are lived and the meanings ascribed to the threat of infectious diseases. indeed, what might look like lack of precaution may turn out to be reasonable given the material and symbolic circumstances of affected individuals and populations. a related challenge, then, is re-examining how public health characterises the general public in research on pandemics and in the more general area of emerging infectious diseases. taking these steps is vital to ensure that the public health response and its communications with the general public are as resonant, meaningful and effective as possible. this paper, therefore, uses inductive, qualitative research methods to develop new knowledge on how members of the general population respond to pandemic influenza, set against the backdrop of the assumed resistance on the part of the general public and related critiques, including, health risk fatigue, the risk communication dilemma and individualism. the analysis poses the question: how do members of the general public respond to the threat of pandemic influenza and to the hygiene, social isolation and other measures proposed by public health? by addressing this question in the manner indicated, the paper offers an alternative framing of pandemic influenza perceptions and behaviours in an effort to contribute to the better health of individuals and populations facing risk of infectious diseases. the following analysis was generated in international research (australian research council discovery project dp ) focusing on the responses of members of the general public to the events of alongside interviews with researchers, clinicians and policy-makers [ , ] and analyses of the public policy texts on pandemic influenza control [ ] . this research has examined general public data in light of sociological and psychological perspectives on responses to pandemic influenza [ , [ ] [ ] [ ] [ ] . the present paper synthesises and builds on the research undertaken on the general public, in particular, and introduces new data analysis to address the public health challenge of effective communication and engagement with members of the general public. interview and focus group participants were recruited through community sampling in melbourne, sydney and glasgow. generating data in australia and scotland addressed the international dimension of pandemic influenza and the events of . australia was closely observed by other nations as early stages of the global pandemic in coincided with the southern hemisphere influenza season. the pandemic quickly affected melbourne, which reported a high and early peak of known infections [ , ] . the city, for a time was known as the 'flu capital of the world.' the first confirmed cases in the uk were in scotland among passengers on a flight from mexico to glasgow [ ] . the uk and australia reported [ ] and [ ] deaths, respectively, associated with the h n pandemic. our analysis of interview and focus group texts reveals more convergence than difference between melbourne, sydney and glasgow, perhaps because the pandemic was managed in those cities by public health professionals who were members of a global pandemic response network. the research aimed to identify how members of the general public respond to pandemic influenza so that public health communications can be designed to engage with how its audiences respond to risk messages and how they enact hygiene, social isolation and related measures. four purposive criteria were used to select respondents in each city: women who were pregnant during (or with a new baby); older members of the community ( years of age and older); people with compromised immune systems and or respiratory illness such as asthma; and people who self-identified as being 'healthy' (e.g., no disclosed health problems) and who did not belong to one of the former categories. in addition, selection of participants was conducted to ensure: a balance of male and female participants and a range of ages from years upwards. drawing on interviews and focus groups ensured depth and breadth. interviews explored in-depth discussion of personal experiences of living through the h n pandemic, seasonal influenza and related concerns. focus groups examined social norms concerning precautionary behaviours regarding pandemic influenza. between april and may , people participated in the research (see table ) in interviews and ten focus groups (with participants). interviews included people from the purposive criteria (pregnant = ; + = ; hiv/respiratory illness = ; healthy = ); a gender mix (women = ; men = ), and; an age range of to + years. focus groups included people from the + group ( ); hiv/respiratory illness ( ) and the healthy group ( ); a gender mix (women = ; men = ), and; an age range of to + years. this pattern of participation reflects the challenges of recruiting women who were pregnant in , the very elderly and men. seven respondents reported having been diagnosed with h n ; none through a laboratory-confirmed test (a reflection of our community sampling). a further eleven interviewees reported that a relative, friend or other social contact had been diagnosed, clinically. it needs to be acknowledged, however, that, as influenza is not ordinarily diagnosed with a laboratory confirmed test [ ] , public health professionals and members of the general public identify and manage the infection on the basis of symptoms. indeed, respondents noted difficulty determining whether they had had influenza participants were asked to speak about their experiences with influenza and the public health response to the pandemic. topics for discussion included: health background (including pre-existing medical conditions, other infectious diseases, influenza vaccination); influenza experiences (including knowledge of pandemic influenza, sources of knowledge, experiences with the pandemic and seasonal influenza, prevention of infection, caring for self and/or someone else with infection); public communications (including broadcast and electronic media, public health advice, advice from gps, workplace and schools). verbatim transcripts of interviews and focus groups were analysed using an inductive, theory-building method. all transcripts were open coded to generate themes for analysis. interpretive memoranda were generated which explained each theme and how it connected with existing perspectives on the general public response to pandemic influenza. the research team reviewed these themes and memoranda to ensure that the themes were understood and that they could withstand refutation. this discussion also provided the basis for an agreed coding scheme that was used to re-code all data. key themes were identified for subsequent, in-depth written analysis in the form of technical reports and draft manuscripts. our approach to coding, memo writing and in-depth analysis sustains a dialogue between theory (pre-existing categories derived from social science theory and the relevant literature) and data (inductively-derived themes). this approach avoids the traps of overly dataor theory-driven analysis and ensures that the research has relevance to the field. this paper, therefore, is based on in-depth, nuanced analysis of interview and focus group texts that offers new perspectives and propositions, which provide the basis for interrogating prevailing assumptions regarding the general public response to pandemic influenza. this approach is consistent with social inquiry of the highest standard [ ] . the assumed complacency and resistance on the part of members of the general public was not in evidence in the narratives provided by our research participants. other factors, centred around health individualism and contextual factors such as gender and biomedical situation do appear to influence how people respond to the threat of pandemic influenza. in what follows, we focus on themes that establish and complicate the role of health individualism and its effects in the responses of members of the general public to pandemic influenza. the interviews and focus groups revealed a tension to do with self and other in relation to the threat of pandemic influenza. as we have discussed elsewhere, respondents endorsed the pandemic control measures advocated by public health authorities [ ] . they agreed that hygiene control measures (coughing and sneezing etiquette) and social distancing were valuable. this endorsement held in australia and scotland. characteristically, however, respondents did not believe that pandemic influenza could be prevented in the long run. they believed that the influenza virus was easy to catch and that hygiene measures and social isolation were difficult given that social interaction was needed to sustain work, schooling, the family and daily life. for this reason, respondents focused on strengthening their immunity through, for example, taking vitamins and eating healthy food: i think if you're healthy, keep up your vitamins and eat the right foods, drink healthily, eat healthily and live healthily. exercise. you've got to do all those things. (heather, +, melbourne) this immunity boosting was seen as a prudent defence against the seemingly inevitable moment of exposure and a means of coping with infection when and if it occurred. importantly, this focus on one's body and immunity in the face of seemingly inevitable infection accentuated health individualism, encouraging members of the general public to focus on their body's abilities to resist and cope with infection. there was evidence that immune boosting has the status of a social norm as those who were seen to succumb to infection were sometimes judged as failing to adequately care for themselves, even though it was admitted that the virus was easy to catch. to some extent individualism is an asset for public health interventions that seek behaviour change at the individual level. however, an individualistic approach to pandemic risk may obscure factors that the individual cannot control and, as indicated by the judgement of those who acquired infection, health individualism may be moralising. health individualism was not the only factor influencing how members of the general public perceived risk for pandemic influenza and took action. respondents who had responsibilities for others (e.g., pregnant women, people in couples or caring for people with health problems, families with children) or who saw themselves as vulnerable to influenza (e.g., respiratory illness, immune disorders) focused on social units such as the couple, family and colleagues at work: well given that the flu broke out at xxxx street primary school and my son was three and he was at xxxx street childcare, i pulled him out. so when my husband picked him up that day i was at work. i said, 'take him home. give him a bath. wash his clothes.' yeah. i stopped sending him and i was one week off my maternity leave so i stopped work a week early … i didn't go to the supermarket, didn't really mix. (gill, pregnant, melbourne, - years) it appears, then, that both health individualism and relationships with important others influence what people do. in this regard, social proximity appears to be important, that is, those others who are close to oneself in terms of social and emotional ties and living situation are factored into health precautions. this social proximity also showed up in the ways in which respondents saw geographical distance and low population density as protective. those respondents living further away from the populous 'epicentres' of infectioncentral melbourne, for examplebelieved that they were less likely to encounter someone with the virus. ' we're familiar with chest infections' one important way in which this tension between responsibility to oneself and to others came to light in interviews and focus groups related to differences between the responses of those with pre-existing conditions and those who identified as 'healthy.' those who faced increased risk of serious disease focused on their relationships with othersincluding strangers they might encounter in public spaceslargely in an effort to protect themselves. those with no vulnerabilities showed themselves to be archetypally focused on their individual health. for example, people with severe respiratory illness reported that engagement with the risks of influenza was a 'well trodden path' for them: as lung patients, we're, we're familiar with chest infections and, as joy says, we could, we could have a flu and not know it. and the gp checks us over. and the only way that i know that they'll know whether it's a chest infection or flu, or pneumonia, is for an x-ray. (arthur, lung disease, melbourne, + years) people with pre-existing lung conditions, then, were commonly hyper-vigilant during the pandemic and their accounts were peppered with examples of how social interaction was imbued with risk for them and also some resentment that the healthy majority seemed to not understand the significant threat that influenza infection might pose to their health [ ] . people with immune disorders in our sampleprimarily hivunderstood they needed to be vigilant but saw influenza as a lower priority than their hiv infection and its effective management. older respondents ( +) conveyed judicious vigilance tempered with an unwillingness to be seen to overreact. important in these accounts was awareness of the vectors of transmission and that one's health was to some extent dependent on those with whom one interacted. in contrast, the healthy majority of our respondents saw pandemic influenza as a personal, though distant, health threat. they saw themselves 'at risk' and possibly as 'a risk' to close family, but not as 'a risk' to unknown others (e.g. a person sitting beside them on public transport). this focus on the 'at risk' self to the exclusion of the self as 'a risk' to others underlines how health individualism manifests in the responses of the 'healthy' majority of the general public. this focus of the healthy on their own health risks (at the expense of others) surfaced in narrative on expectations of recovery from influenza: like you sort of just, you think, maybe you just think influenza as a common cold sort of thing. and it's like, 'it'll pass. i might go to the doctor's and get some, something to help me get through it, ' or something. but yeah, i don't know … it's just like, 'just ignore it and push through.' (chris, healthy, melbourne, - years) this interview participant shows how a healthy individual engages with pandemic influenza as a commonplace and personal risk, in contrast to those with pre-existing conditions who have to take pandemic, and even seasonal, influenza seriously. this expectation that one can 'push through' reinforces the previous theme noted with regard to the focus on the capacity of one's body to deal with infection. it is also an orientation to influenza risk that sets the scene for individuals to determine that infection is a risk worth taking since recovery is likely. also, recovery expectations synergise with the belief that infection is difficult to avoid in the long run. this means that people may assume that, while non-pharmaceutical strategies of pandemic control are sensible, their limited utility is set against the likelihood of recovery. this nexus of risk calculation helps explain why segments of populations appear to be complacent in surveys, as noted above. they may in fact be making multi-layered risk assessments of the likelihood of infection, their health status and expectations of recovery. another important provision on health individualism was the gendered meanings of one's response to infection. particularly in domestic settings, the management of respiratory illness was largely feminised. women provided elaborate accounts of managing the respiratory infections of family members while men did not. importantly, the pejorative term 'man flu' was used to denote the over-inflation of mild symptoms to gain sympathy and respite from normal activities, with connotations of questionable masculinity: it's always a little difficult to tell when you're moving from, sort of, a cold through the man flu to proper influenza. (vincent, healthy, sydney, - years) these findings imply that responses to pandemic influenza in real world settings areas with other health problemsassociated with gender roles which shape behaviour, for example, women may be expected to perform infection control and symptom management, while men are expected to not show their symptoms and 'soldier on' or face accusations of 'man flu.' the uniform implementation of social distancing and other protective measures may therefore be compromised. accentuating the role of gender in response to messages concerning pandemic influenza, pregnant women found themselves thrust into a position of particular risk during the / pandemic, at a time when they were already taking responsibility for the well-being of their unborn child. in particular, the prospect of vaccination elicited varied, often emotion-laden, responses: well, (sigh) when you're pregnant everything is about the baby … you just want to try and make your baby as healthy as possible and you want to try and keep your baby safe. (rebecca, pregnant in , glasgow, - years) the imperatives of good motherhood and responsibility for their unborn children placed these women into the emotionally-charged position of having to make decisions regarding virus protection in circumstances of intense uncertainty [ ] . some distress was apparent among the pregnant women respondents, but also great resilience and active use of public policy information to protect themselves and their babies. as rebecca's account, above, indicates, health individualism in tension with responsibilities to others, gender and one's life situation played out in engagements with vaccination. though recollection was variable, respondents in the present research ( %) reported that they had had an influenza vaccination at some point in their lifetime and there was no evidence of 'in principle' resistance to vaccination. this is a notable finding given that participants were sought in community settingswhere those with anti-vaccine views are thought to be locatedand in light of commentary that members of the general public are resistant to the science and technology used to manage global threats. indeed, endorsement of public health measures and attempted compliance characterised the respondents' accounts, with the provisos on the practical value of non-pharmaceutical strategies of infection control and management, as already discussed. but, taking on vaccination was not always straightforward: i saw in the press releases about the vaccine and i remember ringing the clinic and they said,'well if we were to give it to you, you'd have to come to the hospital and that's gonna put you at risk of getting exposed to it so we'd rather you not come in for the, for the vaccine.' and i was thinking,'well that's a bit of a catch importantly, though, vaccination, like non-pharmaceutical infection control, was mostly discussed as a personal strategy of health protection. apart from those with pre-existing vulnerabilities, vaccination was not readily understood as a method for protecting others and therefore society. this individualistic focus on one's own health implies that efforts to promote 'herd immunity' may not accord with perceptions and behaviours of the healthy majority. the findings question the prevailing view that the general public resists risk communication with regard to pandemic influenza. nor do the related ideas of complacency and fatigue seem relevant. more salient was multi-layered risk management informed by health individualism and to some extent tempered by interpersonal responsibilities, one's personal circumstances, gender, expectations of recovery, and prior experiences with influenza. as others using qualitative methods have also suggested [ ] , respondents did not reject what was done by governments in . they show interest in pandemic influenza, though their mode of engagement with it varied. they indicated that they wished to be informed but reserved the right to interpret and apply advice according to their own situation. public health guidance on hygiene and social isolation was endorsed, though its utility was largely found to have practical, long-term limitations given that social interaction was fundamental to daily life and the transmission of the virus. resistance and the related notions of complacency and fatigue, then, appear to have limited value for explaining how members of the general public respond to pandemics. part of the reason for this inapt attribution of research results to public resistance concerns research approach. forced choice surveys produce measures of hypothesised variables thought to influence behaviour. in-depth interviews and focus groups yield a different picture, where general public perceptions of the dangers of pandemics are placed in the context of what appears to be endorsement of the efforts of public health, tempered with awareness of the practical difficulties of managing influenza on a local basis. personal experience narratives reveal members of the general public to be engaged and willing to apply guidance in real world settings, though also aware of limits on what might be possible in time of pandemic. going beyond the idea of resistance, our analysis offers an alternative framing of how members of the general public respond to pandemic influenza. health individualism complicated by life circumstances (family life, health status) and the gendering of the meanings and practices surrounding the experience of influenza and how to deal with it in real world settings, appear to be important. risk communications are likely to benefit by addressing these influences on risk management behaviours. in particular, emphasising individual responsibility in risk communication may amplify divisions between people with different biomedical vulnerabilities and encourage those who consider themselves healthy to think of themselves as 'at risk' but not 'a risk' to others. this is a major hurdle for public health, particularly when hygiene, social isolation and vaccination are likely to become more important methods for controlling the spread of re-emerging infectious diseases. the pejorative, gendered meanings of influenza, of which 'man flu' stands as exemplary, point towards the deeply inscribed gendering of responses to infectious diseases. the role of gender in social aspects of health care is no surprise, but fully-fledged gender analysis is yet to be acknowledged in the public health address to the general population with regard to pandemics. in particular, messages to enact hygiene and social isolation are likely to accentuate already feminised health care in the domestic sphere. further, it is not simply that women are burdened with the labour of influenza care and men not. if men do find themselves unwell they risk accusations of 'man flu' and may therefore avoid making themselves available for health care interventions, a dynamic which keeps men out of the gp clinic in general [ ] . as recent reviews have indicated [ , ] , the influences of social factors on responses to pandemics need to be foregrounded in the social research agenda for better public health. our research indicates that health individualism and gender need to be part of this new research agenda. our findings also point to several further, specific, challenges for risk communication: ideas of proximity to risk; expectations of recovery, and; vaccination. proximity appears to be a blind spot in risk communications. public health messages of emergency are filtered by perceptions of proximity to threat, consistent with psychological theory [ ] and cultural constructs where the source of contagion is placed at a distance from self [ ] . we found that these ideas of proximity did surface in the narratives of members of the general public. yet, we know that, for example, within six weeks of the infection being detected in australia, people in remote communities in australia were found to be infected [ ] . risk communication needs to attend to these ideas of distance from risk and the related underestimation of the speed with which the influenza virus can travel in a hyper-connected world. expectations of recovery from influenza also appear to dominate narratives. as others have argued [ ] , healthy respondents recognised influenza infection as severerequiring bed and restbut thought that they would eventually recover. this finding implies that members of the general public may interpret infection as a risk worth taking, that is, that they can cope with infection if prevention fails them, due to their own choices or otherwise. members of the general public appear to be actively engaged with manifold risks that they juggle and prioritise in real world settings. our findings also suggest that taking up vaccination is not a simple matter, even among those who endorse the use of the biotechnology. survey findings have found that approximately % of australians are concerned about general vaccine safety [ ] and that australian [ ] and worldwide [ ] rates of h n vaccination have been found to be insufficient, prompting concerns that the 'anti-vaccine lobby' and other detractors are influencing use of this biotechnology. as noted, a slight majority of our respondents reported that they had been vaccinated in their lifetime and none spoke of vaccination as dangerous, though, of course, some may have held these views and not revealed them or opted out of our community-based recruitment strategies. our research, however, points to more immediate and practical considerations that shape how and when people vaccinate, including considerations of relative risk and whether or not a new vaccine should be used in pregnancy. attending to these more immediate concerns may be beneficial for public health, though we acknowledge that public perception of vaccine technologies is also an important public health agenda. the analysis presented is retrospective as the interviews and focus groups were conducted after the end of the pandemic on august [ ] , and therefore when it was known that the mortality rate had at first been overestimated [ ] . importantly, too, the respondents were volunteers selected according to purposive criteria, implying that the sample is not representative and that generalisations to populations are not strictly tenable. what the analysis offers, however, is the opportunity to drill down into how people make sense of pandemic influenza, therefore providing the basis for building theory on how members of the general public, think, feel and act in the contemporary era of efforts to manage global health threats. the perspectives identified here help situate what we know in social context and alert public policy to some dilemmas and alternative explanations of why members of the general public do what they do. for public health to shape the actions people take prior to and during a pandemic, we need to understand and engage with the perspectives of those acting. viewed from the outside, the behaviour of the general public has been cast as resistant. however, viewed from the perspective of ordinary people involved in anticipating and responding to infection, it is clear that public health has engaged its publics. this engagement is frequently informed by individualistic ways of assessing and responding to risk, social norms (e.g. gender roles), knowledge of the clinical uncertainties of influenza infection, and reasoned thinking about the limits of preventing influenza transmission. the current challenge for pandemic influenza preparedness and response is not so much to address public disinterest, but to acknowledge and engage with members of the general publics' experiences of influenza and how they make sense of, and act on, pandemics in real world settings. factors in the emergence of infectious diseases antibiotic resistance: long-term solutions require action now world health organization. the world health report : a safer 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pandemic (h n ) risk for frontline health care workers swine flu confirmed in the uk. in: the guardian australian government department of health and ageing. review of australia's health sector response to pandemic (h n ) : lessons identified. canberra: commonwealth of australia influenza symptoms and the role of laboratory diagnosis making social science matter: why social inquiry fails and how it can succeed again my wife ordered me to come!': a discursive analysis of doctors' and nurses' accounts of men's use of general practitioners a protection motivation theory of fear appeals and attitude change contagious: cultures, carriers, and the outbreak narrative remote community not in quarantine despite nation's first swine-flu death representations of influenza and influenza-like illness in the community-a qualitative study adult vaccination survey: summary results. cat. no. phe the - influenza pandemic: effects on pandemic and seasonal vaccine uptake and lessons learned for seasonal vaccination campaigns world health organization. h n in post-pandemic period: director general's opening statement a virtual press conference influenza a(h n ): lessons learned and preparedness submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution submit your manuscript at www this research was funded by an australia research council discovery project grant (dp ) with additional funding from glasgow caledonian university. we are grateful to casimir macgregor for assisting with interviews and to everyone who agreed to participate in interviews and focus groups. the authors declare that they have no competing interests.authors' contributions md helped conceive of this research, drafted this manuscript, managed the data collection and analysis in melbourne and integration with all data, and is a grantholder. ns helped conceive of this research, contributed sociology of public health perspectives to the manuscript and edited it, managed data collection and analysis in sydney and integration with all data, and is a grantholder. dl collected and analysed data used in this paper, conducted a literature review used in this paper, and contributed to the draft manuscript. ew collected and analysed data used in this paper and contributed to the draft manuscript. pf helped conceive of this research, contributed health psychology perspectives to the manuscript and edited it, managed data collection and analysis in glasgow, and is a grantholder. all authors read and approved the final manuscript. key: cord- -a ju mzx authors: ding, guisheng; zhu, guoding; cao, caiqun; miao, ping; cao, yuanyuan; wang, weiming; gu, yaping; xu, sui; wang, shengqiang; zhou, huayun; cao, jun title: the challenge of maintaining microscopist capacity at basic levels for malaria elimination in jiangsu province, china date: - - journal: bmc public health doi: . /s - - -y sha: doc_id: cord_uid: a ju mzx background: local malaria transmission has decreased rapidly since the national malaria elimination action plan was launched in china in . however, imported malaria cases from africa and southeast asia still occur in china due to overseas laborers. diagnosis by microscopy is the gold standard for malaria and is used in most hospitals in china. however, the current capacity of microscopists to manage malaria cases in hospitals and public health facilities to meet the surveillance needs to eliminate and prevent the reintroduction of malaria is unknown. methods: malaria diagnoses were assessed by comparing the percentage of first visit and confirmed malaria diagnoses at centers for disease control and prevention (cdcs) and hospitals. the basic personnel information for public health departments and hospitals at different levels was investigated. the skills of microscopists for blood smear preparation and slide interpretation were also examined at the county and township levels. results: inaccurate rate with . % and . %, respectively, in and , from and reported cases from sub-provincial levels in jiangsu province. most of the malaria cases reported in nantong prefecture from to involved patients who first visited county cdcs seeking treatment, however, none of these cases received confirmed diagnosis of malaria in townships or villages.the staff at county cdcs and hospitals with a higher education background performed better at making and interpreting blood smears than staff from townships. conclusions: the network for malaria elimination in an entire province has been well established. however, an insufficient capacity for malaria diagnosis was observed, especially the preparing and reading the blood smears at the township and village levels, which is a challenge to achieving and maintaining malaria elimination. remarkable progress has been achieved in china since the national malaria elimination action plan was launched in , and reported malaria cases have declined rapidly; only malaria cases were reported in [ , ] . however, the number of annual imported malaria cases has increased significantly in recent years because of increasing numbers of laborers and businessmen who work in africa and other malaria-endemic areas [ , ] . it is essential to detect all malaria cases in a timely manner for follow-up and foci treatment to prevent transmission or re-introduction. timely diagnosis is also important prior to malaria treatment, especially for falciparum malaria, for which severe symptoms and death can occur without timely treatment with antimalaria drugs [ , ] . furthermore, an accurate malaria diagnosis is crucial for the subsequent focal treatment to combat specific parasite species; this aspect is one of the most important issues for preventing secondary transmission and eliminating malaria in china [ ] . after the severe global sars epidemic in [ ] , cdcs from the national to lower levels in china were rapidly established and developed [ ] . these cdcs replaced the former sanitation and anti-epidemic stations in china, and the current network for malaria control and elimination is based on this system (fig. ) . independent or combined departments from the national to lower-level cdcs (or institutes of parasitic diseases) are responsible for malaria control and elimination; in addition, hospitals at all levels in china are involved. all the cdcs and hospitals are managed under health departments from the national health and family planning commission of the people's republic of china (moh) to the township governments. in this province, the regular refresher training courses are organized by both provincial and prefecture level every year to maintain the microscopical test skills from the majority of the counties' level, and there are two mutual-checking microscopists meetings every year, in which the microscopists from all the prefectures bring their positive and negative slides and checked by each other, in addition, the quality control system for the whole provincial microscopical test has been established, provincial reference lab for malaria diagnosis collect the slides quarterly and reviewed the reading accuracy and feedback the result to the administrative department. the number of rapid diagnostic tests (rdts) that are available and the scale of their use for malaria detection has increased rapidly over the past few years; however, rdts have a relatively poor detection rate for asymptomatic malaria cases with low parasite densities [ ] [ ] [ ] . in addition, limited rdt products for malaria have been registered with the state food and drug administration (sfda) in china; therefore, microscopic examination is still the first choice for malaria diagnosis in most parts of china. in this study, malaria diagnosis in jiangsu province and a selected prefecture (nantong) in central jiangsu province was investigated (fig. ) . the blood smear preparation and interpretation skills of the staff at local public health departments were also assessed. moreover, medical departments at the county and township levels were evaluated in and to identify surveillance challenges to malaria elimination and to prevent re-introduction. basic information, including the public health system network for malaria control and elimination, the number of malaria cases reported annually and the number of cases examined microscopically, was investigated in jiangsu province and nantong prefecture from to . furthermore, the educational background, work experience and number of personnel in public health departments (centers for diseases control and prevention, cdcs) and hospitals involved in malaria control and elimination at the county and lower government levels were investigated in nantong prefecture. the percentage of confirmed diagnoses for malaria among all of the reported malaria cases from to in nantong were investigated, during the initial doctor visit due to febrile-related symptoms at different levels, i.e., the prefecture cdc, county cdc and prefecture hospitals at the county and township levels. to assess operational ability of microscopy examination for malaria diagnosis, half of the township hospitals were randomly selected in nantong, and one microscopist from each county cdc ( ), county hospital ( ) , and selected township hospitals ( ) was randomly selected to assess their skill at interpreting blood smears and tests to identify malaria parasites.ten blood smears from febrile patients diagnosed as non-malaria cases at a cdc or hospital were investigated and scored. ten indicators, including the blood volume, position, diameter, appearance, staining and clearance for both thick and thin blood smears, were scored based on criteria issued by the national cdc in to assess blood smear preparation and staining for malaria parasites [ ] . one point was given for each of the indicators (blood volume, position, diameter, appearance, stain quality and clearance for both thick and thin blood smears) for one slide, and ten slides were thoroughly checked. in addition, five blood smears comprising the four main malaria parasite species and a negative were randomly distributed on-site and tested by a microscopist or clinician. each smear was microscopically checked for eight minutes and scored; points were given for the correct determination of a positive or negative infection with parasites ( points for negative slides), followed by points for species identification. to ensure fair scoring, two experts from the provincial reference laboratory for parasitic diseases at the jiangsu institute of parasitic diseases who passed the diagnostic assessment for malaria parasites and obtained certification from the world health organization participated in the investigation. the average score of these experts was used to assess the preparation and staining of the blood smears. a chi-square test was used to compare the distribution of educational background, work experience and age between the county and lower levels in nantong. an analysis of variance (anova) test was used to compare the ability to accurately interpret parasites among the staff from county cdcs, county hospitals and township hospitals. anova was also used to analyze the role that educational background, work experience and age played in the preparation of blood smears and the interpretation of parasites among the staff of county cdcs, county hospitals and township hospitals. in total, and malaria cases were reported in jiangsu province and nantong prefecture, respectively, from to . both jiangsu province and nantong prefecture exhibited a similar trend for malaria cases and blood examination. first, there was an obvious increasing trend of malaria cases imported from other countries after , and and cases were reported in jiangsu and nantong, respectively, in . second, no indigenous malaria cases have been reported after in jiangsu and nantong. finally, a steady increase in the number of annual febrile patients receiving blood examination was observed from to both in jiangsu and nantong, followed by a rapid increase from to and a decrease from to (fig. ) . in total, and malaria cases were reported by prefectures in jiangsu province in and , respectively. all the reported patient samples were sent to and rechecked by the provincial reference laboratory using both microscopy and pcr-based molecular methods. overall, ( . %) and ( . %) cases, (table ) . almost half of reported malaria cases from to in nantong involved patients who sought a diagnosis in the county hospitals ( . %) or lower township and village hospitals and clinics ( . %) because of malaria symptoms. most of these patients went to the county cdcs ( . %), and only a small percentage of patients visited the upper prefecture hospital ( . %) or cdcs ( . %). similarly, most of the confirmed diagnoses occurred in county cdcs ( . %), followed by county hospitals ( . %), the prefecture hospital ( . %), and the prefecture cdc ( . %). there were no cases with a confirmed malaria diagnosis in the lower township hospitals or village clinics (fig. ) . there was a total of and microscopists involved with malaria diagnosis in county cdcs and township public health centers (phcs), respectively. there was a significant difference (x = . , p < . ) between the county and townships according to the distribution of educational backgrounds, and more county microscopists had bachelor degrees ( %) than those in the townships ( %). however, there were no differences in terms of work experience (x = . , p > . ), and most of the staff from the counties ( %) and townships ( %) had been working less than years ( table ) . in total, microscopists from county cdcs ( ), county hospitals ( ) , and township hospitals ( ) were selected for on-site assessment and testing. the staff from both county cdcs (mean = . , p = . ) and county hospitals (mean = . , p = . ) exhibited a higher score than the staff from township hospitals (mean = . ) for blood smear interpretation. staff with a bachelor degree exhibited a higher blood smear interpretation score than staff without a higher degree (p = . ; p = . ). furthermore, microscopists aged to years had better blood smear interpretation skills than staff younger than years old (p = . ). for blood smear preparation, staff in township hospitals with a bachelor degree performed better than staff with specialized secondary school degrees (p = . ). in addition, staff who were to (p = . ) and to (p = . ) years old performed better than staff who were older than years (table ). jiangsu province has had especially high malaria transmission in the last century; the malaria cases once reached more than million a year, which is almost one-fourth of the total population of the entire province [ ] . after concerted efforts from the national to regional levels, malaria transmission has been well controlled recently, and only hundreds of malaria cases have been reported in jiangsu annually [ ] [ ] [ ] , despite fluctuations after a re-emergence of vivax malaria in central china from to [ ] . no additional local malaria cases have been observed and reported since ; however, the total number of malaria cases increased markedly in the last several years because of oversea laborers who export and trade in china but have contact with areas of endemic malaria [ ] . nantong prefecture was selected in this study because it shows a pattern of malaria spread that this similar to that of the entire province and is a good current representative. the " - - " strategy for the surveillance of and response to malaria elimination was produced by jiangsu province and was recently adopted as the national policy for malaria elimination in china [ , ] . this strategy is defined as the reporting of malaria cases within one day, their confirmation and investigation within three days, and the appropriate public health response to prevent *: all of the malaria cases were diagnosed using microscopic examination or the rdt method in sub-provincial cdcs, hospitals and phcs and were reported to the jiangsu provincial malaria department through the web-based china information system for disease control and prevention (cisdcp) within h **: all of the blood samples in the reported malaria cases were rechecked using both microscopic examination and a pcr-based method in a provincial malaria reference laboratory further transmission within seven days. reporting of information is the first and one of the most important steps for malaria elimination. the correct diagnosis, including malaria infection and detailed parasite species classification, plays very important roles in case verification and focal treatment. a misdiagnosis of a malaria species might lead to the use of inappropriate antimalarial drugs and secondary transmission by local malaria vectors in the absence of timely vector control measures such as irs activity [ ] . in this study, a relatively low reporting accuracy was found in terms of the p.v species from prefectures in jiangsu province, and anopheles sinensis, one of the most effective malaria vectors, especially for transmitting vivax species in china, is widely distributed in the entire province [ ] . when the infection source accumulates without the correct foci treatment due to malarial case misdiagnosis, the infection can re-emerge. an impressive lesson demonstrating a re-emerging infection was observed in greece, where a vivax malaria outbreak occurred in after malaria was declared eliminated in [ ] , in addtion, more countries including italy, cyprus and costa rica have reported the reemerging infection recently (https://www.cdc.gov/malaria/). in china, a public health system network has been established and covers public health from the national to the most basic levels in rural villages. for example, each village has a village clinic with at least one doctor, where patients suspected of having malaria are advised to transfer to hospitals for parasite assessment and treatment as soon as possible, and there are specific sections/ departments that are responsible for public health care, including malaria control and elimination, at health care institutions at the township and upper governmental levels. however, a lack of sufficient technology and ability has always affected the staff in malaria-associated departments, especially at lower levels. furthermore, because the number of malaria cases is decreasing, less attention or financial support is directed to malaria control and elimination, making disease control worse at a basic level. in this study, there was a relatively high percentage of parasite species corrected by a provincial microscopy center from the cases that were reported by the sub-provincial organizations in jiangsu in and (table ). in addition, many patients ( . %) went to township and village hospitals but did not receive a confirmed diagnosis of malaria (fig. ) , which indicates that capacity for diagnosis, including microscopy examination skills, should be improved. the quality of microscopic malaria examination is dependent on the competence and performance of laboratory technicians, including blood smear preparing, staining, and interpreting. in this study, staff with higher education levels were more likely to be found at upper county levels than in townships. this study shows that staff at a county level, including county cdcs and county hospitals, exhibited much better skills than staff from township hospitals or phcs in terms of parasite interpretation. in fact, a small percentage of the staff at township hospitals and phcs could not differentiate falciparum from other species, which could place the current malaria elimination surveillance system at risk. in addition, the ability to prepare slides was also closely related to educational background. for example, microscopists with a bachelor degree had better blood smear a b fig. the distribution of malaria patient treatment and confirmation diagnosis in nantong, jiangsu province. (a) refers to malaria patients who first sought treatment for febrile-related symptoms, and (b) refers to the confirmation of malaria infection preparation skills than those who graduated from a year specialized secondary school. consequently, it is imperative to encourage more young and promising graduates with a higher education level to join the malaria control and elimination network. in elimination settings, a village clinic doctor or township phc workers are responsible for malaria case management and subsequent investigations. in this study, a substantial number (more than %) of the malaria patients went first to the township or lower level to seek medical treatment because of febrile or other malariarelated symptoms. however, none of these patients received a confirmed diagnosis at the township and village level. this inability to diagnose malaria might represent the situation in the entire province, because similar results were found from reporting data in other cities in jiangsu province: a zero or a very low percentage of patients received malaria confirmation at the township or village level. the main reason for this lack of confirmation might be due to inadequate ability in the lowerlevel staff to microscopically distinguish plasmodium parasites from artifacts. in addition, because the staff in township hospitals in particular are responsible for many disease diagnoses and treatments, it is difficult to perform well under time constraints and a heavy workload, and poor quality blood smear preparation might result. accordingly, periodic refresher training, frequent supervision, and the establishment of a testing program should be provided by a provincial reference laboratory to lower level personnel, especially in townships in the province, to maintain microscopic skills and ability. additionally, an alternative approach, such as rdts, should also be considered for use, particularly at the township and village levels, to avoid potential misdiagnoses and missed diagnoses of malaria, which may cause death in falciparum malaria cases due to the lack of timely and appropriate diagnosis and treatment. the insufficient capacity for malaria diagnosis at a lower level is one of the challenges to achieving and maintaining the goal of malaria elimination in china. therefore, regular training and supervision of microscopic examination skills should be provided to staff especially at the township level. in addition, more graduates with a higher degree should be encouraged to join the public health network to improve the current township capacity for malaria elimination. moreover, an alternative approach, such as using rdts, should supplement microscopy examination especially at a lower level. china ( ik ). the funders had no role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript. the datasets generated and/or analyzed in this study are available from the corresponding author on reasonable request. authors' contributions gsd, gdz, hyz and jc conceived and designed the study. gsd, cqc and pm organized the microscopical test. gdz, gsd, yyc, wwm, ypg, and sqw analyzed the data. gdz drafted the manuscript, and hyz and jc revised the manuscript. all of the authors read and approved the final manuscript. ethics approval and consent to participate this study was reviewed and approved by the institutional ethics committee of jiangsu institute of parasitic diseases (jipd). the written informed consent was obtained from all participants before the interview or evaluation. consent for publication not applicable. ministry of health of the people's republic of china. national malaria elimination action plan shrinking the malaria map in china: measuring the progress of the national malaria elimination programme trends of imported malaria in china - : analysis of surveillance data malaria in overseas labourers returning to china: an analysis of imported malaria in jiangsu province epidemiological analysis of the deaths of malaria in china diagnosis and treatment of the febrile child third edition new challenges of malaria elimination in china epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong china dumps cdc head, probes lab world health organization submicroscopic carriage of plasmodium falciparum and plasmodium vivax in a low endemic area in ethiopia where no parasitaemia was detected by microscopy or rapid diagnostic test lessons learned from the use of hrp- based rapid diagnostic test in community-wide screening and treatment of asymptomatic carriers of plasmodium falciparum in burkina faso analysis report of the national technique competition for diagnosis of parasitic diseases in : i. capability analysis of plasmodium detection. zhong guo epidemic and control of malaria in jiangsu province malaria situation in the people's republic of china in malaria situation in the people's republic of china in malaria situation in the people's republic of china in malaria situation in the people's republic of china in malaria from control to elimination in china: transition of goal, strategy and interventions communicating and monitoring surveillance and response activities for malaria elimination: china's " - - " strategy mass drug administration for the control and elimination of plasmodium vivax malaria: an ecological study from jiangsu province susceptibility of anopheles sinensis to plasmodium vivax in malarial outbreak areas of central china a local outbreak of autochthonous plasmodium vivax malaria in laconia, greece-a re-emerging infection in the southern borders of europe? the authors thank the staff from the county centers for disease control and prevention in nantong prefecture for their assistance with this study. this work was supported by the natural science foundation of jiangsu province (bk , bk ), the jiangsu provincial department of science and technology (be and bm ), jiangsu provincial medical youth talent, the project of invigorating health care through science, technology and education ( ), and the general administration quality supervision, inspection and quarantine of the people's republic of the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. • we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord- -ohgkgvry authors: lu, ying; ni, yuxin; li, xiaofeng; he, xi; huang, shanzi; zhou, yi; dai, wencan; wu, dan; tucker, joseph d.; shen, guangquan; sha, yongjie; jiang, hongbo; huang, liqun; tang, weiming title: monetary incentives and peer referral in promoting digital network-based secondary distribution of hiv self-testing among men who have sex with men in china: study protocol for a three-arm randomized controlled trial date: - - journal: bmc public health doi: . /s - - -y sha: doc_id: cord_uid: ohgkgvry background: human immunodeficiency virus (hiv) testing is a crucial strategy for hiv prevention. hiv testing rates remain low among men who have sex with men (msm) in china. digital network-based secondary distribution is considered as an effective model to enhance hiv self-testing (hivst) among key populations. digital platforms provide opportunities for testers to apply for hivst kits by themselves, and secondary distribution allows them to apply for multiple kits to deliver to their sexual partners or members within their social network. we describe a three-arm randomized controlled trial to examine the effect of monetary incentives and peer referral in promoting digital network-based secondary distribution of hivst among msm in china. methods: three hundred msm in china will be enrolled through a digital platform for data collection. the eligibility criteria include being biological male, years of age or over, ever having had sex with another man, being able to apply for kits via the online platform, and being willing to provide personal telephone number for follow-up. eligible participants will be randomly allocated into one of the three arms: standard secondary distribution arm, secondary distribution with monetary incentives arm, and secondary distribution with monetary incentives plus peer referral arm. participants (defined as “index”) will distribute actual hiv self-test kits to members within their social network (defined as “alter”) or share referral links to encourage alters to apply hiv self-test kits by themselves. all index participants will be requested to complete a baseline survey and a -month follow-up survey. both indexes and alters will complete a survey upon returning the results by taking a photo of the used kits with the unique identification number. discussion: hiv testing rates remain suboptimal among msm in china. innovative interventions are needed to further expand the uptake of hiv testing among key populations. the findings of the trial can provide scientific evidence and experience on promoting secondary distribution of hivst to reach key populations who have not yet been covered by existing testing services. trial registration: the study was registered in the chinese clinical trial registry (chictr ) on , august , http://www.chictr.org.cn/showproj.aspx?proj= . prospectively registered. methods: three hundred msm in china will be enrolled through a digital platform for data collection. the eligibility criteria include being biological male, years of age or over, ever having had sex with another man, being able to apply for kits via the online platform, and being willing to provide personal telephone number for follow-up. eligible participants will be randomly allocated into one of the three arms: standard secondary distribution arm, secondary distribution with monetary incentives arm, and secondary distribution with monetary incentives plus peer referral arm. participants (defined as "index") will distribute actual hiv self-test kits to members within their social network (defined as "alter") or share referral links to encourage alters to apply hiv self-test kits by themselves. all index participants will be requested to complete a baseline survey and a -month follow-up survey. both indexes and alters will complete a survey upon returning the results by taking a photo of the used kits with the unique identification number. discussion: hiv testing rates remain suboptimal among msm in china. innovative interventions are needed to further expand the uptake of hiv testing among key populations. the findings of the trial can provide scientific evidence and experience on promoting secondary distribution of hivst to reach key populations who have not yet been covered by existing testing services. trial registration: the study was registered in the chinese clinical trial registry (chictr ) on , august , http://www.chictr.org.cn/showproj.aspx?proj= . prospectively registered. keywords: hiv self-testing, monetary incentives, men who have sex with men, peer referral, secondary distribution background background and rationale men who have sex with men (msm) are one of the key populations affected by human immunodeficiency virus (hiv) [ ] . compared to general populations, the risk of acquiring hiv is times higher in msm [ ] . in china, the hiv infection rate among msm was . % by [ ] . additionally, a large-scale systematic analysis illustrated that prevalence of hiv among msm in china increased substantially from to [ ] . hiv testing is considered as a significant stage of the hiv care continuum [ ] and the treat all strategy [ ] , because serostatus awareness can link patients to timely treatment and prevent wider transmission of hiv [ ] . thus, expanding hiv testing is crucial for hiv prevention and treatment. however, conventional hiv test services like healthcare facility-based tests fail to reach a wider hidden group of people, mainly due to the barriers including the stigma of hiv testing, the lack of confidentiality and privacy, low trust towards healthcare institutions, and inconvenience [ ] [ ] [ ] [ ] . to increase hiv testing among people who do not know their hiv status, the world health organization (who) recommends hiv self-testing (hivst) as an empowering and innovative way to reach those who have limited access to hiv testing and those who are at high risk of hiv infection [ ] . with hivst, individuals can decide where and when to test while ensuring efficiency, privacy, and confidentiality. hivst may be an effective alternative for those who do not regularly attend healthcare facilities, which may also be a promising approach to increase the uptake of hiv testing in key populations such as msm [ , ] . digital network-based secondary distribution of hivst could be an effective strategy for promoting hivst. this is a strategy that individuals (defined as indexes) to apply for multiple hivst kits and distribute them to their sexual partners or other members (defined as alters) within their social network [ , ] . a cohort study conducted in kenya has proven the feasibility and acceptability of secondary distribution of hivst among female sex workers [ ] . one observational study in china also indicated that secondary distribution of hivst successfully reached people who were not covered by traditional testing services and promoted case identification [ ] . digital health is also considered to be an innovative strategy to deal with traditional health challenges, including challenges for hiv prevention [ ] . for example, digital health has been used to promote safe sex, condom use, and awareness of hiv or sexually transmitted diseases among key populations [ , ] . for msm, social networking or dating apps are widely used, especially among young msm, which provides a unique opportunity of leveraging digital health in improving health services among them. combining digital health and social network-based strategy for hiv testing (i.e., secondary distribution) promotion can help surpass traditional barriers and reach more people who have never been reached by the facility-based services and increase case finding. in this study, we intend to examine two modified secondary distribution approaches for hivst through a three-arm randomized controlled trial in zhuhai, china. the main purpose of this study is to compare the effectiveness of two modified secondary distribution approaches (monetary incentives, and monetary incentives plus peer referral) with the traditional secondary distribution approach, in order to determine whether these two approaches can increase the uptake of hivst among msm, especially the first-time testers among alters. our trial aims to enable more chinese msm to receive hiv self-testing, reach more first-time hiv testing alters, and identify more people with an hiv-positive (reactive) result by implementing the photo-verified hiv self-testing method under different scenarios, i.e., standard secondary distribution, secondary distribution with monetary incentives and secondary distribution with monetary incentives plus peer-referral links. hypothesis : compared with standard secondary distribution, secondary distribution with monetary incentives will promote index msm to distribute more hivst kits to people within their social network. hypothesis : compared with standard secondary distribution, secondary distribution with monetary incentives plus peer referral will promote index msm to distribute more hivst kits to people within their social network. hypothesis : compared with monetary alone secondary distribution, secondary distribution with monetary incentives plus peer referral will promote index msm to distribute more hivst kits to people within their social network. this is a three-arm randomized controlled trial among chinese msm. enrolled indexes will be randomly assigned to one of the three groups: standard secondary distribution, secondary distribution with monetary incentives arm, and secondary distribution with monetary incentives plus peer referral. further, indexes will be asked to complete a baseline survey at the beginning of the trial, and a three-month follow-up survey after their hivst kits applications. a flowchart of the trial is shown in fig. . this trial, conducted in zhuhai, is a collaboration among the social entrepreneurship to spur health (sesh) research team, zhuhai center of diseases control (cdc), and zhuhai xutong voluntary services center (hereafter, xutong). zhuhai, located in southern china, has approximately , msm with an hiv prevalence rate of % [ ] . xutong is a local gay community-based organization (cbo) founded in and has developed a digital network-based platform for individuals (all-over time) to apply for free hiv/syphilis self-testing kits provided by zhuhai cdc. with xutong's social impact within the gay community, its volunteers will help with study recruitment, and their online platform will be used to support our intervention implementation. study recruitment advertisement will be posted via xutong's official account on wechat, a popular social site in china similar to facebook and twitter. the recruitment information will also be advertised on blued, the largest social network app within the gay community in china. potential participants can join the trial via the study ads and sign up for xutong's online platform. an eligible index is required to meet the following criteria: ) chinese born biologically male whose age is years old or older; ) ever had sex with another man; ) willing to self-apply hivst kits via xutong's digital platform; ) willing to provide personal contact information for future follow-up. all participants will need to sign an informed consent electronically before the study. randomization will be completed by a computer-generated program with a : : allocation ratio. a consented participant will be allocated to one of three study groups, i.e., standard secondary distribution group, secondary distribution with monetary incentives group, and secondary distribution with monetary incentives plus peer referral group. standard secondary distribution arm/ control arm index msm in this arm will be eligible to apply for up to hivst kits based on personal needs, and a rmb (≈ usd) deposit will be charged for each kit. the charged deposit will be refunded to the index if anyone (an index himself or alters to whom he distributed) return his/her testing result. in addition, the participants will need to provide contact information for kits shipping. all kits shipped to a participant will be packed with instructions in an unmarked box to protect privacy. each kit will be assigned with an identical confirmation code for future distribution tracking, and a unique "st" number for returned results tracking. after receiving kits, an index can choose to use the kits for themselves or distribute additional kits to alters such as sexual partners or friends. self-testing kit users can photograph and upload their results to the online platform anonymously by scanning the qr code attached on each kit box. figure shows the hivst reporting qr code for testers to return results. further, alters will be asked to fill out a survey regarding their experience of and attitude toward hivst. after the survey is completed, the deposit will be returned to the matched index by tracking the confirmation code. index msm in this arm will follow the same application process as in the control arm. differently, a fixed rmb (≈ usd), designed as the financial incentives, will be offered to all self-testers who report their results. when an alter returns his/her results, his/her matched index msm will also receive an extra rmb as incentives. index msm in this arm will first receive the same intervention as the participants received in the monetary incentives arm. in addition, apart from applying for up to five self-testing kits, each index msm in this arm will obtain a unique referral link, which can be shared with up to individuals within their social network to apply for kits, and each alter can apply for only one kit through the link. similarly, indexes will be given rmb for each matched alter who returns the result (whether through peer referral or direct distribution). all testers will receive a monetary incentive of rmb once they complete uploading their results. the follow-up survey will be administered months after indexes apply for hivst kits. this survey focuses on distribution history, the relationship between indexes and alters, and indexes' risky sexual behavior. the results from follow-up survey will be compared with baseline survey results to investigate whether the index msm has changed their behavior after hivst. xutong's volunteers will check returned self-test results. if there is any positive (reactive) result returned, volunteers will contact testers accordingly, and refer them to the local cdc to do confirmation tests. moreover, reactive testers will be encouraged to distribute hivst kits to their sexual partners or provide partners' contact information to volunteers for offering free testing service. the primary outcomes of this trial consist of three parts: ) mean number of motivated alters who have photoverified self-testing per index in each arm; ) proportion of first-time hiv testing among alters in each arm; ) proportion of alters with a positive hiv testing result in each arm. the secondary outcomes of this study consist of three parts ) risky sexual behavior among indexes and alters in each arm; ) adverse events reported during secondary distribution among indexes and alters in each arm; ) attitude towards and past experiences of hivst and sexual behavior among alters in each arm. in general, we aim to examine the effectiveness of our modified secondary distribution models. primary outcomes of this trial are the number of alters, first-time testing alters, and hiv-positive alters in each arm, therefore, all testers' information will be specifically clarified and recorded. all data will be collected through jin-shuju, a secure online platform where participants can apply for hivst kits, report testing results, and complete the baseline and follow-up questionnaires. all data collected from participants will be examined and deduplicated according to phone number and ip. in the baseline survey, we will collect the sociodemographic characteristics, sexual orientation, sexual behavior, hiv testing history, and social network. when alters return the results, they will also complete a questionnaire online. in this survey, except for basic information on socio-demographic characteristics, sexual orientation, sexual behavior, hiv testing history, and social network will be collected. we will also investigate the attitudes and experiences towards self-test. the follow-up survey for indexes will take place months after the application completed, which focuses on experiences and attitudes on using and distributing self-test kits. the survey mainly inquires about the occurrence of intimate partner violence (ipv) or other adverse events, the relationship between the indexes and the alters, whether indexes have tested together with the alters, and whether indexes have guided the alters on how to perform hivst. specifically, in our surveys, socio-demographic characteristics include indexes' age, sex, marital status, the highest level of education completed, and monthly income level. sexual behavior within months includes previous sex with males and females, role during sex with males, condom use, number of sex partners, and drug use. hiv testing history includes health care facility-based and online hiv testing experience. social network collects community engagements [ ] , community connectedness [ ] , identity fusion [ ] , and social cohesion [ ] . all blood samples will be analyzed using sd bioline hiv/syphilis duo test kits (sd bioline company, south korea). participants will collect fingertip blood samples by themselves according to the instruction. the trained staff of the cdc or cbo will check and read the photos of result and record them in jinshuju. the results are subject to the reading of the staff. participants will be involved at one to three stages: the baseline questionnaire, results return, and follow-up survey. however, there might be data missing in the primary and secondary outcomes. if there is < % of participants missing in the follow-up, a complete-case approach will be applied. if there is ≥ % of participants missing in the follow-up, we will investigate the missingness mechanism and use suitable imputation. sample size according to preliminary study results, on average, the number of alters motivated by an index man was . through standard secondary distribution, . through sd/monetary incentives intervention, and . through sd/monetary incentives plus peer referral intervention. we assumed that the variances of the three groups were equal with the same standard deviation of . (preliminary data, unpublished results). further, we estimated an effective sample size of participants ( in each group), with a power of . , an alpha of . , and a lost to follow-up rate of . . all statistical analyses will follow the intention-to-treat principle. missing data will be handled by multiple imputations. categorical variables from the baseline survey will be aggregated in frequency distributions, and numerical variables will be summarized in mean and standard deviation. we will first calculate primary outcomes in each arm, i.e., mean number of alters that each index recruited, proportion of first-time hiv testers, and proportion of alter testers with an hiv-positive result. secondly, we will compare calculated means using two-sample t-test, and proportions using chi-square between sd/monetary incentives arm and control arm, sd/monetary incentives plus peer referral arm and control arm, and also between two intervention arms. results of the follow-up survey for indexes and the survey for alters will be used for measuring secondary outcomes, i.e. risky sexual behavior, adverse events during secondary distribution, and experience and attitude towards hiv testing. high-risk sexual behavior, defined as unprotected sex, substance use, or multiple sexual partners, are determined from survey questions such as "how often do you wear a condom during anal sex?", "in the past three months, how many sexual partners did you have?", "in the past three months, have you used drugs before sex?", etc. adverse events or ipv that happened on alters during distribution are determined from the question "have you experienced any of the following ipv when received the hivst kit from the index?". alters' experience and perception of hivst are determined from total question items, e.g. "how difficult do you feel about completing hiv self-testing?", "how many men did you have anal sex with after hiv selftesting?", "which testing do you prefer, facility-based testing or hiv self-testing?", etc. we will use chi-square tests to compare each outcome of interests between sd/ monetary incentives group and control group, sd/monetary incentives and peer referral group and control group, and also between two intervention arms. despite global hiv control programs, hiv persists as a major public health threat among key populations such as msm [ ] . therefore, the screening of hiv in msm plays a key role in furthering prevention and control. hivst was considered to be an alternative strategy to promote hiv testing. digital network-based secondary distribution takes advantage of digital network, which can be a promising approach to enhance hivst. we apply innovative strategies on the basis of secondary distribution model, adding monetary incentives and peer referral to explore a more effective secondary distribution model and promote hivst to wider populations. however, it is necessary to consider several limitations of this trial. first, due to the digital network strategy, access to this hivst service is limited so that the recruitment might overlook individuals who cannot access online social tools. however, the mobilization and promotion from the local cbo xutong, as well as the faceto-face distribution initiated by index msm can somehow resolve the problem. second, in the online surveys, behaviors of participants are self-reported, which may increase the possibility of social desirability bias. it can lead to the hawthorne effect that participants may have deviations in behavior reporting because of the awareness of the trial. however, the form of the online questionnaire and limiting collection of identifiers can reduce bias. third, from the perspective of implementation and promotion, each participant can only apply once due to the design of the trial, while there may be participants who have the habit of regular testing and request to apply for hivst kits multiple times. while in this project we cannot satisfy such demand, the future implementation model can expand access to multiple applications. this study generates a social innovation and policy implication that expands and improves the public service of hiv prevention and control, with the use of social network strategies. from the perspective of digital health, digital network-based secondary distribution of hivst is an innovative delivery approach that can reach hidden msm. beyond the geographical limitation, some msm, especially those in remote conservative areas, have limited access to facility-based services, while digital platforms might motivate them to perform hiv testing. furthermore, by taking advantage of digital network-based distribution, we aim to reduce fear of stigma associated with conventional hiv testing services in healthcare facilities. social network strategies, especially peer referral, taps into self-identity with a community and trust to provide services more effectively. empowering vulnerable individuals within a community by offering essential resources has both research and policy implementations for expansion of hiv services in other hardto-reach populations. upon completion of the study, we will provide the community with practical digital networkbased hivst interventions and scientific evidence on the feasibility and acceptability of the secondary distribution approaches. in addition, practical experience and knowledge gained from conducting the interventions can be considered and applied to further trials in enhancing hiv testing. if successful, the strategy has the potential to be implemented in similar regions. the study timeline was designed from , september to , may . at the time of writing this draft protocol, study enrollment and data collection are ongoing. due to covid- pandemic, study recruitment expects to be delayed till , september , and the follow-up will be finished by december . thus, we have further updated the trial registration status, and updated the study period as , september to , december . ethics approval will be renewed annually. statistical analysis has not begun. the trial protocol conforms to the standard protocol items: recommendation for interventional trials (spirit) statement. global epidemiology of hiv infection in men who have sex with men unaids. global hiv & aids statistics - fact sheet the prevalence of hiv among msm in china: a large-scale systematic analysis patching a leaky pipe: the cascade of hiv care an ambitious treatment target to help end the aids epidemic. geneva: unaids community engagement in sexual health and uptake of hiv testing and syphilis testing among msm in china: a cross-sectional online survey organizational characteristics of hiv/syphilis testing services for men who have sex with men in south china: a social entrepreneurship analysis and implications for creating sustainable service models hiv-testing behavior among young migrant men who have sex with men (msm) in beijing acceptability of hiv self-testing: a systematic literature review point-of-care testing for sexually transmitted infections: recent advances and implications for disease control status of hiv self-testing in national policies world health organization rapid hiv self-testing: long in coming but opportunities beckon promoting male partner testing and safer sexual decision-making through secondary distribution of hiv self-tests by hiv-uninfected female sex workers and women receiving antenatal and postpartum care in kenya: a cohort study promoting partner testing and couples testing through secondary distribution of hiv self-tests: a randomized clinical trial social-media based secondary distribution of hiv self-testing among chinese men who have sex with men: a pilot implementation program assessment [internet]. ias digital health for sexually transmitted infection and hiv services: a global scoping review effects of internet popular opinion leaders (ipol) among internet-using men who have sex with men popular opinion leaders and hiv prevention peer education: resolving discrepant findings, and implications for the development of effective community programmes measuring community connectedness among diverse sexual minority populations identity fusion: the interplay of personal and social identities in extreme group behavior social cohesion, social participation and hiv testing among men who have sex with men in swaziland publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we appreciate the contributions from all study participants, cbo volunteers, and staff from zhuhai center for disease control and prevention, zhuhai xutong voluntary services center, and social entrepreneurship to spur health group. authors' contributions yl and yn drafted and finalized the paper with inputs from wt, dw and gs. jt provided critical revision of the paper. yz, dw, lh, and wt conceived the study. xh, xl, ys and sh assisted with recruitments. wt, yz, dw, jt, lh, wd, gs and hj provided oversight. wd and hj made insightful contributions to the study conception. all authors read and authorized the final version. this study received support from internal institute funding of zhuhai center for disease prevention and control, and the national institutes of health (nimh r mh - ). the funding source had no role in the process of study design, data collection, and analysis, decision to publish, or preparation of the manuscript. data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.ethics approval and consent to participate ethical review of biomedical research has been obtained from the ethics committee of zhuhai center for disease control and prevention prior to study enrollment. all participants will be provided online consents and sign it electronically prior to taking part in the study. not applicable. the authors declare that they have no competing interests.author details key: cord- -sy ncwgw authors: yap, jonathan; lee, vernon j; yau, teng yan; ng, tze pin; tor, phern-chern title: knowledge, attitudes and practices towards pandemic influenza among cases, close contacts, and healthcare workers in tropical singapore: a cross-sectional survey date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: sy ncwgw background: effective influenza pandemic management requires understanding of the factors influencing behavioral changes. we aim to determine the differences in knowledge, attitudes and practices in various different cohorts and explore the pertinent factors that influenced behavior in tropical singapore. methods: we performed a cross-sectional knowledge, attitudes and practices survey in the singapore military from mid-august to early-october , among personnel in four exposure groups - laboratory-confirmed h n - cases, close contacts of cases, healthcare workers, and general personnel. results: ( . %) participants responded. the mean age was . (se . ) years old. close contacts had the highest knowledge score ( . %, p = . ) while cases had the highest practice scores ( . %, p < . ). there was a strong correlation between knowledge and practice scores (r = . , p < . ) and knowledge and attitudes scores (r = . , p < . ). the significant predictors of higher practice scores were higher knowledge scores (p < . ), malay ethnicity (p < . ), exposure group (p < . ) and lower education level (p < . ). the significant predictors for higher attitudes scores were malay ethnicity (p = . ) and higher knowledge scores (p < . ). the significant predictor for higher knowledge score was being a contact (p = . ). conclusion: knowledge is a significant influence on attitudes and practices in a pandemic, and personal experience influences practice behaviors. efforts should be targeted at educating the general population to improve practices in the current pandemic, as well as for future epidemics. background >in april , a novel strain of influenza a (h n ) surfaced and has since spread widely across the globe with substantial clinical impact [ ] . effective pandemic management requires support from the population at risk for measures undertaken to mitigate the pandemic's spread. previous studies during the severe acute respiratory syndrome (sars) outbreak in have shown that individual beliefs and perceptions play an important role in subsequent desired behavior change [ , ] . higher perceived effectiveness of measures undertaken [ , ] and higher perceived threat of the disease led to higher rates of positive behavioral change, and better knowledge also increased the uptake of preventive measures [ , ] . similarly, in an anticipated h n epidemic these factors also influenced both self and community protective behavior [ ] . during the current influenza pandemic, studies have found that the individual's emotional status mediates behavioral response [ ] and that perceived severity and susceptibility to disease and perceived effectiveness of specific behaviors resulted in the corresponding recommended behavior changes [ , ] . to increase positive perceptions, clear dissemination of information served to reduce misconceptions [ ] . at the same time, interactions with family and friends influenced behavior, and distinct regional differences in behavioral responses were noted across various countries which may be due to socio-cultural differences [ ] . it is therefore important to perform behavioral studies in different populations to understand the determinants that influence behaviors. in tropical regions, influenza exhibits different seasonal patterns with a high baseline influenza-like illness rates and multiple influenza epidemic peaks annually [ ] . this may result in different behaviors towards influenza compared to temperate countries with clear influenza seasons during winter months -for example the generally lower influenza vaccination uptake in the tropics [ ] . however, there have been few studies on the knowledge, attitudes and practices towards the influenza pandemic in a tropical setting. there have also been no studies comparing such differences in various cohorts such as influenza cases, close contacts, and healthcare workers. as such, there is a need to understand the factors influencing such behavioral changes to promote effective management of influenza pandemics in the tropical setting. singapore, a tropical island city-state in south-east asia, experienced the local spread of pandemic influenza a (h n - ) from june to october in a single typical epidemic wave. our study, conducted in the singapore military, aims to study the differences in knowledge, attitudes and practices in various different cohorts and explore the pertinent factors that influenced behavior. we performed a cross-sectional survey in the singapore military from mid-august to early-october , after the peak of the local epidemic which occurred during the first week of august in singapore [ ] . the singapore military comprises of conscript males who serve compulsory military service after high school, and nonconscript regular servicemen. most servicemen stay in camp during weekdays and return to the community/ home during weekends, resulting in interactions within the military and general communities. as part of the military's pandemic response plan, every serviceman was given an information pamphlet on pandemic influenza, with information about the virus and preventive measures that could be taken to reduce risk of transmission and infection. the servicemen were also briefed on the above with emphasis on personal hygiene measures and socially responsible behavior (for example covering the nose and mouth when sneezing and coughing). other measures implemented include daily temperature monitoring, prompt reporting of all illnesses to healthcare staff, and laboratory testing of influenza-like illness clusters. laboratory confirmed cases of h n - were isolated at home for days, while close contacts of these confirmed cases were allowed to continue working but were given post-exposure chemoprophylaxis with oseltamivir and were segregated from the rest of the military units to prevent spread. in addition, all healthcare workers were required to don personal protective equipment including n- masks during their working hours. our study population consisted of distinct exposure groups of military personnel -laboratory confirmed h n - cases, close contacts of h n - cases (defined as those who had worked or lived with a laboratory confirmed h n - case during the infectious period), healthcare workers, and other general servicemen. the military maintained a comprehensive list of all laboratory confirmed cases of h n - and their close contacts, which were identified via contact tracing. an anonymous self-administered paper questionnaire was mailed to the respective servicemen with a self addressed envelope included for return of the survey forms. questionnaires were sent to all laboratory confirmed cases and their contacts, all healthcare workers in the military and general servicemen from various representative units in the military. approval for the study was obtained from the military's research committee. we developed a questionnaire to assess the knowledge, attitudes and practices (kap) regarding pandemic influenza. the questionnaire was based on similar questionnaires on this topic [ , ] , as well as concepts of health behaviours [ , ] , and was pilot tested among military servicemen with similar profiles to the actual cohort. the questionnaire collected basic demographic data on age, sex, ethnicity, education level and housing type while is a commonly-used national proxy for socio-economic status [ ] ; and included questions on knowledge, attitudes, and practices on pandemic influenza. questions on knowledge were used to assess a servicemen's general knowledge on pandemic influenza and on the recommended response measures. questions on attitudes were used to assess perceptions towards pandemic influenza and these measures. questions on practices were used to assess the actual compliance and practice of these measures. a summary of the questions assessed are shown in table . servicemen were asked to rate their agreement with the statements in the questionnaire, which were scored either yes/no or on a point likert scale. to determine the sample size, we assumed that responses within each group were normally distributed with standard deviation of %. to detect a true difference in means between groups of %, we will need participants per group to achieve power of . and p = . . due to the smaller number of known patients and contacts available, we mailed out more survey forms to general servicemen from various units to provide a larger control group and to account for nonresponse. to determine the scores for each individual, the responses were recoded to for an undesired response and for a desired response with the exception of risk perception questions which were scored proportionate to the level of risk perception. the mean scores were summarized as percentages. chi-squared tests of significance were used for analyses of categorical variables, and analyses of variance were used for continuous variables among the four exposure groups of servicemen (patients, contacts, medical personnel and other servicemen). the relationships between knowledge, attitudes and practice scores were examined using bivariate correlational analyses and multivariate linear regression models. all the demographic variables were found to be significant predictors in the bivariate analyses in at least one exposure group of servicemen, and were hence included in the multivariate models, which included the practice scores and attitude scores as the dependent variables. all statistical analyses were performed using spss . for windows (spss inc, chicago, il), with the level of significance set at %. surgical/paper masks are effective in reducing the spread of pandemic influenza. influenza vaccination is an effective measure against influenza. tamiflu is effective for treatment of pandemic influenza a (h n ). tamiflu is effective for prophylaxis (prevention) against pandemic influenza a (h n ). it is likely that i will catch the pandemic virus. how long do you think the pandemic influenza infection will last? are you worried or distressed about the pandemic? results a total of survey forms were mailed out ( patients/contacts, healthcare workers and to general servicemen). the overall response rate was . % ( / ). the response rates for patients/contacts, healthcare workers and other servicemen were . %, . % and . % respectively. table shows the demographics of the respondents. the majority of the respondents were males aged between - years old, reflecting the typical profile of our conscript military. general soldiers were of significantly lower education level and socio-economic status (as measured by the type of housing) compared to the other exposure groups. for the entire cohort, basic general knowledge of pandemic influenza a (h n - ) was in general good with the exception of the low awareness by servicemen that influenza can be spread by touch ( . %) and that it can present with nausea/vomiting ( . %) or diarrhoea ( . %). knowledge regarding efficacy of mask use, oseltamivir and personal hygiene measures were good with more than % positive responses. risk perception of illness was moderate, with almost half of the respondents believing they would be infected with pandemic influenza. for the practices, . % of the cohort had used masks during the course of the pandemic (when ill or as prevention), . % had previous seasonal influenza vaccination, . % had practiced avoidance behaviors such as social distancing, and . % practiced personal hygiene measures. less than a third of respondents avoided seeking medical aid for influenza symptoms despite worries regarding picking up the illness at medical facilities. comparing between the exposure groups of servicemen (table ) , there was a significant difference between knowledge and practice scores. close contacts had the highest knowledge score ( . %), followed by healthcare workers ( . %), patients ( . %) and general servicemen ( . %) (p = . ). patients had the highest practice scores ( . %) followed by healthcare workers ( . %) and contacts ( . %), while general servicemen had the lowest practice score ( . %) (p < . ). there were no significant differences in attitude scores between the cohorts. a greater proportion of patients used masks ( . %) compared to the other groups ( . - %) (p < . ). healthcare workers had the highest seasonal influenza vaccination uptake ( %) as compared to between - % in other groups (p < . ). contacts had the highest practice of avoidance behaviors ( . %) as compared to . %, . % and . % in patients, healthcare workers and general servicemen respectively (p < . ). general servicemen had the lowest mask usage ( . %), vaccination uptake ( . %) and practice of avoidance behaviors ( . %). from the univariate analyses, significant predictors for higher practice scores included female sex, exposure group (patients, contacts and healthcare workers compared to general individuals), ethnicity (malay and indian compared to chinese), older age group, private housing compared to room flats, and higher knowledge and attitude scores. the significant predictors of higher attitude scores were ethnicity (malay compared to chinese) and higher knowledge scores. the significant predictors for higher knowledge scores were contacts and healthcare workers, older age group, higher education levels, and private housing compared to room flats. from the multivariate analyses adjusting for potential confounders (table ) , the final significant predictors of higher practice scores were higher knowledge scores (p < . ), malay ethnicity (p < . ) and exposure group -patients (p < . ), contacts (p = . ) and healthcare workers (p = . ). servicemen with higher education level (ie. university degree) had significantly lower practice scores (p = . ). the final significant predictors for higher attitudes scores were malay ethnicity (p = . ) and higher knowledge scores (p < . ). the final significant predictor for higher knowledge score was being a contact (p = . ). the strongest overall correlation was between knowledge and practice scores (r = . , p < . ), followed by knowledge and attitudes scores (r = . , p < . ). the weakest correlation was between attitudes and practice scores (r = . , p < . ) ( table ). all exposure groups had significant correlation between knowledge and practice scores, as well as knowledge and attitudes scores. only healthcare workers had a significant correlation between attitudes and practice scores (r = . , p < . ). our study provides evidence on the correlation between knowledge, attitudes, and practices among different exposure groups. this has substantial implications for public health educators and planners in implementing pandemic preparedness plans. it was evident that the knowledge score was the main predictor of the attitude and practice scores with strong correlation between knowledge and practice scores and knowledge and attitude scores. on the other hand, attitude scores alone did not predict practice score and the correlation between attitude and practice scores was weak. this shows that good knowledge is important to enable individuals to have better attitudes and practices in influenza risk reduction. in a previous study on sars, better knowledge was also found to equate with better adoption of precautionary practices [ ] . clear communication and provision of updated information also helped improve vigilance and preparedness during the current pandemic [ ] . a recent study found that educating the public about specific actions to reduce risks and communicating about the government's plans and resources helped to improve compliance to good practices [ ] . of interest, higher educational status in our cohort was a significant negative predictor of good practice, showing that educational status alone does not determine behaviours. two previous studies on influenza [ ] and sars [ ] also showed that education level did not have any effect on uptake of recommended behvioural patterns. regarding influenza vaccine uptake and education level, some studies have showed that a higher education level resulted in higher influenza vaccination uptake [ , ] , while another study on influenza vaccination uptake showed varying influence of education levels on influenza vaccination in different countries [ ] . as such, it is important to focus on inculcating the correct knowledge to individuals as it will influence both attitudes and practices. on the other hand, positive attitudes on its own may not translate into desired behavioral change in the absence of adequate knowledge. for the exposure groups, influenza cases had the highest practice scores of all groups. use of masks was also highest among the influenza cases. having been infected with pandemic influenza appears to have a substantial impact in behavior and adopting risk reduction practices. although most if not all of these influenza cases will not be re-infected by the same pandemic virus again, adopting these practices will place them and their close contacts at lower risk for other influenza and respiratory virus infections. at the same time, healthcare workers and contacts of influenza cases also had higher practice scores compared to general servicemen. vaccination uptake was highest among healthcare workers and avoidance behaviors were the highest among contacts of influenza cases. healthcare workers and contacts have had greater and more direct exposure to influenza cases compared to the general population and this first-hand experience may have resulted in behavioral changes. this possibly reflects the effect of actual real-life experiences with influenza on individual behavior. it will therefore be important to determine solutions to instill the same level of positive behaviors in the general population without the need for prior infection or the personal experience such as being close contacts or healthcare workers. one possible solution would be the sharing and imparting of personal experiences to the general community ethnicity may also play a role in determining practices. we found that malays (an ethnic minority) had significantly higher positive practices as compared to the chinese (the ethnic majority). the indians (another ethnic minority) also had higher practice scores as compared to the chinese although this was not statistically significant. a previous study also reported that the ethnic minority groups had a . times higher likelihood of making recommended changes during this current influenza pandemic [ ] . another multi-ethnic study on a different subject (terrorism) showed that worry and voidance behaviours were more common among minority groups, suggesting that this effect may be due to shared perceptions of vulnerability or low levels of control [ ] but further research is required to determine the actual causes for this phenomenon during epidemics. overall efforts at increasing positive behaviours should therefore be rolled out to the entire population, with special focus on the ethnic majority. we found that age, sex, and housing-type (as a proxy of socio-economic status) did not predict knowledge, attitudes or practices. however, the vast majority (> %) of our participants were from the - age group due to the inherent nature of the military and our study was not structured to detect any differences due to extremes of age. in another pandemic study in the united kingdom, younger age was found to have greater uptake of recommended behaviors but not for sex and household income [ ] . however, another study on behavioral changes during sars found that the older age had an increased beneficial effect on behavioral change but not sex [ ] . this shows the differences in behaviors in different settings and towards different threats. future studies need to be performed in different age groups in specific settings to determine the actual platforms for intervention. the possible lack of representativeness of a military cohort to the general population is an inherent limitation of this study, especially for the overall age structure. however, it does represent the behaviors of an important age group for the influenza pandemic, which affects mostly children and young adults. the questionnaire was also administered over a period of time and individuals' responses may have changed across time as they are exposed to different messages across time, include messages highlighting the pandemic's mild nature. we attempted to reduce this by starting the survey after the pandemic's peak and concluding it before the epidemic subsided. the response rate of . % may also be of concern, but the study was sufficiently powered for all groups except influenza cases which numbers were smaller. interestingly, the response rates among cases/contacts was high, and lower among healthcare workers, which may itself suggest behavioral differences which should be further studied. given the anonymous nature of the survey, we were not able to obtain any data about non-responders. finally, our study was a cross-sectional survey and may not have been able to assess the true association between knowledge, attitudes and practices, and future cohort studies should be considered to validate the findings. knowledge is a significant influence on attitudes and practices in a pandemic, and personal experience influences practice behaviors. efforts should be targeted at inculcating relevant knowledge and educating the general population to improve practices in the current pandemic, as well as for future epidemics. world health organisation: pandemic (h n ) -update an 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the community's attitude towards swine flu and pandemic influenza widespread public misconception in the early phase of the h n influenza epidemic swine flu") influenza excess mortality from - in tropical singapore macroepidemiology of influenza vaccination (miv) study group: the macro-epidemiology of influenza vaccination in countries swine flu") social learning theory and the health belief model understanding attitudes and predicting social behavior singapore department of statistics: key indicators of resident households which determinants should be targeted to increase influenza vaccination uptake among health care workers in nursing homes? vaccine rates of influenza vaccination in older adults and factors associated with vaccine use: a secondary analysis of the canadian study of health and aging influenza vaccination uptake and socioeconomic determinants in european countries terrorism-related fear and avoidance behavior in a multiethnic urban population pre-publication history the pre-publication history for this paper can be accessed here knowledge, attitudes and practices towards pandemic influenza among cases, close contacts, and healthcare workers in tropical singapore: a cross-sectional survey we acknowledge the invaluable assistance provided by joseph kang, douglas wong, edmund de silva and vasanth from healthcare branch for their help in collecting the data for the study role of funding source this study was part of a singapore ministry of defence study and no additional funding was required.author details biodefence centre, ministry of defence, singapore. department of epidemiology and public health, national university of singapore, singapore. centre for health services research, national university of singapore, singapore. national centre for epidemiology and population health, australian national university, australia. healthcare branch, ministry of defence, singapore. department of psychological medicine, national university hospital, singapore. authors' contributions jy, vjl and pct conceived the study, collected the data, performed the analysis, and wrote the manuscript together. tyy collected the data and participated in the manuscript writing. tpn performed the analysis and participated in the manuscript writing. all authors have read and approved the final manuscript and the manuscript is currently not submitted for publication elsewhere. the authors declare that they have no competing interests. key: cord- - v ose authors: weston, dale; ip, athena; amlôt, richard title: examining the application of behaviour change theories in the context of infectious disease outbreaks and emergency response: a review of reviews date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: v ose background: behavioural science can play a critical role in combatting the effects of an infectious disease outbreak or public health emergency, such as the covid- pandemic. the current paper presents a synthesis of review literature discussing the application of behaviour change theories within an infectious disease and emergency response context, with a view to informing infectious disease modelling, research and public health practice. methods: a scoping review procedure was adopted for the searches. searches were run on pubmed, psychinfo and medline with search terms covering four major categories: behaviour, emergency response (e.g., infectious disease, preparedness, mass emergency), theoretical models, and reviews. three further top-up reviews was also conducted using google scholar. papers were included if they presented a review of theoretical models as applied to understanding preventative health behaviours in the context of emergency preparedness and response, and/or infectious disease outbreaks. results: thirteen papers were included in the final synthesis. across the reviews, several theories of behaviour change were identified as more commonly cited within this context, specifically, health belief model, theory of planned behaviour, and protection motivation theory, with support (although not universal) for their effectiveness in this context. furthermore, the application of these theories in previous primary research within this context was found to be patchy, and so further work is required to systematically incorporate and test behaviour change models within public health emergency research and interventions. conclusion: overall, this review identifies a range of more commonly applied theories with broad support for their use within an infectious disease and emergency response context. the discussion section details several key recommendations to help researchers, practitioners, and infectious disease modellers to incorporate these theories into their work. specifically, researchers and practitioners should base future research and practice on a systematic application of theories, beginning with those reported herein. furthermore, infectious disease modellers should consult the theories reported herein to ensure that the full range of relevant constructs (cognitive, emotional and social) are incorporated into their models. in all cases, consultation with behavioural scientists throughout these processes is strongly recommended to ensure the appropriate application of theory. the united kingdom (uk) national risk register details a broad range of threats to the public health and security of the uk incorporating infectious disease outbreaks (e.g., pandemics and emerging diseases), malicious attacks (e.g., terrorist incidents), and natural phenomena (e.g., extreme weather, earthquakes) [ ] . the risk of infectious disease outbreaks is so substantial that the uk national risk register ranks a pandemic outbreak as the number one high consequence civil emergency facing the uk (based on likelihood and probable impact [ ] . the coronavirus disease pandemic which, at the time of writing has led to , , confirmed cases and , deaths, presents a stark reminder of this public health threat [ ] . outbreaks of infectious disease, particularly those for which little or no pre-existing immunity existssuch as the covid- pandemicrepresent a significant risk to public health. for example: the - ebola outbreak in west africa led to over , cases with , deaths [ ] , while the ongoing outbreak in the democratic republic of congo has led to over deaths thus far [ ] ; since the identification of middle east respiratory syndrome coronavirus (mers-cov) in , associated deaths have been reported with cases across countries [ ] , and; although less severe than expected [ ] , the h n pandemic was estimated as responsible for between , - , deaths worldwide during the first months [ , ] . even when controlling for confounding factors (e.g., improvements in surveillance, communication infrastructure, etc.), the number of infectious disease outbreaks has substantially increased since to [ ] . similarly, deaths from terrorism have substantially increased from less than in to over , in (peaking with over , in [ ] ), and despite a decline in the number of individuals affected by natural disasters between and , the average death rate has increased over the same time period [ ] . given these trends, it is therefore critical to ensure that emergency preparedness, response and resilience is optimised to mitigate the occurrence and/or impact of these events. behavioural science represents one such broad method of mitigation. the importance of encouraging adaptive and protective behaviour change in response to public health emergencies is emphasised by the world health organisation (who), who provide risk communications guidelines designed to encourage individuals, families, and communities to act to protect themselves [ ] . this is echoed in the context of covid- , with michie and colleagues stating that: "human behaviour will determine how quickly covid- spreads and the mortality. therefore behavioural science must be at the heart of the public health response" [ ] . research in the behavioural sciences has focused on identifying barriers and facilitators to maximising public compliance with recommended emergency response and infection prevention behaviours. for example, decontamination behaviour (e.g. [ ] ), medication adherence (e.g., [ ] ), hand washing (e.g., [ ] ), social distancing/ avoidance behaviour (e.g., [ , ] ), and vaccination (e.g., [ , ] ), to name but a few. furthermore, in the context of infectious disease emergencies, mathematical models are used to both: a) understand and map out the spread and control of disease (incorporating human-to-human transmission) and, b) calculate the potential effectiveness of interventions (including behavioural interventions) to reduce the spread of the disease [ ] . considered together, the importance of human behaviour for emergency responseboth in terms of developing interventions and its relevance for modelling the potential efficacy of said interventionsis clear. however, there is still work to be done to optimise the incorporation of behavioural constructs in public health research, intervention design, and modelling. for example, despite medical research council guidelines recommending interventions be based on appropriate behaviour change theory [ ] (see also [ ] ), reference to theory is often absent in such interventions [ ] . indeed, michie and colleagues, pioneers in the field of identifying and integrating behaviour change theory and techniques in the context of health promotion, note that much intervention design is based on the principle of "it seemed like a good idea at the time", rather than a systematic consideration and assessment of the most appropriate routes to behaviour change ( [ ] , p. ). similarly, a limitation of traditional mathematical models is that they often do not allow for heterogeneous behavioural responses within a population [ ] . this assumption that human behaviour is homogenous can impact on the validity of these models. for instance, including a modest degree of fear-related flight behaviour (i.e., % of individuals in a model respond to fear of infection with flight) into a model in which fear of infection otherwise leads to hiding, caused projected disease incidence to rise to~ %, up from~ % in a model in which fear of infection led all individuals to hide [ ] . although some recent infectious disease models do incorporate social and cognitive predictors of the kinds of self-protective health behaviours that are associated with infectious disease control and emergency response (e.g., vaccination uptake, social distancing etc.), they are more commonly informed by literature from behavioural economics than psychology [ ] . that is not to say that the integration of theory is a silver bullet for the success of mitigation strategies and modelling. for example, there is mixed evidence concerning the efficacy of theory-based interventions (see [ ] , p for a summary), inconsistency that may be based on the relevance of the chosen theory for the behaviour in question [ ] . to illustrate this point, according to michie and colleagues, there are a total of behaviour change theories across the behavioural and social sciences [ ] . over the past three decades, multiple review papers and books have attempted to identify trends in theory use including those most frequently applied (e.g., [ , [ ] [ ] [ ] [ ] ). despite some commonalities in underlying psychological processes (michie and colleagues cede that many of the constructs identified within their book were different labels for overlapping constructs, [ ] ), this proliferation of competing theories and recommendations could indeed make it difficult for researchers, intervention designers, and modellers to decide which theories to use and in what context. this unfortunately leads to a catch- situation: we wish to encourage non-specialists to use appropriate psychological theories and approaches within their own disciplines, yet we fail to recognise the complex and confusing landscape of psychological theory. michie and colleagues have made great strides to simplify the process by which psychological theories are used to inform behavioural interventions [ ] . however, there are still a large number of behaviour change theories that were designed with specific applications in mind: for example, the behavioural-ecological model of adolescent aids prevention [ ] , the integrated theory of drinking behaviour [ ] , or the social ecological model of walking [ ] public health researchers, infectious disease modellers, and practitioners may therefore be understandably perplexed as to how best to model and examine or influence behaviour in the specific context of infectious disease outbreaks or emergency response. this current paper therefore seeks to present a synthesis of the behaviour change theories that are most commonly applied within an emergency response or infectious disease outbreak context. that is, focused specifically on using behaviour change theories to understand and influence individuals' engagement with protective health behaviours that are recommended during infectious disease outbreaks and public health emergencies. to identify these commonly applied theories, we conducted a scoping review of the existing literature, but with a particular focus on identifying reviews using behaviour change theory in an infectious disease or emergency response context. this approach is recognised as a method of distilling a substantial literature into a manageable summary of evidence for decision makers ( [ ] , see also [ ] ). although using this 'review of reviews' approach focused on secondary sources, which may have led to some relevant information being missed, it enabled us to reduce the quantity of papers identified in a large and highly diverse literature to a manageable level while still achieving a broad overview of the state of the art within the field. by dovetailing with weston and colleagues' recent review of the application of human behaviour within infectious disease models [ ] , the outcomes from this current review will enable us to make useful recommendations as to how psychological constructs, theory, and research can be used by public health practitioners, researchers modellers, to improve our understanding of human behaviour within the contexts of infectious disease outbreaks and emergency response. a scoping approach was adopted for our search. scoping reviews are recommended as a mechanism by which a given literature might be summarised for policy makers or practitioners [ ] . as the aim of this review was to summarise and synthesise the psychological literature on behaviour change to inform recommendations for public health researchers and modellers, the adoption of a scoping review framework was a logical and appropriate choice. the literature search was conducted using pubmed, psy-chinfo and medline databases on the th january . the databases were selected based on their coverage of discipline and context specific literature. each database was searched individually to ensure that all medical subject heading (mesh) terms were used effectively. the search terms covered four major categories: behaviour, emergency response (e.g., infectious disease, preparedness, mass emergency), theoretical models, and reviews. supplementary information provides the full list of search terms used for each database. within the theoretical model category, we a priori selected several existing behaviour change models that were either: a) frequently cited within the literature, or b) adjudged to be of particular relevance within the context of infectious disease and emergency preparedness based on the authors combined expertise in these areas. in addition, generic phrases and subject headings for theoretical modelling were included within each search strategy to ensure that papers that do not cite the most common behaviour change models would still be captured within our search. lastly, papers identified through other, non-systematic methods (e.g., some clearly relevant citations in papers, keyword google scholar searches) were also included to try to identify articles that were not indexed within these databases. as the initial search was run in , a condensed follow up search strategy was devised to identify seminal works in the field published since this date. given time and resource constraints in conducting this search, the strategy was designed to identify literature that closely corresponded to the output from the original selection process. for example, the strategy was simplified based on the broad search categories used in the original search, and as literature concerning human immunodeficiency virus (hiv)/ sexually transmitted infections (stis) was excluded from the original data extraction (see inclusion/ exclusion criteria section), the decision was taken to exclude these papers at the search strategy stage here. on / / the following search was conducted on google scholar, sorted by relevance, with a custom date range of - : "review* and behavio* and theor*, or models and infectious disease*, or emergenc* -hiv, -std, -sti"-given time and resource constraints, only the first pages of google scholar were screened, first for title, then for abstract, and finally full-text screening was conducted on any remaining papers. due to limitations concerning the use of wildcard operators (*) on google scholar in the initial top-up search, and the potential for covid- related review papers to have been published in the intervening period, a further optimised top-up search strategy was developed. this strategy consisted of the following two searches (specified for emergency response and infectious diseases respectively), conducted on google scholar on th - th may : review emergency theory behavior or behaviour. review disease theory behavior or behaviour. as for the previous top-up search, the first pages of google scholar were screened for each search (for a total of results). for the original search, duplicates were removed electronically, and all remaining papers were subjected to title and abstract screening by one author (ai) using the inclusion/ exclusion criteria. all papers retained for full text assessment were screened independently by two researchers (ai and dw) to increase the reliability of the selection process. any inconsistencies between the researchers were resolved through a joint discussion. for the top-up search, individual title, abstract, and full-text screening stages were conducted by the first author (dw). as for the original search, all papers retained for full text assessment were screened independently by two researchers (ai and dw) with any inconsistencies between the researchers resolved through a joint discussion. the inclusion/ exclusion criteria employed in the top-up search were the same as those used for the original search. for the optimised top-up search, individual title, abstract, and full-text screening stages were conducted by the first author (dw). due to time constraints imposed by the covid- pandemic, full text screening for this search was conducted by the first author alone. as for the initial top-up search, the same inclusion/ exclusion criteria were employed as used in the original review. the following inclusion/ exclusion criteria were used: (i) type of article: reviews (systematic, scoping and narrative) and meta-analysis. (ii) theoretical model/theory: the papers needed to present or apply a model or theory of behaviour change. leniency in this criterion was initially applied in so far as papers which clearly applied constructs that were adapted from theories/models, were also retained, but this was subsequently restricted to focus specifically on the presentation of behaviour change models/ theories (see original study selection section below). (iii)context: the papers needed to present or apply the theory/model to explain human behaviour in the context of emergency or infectious disease outbreaks. as per [ ] any reviews focusing on diseases that are not transferred from human-tohuman (e.g., vector borne) were excluded. (iv) target behaviour: preventive health behaviours during an emergency or outbreak (e.g. social distancing, vaccination and reducing social ties) were included in the review. (v) other: there were no restrictions on the date reviews were published or the population in question. reviews were included if they were written in the english language and involved human behaviour. for simplicity, papers exploring sti-related health behaviours (total: ) were pragmatically excluded wholesale following the initial screening of the original search as the majority were deemed either: irrelevant according to the above criteria ( ) , of unclear relevance to the researcher (ai) ( ) , or inaccessible to the researcher (ai) ( ) . for consistency, papers exploring sti-related health behaviours have also been excluded during subsequent screening of the top-up searches. based on data extracted as part of previous review work in this area (e.g., [ , ] ), the following information was extracted from the included papers in both the original and top-up stages: (i) title (ii) author (iii)number of studies included in the review (iv) target behaviour(s) (v) theories employed (vi) key outcomes/ conclusions regarding the utility of behaviour change models data concerning the theories employed was identified within the included papers using the original reviews' own definitions or conceptualisations of theory. that is, if an included review referenced a particular theory or model, it was subsequently included in our synthesis. reference to theory was either found in specific citations of theories used by individual papers incorporated within the review (commonly included in summary tables within the included papers), or as a broader framework used by included reviews to collate and synthesise the identified literature. key outcomes and conclusions regarding the utility of behaviour change models were identified similarly, using review authors' references to the theories they cite within their results and discussion sections. data from the included studies were synthesised to identify: a) the behaviour change theories most commonly employed to understand and influence protective health behaviours during public health emergencies and infectious disease outbreaks and, b) any (in) consistency in the reported utility of different behaviour change theories. a total of records were identified through database searching with an additional eight articles identified through other sources. following the removal of duplicate citations, papers were subjected to title/ abstract screening. thirteen papers were retained for full-text eligibility assessment by the first and second authors. following this assessment, one paper was excluded, leaving remaining papers [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] (see fig. ). during the conduct of this review, the focus evolved to be explicitly concerned with only the application of theories rather than a broader focus on theoretically-related constructs. subsequent reconsideration by the first author therefore led to three of these papers being excluded [ , , ] , as although they all presented constructs that are represented within behaviour change theories, none explicitly referenced theory. these papers are explicitly referenced here to signpost the interested reader to their existence. information concerning: (a) the article characteristics, (b) the application/ use of psychological theory within these reviews, (c) the total number of unique articles employing each behaviour change theory and, (d) a summary of the key conclusions regarding the utility of theory within each review, is collated and summarised in this results section. a total of approximately , papers were identified using the google scholar search. of these , , the first pages ( hits) were subjected to title screening. following this stage hits were retained for abstract screening, which yielded five papers for full-text review. following full-text review by the first and second author, two papers were retained for inclusion in this review [ , ] (see fig. ). these two papers were subsequently incorporated into a revision of the initial synthesis and analysis and are presented in table and the supplementary information alongside literature identified through the original screening process. the first pages of each optimised top-up search were subjected to title screening ( hits in total). following this stage, hits were retained for abstract screening, which yielded papers for full-text review. following full-text review by the first author, two papers were retained for inclusion in this review [ , ] (see fig. ). as part of the full-text review process, the decision was taken to exclude two reviews [ , ] which did examine the application of theory in a similar context to that of the two included reviews [ , ] . this decision was taken as the focus of these reviews were more on understanding behaviour during an emergency, rather than the primarily protective or preventative focus of this review. these citations are presented here, in order to signpost them to interested readers. as for the initial top-up process, the two included papers were incorporated into a revision of the synthesis and analysis presented within this manuscript and the accompanying supplementary information. the synthesis including both original and all top-up studies is presented together in the following sections. in addition to peer reviewed academic publications, the sample included reports published by the department of health, uk [ , ] and the european centre for disease prevention and control [ ] , and one review from within an unpublished doctoral thesis [ ] . six of the reviews cited in this synthesis had at least one author in common with another review cited herein [ - , , ] , with one [ ] explicitly cited as an update of another [ ] . to examine the extent to which the papers included in our review were sampling the same citations, this review [ ] forms part of a broader phd thesis in which it is presented as a chapter. given the focus of the chapter on conducting a systematic review of h n perceptions and responses, and the consistency in the theories identified within the review chapter and the thesis' introductory chapter, we elected to include only the specific review chapter in this synthesis. we looked across all papers to see how many citations were fully independent (that is, not cited in any other review included in this manuscript). to do this we either: a) examined the list of included studies provided by the authors of each systematic review, or; b) where such a list was not provided, we examined the full reference list for the manuscript. although the percentage of unique papers varied substantially from review to review, each paper had an average of . % unique papers (see table for the full breakdown). although heavily focused on h n pandemic influenza and vaccination behaviour, these papers did cover a wide range of health-related behaviours (e.g., hand hygiene, face mask wearing) across various infectious disease and public health emergency contexts (e.g., natural disasters, terrorism). specifically, papers [ - , , , , , ] looked at uptake of vaccination against influenza (primarily pandemic, but also including seasonal). one paper [ ] considered the relationship between risk perception and preventive behaviour related to sars and avian influenza (e.g., hand washing, diet, exercise, wearing face masks). four papers [ , [ ] [ ] [ ] also considered other outbreak preparedness behaviours in addition to vaccination (e.g. hand hygiene, non-pharmaceutical measures against influenza etc.). three papers [ , , ] investigated the application of theories/model in non-infectious disease emergencies and disasters (e.g., flood disaster preparedness, earthquake preparedness, climate change, fire preparedness, bushfire emergencies, tornado preparedness, & terrorism preparedness). all reviews were published between [ ] and [ ] [ ] [ ] and all except two [ , ] employed a systematic approach to data collection. in the first instance, we looked across the review papers to see which theories were cited by the highest number of reviews (regardless of the number of cited papers using each theory within each review, and incorporating mentions of particular theories as frameworks for synthesis as in [ , [ ] [ ] [ ] ). this initial examination revealed that the health belief model [ ] was explicitly represented in the most review papers (nine - [ , , , , - , , ] ), followed by the theory of planned behaviour [ ] (eight - [ , , , - , , ] ) and protection motivation theory [ ] (seven - [ - , - , ] ), precaution adoption process model [ ] (four - [ , [ ] [ ] [ ] ), and the common sense model of self-regulation [ ] (four - [ , , , ] ). a further two models were each included in three review papers: extended parallel process model [ ] (three - [ , , ] ), and the theory of reasoned action [ ] (three - [ , , ] ). all other models were cited two times or fewer (see table ) . next, we collated and examined the papers cited across all reviews to identify the most frequently cited theories overall. articles that the reviews specifically cited as including behavioural theories were collated from the nine reviews that extracted such data [ - , self-efficacy theory is listed as 'other' within this paper, but we have incorporated this within our review alongside the additional, explicit self-efficacy theory citation from another included review paper c although this is presented as the common sense model, distinct from the other self-regulation model citation within bults and colleagues' review, further examination of the original papers reveals they are based on the same underlying model, and so are integrated in our synthesis d examination of the reviews citing social cognitive theory [ , ] and the social cognitive model [ ] has revealed that these are distinct theories and are therefore included in our synthesis as such e the authors of these reviews briefly cite examples of additional theories before settling on the protection motivation theory and the protective action decision model respectively. only these two theories are included in this table and in our synthesis where there was close overlap between model/ theory names, we conducted a google search to determine whether the tiles likely reflect the same, or different, models. consequently, social ecological theory (see [ , ] ) and the social ecological resilience model [ ] have been included as separate models in this synthesis. on closer inspection, subjective expected utility theory [ ] and state dependent expected utility framework [ ] refer to the same paper, and so are collapsed together herein. precaution adoption theory [ ] and precaution adoption process model [ , , ] are interpreted as referring to the same theory and so are included together. [ ] [ ] [ ] ] ). thus, papers were not included either: a) if the reviews did not indicate that such papers included behavioural theories or b) from the reviews that did not provide detail on the theories used by their cited papers (specifically, [ , [ ] [ ] [ ] ). papers that were listed as including behavioural theory and were cited by multiple reviews (n = ) were only included once, leaving a total of unique papers which were listed by the various review authors as incorporating one or more behaviour change theories. see supplementary information for an overview of which theories were cited in multiple reviews, and for the overall number of times each theory was cited in a unique paper across all reviews. across the cited literature, four behaviour change theories were applied more than times. these were: when considering the application of behaviour change theories for research, the included reviews report mixed success. while all of the papers cited by [ ] were [ ] informed by theory, several other authors reported that relatively few papers included within their reviews explicitly use behaviour change theories [ , , , , ] . for example, one review found that only around one third of cited papers explicitly refer to a theoretical model [ ] and another failed to find any interventions that used behavioural frameworks in their development [ ] . nevertheless, where theory was cited, across reviews there was support for the utility of the most cited theories across reviews and within individual papers. particular support was provided in the key outcomes and conclusions across reviews for: health belief model [ - , , , , ] , the theory of planned behaviour [ - , , , ] , protection motivation theory [ - , , ] , and the common-sense model [ ] [ ] [ ] (see supplementary information for a summary of theory-related outcomes for each review cited herein). although this is based on key outcomes/ conclusions and not an exhaustive list of all successful theories reported within/ across reviews, the commonly applied behaviour change theories do seem to be identified as relevant for understanding and explaining human behaviour within an infectious disease and emergency response context. however, the use of these theories was not universally lauded: for example, one review argues that the health belief model, protection motivation theory and the theory of planned behaviour do not adequately allow for emotional factors in behavioural decision making (of the three, protection motivation theory does incorporate fear, however the impact of emotion is on threatappraisals rather than a direct effect of emotion on action [ ] ) [ ] . indeed, one review exploring the [ ] application of protection motivation theory for animal owners and emergency responders in the context of bushfire emergencies suggests that emotional attachment (to animals) could override adaptive responding [ ] . similarly, one review strongly supports the relevance of the extended parallel process model for disaster and emergency preparedness but draws on a study examining the mediating role of fear on the threatpreparedness relationship to argue for further work applying the extended parallel process model to look beyond just threat and efficacy in their applications [ ] . furthermore, although several papers do support the relevance of the theory of planned behaviour within this context (e.g., [ , , ] ), one review does identify inconsistent findings regarding the role of the theory of planned behaviour for predicting behaviour within their cited papers (but still advocates the relevance of this theory for vaccination behaviour) [ ] . in terms of intervention development, one review concludes that although there is clear evidence for the success of theory-based interventions for communicable disease control and prevention, there is no substantive difference in theories informing effective or ineffective interventions [ ] . rather than specific theories being of critical importance for intervention development, it is instead the role of theory that is important; positive effects were reported where theories were used to design and develop interventions, but more mixed effects were reported when theories were only used to evaluate interventions [ ] . this echoes points made by leppin and aro in their review of risk perceptions in relation to severe acute respiratory syndrome (sars) and avian influenza. specifically: ) few studies explicitly or theoretically define risk perceptions, ) there is a disproportionate focus on risk probability over risk severity and, ) there is a need for further work to empirically examine the role of risk perceptions as represented within multifactor models rather than just through bivariate relationships [ ] . overall, this literature synthesis yields two key conclusions. firstly, behaviour change theories are of clear relevance for understanding behaviour in the context of infectious diseases and emergency response. secondly, and related to the first conclusion, there is a definite requirement for further work to systematically examine, incorporate and test full behaviour change models within research and interventions in the context of infectious disease and emergency response. papers incorporating a total of different theories (in various combinations) were collated across these reviews. the health belief model, theory of planned behaviour, and protection motivation theory were the most cited theories both across reviews and by individual papers included within reviews. other theories that were commonly cited include: precaution adoption process model, extended parallel process model, theory of reasoned action, and social cognitive theory. although the authors indicate that papers were included in the review, no list of these papers was provided. given this, the full reference list of citations was searched following a synthesis of the key theory-related outcomes and conclusions, there was broad support for the applicability of the most commonly cited theories (listed above) within this context. however, despite this broad support for the applicability of these theories, several reviews reported low levels of explicit use of behaviour change theories in the research they cited. taken together, these results suggest that the most commonly cited theories reported herein represent an excellent starting point for practitioners and public health professionals looking to model and enact behaviour change in the context of infectious disease and emergency response. this point is explored in more detail in the recommendations subsection of the discussion. to the best of the authors' knowledge, this scoping review represents the first attempt to systematically collate review data concerning the application of behaviour change theories within a broad infectious disease and emergency response context. in this review we have synthesised the health behaviours, theories, and applications presented across review papers drawn from both peer reviewed journals and grey literature in the context of infectious disease and emergency response. this synthesis enables us to provide some key recommendations and suggestions for infectious disease modellers, researchers, and public health professionals looking to apply behaviour change theory to understand and influence behaviour in this context. looking across the reviews included in our synthesis provides a clear picture of the typical use of behaviour change theories across the current context. firstly, many papers included within these reviews do not seem to be explicitly based on a specific theory of behaviour change. secondly, whether we take a high-level approach (i.e., number of theories cited by multiple reviews) or a more granular approach (i.e., number of citations per theory across all reviews) to the synthesis, the conclusions are broadly the same. as per michie and colleagues, only a small number of theories were most commonly cited despite the broad number of theories available ( theories detailed within [ ] , and distinct theories cited at least once within our included review papers, although these may not all be present in michie and colleagues work [ ] ). specifically, three theories stand out as the most commonly applied: health belief model, theory of planned behaviour, and protection motivation theory. another four theories are also repeatedly, but less frequently, cited: precaution adoption process model, extended parallel process model, theory of reasoned action, and social cognitive theory. of these seven theories, four are consistent with the most frequently used theories as identified by michie and colleagues [ ] (theory of planned behaviour, health belief model, precaution adoption process model, & social cognitive theory), and with some of the theories cited as frequently used across other health behaviour contexts e.g., [ , ] (health belief model, theory of planned behaviour, & social cognitive theory). of the remaining theories, one (theory of reasoned action) is closely linked to the theory of planned behaviour (the latter having developed from the former [ ] ). the final two most cited theories -protection motivation theory and the extended parallel process model -are closely related (the latter builds on the former [ ] ) and both are particularly concerned with the processes underlying fear appeals and threat messaging, a focus with clear relevance in the context of this review. having identified the commonly applied theories, we subsequently conducted a rapid synthesis of the included reviews' key outcomes with regards to the utility of behaviour change theory. on the basis of this synthesis, we make two key conclusions. firstly, the most frequently cited theories do find broad (though not universal) support within the cited literature. secondly, despite this broad applicability, several reviews cited herein highlight the relative absence of behaviour change theory within research conducted in this context [ , , , , ] . indeed, several of the reviews included herein explicitly advocate further work to study the thorough application of both individual theories and a range of multivariable theories, considering the interrelationship between model factors/ components (e.g., [ , , , , [ ] [ ] [ ] ] ). overall, a clear take-home message from the current review is that there are a range of commonly applied behaviour change theories with broad support for their use within an infectious disease and emergency response context. in the following section, these findings are used to form the basis for recommendations concerning the use of behaviour change theory by researchers, practitioners, and modellers in both research and practice. based on the results of our synthesis, there are two broad categories of recommendations for future work applying and incorporating behaviour change theories into both: ) research and practice (i.e., understanding behaviour, and developing & deploying effective interventions), and; ) infectious disease modelling. furthermore, although most of the literature screening and synthesis for this review was conducted prior to the covid- pandemic, we are aware of some recent and relevant work detailing recommendations and guidance for the use of behavioural science to tackle covid- in practice. some of this work has also been incorporated into this section to signpost interested readers to additional material of relevance. behavioural science can play a critical role in combatting the effects of a global pandemic, such as covid- , both through informing our understanding of public perceptions of the virus, and through developing interventions to reduce barriers and facilitate uptake of recommended behaviours [ ] . indeed, in the context of covid- , west and colleagues indicate that in the absence of robust intervention data, behaviour change theories and constructs should be used to inform the development of policy and practice for increasing uptake of self-protective behaviours [ ] . unfortunately, however, multiple reviews cited herein lament the absence of behaviour change theory in work conducted to date [ , , , , ] , and advocate for the more in-depth study of various behaviour change theory within this context [ , , , , [ ] [ ] [ ] ] . our primary recommendation therefore reinforces that advocated in the literature cited herein. specifically, we recommend that researchers and practitioners working in the context of infectious disease and emergency response, should: a) draw on the available theoretical literature and; b) work with experts in behavioural science to inform both empirical work to understand behaviour, and the design and implementation of interventions to affect behaviour. this primary recommendation is supported by several additional recommendations, which are unpacked in the subsequent paragraphs. in describing the way forward for behaviour change theorising, michie and colleagues [ ] note that the most popular behaviour change theories are relatively context agnostic, and that there may be important insights to be taken from models that are more context dependent. in order to enhance the translation of research into public health practice, we therefore recommend that future research and intervention development should consider both general theories and theories that most closely fits the context of study. the theories identified within this review represent a mix of both context agnostic (e.g., health belief model, theory of planned behaviour) and some more context specific (e.g., protection motivation theory and extended parallel process model) theories, and would therefore seem to be a good starting point for researchers and practitioners working in this area. furthermore, although not a theory identified within the current review (see limitations section), the com-b (capability, opportunity, motivation and behaviour) model [ ] has been advocated as a key starting point for interventions to reduce the transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) during the covid- pandemic (e.g., [ ] ). we would therefore further recommend considering the application of this theory when either conducting research or delivering research into practice. while these recommendations are consistent with the medical council guidelines [ ] , and echo recent work by michie and colleagues (e.g., [ , ] ), it is critically important to approach the incorporation of behaviour change theory -particularly within intervention designin a systematic fashion [ ] . indeed, one review included within our synthesis found that theory had a positive impact on the success of interventions when used at the design and development stage, relative to theory used only at the evaluation stage [ ] . to facilitate the systematic and appropriate use of behaviour change theory, we therefore strongly recommend that researchers and practitioners involve expert behavioural scientists in the design and implementation process, and also make use of available guidance within the behaviour change literature. for example, we are aware of a thorough guide to designing interventions using the behaviour change wheel [ ] that may be of use to practitioners. we also echo michie and prestwich's recommendation for researchers to use their theory coding scheme (a list of items for coding the use of theory within intervention design) to both: a) allow for researchers and practitioners to systematically assess the incorporation of theory within existing interventions and, b) facilitate transparent reporting of the incorporation of theory within novel interventions [ ] . using these resources will enable researchers and practitioners to overcome the limited use of theory acknowledged by the papers included in this review [ , , , , ] while still avoiding "it seemed like a good idea at the time" ( [ ] , p ) interventions. lastly, we include a note on the role of behavioural science in combatting the covid- pandemic. helpfully, a range of prominent behavioural scientists have developed guidelines and recommendations for the application of behavioural science within the context of covid- . for example, michie and colleagues advocate four principles to help reduce transmission by effecting behaviour change [ ] ; the british psychological society have compiled a list of nine recommendations to optimise the effectiveness of changing policy and communication/ guidance [ ] , and; west et al. draw upon com-b to provide an account of components that need to be addressed in order to increase uptake of specific covid- transmission-reduction behaviours [ ] . while this is by no means an exhaustive list, it does reinforce the importance of explicitly and systematically incorporating behavioural science into research and practice within the context of infectious disease and emergency response. alongside our recommendations detailed above, we therefore further advocate that interested readers explore these principles and guidelines in more detail. in our sister review [ ] we find that although the 'gold standard' for incorporating protective behaviour into infectious disease modelling involves the incorporation of a range of cognitive and social constructs, there is very little explicit reference to well-recognised theories of behaviour change (indeed, only five of included papers make any such reference [ ] ). acknowledging the necessary tradeoff between accurately modelling human behaviour and the computational demands of such modelling [ ] , weston and colleagues echo previous recommendations for modellers to familiarise themselves with the relevant behaviour change literature in order to improve their awareness of the main factors underlying human behaviour [ , ] . as a result, the recommendation was made for infectious disease modellers to closely consult with the psychological literature concerning the predictors of health behaviour when developing their models [ ] . based on the outcomes of this current review, we can provide further guidance for infectious disease modellers on both where to begin with this familiarisation, and how/ where to involve behavioural scientists in the process. firstly, in both the current review and weston and colleagues work, the health belief model is the most commonly cited behaviour change theory. we therefore agree that the health belief model represents an appropriate base on which to build infectious disease models incorporating human behaviour [ ] . nevertheless, as noted in the modelling review, there are a broad range of additional factors-including emotional and social constructs-that should be more fully considered when representing infection prevention behaviour [ ] . given the emphasis on protection motivation theory and the extended parallel process model within the literature reported in the current review, we first suggest that infectious disease modellers should consider these models alongside the health belief model to help improve the modelling of emotional responding and defensive avoidance behaviour (but see also bish & michie for further recommendations concerning the use of parallel processing models to incorporate cognitive and emotional constructs, [ ] ). similarly, we would also recommend infectious disease modellers use social cognitive theory, identified as a prominent public health behaviour change theory in the current review, as another starting point for behavioural model formulation. by more fully considering these theories and associated literature, infectious disease modellers will be well prepared to accurately and precisely model a range of relevant social, cognitive, and emotional constructs that may be associated with behavioural responses to a public health emergency. although this familiarisation exercise will be invaluable in helping modellers to develop a deeper understanding of the factors underlying behaviour change and is consistent with recommendations from previous literature as outlined above, it is pertinent to echo a recommendation made by michie and colleagues in the context of intervention design. that is, it is important to ensure that the theory selected is appropriate for the type of behaviour in question. for example, if a behaviour is more likely to be influenced by habitual factors then models concerning deliberative and reflective processing are less likely to be relevant [ ] . as this current review has focused on identifying the broad state of the art for incorporating behaviour change theory within infectious disease and emergency contexts, a full consideration of the appropriate theories for each individual behaviour in each specific disease or emergency context is unfortunately outside scope. however, we recommend that infectious disease modellers work closely with behavioural scientists in the design and development of their models to ensure that the most appropriate theories are being consulted and incorporated for a given target behaviour or context. through this greater collaboration between modellers and behavioural scientists, the discipline will be able to develop a more indepth understanding of the requirements for behavioural theory and the computational limitations to their incorporation within infectious disease models. although the review reported herein represents an impressive effort at addressing a herculean task (namely, the collation of psychological behaviour change theories applied across infectious disease and emergency response contexts), as with any large-scale review there are inevitably trade-offs and potential limitations that should be considered when interpreting the outcomes and recommendations from this review. firstly, although other emergency contexts are represented within the current review, we acknowledge that the papers included within this review are predominantly focused on infectious diseases. although the search strategy did include terms relating to other specific civil emergencies (e.g., terrorism), and emergencies generally (e.g., emergency response, emergency resilience), there were more search terms relating to infectious disease outbreaks/ pandemics. we therefore recommend that future reviews in this area should utilise search strategies optimised more clearly to reflect the full breadth of public health emergency contexts. secondly, and similarly to the first limitation, we are aware of some prominent behaviour change theories (e.g., com-b) that are not represented in the reviews cited herein. although this may represent a limitation of our search strategy, generic phrases and subject headings relating to theoretical models were included to ensure a breadth of focus. furthermore, as our focus was on identifying review articles that have themselves collated primary research involving behaviour change theories in the context of infectious disease and emergency response, it follows that any prominently applied theories should have also been represented within our sample regardless of the specific search terms we used. we are therefore confident that the theories identified herein represent an accurate overview of the most commonly cited theories within this specific context over the period in question (i.e., pre covid- ). thirdly, we acknowledge that several of the reviews included herein were authored by some of the same individuals [ - , , ] , with at least one [ ] explicitly cited as an update of another [ ] . although this may influence the macro-representation of theories across reviews (i.e., at review-level), our decision to also examine the frequency of theory use at a micro-level (i.e., at individual cited study level, excluding repeat citations across reviews) with similar results mitigates the likely impact of this. nevertheless, we acknowledge that frequency of theory usea key outcome within the current reviewis not the same thing as contextual-relevance of theory within these contexts. however, the purpose of this review was to identify the most commonly employed theories of behaviour change within the infectious disease and emergency response contexts. given this focus, we believe that the emphasis on theory frequency within the current review is well founded. nevertheless, we do also provide a synthesis and summary of the key outcomes and conclusions in order to further guide researchers and mathematical modellers to the points of commonality and divergence within the extant review literature. we hope that this review will therefore serve as a jumping off point for further research and modelling work building on our outcomes as detailed in the preceding recommendations section. finally, given the breadth of available primary literature, the proliferation of available reviews of behaviour change theories, and the specificity of our research question (i.e., to identify commonly applied theories of behaviour change within a public health emergency context) we elected to conduct a review of reviews rather than a systematic review of all literature. similarly, although driven by pragmatic concerns, our decision to conduct our top up searches using the first pages of google scholar searches may have limited the number of potentially relevant manuscripts for screening. furthermore, given both the unclear relevance /lack of access to a number of papers within the current review, we elected to wholesale exclude reviews concerning sexually transmitted infection. although these decisions and outcomes may have narrowed our focus, we argue that the close parallels between the theories identified herein and those remarked as commonplace within previous review work (e.g., [ ] ) render this claim ill founded. indeed, when combined, our top-up searches (which were sorted by relevance) allowed us to search through citations published since . the number of unique citations across papers included in our review (see table ) further suggests that we have succeeded in drawing together a broader range of literature than the independent systematic reviews themselves managed. nevertheless, we consider the current work to be an initial attempt at identifying and integrating the literature applying behaviour change theories in the context of infectious disease and emergency response. we therefore invite and encourage the conduct of a full and systematic review of all primary literature concerning the application of behaviour change theories across public health emergency contexts using our search strategy and extraction terms as a guide. behavioural science can play a critical role in combatting the effects of an infectious disease outbreak or public health emergency, such as the covid- pandemic. however, the proliferation of available theories, with either general or specific application, can made the landscape confusing for researchers, infectious disease modellers and public health practitioners alike. in an effort to simplify the considerable behaviour change literature for ease of use by public health emergency researchers, we conducted a systematised scoping 'review of the reviews' concerning the application of behaviour change theories in infectious disease and emergency response emergency contexts. our search strategies revealed relevant review papers from which we were able to identify and collate the seven most commonly cited and applied behaviour change theories in this context: health belief model, theory of planned behaviour, and protection motivation theory as most commonly applied, followed by precaution adoption process model, extended parallel process model, theory of reasoned action, and social cognitive theory. following a synthesis of the key theory-related outcomes and conclusions, we conclude that while there is broad support for the use of the most commonly cited theories within this context, the previous application of these theories within the literature is patchy. that is, much research in this context has not drawn on relevant theories of behaviour change. based on these identified theories and our synthesis of review outcomes, and in conjunction with a recent review by weston and colleagues [ ] , we make recommendations to assist researchers, intervention designers, and mathematical modellers to incorporate psychological behaviour change theories within infectious disease and emergency response contexts. first, we echo previous recommendations that future research and intervention design within this context should be based explicitly and systematically on relevant behaviour change theories, and in close consultation with experts in behavioural science. the theories identified herein represent an excellent starting point for this work, and we further signpost the reader to both general materials to aid in intervention design, and guiding principles for practitioners and researchers working on covid- . second, we recommend that mathematical modellers should consult the theories identified herein, and work closely with behavioural scientists to familiarise themselves with the key factors underlying behaviour change within an infectious disease and emergency response context. considered together, the results and recommendations reported herein therefore represent an important resource to enable researchers, modellers, and practitioners working in the context of infectious disease and emergency response to better incorporate a systematic and evidence-based consideration of human behaviour into their work. national risk register of civil emergencies edition. london: cabinet office world health organisation. ebola in the democratic republic of the congo. health emegency update middle east respiratory syndrome coronavirus (mers-cov the influenza pandemic. an independent review of the uk response to the influenza pandemic. london: cabinet office estimated global mortality associated with the first 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review. london: department of health factors associated with uptake of vaccination against pandemic influenza: a systematic review compliance with anti-h n vaccine among healthcare workers and general population the determinants of pandemic a/ h n influenza vaccination: a systematic review perceptions and behavioural responses of the general public during the influenza a (h n ) pandemic: a systematic review application of behavioral theories to disaster and emergency health preparedness: a systematic review risk perceptions related to sars and avian influenza: theoretical foundations of current empirical research acceptance of a pandemic influenza vaccine: a systematic review of surveys of the general public factors influencing pandemic influenza vaccination of healthcare workers-a systematic review preferred reporting items for systematic reviews and meta analyses: the prisma statement using behavior change frameworks to improve healthcare worker influenza vaccination rates: a systematic review barriers of influenza vaccination intention and behavior-a systematic review of influenza vaccine hesitancy human response to emergency communication: a review of guidance on alerts and warning messages for emergencies in buildings expanding protection motivation theory: investigating an application to animal owners and emergency responders in bushfire emergencies advances in human factors in simulation and modeling. ahfe . advances in intelligent systems and computing the role of social identity processes in mass emergency behaviour: an integrative review historical origins of the health belief model the theory of planned behavior a protection motivation theory of fear appeals and attitude change a model of the precaution adoption process: evidence from home radon testing the common-sense model of regulation of health and illness putting the fear back into fear appeals: the extended parallel process model belief, attitude, intention, and behaviour: an introduction to theory and research social foundations of thought and action: a social cognitive theory transtheoretical therapy: toward a more integrative model of change diffusion of innovations health program planning: an educational and ecological approach applying principles of behaviour change to reduce sars-cov- transmission the behaviour change wheel: a new method for characterising and designing behaviour change interventions are interventions theory-based? development of a theory coding scheme slowing down the covid- outbreak: changing behaviour by understanding it behavioural science and disease prevention: psychological guidance incorporating individual health-protective decisions into disease transmission models: a mathematical framework nine challenges in incorporating the dynamics of behaviour in infectious diseases models publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge charlotte hall for providing additional support during the redrafting of this manuscript. supplementary information accompanies this paper at https://doi.org/ . /s - - - .additional file : supplementary information . search terms for the original selection process additional file : supplementary information . summary of key theory-related conclusions additional file : supplementary information . breakdown of: a) how many/ which theories are presented across multiple reviews, and; b) how many times each theory is cited by a unique article across all reviews authors' contributions dw conceived of the project, secured funding, contributed to the design, contributed to developing the search strategy and exclusion & inclusion criteria, provided full-text review of potential papers, read all included papers, re-analysed and re-extracted data following the initial extraction and analysis, substantially revised the initial draft of the manuscript. dw also led on manuscript revisions including the rapid synthesis of outcomes/ conclusions, the screening of citations for the top-up search, the screening of citations for the optimised top up search, and the extraction and analysis of all subsequent data. ai contributed to developing the search strategy and exclusion & inclusion criteria, conducted the review (i.e., ran the searches and conducted title/ abstract and full text review), conducted initial data extraction and analysis, prepared an initial draft of the manuscript, and developed the strategy for the top-up search. ra contributed to the conception, design, and securing funding for the project and commented on drafts of the paper. all authors approved the authorship order, and all authors read and approved the final manuscript. availability of data and materials all data generated or analysed during this study are included in this published article and its supplementary information files.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord- - rn rf authors: shoja, esmail; aghamohammadi, vahideh; bazyar, hadi; moghaddam, hamed rezakhani; nasiri, khadijeh; dashti, mohammad; choupani, ali; garaee, masoumeh; aliasgharzadeh, shafagh; asgari, amin title: covid- effects on the workload of iranian healthcare workers date: - - journal: bmc public health doi: . /s - - -w sha: doc_id: cord_uid: rn rf background: in this study, we aimed to evaluate the impact of the covid- epidemic on the workload and mental health of iranian medical staff using the general health questionnaire (ghq- ) and nasa -task load index (nasa-tlx) questionnaire between march and april , respectively. methods: the present cross-sectional study was conducted from march th to april th, . to evaluate the workload and mental health of participants nasa-tlx and ghq- online questionnaires were distributed. data were entered into software spss (version ) and t-test, anova, regression methods were used for data analysis. results: health workers who encountered covid- patients, were subjected to more task load compared to those who had no contact with covid- patients at the workplace (p < . ). in terms of the subscale score of nasa-tlx, nurses had more scores in mental pressure, physical pressure, time pressure (temporal), and frustration compared to the other jobs (p < . ). moreover, nurses had significantly more workload compared to the other jobs. conclusions: type of job, the shift of work, educational level, and facing covid- affected the score of nasa-tlx. nasa-tlx scores were higher in nursing compared to the scores of other health staff groups. the results of this study indicate that the scores of nasa-tlx and ghq- among staff who had contact with covid- patients were significantly higher than those who did not face covid- patients. we suggested that a comprehensive assistance should be provided to support the well-being of healthcare workers especially nurses and healthcare workers who treated covid- patients. supplementary information: supplementary information accompanies this paper at . /s - - -w. the novel coronavirus (covid- ) appeared in december , in wuhan, china. covid- was shown to be caused by sars-cov- , which is a positivesense single-stranded rna virus belonging to the subgenus sarbecovirus (beta-cov lineage b) [ ] . on th january , due to the spread of this virus to other countries following a logarithmic growth, who stated the outbreak of covid- as a public health emergency of international concern (pheic) [ ] . despite the low mortality rate of that as %, the covid- virus has a high transmission rate as well as a higher mortality rate than that caused by both severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) [ ] . in this regard, to reduce the rate of transmission, iran's government in march required all public members to stay at home, except for necessary purposes [ ] . as a consequence of this pandemic, health workers are being faced with a heavy workload pressure, besides the increased total health expenditures. the immense burden of covid- disease could cause caregiver burnout. notably, the major sources of psychological distress among healthcare workers are as follows: increased work hours, lack of sleep quality, fatigue, and the risk of infecting with this virus and then putting their family members at the risk of a life-threatening condition [ ] . moreover, health care workers feel chronic fear of infection due to this virus's contagious nature, unknown transmission modes, close contact with patients, and getting infection from their colleagues [ ] . recent research into the major sources of psychological distress among healthcare workers suggests that the well-being of the health care workforce is the basis of each wellfunctioning health system [ , ] . unfortunately, in iran, at least healthcare workers passed away due to covid- infection and dozens have reportedly been under observation after presenting signs and symptoms of covid- infection. physicians' burnout and lack of health care workforce have serious consequences for patients and could also lead the medical system to the verge of a devastating collapse [ ] . in this study, we aimed to evaluate the impact of the covid- epidemic on the workload and mental health of iranian medical staff using the general health questionnaire (ghq- ) and nasa-tlx questionnaire between march and april , respectively. the present cross-sectional study was conducted from march th to april th, . we targeted all of the health care workers such as nurses, doctors, emergency medical service staff, clinical, and public health technicians working in iran ministry of health and medical education. we aimed for a convenience sample of participants. informed written consent was obtained from all the participants included. afterward, the anonymous online questionnaires were distributed among them. accordingly, each health worker was allowed to fill the questionnaire for only one time. this questionnaire included the subjects' sociodemographic information such as age, marital status, sex, job title, shift working (fixed morning, fixed evening, fixed night or rotational), type of employment (contractual or permanent), over times per month (hrs.), duration of employment (in years), educational level (diploma, bachelor's, master's, doctoral, and higher), governmental workplace (yes or no), having contact with covid- patients at workplace (yes or no), interest in job (yes or no), the increased working hours due to covid- prevalence (yes or no), ward of work (icu, operating room, laboratory, emergency, radiology, nursing station, covid- service center, or others). to assess workload, we applied the nasa-tlx (nasa -task load index) technique. correspondingly, this technique was developed by the human performance group at nasa ames research center, which involved subscales as follows: mental pressure, physical pressure, temporal pressure, performance, effort, and frustration. -step bipolar scales were then used to obtain ratings for these subscales. in this regard, the score of each scale was from to . nasa-tlx score was also calculated by multiplying each subscale rate to its weight. afterward, the overall workload was obtained by summing across scales and dividing by [ , ] . mohammedi et al. in their study indicated the acceptable reliability of the nasa-tlx among health workers, with cronbach's alpha = . [ ] . to evaluate the mental health (the psychosocial wellbeing), the general health questionnaire- (ghq- ) was applied. accordingly, ghq was developed by goldberg & williams in . although this instrument initially had items, currently there is a range of brief versions of the questionnaire including the ghq- , the ghq- , the ghq- , and the ghq- . out of them, the ghq- is short and easy to complete, and its application is appropriate in research settings. the ghq- comprises of items (six of which were positively phrased and six others were negatively phrased). each item is rated on a -point scale (less than usual, no more than usual, rather more than usual, or much more than usual). correspondingly, we used goldberg's original scoring method ( , , , and ). this method supplies scores ranging from to [ ] . also, the appropriate reliability of persian translation of the ghq- was shown in a study by montazeri et al. with cronbach's alpha = . [ ] . all statistical analyses were performed using ibm spss statistics software. the normality of variables was confirmed using the kolmogorov-smirnov test. moreover, chi-square test was used to compare the categorical data between the studied groups. the comparisons of the variables' difference between the groups were performed using the independent student's t-test and anova. linear regression analysis in models (model : linear regression analysis without adjustment; model i: linear regression analysis with adjustment for the encounter to coronavirus; and model ii: linear regression analysis with the correction of the encounter to the coronavirus, age, gender, marital status, job, experience, type of employment, shift, educational level, governmental, interested, and ward of work) was used for the determination of the association between overtimes of total task load score and ghq score. moreover, spearman-test was used to indicate the correlation among overall task load score and nasa-tlx questionnaire components' ghq scores and age, educational level, and experience. a p-value of less than . was considered to be statistically significant. in the present study, we analyzed of the health workers who filled out the questionnaire, because questionnaires were excluded from the study due to incomplete data. in terms of gender, . % of the respondents were women. also, the majority of respondents were nurses ( . %). regarding having contact with covid- patients at the workplace, . % of respondents reported that they have contact with covid- patients. the participants' characteristics in terms of the type of gender are shown in table . in this regard, the differences in job, ward of work, and encountering covid- patients were significant between women and men (p < . ). moreover, men had significantly higher over time compared to women ( . ± . vs. . ± . , p = . , respectively). (table ) . as shown in table , women had significantly higher ghq scores compared to men ( . ± . vs. . ± . , p = . , respectively). total task load and ghq scores according to different qualitative variables are presented in table . health workers who encountered covid- patients, were subjected to more task load and a lower ghq score compared to those who had no contact with covid- patients at the workplace (p = . ). notably, total task load score was significantly higher in nurses compared to doctors and health assistants ( ± . vs. . ± . , p < . ; ± . vs. . ± . , p < . ). furthermore, health experts had a higher task load compared to doctors ( . ± . vs. . ± . , p = . , respectively). the differences in total task load scores were not significant among nurses and health experts (p = . ), radiology and laboratory experts (p = . ), and other jobs (p = . ). regarding the ward of work, health workers of the corona center had more total task load scores compared to the staff of health centers ( . ± . vs. . ± . , p = . ). (table ). in terms of the subscale score of nasa-tlx, nurses had more scores in mental pressure, physical pressure, time pressure (temporal), and frustration compared to the other jobs (p < . ). moreover, nurses had significantly more workload compared to the other jobs. (table ) . as shown in table , total ghq score had a significant positive correlation with age (r = . , p = . ), educational level (r = . , p = . ), and experience level (r = . , p = . ). a positive significant correlation was also observed between mental pressure and age (r = . , p = . ). in addition, a positive week significant correlation was observed between mental pressure and experience level (r = . , p = . ). notably, task load score, mental pressure, temporal, and performance had negative correlations with educational level (p < . ). ( table ). the relationship of overtime with total task load and ghq scores is illustrated in supplemental table. in the unadjusted model, there was a significant association between total task load score and overtime (b = . , p = . ), which did not remain significant after further adjustment for the encounter to covid- patients (model ), so it was adjusted for the encounter to the covid- patients, age, gender, marital status, job, experience, employment status, shift, educational level, governmental workplace, interested in the job, and ward of work.(supplemental table) . in the present study, the workload and mental health levels affected by the covid- outbreak were assessed among iranian health care staff. more than % of the participants encountered covid- patients in the workplace. several variables such as age, marital status, experience, educational level, type of employment, ward of work interest in the job, and having contact with covid- patients in the workplace had influences on the score of ghq. moreover, jobs, the shift of work, educational level, and facing covid- affected the score of nasa-tlx. generally, nasa-tlx scores were higher in nursing compared to other health staff groups. the results of this study indicated that the total workload and mental health levels of staff who treated covid- patients were significantly worse than those who had no contact with covid- patients. in a study by lucchini et al., a % increase was indicated in the nursing workload among those who worked with covid- patients in icu. the authors suggested their colleagues worldwide to make an effort to increase the icu nursing staff, to start training registered nurses from general wards to perform basic icu procedures, and to dedicate intensive care nurses to manage more complex procedures, in order to be prepared to face the epidemic [ ] . during the covid- pandemic, it was shown that healthcare workers are at a higher risk of exposure, so the application of personal protective equipment (ppe) is necessary. accordingly, the mandatory use of ppe dramatically elevates both nursing workload and fatigue [ ] . achieving a sufficient health care workforce during this infection epidemic not only needs a sufficient number of health care providers, but also maximizes the ability of each clinician in caring for a high volume of patients [ ] . cao et al. in their study concluded that the hospital emergency management plan of west china hospital could reduce the emergency department (ed) workload, protect healthcare staff, and control the cross-infection during the covid- epidemic. additionally, they approved that each hospital should the results are described as mean ± sd for quantitative data and number (%) for qualitative data *p < . was considered as significant using independent t-test for comparison between the two groups and chi-square test for parametric and categorial data, respectively the results are described as mean ± sd. *p < . was considered as significant using independent t-test for comparison between the two groups abbreviation: nasa-tlx nasa task load index, ghq general health questionnaire the results are described as mean ± sd. *p < . was considered as significant using independent t-test for comparison between the two groups abbreviation: nasa-tlx nasa task load index, ghq general health questionnaire establish a specific contingency plan according to its condition [ ] . few studies have been conducted on the physical and psychological effects of outbreaks of serious infectious diseases among the medical staff, particularly when they have increased workload and the stress associated with the risk of infection [ ] . liu et al. conducted a qualitative study on nurses and physicians who were selected from five covid- designated hospitals in hubei province. in line with our findings the authors indicated that intensive work drains healthcare providers both physically and emotionally. healthcare providers showed their resilience as well as a great strength of professional dedication to overcome problems. the authors suggested that a comprehensive support should be supplied to protect the well-being of healthcare providers. also, a regular and intensive training plan for all healthcare providers is necessary to promote their preparedness and efficacy to deal with crises [ ] . the current study showed that workload and shift working had a significant association with each other, and night shift had higher workload scores compared to rotational and morning shifts. accordingly, these findings are consistent with the findings of the hoonakker et al.'s study. they showed that night shifts had a higher workload compared to the morning shift. also, their study showed that shifts with an h cycle time had a lower mental workload in comparison with a -h shift time [ ] . so, shortening work shifts and adjusting shifts to psychophysiological characteristics workers can improve worker performance to manage crisis [ , ] . the limitations of this study were as follows: firstly, the sample composition was uneven. moreover, a lack of response to the questionnaire due to potential bias like the covid- crisis in responding to questionnaires, not assessing the income of healthcare workers, and having any other disease were the other limitations of the present study. type of job, the shift of work, educational level, and facing covid- affected the score of nasa-tlx. generally, nasa-tlx scores were higher in nursing compared to the scores of other health staff groups. the results of this study indicate that the scores of nasa-tlx and ghq- among staff who had contact with covid- patients were significantly higher than those who did not face covid- patients. we suggested that a comprehensive assistance should be provided to support the well-being of healthcare workers especially nurses and healthcare workers who treated covid- patients. supplementary information accompanies this paper at https://doi.org/ . /s - - -w. additional file : supplemental table. the relationship between overtime with total task load score and ghq score (dependent variables). clinical features of patients infected with novel coronavirus in wuhan world health organization declares global emergency: a review of the novel coronavirus (covid- ) covid- : what is next for public health? iranian mental health during the covid- epidemic factors related to physician burnout and its consequences: a review covid- and telemedicine: immediate action required for maintaining healthcare providers well-being covid- in wuhan: immediate psychological impact on health workers assessment of workload using nasa task load index in perianesthesia nursing the appraisal of reliability and validity of subjective workload assessment technique and nasa-task load index nasa-task load index (nasa-tlx); years later designing questionnaire of assessing mental workload and determine its validity and reliability among icus nurses in one of the tums's hospitals factor structure of the -item general health questionnaire in the korean general adult population the -item general health questionnaire (ghq- ): translation and validation study of the iranian version nursing activities score is increased in covid- patients. intensive crit care nurs findings of lung ultra sonography of novel corona virus pneumonia during the - epidemic understanding and addressing sources of anxiety among health care professionals during the covid- pandemic hospital emergency management plan during the covid- epidemic the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china the experiences of health-care providers during the covid- crisis in china: a qualitative study measuring workload of icu nurses with a questionnaire survey: the nasa task load index (tlx) neural and psychophysiological correlates of human performance under stress and high mental workload supporting the health care workforce during the covid- global epidemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors thank of all those who gave their lives for the health of others, healthcare workers, and fight against covd- , and all of participant in this study. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.ethics approval and consent to participate this research approved by the medical ethics committee of esfarayen university medical science (approval number: ir.esfarayenums.rec. . ). informed written consent was obtained from each participant. no individual or personal data is included in this manuscript. the authors have no competing interests to declare. authors' contributions esh, va, sha and aa contributed to the conception and design of the study and the study protocol. mg, hb and md managed the running of the study. ach, khn and hrm conducted data analysis and all authors helped with data interpretation. va wrote this manuscript with input from all co-authors. all authors read and approved the final version of the manuscript. this study is financially supported by esfarayen university medical science. key: cord- -gf wy a authors: idowu, abiodun benjamin; okafor, ifeoma peace; oridota, ezekiel sofela; okwor, tochi joy title: ebola virus disease in the eyes of a rural, agrarian community in western nigeria: a mixed method study date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: gf wy a background: ebola virus disease (evd) is a severe hemorrhagic disease caused by ebola virus. several outbreaks have been reported in africa and often originated from remote agrarian communities where there are enormous misconceptions of the disease, refusal of early isolation and quarantine, and unsafe burial rites practices which aggravates the epidemics. it is on this basis that this study was conducted to (assess) the knowledge, perceptions, beliefs and preventive practices against evd in a predominantly agrarian rural community in southwest nigeria. methods: this was a cross-sectional study conducted in igbogila town, yewa north local government area of ogun state, southwest nigeria in the latter part of during the evd outbreak. mixed methods were used for data collection. quantitative data collection was done using a pre-tested interviewer administered questionnaire. four hundred and seven respondents selected by multi-stage sampling technique were interviewed. descriptive and inferential statistics were done, and the level of significance was set at . . qualitative data collection involved four focus group discussions a year after the epidemic was declared over in the country. the discussions were recorded, transcribed and analyzed along major themes. results: all respondents were aware of evd with radio and television being the major sources of information. knowledge of the disease was however very poor with many misconceptions and it was significantly influenced by educational level of respondent. evd survivors will be welcomed back into the community by few residents ( . %) and a much fewer proportion ( . %) will freely entertain a survivor in their house. most would prefer local herbalists over orthodox medical practitioners to care for their loved one in case they contract evd. although respondents knew that burying a victim is dangerous, they opposed cremation. conclusion: there was poor knowledge of evd with a lot of misconceptions. community members were not pro-active about prevention with dire consequences in the event of an outbreak. continuous public education should be done via mass media, traditional institutions and other community-based channels as part of emergency preparedness. ebola virus disease (evd) is a severe hemorrhagic disease caused by ebola virus: a non-segmented, enveloped, negative-strand rna virus [ ] . the first case of evd was identified in , since then, several outbreaks have been reported in africa [ ] . in the last years, an outbreak of evd has been reported at least every years [ , ] . in ; the deadliest, most widespread (affected ten countries), evd outbreak that lasted approximately years occurred making it a global emergency [ ] . current corona virus disease (covid- ) pandemic has again brought to the fore, the need for countries to maintain a high standard of preventive measures and preparation for emergency response for any emerging or reemerging infectious disease. populace needs to be enlightened on evd preventive measures such as maintenance of careful hygiene (washing hands with soap and water or an alcohol-based hand rub), avoiding contact with non-human primates and bats, avoiding contact with infected person's body fluids or infected items, and avoiding funeral or burial rituals that require handling of the body of someone who has died from evd (confirmed or suspected) [ ] . public health response to evd outbreak include: case finding (suspected, probable and confirmed), contact tracing, isolation and early quarantine, treatment of symptomatic cases, and ensuring appropriate burial for the deceased [ ] . however, a closer look at past evd outbreaks revealed that they often originated from rural agrarian communities where there are many misconceptions about the disease, refusal of early isolation and quarantine, and unsafe burial rites practices which aggravate epidemics [ , ] . it is on this basis that this study was conducted to assess the knowledge, perception, beliefs and preventive practices among residents of an agrarian community in ogun state, southwest nigeria. findings will provide useful information to aid future outbreak prevention and control as well as emergency preparedness efforts. this was a descriptive cross-sectional study which employed mixed-method (quantitative and qualitative) approach in data collection. the study setting was igbogila town, ibeshe ward, yewa north local government area of ogun state, southwest nigeria. yewa north is located at the west end of ogun state sharing border with benin republic (a neighboring country). igbogila is predominantly rural and agrarian with many of the residents engaged in agro-forestry related occupations. at the time of the study, the town had one primary healthcare centre, two public secondary schools, five public primary schools, one major market, few churches and mosques. only residents between and years that had been living in the study area for at least months prior to the study participated in this study. quantitative data were collected during the ebola epidemic in nigeria (july -september ). sample size was determined using cochran's formula (n = z p( -p)/ e ) [ ] . the calculation was based on: prevalence of good knowledge (p) of % obtained from a similar study [ ] , standard normal deviate (z) at % confidence being . and % margin of error (e) resulting in a minimum sample size of . this was increased by % ( ) to make up for non-responses and incomplete questionnaires giving a total sample size of . multi-stage sampling was used to select the respondents. in the first stage, one ward (ibeshe) was selected from the eleven wards in yewa north using simple random sampling technique (balloting). in the second stage, one town (igbogila) was selected from the seven towns in ibeshe ward. igbogila comprises nine smaller communities which were all included in the study. respondents were equally allocated to the communities i.e. about respondents were required from each community. the third stage involved the selection of houses following enumeration and systematic sampling of houses. the houses in the communities largely had no numbering system, so, the research team carried out house numbering. in the fourth stage, households were selected from the houses. only one household was selected per house (simple random sampling (balloting) was used to select one when there were more than one household). in the final (fifth) stage, respondents were selected from households. only one respondent that met the inclusion criteria was interviewed per selected household (simple random sampling (balloting) was used to select only one respondent when there were more than one eligible respondent). respondents were interviewed face-to-face using a pre-tested interviewer administered questionnaire adapted from similar studies [ , ] . eight research assistants who were fluent in yoruba, english and 'pidgin' english were trained for data collection. the questionnaire sought information on socio-demographic characteristics, awareness, knowledge, attitude and perception of evd. knowledge was assessed using questions on cause, transmission, symptoms, prevention and cure of evd. perception and attitude to evd were assessed using respondents' agreement or disagreement to a set of likert statements. data were coded, entered and analyzed using epi info™ . statistical package [ ] . descriptive statistics (frequency, mean and standard deviation) and inferential statistics (chi-square test) was used to test association between categorical variables. level of significance was set at %. in the knowledge section, each correct response given by respondents was allotted one point. overall knowledge was assessed using five domains: cause ( point), transmission ( points), symptoms ( points), prevention ( points) and cure ( point). this gives a total maximum score of points converted to percentage. using % cut-off point; respondents with total score < % were graded as 'poor knowledge' while those with > % were graded as 'good knowledge'. attitude was scored using three points likert scale; the maximum obtainable score was and the least was . using the mid-point ( ) as cut-off point, respondents with score < were graded as having "poor attitude" while those with scores > were graded as having "good attitude". for the qualitative aspect, focus group discussions (fgds) were conducted in november , about a year after the epidemic was declared over by who [ ] . the main purpose for the fgds was to explore explanatory models for the disease in rural communities and their preventive practices against an outbreak. according to the who, this is important in any epidemic preparedness and response [ ] . discussants were approached face-toface and selected into one of four groups: higher secondary education students ( discussants), females of reproductive age ( discussants), adult male ( discussants), elderly female ( discussants). fgd participants were selected by purposive sampling as discussants in each group were selected to be of the same gender and about same age as suggested by ritchie and lewis qualitative research framework [ ] . in each group, one of the discussants volunteered his/her home for the discussion. fgds were moderated by the principal researcher with the assistance of one note taker and a time-keeper. each session lasted for about h. discussions were held mainly in local (yoruba) language understood by all the participants and taperecorded in addition to notes. each discussant was assigned a number. at the end of each session, discussants were given light refreshments. the recordings were later translated and transcribed in english. data was saturated in domains of cause, and spread of evd, but, unsaturated in domains of treatment. thematic analysis was done manuallyrecurring themes from the data were identified, emerging patterns noted, and report written based on these identified patterns. for the purpose of presentation, the groups were coded as follows: higher secondary school students (hs), adult males (am), older females (of), and women of reproductive age (rf). participation was voluntary and formal consent was obtained from each participant. respondents were informed of their right to withdraw at any point of the study without prejudice in line with helsinki declaration [ ] . a total of respondents completed their interviews while respondents withdrew their participation, making the response rate to be . %. mean age of respondents was . + . years with slightly more males (n = , . %). almost one-quarter, ( . %) had no formal education and half (n = ) earning less than , naira monthly (less than us dollars) ( table ) . all the respondents were aware of evd. majority, ( . %) heard of it through radio and television, ( . %) got to know from their friends or family members. print media such as newspapers and flyers were not reported as a source of information by the respondents. 'dirty environment' was the most commonly mentioned cause of evd ( . %), only ( . %) knew that a virus is implicated. few ( . , . and . % respectively) knew that eating poorly cooked bush meat or contact with non-human primates or contact with body fluids of infected persons pose risk of evd transmission. a minority knew fever ( . %), vomiting ( %) and headache ( %) as symptoms of evd. (table ) . a third ( . %) knew hand washing and avoidance of contact with non-human primates as preventive measures while only ( . %) knew that avoiding funeral or burial rituals involving contact with victims' corpses is a preventive measure (table ) . neither age nor sex of the respondents significantly influenced their knowledge of evd. however, those respondents with at least secondary education were more likely to have good knowledge of evd (p = . ) ( table ). a majority ( . %) believed that evd really exists and ( . %) perceived it to be very fatal. while ( . %) agreed that it is not curable, ( . %) believed that victims could survive if given prompt medical intervention. almost a quarter, ( . %) saw it as a political ploy that government officials wanted to use to embezzle funds and only about half ( . %) thought that the country was truly ebola free (table ). in respect to their attitude; ( %) reported that they would accept to be quarantined if they were found to have had close contact with a case, ( . %) would support and empathize with a friend or relative who is infected, however, only two-fifths ( %) would buy from a shopkeeper who has recovered from evd and even a lesser proportion ( . %) would welcome a survivor back to the neighbor-hood. only ( . %) would entertain a survivor in their homes. overall, respondents ( %) had a good attitude towards evd ( table ). sociodemographic characteristics of discussants the mean age of the fgd participants was + . years, ( %) were females, ( %) had no formal education while ( %) had tertiary education. the participants were largely farmers ( %), and petty traders ( %). one discussant was a herbalist (table ) . the recurring themes on how ebola disease can be contacted were: eating infected bush meat, unprotected contact with infected persons, and intercourse with multiple sexual partners. "it is gotten by coming in contact with infected animals, animals such as bats and bush meats" -hs ( years old male student). "the disease is catching whoever has sex with prostitutes …" -am ( year old bricklayer). more respondents believed that local herbalists know the cure for ailment. "i will call a herbalist to come and treat the person (a case) at home" -rf ( years old female farmer). "i believe that they are lying by saying there is no cure for the disease … … , if the victim is taken to good traditional healers, the person will be cured" -hs ( year old male student). when asked how best to handle the corpse of a close relative that died of evd, it was evident that the people knew that burying someone with evd is not without any risk. "i will not move close to the corpse. the people who died of the disease are usually burnt but i cannot allow my own dead family member to be burnt. i will just call them at the centre (primary health facility in the area) to come and help me bury the corpse" -hs ( year old male student). while some ( out of the ) of the respondents did not stop eating bush-meat (bats inclusive), many ( out of ) of the respondents stopped eating bush meat. the precautionary measure was however for a while as it was found that these respondents that initially restrained their intake of bush meat had resumed its consumption. "i stopped eating bush meat and bat, but when i later saw that people who ate bush meat did not die, i started eating them back" -am ( year old male farmer). the important theme that emerged on preventive measures for evd was the use of salt water. some respondents bathed with salt water, drank and mandated its use in their family till they experienced related adverse effects. "i bathed with salt water as instructed by my father" -hs ( years old male student). "my six children and myself used salt water to bath for some days but stopped when we started having skin rashes" -of ( year old female trader). their current preventive practices were explored (without prompting). majority of the respondents confessed that they were eating bush meat as before. they were mostly not taking any pro-active preventive measures to prevent evd such as limiting close physical contact or direct contact with bush animals. "i am not doing anything. i am eating bush meat …." -rf ( year old female farmer). "i am not doing anything … … i did not need to bother myself" -of ( year old female). at the outset of the evd outbreak, the nigerian government embarked on widespread health campaign with major attention on mass media. the mass-media platforms successfully raised evd awareness as all the rural dwellers in this study were aware of evd and they indicated that radio and television were their main sources of information. mass-media played similar pivotal role in purveying awareness for residents of urban communities in lagos, nigeria [ ] and for locals at epicenters in sierra leone [ ] . however, the high level of awareness did not translate to better knowledge of the disease. most respondents had poor knowledge riddled with many misconceptions. for instance, most of them either did not know the cause of evd or misconceived the cause to be dirty environment. there are evidences that have implicated bush-meats especially non-human primates e.g. bats in the spread of evd, yet only few ( %) knew that evd is spread by contact with infected non-primate animals [ , ] . the prominent misconception of the cause of evd as revealed in the fgd was the belief that ebola disease is acquired by leading a promiscuous lifestyle. this apparent disparity between biomedical and traditionally perceived etiology could stymie prevention in the event of another outbreak because based on etiological variances, local perception of prevention will conflict with orthodox suggestions [ ] . apart from the misconception of cause of evd, the knowledge of community-based modes of transmission (from infected individual to others, and from infected fomites/objects to man) of evd were also less known among the residents of the agrarian community. this is worrisome because during outbreaks, community-based transmissions are responsible for most secondary cases and thus responsible for perpetuating the spread of infection [ ] . the knowledge of prevention of evd was also found to be inadequate. more than % did not know that; avoiding direct contact with people, frequent hand washing, avoiding contact with non-human primates' body fluids and blood, and avoiding contact with infected items are precautionary measures. when the respondents were asked how they will handle the corpse of a relative that died of evd; it was evident that the people knew that burying someone with evd is not without risk but they opposed cremation -"… i cannot allow my own deceased family member to be burnt". cremation is rejected because it is not culturally acceptable in most parts of west-africa where autochthonous residents strongly believe that deceased soul will haunt living relatives if not given a traditionally acceptable burial [ ] . this has potential to impede effective burial of dead cases and it can aggravate epidemics as evidenced by catastrophic events that followed unsafe burial of cases at the early stages of the outbreak (in sierra leone and liberia) [ , ] . it may be beneficial to gradually institute interventions involving anthropologists and traditional institutions to discuss and relay such messages at the grass root level. exploring the respondent's knowledge of cure of evd, it was found that although some ( . %) knew that there is no cure for the disease, yet, most preferred local herbalists over orthodox medical practitioners to care for their loved one in case he/she contacts evd. being a rural setting, this is not surprising. the rationale behind this preference is the fear of having their relative isolated from them: "… ..once they carry the person (victims) away from you, you will not be allowed to see them again …" the discussants' preference of local herbalist over medical practitioners is another cause for concern as such misconceptions had made people in gulu district, uganda to resort to traditional practices such as 'ryemo gemo' rituals (wild shouting, jumping and running into nile river), 'chani labolo' rituals (slaughtering and littering intestines of several goats on ground) in kotido district of uganda, all in an attempt to 'cure' the disease. such practices only enhanced the spread of the disease and complicated the economic cost of the outbreak [ , ] . this also has implications for other highly infectious diseases such as lassa fever and covid- that require isolation of confirmed positive cases as part of containment. in such situations, similar preference for alternative treatment options may negatively impact control efforts. the factor that was found to significantly influence participants knowledge about evd was their educational status. the agrarian community dwellers with at least secondary education in this study were more likely to have good knowledge of evd compared to those with only primary or no formal education. this highlights the need to increase education coverage in local communities as the level of education of the populace could play an important role in determining the magnitude of spread as modelled by outcomes in two separate outbreaks in sudan [ ] . most respondents indicated stigmatizing attitudes towards evd survivors. a total of % stated that they will not buy any goods from a survivor, many expressed that they will not welcome a survivor back into the community nor allow survivor into their house. these discriminatory statements were similar to the initial problems local residents at ebola epicenters posed during early phases of the outbreak in liberia [ ] . the danger in this is that persons that suspect that they may have evd, and indeed any infectious disease hide it because of fear of stigmatization. this could drive disease outbreaks further. during the outbreak, the preventive method most respondents in this study observed was avoiding bush meat and use of salt water which are largely misconceptions. the use of salt water may have negative health consequences. though the exposure is there with consumption of bush meat, the key thing is close contact and method of handling during preparation of the animals. this was not really a big issue in evd outbreak in nigeria as the cases recorded were invariably linked to the imported case. the natives already exhibited poor knowledge and bush meat is commonly consumed due to their agro-forestry background hence the need for proper education. one year later, majority of the discussants stated that they had resumed bush meat consumption and were no longer taking any recommended precautions to prevent contracting evd. the main reason for this in-action could be linked to their religious belief, that 'god' protects them from 'evil diseases' like evd (table ) . unfortunately, this behavior may have serious consequences in the re-occurrence of evd outbreak in the country. the study was conducted in a setting that can be described as 'high risk' for evd outbreak. data was collected prospectively, and the mixed-method approach yielded more information necessary for understanding community explanatory models of the disease in the context of outbreak preparedness and control. the study did not emphasize on how local beliefs and practices could aid control efforts in such epidemics. more content could have been covered by adapting dunn's framework [ ] and this could be addressed in larger scale studies. the grading system adopted for measuring 'attitude' could have affected the result of the overall attitude (majority had good attitude) as their 'neutrality' was not factored into the grading system. no case of evd was recorded in the study area during the outbreak, nevertheless the limited data provides relevant information useful to researchers and other public health stakeholders in infectious disease prevention and control. the study has shown very poor knowledge of evd with misconceptions. though majority perceived the disease to be severe, some believed it was a ploy of whites against african countries and avenue for government officials to embezzle money. respondents exhibited stigmatizing attitude which may hinder control efforts in disease outbreaks. they were also not pro-active about prevention of possible future outbreak as most had gone back to harmful practices initially abandoned because the outbreak was declared to be over in the country. immunopathology of highly virulent pathogens: insights from ebola virus world health organization. ebola hemorrhagic fever in zaire, -report of an international commission outbreaks chronology: ebola virus disease emergencies preparedness response: ebola virus disease outbreak news overview, control strategies, and lessons learned in cdc response to the - ebola epidemic ebola response: package and approaches in areas of intense transmission of ebola virus. geneva: world health organization ebola viral hemorrhagic disease outbreak in west africa − lessons from uganda the ebola epidemic: a global health emergency sample size determination study on ebola virus disease knowledge, attitudes and practices of nigerians in lagos state public knowledge, perception and source of information on evd in epi infotm -a database and statistics program for public health professionals world health organization. who declares end of ebola outbreak in nigeria world health organization. recommended guidelines for epidemic preparedness and response: ebola hemorrhagic disease. geneva: world health organization qualitative research practice: a guide for social science students and researchers world medical association declaration of helsinki. ethical principles for medical research involving human subjects study on public knowledge, attitudes and practices relating to ebola virus disease prevention and medical care in sierra leone epelboin a mv. human ebola outbreak resulting from direct exposure to fruit bats in luebo, democratic republic of congo information note: ebola and food safety dilemma with the local perception of causes of illnesses in central africa: muted concept but prevalent in everyday life factors that contributed to undetected spread of ebola virus and impeded rapid containment; one year into the ebola epidemic the impact of traditional and religious practices on the spread of ebola in west africa: time for a strategic shift community perspectives about ebola in bong, lofa and montserrado counties of liberia. results of a qualitative study a time for fear: local, national and international responses to a large evd outbreak in uganda cultural contexts of ebola in northern uganda modelling the role of public health education in ebola virus disease outbreaks in sudan the liberia ministry of health. national knowledge, attitudes and practices study on ebola virus disease social determinants in tropical disease springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors wish to thank the research assistants and participants for their commitment throughout the period of study. special thanks to adebolu olayinka, ogundan olayinka and taiwo toyosi for their assistance with data entry and transcription. authors' contributions abi-was involved in the conception, design, acquisition, analysis, interpretation of data and drafting and revision of the manuscript. ipo-was involved in the conception, design, analysis, interpretation of data, drafting of the manuscript and substantively revised it. eso-was involved in the interpretation of data and substantive revision of the manuscript. tjo-was involved in interpretation of data and substantive revision of the manuscript. all authors read and approved the final manuscript. there were no external funding for this study. the datasets used and/or analyzed during the study are available from the corresponding author on reasonable request. ethical approval was obtained from health research ethics committee of the lagos university teaching hospital (approval number: adm/dcst/hrec/ app/ ). informed consent (in writing) was duly obtained from participants. not applicable. the authors declare that they have no competing interests. key: cord- -d l nqgh authors: chui, kenneth kh; cohen, steven a; naumova, elena n title: snowbirds and infection--new phenomena in pneumonia and influenza hospitalizations from winter migration of older adults: a spatiotemporal analysis date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: d l nqgh background: despite advances in surveillance and prevention, pneumonia and influenza (p&i) remain among the leading causes of mortality in the united states. elderly adults experience the most severe morbidity from influenza-associated diseases, and have the highest rates of seasonal migration within the u.s. compared to other subpopulations. the objective of this study is to assess spatiotemporal patterns in influenza-associated hospitalizations in the elderly, by time, geography, and intensity of p&i. given the high seasonal migration of individuals to florida, this state was examined more closely using harmonic regression to assess spatial and temporal patterns of p&i hospitalizations by state of residence. methods: data containing all medicare-eligible hospitalizations in the united states for - with p&i (icd- -cm codes - ) were abstracted for the + population. hospitalizations were classified by state of residence, provider state, and date of admissions, specifically comparing those admitted between october and march to those admitted between april and september. we then compared the hospitalization profile data of florida residents with that of out-of-state residents by state of primary residence and time of year (in-season or out-of-season). results: we observed distinct seasonal patterns of nonresident p&i hospitalizations, especially comparing typical winter destination states, such as california, arizona, texas, and florida, to other states. although most other states generally experienced a higher proportion of non-resident p&i during the summer months (april-september), these states had higher nonresident p&i during the traditional peak influenza season (october-march). conclusions: this study is among the first to quantify spatiotemporal p&i hospitalization patterns in the elderly, focusing on the change of patterns that are possibly due to seasonal population migration. understanding migration and influenza-associated disease patterns in this vulnerable population is critical to prepare for and potentially prevent influenza outbreaks in this vulnerable population. synchrony and latitudinal gradients in epidemic peaks [ ] . the timing of the seasonal peak in influenza changes annually, ranging from th to rd julian calendar day [ ] . together, space and timing of the seasonal peak work in synchrony to dictate the epidemiological effects of influenza in the population [ ] . the severity of influenza also varies by individual influenza season [ ] . accurate monitoring and estimation of influenza activity require understanding not only influenza dynamics, but also population characteristics and their changes. important dynamic factors such as the transmissibility of influenza strains, the accuracy of contact rate assessment, and the movement of populations within and between geographical units, if not clearly understood and properly modelled, may compromise the precision and accuracy of the estimation. the sars epidemic of [ ] illustrates these complexities by demonstrating the potential of global travel patterns to impact the spread of a virulent infectious agent, the coronavirus, necessitating a systematic investigation on how travel and migration patterns affect disease epidemics. although some historical influenza epidemics and pandemics disproportionately affect the younger population, such as the spanish influenza [ ] and the recent h n pandemic of [ ] , for most seasonal influenza, the elderly (defined as the population aged and above) are the most severely affected. from to , over % of influenza-associated mortality occurred in the elderly, much of which from influenzaassociated pneumonia co-infection. influenza-associated morbidity is highest in the elderly. patients with a primary diagnosis of pneumonia accounted for nearly , average annual hospitalizations from to . there were over . million hospitalizations in the elderly with any-listed diagnosis of pneumonia during that period [ ] . the elderly, who experience the most severe morbidity and highest mortality from influenza, are also one of the most mobile population groups due to their frequent seasonal migrations. popular destinations in the u.s. include florida, arizona, and texas. these migrations can be sizable: in , the proportion of non-permanent elderly residents increases from . % in september (summer time in the us) to . % in january [ ] . unlike younger populations who may travel temporarily for work and leisure, the elderly tend to stay for longer periods of time and use more health services [ ] . these migrations may affect influenza transmission and, as a consequence, change health care service utilization patterns both at their home state and in their temporary residence or lodging [ ] . evidence suggests that hospitalization patterns for in-state residents differ from temporary residents [ ] . this has important implications, not only by potentially affecting the dynamics and transmission patterns of influenza itself, but also by impacting health care service providers. peak seasonal migration to florida and other southern states coincides with the typical peak in influenza, which generally occurs in the winter months [ , ] . there are few studies that have assessed differences in patterns of influenza-related hospitalization in the medicare population simultaneously by time of year, provider state, and state of residence. the purpose of this analysis is to quantify these spatiotemporal patterns in influenza-associated hospitalizations in the elderly using medicare-associated hospitalization claims in the united states for years, including complete influenza seasons (july -june ). we compare spatiotemporal patterns of influenza activity across all states of the u.s., emphasizing the simultaneous comparison of seasonal migration patterns by season. we then focus the analysis on florida, a state known for extensive seasonal migration of elderly adults, to examine how seasonal migration to florida affects the timing, geography, and intensity of pneumonia and influenza across seasons. we abstracted . million out of . million hospitalization records obtained from centers for medicare and medicaid services (cms) based on a set of previously established entry criteria [ ] : admission happened from through , patient's age was or above when admitted, and the patient's diagnoses includes pneumonia and influenza (p&i; international classification of diseases, ninth revision, clinical modification codes - ). variables used in this analysis are patient's age, date of admission, state of residence, and state in which the patient was hospitalized, referred to as "provider state" hereafter. for the national state-level analysis, we compiled cumulative frequencies of the p&i hospitalization in two time periods-october st through march st and april st through september th -approximating the in-and off-seasons. for the analysis on florida, we created a -day-long time series by compiling daily counts of the p&i hospitalization for floridians and non-floridians. the first part of the analysis assessed the spatiotemporal patterns of influenza-associated hospitalizations for all states plus the district of columbia by comparing the ratios of hospitalized residents to hospitalized nonresidents between the two time periods with χ tests. to better explore the relative changes in rates and counts of p&i hospitalizations in specific state of residence and provider state, we visualized these multivariate relationship using bubble matrix plots [ ] . as an extension of the aforementioned χ analysis, a second bubble matrix was made to show the natural log transformed ratio of the number of non-floridians to the number of floridians for each combination of the provider states and states of residence. the second part of the analysis focused on understanding the residential makeup and temporal fluctuation of the elderly hospitalized in florida. demographic characteristics of the two groups (floridian vs. non-floridian) were compared with t-test and χ test. the original states of residence of the non-floridian were tabulated. the counts were then segregated by the two periods of time for calculating the seasonal ratios (frequency of hospitalizations in april-september divided by frequency of hospitalizations in october-march). the resultant ratios were visualized using mapping. to understand the temporal differences between the two residential groups, time-series plots were created illustrating the change in the hospitalization counts between the two groups. we then used harmonic regression to estimate the times to peak for each group, controlled for long-term trends. the general equation of the harmonic regression is as follows: ln[e(counts)] = β + β sin( π t) + β cos( π t) + β (t) + β (t ), where ln[e(counts)] are hospitalization counts modelled with poisson distribution, π is the constant, ω is the frequency, and t is the day in a time series ranging from st to th day. the terms β (t) and β (t ) control for longterm linear and quadratic trends. the coefficients β and β are needed to derive peak timing in days. detailed methods can be found elsewhere [ ] . sas version . (cary, nc) and s-plus version (palo alto, ca) were used for the data abstraction and analysis, respectively. arcgis version . (redlands, ca) was used for mapping. the tufts medical center institutional review board approved the study protocol for this analysis of the cms data. for the majority of states, a significantly higher proportion of non-resident p&i hospitalizations occurred from april-september than from october-march (table ) . significantly higher proportions of non-resident p&i hospitalizations occurred from october-march than in april-september in a minority of states-arizona, california, florida, hawaii, nevada, south carolina, and texas. examining the non-resident p&i hospitalizations, we observe uneven patterns in the distribution of state of residence. figure depicts a bubble plot of the crossclassification of provider state and state of residence for all p&i cases from through from october through march. the size of the bubble represents frequencies of hospitalization and the hue represents rates. information in the diagonal cells was omitted because those cells would be of much higher counts and rates, which is natural because most people are hospitalized in their own state, dwarfing the small but important distinctions among the discordant cells. residents of certain states have a greater propensity to be treated out-of-state for p&i than many other states. non-residents of states such as california, arizona, florida, and texas comprise a notable proportion of the total p&i hospitalizations treated in hospitals in these states. states are displayed alphabetically within census divisions. in general, adjacent groups of states tend to have the largest discordances between provider state and state of residence for p&i cases. this is especially evident in several new england states, new york, new jersey, and pennsylvania, as well as many residents of alabama being treated in neighbouring georgia and florida, and vice versa. there were notable similarities and differences between the typical high season for influenza-october through march-compared to the period of time between april and september, which generally has lower rates of disease. figure depicts the ratio of p&i hospitalizations comparing counts from october to march to counts from april to september, by provider state and state of residence. orange dots represent states in which the rates are higher for october-march than for april-september. blue dots represent states in which p&i rates are higher for april-september than for october-march. higher colour saturations represent rate ratios of higher magnitude. certain states, such as hawaii, arizona, texas, and florida show higher rates of non-resident p&i hospitalizations in october-march than for the time period of april-september for most states. the non-resident p&i cases in arizona appear to come from a fairly even distribution of many other states. in contrast, out-of-state residents being hospitalized in florida for p&i were derived primarily from northeastern, and midwestern states. many northern states had the opposite pattern entirely: the northernmost states-including maine, vermont, north dakota, and montana and others-actually experienced decreases in out-of-state resident p&i hospitalizations during the influenza season compared to the off-season. table . a closer examination of the specific states from which the non-resident p&i cases hospitalized in florida reveals that a large proportion of those individuals are residents of northeast and midwestern states ( table ) . the top six states provided the majority ( . %) of all out-of-state cases: new york, michigan, ohio, pennsylvania, new jersey, and georgia. the two states that share a border with florida, georgia and alabama, provide . % of all non-resident p&i cases. furthermore, the mapping of the seasonal ratios (frequency in april-september/frequency in october-march) of non-floridians hospitalized in florida reveals a distinct spatial pattern ( figure ). states shaded in purple provide more non-resident p&i hospitalizations to florida during between october and march than between april and september. the darker the hue, the greater the difference is between october-march and april-september. in states shaded in green-namely california, nevada, texas, louisiana, alabama, south carolina, hawaii, and florida itself, there were more non-resident p&i cases occurring in florida during april-september than between october and march. examining all p&i cases occurring in florida comparing residents to nonresidents, we observed distinct seasonality in the numbers of p&i hospitalizations attributable to out-of-state residents but who sought care in florida (figure ). this graph illustrates the seasonal peaks in weekly counts of both the resident and nonresident p&i hospitalizations in florida. there is also distinct seasonality in the percent of all p&i hospitalizations attributable to non-florida residents. this percentage oscillated between approximately % during the seasonal nadirs in the summer months to % during the typical wintertime increases. according to the results of the harmonic regression, hospitalizations of the out-of-state patients peaked at about the third week of january, which is about one week later than that of the same-state patients ( th ± . julian calendar day vs. rd ± . , p < . ). we found distinct, state-specific hospitalization patterns that differ across provider states and over time. in several states, such as california, arizona, texas, and florida, among others, the proportion of non-residents being hospitalized for p&i was higher in the winter months than in the summer months, although for most states, the opposite was true. in florida, the proportion of all p&i hospitalizations attributable to out-of-state residents was over three times as high between october and march compared to the usual nadir of influenza activity, april through september. a large portion of out-of-state resident p&i hospitalizations in florida are derived from northeastern and midwestern states, such as new york, michigan, pennsylvania, and ohio. the patterns observed in florida are similar to those observed in other destination states for seasonally migrating elderly, including texas, california, and arizona, except that the composition of states of primary residence are slightly different than that of florida. furthermore, the top contributors of hospitalized nonresidents are not necessarily with the largest proportions of the national elderly population ( figure ). clear discrepancies exist between the proportion of all u.s. elderly living in the state and each state's contribution to non-resident p&i hospitalizations in florida. michigan, for example, has the eighth largest population of elderly in the nation, yet the state contributed the second-highest number of p&i cases to the non-resident p&i hospitalizations in florida. texas contains the national data on seasonal migration of the elderly within the united states are not readily available. estimates of seasonal migration are available only through proxies or surveys [ ] . our findings contribute to the body of knowledge into seasonal migration of elderly in two important ways. first, these findings provide a framework to estimate seasonal migratory patterns of the u.s. elderly population at the level of stateto-state transference. second, these findings highlight the need for adjusting and fine-tuning public health and medical infrastructure necessary to provide critical care for those elderly patients. public health and medical practitioners could use these findings to identify areas where and time when out-of-state elderly visitors may overwhelm the local infrastructures [ ] . suggested services to be evaluated include vaccination programs, hospital beds, home care services, and medical treatments for complications of p&i, particularly for resident and non-resident elderly, who face the most severe morbidity and highest mortality from these diseases. pneumonia and influenza prevention and treatment for elderly has never been more important. as of , the u.s. has million medicare beneficiaries [ ], most of whom are elderly. exacerbating this situation are the rapid expansions of both size and proportion of the elderly population: as the large baby boomer cohort enters the age groups most vulnerable to the effects of influenza-associated morbidity and mortality, the impact of influenza will likely grow precipitously, resulting in an even greater, yet largely preventable strain on the already burdened health care delivery system [ ] . a major strength of this analysis is the use of cms data set, which is one of the most complete ( % coverage [ ] ) sources of information on u.s. elderly hospitalization profile. the recorded dates of admission permitted us to estimate the peak time of the outcome to the day level. other in-depth analyses, such as relationship between hospitalizations with climatic features and holidays, can also be performed [ ] . the analysis has some important limitations, however. first, the data used for the analysis are only a part of all insurance claims, and therefore do not represent the overall burden of p&i in the elderly population. our cases likely represent only the more severe cases of influenza and its complications. furthermore, medicare covers approximately % of the elderly population. therefore, the total number of p&i cases is likely an underestimate of the total p&i burden in the elderly [ ] . second, we defined the patients with out-of-state residential code as non-permanent residents, but we do not know whether non-residents of each state hospitalized for p&i in that state were living a substantial portion of the year in that particular year, or if they were in the state for a short period. there have been reports on elderly population keeping their original state identity while living in another state for a long term, mostly for tax-related benefits [ ] . so, part of the increase in the ratios during winter could have been due to increase in seasonal migrants, while another part could have been due to those long-term stayers who have moved to a warmer place due to their deteriorating health while decided to keep their original state identity. studies on whether snowbirds have less robust health compared to the national elderly are limited, and the results are inconclusive [ ] . in either of the two circumstances, our findings still emphasize the importance to understand more on this non-residential hospitalized elderly population. despite the limitations outlined above, our study is among the first to quantify pneumonia and influenza hospitalization patterns in the elderly with respect to seasonal migration in the united states. information on this seasonal migration patterns and influenza-associated disease patterns in this vulnerable population is critical in preparing for and controlling a potential influenza outbreak. we observed that nearly % of all p&i hospitalizations that occurred in florida in peak influenza months were from patients visiting from another state. influx of people can profoundly impact the health care system in destination states. the statistically significant delay of five days in the hospitalization peak time for the non-floridian implies possible differences in susceptibilities or health seeking behaviors between the two groups or time and place of potential exposure to virus. the results of this and future related studies may explicate certain populations to target with public health interventions, such as vaccination, at the appropriate time to maximize effectiveness and reduce the burden of pneumonia and influenza in the elderly. in future intervention studies, seasonally migrating elderly individuals could be universally vaccinated in their state of primary residence before the start of the influenza season to determine if this process could curtail the spread of influenza in their destination state. additionally, flow mapping with multivariate visualization [ , ] and network analyses [ ] show promise as valuable tools to quantify spatially and temporally how influenza dynamically flows among states to provide the most vulnerable populations the appropriate medical care and preventive measures. this study simultaneously assessed the spatial and temporal components of influenza-associated hospitalizations in the american elderly population, highlighting the seasonal patterns of influenza potentially related to seasonal migration of elderly individuals. given the lack of national data on inter-state seasonal migration, we demonstrated the use of medicare hospitalizations to quantify the impact of seasonal or temporary migration patterns on the distribution of pneumonia and influenza in the united states. understanding where, when, and to whom hospitalizations occur is a critical component to predict, contain, or even prevent the spread of influenza to the vulnerable population of elderly adults, and will allow state and local health officials to plan for localized outbreaks and timely changes in health care services utilization. distribution of influenza vaccine to highrisk groups deaths: final data for seasonal synchronization of influenza in the united states older adult population dynamical resonance can account for seasonality of influenza epidemics influenza seasonality: underlying causes and modeling theories grandparental caregiving, income inequality and respiratory infections in elderly us individuals global patterns in seasonal activity of influenza a/h n , a/h n , and b from to : viral coexistence and latitudinal gradients synchrony, waves, and spatial hierarchies in the spread of influenza the impact of influenza epidemics on mortality: introducing a severity index the severe acute respiratory syndrome the spanish influenza pandemic in occidental europe ( - ) and victim age comparative age distribution of influenza morbidity and mortality during seasonal influenza epidemics and the h n pandemic trends in hospitalizations for pneumonia among persons aged years or older in the united states snowbirds, sunbirds, and stayers: seasonal migration of elderly adults in florida temporary migration: a case study of florida differences in hospitalizations among seasonal migrants, adjacent-state and in-state aged medicare beneficiaries choice of study discipline and the postponement of motherhood in europe: the impact of expected earnings, gender composition, and family attitudes seasonality assessment for biosurveillance systems impact of local resources on hospitalization patterns of medicare beneficiaries and propensity to travel outside local markets experts predict visits by baby boomers will soon strain emergency departments overcoming potential pitfalls in the use of medicare data for epidemiologic research daily variation in usa mortality seasonal influenza in the united states, france, and australia: transmission and prospects for control pension tax may spur snowbirds to relocate. the detroit news detroit sociodemographic and health characteristics of anglophone canadian and u.s. snowbirds visual analytics of spatial interaction patterns for pandemic decision support flow mapping and multivariate visualization of large spatial interaction data how disease models in static networks can fail to approximate disease in dynamic networks pre-publication history the pre-publication history for this paper can be accessed here submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution we thank the national institute of allergy and infectious disease (n ai ) for approving the study design and providing financial support. we also wish to thank the centers for medicare and medicaid services for supplying the outcome dataset. the above agencies do not have any influence on the collection, management, analysis, and interpretation of the data; nor in any stage of the preparation of this manuscript. the use of the dataset was approved by the tufts medical center institutional review board. authors' contributions kkhc led the writing process, executed the data visualization, and carried out the time-series analysis; sac conceptualized the analysis, drafted the manuscript, and carried out the rest of the statistical analysis. both kkhc and sac contributed equally to the work. enn purchased the medicare data used in the analysis and provided substantive editorial feedback. all authors read and approved the final manuscript. the authors have no specific financial interests, relationships, or affiliations relevant to the subject of this manuscript. key: cord- -m e ffv authors: winters, maike; jalloh, mohamed f.; sengeh, paul; jalloh, mohammad b.; zeebari, zangin; nordenstedt, helena title: risk perception during the – ebola outbreak in sierra leone date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: m e ffv background: perceived susceptibility to a disease threat (risk perception) can influence protective behaviour. this study aims to determine how exposure to information sources, knowledge and behaviours potentially influenced risk perceptions during the – ebola virus disease outbreak in sierra leone. methods: the study is based on three cross-sectional, national surveys (august , n = ; october , n = ; december , n = ) that measured ebola-related knowledge, attitudes, and practices in sierra leone. data were pooled and composite variables were created for knowledge, misconceptions and three ebola-specific behaviours. risk perception was measured using a likert-item and dichotomised into ‘no risk perception’ and ‘some risk perception’. exposure to five information sources was dichotomised into a binary variable for exposed and unexposed. multilevel logistic regression models were fitted to examine various associations. results: exposure to new media (e.g. internet) and community-level information sources (e.g. religious leaders) were positively associated with expressing risk perception. ebola-specific knowledge and hand washing were positively associated with expressing risk perception (adjusted or [aor] . , % confidence interval [ci] . – . and aor . , % ci . – . respectively), whereas misconceptions and avoiding burials were negatively associated with risk perception, (aor . , % ci . – . and aor . , % ci – . , respectively). conclusions: our results illustrate the complexity of how individuals perceived their ebola acquisition risk based on the way they received information, what they knew about ebola, and actions they took to protect themselves. community-level information sources may help to align the public’s perceived risk with their actual epidemiological risk. as part of global health security efforts, increased investments are needed for community-level engagements that allow for two-way communication during health emergencies. in a small remote village in guinea in december , an -month-old boy suddenly became very ill and died [ ] . the virus that killed him was later confirmed to be ebola. in a few months, the outbreak spread to neighbouring liberia and sierra leone [ ]. the ebola outbreak had already spread to the capital cities of all three affected countries by the time the world health organization declared it a public health emergency of international concern in august [ ] . it took more than years to stop the ebola outbreak in west africa. in the three most heavily affected countries, more than , people became infected, of which more than , died [ ] . fear, worry and perception of ebola risk spread across the globe despite the majority of cases occurring in west africa. people in countries far away from the actual epidemic reportedly felt at risk of getting ebola [ , ] . the few ebola cases that occurred in europe and the united states might have exacerbated the risk perception in places where there was virtually no transmission risk [ ] . on the other hand, in ghana, closer to the actual epicentre of the ebola epidemic, a majority of % of survey respondents in the greater accra region reported that they did not feel at risk of contracting ebola [ ] . in sierra leone, the country with the largest number of ebola cases, risk perception was expectedly elevated, with % of survey respondents reporting that they felt at-risk of contracting ebola in august -just months from the declaration of the country's ebola outbreak [ ] . a different survey conducted in march in sierra leone, several months after the peak of the outbreak, found that % of respondents felt that they were at-risk of contracting ebola [ ] . risk perception is defined as "people's subjective judgments about the likelihood of negative occurrences such as an injury, illness, disease and death" [ ] . according to the psychometric paradigm, risk perception depends on a wide range of characteristics of that risk [ ] . for instance, risks that are not controllable, have catastrophic potential, are certain to be fatal, and where the effects are immediate and not known to science, are more likely to be perceived as more dangerous [ ] . the ebola outbreak ticked all of those boxes. worldwide fears of an ebola pandemic were likely further fuelled by non-stop media coverage of the outbreak [ ] . the media's role in the perception of risk is highlighted in the social amplification of risk framework [ ] . this framework states that social, psychological and cultural processes all have the potential to heighten or to attenuate the perceived risk. an especially important role in this framework is assigned to communication, both through interpersonal communication and through the news media. the media generally favours 'newsworthy stories' that are new, unusual or dramatic, thereby potentially amplifying the perceived risk [ ] . a survey in germany showed that people who increased their media use to keep informed about ebola were more likely to feel worried about the outbreak [ ] . an analysis of news coverage of the ebola outbreak in the united states found that % of the analysed news stories contained at least one risk-elevating message, whereas % of the news stories contained at least one risk-minimizing message [ ] . in a situation like the ebola epidemic or the ongoing covid- pandemic, large-scale behaviour change of the public is needed to curb the outbreak [ ] . in many west african communities, people needed to stop traditional burial practices such as washing and touching corpses, as this formed an important risk of ebola infection [ ] . risk communication and social mobilization interventions aimed to inform and engage the public to elicit the desired behavioural change. previous research in sierra leone found that exposure to information sources was associated with increased ebola-specific knowledge and protective behaviours [ ] . risk perception is thought to be an important determinant of behaviour change [ , ] . according to who's risk communication guidelines, 'risk perception is the primary predictor for disaster prevention and mitigation behaviours' [ ] . behaviour change models such as the health belief model point to the importance of risk perception in influencing behaviour change [ ] . vice versa, risk perception can in turn be influenced by behaviour change, as put forward in the risk reappraisal hypothesis [ ] . not much is known about the determinants of risk perception and how knowledge and behaviours influence risk perception. therefore, this study aims to investigate the association between exposure to information sources and risk perception in the ebola outbreak in sierra leone. furthermore, it investigates how behaviour and knowledge may be associated with risk perception. three knowledge, attitudes and practices (kap) surveys were carried out in in sierra leone, one of the poorest countries in the world [ ] . when the ebola outbreak started in , the country was still recovering from a long civil war that crippled the country between and [ ] . a large majority of % of sierra leoneans have access to radio, but only % have access to newspapers [ ] . of the total population, % can surf the internet through computers or mobile phones, with up to % in urban areas [ ] . the first survey was conducted in august (n = ) just months into the outbreak and around the time it peaked in the eastern province. the second and third surveys were conducted about a month before (october, n = ) and a month after (december, n = ) the general peak of the outbreak with high transmission occurring in the northern province and western area. the sampling methods of the kap surveys have been described in more detail elsewhere [ , ] . in short, multistage cluster sampling was used, for which the sierra leone population and housing census list of enumeration areas served as the sampling frame. in the first kap survey, out of the districts of sierra leone were included, focusing mainly on the districts where ebola cases were reported at that time. as the virus spread throughout the country, all districts were included in surveys and . within the randomly selected enumeration areas, the data collector started in the centre of the enumeration area where a pen was dropped. in the direction of the tip of the pen, households were approached based on a predetermined skip interval. in every household, two people were interviewed: the head of the household and either a younger person (age - years) or a woman age or above. all three surveys aimed to produce national and regional-level estimates at a % confidence interval, within a . % margin of error for national estimates and a . % margin of error for regional estimates. the level of risk perception of respondents was measured in the kap surveys by asking 'what level of risk do you think you have in getting ebola in the next months?' to which respondents could answer 'no risk, small, moderate or great'. answers were dichotomised into 'no risk perception' and 'some level of risk perception'. exposure to different information sources was ascertained by the question 'through what means/ways did you learn about ebola?' this was an open question, where data collectors selected one or more pre-coded options that most closely matched the responses provided. additional response options were incorporated into the second and third surveys. mutually exclusive categories were subsequently made by grouping similar information sources into five categories, taking local media landscape into account: electronic media (radio and television), print media (newspapers, brochures and other print materials), new media (mobile phones, text messages, internet), government (house visits by health workers, governments campaigns) and community (religious and traditional leaders, megaphone public announcements, community meetings, friends and relatives). information sources were also categorized by how many sources someone was exposed to: - source, , and - sources. because sample sizes for and sources were low (n = and n = respectively), they were combined with and sources. ebola-specific knowledge was ascertained in the kap surveys through open-ended and closedended questions (see table s in supplementary file). two scores were created from this: a knowledge score with a maximum score of points in surveys - and a misconceptions score, with a maximum score of . the scores were dichotomised based on the means [ ] . three ebola-specific behaviours that are important to transmission control were included in this analysis as outcomes: washing hands with soap and water, avoiding physical contact with people suspected to have ebola, and avoiding burials that involve contact with the corpse. these behaviours were ascertained through an open question: 'in what ways have you changed your behaviour or took actions to avoid being infected?' analyses were adjusted for the following covariates: sex (male, female), age ( - , - , - , + years), education (no education, primary education, secondary and above), religion (islam, christianity) and region (northern province, eastern province, southern province, western area). in an outbreak situation that varies in intensity in different regions at different time points, it is likely that there is a high correlation between time and region. this violates the statistical assumption of independent observations. to account for this, data were analysed using multilevel modelling. in total across the surveys, sampling clusters were used on the first level, after which data were analysed on the individual level. original survey weights were not applied, as the samples were collected proportionally to the district size in the population and the response rate was %. within the multilevel models, associations were estimated with odds ratios (ors) and their % confidence intervals (cis). four variables had some missing data; age (n = ), education (n = ), religion (n = ) and sex (n = ). respondents with missing data (n = , % of the sample) were excluded from the multilevel analyses to allow for complete-case analysis. mediation analyses were carried out using the mediated effect model [ ] to estimate if knowledge, misconceptions and ebola-specific behaviours had a mediating effect on risk perception. from the adjusted models, the β coefficients for a and b were obtained (see figure s in supplementary file), after which they were multiplied. the χ distribution within degree of freedom was used to determine statistical significance of the mediated effect. the analyses were carried out in stata and α was set to . for statistical significance. ethical permission for the surveys was granted by the sierra leone research and ethics review committee and approved by the ethical review board at karolinska institutet in stockholm, sweden (dnr / - ). pooling data from the three surveys resulted in a total sample size of respondents. descriptive statistics of the demographics (table ) show that across the four regions in sierra leone, around one third of respondents were between and years old. females comprised % of the total sample. secondary education was attained by % of respondents, and the highest education attainment was reported from the western area (where the capital city freetown is located), with % of the respondents attaining secondary education or higher levels. among the four geographic regions, the northern province had the largest share of non-educated respondents ( %). islam was the most common religious affiliation across the sample ( %) and in all regions. between and % of respondents expressed some level of risk perception during the first survey in the four regions. this decreased during the second survey for all regions apart from the northern province. having secondary school education or higher was positively associated with expressing ebola risk perception (adjusted or [aor] . , % ci . - . ) compared to having no education. residing in the northern province was strongly associated with expressing ebola risk perception compared to residing in the western area (aor . , % ci . - . ). risk perception was significantly lower in the second survey in october (aor . , % ci . - . ) and third survey in december (aor . , % ci . - . ) compared to the baseline survey in august (table ) . in the crude and adjusted models, two information sources had a positive association with expressing risk perception (table ) : new media (aor . , % ci . - . ) and community sources (aor . , % ci . - . ). print media had a borderline positive association with expressing risk perception (aor . , % ci . - . ). compared to people who were exposed to none or just one of the information sources, exposure to any three sources was associated with increased risk perception (aor . , % ci . - . ). exposure to four or five sources had an even stronger association (aor . , % ci . - . ). in the fully adjusted models, ebola-specific knowledge was positively associated with expressing ebola risk perception (aor . , % ci . - . ), see table . having misconceptions on the other hand was negatively associated with risk perception (aor . , % ci . - . ). in terms of behaviours, hand washing had a positive association with risk perception (aor . , % ci . - . ) and avoiding burials was negatively associated with risk perception (aor . , % ci . - . ). there was no association between avoiding physical contact with ebola-suspects and risk perception (aor . , % ci . - . ). knowledge and misconceptions played a mediating role in the association between all information sources (apart from electronic media) and risk perception, see table . hand washing only mediated the association between government and community sources and risk perception. whereas there was no direct association between avoiding physical contact with suspected ebola patients and risk perception (table ) , this behaviour mediated the association between all information sources apart from electronic media and risk perception. this study shows that exposure to print media, new media or community-based sources of information was associated with increased risk perception of getting ebola in the next months from the time of being interviewed. ebola-specific knowledge and hand washing were positively associated with risk perception, ebolaspecific misconceptions and avoiding unsafe burials were negatively associated with risk perception. mediation analyses revealed that knowledge, misconceptions and ebola-specific behaviours mediated the associations between exposure to various information sources and risk perception. whereas risk perception is deemed to be a key determinant to elicit behaviour change, previous studies have shown ambiguous results when testing the role of risk perception in changing the public's behaviour [ ] [ ] [ ] . our findings regarding various behaviours and risk perception similarly go in various directions. brewer's [ ] observation that many studies use cross-sectional surveys to interpret the influence of risk perception on behaviours might explain this inconsistency. as brewer points out in the 'risk reappraisal hypothesis', over time, and especially in an ever-evolving situation such as the ebola outbreak, adopted behaviours might in turn influence the level of perceived risk [ ] . the observed positive association between hand washing and risk perception can therefore be interpreted in various ways; those who feel at risk are more inclined to wash their hands. or, those who wash their hands do so for a reason; they felt at risk. similarly, the negative association between avoiding burials and risk perception can be interpreted in this direction: people who avoided unsafe traditional burials did not perceive themselves to be at risk of getting ebola. ideally, temporal data is used to test this hypothesis [ ] . our data, while collected at three progressive time periods that aligned with different stages of the outbreak, is considered cross-sectional data. however, our results show that over time, overall risk perception decreased compared to the first survey in august . this is in line with the actual risk of transmission over time and might indicate that by adopting protective behaviours, the perception of risk was lowered over the course of the outbreak -supporting the risk reappraisal hypothesis. risk perception has been described to have two components: a subjective component based on feelings and an analytical component based on available facts [ ] . whereas in theory the analytical component should make calculations based on actual risk, it has been shown that people are relatively insensitive to understanding probability. the subjective component will often take over, whereby feelings determine the level of perceived risk [ ] . the finding that risk perception decreased over time, might therefore point to successes in risk communication to match the public's subjective risk to the actual risk of transmission. however, as many other interventions were implemented concurrently, we cannot discern the size of the effect of any risk communication intervention using an observational design. furthermore, social learning may have occurred intrinsically without external interventions. for instance, when people observed fewer cases of ebola in their communities, districts, and country, they might have felt less at risk of getting ebola. therefore, intrinsic social learning may also contribute in explaining why risk perceptions declined sharply between the first survey (administered before the peak of the outbreak) and third survey (administered after the peak). exposure to community-based information sources through community leaders, community meetings and friends and relatives was associated with expressing ebola risk perception. together, these community-based sources form a group of people who are highly trusted and respected [ ] . whereas the initial response to the outbreak was criticized for prioritizing top-down risk communication messaging instead of focussing on community engagement, local leaders were actively engaged later in the outbreak response [ ] . community sources and new media are comparable in that they both facilitate active interaction between the messenger and the recipient of that message [ ] . as opposed to top-down messaging, this form of two-way communication allows recipients to ask questions, express concerns and discuss solutions [ ] . it is plausible that by potentially getting a better understanding of the disease and the outbreak through these interactions, the perception of risk might have been enhanced. having ebola-specific knowledge was also positively associated with risk perception. it is plausible that people with enhanced risk perception sought more knowledge, even though with this study design it is equally possible that people with increased knowledge may have elevated risk perception. however, an online survey in the usa found that higher knowledge was associated with decreased perceptions of risk about ebola [ ] . in another online survey in germany, there was no association between ebola-specific knowledge and being worried about ebola [ ] . the closeness and actual immediate risk in sierra leone, and the accuracy of risk perceptions might have played a role in this [ ] . it is also possible that a combination of the directions of the association occurred. however, with the available data we cannot discern this. finally, having misconceptions about ebola was negatively associated with perceiving some level of risk. this is an important finding, as misconceptions can also be associated with risk behaviour [ ] . a survey from the north kivu and ituri ebola outbreak in the democratic republic of the congo shows that belief in misinformation was associated with a decreased likelihood of adopting protective behaviours [ ] . a major strength of this study was the relatively large sample sizes of the three kap surveys. the surveys captured population-level data during an ongoing largescale outbreak at several timepoints across all geographic regions of sierra leone. the sampling method and the high response rates should mitigate the risk of selection bias. the kap survey instruments were not validated because of the ongoing emergency and the need of gathering data rapidly. however, the survey instruments were pilot-tested and kap surveys have shown to be a useful tool in several outbreaks [ , , , ] . risk perception was measured using a generic unidimensional likertitem in the three kap surveys that our analyses are based on. models and theories of risk perception and behavioural change assert that risk perception is a complex phenomenon that is driven by the multiplicity of affective responses to the hazard, subjective appraisals of its likelihood, and perceptions of its consequences [ ] . given the multidimensionality of risk perception, future ebola (or similar epidemic) risk perception assessments should consider including multiple items that reflect the underlying domains of risk perception such as affect, probability, and consequence [ ] . exposure to information sources was dichotomised into exposed and unexposed. we did not have information on the content of the messaging, the framing, the tone or the amount of actual coverage. these factors can all potentially play a role in amplifying or attenuating the perceived riskespecially in a fluid and chaotic outbreak context [ ] . moreover, we carried out mediation analyses with cross-sectional data, and therefore cannot establish if the assumed exposure to information sources happened before the assumed mediators (knowledge, misconceptions, and behaviour) and outcome (risk perception). however, it is plausible that the public in sierra leone first learned about the existence of an outbreak through at least one of the information sources we included in this study. we attempted to account for the high correlation between time and region by applying multilevel modelling. whereas we adjusted for several demographic factors, unmeasured, residual confounding could have had an influence on the outcomes. the three surveys covered all regions in sierra leone, but contrary to survey and , survey only covered out of districts. to mitigate this limitation, the multilevel approach accounted for the effects of geographic clusterswhich were more granular than districts. our results provide novel insights into the complex relationship between risk perception and human behaviour during an unprecedented ebola outbreak. exposure to community-level information sources was positively associated with perceiving some ebola risk. more people perceived themselves to be at risk before the peak of the outbreak compared to after the peak. individuals who said they took protective actions against ebola perceived themselves to be at decreased risk of getting ebola. these findings reinforce the importance of effective risk communication, especially in the early stages of an outbreak, to help the public understand their risk and take appropriate actions to reduce their acquisition risk. community-level information sources may help to align the public's perceived risk with their actual epidemiological risk through continuous exchange of information that help to improve knowledge, reduce misconceptions, and facilitate uptake of protective behaviours. as part of global health security efforts, increased investments are needed for community-level engagements that allow for two-way communication during health emergencies. supplementary information accompanies this paper at https://doi.org/ . /s - - - . additional file : table s . composite variables for ebola-specific knowledge and misconceptions. figure s . mediation analysis among information exposure, knowledge, behaviour and risk perception, sierra leone, . abbreviations aor: adjusted odds ratio; ci : confidence interval; kap : knowledge, attitudes, practices; or : odds ratio; se : standard error ground zero in guinea: the ebola outbreak smoulders -undetected -for more than months ebola outbreak in west africa what does the public know about ebola ? the public's risk perceptions regarding the current ebola outbreak in an as-yet unaffected country ebola risk perception in germany ebola-related stigma in ghana: individual and community level determinants national survey of ebola-related knowledge, attitudes and practices before the outbreak peak in sierra leone rapid assessment of knowledge, attitudes, practices, and risk perception related to the prevention and control of ebola virus disease in three communities of sierra leone risk perceptions and risk characteristics perception of risk media 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behaviour among young slum dwellers in ibadan relation between perceived vulnerability to hiv and precautionary sexual behavior perceived risk and vulnerability as predictors of precautionary behaviour risk as analysis and risk as feelings social mobilization and community engagement central to the ebola response in west africa: lessons for future public health emergencies a community-engaged infection prevention and control approach to ebola emergency risk communication: lessons learned from a rapid review of recent gray literature on ebola, zika, and yellow fever knowledge and risk perceptions of the ebola virus in the united states institutional trust and misinformation in the response to the - ebola outbreak in north kivu , dr congo: a population-based survey ebola virus epidemic in war-torn eastern dr congo developing a broadly applicable measure of risk perception media risk communicationwhat was said by whom and how was it interpreted publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank the respondents of the surveys for their time, and the data collectors for carrying out this important work during a health emergency. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. ethical permission for the surveys was granted by the sierra leone research and ethics review committee and approved by the ethical review board at karolinska institutet in stockholm, sweden (dnr / - ). written consent was obtained from study participants before the start of the survey. for participants under years of age, written consent was obtained from a parent or guardian (the head of the household). not applicable. the authors declare no conflict of interest. authors' contributions mfj, ps, mbj contributed to the study design and the data collection. mw, mfj, zz, hn contributed to the analysis plan for this study. mw, mfj, ps, zz, hn contributed to the data management and statistical analysis. mw, mfj, hn contributed to writing the manuscript. all authors read and approved the final manuscript. this study was funded by the cdc foundation and the swedish research council (vetenskapsrådet: - ). the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. open access funding provided by karolinska institute. key: cord- - sfleb b authors: chan, ta-chien; hwang, jing-shiang; chen, rung-hung; king, chwan-chuen; chiang, po-huang title: spatio-temporal analysis on enterovirus cases through integrated surveillance in taiwan date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: sfleb b background: severe epidemics of enterovirus have occurred frequently in malaysia, singapore, taiwan, cambodia, and china, involving cases of pulmonary edema, hemorrhage and encephalitis, and an effective vaccine has not been available. the specific aim of this study was to understand the epidemiological characteristics of mild and severe enterovirus cases through integrated surveillance data. methods: all enterovirus cases in taiwan over almost ten years from three main databases, including national notifiable diseases surveillance, sentinel physician surveillance and laboratory surveillance programs from july , to december , were analyzed. the pearson’s correlation coefficient was applied for measuring the consistency of the trends in the cases between different surveillance systems. cross correlation analysis in a time series model was applied for examining the capability to predict severe enterovirus infections. poisson temporal, spatial and space-time scan statistics were used for identifying the most likely clusters of severe enterovirus outbreaks. the directional distribution method with two standard deviations of ellipse was applied to measure the size and the movement of the epidemic. results: the secular trend showed that the number of severe ev cases peaked in , and the number of mild ev cases was significantly correlated with that of severe ones occurring in the same week [r = . , p < . ]. these severe ev cases showed significantly higher association with the weekly positive isolation rates of ev- than the mild cases [severe: . , p < . vs. mild: . , p < . ]. in a time series model, the increase of mild ev cases was the significant predictor for the occurrence of severe ev cases. the directional distribution showed that both the mild and severe ev cases spread extensively during the peak. before the detected spatio-temporal clusters in june , the mild cases had begun to rise since may , and the outbreak spread from south to north. conclusions: local public health professionals can monitor the temporal and spatial trends plus spatio-temporal clusters and isolation rate of ev- in mild and severe ev cases in a community when virus transmission is high, to provide early warning signals and to prevent subsequent severe epidemics. in july , children died of infections with enterovirus- (ev- ) in cambodia [ ] . before the laboratory results came back, the media called it a mystery disease, which made numerous asian parents worried. in fact, severe epidemics of enterovirus have occurred frequently in asia, including malaysia [ ] , singapore [ ] , taiwan [ , ] and china [ ] . the clinical severity varied from asymptomatic to mild symptoms [hand-foot-mouth disease (hfmd) and herpangina], severe pulmonary edema, hemorrhage and encephalitis [ ] . the ev- infections involved - % asymptomatic infection, - % non-specific viral syndrome, and %- % hfmd/ herpangina symptoms [ ] . among the non-polio enterovirus serotypes, ev- , which has caused severe clinical illness and many fatal cases [ ] , and particularly a high risk of poor prognosis for children under one year of age [ ] , has become one of the most important public health concerns since the world health organization (who) launched the "global polio eradication initiative" program in [ ] . however, children with an asymptomatic and mild infection of ev- still can carry the virus to transmit to others [ ] . during ~ , . % ( / , ) of severe ev cases in taiwan had only encephalitis complications, and . % ( / , ) had encephalitis with pulmonary edema or hemorrhage [ ] . in other words, whether increasing numbers of mild ev cases would provide a possible sentinel signal of the early stage of an epidemic is worth investigating, particularly as a vaccine and more effective drugs for ev- have not been available [ , ] . therefore, using an integrated surveillance system to monitor the enterovirus activity and fully understanding the difference in epidemiological characteristics between mild and severe enterovirus cases will be the most important prevention and control measures in public health. after the first nationwide epidemic of ev- occurred in taiwan in , there were another three cross-county figure geographical distribution in the cumulative incidence of pediatric severe ev cases (aged - ) in taiwan from july to december . epidemics in - , - , - [ ] . the question is, what are the important epidemiological characteristics that will be helpful in surveillance of ev- to minimize the severity of future epidemics? the specific aims of this study were: ( ) to elucidate the spatio-temporal correlations between the mild and severe enterovirus cases through integrating the data of the three enterovirusrelated surveillance systems, including the sentinel physician, national notifiable diseases and laboratory surveillance systems in taiwan, ( ) to find out the feasibility of establishing an early warning signal using the increasing numbers of mild ev- cases and their lag time periods to appearance of severe ev- cases, and ( ) to evaluate the trends of severe ev- cases over a . -year period for providing better recommendations on public health efforts in the future. with full understanding of the epidemiological characteristics, hopefully we can develop better measures and indicators from mild cases to provide early warning signals and thus minimizing subsequent numbers of severe cases. the temporal trend between severe ev cases and average mild ev cases per doctor. the x axis is the time in digits; the first four digits are the year, and the last digits are the week number. [ ] . for the sentinel-physician surveillance system, involving voluntary-based sentinel physicians in taiwan, there were around sentinel physicians from clinics and hospitals [ ] . the cases with hfmd or herpangina reported through this system were compiled on a weekly basis. for virological surveillance data, all those specimens that were collected by sentinel physicians for highly suspected ev cases and sent to the regional contracted laboratories of the tw-cdc were used to examine the viral types, including ev- , coxasackievirus groups a/b, echovirus, and other enterovirus [ ] . in this study, the temporal unit was the week, and the spatial unit was the city or county. to compare the trends between the mild and severe ev cases and between the isolation rates of different serotypes of ev and the number of severe ev cases, pearson's correlation coefficients were applied for measuring the consistency of the weekly data with the statistical software, spss (version . , spss science, the temporal trend between ev- isolation rate and severe ev cases. chicago, il). because the data of sentinel physicians were collected on a weekly basis, the counts of the severe ev cases and virological results were also aggregated into a weekly basis for better comparison. weekly numbers of severe cases and ev-positive isolation rates were used to compare their temporal trends, whereas the weekly incidence rates of severe ev-cases were employed to describe spatial distributions over time. a lag effect between mild and severe ev cases was taken into account to find out whether mild ev cases occurred earlier or later than severe ev cases, in order to determine whether mild cases might serve as early warning signals for severe cases. in addition, we applied cross-correlation analysis in a time series model to see whether there was any conditional correlation among the severe and mild ev cases and four types of ev isolation. an arma model (autoregressive moving average model) was fit using the sas release . software (cary, nc). the selection of the autoregressive (ar) and moving average (ma) was based on the minimum information criterion (minic) method [ ] . because the mild and severe ev cases were from different surveillance systems, the age definition of the ev cases we used was different. the mild ev cases were from sentinel surveillance, which had aggregated reported cases without age information. thus, the age definition of mild ev was all ages. the severe ev cases were from the notifiable infectious disease system, which had complete age information. because most of the high risk population of severe ev cases was children during the study period, we selected the cases aged equal or less than years ( . %, , / , , median age = . months) for further cluster analysis. the cumulative incidence of the pediatric severe ev cases was calculated with the corresponding mid-year population from july to . most likely clusters with high incidence of severe ev cases were detected retrospectively using spatial statistic, temporal statistic, and space-time scan statistic implemented in satscan v. . . . [ ] . the population data throughout the study period in each city or county were collected from taiwan's national statistics website (http://ebas .ebas.gov.tw/pxweb/dialog/statfile .asp). all the . years cases' data were used, with a maximum cluster population size of % to minimize false clusters, and a maximum temporal window of one month to examine the temporal-cluster using the software of satscan. the analyses of data with case counts were carried out using the poisson probability model (for a few pediatric ev cases among the child population) with monte carlo replications to test for the presence of statistically significant spatial clusters [ ] , and choosing the parameter for no geographic overlapping clusters to avoid repeated counting. after identifying the space-time clusters of the severe ev cases, the corresponding data of the mild ev cases from sentinel physician surveillance were further analyzed for consistent temporally increasing trends or even earlier increasing trends. space-time permutation was applied for detecting the mild ev clusters due to the lack information of the population at risk [ ] . the directional distribution method was employed, with two standard deviations of the ellipse size weighted by either the mild ev cases per doctor or the number of severe ev cases [ ] . then, we applied gis software (arcmap, version . ; esri inc.,redlands, ca, usa) for visualization of all detected statistically significant clusters. among the , severe ev cases notified to the taiwan-cdc during the study period, the mean age was months [mean ± standard deviation (s.d.) = ± . ], . % were male, % were hospitalizations or referrals, and % were fatal. in the virological surveillance database, the mean age of ev- cases was . months (s.d. = . months, n = , ) and that of non-ev- cases was . months (s.d. = . months, n = , ). most of the severe ev cases were aged less than years, [ . % ( , / , )] which was the group used for cluster analysis. the distribution of incidence of severe ev aged - during the study period was high in central and southern taiwan and surrounding islands including penghu county and kinmen county (figure ). temporal analysis in figure found that the mild ev cases and all the severe ev cases occurring in the same week were significantly correlated (pearson's correlation coefficient = . , p < . ). severe ev cases had two peaks starting from , but the second peak was less pronounced beginning in . after considering the lag effect, the correlation between mild ev cases and weeks ahead and the later severe ev cases was . (p < . ) and . (p < . ), respectively. on the other hand, the correlation between severe cases which were or weeks earlier and the subsequent mild ev cases was . (p < . ) and . (p < . ) in table , respectively. the highest correlation coefficients shifted from the mild ev cases earlier to severe ev cases earlier since - . in table , the correlation among mild and severe ev cases and the isolation rates of the major four types of nonpolio enterovirus are shown. the isolation rates of ev- were highly correlated with the occurrence of severe ev cases (r = . , p < . ). their temporal pattern is shown in figure . such weekly correlation coefficients were much lower for other types of ev [ . (p < . ) for coxsackie a virus, . (p < . ) for coxsackie b virus and . (p < . ) for echo virus]. in table , the dependent variable was the severe ev cases each week. the explanatory variables were the mild ev cases, the isolation rates of ev- , coxsackievirus a virus, coxsackievirus b virus, and echovirus in each week. in the first model, without considering the arma effect, only mild ev cases (coefficient = . , p < . ) and the ev- isolation rate (coefficient = . , p < . ) were significant predictors. in the second model, considering arma ( , ) which was selected by minic function in sas, only the ar effects and mild ev (coefficient = . , p < . ) were significant predictors. on the other hand, we also switched mild ev cases as the dependent variable and severe ev cases as an explanatory variable. after considering the ar effect, severe ev cases could not be significant predictors for mild ev cases (p = . , data are not shown). to fully understand the temporal, spatial and tempo-spatial distributions of ev cases, we then monitored the trends in ev cases using these three methods separately. with the temporal scan method alone, the temporal cluster was only detected in june , which had the highest number of monthly severe ev cases (n = ) during the study period. in the further analysis, the number of the severe ev cases from april to june was , which was also the highest value for any three-month period during the study period. with the spatial scan method alone, there were two years without statistical significant spatial clusters (i.e. , and ), while the other seven years had statistical significant spatial clusters: july july - july , july , july , july , july , july and . throughout the study period (figure ) , penghu county in july - , and had the highest local spatial risk ( . and . , p < . ). with the integrated space-time scan method, the five cities or counties which had the highest number ( ) of severe cases throughout the study period and the highest number ( ) of fatal cases in were identified ( figure a ). three space-time mild ev clusters were detected in ( figure b ). in tainan city, consistent mild and severe ev clusters were both detected in june . another two mild ev clusters in were found earlier, in april and may. penghu county also had the highest local tempo-spatial risk among these ( . , p < . ). then, we analyzed the temporal trend in mild ev cases per doctor in . in figure , the period of june , which is marked as the gray dashed square, was also the peak of the mild ev cases. however, the increasing trend of severe ev cases surged starting in week , , (april , and mild ev cases also surged in the following week (april , ). in figure (table ). epidemics of enterovirus have continued playing a major public health threat in the asia-pacific region [ ] . during the past decade, epidemics have also occurred in european countries, including denmark [ ] , the united kingdom [ ] , hungary [ ] , france [ ] and the netherlands [ ] . the integrated information from different enterovirus surveillance systems (rather than from a single source) plus spatio-temporal analyses of epidemiological data in taiwan might provide valuable experience for other countries. enhanced surveillance and non-pharmaceutical public health policy such as school closure have been the major strategies implemented for preventing enterovirus epidemics, because effective vaccines and antiviral drugs have not been available. in this study, we have shown that integrated surveillance, including sentinel physicianbased clinical surveillance, virological surveillance, and notifiable infectious disease surveillance, reflected not only the whole spectrum of ev cases from mild to severe but also the types of virus activity at the community level. with the spatial scan and spatio-temporal scan statistics, we found that central taiwan and penghu county, which is an island located km offshore, were the locations of major clusters of severe ev cases. in the temporal pattern, the severe ev cases occurred either one week earlier than the mild ev cases or surged simultaneously, during the same week. however, taking the autoregressive effects and ev isolation rates together, severe ev cases could not significantly explain the temporal trend of mild ev cases. in contrast, mild ev cases might have better prediction capability even after controlling for the ar effects. in this study, the peak of the mild and the severe ev cases occurred almost the same week. in the years of and , the increases of the mild ev cases occurred one to two weeks earlier than the increases of the severe ev cases. after , the pattern changed to consistently high in the same week, or severe cases rising even much earlier. several possible reasons might explain this phenomenon. first, the outbreak of sars in made physicians in taiwan more aware of unusual increases in case numbers of infectious diseases. once severe ev cases were reported and announced through mass media, even at the early stage, it might have alerted the physicians to pay attention to additional suspected ev cases. second, ev- was highly correlated with severe ev cases. this is consistent with the facts, that ev- was known to have high virulence, and pathogenicity in the central nervous system by inflammatory cytokines/chemokines [ , ] , severe pulmonary edema and heart failure [ ] . the early information on the positive isolation rate of ev- also can be helpful to predict the more likely occurrence of severe ev cases in the following one to two weeks. with the space-time scan method, we found temporal clusters in june , and spatial clusters in five cities and counties. one nearby island, penghu, where the seashore is a famous summer tourist destination, had the highest local risk in and . the possible reasons for this phenomenon might have been the smaller number of children amongst the population, lack of medical resources, and close transportation to another epidemic center, china. the data in this study have three major limitations. because of the de-identification between different released databases, direct linkage between the severe ev cases and the results of ev isolation was not feasible. hence, it was hard to elucidate the correlation between local epidemics and the specific types of enterovirus circulated. age-related data for mild ev incidence were not available in the sentinel surveillance database. therefore, it was hard to differentiate among incidence in preschool children or school-aged children. integration among different surveillance systems would be beneficial for disease surveillance. public health surveillance and clinical surveillance could help detect aberrations at the early stage. laboratory surveillance could help determine the severity of epidemics. in the future, utilizing community surveillance, hospitalbased syndromic surveillance and national health insurance data, which cover % of the population in taiwan, for monitoring age-specific enterovirus cases will offer the best chance to detect enterovirus activity with better sensitivity and timeliness at the local community level. local public health professionals can monitor the temporal and spatial trends plus spatio-temporal clusters and isolation rate of ev- in mild and severe ev cases in the community when virus transmission is high to provide early warning signals and to prevent subsequent severe epidemics. the increase of mild ev cases might be a possible predictor for the occurrence of severe ev cases with a time series model. in addition, comprehensive surveillance of school children might detect earlier signals and allow social distance intervention to minimize the size of spatial clustering. severe complications of hand, foot and mouth disease (hfmd) caused by ev- in cambodia -conclusion of the joint investigation hand foot and mouth disease due to enterovirus in malaysia the changing seroepidemiology of enterovirus infection among children and adolescents in singapore incidence rates of enterovirus infections in young children during a nationwide epidemic in taiwan enterovirus in taiwan epidemiology of hand, foot, and mouth disease and genotype characterization of enterovirus in jiangsu an eight-year study of epidemiologic features of enterovirus infection in taiwan challenges to licensure of enterovirus vaccines an epidemic of enterovirus infection in taiwan. taiwan enterovirus epidemic working group non-polio enteroviruses in acute flaccid paralysis children of india: vital assessment before polio eradication transmission and clinical features of enterovirus infections in household contacts in taiwan enterovirus vaccine: when will it be available? antiviral effect of geraniin on human enterovirus in vitro and in vivo guidelines for communicable disease surveillence. taipei, taiwan: taiwan cdc epidemiology and surveillance system of human influenza viruses circulating viruses associated with severe complicated enterovirus infection in taiwan: a multi-year analysis time series analysis: forecasting and control evaluating cluster alarms: a space-time scan statistic and brain cancer in a spatial scan statistic a space-time permutation scan statistic for disease outbreak detection novel measurement of spreading pattern of influenza epidemic by using weighted standard distance method: retrospective spatial statistical study of influenza virology, epidemiology, pathogenesis, and control of enterovirus clinical and virological features of enterovirus infections in denmark molecular epidemiology of human enterovirus in the united kingdom from to human enterovirus (ev ) in acute paediatric respiratory disease in hungary screening and detection of human enterovirus infection by a real-time rt-pcr assay detection of recombination breakpoints in the genomes of human enterovirus strains isolated in the netherlands in epidemic and non-epidemic years enterovirus infection with central nervous system involvement cytokine immunopathogenesis of enterovirus brain stem encephalitis cardiopulmonary manifestations of fulminant enterovirus infection submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution the authors would like to express our sincere gratitude to public health professionals at local departments of health and central public health officials at the centers for diseases control in taiwan (taiwan-cdc) for their effort in surveillance of enterovirus-related diseases. this study was supported by grants from the center for disease control taiwan the authors declare that we do not have any competing interests related to this study.authors' contributions tcc did all spatio-temporal data analysis and writing for the whole manuscript. jsh participated in spatio-temporal statistics. rhc did most data analyses from surveillance by types of enteroviruses. cck guided epidemiological study between mild and severe enterovirus cases and also the revision of this manuscript. phc participated in gis analysis and the revision of this manuscript. all authors read and approved the final manuscript. key: cord- - dfphxq authors: brown, lawrence h; aitken, peter; leggat, peter a; speare, richard title: self-reported anticipated compliance with physician advice to stay home during pandemic (h n ) : results from the queensland social survey date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: dfphxq background: one strategy available to public health officials during a pandemic is physician recommendations for isolation of infected individuals. this study was undertaken during the height of the australian pandemic (h n ) outbreak to measure self-reported willingness to comply with physician recommendations to stay home for seven days, and to compare responses for the current strain of pandemic influenza, avian influenza, seasonal influenza, and the common cold. methods: data were collected as part of the queensland social survey (qss) , which consisted of a standardized introduction, demographic questions, and research questions incorporated through a cost-sharing arrangement. four questions related to respondents' anticipated compliance with a physician's advice to stay home if they had a common cold, seasonal influenza, pandemic (h n ) influenza or avian influenza were incorporated into qss , with responses recorded using a balanced likert scale ranging from "very unlikely" to "very likely." discordance between responses for different diseases was analysed using mcnemar's test. associations between demographic variables and anticipated compliance were analysed using pearson's chi-square or chi-square for linear-by-linear association, and confirmed using multivariate logistic regression; p < . was used to establish statistical significance. results: self-reported anticipated compliance increased from . % for the common cold to . % for seasonal influenza (p < . ), and to . % for pandemic (h n ) influenza and . % for avian influenza (p < . for both versus seasonal influenza). anticipated compliance did not differ for pandemic (h n ) and avian influenza (p = . ). age and sex were both associated with anticipated compliance in the setting of seasonal influenza and the common cold. notably, . % of health and community service workers would not comply with physician advice to stay home for seasonal influenza. conclusions: ninety-five percent of people report they would comply with a physicians' advice to stay home for seven days if they are diagnosed with pandemic (h n ) or avian influenza, but only % can be expected to comply in the setting of seasonal influenza and fewer still can be expected to comply if they are diagnosed with a common cold. sub-populations that might be worthwhile targets for public health messages aimed at increasing the rate of self-imposed isolation for seasonal influenza include males, younger people, and healthcare workers. in late march an outbreak of a new strain of influenza a (h n ), swine-origin influenza virus (s-oiv) or "swine flu," was reported in north america [ , ] . this disease quickly spread across the globe, and the world health organization declared a pandemic on june [ ] . the first cases of pandemic (h n ) influenza in australia were reported in may , coinciding with the onset of the annual influenza season. as of january , , cases of pandemic (h n ) influenza had been confirmed in australia, with deaths [ ] . at the time the australian cases peaked, there was no approved vaccine for pandemic (h n ) virus; traditional public health measures were critical to containing the outbreak. one strategy available to public health officials is physician recommendations for self-imposed isolation of infected individuals; specifically, to stay home for at least seven days. such public health measures, however, only work if patients are willing to comply [ ] [ ] [ ] . this study was undertaken during the height of the australian pandemic (h n ) outbreak to measure self-reported willingness to comply with physician recommendations to stay home for seven days, and to compare responses for the current strain of pandemic influenza, avian influenza (h n ), seasonal influenza, and the common cold. data for this study were collected as part of the queensland social survey (qss) . qss is an annual statewide survey conducted by the population research laboratory (prl) in cquniversity australia's institute for health and social science research. through a costsharing arrangement, qss enables researchers and policy-makers to incorporate questions into the survey. queensland is the second largest australian state by land area, and the third most populous state. qss uses a computer-assisted telephone interviewing (cati) system and trained interviewers to randomly sample households across queensland, including metropolitan brisbane (south east queensland) and the rest of the state (other queensland). to ensure equal representation of males and females, households are randomly pre-determined to provide a male or female respondent; if a person of that sex is not available then the household is not included in the survey. qss consisted of a standardized introduction, specific questions incorporated by researchers and the university, and demographic questions. the questions were pilot tested by trained interviewers in randomly-selected households, with modifications to the questions guided by both responses from the pilot study subjects and feedback from the interviewers. final interviewing was conducted between july and august , between the hours of : am to : pm and : pm to : pm on weekdays, and between the hours of : am and : pm on weekends. four questions related to respondents' anticipated compliance with a physician's advice to stay home if they had a viral respiratory illness were incorporated into qss . the four questions were: • if you had a common cold and your doctor recommended that you stay home for at least seven days so as not to infect anyone else, how likely are you to do so? • if you had the regular flu, but not swine or bird flu, and your doctor recommended that you stay home for at least seven days so as not to infect anyone else, how likely are you to do so? • if you had the swine flu and your doctor recommended that you stay home for at least seven days so as not to infect anyone else, how likely are you to do so? • if you had the avian or bird flu and your doctor recommended that you stay home for at least seven days so as not to infect anyone else, how likely are you to do so? responses were recorded using a -point likert scale ranging from "very unlikely" to "very likely." responses were subsequently dichotomized as "yes" (very likely or likely) and "no" (very unlikely or unlikely) and crosstabulated in a × table. because the data are essentially repeated measures of likelihood to comply under different circumstances, discordance between responses for the different diseases was analysed using mcnemar's test. bivariate associations between relevant demographic variables and anticipated compliance were analysed using chi-square or fisher's exact test; where demographic variables were recorded as ordinal data, analyses utilizing chi-square for linear-by-linear association were conducted to identify any significant trend effects. subsequently, multivariate logistic regression was conducted to identify covariates and interaction effects, and to adjust for confounding. each variable was entered into or removed from the logistic regression model using both forward and backward methods to identify significant covariates, the remaining variables were then individually entered into the model to identify potential confounders. the final model included significant covariates, potential confounders and significant interaction effects. for all analyses, p < . was used to establish statistical significance; for the multivariate analysis, adjusted odds ratios (aor) and their % confidence intervals (ci) are reported. qss had a target sample size of , subjects, with subjects from south east queensland and from other queensland; thus the a priori estimated sampling error at the % confidence level was ± . % overall, ± . % for the south east queensland sub-sample, and ± . % for the other queensland sub-sample. panel at cquniversity (h / - ) and the incorporation of the influenza-related questions was approved by the human research ethics committee at james cook university (h ). qss contacted or attempted to contact , households; , subjects declined participation, households could not be contacted, and were otherwise ineligible. thus, the final sample for qss included , respondents; from south east queensland and from other queensland for an overall response rate of . %. the sample was nearly equally divided between males and females ( . % vs. . %). younger people (aged - years) were under-represented in the sample and older people (aged > years) were over-represented in the sample, otherwise the demographics of the participants reasonably approximated that of the general population [ ] as shown in table . responses to the four questions concerning anticipated compliance with a physician's advice to stay home are shown in table bivariate associations between demographic variables and anticipated compliance with a physician's advice to stay home for the four viral diseases are shown in additional file : table s . as anticipated compliance in the setting of pandemic (h n ) and avian influenza was near universal, there were no significant associations between demographic variables and anticipated compliance. for the common cold and seasonal influenza, however, there were a number of significant associations. respondents who were male, younger, employed (versus unemployed), and had a higher level of education were less likely to report anticipated compliance with stay home advice for both a common cold and seasonal influenza. married/partnered people and those who lived in south east queensland were also less likely to comply with advice to stay home for a common cold. people who lived in urban areas, and people employed in the health and community services sector were more likely than others to comply with advice to stay home for seasonal influenza, although . % of health and community service workers would be unlikely to comply with such advice. in multivariate analysis, only sex and age remained significantly associated with anticipated compliance, and there was no interaction effect between these two variables. (additional file : table s ) females were more likely than males to report anticipated compliance for both the common cold (aor = . ; ci: . - . ) and seasonal influenza (aor = . ; ci: . - . ). nearly every respondent in this study reported they would comply with a doctor's advice to stay home for seven days if they were diagnosed with pandemic (h n ) influenza, and the same level of compliance could be expected in the setting of avian influenza. these findings are similar to those that have been previously reported; our study adds data in the context of an actual, rather than hypothetical, pandemic. prior to the current pandemic, eastwood et al read a brief description of a pandemic influenza outbreak analogous to the spanish flu to australian telephone survey participants, and found . % of respondents would stay home for seven to ten days if they were told they might have had contact with the disease [ ] . similarly, barr et al [ ] reported % of australians would be at least moderately willing to isolate themselves from others during an influenza pandemic. blendon et al [ ] reported % of americans would comply if they contracted a pandemic influenza and public health officials recommended they stay at home for seven to ten days. in a more recent survey from june of , blendon et al [ ] identified respondents who reported that they themselves or someone in their household had experienced flu-like symptoms, and % of those with symptoms had stayed home. other studies have also found support for explicit government action to contain pandemic influenza, including "encouraging" people to work from home, and quarantining infected individuals [ , ] . interestingly, digiovanni et al [ ] reported that compliance with quarantine measures during the severe acute respiratory syndrome (sars) outbreak in toronto, canada was affected more by compliance monitoring, fighting boredom and stress, and minimizing stigmatization than with any actual threat of enforcement. from a public health planning perspective, the more useful data from this study may be that regarding the level of compliance with stay at home advice that can be anticipated for seasonal influenza, and the relative lack of compliance that can be expected for the common cold. seasonal influenza is a more common disease, each year leading to approximately , hospitalizations and costing around $ million in australia; the burden in the united states is much greater with the direct costs of influenza-related medical care exceeding $ billion [ ] . yet, these data confirm that people do not view seasonal influenza with the same level of concern as pandemic strains of influenza. while it is encouraging that respondents appear to differentiate between seasonal influenza and the common cold, the questions in this survey presumed a physician diagnosis. large numbers of people do not seek medical care for mild to moderate respiratory illness, and it is not practical to expect lay people to reliably differentiate between a common cold and influenza. public health efforts to encourage people to self-isolate for influenza-related illnesses may be more successful if they target symptoms (i.e., "cough and fever") rather than specific diagnoses. this study did find some significant associations between demographic characteristics and likelihood to comply with stay at home advice for seasonal influenza that might be useful for targeting public health efforts to increase compliance. males were less likely to report anticipated compliance with stay home advice for both a common cold and seasonal influenza, and this is consistent with other studies from australia [ , ] . males have also previously been reported to feel less susceptible than females do to pandemic influenza, [ ] although this study found no differences between males and females for anticipated compliance in the setting of pandemic (h n ) or avian influenza. increasing age was associated with increased anticipated compliance with stay at home advice for both the common cold and seasonal influenza, while increasing education and income were associated with decreased anticipated compliance for both diseases. although the associations for education and income did not withstand multivariate analysis, the finding is consistent with previous work and both variables were retained as potential confounders in the final logistic regression model. like males, wealthier and better educated people tend to view themselves as less susceptible to influenza, while older people tend to view themselves as more susceptible [ ] . many influenza-related public health campaigns target older populations; targeting stay at home messages to wealthier and better educated populations might be a novel but worthwhile effort for containing seasonal influenza. employed respondents were less likely than unemployed respondents to report anticipated compliance with stay home advice for both a common cold and seasonal influenza. this association, also, did not withstand multivariate analysis, but it is an intuitive finding. even in the setting of pandemic influenza, many people would have to forgo income in order to stay home [ ] . for example, a survey of key decision makers at u.s. businesses found % of the businesses provided for paid employee sick leave, but % of businesses did not provide for any employee sick leave, whether paid or unpaid [ ] . still, this study found no difference in anticipated compliance rates in the setting of pandemic (h n ) or avian influenza. this is consistent with the findings of barr et al [ ] who reported similar rates of "willingness to comply with health protective behaviours" between employed ( . %, %ci: . %- . %) and unemployed ( . %, %ci: . %- . %) survey respondents in the setting of pandemic influenza. eastwood et al, [ ] however, reported the contrary, finding that employed people who were unable to work from home would be less likely to self-isolate in the setting of pandemic influenza. how closely the level of actual compliance approaches the level of self-reported anticipated compliance may well be affected by issues related to income, financial security, and employer leave policies. a particularly novel and important finding of this study was that more than one-quarter of health and community service workers reported they would not comply with a physician's advice to stay home if they had seasonal influenza. this may represent a misplaced sense of duty. previous research has demonstrated that most healthcare workers (hcws) would not abandon their responsibilities during an influenza pandemic, [ , ] but isolating one's self when one has symptoms or a diagnosis of disease is a different proposition than simply refusing to work. despite evidence of the efficacy of vaccinating hcws, [ ] [ ] [ ] [ ] [ ] [ ] influenza vaccination rates among hcws are low, [ ] which presents a risk of hcw-to-hcw as well as hcw-to-patient transmission if infected hcws report to work. notably, as the sars outbreak subsided and precautions were relaxed, a second wave of the disease including cases of nosocomial infections emerged; . % of those nosocomial infections were associated with exposure to an infected hcw. seventeen nurses contracted sars, and ( . %) had worked with a symptomatic co-worker within days of developing symptoms. indeed, having worked with a symptomatic co-worker was associated with increased risk (rr = . ) of an hcw developing the disease [ ] . we are not aware of any previous reports measuring anticipated self-isolation among hcws with influenza. public health officials and health facility supervisors must impress upon health workers the clinical and ethical importance of protecting both patients and other staff from exposure to employeeborne influenza, including seasonal influenza [ ] . this study was limited in that it relied upon a telephone survey to collect data, but telephone surveys have been previously used to gather information regarding public perceptions of risk and willingness to comply with containment strategies for influenza, [ , , [ ] [ ] [ ] [ ] and even to assess for the prevalence of influenza [ ] . the response rate for this survey was . %; while this may indicate some response bias the sample was fairly representative of the general population, and the overall survey was not specific to influenza. that is, there is no reason to suspect that any potential respondent's decision about whether to participate in the survey would be related to their anticipated compliance with a physician's advice to stay home. a more important limitation of the study is that it measured self-reported anticipated behaviour in the context of a physician diagnosis of disease. actual behaviour may differ, particularly since many individuals with mild to moderate viral respiratory syndromes do not seek physician care. also, other factors including perceived severity of illness, social norms, and financial considerations could affect compliance. thus, the rates of anticipated compliance reported by respondents to this survey must be viewed as a best-case scenario, and actual compliance might be lower. still the results, both in terms of anticipated compliance and associations with demographic factors, are consistent with those of other studies [ , , [ ] [ ] [ ] [ ] . finally, early in the australian pandemic (h n ) experience there was a perceived association between international travel and increased risk, [ ] but qss did not inquire as to respondents' individual travel history or exposure to international travellers. ninety-five percent of people report they would comply with a physicians' advice to stay home for seven days if they are diagnosed with pandemic (h n ) or avian influenza, but only % can be expected to comply with the same advice in the setting of seasonal influenza and fewer still ( %) can be expected to stay home if they are diagnosed with a common cold. sub-populations that might be worthwhile targets for public health messages aimed at increasing the rate of self-imposed isolation for seasonal influenza include males and younger people. notably, more than one-quarter of health and community service workers report that they are unlikely to comply with stay home advice for seasonal influenza; thus they too may be an appropriate (although counter-intuitive) target for influenza-related public health campaigns. additional file : table s -bivariate associations between demographic variables and anticipated compliance with physician's advice to stay home for seven days for common cold and three strains of influenza. a group on influenza: pneumonia and respiratory failure from swine-origin influenza a (h n ) in mexico severe respiratory disease concurrent with the circulation of h n influenza who announces pandemic alert phase , of moderate severity public support for government actions during a flu pandemic: lessons learned from a statewide survey legal rights during pandemics: federalism, rights and public health laws -a view from australia knowledge about pandemic influenza and compliance with containment measures among australians pandemic influenza in australia: using telephone surveys to measure perceptions of threat and willingness to comply public response to community mitigation measures for pandemic influenza influenza a(hin )/swine flu survey iii what australians know and believe about bird flu: results of a population telephone survey factors influencing compliance with quarantine in toronto during the sars outbreak influenza-related disease: the cost to the australian healthcare system business preparedness: novel influenza a (h n ) will they just pack up and leave?" -attitudes and intended behaviour of hospital health care workers during an influenza pandemic how would australian hospital staff react to an avian influenza admission, or an influenza pandemic? influenza vaccination of health care workers in long-termcare hospitals reduces the mortality of elderly patients influenza vaccination for healthcare workers who work with the elderly (review) the effects of influenza vaccination of health care workers in nursing homes: insights from a mathematical model modeling the effects of influenza vaccination of health care workers in hospital departments applying network theory to epidemics: control measures for mycoplasma pneumoniae outbreaks keeping vulnerable children safe from pertusis: preventing nosocomial pertusis transmission in the neonatal intensive care unit risk of respiratory infections in health care workers: lessons on infection control emerge from the sars outbreak phase ) of severe acute respiratory syndrome (sars) in toronto, canada what happened? semmelweis revisited: the ethics of infection prevention among health care workers telephone survey to assess influenzalike illness swine flu and travellers: an australian perspective the authors declare that they have no competing interests. key: cord- -daiikgth authors: van velsen, lex; beaujean, desirée jma; van gemert-pijnen, julia ewc; van steenbergen, jim e; timen, aura title: public knowledge and preventive behavior during a large-scale salmonella outbreak: results from an online survey in the netherlands date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: daiikgth background: food-borne salmonella infections are a worldwide concern. during a large-scale outbreak, it is important that the public follows preventive advice. to increase compliance, insight in how the public gathers its knowledge and which factors determine whether or not an individual complies with preventive advice is crucial. methods: in , contaminated salmon caused a large salmonella thompson outbreak in the netherlands. during the outbreak, we conducted an online survey (n = , ) to assess the general public’s perceptions, knowledge, preventive behavior and sources of information. results: respondents perceived salmonella infections and the outbreak as severe (m = . ; five-point scale with as severe). their knowledge regarding common food sources, the incubation period and regular treatment of salmonella (gastro-enteritis) was relatively low (e.g., only . % knew that salmonella is not normally treated with antibiotics). preventive behavior differed widely, and the majority ( . %) did not check for contaminated salmon at home. most information about the outbreak was gathered through traditional media and news and newspaper websites. this was mostly determined by time spent on the medium. social media played a marginal role. wikipedia seemed a potentially important source of information. conclusions: to persuade the public to take preventive actions, public health organizations should deliver their message primarily through mass media. wikipedia seems a promising instrument for educating the public about food-borne salmonella. with an estimated . million cases each year, foodborne salmonella infections are a worldwide concern [ ] . in developing areas in africa, asia and south-america, salmonella typhi and paratyphi are an important cause of severe illness, leading to more than million cases and . deaths in children and young people every year [ ] . a typical salmonella infection can lead to fever, diarrhea, nausea, vomiting, abdominal cramps, and headache. symptoms usually appear between to hours after eating contaminated food, and last three to seven days. the incidence rate of salmonella is highest among infants and young children. as there are many different types of food-borne salmonella, each with their own food sources, control is difficult. proper hygiene in the kitchen (e.g., washing hands, thoroughly heating and baking meat) can prevent a salmonella infection. however, studies among the general public in italy [ ] , turkey [ ] and new zealand [ ] showed that compliance with preventive hygiene advice is low to very low. a possible explanation is that most people believe that a food-borne infection is "something that happens to others" [ , ] . educating the public about food safety is crucial in preventing food-borne infections. according to medeiros and colleagues [ ] , food-borne salmonella infections should be prevented by educating the general public about adequate cooking of food, and by instructing them about the risks of cross-contamination. traditional communication means, such as flyers, are well suited to achieve these educational goals [ ] . however, when a food-borne infection breaks out on a large scale, the dynamics of the situation shift tremendously. due to an uncertain course of events, decisions have large consequences, the general public is stressed, and the media is eager for news [ ] . in these circumstances, health organizations should inform the public about the situation and persuade them to take preventive actions. to be effective in this endeavor, they should use the communication channels the general public expects them to use, and provide the public with the information they want and need. a study among malaysians during the a(h n ) influenza outbreak in , uncovered that their main sources of information were newspapers, television and family members; their information needs were instructions on how to prevent or treat infections [ ] . in the netherlands, the severe acute respiratory syndrome (sars) outbreak and the enterohaemorrhagic e. coli (ehec) outbreak showed us that the dutch general public mostly turns to traditional media (i.e., television and radio), and news websites [ , ] . in recent years, the rise of social media (e.g., facebook, twitter) has provided new avenues for reaching the general public during infectious disease outbreaks. although social media have proven very valuable during disaster relief as a crowdsourcing tool [ ] , an exploratory study of their worth as a communication tool during an infectious disease outbreak suggested their value to be limited [ ] . research on the information behavior of the general public during infectious disease outbreaks is scarce. but this knowledge is crucial in serving the general public in their information needs, and in maximizing citizen compliance with preventive advice. in this study, we uncovered the general public's perceptions, knowledge, preventive behavior, and sources of information during a large, national salmonella outbreak by a large-scale online survey. as a result, we were able to answer our main research question: which information should health organizations convey during a largescale salmonella outbreak, and by which channels, to maximize citizen compliance with preventive advice? in the beginning of august , an outbreak of salmonella thompson occurred in the netherlands [ ] , later traced back to contaminated smoked salmon from one producer. by september , all smoked salmon of this producer was recalled. in the following week, other products containing this producer's smoked salmon (e.g., salads) were also recalled. citizens were advised to check the batch number of their products and to dispose of possible contaminated products. after implementing those measures, the number of cases decreased rapidly and by the end of , the outbreak came to an end. , laboratory-confirmed patients and four deaths were reported [ ] . the actual number of patients is thought to be higher, as individual cases of salmonella gastro-enteritis are not mandatory notifiable in the netherlands and laboratory confirmation usually merely takes place in a fraction of all patients presenting with diarrhea. according to dutch standards, this situation classifies as a large-scale outbreak, as it is an occurrence of disease greater than would otherwise be expected at a particular time and place. normally around four cases of salmonella thompson are seen in the netherlands per year. we developed an online survey to assess the general public's perceptions, knowledge, preventive behavior, and information use during the salmonella thompson outbreak. the instrument was constructed on the basis of the health belief model [ ] , and research on citizen channel choice for medical information [ , ] . the survey contained questions, and was divided into five domains: participants' information intake about the outbreak through the media, and where they went to look for answers to questions related to salmonella infections and the outbreak. perceptions were assessed by multiple statements with five-point likert scales (ranging from disagree ( ) to agree ( ) ). items were based on bults et al. [ ] . knowledge was assessed by nine true/false statements. preventive behavior was assessed by multiple-choice questions about what respondents did after hearing about the outbreak. sources of information were determined by questioning how often and where respondents saw, heard or read about the outbreak. next, we asked respondents if they had wanted more information about the outbreak or an answer to a specific question about the outbreak. if so, we asked where they had sought this information or the answer. if they had so through the internet, then we asked them if they had found it through a google search, whether they had found what they were looking for, how satisfied they were with the website, and how much they trusted the information. to keep the length of the survey acceptable, we only posed these questions for one website the participants named. if they named more than one website, the website was chosen at random. the survey can be found in additional file . respondents were recruited by a commercial panel that also hosted the survey in their online environment. the panel supplied standard demographics for each respondent (e.g., age and income). a stratified sample was taken to create a representative group of the dutch population. the minimum age for participation was years. the target sample size was , respondents, to allow for satisfactory statistical power, and to maximize our chances of including people who contracted a salmonella infection. respondents received points for participating, with which they could buy gifts in an online shop. panel participants received an individual invitation via email of which the first was sent out on november , . the survey was closed on november , . due to the method of recruitment, a response rate could not be calculated. written informed consent was obtained from each respondent for publication of this report. the nature of this general internet-based survey among healthy volunteers from the general population does not require formal medical ethical approval according to dutch law [ ] . descriptive statistics were performed for the demographics, respondents' preventive behavior, and sources of information. cronbach's alpha was calculated to assess internal consistency for the psychological rating scales. these scores were . for perceived severity of salmonella, . for perceived severity of the outbreak, . for carefulness with salmon preparation during the outbreak, . for carefulness with general food preparation during the outbreak, . for interest in health information, and . for perceived health. next, mean scores were computed for the aforementioned psychological rating scales, while the statements for assessing knowledge about salmonella infections resulted in a sum score (ranging from to , where is no knowledge and is very high knowledge). to establish the influence of factors determining respondents' application of preventive measures during the outbreak (dependent variable), we performed stepwise backward regression analyses. following [ ] [ ] [ ] , we included the following independent variables in the initial model: the demographics age, education, income and sex, and the factors perceived severity of a salmonella infection, perceived severity of the outbreak, knowledge about salmonella infections, and increased general kitchen hygiene during the outbreak. education was recoded into a new variable with three options: low, middle or high, while sex was included in the regression analyses as a dummy variable. these actions make it possible to include these nominal variables in this kind of regression analysis. factors were removed from the model if p > . . the procedure was repeated for determining the factors that influence the consumption of information about the salmonella outbreak for different media. here, consumption of information on a medium was the dependent variable for the different models (each model explaining the information consumption for a specific medium.). we included the following independent variables in the initial models: the demographics age, having children, education, income, and sex (based on [ , ] ), as well as the factors perceived severity of a salmonella infection, perceived severity of the salmonella outbreak, knowledge about salmonella infections, interest in health information, and perceived health (based on [ ] ), as well as the application of measures to prevent a salmonella infection, and increased carefulness with preparing food (following [ ] ). for the variables using twitter or not, and having children or not, we also created a dummy variable. these analyses allowed us to formulate recommendations in line with our main research question: which information should health organizations convey during a large-scale salmonella outbreak, and by which channels, to maximize citizen compliance with preventive advice? in total, , respondents completed the survey. table displays their demographics, showing that the sample is fairly representative for the dutch population. figure shows how often the respondents made use of different media. most respondents watched television more than two hours a day. radio was less popular, although one quarter listened to this medium more than four hours a day. the majority spent some time each day reading a newspaper. most respondents used the internet intensively. finally, . % had a twitter account, . % a hyves (a dutch social network) account, and . % a facebook account. respondents perceived salmonella thompson to be quite a severe infection (m = . ; sd = . ). this finding is corroborated by the comparison respondents made between a salmonella infection and other illnesses. this comparison is displayed in table , and shows that salmonella is estimated as severe as asthma and diabetes. the outbreak was also estimated as quite severe (m = . ; sd = . ). respondents' mean interest in health information (m = . ; sd = . ), and their perceived health (m = . ; sd = . ) were neutral. we assessed respondents' knowledge about salmonella infections by nine true/false statements (see table ). the respondents appeared to be well informed, with a few exceptions. % was unaware of the common sources of a salmonella infection, , % unaware of its incubation period, and , % was unaware of how salmonella is treated in general. we calculated a sum score for each respondent's knowledge (with a maximum of ). the mean score was . (sd = . ). respondents' self-reported application of measures to prevent a salmonella infection during the outbreak was below the neutral point (m = . ; sd = . ), as was their estimation of an increase in kitchen hygiene during the outbreak (m = . ; sd = . ). however, in both cases standard deviations are quite high, implying that there were people who increased their kitchen hygiene tremendously, and people who absolutely did not. our regression analysis showed that the application of preventive measures (dependent variable) was influenced by increased general kitchen hygiene during the outbreak (β = . ; p < . ), by perceived severity of the outbreak (β = . ; p < . ), and by the demographics income (β = . ; p < . ) and sex (higher for women; β = . ; p < . ). a significant beta means that a factor influences the dependent variable (in this case application of preventive measures). a low beta stands for a small influence, a high beta for a large influence. in this case, the betas show that four factors influence the application of preventive measures; of which increased general kitchen hygiene is by far the greatest influence. explained variance (r ) for the model was . (which means that the dependent variable is explained for a large part by the identified independent variables, but also by some, as of yet, unidentified variables). in our sample, eight respondents (. %) indicated to have gotten a salmonella infection from eating contaminated salmon. a larger group ( respondents; . %) knew someone in their close vicinity (friends or family) who ate contaminated salmon and then got a salmonella infection. we asked the respondents whether they checked if they had salmon at home when they heard of the outbreak. it turned out that: respondents ( . %) checked but did not have salmon at home; respondents ( . %) checked and did have salmon at home; respondents ( . %) did not check if they had salmon at home. next, we assessed what the respondents did who had salmon at home: respondents ( . %) found out their salmon was not contaminated; respondents ( . %) threw all salmon away; respondents ( . %) found out they had contaminated salmon and threw it away; respondents ( . %) found out they had contaminated salmon, but did eat it; respondents ( . %) did something else, mostly returning contaminated salmon to the supermarket. in assessing the information behavior of the general public during the salmonella outbreak, we made a distinction between passive and active information behavior [ ] . passive information behavior consists of situations in which a person receives information without actively searching for it (e.g., listening to the radio, stumbling upon an item when surfing on a news website). in other words, a person is exposed to information without a direct and specific need for this information. active information is caused by a question or explicit need for information, after which a person actively seeks out information. figure displays the channels and popular online sources from which the respondents have passively received information about the salmonella outbreak. television was the medium that delivered most information, followed by radio and newspapers. news website nu.nl was also a relevant source of information. finally, social media played a marginal role, whereby social network sites were more important than twitter. next, we assessed what factors influence passive information consumption for each channel or source (dependent variables). results for the different regression analyses can be found in table (each column representing the regression analysis for a specific medium). time spent on the medium was the most influential predictor for passive consumption of information for several media or sources. interest in health information, and perceived health influenced passive consumption of information for all media and sources, except for social media. perceived severity of the salmonella outbreak played a small role in the passive consumption of outbreak-related information through traditional media. the other factors and demographics played no or a marginal role, with one exception for age in the case of nu.nl (a popular news website in the netherlands), where lower age was an important predictor. we also encountered active information behavior among the respondents. ninety-one respondents ( . %) finally, we focused on a specified range of online sources, and if a website was visited by a respondent, we asked how the website was found, whether it provided the information the respondent was looking for, how satisfied he/she was with it, and whether he/she trusted the information. the number of respondents who answered these questions was relatively low (ranging from for the nvwa website, to for facebook and hyves). most online sources were either found through a google search or directly by entering the url. the nvwa website and wikipedia were predominantly found through a google search, and newspaper websites were mostly accessed directly. virtually all sources provided the seekers with the information they were looking for. satisfaction with the source was high for wikipedia, the nvwa website, and if you have symptoms from salmonella (like vomiting or diarrhea), you are temporarily not allowed to work in healthcare. true salmonella can predominantly be found on chicken, raw vegetables, and fruit. true . % after you have eaten salmonella-contaminated food, it can take weeks before you become ill. false . % salmonella is almost always treated with antibiotics. false . % figure number of times news about the salmonella outbreak was received per source (n = , ). note: nu.nl is a popular news website in the netherlands. the website of the municipal health service, while it was low for facebook and hyves. trust in the online source was relatively high for the websites of the government organizations: the rivm, the nvwa, and the municipal health service. trust in the website of the company that was the source of the outbreak and of the social networks facebook and hyves was relatively low. our results show that shortly after salmonella thompson broke out nationally in the netherlands, the general public perceived salmonella gastro-enteritis as a serious illness, comparably severe to asthma and diabetes. they also perceived the outbreak as severe. respondents' knowledge of salmonella (gastro-enteritis) was appropriate, except for the common food sources of a salmonella infection, the duration of the incubation period, and the fact that treatment with antibiotics is usually not needed. this study reveals gaps in the public's knowledge on salmonella infections, and shows where health education efforts should be put in by health organizations. moreover, it also shows that it is important to assess existing public knowledge regarding different infectious diseases, in order to improve health communication, and to fill knowledge gaps. despite warnings through mass media channels, the majority of the respondents neither checked whether they had contaminated batches of smoked salmon products at home, nor did their kitchen hygiene increase during the outbreak. while the perceived severity of the outbreak influenced the adoption of preventive measures to some degree, increased general kitchen hygiene during the outbreak appeared to be the most important antecedent. this suggests that being careful to avoid a foodborne infection during an outbreak is primarily done by people who are already concerned about food safety. since salmon is very popular and processed in many other products, it is well possible that people did not realize they owned contaminated products. some people even knowingly ate contaminated salmon, thereby neglecting health officials' advice to throw contaminated salmon away, or to return it to the supermarket. during the infectious disease outbreak, the general public mostly receives information through traditional media and popular news(paper) websites. health organizations should focus on these media to inform the general public, and to persuade them to take preventive actions. we came to a similar conclusion after studying information behavior during the german ehec outbreak [ ] . we uncovered that people do not use social media in these situations, as they think healthrelated information is 'out of place' there, or unreliable [ ] . investing time and effort in a social media campaign may serve only a very small portion of the population, resulting in a low return on investment. the consumption of outbreak-related information through a traditional medium and twitter was mostly determined by time spent on the medium, suggesting that consuming outbreak-related information is for a large part coincidental, and highly determined by the news selection of the different media. a higher interest in health information also resulted in more outbreakrelated information consumption. however, this could also be due to a recall bias, as those interested in such information might more easily remember receiving it. other predictors played no or a marginal role, with the exception of lower age for the popular dutch news website nu.nl. only a small sample of our respondents actively searched for information about salmonella or the outbreak. those who did mostly turned to the internet. there, they consulted multiple sources, found through a google search or by entering the url, like national food safety institutes, online newspapers, websites of municipal health services, and wikipedia. the latter has also been found to be an important source of information during other infectious disease outbreaks [ , ] . it should be noted, however, that the popularity of wikipedia could be due to the high ranks it receives in google. the website of the national institute for public health and the environment (the dutch equivalent of the american centers for disease control and prevention) was consulted less than the aforementioned sources. this implies that such national institutes should not solely rely on their own communication efforts, but they should collaborate with local health organizations, and they should contribute to relevant wikipedia articles. there has been some debate, however, concerning the quality of wikipedia articles for the goal of public health education, and studies on this matter show mixed results. the quality of medical wikipedia articles has been found to be good but inferior to official patient information [ ] , of similar quality as official patient information [ ] , or incomplete, which might have harmful effects [ ] . these results imply that if health organizations decide to use wikipedia to inform the public during a large-scale salmonella outbreak, they should make a continuous effort to continuously monitor the relevant articles and to improve their quality. our analysis did not result in a clear set of predictors for consuming outbreak-related information through social media. also, the predictors that are often found for consuming health information through traditional media (like interest in health information, and perceived health) did not hold for these services. if we are to find a set of predictors for this contextpresuming they do exist, considering the little use the general public made of social media during the outbreakwe will have to step off the beaten path and gather a set of new predictors. we conducted the survey at the end of the salmonella outbreak. while this allows for a good retrospective view, the general public's perceptions and behavior may evolve during an outbreak. different phases induce different information needs, related to the uncertainties of the situation (e.g., fear may play a bigger role when the outbreak source is still unknown) [ ] . a longitudinal setup would provide insight in these developments, and it would be an interesting direction for future research. second, the number of people in our study that actively searched for more information or for answers to their questions was relatively low. it is therefore difficult to base generalizable conclusions on these results, and our efforts should be viewed as explorative. they do provide valuable input for in-depth studies aimed at assessing people's outbreak-related information seeking processes. such studies have already generated important insights for the health domain (e.g., [ ] ). but it is also possible that, in this context, people actively searching for more information is a rarity, possibly due to the fact that the information provided by the different media is perceived as adequate. other studies should acknowledge or refute this thesis. finally, our study was restricted to the dutch general public. we do not have any indications that these results would not hold for other western european countries, but these should be validated for countries where the process of outbreak-related information provision and the internet penetration rate are fundamentally different. this study aimed to determine which information health organizations should convey during a large-scale salmonella outbreak, and by which channel, to maximize citizen compliance with preventive advice. we found that after the outbreak, the general public perceived salmonella gastro-enteritis as severe, but the public did not wholeheartedly apply the advised preventive measures. health organizations should use traditional media, and news and newspaper websites to inform the public, and to persuade them to take preventive actions. they should increase knowledge about salmonella infections, and stimulate citizens to check for possibly contaminated products at their home, and to increase kitchen hygiene. future research should focus on the role wikipedia can play during infectious disease outbreaks, not only those caused by salmonella. we are especially interested in case studies in which health organizations have used wikipedia as a public health education tool, and in how they experienced this in terms of public appreciation, and organizational investment. furthermore, studies assessing the quality and completeness of health-related wikipedia articles can be very valuable in helping health organizations decide on which articles they should use or improve the quality of. finally, our study pointed out that there is a group of people who knowingly take risks the global burden of nontyphoidal salmonella gastroenteritis global trends in typhoid and paratyphoid fever food safety at home: knowledge and practices of consumers the knowledge and practice of food safety by young and adult consumers van der logt p: survey of domestic food handling practices in new zealand consumer perceptions of food safety risk, control and responsibility south and east wales infectious disease group: differences in perception of risk between people who have and have not experienced salmonella food poisoning food safety education: what should we be teaching to consumers? development and evaluation of a risk-communication campaign on salmonellosis risk communication for public health emergencies public sources of 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preventive behavior during a large-scale salmonella outbreak: results from an online survey in the netherlands by eating contaminated products during a salmonella outbreak. a future study should focus on this group, and uncover their motivations for doing so (e.g., by interviewing patients with an infection who were seen by doctors during a salmonella outbreak), to improve health education for this group. additional file : survey.abbreviations ehec: enterohaemorrhagic e. coli; nvwa: the netherlands food and consumer product safety authority; rivm: national institute for public health and the environment. the authors declare that they have no competing interests. lvv contributed to the study design and collection of data, analyzed the data, and drafted the manuscript as the lead writer. djmab contributed to the study design and collection of data, and critically reviewed the first draft of the paper. jewcgp and jes contributed to the study design. at contributed to the study design and collection of data, and critically reviewed the first draft of the paper. all authors approved the final version. key: cord- -qssbwz authors: pinto, cátia sousa; nunes, baltazar; branco, maria joão; falcão, josé marinho title: trends in influenza vaccination coverage in portugal from to : effect of major pandemic threats date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: qssbwz background: vaccination is the key measure available for prevention of the public health burden of annual influenza epidemics. this article describes national trends in seasonal influenza vaccine (iv) coverage in portugal from / to / , analyzes progress towards meeting who coverage goals, and addresses the effect of major public health threats of the last years (sars in / , influenza a (h n ) in / , and the influenza a (h n ) pandemic) on vaccination trends. methods: the national institute of health surveyed ( times) a random sample of portuguese families. iv coverage was estimated and was adjusted for age distribution and country region. independence of age and sex coverage distribution was tested using a modified f-statistic with a % significance level. the effect of sars, a (h n ), and the a (h n ) pandemic was tested using a meta-regression model. the model was adjusted for iv coverage in the general population and in the age groups. results: between / and / iv, coverage in the general population varied between . % (ci ( %): . %– . %) and . % (ci ( %): . %– . %). there was no trend in coverage (p = . ). in the younger age group (< years) a declining trend was identified until / (p = . ). this trend reversed in / . there was also a gradual and significant increase in seasonal iv coverage in the elderly (p for trend < . ). after / , iv coverage remained near %. adjusting for baseline trends, there was significantly higher coverage in the general population in / (p = . ) and / (p = . ). the high coverage observed in the < -year age group in season / was also significant (p = . ). conclusions: iv coverage in the elderly population displayed an increasing trend, but the % who target was not met. this result indicates that influenza vaccination strategy should be improved to meet the ambitious who coverage goals. the major pandemic threats of the past decade had a modest but significant effect on seasonal influenza vaccination. there was an increase in vaccine uptake proportion in the general population in / and in / , and in individuals < years old in / . the public health burden of annual influenza epidemics represents ongoing vulnerability to pandemic influenza and highlights gaps in bioterrorism preparedness and response efforts [ , ] . the recent emergence of the pandemic influenza a (h n ) virus is a good example of how influenza can impact health systems around the world [ ] . currently, vaccination is the key measure available for prevention of influenza and associated complications. strategies that focus on providing routine vaccination to persons at higher risk for influenza complications have long been recommended, although coverage among most of these groups remains low [ ] . concurrently, there is a need to increase seasonal vaccine use through clear immunization policies as a way to stimulate industry to boost production capacity [ ] . during the / season, the influenza pandemic led to reinforcement of influenza vaccination recommendations in european countries, including portugal. the pandemic also led to renewed interest in influenza vaccination surveillance. continued annual monitoring is needed to determine the effects of vaccine supply, changes in influenza vaccination recommendations, changes in groups targeted for vaccination, and other factors, on vaccination coverage among adults and children [ ] . vaccine coverage rates constitute the basic measure for evaluation of public health programs designed to improve vaccination uptake and for estimation of how the vaccination program affects the rate of disease. circumstantial factors (e.g., personal reasons) may affect the rate of vaccination [ ] . in the last years three major pandemic threats, not all caused by influenza virus, affected public and healthcare professionals' perceptions of the need for influenza vaccine (iv) uptake. these pandemic threats were severe acute respiratory syndrome (sars) in , "avian influenza" (influenza a (h n )) in , and the recent influenza a (h n ) pandemic. the rapid worldwide dissemination of sars in was a rehearsal for the next influenza pandemic [ ] . in , the world health organization (who) declared that the emergence and persistence of influenza a (h n ) in birds and the associated human fatalities were a public health threat and fostered early response strategies to contain the pandemic [ ] . in april , the spread of novel swine flu origin influenza a (h n ) prompted the declaration of a pandemic by who in june of the same year [ ] . whether this raised awareness had a positive or negative effect on iv uptake varies according to country and to situation [ , , ] . every year, based on surveillance of clinic and laboratory data provided by a global network of influenza surveillance centers, the who recommends the composition of the vaccine that will be used the next season [ ] . the general directorate of health (dgs) in portugal issues an information guide to ministry of health and private sector doctors in september/october of each year. the guide describes vaccine specifications for the current season and indications for vaccine uptake. each flu season, the main objective of the dgs has been to increase iv coverage in high risk groups (i.e., individuals > years old and patients with specific chronic diseases) and priority groups of health professionals [ , ] . table describes how the recommendations have changed over time. in , who established a % iv coverage target in the elderly (> years) that was in effect until [ ] . in , dgs established an interim target of % vaccine coverage among individuals aged years and over for the / season [ ] . despite the occurrence of a pandemic due to a new strain of influenza virus in , the dgs has maintained the same seasonal iv recommendations for the major risk groups [ ] . concurrently, the recommendation expanded to include vaccination against pandemic influenza a (h n ) for children from months to years. older individuals were included only if they had a specific chronic disease [ ] . since the / season, the department of epidemiology (dep) of the national institute of health doctor ricardo jorge (insa; previously the national health observatory (onsa)) has monitored iv coverage. this system is the only one in the country that estimates iv coverage in the general portuguese population and in subgroups. this information cannot be obtained from a count of vaccine sales or from vaccine administration data. this article describes national trends in seasonal iv coverage in portugal from and in the general population and in age groups presents an analysis of progress towards who coverage goals. it also addresses the effects of the major pandemic threats (sars in , influenza a (h n ) in , and the influenza a (h n ) pandemic) on vaccination trends for the last years. between / and / , insa conducted household telephone surveys using a panel of families (ecos -em casa observamos saúde/observing health at home). these surveys were used to collect data on iv coverage in the mainland portuguese population. the ecos panel consisted of a random sample of portuguese families with a landline telephone and of families with landline and mobile phone since the / sample (dual sample frame). the sample was stratified and was evenly distributed to represent the five health regions of the country. landline phone households were selected by simple random selection from the national telephone directory. mobile phone households were selected by random digit generation. all households received a letter from insa with an invitation to participate in the ecos panel and provide informed consent. telephone contact was then used to formalize participation and record each household member's demographic data. the households included in each panel were renewed approximately every years. the ecos panel of families was approved by the portuguese data protection authority, which is in charge of ethical issues and protection of individual data collection in portugal. the seasons included in the surveys were the winters from / to / , except for the winter of / . in / , a specific recommendation for vaccination against pandemic influenza virus a (h n ) was also issued, and included the abovementioned groups (except elderly and residents of institutions) and also healthy children under years old, caretakers of infants under months old, and professionals performing core roles, according to priority groups. no investigation was carried out in / season owing to lack of financing. all surveys used the same questionnaire. the questionnaire was presented to one individual (≥ years of age) in each household using cati (computer assisted telephone interview) technology. this individual provided information on his/her vaccination status and information on the household. the terminology "percent of vaccinated" used in reporting results refers to individuals who reported being vaccinated or on which the respondent said they were vaccinated. the (table ) . a detailed description of the ecos methodology can be found in a published report [ ] . permission to use the data for this study was obtained from the national institute of health. iv coverage was analyzed for the entire sample and for specific groups defined by age and sex. information on demographic questions was collected during the initial survey done at household recruitment time. for the surveys conducted in / to / , all iv coverage estimates were adjusted by health region using the portuguese population census data ( census data from the national institute of statistics). for the surveys of the / and / periods that were conducted using the dual sample frame, the iv coverage estimates were adjusted by health region (census population ) and for cell phone and landline phone coverage of portuguese households using the methodology described in brick [ ] and kennedy [ ] . weighting factors were adjusted by post stratification for population age and sex distribution. to test the association (or independence) with disaggregation variables, we used the modified f-statistics of the second order adjustment of the rao-scott chi-squared test [ ] whose properties are presented in rao and thomas [ ] . a % significance level was used for the statistical tests, and the null hypothesis was rejected when the probability of test significance (p-value) was < . . we also calculated % confidence intervals for all proportions. we used a meta-regression model to test the linear trend in iv coverage throughout the study period, and the effect of the sars, a (h n ), and a (h n ) pandemics. each survey estimate was weighted by the inverse of the variance in the logit scale. the model fitted to the logit of iv coverage included three dummy variables (one for each event) and a sequence of numbers from to years to measure and test the time trend effect. the model was adjusted to iv coverage in the general population and age groups. all analyses were performed using the statistical programs spss [ ] or stata se [ ] . for sex distribution, there were no significant deviations from the population census distribution (i.e., all confidence intervals included the census population estimates). there were small differences between the age group distribution in the panel data and the population age group distribution observed in the census. these differences varied by year. between / and / , iv coverage in the portuguese general population (table , figure ) there was no trend in iv coverage of the general population during the study period (p = . ). over all the studied seasons, there were no statistically significant differences in iv coverage between women and men. however, iv coverage was higher for women than for men in of the seasons (table ). the difference between women and men was marginally significant for the / (p = . ) and the / (p = . ) seasons. differences in iv coverage by age group occurred in all seasons (table , figure ). in the younger age group (< years), a declining trend (with small fluctuations) was present from / to / (p = . ). this trend reversed in / , with one of the highest seasonal iv coverages for this age group ( . %, ci % : . %- . %). as expected, the highest iv coverage was observed in individuals > years old. between / and / , there was a gradual and significant increase in seasonal iv coverage in the elderly (p for trend < . ). in the / season, iv coverage was . % (ci % : . %- . %) and in the / season it was . %, which was similar to the % coverage achieved in the four previous seasons (figure , table ). an increasing trend was also identified in individuals aged - years old (p for trend . ). a trend was not present in the - -year age group (p for trend . ). (table ) . hypothesis. however, the potential effect was not particularly strong considering that elevated vaccine uptake in season / was not significantly higher than the other three seasons. individuals > years old had the highest coverage in all seasons. values ranged from . % in / to . % in the / season (point estimates). regarding the -year pattern, a statistically significant increasing trend (p < . ) was observed for iv coverage in portugal since in the elderly. however, after % coverage was achieved in / , a plateau was reached and no further improvement was observed in the last years of the study period. the pandemic did not affect seasonal vaccination coverage in the elderly population in portugal. coverage was around %, which was similar to the three previous periods. this result is consistent with the fact that seasonal vaccine recommendations did not change throughout this period. unchanged seasonal coverage rates were also observed in an elderly population in france [ ] . in europe, estimates for iv coverage in the elderly indicate that some countries failed to meet the target of % coverage in . portugal was not one of these countries [ ] . however, other countries achieved the % coverage target for . these countries were england, scotland, wales ( % in the / season) [ ] , and the netherlands ( % ci % : %- % in / ) [ ] . a recent study of european countries ( / season) found that spain, with % coverage, was close to meeting the goal [ ] . this study also estimated that there was % iv coverage in portugal for individuals ≥ years, which is consistent with the estimate obtained in our study ( . %, ci % : . %- , %). compared with the other countries included in the study (united kingdom, germany, italy, france, spain, austria, czech republic, ireland, finland, and poland), iv coverage in the elderly (≥ years) in portugal was sixth, but was similar to the overall estimate for all countries ( . %). in another european study that included european countries ( / season), portugal ranked thirteenth for iv coverage in the elderly, and represented the median value for coverage in europe [ ] . this finding was consistent with the findings of the previous study. given that the elderly had been targeted for vaccination for many years and are the largest risk group, these results indicate that progress has been made toward meeting the who coverage goals. they reflect positively on portuguese vaccination policies. nevertheless, the % coverage goal for remained far from being achieved. the % coverage plateau since / indicates that additional effort is needed to further improve vaccination levels. receiving advice from the family doctor/nurse has been identified as the main motivation to get vaccinated among the portuguese population [ ] , followed (at a considerable distance) by old age as a reason. this result suggests that efforts directed at family doctors could have the greatest effect on iv uptake in the elderly. public information campaigns that are directed at risk groups may also have an effect. effect of major pandemic threats on influenza vaccine coverage from / to / we hypothesized that / , / , and / were seasons during which there was special awareness about vaccination among the general portuguese population, and/or among subgroups defined by age. we used a meta-regression model to test this hypothesis. these seasons were selected based on major public health threats worldwide: sars in / , the increase in h n virus infections in humans in southeast asia in / , and the declaration of an influenza pandemic in / . global and national health authorities, and the medical community worldwide, reinforced flu vaccination recommendations in / [ ] . in / , the pandemic threat, with associated vaccination recommendations, led to news and opinions that circulated in the medical community and in the general population. this news coverage could have led to an increased demand for the influenza vaccine. in fact, in a study on iv coverage in germany ( ) ( ) ( ) ( ) ( ) ( ) , the authors found that coverage increased during the / season. they suggested that the greater media focus on pandemic influenza was one factor that explained the increased vaccine demand [ ] . in / , the declaration of a worldwide influenza pandemic by who focused the attention of the media on influenza. health ministries worldwide, including in portugal, issued broad guidance to health services that was also reported by the media. the results of the meta-regression model (table ) these findings indicate that when accounting for the baseline trend, there was an increase in iv coverage during the / and / seasons, which suggests that awareness about vaccination could have increased in the general population and in specific age groups. although the . % coverage in children was not the highest of all the seasons was still an important increase. risk perception regarding flu in children may have increased during the / season, and pandemic awareness and special recommendations for children to be vaccinated during the pandemic could have affected seasonal vaccine uptake in portugal in the / season in this group. risk perception affects vaccine uptake [ , ] . although results vary in degree and direction, perceptions about the risk of disease and severity of infection that follow major pandemic threats may affect uptake of seasonal influenza vaccine [ ] [ ] [ ] . the results of our study suggest that these events may have had a positive effect on iv uptake in portugal. more research is needed to understand the factors underlying an individual's decision to be vaccinated against influenza. ecos is a sample of families from mainland portugal, with landline and mobile telephones, who agree to complete periodic health surveys. residents of portugal who do not have a landline or mobile telephone were not represented in this study. between / and / , the ecos panel sample was renewed three times ( , , and ) . therefore, the estimates of iv coverage were obtained using four different samples that were selected using the same methodology. using the same sample for more than one consecutive season could lead to biased coverage estimates. specifically, the application of the questionnaire to the same sample in two consecutive seasons could lead to a greater proportion of individuals who choose to be vaccinated the next season. this change in behavior could artificially increase iv coverage, which would not represent coverage in the general population. there is no evidence of this bias in our study, because in each population group, iv coverage increase was not consistent or systematic for the four periods between changes in the sample population ( to , to , to , and to the present). as previously described, the representativeness of the samples studied in comparison with estimates from the census of the portuguese mainland population found age deviations from this reference population. these deviations could be translated into an iv coverage bias in the general population. however, in risk groups for whom vaccination is recommended, particularly the elderly (≥ years), and for whom iv coverage monitoring is more critical for control measures, the age bias presented by our samples was less relevant. recall bias may occur when individual recall of information is used to obtain data. however, individuals were vaccinated some months before each survey and this time differed from survey to survey. additionally, only one individual (> years) per household answered questions about vaccination status of household members. surveying all of the individuals in a household would make the procedure more complex and could lead to a failure of the entire process, which occurred during previous surveys using the ecos panel [ ] . from / to / , seasonal iv coverage in portugal varied between . % and . %. no significant increasing trend was observed in the portuguese general population during this period. there was a clear, increasing trend in iv coverage in the elderly population (p < . ). coverage increased from . % in / to . % in / . after / , however, iv coverage in the elderly has remained near %, which suggests that there has been a slowdown in the growth trend. thus, in , the % who target in this major risk group had not been met. this result indicates that there is a need to improve the influenza vaccination strategy in portugal to comply with the ambitious coverage goals proposed by who. the major pandemic threats of the last decade had an effect on seasonal influenza vaccination. there was a significant increase in vaccine uptake in the general population in / (p = . ) and in / (p = . ). the / seasonal vaccine coverage in the general population was not significantly higher when accounting for the baseline trend, but the . % of vaccination occurred in individuals < years old. although not the highest of all the seasons, this result was significant when accounting for vaccination trend in this age group during the past decade. influenza vaccination in the elderly: impact on hospitalisation and mortality universal influenza vaccination: the time to act is now world health organisation, global influenza programme: public health research agenda for influenza: version . geneva centers for disease control and prevention: prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices (acip). mmwr world health organization: global pandemic influenza action plan to increase vaccine supply impact of severe acute respiratory syndrome and the perceived avian influenza epidemic on the increased rate of influenza vaccination among nurses in hong kong the role of influenza vaccine in healthcare workers in the era of severe acute respiratory syndrome pandemic h n vaccine development: an update why do i need it? i am not at risk! public perceptions towards the pandemic (h n ) vaccine low acceptability of a/h n pandemic vaccination in french adult population: did public health policy fuel public dissonance? did the pandemic have an impact on influenza vaccination attitude? a survey among health care workers world health organization: who recommends influenza vaccine composition for northern hemisphere - influenza season gripe: vacinação contra a gripe em gripe: vacinação contra a gripe em circular informativa nº: /dspcd direcção-geral da saúde: campanha de vacinação contra a infecção pelo vírus da gripe pandémica (h n ) . lisboa: circular normativa n.º: a/dspcd em casa, pelo telefone, observamos saúde: descrição e avaliação de uma metodologia evaluating the effects of screening for telephone service in dual frame rdd surveys nonresponse bias in dual frame sample of cell and landline numbers on chi-squared tests for multiway contingency tables with cell proportions estimated from survey data analysis of categorical response data from complex surveys: an upraise and update spss inc: statistical package for the social sciences chicago: spss statacorp: stata statistical software: release influenza vaccination coverage against seasonal and pandemic influenza and their determinants in france: a cross-sectional survey developments in influenza vaccination coverage in england, scotland and wales covering five consecutive seasons from does a population survey provide reliable influenza vaccine uptake rates among highrisk groups? a case-study of the netherlands seasonal influenza vaccination low coverage of seasonal influenza vaccination in the elderly in many european countries vaccination coverage rates in eleven european countries during two consecutive influenza seasons world health organization: influenza vaccination for the - season: recommendation in the context of concern about sars trends in influenza vaccination coverage rates in germany over five seasons meta-analysis of the relationship between risk perception and health behaviour: the example of vaccination risk perceptions related to sars and avian influenza: theoretical foundations of current empirical research the impact of the influenza a (h n ) pandemic on attitudes of healthcare workers toward seasonal influenza vaccination / low acceptability of a/h n pandemic vaccination in french adult population: did public health fuel public dissonance? trends in influenza vaccination coverage in portugal from to : effect of major pandemic threats the authors declare that they have no competing interests.authors' contributions cp participated in drafting the manuscript and in the statistical analysis. bn participated in the design and coordination of the study, in the statistical analysis, and reviewed the manuscript. mj reviewed the manuscript and participated in its design and organization. all authors read and approved the final manuscript. key: cord- - ulk euw authors: wang, jianming; fei, yang; shen, hongbing; xu, biao title: gender difference in knowledge of tuberculosis and associated health-care seeking behaviors: a cross-sectional study in a rural area of china date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: ulk euw background: tuberculosis (tb) detection under the national tb control program in china follows passive case-finding guidelines, which could be influenced by the accessibility of health service and patient's health-care seeking behaviors. one intriguing topic is the correlation between men and women's knowledge on tb and their health-care seeking behaviors. methods: two cross-sectional studies were separately carried out in yangzhong county, a rural area of china. one study, by using systematic sampling method, including , subjects, was conducted to investigate the tb knowledge among general population. another study in the same source population screened , people aged years or over among stratified cluster-sampled villages for identifying prolonged cough patients at households and individual interviews were then carried out. gender difference in the knowledge of tb and health-care seeking behaviors was analyzed particularly. results: among general population, only . % (men . % vs. women . %) knew the prolonged cough with the duration of weeks or longer was a symptom for suspicious tb. fewer women than men knew the local appointed health facility for tb diagnosis and treatment as well as the current free tb service policy. moreover, women were less likely to learn information about tb and share it with others on their own initiatives. on the contrary, after the onset of the prolonged cough, women ( . %) were more likely to seek health-care than men ( . %) did. however, a large part of women preferred to visit the lower level non-hospital health facilities at first such as village clinics and drugstores. conclusion: tb and dots program were not well known by rural chinese. gender issues should be considered to reduce diagnostic delay of tb and improve both men and women's access to qualified health facility for tb care. strengthening awareness of tb and improving the accessibility of health-care service is essential in tb control strategy, especially under the current vertical tb control system. tuberculosis (tb) is a leading cause of death world-wide, especially in low-income and middle-income countries [ ] . although tb prevalence and death rates have probably been falling globally for several years, the total number of new cases is still rising slowly, due to the caseload continuing to grow in the african, eastern mediterranean and south-east asia regions [ ] . china has the world's second largest number of tb cases [ ] . to fight against tb, the chinese national tb control program (ntp) has adopted the directly observed treatment, short course (dots) strategy since [ ] . however, the progress in tb control was slow during the s, resulting in the detection rate of tb stagnating around at %, far below the target set by world health organization (who) [ ] . recently, especially after the outbreak of severe acute respiratory syndrome (sars) in , the chinese government has taken a series of measures to strengthen its public health system and put great efforts on tb control. however, as a country with large populations, china is still facing great challenges, especially in rural areas. one of them is the accessibility of tb services toward the entire population [ , ] . although china's ntp has set a free tb service policy, in most places access to tb care is still unsatisfactory. tb control system in china is vertically composed by specialized tb dispensaries and tb control departments from county/district level to national tb center. the basic unit of tb control in rural china is the county tb dispensary which is the main place for dots implementation. as case detection in the ntp in china follows who recommended passive case-finding guidelines, people with tb related symptoms should be identified when they seek care at a general health facility, and referred to the specialized tb dispensary for diagnosis, treatment and case management. therefore, early detection of tb depends on whether patients could perceive their needs of seeking health-care for tb symptoms such as cough; and whether patients could be promptly referred to tb dispensaries by doctors in general hospitals and other health providers [ ] . however, under the current fee for service and bonusrelated revenue mechanism in china's health system, it is not surprising to find that the referral does not work well in many places [ ] . thus, making people understand when and where they should seek health-care is of great importance. several studies have proved that lack of knowledge to tb is likely to hinder positive health-care seeking behavior whilst better knowledgeable on tb was significantly related to health-care seeking action [ ] [ ] [ ] . studies also found that there was gender difference in knowing tb. as reported by agboatwalla in pakistan and shetty in london, knowledge of tb was generally deficient in women, particularly in rural women [ , ] . gender disparity is focused world-wide as higher notification rates of tb among men than women have been observed in many countries [ ] . these findings raise the hypothesis that tb among women might be underreported in developing countries. it has been supported by the results from several studies comparing active and passive case-finding strategies [ ] . one study in bangladesh reported that women, in comparison with men, had significantly longer diagnostic delay and patient delay [ ] . similar results could be found in shandong province of china, where women experienced longer health system delays than men, and that the higher the level of health facility patients first visited, the less time was needed to achieve a diagnosis [ ] . our former qualitative study in china also found a gender disparity in the experiences of health-care seeking and access to tb care [ ] . factors affecting patient's behavior were complex. whether the gender difference in health-care seeking behavior is associated with the disparity of knowledge to tb among men and women is unclear. few studies have been focused on this issue. the purpose of the present study was to understand whether and what extent people in rural china know tb and aware of the pro-poor dots program, and further to understand the collation between rural people's knowledge and awareness of tb and their health-care seeking behaviors from a gender perspective. this study was conducted in yz county, an island locating on the middle of yangtze river in the southeast part of china, with a population of about . million and an area of about km . this is a relatively rich area ranked as one of the richest counties in china. the county tb dispensary is affiliated to cdc (center for disease control and prevention), which was formerly called anti-epidemic station. it is the exclusive appointed health facility responsible for tb diagnosis and treatment for the county residents (county hospital is appointed for severe inpatients). all suspected tb patients should be referred to this unit for further examination. free diagnosis and treatment are available in tb dispensary for sputum smear positive patients (it has been expanded to all patients including sputum smear negative patients since ). here, 'free' means no charges for sputum smear test, chest x-ray examination and anti-tuberculosis medications distributed by government. all other health facilities in this county including township health centers, private practitioners and village health stations are responsible for referring tb suspects to the county tb dispensary, and smear microscopy tests and anti-tuberculosis medicines are not available in these facilities. two cross-sectional studies were separately conducted in the study site. ( ) knowledge on tb among general population sampling strategy in the current study followed the guidelines designed by china cdc. after sorting all towns in yz county by socioeconomic status (gross domestic product), towns were selected at the first stage by using a systematic sampling technique. then villages from each town were systematically sampled. at the third stage, households were systematically sampled from each village based on the list of householders' names. in each household, two family members (aged to ) whose birthday (month and day) was close to the investigation date (month and day) were selected as study subjects and were then interviewed by trained investigators with a detailed questionnaire. this questionnaire we adopted in the study referred to the questionnaire designed by china cdc, which has been applied in a national survey on the knowledge, attitudes and practices (kap) towards tb in china [ ] . ( ) health-care seeking behaviors among tb suspects among the same source population, a stratified cluster sampling method was used to select sample units for tb screening. totally, villages were randomly sampled from towns (one town named as sm where the county center located was not involved in the sampling process). all permanent inhabitants aged years or over were the study population and then screened by using a simple questionnaire for identifying people at each household with prolonged cough which was a main symptom for tb. a detailed structured questionnaire was then administered for all identified cough cases to collect socioeconomic and demographic variables, symptoms other than cough and health-care seeking behaviors. these patients with prolonged cough were regarded as tb suspects and were then referred to cdc for free x-ray examination and sputum smear microscopy test. in this study, delays in tb diagnosis are generally divided into 'patient delay" and 'system or service provider delay'. 'patient delay' refers to the time between the first onset of symptoms and first utilization of a healthcare provider, whilst 'system delay' refers to the time between the first utilization of a health provider and a confirmed diagnosis of tb [ ] . data were analyzed by spss . software (chicago, illinois, usa). chi-square test for proportions and student's t-test and kruskal-wallis h test for continuous variables were used to describe differences between groups. about % of all cases were randomly selected to be re-inter-viewed through telephone by the supervisor after field investigation. in this study, a prolonged cough was defined as the cough lasting for weeks or longer. healthcare seeking behaviors included buying drugs in pharmacies and visiting private practitioner, village health workers, physicians in town, county or upper level hospitals and the county tb dispensary. formal health-care seeking was exclusively defined as the experience of visiting town or upper level hospitals. health-care seeking delay referred to a period from the onset of symptoms to the first utilization of a health facility. oral inform consent was obtained in the study on the knowledge of tb among general population. written inform consent was obtained from all participants in the study on health-care seeking behavior among tb suspects. the study was approved by institutional review board in school of public health, fudan university. one thousand and two hundred adults were selected for the survey of knowledge on tb and subjects completed the questionnaire. the proportion of men and women were . % and . % respectively, with the average age of . ± . years. the median annual income per capita was around cny (chinese yuan). as shown in table , . % of the subjects have heard about tb and a large part of them regarded it as a contagious disease (men . %; women . %). many of them thought tb was a relatively severe disease, which could influence the labor ability. about . % of them actively acquired information about tb and . % of them shared it with others on their own initiatives. significantly more men than women actively learned knowledge about tb (men . % vs. women . %, p < . ). sixteen percent of them (men . % vs. women . %) understood that the prolonged cough with the duration over weeks was a suspicious symptom for tb. when inquired about the current tb policy in yz county, . % (men . % vs. women . %, p < . ) answered that they knew about the appointed health facility for tb diagnosis and treatment. less women than men knew the local policy for free tb service with a significant gender disparity. approximately . % women vs. . % men (p = . ) knew that it was free for tb diagnosis as well as . % women vs. . % men (p < . ) knew that it was free for tb treatment in the local county. only . % (men . % vs. women . %) believed tb was a curable disease at the present time. by screening , people ( , men and , women), subjects were notified with a prolonged cough within the past three months. after recheck, patients were excluded due to the short durations of cough. another former tb patients diagnosed three months ago were also excluded. finally, subjects ( men and women) identified as tb suspects were involved in the analysis. as shown in table and table , . % of them had sought for health-care during the current cough episode and only . % of them went to the town hospital or upper levels seeking for formal healthcare. nearly . % of them firstly visited village clinics or drugstores after the onset of cough. the median of house-hold per capita income was cny and cny respectively in the group with or without seeking healthcare (p = . ). more women than men sought healthcare for the current prolonged cough with a significant gender difference (women . % vs. men . %, p = . ). however, men preferred to visit upper level health facilities first, whereas women preferred to visit lower level health facilities first (table ) . even in the second health-care seeking episode, this gender difference still existed. the median of delay from the onset of symptoms to the first visit at health facility was days. there was no with the vertical tb control system, dots program characterized by the free tb diagnosis and anti-tuberculosis treatment is only available in tb dispensary. in rural areas, the lowest level of tb control system is the county tb dispensary where patients with cough and/or other tb symptoms do not routinely visit. in the context of china's tb control policy, it's not possible to see this system being replaced by the non-specialized health facilities in a near future. so the accessibility of dots in china relies on referral by doctors in general hospitals, and/or self-referral by patients. to empower patients, and to make people understand when and where they should seek health-care, chinese government has initiated a massive education program on tb in general population, especially people living in the rural areas. one of the objectives of this education program is to help potential tb patients identify the suspicious symptoms and go to the right place for treatment in time. either in the urban hospitals or in the remote rural health facilities (even in the village health station), there are posters on the wall, such as 'if coughed for more than weeks, you are suspect for tb', 'the government provides free treatment for communicable tb' and 'local cdc (tb dispensary) provides free service for sputum smear test, chest x-ray and anti-tuberculosis medicines'. this information also spread through other vivid and dramatic manners such as newspaper, website, television, broadcast, brochure and leaflet. people would argue that it does not sound reasonable to expect non-patients and/or potential patients to know where to go for tb diagnosis and treatment, but it's a compromise to the vertical tb control system. theoretically, the health staff that tb patients encounter should refer them to the correct place for diagnosis and treatment, where dots program is available. however, this referral system does not work well in many places [ , ] . as we know, under china's health system reforms, hospitals and other health facilities have adopted fee for service and bonus-related revenue systems to encourage their medical staffs to make more money [ ] . it is not surprising, therefore, that these health facilities have been developing a variety of means to attract patients in order to generate more revenues by providing more services and selling more drugs [ ] . it is also common to see that, repeated outpatient visits before diagnosis, over-prescription of drugs and prolonged treatments instead of referral to appointed health facilities in time [ ] . admittedly, the heavy financial burden on tb patients is one of the major problems in china's tb control which has been the main reason for poor access to tb care and treatment compliance. pressure to generate revenue and competence of health workers at different levels cause diagnostic delay and high economic burden to tb patients and ultimately impede effective tb control in china [ ] . but, if patients know tb diagnosis and treatment should be free, they would have more chances to ask why they should pay for tb care and what cost should be covered by the free care. therefore, on one hand, regulating doctors' referral could be effective to shorten diagnosis delay for tb; on the other hand, educating general population to seek health-care in an appropriate way is also an alternative. massive health education programs in china have been proved to make a great impact on the enhancement on people's knowledge about tb. from the current study, we are also glad to find that almost all people have heard about tb and more than % knew it was a transmissible disease. however, knowledge about tb linked with health-care seeking behaviors still seems unsatisfactory. only % of them knew that cough lasting for more than weeks was a suspicious symptom for tb and less than half of them knew the free policy for tb diagnosis and treatment. the incomprehensive perception on tb among general population after the massive education program arouses our consideration on the health educations in china: whether it is a successful campaign and what is the cost-effective way? one interesting result in our study is that the gender disparity of knowledge towards tb among men and women was inconsistent with the health-care seeking behaviors. compared with men, women lacked knowledge about tb symptoms and the pro-poor service policy. however, they were more likely than men to seek health-care after the onset of tb suspicious symptoms. as proved in several studies, deficient knowledge in women and patient's recognition of tb were statistically significant factors of diagnostic delay for tb [ , ] . a study in rural inner mongolia of china also reported that women with less education tended to be less knowledgeable about tb and were less likely to seek care than men though gender difference was not statistically significant in the quantitative survey [ ] . in our current study, lack of knowledge among women did not show negative impacts on their health-care seeking. this phenomenon could also be found in south india that despite facing greater stigma and inconvenience, women were more likely than men to access health services and adhere to treatment [ ] . however, when we take a deep look on the data and further explore their health seeking experiences, it is not surprised to find that men and women have different preference on the health-care service. men preferred to visit upper level health facilities -the hospitals, whereas women preferred to visit lower level health facilities such as village health stations. as proved by other studies, patients who chose the village clinic or private providers as their first health facility usually experienced a much longer health system delay than that of those choosing other formal heath facilities [ , ] . thus though women were more likely to seek health-care for tb suspicious symptoms, it might not help shorten the health system delay due to the weakness in diagnosis in non-formal health facilities. there are several explanations for this phenomenon. one might be the deficient knowledge on tb we discussed above. another might be the special role of women in china. in rural areas of china, most work in the household is undertaken by women in addition to agricultural work, which may mean that they have less time seek health-care in a township health center or general hospital. women may therefore prefer to visit facilities that are geographically accessible such as village health stations or private practitioners. another intriguing phenomenon found from this study also need to be further studied, which was that, though free service was provided to the identified cough patients, some of them were still not willing to get further examination. when inquired about the potential reasons, some patients answered "free? i don't believe it. after examination, i am sure they will administrate many drugs and charge me a lot", and others said "that is only cough. i know it will not be a serious disease..." more reasons undermining this aspect need further studies. one of the limitations in this study is that data were only collected from one county, which might not truly reflect the vision of the whole population in china. though the study is very small, and findings from this study may not be comprehensive, it does have impacts on gender equity in tb control of china. another limitation is that information depended on self-reported data and the survey on health-care seeking behavior was based on recall history. to minimize recall bias, some strategies had been taken, such as questionnaires were pre-tested and all questions were set to be easy understood; investigators were carefully trained and supervised. ten percent of subjects were re-interviewed through telephone and the consistency was more than %. findings from our study indicate that knowledge and awareness of tb are still unsatisfactory in rural chinese population. compared with men, women have less knowledge on the current tb service policy and reluctant to actively acquire information about tb. though they are more likely to seek health-care after the onset of prolonged cough, women usually visit village clinics or drugstores whilst men prefer to seek health-care in upper level hospitals. gender issues should be considered in promoting patients' health-care seeking behavior and to shorten the delay of diagnosis. improving the accessibility of healthcare service is essential in tb control strategy, especially under the current passive case-finding guidelines. results of this study are derived from a rural population of china, but could be discussed also in relation to other populations with the similar condition. global tuberculosis control -surveillance, planning, financing progress in tuberculosis control and the evolving public-health system in china what lessons can be drawn from tuberculosis (tb) control in china in the s? an analysis from a health system perspective. health policy access to tuberculosis care: what did chronic cough patients experience in the way of healthcareseeking? scandinavian journal of public health barriers in accessing to tuberculosis care among non-residents in shanghai: a descriptive study of delays in diagnosis multiple perspectives on diagnosis delay for tuberculosis from key stakeholders in poor rural china: case study in four provinces knowledge and healthcare seeking behaviour of pulmonary tuberculosis patients attending ilala district hospital, tanzania. tanzania health research bulletin community knowledge, attitudes and practices towards tuberculosis and its treatment in mpwapwa district, central tanzania. tanzania health research bulletin knowledge of tuberculosis and associated health-seeking behaviour among rural vietnamese adults with a cough for at least three weeks gender perspectives on knowledge and practices regarding tuberculosis in urban and rural areas in pakistan abbas a: knowledge, attitudes and practices regarding tuberculosis among immigrants of somalian ethnic origin in london: a cross-sectional study gender differences in tuberculosis: a prevalence survey done in bangladesh a review of sex differences in the epidemiology of tuberculosis gender differences in delays in diagnosis and treatment of tuberculosis. health policy and planning factors affecting delays in tuberculosis diagnosis in rural china: a case study in four counties in shandong province perceptions and experiences of health care seeking and access to tb care-a qualitative study in rural jiangsu province, china. health policy gong gong wei sheng yu yu fang yi xue pathways from first health care seeking to diagnosis: obstacles to tuberculosis care in rural china how affordable are tuberculosis diagnosis and treatment in rural china? an analysis from community and tuberculosis patient perspectives gender and literacy: factors related to diagnostic delay and unsuccessful treatment of tuberculosis in the mountainous area of yemen perceptions of tuberculosis and health seeking behaviour in rural inner mongolia, china. health policy gender disparities in tuberculosis: report from a rural dots programme in south india delay and discontinuity-a survey of tb patients' search of a diagnosis in a diversified health care system this investigation partly received financial support from the undp/world bank/who special program for research and training in tropical diseases (grant no. who/tdr/seb a ) and natural science foundation of jiangsu (bk ). thanks for the support of shanghai leading academic discipline project (b ) for publication. the authors declare that they have no competing interests. jw and bx conceived the idea, implemented the field study and wrote the manuscript. yf participated in the design and implement of the study and statistical analysis. hs participated in data analysis and helped to draft the manuscript. all authors read and approved the final manuscript. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- - e zjaz authors: park, ji-eun; jung, soyoung; kim, aeran; park, ji-eun title: mers transmission and risk factors: a systematic review date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: e zjaz background: since middle east respiratory syndrome (mers) infection was first reported in , many studies have analysed its transmissibility and severity. however, the methodology and results of these studies have varied, and there has been no systematic review of mers. this study reviews the characteristics and associated risk factors of mers. method: we searched international (pubmed, sciencedirect, cochrane) and korean databases (dbpia, kiss) for english- or korean-language articles using the terms “mers” and “middle east respiratory syndrome”. only human studies with > participants were analysed to exclude studies with low representation. epidemiologic studies with information on transmissibility and severity of mers as well as studies containing mers risk factors were included. result: a total of studies were included. most studies from saudi arabia reported higher mortality ( – . %) than those from south korea ( . %). while the r( ) value in saudi arabia was < in all but one study, in south korea, the r( ) value was . – . in the early stage and decreased to < in the later stage. the incubation period was . – . days in saudi arabia and – . days in south korea. duration from onset was – days to confirmation, . – . days to hospitalization, – days to death, and – days to discharge. older age and concomitant disease were the most common factors related to mers infection, severity, and mortality. conclusion: the transmissibility and severity of mers differed by outbreak region and patient characteristics. further studies assessing the risk of mers should consider these factors. middle east respiratory syndrome (mers) was first reported in in saudi arabia [ ] . although most patients are linked to the arabian peninsula geographically, mers has been detected in many other parts of the world [ ] . a large mers cluster was also observed in in south korea [ ] . mers causes sporadic infection and intrafamilial and healthcare-associated infection. its symptoms can vary from asymptomatic infection to death. despite the infection's association with high mortality, specified antiviral therapy is lacking, especially for patients with concomitant diseases [ ] . many previous studies have assessed the risks of mers, such as factors dictating severity or an infection risk, yet the indices they present vary. for example, the case fatality rate was found to be . % in the middle east area, but . % in south korea [ ] . the incubation period was reported to be . - days in south korea [ , ] , but . in a study using data from multiple areas [ ] and . in saudi arabia [ ] . accurate assessment of the risk of mers is essential for predicting and preventing infection. a systematic review of the risk of mers, as covered in previous studies, is potentially helpful for predicting this spread, and its future impact. this study aimed at reviewing the risk of mers, focusing on indices related to infectivity and severity. we searched international (pubmed, sciencedirect, cochrane) and korean databases (dbpia, kiss) using the term "mers" or "middle east respiratory syndrome", encompassing articles published after . the search process was conducted in october . we also manually searched the reference lists of the included studies. human studies were included, while animal studies and reviews were excluded. only articles in english or korean were included. even if a study collected data on humans, such as collecting specimens from religious pilgrims, it was excluded if there were no mers patients in the study sample. additionally, case studies including fewer than mers patients were excluded as they were considered as having insufficient mers patient numbers and representative information. the included studies were classified as epidemiologic studies and those covering risk factors of mers. in the epidemiologic category, indices related to the risk of mers were divided into two categories; related to infectivity and related to severity. the index related to infectivity included the reproduction number (r), attack rate, incubation period, serial interval, and days from onset to confirmation. the index related to severity included the case fatality rate (cfr), days from onset to hospitalization, days from onset to discharge, days from onset to death, and days from hospitalization to death. in the risk factor category, factors related to infection, transmission, severity, and mortality of mers were analysed. even if the included studies investigated factors that were related to mortality, when they did not analyse risk factors of severity or mortality using appropriate statistical methods (e.g., regression analysis, cox proportional hazards model) or only compared prevalence factors, we excluded them from the risk factor category. in all categories, we extracted the study period, number of participants, and geographical region where the data were collected using a data extraction form confirmed after pilot assessment. a total of studies were searched, and were reviewed, excluding duplicate studies. after the title and abstract review, a further and were excluded, respectively. another four studies were included via a manual search, which left a total of studies for analysis ( fig. ). the of total included studies were classified as epidemiologic studies (table ) . r value, representing the reproduction number, indicates the average number of secondary cases generated by infectious individuals. thirteen studies reported r value of mers. four studies that used data from multiple areas had r < . [ , [ ] [ ] [ ] . studies using saudi arabia or middle east area data reported r < , at . - . [ ] [ ] [ ] [ ] , though one reported . - . [ ] . studies using south korea data showed higher values, at . - . [ ] [ ] [ ] [ ] , in the early stage, and < in the later period [ ] or with control intervention [ ] . a total of eight studies reported the attack rate. four reported the overall or secondary attack rate, and the other four reported the attack rate of specific participant groups. two studies conducted in saudi arabia showed . % [ ] and % [ ] secondary attack rates. studies in south korea showed secondary attack rates of . % in one study [ ] and . - . % in another [ ] . two studies reported the attack rate among healthcare workers (hcws). one study in south korea reported a mers incidence of . % among hcws [ ] , and another study using multiple area data reported a . - . % infection rate among hcws [ ] . the attack rate among hospital patients was % in one study [ ] and % in the early and % in the later period in another [ ] . the incubation period is the period between infection and appearance of signs of a disease. a total of studies reported the incubation period of mers. nine used data from south korea and showed a - . day incubation period [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . one study using data from saudi arabia reported a . day incubation period [ ] , and another using data from multiple areas reported a . day incubation period [ ] . sha et al. compared the incubation periods between the middle east area and south korea and reported . - and days, respectively [ ] . the serial interval of an infectious disease represents the duration between symptom onset of a primary case and of its secondary cases. two studies used south korea data, reporting serial intervals of mers of . and . days, respectively [ , ] . among five studies reporting days from onset to confirmation, three studies used data from south korea. one study analysing all south korea cases reported days from onset to confirmation [ ] . park et al. reported . days for all cases, for second generation and for third generation [ ] . one study from taiwan reported days for hcws and for non-hcws [ ] . a study from saudi arabia reported days from onset to confirmation [ ] . sha et al. compared the data from middle east and south korea areas and reported - and - days, respectively [ ] . two studies from saudi arabia reported days from onset to hospitalization. one reported . - days [ ] , and the other reported . days [ ] . twenty-six studies reported on mers-related mortality. ten reported the mortality rate in south korea as . - . % [ , , - , , , , ] ; one of which, including all mers patients in south korea, reported a mortality rate of . % [ ] . ten studies analysing data from saudi arabia reported higher mortality rates, of - . % [ , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] , although others reported mortality rates % [ ] and . % [ ] . a taiwanese study reported a mortality rate of . % [ ] . studies using data from multiple areas reported mortality rates ranging from . % [ ] to . % [ , ] . three studies reported days from mers onset to discharge. sha et al. reported days in the middle east area and in south korea [ ] . one study from saudi arabia reported days [ ] , and another in south korea reported [ ] . two korean studies reported similar periods of - days from onset to death: - . in park et al. [ ] and in ki et al. [ ] . although one study from saudi arabia reported longer than days from onset to death [ ] , sha et al., comparing data between the middle east and south korea, reported similar periods of . and days, respectively [ ] . one taiwanese study also reported a similar period of - days [ ] . two studies reported a similar length of hospitalization: [ ] and . days [ ] . of the studies included in the risk factor category, four were duplicates of studies in the epidemiologic category as they had information regarding the epidemiologic index and risk factors ( table ) . two studies reported on the risk factors of mers infection. alraddadi et al. [ ] analysed the effect of nonhuman contact, including travel history, animal-related exposure, food exposure, health condition, and behaviour and reported direct dromedary exposure, diabetes or heart disease, and smoking as risk factors of mers infection. another study reported older age, outbreak week, and nationality as risk factors [ ] . three studies analysed factors associated with spreaders. non-isolated in-hospital days, hospitalization or emergency room visits before isolation, deceased patients, and clinical symptoms, including fever, chest x-ray abnormality in more than three lung zones, and the cycle threshold value, were related to spreaders [ , , ] . four studies reported risk factors of mers severity. the included studies showed that the prnt and cd t cell response [ ] as well as a high mers virus load [ ] were associated with the severity of mers. additionally, male sex; older age; concomitant disease, including hypertension; and symptoms, including fever, thrombocytopenia, lymphopenia, and low albumin concentration, were related to mers severity or secondary disease [ ] [ ] [ ] . fifteen studies reported risk factors of mortality in mers patients. older age [ , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] and comorbidity [ , [ ] [ ] [ ] ] , including diabetes [ , ] , chronic kidney disease [ ] , respiratory disease [ , ] , pneumonia [ ] , cardiac disease, and cancer [ ] , were the most prevalent in the included studies. male sex was reported as a risk factor in one study [ ] . smoking [ , ] and location of acquisition [ , ] were also reported. while one study noted that hcw, as a profession, was associated with mortality [ ] , non-hcws were reported to be related to mortality in two other studies [ , ] . additionally, a shorter incubation period [ , ] , longer duration of symptoms [ ] , more days from onset to confirmation [ ] , later epidemic period [ ] , and longer hospitalized days [ ] were reported as mortality risk factors. symptoms at diagnosis, including abnormal renal function [ ] , respiratory symptoms [ ] , gastrointestinal symptoms [ ] , lower blood pressure [ , ] , and leucocytosis [ , ] , were also found to be associated with mortality in mers patients. severity of illness, [ , ] such as need for vasopressors [ ] , chest radiographic score [ ] , health condition [ ] , use of mechanical ventilation [ ] , and occurrence of dyspnoea [ ] were also found to increase the mortality risk. the characteristics of mers differ between south korea and the middle east area. the r value of mers was reported to be below in the middle east area, except in one study [ ] , but was from . - . in south korea [ ] [ ] [ ] [ ] [ ] . although studies using data from the middle east area reported . - % secondary attack rates, studies in south korea reported - % secondary attack rates for patients or hospital visitors [ ] , and . - . % for the overall attack rate [ , ] . the mers incubation period was reported to be . - . days in the middle east area [ , ] , but this period was found to be slightly longer in south korea [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the severity of mers also differed between the middle east area and south korea. mortality of mers patients was found to be . % in south korea based on a report including all cases [ ] , but most studies from saudi arabia reported higher rates, from to . % [ , , , [ ] [ ] [ ] . days from onset to confirmation were similar, - days in the middle east area [ , ] and - . days in south korea [ , , ] . days from onset to discharge were slightly longer in south korea, - days in the middle east area [ , ] and - days in south korea [ , ] (table ). the transmissibility and severity of mers were different by outbreak countries, especially between the middle east area and south korea. the virus, host, and environmental factors may be the causes of the mers outbreakrelated differences between the two regions. from the standpoint of viral factors, there was a mutation of the mers coronavirus (mers-cov) in the south korea outbreak. kim et al. [ ] reported a point mutation in the receptor-binding domain of the viral spike protein in mers-cov, and another study showed that mers-cov in south korea had higher genetic variability and mutation rates [ ] . individual characteristics can also affect mers transmission. as previous studies showed, there is an association between older age and mers infection [ ] , severity [ ] , and mortality [ , ] , and the population structure may be related to transmission and severity. additionally, individuals aware of mers were found to be more likely to practice preventive behaviour [ ] , which differed by demographic characteristics [ , ] . the transmission environment may also contribute to the difference. while many mers cases were contracted through exposure to camels in saudi arabia [ ] , the south korea outbreak involved multiple generations of secondary infections caused by intra-hospital and hospital-tohospital transmission [ , ] . strategies considering various factors are therefore needed to assess the impact of mers and to better control its spread. although several studies have reported the overall r value [ , , , ] , others have shown that this value this can be variable based on the generation or a control intervention [ , , ] . especially in the south korea epidemic, the r value was particularly high in the early stage or first generation, at . - . , though it later decreased to . - . [ , ] . further studies should consider and analyse the variation of the r value depending on the period or control intervention. while earlier studies on infectious diseases assumed a homogeneous infection ability of a population, recent studies have shown the existence of so-called super spreaders, individuals with a high potential to infect others in many infectious diseases, including ebola and severe acute respiratory syndrome (sars) [ ] . the role of the super spreader is also important in the spread of mers. in south korea, . % of mers patients were associated with five super-spreading events [ ] . stein et al. [ ] asserted that super spreaders were related with the host, pathogen, and environmental factors, and wong et al. [ ] reported that individual behaviours could also contribute to disease spread. there are variations in the mortality and attack rates among studies using south korea data. for example, park et al. [ ] reported a . % mers mortality, while reports from the korean ministry of health and welfare showed . % mers mortality. this disparity may, in part, be due to small sample sizes. park et al. [ ] included only patients because the study was conducted in an early phase of a mers outbreak. we excluded studies that included cases with < subjects, which were mostly case series, to reduce those types of biases. the present review found that older age and concomitant disease were risk factors of mers infection and mortality. these results are consistent with a recent systematic review that reported older age, male, and an underlying medical condition as predictors of death related to mers [ ] ; therefore, these factors should be prioritized in protection and treatment procedures. one limitation of this study was the possibility of subject duplication. especially in south korea, the korean government publishes mers reports that include all patients. the epidemiologic index in other studies might be biased since they included partial korean patients and were analysed in the middle of an outbreak. however, we included those studies because they showed the characteristics of mers in different situations and different stages. we did not conduct a meta-analysis because of the small number of studies for each index, which might be another limitation of this study. although this study reviewed the risk factors of mers and their impact, assessing the effect size of each risk factor is important. more studies investigating the effect of risk factors on mers need to be constantly conducted. most studies on the transmissibility and severity of mers have originated from saudi arabia and south korea. even though the r value in south korea was higher than that in saudi arabia, mortality was higher in saudi arabia. the most common factors behind mers infection and mortality were older age and concomitant disease. future studies should consider the risk of mers based on the outbreak region and patient characteristics. the results of the present study are valuable for informing further studies and health policy in preparation for mers outbreaks. isolation of a novel coronavirus 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respiratory syndrome coronavirus and the multiple generations of secondary infection in south korea the role of super-spreaders in infectious disease super-spreaders in infectious diseases clinical determinants of the severity of middle east respiratory syndrome (mers): a systematic review and meta-analysis authors' contributions jep (corresponding author) designed the study, and conducted the data search and the analysis with jep ( st author). syj and ark participated in the data review. jep (corresponding) drafted the manuscript, and jep ( st), syj, and ark revised it. all authors read and approved the final manuscript.ethics approval and consent to participate not applicable. the authors declare that they have no competing interests. key: cord- -ijncfuxi authors: wang, yuheng; cheng, minna; wang, siyuan; wu, fei; yan, qinghua; yang, qinping; li, yanyun; guo, xiang; fu, chen; shi, yan; wagner, abram l.; boulton, matthew l. title: vaccination coverage with the pneumococcal and influenza vaccine among persons with chronic diseases in shanghai, china, date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: ijncfuxi background: adults with chronic conditions such as heart disease, diabetes, or lung disease are more likely to develop complications from a number of vaccine-preventable diseases, including influenza and pneumonia. in this study, we use the data from a chronic disease management information system in shanghai to estimate vaccination coverage and characterize predictors of seasonal influenza and -valent pneumococcal polysaccharide vaccine (ppsv ) vaccination among people with chronic disease in shanghai. methods: the shanghai centers for disease control and prevention have information systems related to chronic disease management, hospital records, and immunizations. data from individuals with hypertension, diabetes and chronic obstructive pulmonary disease (copd) were abstracted during july . the main outcome was coverage of pneumococcal and influenza vaccination. vaccination coverage was calculated across demographic groups. significance in bivariate associations was assessed through pearson’s chi-square tests, and in multivariable models through logistic regression models with a forward stepwise method to select variables. results: in the sample of , , individuals ≥ years, . % were vaccinated for pneumonia from january to july , and the vaccination coverage of influenza in the / influenza season was . %. vaccination coverage was highest in those – and lowest in those younger than . compared to urban areas, uptake in rural areas was higher for pneumonia vaccination (or: . , % ci: . , . ), but lower for influenza vaccination (or: . , % ci: . , . ). having a greater number of chronic diseases was associated with higher likelihood of pneumonia vaccination ( vs : or: . , % ci: . , . ), but this relationship was not statistically significant for influenza vaccination. conclusions: we found low levels with of pneumococcal vaccination, and extremely low uptake of influenza vaccination among individuals with high risk conditions in shanghai who should be priority groups targeted for vaccination. interventions could be designed to target groups with low uptake – like younger adults, and individuals who have not yet retired. adults with chronic conditions such as heart disease, diabetes, or lung disease are more likely to develop complications from certain vaccine-preventable diseases, especially pneumonia and influenza. these complications can include long-term illness, hospitalization, and even death [ ] . persons with diabetes or chronic obstructive pulmonary disease (copd) often have immune system impairment sometimes leading to greater morbidity or mortality following infection with influenza compared with healthy adults of the same age. these individuals also have an influenza-related hospitalization and excess mortality rate significantly higher than those without chronic disease [ ] [ ] [ ] . one study showed diabetics had . times higher odds of developing serious complications from the influenza compared to non-diabetics ( % confidence interval (ci): . , . ) [ ] . in one systematic review of avian influenza, people with diabetes had . times the odds of hospitalization with influenza compared to healthy people ( % ci: . , . ) and those with copd had . times ( % ci: . , . ), . times ( % ci: . , . ) and . times ( % ci: . , . ) higher odds of hospitalization, being admitted to the icu, and requirement ventilator assistance, respectively [ ] . several studies have found a benefit of administering pneumococcal polysaccharide and seasonal influenza vaccines to people with chronic illness [ ] [ ] [ ] . simultaneous vaccination of pneumococcus and influenza in elderly copd patients could reduce pneumonia hospitalization by % and overall mortality by % [ ] . influenza vaccination could substantially reduce hospitalization and mortality among diabetic patients and was well tolerated during an influenza season [ ] . the combination of seasonal influenza and pneumococcal vaccine (including valent pneumococcal polysaccharide vaccine (ppsv )) significantly reduced the hospitalization rate and mortality of influenza, pneumonia and other diseases such as respiratory disease, copd and congestive heart failure among the elderly compared to the uptake of influenza or pneumococcal vaccine alone [ , ] . co-administering these vaccines could significantly reduce the rate of intensive care and prolong the survival period of elderly patients with chronic diseases [ ] , and has been shown to be cost-effective [ ] . the elderly and patients with chronic disease including diabetes, copd and heart disease are recommended to be priority groups for pneumococcal and influenza vaccination by the world health organization (who) [ , ] and by the us centers for disease control and prevention (cdc) [ ] . according to chinese guidelines for vaccination, adults with these chronic diseases are recommended to receive the seasonal influenza and ppsv vaccines [ , ] . pneumococcal vaccines (ppsv and -valent pneumococcal conjugate vaccines) are also available to children for a fee. according to the manufacturer's instructions, children and younger adults with certain chronic conditions (cardiovascular disease, lung disease, diabetes, cirrhosis, spleen dysfunction, sickle cell disease, chronic renal failure, organ transplants, hiv, cerebrospinal fluid leakage) or who live in certain environments (individuals in long-term care facilities, staff at welfare organizations) are recommended to get the ppsv vaccine. these recommendations are consistent with global guidelines for prevention and treatment of chronic diseases [ , ] . the governments of some cities in china such as beijing, shenzhen, karamay and xinxiang have published policies providing free influenza vaccination to local elderly residents, while some other cities such as chongqing and ningbo implemented subsidies for the influenza vaccine in medical insurance programs for target residents [ ] . shanghai has implemented a government program providing people over years old with a free pneumococcal vaccination (ppsv ) since , but the influenza vaccine is not offered under the government's expanded program on immunization (epi) and is instead administered for a fee. there is a large population of chronic disease patients in shanghai [ ] , but data about pneumococcal and influenza vaccination coverage among patients with chronic disease is absent. a survey from china found that influenza vaccination was actually lower in adults with highrisk health conditions ( . %) than those without ( . %) [ ] . more information is needed about who gets vaccinated. in this study, we use the data from a chronic disease management information system in shanghai to estimate vaccination coverage and characterize predictors of influenza and pneumococcal vaccination among people with chronic disease in shanghai. we assess whether there are differences in coverage in pneumococcal vaccine and influenza vaccine across age groups, urbanicity and chronic disease diagnoses. we hypothesize that influenza vaccine has lower coverage than pneumococcal vaccine due to differentials in price, that uptake of both vaccines is lower in low age groups compared to high age groups, that uptake of both vaccines is lower in rural areas than in urban areas, and that coverage for both vaccines is higher among those with more chronic diseases. this study used a retrospective cohort design. during july , the data were obtained from three distinct sources -( ) the shanghai chronic disease management information system and ( ) the shanghai immunization program information system which are both housed at the shanghai cdc, and ( ) the hospital record system, which is located at the shanghai health commission for hospital records. the individual's personal id was used to link the three information systems. throughout shanghai, patients ≥ years old diagnosed with hypertension and diabetes are asked if they want to be included in a centralized databasethe chronic disease management information system. inclusion in the database means that the patients will receive more standardized management of their disease. an estimated % of individuals with hypertension and diabetes in shanghai are enrolled in this database. the other % include those who do not know they have a chronic disease, who have not gone to visit the doctor, or who are unwilling to be enrolled into the system. general practitioners follow up with patients every months at community health centers and input data related to these visits into the chronic disease management information system. this database contains information on sex, birthdate, township residence, occupation and diagnostic information pertaining to hypertension and diabetes. no other individual-level information was available from the dataset. all patients from the shanghai chronic disease management information system were included in this study. data in the immunization program information system were captured and entered by vaccination providers at community health care centers. data are uploaded daily from these health centers' electronic registries into the immunization program information system. pneumococcal vaccination information from january to july and influenza vaccination information from the / influenza season were obtained from the shanghai immunization program information system. types and dates of vaccination were extracted from the immunization program information system. the shanghai cdc and the shanghai health commission implement regular data quality checks of the immunization program information system. diagnosis of copd was obtained from the hospital record system. the international classification of diseases (icd) was used to define chronic diseases in the chronic disease management information system and the hospital record system. hypertension was defined as i -i , diabetes was defined as e -e and copd was defined as j . the chronic diseases in this study represent those at risk for pneumococcal disease or influenza [ , ] . the american diabetes association recommends individuals with diabetes to have both vaccines [ ] . the global initiative for chronic obstructive lung disease has similar recommendations for those with copd [ ] . hypertension is not thought to be linked to either disease, but individuals with hypertension were still included because they were in the original chronic disease management information system and because many are older, and thus may be age-eligible for a free ppsv in shanghai. urbanicity was defined by characteristics of the township where participants resided. residency status refers to locals vs. non-locals, with locals defined as registered permanent residents of shanghai, and non-locals as migrants from other cities who have moved into shanghai for over months. urban areas are those where ≤ % of locals and ≤ % of non-locals were engaged in agricultural work; suburban areas had ≤ % of locals but > % of non-locals engaged in agricultural work; and rural areas had > % of locals in agricultural occupations. classification of occupation was defined according to the china national standard [ ] . the main outcome was receipt of pneumococcal and influenza vaccination. vaccination coverage was calculated by sex, age group, urbanicity, occupation, type and number of chronic diseases. pearson's chi-square test was used to compare the vaccination coverage among the different subgroups. we also analyzed the relationship between predictor variables (sex, age group, urbanicity, occupation, type and number of chronic diseases) and the outcomes using logistic regression models through a forward stepwise method (variable included at p-value of . , excluded at p-value of . , with α = . ). data were analyzed using spss version . vaccination status by township was mapped with qgis . (qgis geographic information system. open source geospatial foundation project). the shapefile map was obtained from shanghai surveying and mapping institute (https://www.shsmi.cn/info/ilist.jsp?cat_id= ). the sample of , , patients from the chronic disease management information system included a majority of females ( . %), more individuals above years ( . %) than other age groups, more urban residents than other locales ( . %), and most individuals were retired ( . %). the majority of patients had hypertension ( . %) with fewer diagnosed with diabetes ( . %) and copd ( . %); a very low proportion had been diagnosed with all three ( . %) ( table ) . only . % patients were vaccinated for pneumococcal from january to july , and vaccination coverage of influenza in / influenza season was exceedingly low at . %. vaccination coverage differed significantly across most socio-demographic characteristics. for both pneumonia and influenza vaccinations, coverage was highest in those - years ( . and . %, respectively) compared to other age groups (p < . ). pneumococcal vaccination was highest in rural areas ( . % compared to . % in urban areas, p < . ) whereas influenza vaccination was highest in urban areas ( . % compared to . % in rural areas, p < . ). for both pneumococcal and influenza vaccination, coverage was highest among those with copd ( . and . %, respectively), compared to those with hypertension ( . and . %, respectively) or diabetes ( . and . %, respectively) (p < . , respectively). there was a dose-response relationship between number of chronic diseases and vaccination coverage; pneumococcal vaccination uptake was . % among those with three conditions, compared to . and . % for those with or only condition (p < . ). influenza vaccination coverage was . , . and . % for those with , , or conditions (p < . ). vaccination coverage also varied geographically, with pneumococcal vaccination coverage highest in jiading and songjiang, at the periphery of shanghai, and was relatively low in the inner districts of huangpu, jing'an, hongkou, and yangpu (fig. ) . influenza vaccination coverage was comparatively low across all districts, ranging from . % in fengxian to . % in xuhui. table shows the multivariable logistic regression models. these models are largely in line with the unadjusted results from table . individuals aged - had . times higher odds of pneumococcal vaccine uptake compared to individuals in their s ( % ci: . , . ). individuals in rural areas and suburban area had higher odds of pneumococcal vaccine uptake compared to individuals in urban areas. patients with and chronic diseases had respectively . ( % ci: . , . ) and . ( % ci: . , . ) times higher odds of vaccination compared to patients with chronic disease. all subjects were included in the multivariable analysis. in the adjusted model of influenza vaccination, patients aged - and above had . ( % ci: . , . ) and . ( % ci: . , . ) times higher odds of vaccination, respectively, compared to patients aged - . compared to patients in urban area, patients in suburban and rural areas had, respectively, . ( % ci: . , . ) and . ( % ci: . , . ) times the odds of influenza vaccination. patients with chronic diseases had . times the odds of uptake influenza vaccine compared to patients with kind of chronic disease ( % ci: . , . ), but there was no significant difference in those with vs chronic diseases. patients with a dose of pneumococcal vaccine had . the odds of receiving the influenza vaccine compared to those with no pneumococcal vaccine ( % ci: . , . ). influenza and pneumococcal vaccination are important for preventing illness and the elderly with chronic diseases [ ] [ ] [ ] . in a large sample of individuals with chronic diseases residing in shanghai, china, we found low pneumococcal vaccination coverage over a -year study period and even lower influenza vaccine coverage. uptake of both vaccines increased in those with more chronic diseases and with older age. chronic disease patients should be targeted for attaining high vaccination coverage compared to the remaining population. there are several overriding factors for exceptionally low coverage of pneumococcal and influenza vaccination among chronic disease patients in shanghai community: ( ) studies have found that individuals lack awareness of pneumococcal and influenza vaccine [ , ] , and physicians do not often recommend vaccinations. ( ) vaccination for adults is not convenient. community health care centers were responsible for implementing vaccinations in shanghai. most centers only provide or half days available for adult vaccination per week, while half days are available for childhood vaccination. ( ) some adverse news related to vaccines have made people reduce their trust in vaccination programs [ , ] . people with chronic disease and the elderly should have priority to take these vaccines due to their risk factors, but their chronic diseases may lead them to believe they have a higher risk for adverse reactions. ( ) there is a limited supply of influenza vaccine. these reasons were not assessed in the current study, but could be explored in future research. pneumococcal vaccination coverage among adults - years at increased risk for pneumococcal disease was . % in in the united states although it was much higher at . % among adults over years old [ ] . this is consistent with a study from spain showing a higher proportion of adults over years had received the pneumococcal vaccine ( . %) [ ] and demonstrating that vaccination levels in both young and elderly chronic disease patients in shanghai are substantially lower than those found in the us or spain. because residents over years of age in shanghai are provided with free pneumococcal vaccination, the coverage in this age groups was not surprisingly higher than younger age groups and approaching that seen in those over years in hong kong in ( %) [ ] which also offers free pneumococcal vaccination to the elderly [ ] . in our study, less than % of individuals received an influenza vaccine, which is far lower than in other countries, many of which provide free vaccine through government-sponsored or private insurance programs. similar studies have shown higher influenza vaccination coverage in the united states ( . %, among adults over years, / season) [ ] , uk ( . %, chronic disease patients, / season) [ ] , poland ( . %, chronic disease patients, / season) [ ] , korea ( . %, over years, ) [ ] , and hong kong ( %, over years, ) [ ] . our findings were relatively consistent with prior studies in china showing an average national vaccination coverage ranging between . and . % in and [ ] . the coverage among patients over years was significantly higher vs younger age groups below which was almost non-existent (i.e. close to %). one previous study found that elderly individuals who live with other family members are more likely to get vaccinated [ ] , perhaps as a result of other family members thinking the elderly, but not younger adults, need to get vaccinated or elderly individuals wanting to protect themselves against influenza as they care for their grandchildren. we found that pneumococcal vaccination coverage was higher in rural areas which distinctly contrasted with influenza vaccination coverage which was lowest in rural areas. for influenza vaccinationwhich requires payment, individuals in urban area might be more able to afford the cost of influenza vaccine while patients in rural area might not [ ] . higher pneumococcal vaccination coverage in rural areas may result from individuals trusting health care workers more [ ] . the study showed that patients with multiple chronic diseases would be more likely to take pneumococcal vaccination than those with only one kind of chronic disease. this association could arise for several reasons. individuals may perceive a greater personal risk of disease as they gain experience with more diseases. or individuals with more co-morbid chronic diseases may have had more opportunities to get immunized through having more healthcare encounters. the overall difference in uptake between influenza and pneumococcal vaccination could also be tied back to experiences and risk perceptions, as influenza could be seen as a nuisance disease that will quickly pass [ ] . the lack of funding to influenza vaccination from the government might be another important reason. pneumococcal vaccine uptake was a strong predictor of influenza vaccine uptake, which indicates that acceptance of one vaccine probably predicts for acceptable of others. since the observation of pneumococcal vaccination was from january to july and the observation of influenza vaccination was only / season, co-administration of both pneumococcal and influenza vaccines could reduce the incidence of various complications, hospitalization and mortality of chronic disease [ , , ] . only . % of total sample had taken both pneumococcal and influenza vaccine in / season, lower than that of hospitalized persons aged over years in victoria ( . %) [ ] . our study looked at vaccination coverage for influenza and pneumococcal disease including predictors for vaccination among community members in shanghai with chronic diseases. interventions or policies like government funding as a potential strategy to encourage vaccination, especially influenza vaccination among chronic disease patients, should be implemented. future studies should further examine differences in uptake of vaccines across different demographic groups. there are several strengths and limitations to this study. a strength of this study is the use of several comprehensive information systems as data sources, and the large number of individuals in the chronic disease management system. this system is opt-in for individuals with certain chronic diseases in the municipality, and an estimated % of individuals with chronic disease participate in it. it is possible that the individuals who participate in the chronic disease management system differ from those who do not. non-participants, for example, likely have lower health-seeking behaviors and so our estimates of vaccination coverage may overestimate trends in the entire population of those with these chronic diseases. future studies could evaluate why and how individuals participate in this database. in addition, limitations include a lack of information on key variables, like education and income. we only have data of pneumococcal vaccination coverage from onward and season of influenza vaccination coverage, and inclusion of additional years would have permitted analysis of trends over time. the very low vaccination coverage, particularly for influenza vaccination, limits our ability to make recommendations beyond a general recommendation to increase coverage. we found very low levels of both pneumococcal and influenza vaccination among individuals with chronic diseases residing in shanghai. these individuals should be prioritized for vaccination with both vaccines. concomitantly, there can be greater ease of access to vaccines, and promotional materials can focus on complications of disease in those with high risk conditions. clinical evaluation of chinese guidelines for community-acquired pneumonia the influence of chronic illnesses on the incidence of invasive pneumococcal disease in adults diabetes and the severity of pandemic influenza a (h n ) infection chronic obstructive pulmonary disease in the absence of chronic bronchitis in china clinical courses and outcomes of hospitalized adult patients with seasonal influenza in korea populations at risk for severe or complicated avian influenza h n : a systematic review and meta-analysis influenza vaccination of elderly persons: reduction in pneumonia and influenza hospitalizations and deaths the additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease influenza vaccine for patients with 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vaccination policy of influenza in beijing, china: the vaccine coverage and its associated factors cross-cultural perspectives on the common cold: data from five populations influenza and pneumococcal vaccine coverage among a random sample of hospitalised persons aged years or more springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we appreciate the work of vaccination providers and primary care physicians in the city of shanghai who contributed data and who work on improving the health of populations with chronic diseases. authors' contributions yw conceived of the study, analyzed the data, and wrote the first draft. mc and cf contributed to study conception revised the manuscript for intellectual content. sw, and fw contributed to data analysis and revised the manuscript for intellectual content. qy , qy , yl, and xg contributed to acquiring data and revised the manuscript for intellectual content. ys, aw, and mb contributed to interpreting the data and revising the manuscript for intellectual content. all authors gave final approval for the study to be published. research was supported by the chinese association of preventive medicine (grant # to yan shi) and the shanghai health commission (grant # to yuheng wang). the funding body had no role in the design of the study and collection, analysis, or interpretation of data. the datasets analyzed for the current study are not publicly available because they contain detailed medical histories of chronic patients, but are available from the corresponding author on reasonable request. the protocol for this research was approved by the ethical review board of the shanghai municipal center for disease control and prevention (scdc). informed consent was exempted because it was limited to analysis of previously de-identified data collected for medical and public health surveillance purposes. not applicable. the authors declare that they have no competing interests. key: cord- -n odrlvk authors: osbjer, kristina; boqvist, sofia; sokerya, seng; kannarath, chheng; san, sorn; davun, holl; magnusson, ulf title: household practices related to disease transmission between animals and humans in rural cambodia date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: n odrlvk background: zoonotic diseases are disproportionately affecting poor societies in low-income countries and pose a growing threat to public health and global food security. rural cambodian households may face an increased likelihood of exposure to zoonotic diseases as people there live in close association with livestock. the objectives of the study was to identify practices known to influence zoonosis transmission in rural cambodian households and relate the practices to agro-ecological region, socio-economic position, demographics, livestock management and zoonosis awareness. methods: the study was conducted in three different agro-ecological regions of cambodia; villages each in the central lowlands, north-west wetlands and on the south coast, where information was obtained in questionnaires administered to households, and village heads and animal health workers. results: descriptive analysis revealed a gender difference in responsibility for livestock and that the main purpose of raising livestock was for sale. few respondents ( %) perceived a likelihood of disease transmission in their village between livestock, humans and wildlife, despite household practices related to zoonosis transmission being common. more than one-forth of households practised behaviours such as culling sick animals for consumption, eating animals found dead and allowing animals to enter sleeping and food preparation areas. associations between household practices and possible explanatory factors were analysed with multivariable models using generalised estimation equations to account for clustering of practices within villages. factors found to influence household practices were agro-ecological region, socio-economic position, number of people in the household, livestock species reared and awareness of zoonoses. conclusions: cambodia has experienced numerous fatal human cases of zoonotic influenza and extensive influenza information campaigns have been run, yet only a few of the households surveyed here reported the threat of zoonosis to be a concern in their village. zoonosis awareness was positively related to hand washing behaviour, but other practices associated with an increased or decreased likelihood of exposure to zoonotic pathogens were unaffected by awareness. the findings indicate a knowledge-to-action gap among rural farmers and highlight the necessity for reconstructed interventions in zoonotic disease control. electronic supplementary material: the online version of this article (doi: . /s - - - ) contains supplementary material, which is available to authorized users. zoonotic diseases, naturally transmissible between animals and humans, make up more than % of emerging infectious diseases (eids) in humans [ ] and are regarded as posing a growing threat to public health and global food security [ ] . zoonotic diseases are estimated to cause about a billion cases of illness in people and millions of deaths every year and disproportionally affect low-income countries, with the poorest within society affected the most [ ] . the true public health and economic impact of zoonotic diseases are most likely underestimated, mainly due to under-reporting of disease events [ ] . southeast asia has been identified as a hotspot for eids, in particular zoonotic diseases, as a result of many factors, including population growth, urbanisation, political and social disruption, agriculture and livestock intensification, deforestation, and climate change [ ] . the region has seen the emergence of several recent epidemics, such as severe acute respiratory syndrome (sars), highly pathogenic avian influenza h n and pandemic influenza a (h n / ) [ , ] . cambodia, which is among the poorest countries in southeast asia, has a population of million, with % living in rural areas [ ] . resource-scarce smallholder farmers represent the majority of agricultural producers [ ] and livestock are traditionally raised in a mixed farming system [ ] . close interaction between livestock and humans is enabled by free ranging poultry and livestock pens bordering the house, allowing animals to access cooking and sleeping areas. in these households access to health and veterinary services is limited and household practices associated with an increased likelihood of exposure to zoonotic pathogens are frequent [ ] . one study in cambodia showed that inadequate hand washing and slaughtering of poultry were risk factors for h n virus infection in humans [ ] . other studies in several countries have found that consumption of undercooked meat is a major risk factor for human infection with toxoplasma gondii [ ] , while a study in canada identified associations between zoonotic disease transmission and feeding animals raw meat [ ] . several factors affecting household practices have been identified. these include risk perception, agro-ecological conditions [ ] , household demographics [ ] , cultural aspects [ ] , level of education and socio-economic position of the household [ ] . there is, however, a need for a thorough understanding about these factors and how they are interrelated. such knowledge can guide extension services in achieving more effective zoonosis control. the objective of the study, which was carried out in cambodia, was to identify practices known to influence zoonosis transmission in rural households and relate these practices to the agro-ecological region, socio-economic position, demographics, livestock management and zoonosis awareness. the study involved three out of cambodia's four agroecological regions, to cover possible differences in climate, farming traditions and culture. these regions were: kampong cham province, a lowland area characterised by fertile cultivated plains close to the mekong river; battambang province, characterised by immense wetlands resulting from flooding which have substantial biological diversity and border lake tonle sap [ ] ; and kampot province, a coastal area dependent on fish and containing the wildlife-rich preah monivong bokor national park ( figure ). data were collected on days per region, with kampong cham province visited in may , battambang province in july and kampot province in march . in each region, villages were included and each village was visited for one full day. the number of villages was decided based on practical and economic considerations for sample collections as this study formed part of a larger research project on zoonotic diseases. selected villages were those best meeting the following three criteria: the village had to be situated within km from a main road; it had to have various species of livestock; and there had to be interactions between humans, domestic animals and wildlife. within each village, the households keeping as many different livestock species as possible according to the village animal health worker and village head were selected as a purposive sample. a total of villages and households in the three regions were included. the target number of households was calculated based on requirements for the larger research project on zoonotic diseases and was based on sample size for expected disease prevalence, with addition of % to adjust for possible confounding and interaction in the statistical modelling [ ] . the number of households included also ensured that the minimum requirements for "qualitative health research" were met [ ] . geographical position at the central point of the villages included in the study was recorded using a handheld global positioning system (gps; garmin etrex h). two questionnaires were developed: i) a village questionnaire targeted at the village head and animal health worker, with questions on development support and livestock management; and ii) a household questionnaire, targeted at the female head of the household, with questions on household practices related to zoonosis transmission (table ) , as well as socio-economic position, demographics, livestock management and zoonosis awareness. the household questionnaire targeted the female head, as women are traditionally, and to a larger extent than men, responsible for day-to-day household duties and subsistence farming in cambodia [ ] . the questionnaires, which each took around minutes to complete, consisted of open, closed and semi-closed questions (two-choice and ranking questions), with some probing questions to clarify the answers. the questionnaires were pre-tested in two villages in a non-participating province and adjusted according to input before the study began. the household questionnaire also included validation questions, which allowed questionnaires to be checked for internal consistency. the households and villages included were allocated a code. interviews were conducted in khmer and all data were checked for accuracy by the team leader. prior to the interviews, village heads and participating household members were informed about the study per se, that participation was voluntary and that their identity should not be disclosed. people selected for an interview were asked for verbal consent before the interviews were conducted, and were given a project t-shirt and bar of soap at the end, as a thank you for their involvement. each village was visited by a survey team that entailed - members and was led by the author ko. the team consisted of staff from the national veterinary research institute in phnom penh; final year students from the preak leap national school of agriculture, phnom penh, and the royal university of agriculture, phnom penh; and district and commune livestock officers in the study regions. the team was trained for one full day prior to the field work to ensure that the questionnaires and the aims of the study were fully understood. the questionnaires are provided as additional files. the village questionnaire (additional file ): zoonoses in humans and livestock in rural cambodia -village questionnaire) and the household questionnaire (additional file : zoonoses in humans and livestock in rural cambodia -household questionnaire). each village that participated in the study had ongoing externally supported development projects. in kampong cham province, different development projects supporting livestock management and human health improvements were reported as ongoing. battambang and kampot provinces each had five different development projects ongoing supporting livestock management and human health improvements. the projects were run by the cambodian government, international organisations and non-government organisations. the reported ongoing projects were of similar size and type in the three regions. a wealth index based on household land ownership, household dwelling and household ownership of consumer durables was calculated to define the socio-economic position of participating households [ ] . this was done by collecting information on eight self-reported household belongings (table ) . households with the listed belongings were given a score of one for each of the eight belongings. to get a final indicator each belonging was then multiplied by a weighting factor of - . the weighting factor was based on previous research in the region where housing construction and access to safe water was identified as more closely linked to the socio-economic position of the household than ownership of livestock and consumer durables [ , ] . the final wealth index was calculated as the sum of all indicators with a maximum score of . data collected were independently translated by two translators from khmer into english and compared for consistency before being transcribed into spreadsheets in microsoft office excel . statistical analysis was performed in sas for windows . (sas institute inc., cary, nc). descriptive statistics were calculated to define demographic characteristics and livestock management. a one-way analysis of variance (anova) was used to test the difference in means of the wealth index between regions. spearman's rank correlation coefficient was used as an exploratory tool to test putative relationships between household practices and agro-ecological region, socio-economic position, number of people in the household, number and species of livestock reared in the household, and awareness of zoonoses. all variables were further analysed by a multivariable logistic regression analysis using generalised estimation equations to account for clustering of practices within villages. models were built to investigate associations between household practices related to zoonosis transmission and possible explanatory factors selected on the basis of prior knowledge of possible confounders and potential influence on household practices. one model was built for each of the household practices, with the practices as interchanging response variables against all the explanatory household factors: agro-ecological region; socio-economic position; number of people in the household; whether there were children in the household; number of chickens, ducks, other avian species, pigs, cattle and buffalo; whether the respondent knew of any zoonotic diseases; and whether the respondent perceived a likelihood of zoonoses in the village. village was added to all models for the working correlation of the generalised estimating equations analysis to account for clustering of repeated measures within village, as nested within region. all models were applied using backward removal of variables with a p-value of ≤ . , with this higher p-value chosen to avoid early exclusion of variables that might influence the model [ ] . manual backward step-down selection was then applied at a p-value of ≤ . . confounding was controlled for by including omitted variables that changed the estimate of the other variables by more than %. two-way interactions between all explanatory factors were investigated. the statistical significance level was defined as a two-tailed p-value ≤ . . qgis . . software was used to map the distribution of villages in © openstreetmap contributors (openstreetmap.org). ethical approval ( nechr, th april ) was obtained prior to the survey from the national ethics committee for health research, ministry of health in cambodia, and an advisory ethical statement (dnr / ) was obtained from the regional board for research ethics in uppsala, sweden. the median household size in the households investigated was . (range - ), with a mean of . (standard deviation (sd) . ), where a household was defined as a group of people making common arrangements for food and shelter. the mean wealth index for the three regions was . (sd . ) in kampong cham, . (sd . ) in battambang and . (sd . ) in kampot. the difference in mean wealth index between the regions was significant (p = . ), with kampot province showing the widest range of index scores (figure ). the village-level questionnaires indicated that % of all households in the villages surveyed raised poultry (chicken and ducks), while % had pigs and % ruminants (cattle and buffalo). of the households that were actually visited in the study, ( %) raised livestock. the four households without livestock were situated in kampong cham province and had recently lost or sold their livestock. participating households in kampot province raised more livestock than households in the other two provinces: % raised chickens, % pigs and % cattle ( table ). in kampong cham province, buffalo were more common, being present in % of households compared with % of the households in kampot province and in none of the households in battambang province. poultry were in general raised in larger numbers than cattle, pigs and buffalo. the livestock housing system differed between livestock species. pigs were raised in a free range system by % ( / ) of the households who kept pigs, while % ( / ) and % ( / ) of the households with poultry and ruminants, respectively, raised them entirely free ranging or free ranging and confined combined. the responsibility for poultry, pigs and ruminants was shared between women, men and children in about % of the households (table ). in the remaining households, women took more responsibility for poultry and pigs and men for ruminants. the most common reasons for raising poultry were reported as sale and family consumption ( table ). the main purpose of raising pigs and ruminants was sale, to earn an income. only % of households regarded disease transmission between livestock, humans and wildlife as likely within their village, although % knew of a disease transmissible between animals and humans. avian influenza was mentioned as a zoonosis by % of all households and swine influenza, diarrhoea, tuberculosis or rabies were also mentioned, each by less than % of households. each of the household practices presented in table : self-reported household practices by province in three different agro-ecological regions, were analysed in a separate model for associations with potential explanatory household factors and confounders. all response variables except eating undercooked meat, and capturing and slaughtering wild animals for consumption were associated with at least one explanatory factor. models with significant associations between household practices and explanatory factors are presented in table . feeding animals uncooked slaughter waste was associated with region. this practice was also more frequently reported in households where the respondent knew of a zoonosis and where they perceived a likelihood of zoonosis transmission between wildlife, livestock and humans in the village. eating animals found dead was associated with region. the factor number of buffaloes was not significantly associated with the practice to eat animals found dead, but was correlated to province (p = . ) and changed the model estimate by more than % when removed from the model, suggesting that number of buffaloes was a confounder in the model. washing hands before and after cooking was associated with region and was more commonly reported in households where the respondent knew of any zoonosis. the related practice of washing hands with soap after handling live animals was also associated with region and was similarly increased in households where the respondent knew of any zoonosis. keeping animals away from sleeping and food preparation areas was associated with region and was more common in households with a lower wealth index. burning or burying meat waste products was associated with a higher number of people in the household. daily collection of manure indoors and outdoors was associated with households rearing more cattle. finally, the practice of slaughtering domestic animals was associated with region and was found to be more common in households with a higher number of people, rearing more chickens and in households where the respondent knew of any zoonosis. no significant interactions or correlations, apart from the one presented, were found between the explanatory factors. understanding the factors governing transmission of zoonoses in rural southeast asian settings is important given the regional zoonosis emergence. this study showed that despite knowledge of zoonoses, few respondents in the rural cambodian households surveyed perceived a likelihood of disease transmission between livestock, humans and wildlife in their village and many households carried out practices associated with an increased likelihood of exposure to zoonotic pathogens. the study also identified associations between household practices linked to zoonosis transmission and the household's agro-ecological region, socio-economic position, number of people in the household, species and numbers of livestock reared and zoonosis awareness. lastly was a clear gender division in responsibility for livestock found and a divergence was observed in the purpose behind rearing different livestock species. household practices analysed in this study were selected from previously described practices related to zoonosis transmission with the aim of covering various table association between the response variable household practice and the explanatory factors: agro-ecological region, socio-economic position , number of people in the household , number and species of livestock reared , and zoonosis awareness (n = ) transmission routes for pathogens known to pass between humans, livestock and wildlife in low-biosecurity backyard farming systems [ , , [ ] [ ] [ ] . information on occurrence of household practices was obtained through self-reporting, which is less intrusive than structured observation and can be carried out with a single household visit. while being well aware of the possibilities for underreporting of hazardous behaviour and over-reporting of good hygiene practices due to intentionally or unintentionally perceived desirable responses, we opted for the self-reporting methodology to enable inclusion of a larger number of households [ , ] . validation questions on household practices were included in the household questionnaire as a precaution to minimise bias. replies to ordinary questions and validation queries matched well, confirming the legitimacy of responses. we found the household practice of burning or burying meat waste products to be associated with a higher number of people in the households which possibly could be explained by the need, in crowded households, to effectively dispose of a larger volume of household waste. the socio-economic position has in other studies been shown to influence precautionary household practices as a better economic condition allows upgrading of housing, sanitation and purchase of hygiene products [ , ] . such associations were in our study not found. instead was the practice of chasing animals away from sleeping and food preparation areas associated with a lower wealth index. a possible explanation could be that animals easily can enter cooking and sleeping areas in poor households with an open housing construction. households with a lower wealth index will thus actively have to chase away animals while in the wealthier households the more solid housing construction used will keep animals out. the practice of chasing animals away from sleeping and food preparation areas was also associated with the agro-ecological region of the household. the regional associations identified for most of the household practices studied here may partly be explained by the different farming challenges deriving from climatic and physical conditions in the different agro-ecological regions. the results presented here, however, are likely to move beyond agro-ecology and, among other factors, also depend upon regional differences in socio-economic opportunities and development support. we believe that one explanation to the high average wealth index in kampong cham might be that the villages in that province had more than twice as many development support projects ongoing. regional differences in the households' socio-economic position could not, however uniformly explain the differences in practices between regions. households in kampong cham province had the highest average wealth index, but precautionary household practices were not reported more frequently there than in the other two regions. in all, % of the respondents in this study mentioned avian influenza as a disease transmissible between animals and humans. awareness of avian influenza can possibly be explained by the nation-wide influenza awareness activities and development support in cambodia, resembling those reported in the study villages. remarkably, the threat of zoonoses was not reported to be a concern for the households surveyed and only a small proportion of the respondents considered disease transmission between livestock, humans and wildlife to be likely in their village. these results should be seen in the light of poultry outbreaks and confirmed human cases of highly pathogenic avian influenza (h n ) reported from cambodia between and [ , ] . influenza information campaigns have been regularly run in cambodia since and several studies have reported raised awareness of human-animal disease transmission among the rural population. despite this, practices associated with zoonosis transmission persist [ ] [ ] [ ] . thus messages provided on disease control apparently only partially penetrate to the level of farm practices. previous studies have revealed that simply increasing farmers' knowledge is insufficient to change farmers' behaviour [ ] . in this study we showed that more than % of the households practised behaviours such as culling sick animals for consumption, eating animals found dead and allowing animals to enter sleeping and food preparation areas. a positive effect of zoonosis knowledge was associated with the practice of washing hands before cooking and after handling live animals, yet a contrasting association was found for some other practices. feeding animals uncooked slaughter waste and carrying out slaughter was increased in households where the respondent had knowledge of zoonoses. in line with other studies in the region, our results indicate a knowledge-to-action gap [ , ] . some understanding of the rationale behind practices may be found in the theory of planned behaviour [ ] . it suggests that attitudes towards behaviours and subjective norms are among key components determining behaviour and that both attitude and norms are influenced by various background factors. in this study, apart from zoonosis awareness and socio-economic position, such factors were identified as being: agro-ecological region of the household, household size and livestock species reared. larger households and households with a greater number of chickens were more likely to carry out slaughter, while daily collection of manure was increased in households with cattle. livestock management is known to be a key contributor to food security and nutrition in rural settings, but poor control of zoonoses poses a threat to human health and to livestock productivity [ , ] . when discussing risk mitigation and preventive measures for zoonotic diseases, it is important to understand the characteristics of rural livestock production, such as purpose and gender roles. here we found that while ruminants play an important role in producing draught power and poultry are often kept for family consumption, the predominant purpose of raising poultry, pigs and ruminants was sale. women took the main responsibility for the homestead species (poultry and pigs) and men for ruminants, which is a common division of labour in low-income countries [ , ] . other studies have shown that decisions regarding household practices may not be evenly distributed between women and men [ ] . thus understanding and considering gender dynamics within the household should be a primary consideration in the development of zoonosis control programmes. interventions may also be directed towards certain target groups depending on livestock species and their contribution to livelihoods. households were selected for inclusion in this study based on a set of criteria rather than random sampling. caution is needed when generalising the results to the rural cambodian population, as the selection was based on households with many different livestock species in easy accessible parts of three agro-ecological regions. this sampling method may have resulted in a selection bias. we believe, however, that our sample can serve as an approximation of a population-based design for species-diverse households, as the study involved a considerable number of households in different villages. the study targeted female heads of the households, which may have influenced some of the responses and caused a bias towards homestead livestock species, which are traditionally cared for by women. the emphasis on women may also be reflected in the level of zoonosis awareness, as illiteracy is more prevalent in women and extension activities tend to have been targeted towards men in the past [ , ] . we also considered possible confounders due to seasonal variations, as data were collected during the hot season (may and march) in kampong cham and kampot province and during the rainy season (july) in battambang province. seasonal differences, however, are likely to have had a minor impact on the results presented. cambodia has experienced numerous fatal human cases of zoonotic influenza (h n /h n ) and extensive influenza information campaigns have been run, yet only a few of the households surveyed here reported the threat of zoonosis to be a concern in their village and household practices linked with zoonotic disease transmission were common. agro-ecological region, socio-economic position, livestock species reared and zoonosis awareness were factors found to be associated with household practices. zoonosis awareness was positively related to hand washing behaviour, but other practices associated with an increased or decreased likelihood of exposure to zoonotic pathogens were unaffected by awareness. the findings indicate a knowledge-to-action gap among rural farmers and highlight the necessity for reconstructed interventions in zoonotic disease control. global trends in emerging infectious diseases ecology of zoonoses: natural and unnatural histories mapping of poverty and likely zoonoses hotspots. uk: in report to department for international development the multiple burdens of zoonotic disease and an ecohealth approach to their assessment emerging infectious diseases in southeast asia: regional challenges to control canberra: 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is it influenced by the social characteristics of the population and the presence of taenia asiatica exploring the gap between hand washing knowledge and practices in bangladesh: a cross-sectional comparative study natural resources management for human security in cambodia's tonle sap biosphere reserve veterinary epidemiologic research: avc incorporated determining sample size roles and rights: gender, participation and community fisheries management in cambodia's tonle sap region estimating wealth effects without expenditure data-or tears: an application to educational enrollments in states of india comparison of health-seeking behaviour between poor and better-off people after health sector reform in cambodia economic inequality and undernutrition in women: multilevel analysis of individual, household, and community levels in cambodia confounder selection in environmental epidemiology: assessment of health effects of prenatal mercury exposure use of personal protective measures by thai households in areas with avian influenza outbreaks development and delivery of evidence-based messages to reduce the risk of zoonoses in hygiene behaviour in rural nicaragua in relation to diarrhoea reactivity and repeatability of hygiene behaviour: structured observations from burkina faso comparing the performance of indicators of hand-washing practices in rural indian households risk factors for acute diarrhoea among inhabitants of kampala district outbreaks of highly pathogenic avian influenza (subtype h n ) in poultry notified to the oie * from the end of cumulative number of confirmed human cases for avian influenza a (h n ) reported to who bridging the gap between hpai 'awareness' and practice in cambodia: recommendations from an anthropological participatory assessment. in: emergency centre for transboundary animal disease (ectad), fao regional office for asia and the pacific knowledge, attitudes and practices towards avian influenza a (h n ) among cambodian women: a cross sectional study interaction between humans and poultry, rural cambodia pig farmers' perceptions, attitudes, influences and management of information in the decision-making process for disease control the theory of planned behaviour: reactions and reflections a community-based education trial to improve backyard poultry biosecurity in rural cambodia invited review: role of livestock in human nutrition and health for poverty reduction in developing countries national gender profile in agricultural households. report based on the cambodia socio-economic survey. food and agriculture organization of the united nations, and national institute of statistics/ministry of planning gender issues in livestock production: a case study of zimbabwe are agricultural extension programs gender sensitive? cases from cambodia we thank the cambodian families who participated in the study. we also extend our thanks to the commune, district and provincial veterinarians in participating regions for assistance during the field work and to the invaluable field teams for collection of data. the work was financially supported by the swedish civil contingencies agency (msb) and the swedish international development cooperation agency (sida), sweden. additional file : zoonoses in humans and livestock in rural cambodia -village questionnaire.additional file : zoonoses in humans and livestock in rural cambodia -household questionnaire. the authors declare that they have no competing interests.author's contributions ko designed the questionnaires, led the fieldwork, analysed the data and drafted the manuscript. sb and um contributed to the concept, design and analysis of the study, including critical revision of the manuscript. sso contributed to the design, translation, fieldwork and analysis of the study. ck, ssa and hd participated in the translation, design and coordination of the study. all authors have read and approved the final manuscript.submit your next manuscript to biomed central and take full advantage of: key: cord- -cp qr f authors: matsuyama, ryota; nishiura, hiroshi; kutsuna, satoshi; hayakawa, kayoko; ohmagari, norio title: clinical determinants of the severity of middle east respiratory syndrome (mers): a systematic review and meta-analysis date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: cp qr f background: while the risk of severe complications of middle east respiratory syndrome (mers) and its determinants have been explored in previous studies, a systematic analysis of published articles with different designs and populations has yet to be conducted. the present study aimed to systematically review the risk of death associated with mers as well as risk factors for associated complications. methods: pubmed and web of science databases were searched for clinical and epidemiological studies on confirmed cases of mers. eligible articles reported clinical outcomes, especially severe complications or death associated with mers. risks of admission to intensive care unit (icu), mechanical ventilation and death were estimated. subsequently, potential associations between mers-associated death and age, sex, underlying medical conditions and study design were explored. results: a total of eligible articles were identified. the case fatality risk ranged from . to %, with the pooled estimate at . %. the risks of icu admission and mechanical ventilation ranged from . to % and from . to %, with pooled estimates at . and . %, respectively. these risks showed a substantial heterogeneity among the identified studies, and appeared to be the highest in case studies focusing on icu cases. we identified older age, male sex and underlying medical conditions, including diabetes mellitus, renal disease, respiratory disease, heart disease and hypertension, as clinical predictors of death associated with mers. in icu case studies, the expected odds ratios (or) of death among patients with underlying heart disease or renal disease to patients without such comorbidities were . ( % confidence interval (ci): . , . ) and . ( % ci: . , . ), respectively, while the ors were . ( % ci: . , . ) and . ( % ci: . , . ), respectively, in studies with other types of designs. conclusions: the heterogeneity for the risk of death and severe manifestations was substantially high among the studies, and varying study designs was one of the underlying reasons for this heterogeneity. a statistical estimation of the risk of mers death and identification of risk factors must be conducted, particularly considering the study design and potential biases associated with case detection and diagnosis. electronic supplementary material: the online version of this article (doi: . /s - - - ) contains supplementary material, which is available to authorized users. cases of middle east respiratory syndrome (mers), caused by mers-associated coronavirus (mers-cov), have continuously been reported since june . as of june , the total number of laboratory-confirmed cases notified to the world health organization (who) reached , cases, including deaths [ ] . particularly large outbreaks of mers-cov infection have been reported in the kingdom of saudi arabia (ksa) and the republic of korea (rok), while smaller outbreaks and importation events have been reported in other countries [ ] . of these, countries are located in the middle east, countries in europe, countries in africa, countries in southeast and east asia, and in north america (the united states of america) [ ] [ ] [ ] . because of the regular reporting of mers cases in the middle east, countries across the world are now facing a continuous threat of mers outbreak. to understand the clinical burden of mers, it is necessary to quantify the risk of developing severe clinical manifestations. the case fatality risk (cfr) is a measure of the risk of death among those who satisfy the case condition [ ] , while risks of admission to an intensive care unit (icu) and that of requiring mechanical ventilation are also useful to measure the extent of developing severe mers complications. however, it is not only necessary to estimate such risks, but it is also critically important to identify epidemiological determinants of those risks to then predict the risk of severe complications for each patient before the onset of disease exacerbation [ ] . in previous studies, the risk of death among secondary cases was estimated based on statistical modelling and was found to range from to %, approximately [ ] [ ] [ ] [ ] [ ] . meanwhile, among the primary cases, the risk of death was estimated to be greater at approximately %, perhaps because of biases associated with case detection and diagnosis [ ] [ ] [ ] . as for epidemiological determinants of mers death, elderly patients with underlying comorbidities have been identified as the most susceptible population with a high risk of death [ , , ] . despite our further understanding of the risk of developing severe mers, the abovementioned estimates are mostly based on a subset of mers cases; for instance, some of the risk estimates are a result of the analysis of cases diagnosed in in the rok or ksa alone. published articles with different study designs and populations have yielded different estimates and effect sizes associated with mers death. because of this variability, it is valuable to comprehensively and systematically analyze published mers studies that have recorded the clinical prognoses of cases. a systematic review is a highly informative review method that combines published results from different studies, thereby merging and contrasting results across multiple studies and answering study questions using the pooled estimates [ ] . thus, we aimed to perform a systematic review to assess risks of death and other severe complications and determine the risk factors for mers-associated death and contrast these results by study population and study design. the present study was a systematic review conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (prisma) statement [ ] . pico statement: our study question is focused on laboratory confirmed cases of mers regardless of their treatment status, and thus, involves only retrospective observational studies, measuring their risks of admission to intensive care unit (icu) and death and comparing those risks by age, gender and underlying comorbidities. our systematic review protocol is summarized as additional file . published studies that referred to the clinical prognosis of mers cases were retrieved from medline (pubmed) and web of science electronic databases on may . the following search terms were used in "all fields" to identify relevant published articles: . "mers" or "middle east respiratory syndrome" or "novel coronavirus" or "novel coronavirus " . "sever*"or "fatal*"or "death" or "mortalit*" . "hospitalization" or "intensive care" or "icu" . and and we limited the search to articles published between april (i.e., after the first mers case was reported) and june . additional studies reporting associated outcomes that were not identified by the abovementioned search strategy were manually retrieved by tracking the references of included articles (i.e., ancestry and discordancy approach). we restricted ourselves to publications written in english. all titles identified by the abovementioned search strategy were independently screened by two authors (rm and hn). abstracts of potentially relevant articles were subsequently reviewed for eligibility, and if a description of severe or lethal mers was available, articles were selected for closer examination of the full text. to be eligible for inclusion, published studies were required to meet the following characteristics: (i) studies focused on patients infected with mers-cov and (ii) explicitly documenting clinical outcomes (i.e., prognosis) and characteristics of both surviving and deceased patients. studies that allowed us to stratify the risk of severe or fatal mers by demographic or medical condition were preferred, but this was not an essential inclusion criterion. to calculate the risk of severe mers or mers death, we excluded case reports that documented only one or two cases (i.e., case reports with a sample size n ≥ were eligible). included studies were further classified into five groups based on the study design and population studied: (i) case reports comprising published studies that described the clinical course of individual patients including mild cases; (ii) studies including only icu cases (hereafter referred to as icu studies): case reports or retrospective studies that reported outcomes of patients admitted to the icu only; (iii) hospital studies: retrospective or descriptive studies that aimed to document the outbreak in a hospital or healthcare-associated facility; (iv) retrospective studies: published studies that retrospectively analyzed the series of mers cases that were registered in the patient database or tracked medical records; and (v) surveillance studies: published studies that extracted data from a database of cases, systematically gathering epidemiological data, as coordinated by a country or who. the primary data extracted were the proportions of deceased mers patients, patients admitted to the icu and patients undergoing mechanical ventilation. all of these outcomes were dealt with as dichotomous variables, and thus, we calculated the % confidence interval (ci) for each included study using the binomial distribution. whenever possible, we stratified the risk of death by age, sex, underlying medical condition and study design. for the analysis of the effect of each covariate on the outcome, the odds ratio (or) for death among those with underlying conditions was calculated and compared with those without comorbidities. stratified analysis could not have been made for the proportions of icu admission and mechanical ventilation because the dataset of such covariates was not commonly available for these two outcomes. we employed a fixed effects inverse variance weighted model. weighted means (i.e. pooled estimate) of the abovementioned proportions and the or for death by each covariate were calculated using the inverse of variance estimates from each study. the heterogeneity among identified studies was statistically assessed by the i statistic. to explore the possible sources of heterogeneity, we stratified pooled estimates by study design. a forest plot was used to illustrate the distribution of the outcome and effect size obtained from each published study. the flow diagram of the search and study selection process is shown in fig. . among a total of potentially relevant articles, and articles were excluded by screening of the titles and abstracts, respectively. one article was excluded by full-text screening. following the same process for additional manually identified articles, a total of articles were selected as eligible articles [ , and all were subject to meta-analysis. of these, four studies were classified as case reports, four as reports of icu cases, four as hospital outbreak studies, eight as retrospective studies and five as surveillance study. the majority of included articles were reported either from the ksa or the rok, except for one study conducted in jordan [ ] and the who the estimated cfr was reported in articles, ranging from . to % (fig. ) . the pooled cfr was . % ( % ci: . , . ), but the i was as large as . %. the sample size of case reports ranged from to , while studies with other designs tended to have larger samples, with or more cases, except for one icu study, one retrospective study and one hospital outbreak study. the proportions of icu admission and mechanical ventilation among all cases were available in and articles, respectively. the proportion of icu admission ranged from . to % with the pooled estimate at . % ( % ci: . , . ) and an i value of . %. the proportion of mechanical ventilation ranged from . to % with the pooled estimate at . % ( % ci: . , . ) and an i value of . %. [ ] age and sex distributions are shown in relation to the risk of death by mers in fig. . in the majority of the studies (except for a study from jordan), survivors were younger than those who died of mers. although not generally, infected men tended to die more often than women, and the pooled or of death among men compared with women was . ( % ci: . , . ). the i value of the sex difference for the risk of death was . %. the risks of death, icu admission and mechanical ventilation were stratified by study design and are shown in fig. , in which the pooled estimate for each study design was compared. the risk of death in the hospital outbreak and surveillance studies was significantly smaller than in icu case and retrospective studies. risks of icu admission and mechanical ventilation were the highest among icu case studies, followed by case report and retrospective studies. hospital outbreak studies yielded the smallest pooled risks of icu admission and mechanical ventilation. when comparing surveillancebased data between ksa and rok (fig. ) , the risk of death in rok (i.e., . - . % [ , , ] ) tended to be lower than that in ksa (i.e., . % by alsahafi and cheng [ ] ), perhaps reflecting the presence of the contact tracing effort in the rok. figure shows the possible association between five selected underlying medical conditions and the risk of death by mers. pooled estimates of the or were greater than the value of for all five comorbidities, including diabetes mellitus (n = studies), renal disease ( studies), respiratory disease ( studies), heart disease ( studies) and hypertension ( studies). among a total of five predictors, heart disease yielded the greatest or value at . ( % ci: . , . ) followed by respiratory disease with an or of . ( % ci: . , . ). figure shows the potential association between the risk of death by mers and potential predictors, including sex, heart disease and renal disease. men from icu studies tended to yield a greater or for death compared with other study designs. conversely, expected values of ors for death among those with heart disease and renal disease compared with those without appeared to be lower than the value of . . the present study systematically reviewed the risk of severe manifestations and death by mers by systematically searching and analyzing published articles from the ksa and the rok and calculating not only the cfr but [ ] . icu represents intensive care unit also the risks of icu admission and requiring mechanical ventilation. several clinical predictors of death were identified including older age, male sex and underlying medical conditions, including diabetes mellitus, renal disease, respiratory disease, heart disease and hypertension. the risk estimate appeared to vary by study design. in particular, studies focusing on patients in the icu yielded the greatest estimates, while the cfrs for surveillance and hospital outbreak studies were smaller. these findings indicate that ascertainment biases in surveillance and hospital outbreak studies, frequently involving case finding effort, were smaller than in other types of studies. the importance of case finding effort is likely reflected in the different cfr estimates based on surveillance data between ksa and rok. although the presently identified clinical predictors are in line with previously published studies [ , , ] , the present study is the first to systematically analyze published studies, including clinical research studies, and extract findings that echo those of published articles. as was observed in this study, systematic search and analysis of the transmission characteristics [ ] and spatial spreading patterns of mers [ ] have been successful. an important contribution of the present study is that we demonstrated that the risk of death or severe manifestations is highly heterogeneous for various reasons, including different study designs. it is recognized that mers involves asymptomatic infection [ ] , and thus, studies must be clear as to how the risk is estimated, including the definition and diagnostic methods used to identify infected individuals. depending on the study design, the clinical predictors of death also differed. for fig. estimated risks associated with middle east respiratory syndrome (mers) by study design. panels show the risk estimates by study outcome: (a) risk of death, (b) risk of admission to intensive care unit (icu) and (c) risk of mechanical ventilation. cfr represents the case fatality risk. the estimate for each study design represents the pooled risk of death calculated using the inverse variance of the risk of death in each published study. the size of the diamonds reflects the sample size, and the whiskers extend to the lower and upper values of the % confidence interval (ci). the diamond without fill represents the pooled estimate using the inverse variance of the risk of death. i measures the extent of the heterogeneity, representing the proportion of variance in a meta-analysis that is attributable to study heterogeneity example, renal and heart diseases might not predict the risk of death in an icu setting, but they may be critically important in other settings that involve milder cases. not only studies in icu settings, but also retrospective studies yielded relatively high risk estimates for severe manifestations and death. our finding raises concerns regarding the retrospective analysis of confirmed cases in registered databases without referring to biases associated with case detection and diagnosis, which could yield a biased risk estimate of mers severity. in fact, that could explain why the cfr of confirmed cases among registered cases in patients' database has been as high as %, while the cfr of secondary cases in the presence of contact tracing has been estimated at about % [ ] [ ] [ ] [ ] [ ] . the comorbidities identified in our study are in line with those already identified elsewhere [ , ] . the identification of comorbidities is not only stressed based on previous and present findings [ ] , but it is critically important to understand the underlying pathophysiological mechanisms. high representation of men among deceased cases may reflect the interaction of factors related to sex-specific lifestyle (e.g., smoking habits in the middle east). older age might reflect the greater likelihood of having underlying medical conditions. diabetes, renal and respiratory diseases could predispose patients to be immunologically vulnerable and heart disease could induce water retention (e.g., secondary aldosteronism), both exacerbating the systemic condition. hypertension could have been confounded by some other explanatory factor (s), for example, obesity could have likely led to both hypertension and mers death. nevertheless, identified predictors are accompanied by reasonable biological explanations. the present study is not free from limitations. the biggest concern is, given the absence of identifying information, the included articles most likely referred to the same cases multiple times, potentially overestimating the . the vertical dashed line shows the threshold value of or = . the diamond without fill represents the pooled estimate using the inverse variance of the or. i measures the extent of heterogeneity, representing the proportion of variance in a meta-analysis that is attributable to study heterogeneity number of cases. in fact, the total number of diagnosed and reported cases of mers as of june is approximately , cases, but our systematic review included as many as , cases. thus, it is likely that multiple reports from rok (e.g., cowling et al. [ ] , kcdcp [ ] and majumder et al. [ ] ) reported on the same cases multiple times. rather, we did not avoid any overlap of cases in datasets because that adjustment forced us to adjust the overlap among the cases from the ksa in a similar manner. for this reason, the pooled estimate would never represent the actual pooled outcome data because the same case was counted multiple times. if we remove cowling et al. [ ] and majumder et al. [ ] from our analysis and include kcdcp [ ] , which had the largest sample size, the pooled estimate of the cfr would be increased to . % ( % ci: . , . ). this is understandable owing to the diminished impact of the extensive contact tracing effort in the rok. despite these overlaps, we conducted this systematic review to demonstrate that ascertainment biases likely act as a key factor that characterizes differential mortality across countries. to avoid any overlap of cases and better identify risk factors of icu admission and death, it is advised to set up a common case registration system across countries and allocate identity number for each individual case. as the second technical limitation to remember, it should be noted that the access to individual data was not achieved, and thus, for instance the age-related analysis did not rest on individual age data, and similarly, we have had limitations in the precision of the majority of outcome evaluations. third, clinical predictors of death have been classified only at organ level, and moreover, individual behavioral factors or habitat [ ] have not been examined in relation to the risk of mers death. fourth, non-english language manuscripts have been missed, and they include at least a few publications in korea and one from jordan. despite these problems, we cannot help but consider that the present study successfully and systematically . odds ratio (or) represents the odds ratio of death among men with underlying medical condition compared with women without comorbidities, respectively. the size of the diamonds reflects the sample size, and the whiskers extend to the lower and upper values of the % confidence interval (ci). the diamond without fill represents the pooled estimate using the inverse variance of the risk of death. i measures the extent of heterogeneity, representing the proportion of variance in a meta-analysis that is attributable to study heterogeneity evaluated the risk of severe manifestations and death by mers by collecting published information on clinical predictors of the risk of death. an important consideration is that the associated risk estimation and identification of risk factors of mers call for particular care in terms of study design, especially in aiming to eliminate biases associated with detection and diagnosis. heterogeneity in risks of death and severe manifestations secondary to mers was substantial. differential study design was one of underlying reasons for the large heterogeneity. statistical estimation of the risk of mers death and identification of risk factors must be conducted with particular careful attention paid to study design, especially accounting for biases associated with case detection and diagnosis. additional file middle east respiratory syndrome coronavirus (mers-cov). geneva: world health organization clinical and laboratory findings of the first imported case of middle east respiratory syndrome coronavirus (mers-cov) into the united states 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transmission dynamics of the middle east respiratory syndrome (mers) outbreak in the republic of korea, : a retrospective epidemiological analysis funding hn received funding support from the japan agency for medical research and development, the japanese society for the promotion of science (jsps) kakenhi grant numbers kt , k and , the japan science and technology agency (jst) crest program and ristex program for science of science, technology and innovation policy. no received funding support from the ministry of health, labor, and welfare, japan (h -shinkogyosei -shitei- ). the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. collected datasheet is available from the authors (rm) upon request. authors' contributions hn conceived the systematic review. rm and hn implemented systematic search. rm and hn performed statistical analyses. rm and hn drafted the early version of the manuscript and hn substantially rewrote the text. sk, kh and no further revised the manuscript. all other authors gave comments on the revised manuscript and approved the final version of the manuscript. the authors are experts with interest in infectious disease epidemiology and also in clinical infectious diseases, and the team of lead author is led by professor from hokkaido university graduate school of medicine. the authors declare that they have no competing interests. not applicable.ethics approval and consent to participate not applicable.author details graduate school of medicine, hokkaido university, kita jo nishi chome, kita-ku, sapporo - , japan. crest, japan science and technology agency, - - , honcho, kawaguchi-shi, saitama - , japan.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord- -hs cfdsu authors: gona, philimon n.; gona, clara m.; ballout, suha; rao, sowmya r.; kimokoti, ruth; mapoma, chabila c.; mokdad, ali h. title: burden and changes in hiv/aids morbidity and mortality in southern africa development community countries, – date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: hs cfdsu background: the southern africa development community (sadc) countries remain the epicentre of the hiv/aids epidemic with the largest number of people living with hiv/aids. anti-retroviral treatment (art) has improved survival and prevention of mother-to-child transmission (pmtct) of hiv, but the disease remains a serious cause of mortality. we conducted a descriptive epidemiological analysis of hiv/aids burden for the sadc countries using secondary data from the global burden of diseases, injuries and risk factor (gbd) study. methods: the gbd study is a systematic, scientific effort by the institute for health metrics and evaluation (ihme) to quantify the comparative magnitude of health loss due to diseases, injuries, and risk factors by age, sex, and geographies for specific points in time. we analyzed the following outcomes: mortality, years of life lost (ylls), years lived with disability (ylds), and disability-adjusted life-years (dalys) due to hiv/aids for sadc. input data for gbd was extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service utilisation, disease notifications, and other sources. country- and cause-specific hiv/aids-related death rates were calculated using the cause of death ensemble model (codem) and spatiotemporal gaussian process regression (st-gpr). deaths were multiplied by standard life expectancy at each age-group to calculate ylls. cause-specific mortality was estimated using a bayesian meta-regression modelling tool, dismod-mr. prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases to calculate ylds. crude and age-adjusted rates per , population and changes between and were determined for each country. results: in , hiv/aids caused , deaths overall in sadc countries, and more than million dalys. this corresponds to a -fold increase from , deaths ( , , dalys) in . the five leading countries with the proportion of deaths attributable to hiv/aids in were botswana at the top with . % ( % ui; . – . ), followed by south africa . % ( . – . ), lesotho, . % ( . – . ), eswatini . % ( . – . ), and mozambique . % ( . – . ). the five countries had relative attributable deaths that were at least times greater than the global burden of . % ( . – . ). similar patterns were observed with ylds, ylls, and dalys. comoros, seychelles and mauritius were on the lower end, with attributable proportions less than %, below the global proportion. conclusions: great progress in reducing hiv/aids burden has been achieved since the peak but more needs to be done. the post- decline is attributed to pmtct of hiv, resources provided through the us president’s emergency plan for aids relief (pepfar), and behavioural change. the five countries with the highest burden of hiv/aids as measured by proportion of death attributed to hiv/aids and age-standardized mortaility rate were botswana, south africa, lesotho, eswatini, and mozambique. sadc countries should cooperate, work with donors, and embrace the un fast-track approach, which calls for frontloading investment from domestic or other sources to prevent and treat hiv/aids. robust tracking, testing, and early treatment are required, as well as refinement of individual treatment strategies for transient individuals in the region. we sought to determine hiv/aids related morbidity and mortality trends from to . we assessed morbidity and mortality in the sadc countries using a descriptive epidemiological analysis of hiv/aids burden based on secondary data from gbd study in , , , and . we used secondary data from the gbd study. examining time trends of hiv/aids morbidity and hiv/aids mortality enable comparisons across the countries to understand the changing burden facing the sadc population to support policy and programmatic development in the region. the united nations (un) fast-track or " - - " approach to combatting the worldwide hiv/aids epidemic calls for % of people living with hiv knowing their status, % of people who know their status receiving treatment, and % of people on hiv/aids treatment having a suppressed viral load by [ , ] . the second phase of the approach calls for upgrading the framework to - - by [ ] . hiv/aids-related deaths more than halved since the peak in . in , approximately , people died from the disease worldwide, compared to . million in and . million in [ ] . in , approximately . million new hiv infections occurred, compared to . million in [ ] . a better understanding of the long-term trends in hiv/aids-related morbidity and mortality is needed to enable continued improvements on the impact of ongoing hiv/aids treatment programs [ , ] . sub-saharan africa (ssa), with more than billion people, is the epicenter of the hiv/aids pandemic. the southern african development community (sadc) countries comprise ground-zero of the pandemic, with prevalence in eight countries exceeding % in [ ] . while incidence has progressively declined since the mid- s, hiv/aids morbidity and mortality nonetheless continued to increase (see fig. right panel) , reaching a peak in [ , ] . between and incidence of hiv declined by % worldwide. there was an estimated % fewer hiv/aids-related deaths in ssa in versus [ ] . despite the gains sadc countries have the highest morbidity of hiv/aids, with approximately million people living with the disease in [ ] . of all people living with hiv/aids worldwide at the peak of the epidemic , % resided in ten sadc countries, making hiv/aids the leading cause of death [ ] . hiv/ aids-related mortality in southern ssa increased from being ranked th in to st in ; in eastern ssa countries the ranking increased from th to rd [ , ] . .while great progress has been achieved since to , with a decline in, the number of hiv/aids-related deaths globally by %, sadc countries accounted for nearly in of all people dying from hiv/aids-related causes in [ ] . hiv/aids, therefore, remains a massive public health threat in the region. timely and robust evidence on mortality and trends are essential to informing policy and goal setting, program evaluation, and decision-making. such assessment is an essential starting point for informed health policy debate to measure progress in achieving the united nations (un) health-related strategic development goals (sdgs) [ , , ] and un fast-track approaches " - - " and " - - ". the gbd is a systematic, scientific effort by the institute for health metrics and evaluation (ihme) to quantify the comparative magnitude of health loss due to diseases, injuries, and risk factors by age, sex, and geographies for specific points in time. the gbd study estimates country-specific incidence, prevalence, mortality, years of life lost (ylls), years lived with disability (ylds), and disability-adjusted life-years (dalys) due to diseases such as hiv/aids. input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service utilization, disease notifications, and other sources. cause-specific crude and age-standardized death rates per , population were obtained from the cause of death ensemble model (codem) and spatiotemporal gaussian process regression (st-gpr). deaths were multiplied by standard life expectancy at each -year age-group to calculate ylls. cause-specific mortality was estimated using a bayesian meta-regression modelling tool, dismod-mr. prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases to calculate ylds [ ]. ylls were calculated using the product of age-specific life expectancy from the reference life table used in the gbd study. ylds were calculated as a product of the prevalence of hiv/aids and the disability weights used to quantify health levels associated hiv/aids [ , ] . case definition for hiv/aids used in the gbd and comprehensive details for the methodology and modeling processes for hiv/aids are provided in supplementary appendix , page www.thelancet.com/ journals/lancet/article/piis - ( ) - /full-text#seccestitle [ , ] . all gbd estimates adhere to the guidelines on accurate and transparent health estimate reporting (gather). gather recommends making available statistical code, details on why some sources are used and others are not, and how primary data are adjusted. methodology underlying distinct differences in estimation among unaids, who and ihme are provided [ ] . .the hiv/aids-related outcomes were assessed for each country in sadc, a regional economic community whose aim is to increase regional socioeconomic integration to achieve greater economic growth and poverty alleviation. levels of development and poverty, social service delivery, and economic performance vary greatly. nine of the countries were classified in as either low or low-middle income. only mauritius seychelles and south africa were classified as high-middle income. the ability for each country to respond to the high burden of hiv/aids also varies considerably. sadc aims to strengthen economic cooperation and integration, providing for cross-border investment and trade, and free movement of goods and services across borders [ , ] . the gbd results tool was used to extract sex-pooled age-standardized morbidity and mortality rates per , population for years , , , and . (available at http://ghdx.healthdata.org/gbd-results-tool). to facilitate comparison of hiv/aids outcomes of morbidity and mortality across countries, time, age-groups, and sex, the institute for health metrics and evaluation (ihme) improved previously established metrics like prevalence and incidence. how long do people live with hiv/aids is assessed using hiv/aids-specific mortality rates and hiv/aids-specific years ylls. what causes people to get sick is assessed hiv/aids-specific ylds which reflect the amount of time in a year that people live with a condition accounting for the severity of that condition. adding together ylls and ylds yields dalys. to facilitate comparisons across sadc countries and eliminate potential confounding by age, outcomes are presented as age-standardized rates per , population i.e., the average of the age-specific hiv/aids rates weighted by country-specific proportions of a standard population in the corresponding age groups [ , , , ] . expected rates (e) were determined using a linear equation with the country's socio-demographic index (sdi) in used as a linear predictor [ ] . the sdi, which ranges from to is a summary measure of where a location is on the spectrum of socio-demographic development. the index is calculated from the geometric mean of three rescaled components: total fertility rate of women under years of age, lag-distributed income per capita, and average educational attainment in the population > years., we calculated the observed-to-expected (o/e) rate ratio. uncertainty for each outcome was quantified using uncertainty intervals (uis) based on bootstrap draws from the posterior distribution [ , ] . uis were determined by the th and th ordered values of the posterior distribution of the draws, and point estimates were computed from the mean of the draws. changes over time were considered statistically significant when the % ui of the percentage change did not cross zero [ ] . gbd uses the joint united nations program on hiv and aids (unaids) estimates as inputs in their modeling ensemble [ , ] . for example, pediatric hiv/aids mortality estimates in gbd were produced with the cd -countspecific mortality and progression parameters developed by unaids [ ] . each iteration of gbd re-analyses the entire time series by use of newly available data sources from across all estimation years and continually improved methods. new data and modelling approaches effectively improve model validity and decrease uncertainty from various sources with the consequence that estimates for a given cause, location, and year might differ between gbd iterations and unaids. statistical, analytical, processing, and estimation code used to generate the gbd results are available on their website: http://ghdx.healthdata.org hiv/aids morbidity and mortality remain major public health problems in sadc countries. nearly all new infections in worldwide occurred in just countries, four sadc countries, i.e., mozambique, zimbabwe, zambia, and tanzania. between and , hiv incidence worldwide declined by %, and hiv/aids mortality declined by %, but corresponding declines in sadc countries during the same period were and %, respectively. the five leading countries with the proportion deaths attributable to hiv/aids in were botswana at the top with the five leading countries with the greatest agestandardized mortality rate per , population in were lesotho . ( . - . ) at the top, followed by table ). these five countries had agestandardized mortality exceeding -fold the global mortality rate of . ( . - . ). while the % uis for eswatini, south africa, mozambique, botswana overlap, there is no substantial difference in the rates for these countries, but the rate for lesotho is substantially higher than that for the other four since the % uis do not overlap. seychelles, mauritius and comoros had mortality rate lower than the global rate per , . heterogeneity in rates between countries in was high, with rate ratio between comoros, the country with the lowest age-standardized mortality rate ( . ( . - . )), and lesotho, the country with the highest age-standardized mortality rate ( . (( . - . ) nearly -fold higher. looking back in time, in , , and , botswana and eswatini had consistently the highest age-standardized mortality rates. zimbabwe dropped out of the top in (table ) . (table ) . the map on fig. shows the annual percent changes in hiv-associated mortality for males and females from for each metric, the sdi, a measure of where the country is on the spectrum of development based on income, (table ) , ylds (table ) and dalys (table ) . to gain better perspective on the ylls percentage for sadc countries, the corresponding ylls percentages were . and . % in the member states of the organisation for economic co-operation and development (oecd) and the member states of the european union (eu) ( - % deficit), respectively. figure displays the ratio of ylls to ylds as proportions of dalys attributable to hiv/aids in sadc countries, worldwide, oecd, and eu . more dramatically from fig. , and highlighting the heterogeneity of the changes in the burden among rich and poor countries, the levels of ylls proportions of dalys due to hiv/ aids in sadc countries in were equal to the levels in oecd and eu countries, several years before the advent and widespread use of highly active antiretroviral treatment (haart). botswana, south africa, lesotho, eswatini, mozambique, and namibia all had increasing (worsening) burden, with aroc ranging from + . % in botswana to + . % in madagascar, suggesting that in these countries, the burden of hiv/aids has not abated, but has worsened compared to the levels in . (fig. ). we analyzed mortality and morbidity due to hiv/aids in sadc countries between and using estimates from the gbd study. the five leading countries with the proportion deaths attributable to hiv/aids in were botswana, south africa, lesotho, eswatini, and mozambique, also had the highest age-standardized mortality, yll, yld rates. botswana, eswatini, and lesotho were among the top five countries with highest mortality and morbidity in , , , and . comoros, seychelles, mauritius and madagascar had the lowest rates in . double-digit increasing slopes in aroc (%) observed in countries is worrisome. indicating significant risk that the progress made in slowing the hiv epidemic could be reversed without a continued robust investment in health. while the negative aroc (%) in four countries, drc, tanzania, zimbabwe, and zambia is encouraging, the aroc (%) observed in madagascar, south africa, and angola are concerning. while most sadc countries, except for comoros, seychelles, madagascar and mauritius had morbidity and mortality rates in greater than the global rate, there was substantial heterogeneity among the countries. the disparity in rates, measured using rate ratios, between the lowest rates observed in comoros, and highest rates observed in lesotho exceeded -fold in suggesting that sadc countries are on very diverse trajectories regarding the burden of hiv/aids. while art has extended life for most people living with hiv, it is sobering that two-thirds of hiv/aids-related deaths in lmics occurred in individuals not on art [ ] . loss to follow-up from care and defaulting, especially for first-line treatment, significantly affect survivability. ideally, when one defaults on the first line, the next step would be initiation into the second line, which because of cost, is out of reach for most rural communities in the sadc, thereby compromising survival of patients [ , ] . our most poignant finding is that the ratio of hiv/ aids-related ylls/dalys of . % for oecds in (fig. , first bar) is nearly equivalent but smaller, at . %, than the hiv/aids-related ratio of ylls/dalys in sadc countries nearly three decades later in (fig. , sadc bar) [ ]. it is astounding that the ratio for sadc was lower than the ratio experienced in oecd member states years prior, a period during which there was no widespread use of art or secondary prophylaxis against opportunistic infections? despite the advent of potent art, sadc still lags by almost years demonstrating the uneven progress that has been achieved in different regions. notably, unaids endorsed the concept of "undetectable" = "untransmittable" based on strong scientific evidence that hiv is not sexually transmitted from people living with hiv/aids to their hiv-negative partner if the partner hiv-positive continues to take effective art and is virally suppressed [ ] [ ] [ ] [ ] . having many infected people not on treatment increases the risks for infection to the general population. ensuring those who are infected are virally suppressed is a powerful tool to improve survival for those infected and prevent new infections. it has been argued that hiv/aids has remained a massive public health threat, but global financing has plateaued, domestic health spending has stayed low among high-burden countries, and the disease incidence has not declined as quickly in younger as in older populations [ ] . eswatini, botswana, and lesotho had among the highest mortality rates in the world before the downward shift of the world epidemic since , suggesting that the extremely high rates during the peak in continue to drive the epidemic decades later. the mortality rates in eswatini and lesotho remain among the highest in the world, exceeding more than a decade after the global decline. our study showed hiv/ aids caused more ylls than ylds at all times, underscoring that in sadc countries survival following hiv infection is very short. it is desirable to decrease the proportion of ylls contributing to dalys so that patients live longer. one likely explanation of the relatively small proportion of ylds to dalys in sadc is people with hiv/aids present late for care after the onset of opportunistic infections, underscoring the need for early and periodic testing for hiv while their health is still intact. strategies should be developed to ensure that more people who are unaware of their hiv status are tested and if necessary linked to care immediately. health systems in the sadc region need improvement to help lengthen the lives of individuals with the disease and convert the burden of hiv/aids into mostly ylds rather than ylls. premature mortality, measured using ylls, is indicative of failure of healthcare management of hiv/aids cases in the region to convert the burden of hiv/aids into mostly ylds, therefore extending the lives of the hiv/aids-affected individuals. countries with better healthcare access and quality index have the potential to reduce future burden [ ] . we detected huge disparities between the observed mortality compared to that expected based on the country's level of sdi. accordingly, sadc countries are relatively underperforming with respect to the expected reduction in disease burden compared to other countries of similar sdi. at current rates of decline in the burden of hiv/aids, sadc countries might not meet the sdgs target for the disease and are far from the unaids goal of ending aids by [ ] . our study suggests that sadc countries have made some progress, but hiv/aids mortality and morbidity rates are still unacceptably high. while the global mortality and morbidity rates in were approximately doubled compared to levels, sadc countries such as south africa had rate that was -times, angola -times, and mozambique -times the rate, increases pointing to a cascade of orders of magnitude. in the sadc region, most people with hiv/aids are reliant on medications provided by sources outside of the region. individuals between and years of age, the peak years of economic production, are the most affected by the epidemic [ ] . our findings, therefore, imply that sadc countries are economically and socially vulnerable. the number of people who do not know their hiv status is of concern. a pregnant woman with untreated hiv has up to a % chance of transmitting the virus to the baby. if the woman and their baby receive antiretroviral treatment, that risk drops to % [ , ] . for hiv infection to become a rare occurrence, sadc countries should coordinate efforts to reduce new hiv infections, increasing access to hiv/aids treatment and care, particularly to religious minorities that discourage contact of their members with the healthcare system [ ] [ ] [ ] . government health spending is a primary source of funding in the health sector across the world, but in ssa, only about a third of all health spending is sourced from the government [ ] . in southern africa, public funding for healthcare grew by only . % each year between and [ ] . keeping the coverage of aids-related services at levels would lead to an increase in the burden of hiv/aids in almost all sadc countries. art in sadc countries is available through "cost-free" programs funded by the global fund, pepfar, and corresponding governments [ , ] . the heavily donor-funded art programs have been a success story, but there is uncertainty about their long-term sustainability [ ] . pepfar was the largest donor, providing $ . billion in , followed by the global fund: with contributions from the uk ($ . million), france ($ . million), the netherlands ($ . million), and germany ($ . million). the us government recently proposed a % reduction in pepfar and global fund assistance [ , ] . any reduction in funding could have significant impact on hiv prevention and treatment, as most of the countries are dependent on these organizations for most of their hiv/aids programming budgets [ ] . sadc countries should try to ramp up their domestic financing programs in order to reduce dependency on these other organizations/countries and be able to sustain the programs. the un fast-track framework advocates for frontloading resources required for full implementation of basic programs by investing $ . billion in lmics in . by , the investment amount would drop to $ . billion, in the process averting nearly million new hiv infections and million aids-related deaths [ , , ] . for fast-track goals to be successful in marking a transition toward ending the hiv/aids epidemic, sustained and intensified regional commitment by sadc countries together with the un and the african union over the next decade will be required. our study is subject to a few previously described limitations regarding the estimation of hiv/aids burden [ , ] . firstly, our study estimated mortality with hiv/aids as the underlying cause of death without accounting for deaths from other non-communicable causes among people with hiv/aids. secondly, national-level estimates may obscure substantial heterogeneity at sub-national level. thirdly, we had no access to traditional risk factors that influence transmission of hiv/aids such as presence of other sexually transmitted infections, stage of infection, male circumcision, and use of art and pre-exposure prophylaxis (prep), therefore we could not explore the importance of these factors. fourthly, sdi was used as a linear predictor to estimate expected rates in , yet the sdi does not always exhibit a linear association with all causes of death including hiv/aids-related deaths. fifthly, time lags in available data, absence of data from specific regions, age groups, or time periods, or unreliability in the data that are available or for geographical areas with the highest hiv/aids-related mortality can affect the precision of estimations. sixth, because gbd results for hiv/aids are a combination of data and estimation, lags in data reporting mean that estimates for the most recent years rely more on the modelling process, as do estimates for locations with low levels of data completeness. despite these limitations, this study gives an insight on the disparities in morbidity and mortality within the sadc region. efforts are underway to collect data at local levels to further reveal the granularity of estimates to reveal nuances hidden by aggregated data. this higher resolution will aid governments in focusing their efforts in regions with higher burden. for better resolution and to illuminate geographic inequality in hiv/aids burden, future analyses should use spatially resolved data at a × -kilometer grid level. community-level estimates can help identify where interventions and health policies will have the greatest impact by targeting the most vulnerable individuals. in the absence of a preventive vaccine, at current rates of decline in the burden of hiv/aids, sadc countries will not meet the un's health-related sdgs by or achieve the unaids goal of ending aids by [ , ] . our study should help to inform decisions about policy and programs aiming to improve resource allocation and track accountability. sadc countries need to continue to ensure access and adherence to art and strengthen behavioral interventions to prevent new infections. early testing should be encouraged, perhaps rewarded, in order to link individuals testing positive to care early, when their immune systems are still strong, potentially increasing ylds while reducing ylls and preventing new infections. eliminating hiv/aids will take sustained coordination across multiple health and social sectors in the region, along with adequate funding and supportive public policies. governments in sadc countries should plan strategically as a block in efforts to eliminate the hiv/aids epidemic. the double-digit increasing slopes in aroc (%) observed in countries indicate significant risk that the progress made in slowing the hiv epidemic could be reversed without a continued robust investment in health. it is unacceptable for governments to outsource the huge financial undertaking to outside forces. governments should take responsibility for their people by making hiv/aids funding a priority. hiv/aids programming, including funding for art manufacture, procurement, and distribution across the region, should comprise a significant proportion of the national budgets. sadc should expand its mission to include increasing domestic funding, collaborative licensing, and procurement and manufacture of art. rather than importing hiv/aids medications from abroad, local manufacturing and distribution of art would guarantee seamless supply of the medications for all people in need. for this strategy to be effective, the sadc countries should gaurantee access to medications for people in transit and and make sure they receive care upon return. the coronavirus disease (covid- ) pandemic disrupted and put the world on edge forcing governments to implement, social distancing, and community containment, city lockdowns or traffic controls, measures which disrupted the continuum of hiv/aids care because of restricted hospital visits, sadc government and community partners should collaborate to sustain hiv service provision for people living with hiv/aids to avoid disruption of routine hiv services. strategies such as dispensing art in - -month doses to meet the needs of people living with hiv and reduce facility visits would reduce disruption [ ] . while our study looked at epidemiological data on the burden of hiv/aids in the sadc countries, gbd data does not address issues surrounding the economic impact of hiv, such as healthcare and occupational perspectives. healthcare costs of hiv/aids and the occupational situation of people living with hiv/aids need to be discussed. in high-income countries, the trends indicate that an increasing proportion of the intermediate-age hiv-positive population will age prematurely, experiencing high rates of cardiovascular disease events, cancers, and neurocognitive impairment [ ] and becoming frailer. regarding occupational perspectives, the decreased life expectancy of hivpositive persons may prompt this population to retire early from the labor market [ , ] . strategies should be developed to alleviate poverty, improve economic and financial opportunities for people with hiv/aids, and improve infrastructures to empower individuals with hiv/aids to continue with productive economic activity. gbd results are detailed and carefully researched using transparent methods but they are estimated and rely on many assumptions. to minimize the need for extrapolation, more primary data are needed from all countries where data accuracy and reliability can be poor. in nearly four decades the hiv/aids epidemic has changed dramatically as the virus has rapidly spread to all geographic regions. globally, significant progress has been made in improving diagnosis and access to treatment. however, if hiv/aids-related mortality continues at current level in sadc, none of the countries will reach the sdg target of ending the epidemic by . the downward trajectories observed elsewhere have been sluggish in the sadc regions. there is a need to strengthen existing strategies and create new ones to help end the disparity and help keep hiv/aids on a steeper downward trajectory. education about hiv transmission and prevention and testing and immediate treatment of individuals who test positive, should be implemented and maintained and funded. health ministries should increase efforts to ensure that accessible, affordable and stigma-free testing and treatment, including better access to viral load testing, is available to all people living with hiv/aids [ ]. additionally, pharmaceutical interventions like pre-and post-exposure prophylaxis which have changed prevention and treatment protocols for hiv/aids in other regions have not been fully implemented in sadc. sadc countries are facing challenges in meeting hiv/aids-related sdg targets; however, 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active antiretroviral therapy era -reflections looking forward publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations none of the other authors has competing financial interests. all authors report no conflicts.authors' contributions png conceptualized the study, had access to raw data, analyzed data, wrote the first draft of the manuscript, and interpreted the data. cmg, sb, ccm, and rk, contributed to the clinical, epidemiological, policy implications sections, and strengthened the intellectual content and recommendations of the study. srr co-wrote the first draft of the paper strengthened the intellectual content of the study. ahm supervised the development of the study, critiqued earlier drafts, and shaped the overall interpretation in relation to previous related studies. the authors read and approved the final manuscript. bill & melinda gates foundation. the funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit the manuscript. data that support the findings of this study are available at: table : http://ghdx.healthdata.org/gbd-results-tool?params=gbd-api- permalink/ c dc c b f c f tables , , , : http://ghdx.healthdata.org/gbd-results-tool?params=gbdapi- -permalink/ aea bf cff c deb a a b, or by request from the authors.ethics approval and consent to participate not applicable. not applicable. none.author details key: cord- - v f yz authors: sobers-grannum, natasha; springer, karen; ferdinand, elizabeth; john, joy st title: response to the challenges of pandemic h n in a small island state: the barbadian experience date: - - journal: bmc public health doi: . / - - -s -s sha: doc_id: cord_uid: v f yz background: having been overwhelmed by the complexity of the response needed for the severe acute respiratory syndrome (sars) epidemic, public health professionals in the small island state of barbados put various measures in place to improve its response in the event of a pandemic methods: data for this study was collected using barbados’ national influenza surveillance system, which was revitalized in . it is comprised of ten sentinel sites which send weekly notifications of acute respiratory illness (ari) and severe acute respiratory illness (sari) to the office of the national epidemiologist. during the h n pandemic, meetings of the national pandemic planning committee and the technical command committee were convened. the pharmaceutical and non-pharmaceutical interventions (npis) implemented as a result of these meetings form the basis of the results presented in this paper. results: on june , , barbados reported its first case of h n . from june until october , there were laboratory confirmed cases of h n , with one additional case occurring in january . for the outbreak period (june-october ), the surveillance team received reports of , ari cases, compared to cases for the same period in . the total hospitalization rate due to saris for the year was . per , people, as compared to . per , people for . barbados’ pandemic response was characterized by a strong surveillance system combining active and passive surveillance, good risk communication strategy, a strengthened public and private sector partnership, and effective regional and international collaborations. community restriction strategies such as school and workplace closures and cancellation of group events were not utilized as public health measures to delay the spread of the virus. some health care facilities struggled with providing adequate isolation facilities. conclusions: the number of confirmed cases was small but the significant surge in ari and sari cases indicate that the impact of the virus on the island was moderate. as a result of h n , virological surveillance has improved significantly and local, regional and international partnerships have been strengthened. its response in the event of a pandemic. in accordance with the resolution at the th world health assembly (wha) entitled strengthening pandemic infl uenza prepared ness and response [ ] , barbados developed a national infl uenza pandemic preparedness plan (nipps) in august [ ] . in september , a pandemic fl u outbreak training workshop was held and a pandemic manual was subsequently developed. th is manual was later revised by a team of managers of the public community health centres, and a two day seminar was held in april for private and public sector health care professionals to launch this protocol and to educate participants regarding the appropriate response to dangerous infectious diseases. th ese measures were accomplished through technical cooperation with the pan american health organization (paho) and the caribbean epidemiological centre (carec). in , the national infl uenza surveillance system was revitalized beginning with surveillance of cases of acute respiratory illness (ari) at the countries eight community health centres which served as sentinel sites. th ese sentinel sites (polyclinics) are located at strategic points across the island (figure ). th is was expanded in january , to include the island's lone tertiary public hospital where cases of severe acute respiratory illness (sari) are detected routinely through active surveillance. barbados' nipps plan follows international guidelines with recommendations for both pharmaceutical and non-pharmaceutical interventions to be implemented at various stages of a pandemic. in april , when the world health organization (who) announced that the world was experiencing an infl uenza pandemic, barbadian public health offi cials responded to the threat. in this paper, we examine the response of public health professionals in implementing plans regarded as best practice for developed nations and consider the peculiarities of implementation in a small island state. data for this study was collected using barbados' national infl uenza surveillance system which is comprised of ten sentinel sites, responsible for sending weekly notifi cations to the ministry of health of ari and sari. using guidelines provided carec [ ] , a case was reported as an ari if it met the following case defi nition: acute (sudden) febrile illness (> . ºc or . ºf) in a previously healthy person, presenting with cough or sore throat with or without respiratory distress. cases were reported as sari if they presented a sudden onset of fever over ºc, cough or sore throat, shortness of breath or diffi culty breathing, and required hospital admission. during the pre-pandemic period, as part of routine surveillance, nasopharyngeal swabs were taken from all cases of sari detected at the hospital sentinel site and a sample of six swabs from patients meeting the criteria of ari from two of the most centrally located ambulatory sites. in april , after the announcement by the who that the world had entered pandemic phase fi ve, an enhanced testing strategy was introduced and all primary health care facilities, both private and public, were asked to take nasopharyngeal swabs from all persons who presented with fever (> ºc) with respiratory symptoms and a travel history to an aff ected area. when sustained community transmission of h n was established, this testing strategy was returned to the pre-pandemic level. nasopharyngeal samples taken from suspected cases were sent fi rst to the barbados public health laboratory (local) where they underwent preliminary screening using immunofl uorescence testing. using this method, it is possible to detect infl uenza a virus, adenovirus, respiratory syncitial virus, parainfl uenza types , and and infl uenza b. all samples which met the criteria for testing, irrespective of result, were sent to carec. at the peak of the epidemic in the caribbean, barbadian health offi cials began sending some samples to the u.s. centers for disease control and prevention (cdc) in atlanta, georgia in an attempt to reduce the burden being placed on carec. th e cdc and carec collaborated during the outbreak to provide critical guidance and technical capacity to the region. during the pandemic, the ministry of health's public health offi cials convened meetings of the national pandemic planning committee which met at least weekly for the fi rst two months of the declaration of a pandemic and then monthly for the duration of the outbreak in barbados. a smaller technical command committee was also convened to manage the response to the pandemic and met weekly. at the end of the outbreak period in barbados, a formal evaluation was conducted by many of the major stakeholders within the health sector. th e pharmaceutical and non-pharmaceutical interventions (npis) implemented as a result of these meetings form the basis of the results presented in this paper. the evidence surrounding the use of some npis to delay spread of infection in a pandemic has been found to be weak [ , , ] . aledort et al. published a systematic review which examined the literature and also made recommendations based on expert opinion in cases where there were no or very low quality articles available as a study. here we consider the pharma ceutical and non-pharmaceutical interventions carried out by the government of barbados through the ministry of health, and compare these interventions to the recommendations of the article by aledort et al [ ] . queen elizabeth hospital polyclinic district hospital sobers-grannum et al. bmc public health , (suppl ):s http://www.biomedcentral.com/ - / /s /s . th e cases range in age from -days-old to -years-old, with a mean age of -years-old; the greatest proportion of our cases occurred in the - age group and the second highest in the - age group. a little more than half ( . %) of all confi rmed h n viral infections occurred in females. th e most common presenting symptoms were fever - . % ( cases); and cough or sore throat - . % ( cases). only . % ( ) of cases presented with gastrointestinal symptoms. of the confi rmed cases, there were three fatalities, which occurred in persons with underlying chronic conditions, all of whom were morbidly obese. for the outbreak period (june to october ), the surveillance team received reports of , cases, compared to cases for the same period in . th ere were sari cases from june to october , % ( ) of which required ventilation and care in the intensive care unit. during this time there were seven sari deaths. of these, four received nasopharyngeal swabs that were tested for h n and three tested positive. th e total hospitalization rate due to saris for the year was . per , people, compared to . per , people for . th e highest hospitalization rate occurred in children less than one year ( per , ) followed by those to years old ( per , ). during the initial phases of the pandemic while knowledge of the virus' characteristics was limited, all suspected cases in the island were reported to the offi ce of the national epidemiologist and nasopharyngeal swabs taken. all cases suspected of having h n were investigated and close contacts monitored until the results of the swab were obtained. as the outbreak advanced, only laboratory-confi rmed cases and suspected hospitalized cases were reported. immuno fl ourescent testing was done on the swabs in country to test for infl uenza a virus, but this test was incapable of subtyping and thus swabs had to be sent to a regional centre for real-time polymerase chain reaction testing to be done. th is resulted in wait times for results that averaged one week but were occasionally as long as six weeks. rapid testing was not utilized in barbados. th e ministry of health placed great emphasis on hand hygiene and respiratory etiquette in its communication messages to the public. th e who outbreak communication guidelines [ ] were used as the risk communication guide in responding to the emergence of h n in our community. th ese guidelines use trust, early announcements, transparency, listening and planning as key components of risk communication [ ] . several protocols were distributed on hand hygiene to schools, day care centres, workplaces and the general public. an infectious waste protocol was developed to guide health facilities in the disposal of infectious waste. circulated. th e central storage facility has been improved upon during this time but remains challenged by lack of security to prevent theft and insuffi cient human resources for effi cient stock-taking. as part of their eff orts towards pandemic preparedness, the ministry of health in barbados held a seminar in april , at which they disseminated a manual on management of dangerous infectious diseases to middle-and senior-level managers of at least % of health care facilities in the country. th is manual provided detailed instructions to health care leaders on the structure and type of isolation facilities that ought to be available at their facility. during the outbreak, health care facilities attempted to follow these evidence-based guidelines but were challenged in some regards by their existing structures and layout, and restricted by the high costs that would have been necessary to change these facilities. th e island's lone public hospital is the only major health centre with designated isolation facilities but its capacity was signifi cantly overwhelmed during the outbreak. th e community health centres created temporary isolation areas by reorganizing, and in some cases, curtailing routine services. administrators and health care providers remained committed to the principles of patient isolation for dangerous infectious diseases and have stated their intention to revise their protocols so that there are evidence-based and yet feasible and practical for each facility. ministry of health offi cials took the decision early in the pandemic that there was insuffi cient evidence to support quarantining of asymptomatic persons who had been in contact with a probable or confi rmed case or had travelled to an aff ected area internationally. th e protocol adopted for contact tracing varied according to whether persons were regarded as probable or confi rmed cases. a probable case is an individual with an infl uenza test that is positive for infl uenza a, but is unsubtypable by reagents used to detect seasonal infl uenza virus infection, or an individual with a clinically compatible illness or who died of an unexplained acute respiratory illness, and who is considered to be epidemiologically linked to a probable or confi rmed case. a close contact is an individual who has cared for, lived with or had direct contact with respiratory secretions or body fl uids of a probable or confi rmed case of infl uenza a/h n . for probable cases, close contacts were followed at home and work. contact tracing was coordinated by the medical offi cer of health (community-based public health leader) and a team operating within the community. close contacts with symptoms were isolated at home or in hospital depending on the severity of symptoms. contacts were given a short sensitization session and fact sheets on hand hygiene, respiratory etiquette and proper cleaning methods of laundry and other household items. at the peak of the epidemic in barbados, many primary (ages - ) and secondary schools (ages - ) reported absenteeism rates from schools ranged from as low as % to as high as %. based on the latest available evidence, the ministry of health, in collaboration with ministry of education, decided not to close schools in hope of preventing further spread because the benefi t of doing so was not suffi cient enough to justify the social and economic consequences of such an action. th ere was still, however, some disruption within schools. at the start of the pandemic each school that was aff ected through infection by either students or teachers, was visited by public health offi cials to educate and allay fears of mass morbidity and mortality. th is meant that classes were cancelled for approximately - hours in each case as fears were addressed. public health offi cials also visited the workplaces of the fi rst reported cases to conduct similar educational seminars, so some productivity would have been lost during that time. one school, however, reported high ( %) absenteeism among staff , which resulted in education offi cials making the decision to close the school to prevent issues of discipline and security from arising. th e 'crop over festival' is barbados' major cultural extra vaganza for the calendar year and is a signifi cant source of revenue for the island. th e festival is held from july to august each year and is characterized by social gatherings throughout the season, which may range from to , persons. given the available evidence, the decision was taken not to cancel any of the events associated with the festival, but ill persons were asked not to attend the gatherings. patrons were asked to refrain from their usual custom of waving rags and using shared drink containers. th e festival activities were used to educate the populace in the use of appropriate hand hygiene and respiratory etiquette. th is education was done using calypso jingles that represent the signature musical genre of the festival, as well as through distribution of fl yers along the highways as persons engaged in the festivities. th e barbados drug service was able to procure , courses of oseltamivir (tamifl u) as part of pre-pandemic preparedness. a protocol was developed by the ministry of health to manage the distribution of tamifl u in both the private and public sector. th is protocol was fi rst circulated in may , and use was restricted to those with moderate to severe respiratory illness who met the case defi nition of a suspected case, which at that time included fever, cough and/or sore throat and a travel history to an aff ected area. as the disease became more widespread in barbados, the case defi nition for a suspected case of h n was modifi ed to exclude the travel requirement, and tamifl u usage was thus increased. as more information became available about the virus, the protocol was revised; in july those with mild respiratory illness who had certain specifi ed chronic diseases and those with moderate to severe illness were eligible to receive tamifl u. th e drug was widely used throughout the outbreak and no cases of resistance were reported. plans for procurement of h n vaccine were made through the revolving fund of the pan american health organization. a conference of the sub-regional workshop for the planning of pandemic vaccine introduc tion was attended by ministry of health offi cials to develop a plan for the deployment of the vaccine within two to four weeks after its arrival on the island. th e plan, which was based on a paho vaccination guide [ ] , identifi ed health care workers, pregnant women, and persons over six months with underlying diseases as the main target groups for vaccination. th e initial target was , doses based on estimations of prevalence of the diseases in the barbadian population. due to economic constraints and estimates of anticipated vaccine uptake, the actual number of doses acquired by the government was , doses at a cost of approximately usd , . th is cost includes only that of the actual vaccine and excludes the extra supplies and human resources that would be needed to administer the vaccine. th e vaccination campaign began in february . after four weeks, % of the estimated target group had been reached- % of health care workers, % of pregnant women and % of persons who had been targeted with chronic disease. th e vaccine campaign was extended for a further months; , ( %) doses of the vaccine have been utilized. generally, public health leaders in barbados responded quickly and decisively to the threat of pandemic h n . protocols were developed, disseminated and adhered to in the majority of the private and public sector. th e response was characterized by technical cooperation between public and private sector within the country as well as regional (paho and carec) and extra-regional (cdc) alliances. th e risk communication techniques employed served to construct and reaffi rm partnerships and reassure the barbadian public. one local newspaper produced a headline at the start of the outbreak remarking on the public's "calm response to h n " [ ] . most of the non-pharmaceutical interventions employed (table ) closely followed recommendations made by international organizations such as the who and cdc [ , , ] . for example, hand hygiene and respiratory etiquette which received the strongest evidence in the scientifi c literature [ , , , ] formed the foundation of barbados' pandemic response. for interventions with less conclusive scientifi c evidence, social and economic factors weighed heavily in deciding whether or not to include them. th e use of rapid tests in the pre-pandemic and early pandemic phases was recommended aledort et al [ ] . however, the recommen dation was made with the reservation that these tests often have suboptimal sensitivity [ , ] . several other sources advised against the use of these tests [ ] . in barbados, having weighed the benefi ts of rapid diagnosis against the high costs and wide margins of error, the use of rapid tests was decided against. aledort et al. recommended against the use of surgical and n masks for the general public at all pandemic phases with the exception of the advanced stage where it is stated that the evidence was inconclusive [ ] . however, jeff erson et al. have shown that in health care settings, the use of masks could reduce the transmission of infl uenza [ ] . in barbados' response, persons entering health care facilities such as the polyclinics were asked to wear surgical masks. it is diffi cult to determine the true impact of h n as compared to regular seasonal infl uenza in the island since the national surveillance system is still relatively new. in fact, virological surveillance was practically non-existent prior to the announcement of pandemic phase fi ve. th is component of surveillance was present in the protocol but lacked suffi cient physician motivation and thus ministry of health offi cials used the opportunity of the emerging virus to encourage the taking of nasopharyngeal swabs. th e number of confi rmed cases was small, but the signifi cant surge in ari and sari cases noted at the sentinel sites indicate that the impact of the virus on the island was moderate. barbados enjoyed excellent political commitment to the executing of its pandemic plan but was challenged by limited fi nancial resources. as a result of h n , virological surveillance has improved signi fi cantly and local, regional and international partnerships have been forged and in some cases strengthened. pan american health organization: public health in the americas world health organization: strengthening pandemic-infl uenza preparedness and response, including application of the international health regulations edited by ministry of economic aff airs statistics/ human development/united nations development program world health organization: strengthening pandemic infl uenza preparedness and response caribbean epidemiological centre: regional communicable disease surveillance systems for carec member countries -policy guidelines. port of spain non-pharmaceutical public health interventions for pandemic infl uenza: an evaluation of the evidence base non-pharmaceutical interventions for pandemic infl uenza, national and community measures aiello ae ea: findings, gaps, and future direction for research in nonpharmaceutical interventions for pandemic infl uenza world health organization: who outbreak communication guidelines pan american health organization: tag fi nal recommendations on pandemic infl uenza calm response to h n h n flu: infection control interim guidance for the detection of novel infl uenza a virus using rapid infl uenza diagnostic tests world health organization: who recommendations on the use of rapid testing for infl uenza diagnosis guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hipac/shea/apic/idsa hand hygiene task force mask use, hand hygiene, and seasonal infl uenzalike illness among young adults: a randomized intervention trial centers for disease control and prevention: respiratory hygiene/cough etiquette in healthcare settings eff ect of hand hygiene on infectious disease risk in the community setting: a meta-analysis comparison of the directigen fl u a+b membrane enzyme immunoassay with viral culture for rapid detection of infl uenza a and b viruses in respiratory specimens physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review response to the challenges of pandemic h n in a small island state: the barbadian experience the authors acknowledge the contribution of the following persons to the pandemic response: the barbados drug service, the medical offi cers of health and senior health sisters of all community health centres (polyclinics) in barbados, and senior managers within the ministry of health including the chief public health nurse, chief environmental health offi cer, chief nursing offi cer as well as the health promotion team. we also wish to acknowledge the authors would like to state that they have no competing interests.authors' contributions nsg made substantial contributions to the acquisition of, analysis and interpretation of data and was responsible for drafting the manuscript. ef, ks and jsj contributed to the conception and design of the study. all authors were involved in revising it critically for important intellectual content and have approved the fi nal version of this publication. key: cord- - mnsjbib authors: maman, issaka; badziklou, kossi; landoh, essoya d; halatoko, afiwa w; nzussouo, talla n; defang, gabriel n; tamekloe, tsidi a; kennedy, pamela j; thelma, williams; kossi, komlan; issa, zoulkarneiri; kere, abiba b title: implementation of influenza-like illness sentinel surveillance in togo date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: mnsjbib background: the emergence of avian influenza a/h n in as well as the pandemic influenza a (h n ) pdm highlighted the need to establish influenza sentinel surveillance in togo. the ministry of health decided to introduce influenza to the list of diseases with epidemic potential. by april , togo was actively involved in influenza surveillance. this study aims to describe the implementation of ili surveillance and results obtained from april to december . methods: two sites were selected based on their accessibility and affordability to patients, their adequate specimen storage capacity and transportation system. patients with ili presenting at sentinel sites were enrolled by trained medical staff based on the world health organization (who) case definitions. oropharyngeal and nasopharyngeal samples were collected and they were tested at the national influenza reference laboratory using a u.s. centers for disease control and prevention (cdc) validated real time rt-pcr protocol. laboratory results and epidemiological data were reported weekly and shared with all sentinel sites, ministry of health, division of epidemiology, who and cdc/namru- . results: from april to december , a total of samples were collected with % of the study population aged between and years. of the samples, ( . %) tested positive for influenza viruses; with ( . %) positive for influenza a and ( . %) positive for influenza b. the highest influenza positive percentage ( %) was observed in – years old and patients aged – and > years had the lowest percentage ( %). clinical symptoms such as cough and rhinorrhea were associated more with ili patients who were positive for influenza type a than influenza type b. influenza viruses circulated throughout the year with the positivity rate peaking around the months of january, may and again in october; corresponding respectively to the dry-dusty harmattan season and the long and then the short raining season. the pandemic a (h n ) pdm was the predominantly circulating strain in while influenza b was the predominantly circulating strain in . the seasonal a/h n was observed throughout year. conclusions: this study provides information on influenza epidemiology in the capital city of togo. influenza-like-illnesses (ili) is a significant source of morbidity and mortality worldwide [ ] . the world health organization (who) estimates that globally influenza accounts for between and million severe cases and . to . deaths annually, with most deaths occurring among elderly populations [ ] . in temperate regions, ili is reported throughout the year with a marked increase in cases recorded during winter periods [ ] . however, in tropical and subtropical regions where viral transmission occurs throughout the year, the data on the burden of influenza-like-illness are limited. nevertheless there is some evidence of a slight increase in cases during the rainy season [ , ] . the emergence of new highly pathogenic influenza a/ h n viruses in [ ] , their wide circulation in wild and domestic birds and its association with human infections which involves high mortality, has raised global concern about the risk of another influenza pandemic. the emergence of novel human pandemic influenza a (h n ) in april [ , ] and its rapid worldwide spread has motivated the monitoring of influenza and has enhanced preparedness to counter a possible emerging pandemic. in the african region, countries in collaboration with international partners (e.g. who, cdc, namru- , etc.) put efforts together to establish influenza surveillance capacities as part of the broader strategy for integrated disease surveillance and response (idsr) [ , ] . while most countries in asia, north america and europe have wellestablished influenza surveillance, few such systems have been established in sub-saharan africa [ , ] . influenza surveillance helps in understanding the epidemiology and impact of the disease; therefore providing information about seasonality and the groups at high risk of influenza infection. furthermore, the identification and characterization of circulating viruses will help to provide influenza isolates for monitoring changes in viral antigens and the development of vaccines. thus influenza surveillance provides data for pandemic influenza monitoring and planning as well as for decision-making [ ] [ ] [ ] . in togo, the first suspected cases of human avian influenza a/h n were reported between and in the maritime region, a few kilometers from the capital city lomé, which has a population of more than millions. between april and december , cases of ili were observed and were suspected to be pandemic influenza given the emergence of the novel human pandemic influenza a (h n ) pdm . with no ongoing influenza surveillance, our country was not yet ready to confirm and effectively monitor the severity of the disease. the lack of molecular laboratory technology to detect influenza viruses significantly reduced our ability to manage and control the pandemic. therefore, the ministry of health (moh) in collaboration with the institut national d'hygiène (inh) decided to add influenza to the list of diseases with epidemic potential to be monitored and reported through the idsr program. by april , togo was actively involved in ili surveillance with the support of united state government through the centers for disease control (cdc) and the naval medical research unit- (namru- ). this study aims to describe the implementation of ili surveillance and results obtained from april to december . the ili surveillance system constitutes a collaborative partnership between several togolese institutions within the ministry of health (moh). the departments involved in this surveillance are the division of epidemiology, the national influenza reference laboratory (nil) hosted by the institut national d'hygiène (inh), and the sentinel sites located at the hôpital de bè and military health services in the capital city lomé (figure ) . a protocol for influenza surveillance was written with the technical support of cdc and namru- experts. the ili sentinel surveillance sites were selected based on their accessibility and affordability to patients with low socioeconomic status, the qualifications of medical staff, adequate specimen storage capacity, and an established transportation system to the national influenza reference laboratory (nil). the first site was hôpital de bè, established in april and located in district n° . this site was chosen for its geographical location in an area of high population density and high consultation rate. this hospital hosts a pediatric unit and a general medicine ward. the second site established in december , is under the management of the military health services and located in district n° ; its selection was based on the essential role of the armed forces in case of a pandemic and their ability to serve both military and civilian populations. this military site is composed of three units and is attended by military personnel, their families as well as civilians. the two sentinel sites are located in the capital city of togo where approximately % of the country's population lives. lomé has two rainy seasons and two dry seasons: the long rainy season (april to june) and the short rainy season (mid-september to october). the long dry season extends from december through march, while the short dry season lasts for two months (july to august). lomé is a coastal city that borders the atlantic ocean to the south, ghana to the west, benin to the east ( figure ) and is at the crossroad with considerable commercial exchange of goods and movements of population. the who case definition [ ] that was used, defined ili as "any person with a sudden onset of fever (≥ °c) and cough or sore throat accompanied or not by general symptoms such as myalgia, prostration, headache or malaise". this definition was used during - period. in , the definition was changed to "any person with a sudden onset of fever (≥ °c) or history of fever and cough or sore throat accompanied or not by general symptoms such as myalgia, prostration, headache or malaise". at both sentinel sites, from monday to friday physicians enrolled the first two outpatients who met the case definition and samples were collected during consultation. the study population included every outpatient, between april to december , presenting at any of the sentinel sites and meeting the ili case definitions regardless of age or sex and who consented to participate in the surveillance. this population represents a wide cross-section of ethnic and socioeconomic groups. samples collected were nasopharyngeal and oropharyngeal swabs and were placed in the same tube containing a viral transport medium (vtm). they were stored between to °c at the bacteriology laboratory of the sentinel site prior to delivery to the nil within hours. before samples were transported, laboratory personnel at the sentinel site conducted quality control checks of information on patients' case report forms. the nil provides the sentinel sites with logistical and material support such as swabs, viral transportation media, cryovials, cool boxes, and ice packs. a quota of samples was targeted from each sites and transported twice a week (tuesday and thursday) to the nil. review meetings with all stakeholders were organized two or three times per year as part of a strategy to in at sigbéhoué (district des lacs), adétikope (district du golfe) and agodekê (district de zio). in at agbata (district des lacs). all theses foci were located at few kilometers from the capital city, lomé. improve the surveillance system by identifying strengths and areas of concern during these meetings. socio-demographic (age, sex, date of birth, residential area, travel history) and clinical (date of onset, date of consultation, previous treatment, vaccination status, co-morbidities) data were collected from all patients using a case report form (crf) during consultation. epidemiological data were stored in a single database with laboratory data using a single identification number for each patient. each week, nil provided reports on the distribution of total samples collected, as well as on the number of confirmed influenza cases to the moh, to the sentinel sites, who flunet, cdc, and namru- . samples collected were analyzed at the national reference influenza laboratory at inh. from every sample, three aliquots were made, two of which were stored at − °c for external quality control and further analysis (if not subtyped) at namru- in cairo, egypt. the other one was kept between to °c for rna extraction followed by influenza virus detection by real time rt-pcr within hours after sample reception. for the testing of influenza viruses, rna extraction was performed from μl of naso and/or oro-pharyngeal cells contained in the vtm by using a qiamp viral rna mini kit (qiagen) following the manufacturer's protocol. for detection and typing, it was run on an abi machine, the real time rt-pcr using the ambion enzyme agpath one-step (ambion, applied biosystems) that amplifies influenza a and b. the u.s. cdc provided the protocol used to detect influenza viruses [ ] . in order to determine the quality of the sample, the presence of human ribo-nucleoprotein (rnp) was assessed for each specimen tested. socio-demographic and clinical epidemiological data were entered into a database created using epi-info software version . . data analysis was conducted using spss software version . (spss inc., chicago, il). student t-test was used for comparison of mean age and the pearson chi-square or fisher exact test to compare laboratory results by age groups and clinical symptoms. the protocol was approved by the moh as part of the monitoring of diseases with epidemic potential and therefore did not require ethical review. verbal consent was obtained from all patients. a total of patients were enrolled in this study. seven hundred and twenty seven ( %) patients were enrolled from the hôpital de bè and ( %) from the military health service site (table ). there was no significant difference in the proportion of females compared to males enrolled in this study ( . % vs. . %; p = . ), and the gender distribution at the two sites was similar. most of patients ( %) were under years of age, while less than % were years or older. patients who presented at the hôpital de bè were significantly older (mean age = . years) compared to those who were seen at the military health service (mean age = . years with % of patients aged less than years) (p = . ). approximately % of the patients reported having received influenza vaccination within the last year. of the samples collected for ili surveillance, ( . %) tested positive for influenza viruses. of these, ( . %) tested positive for influenza a virus and ( . %) for influenza b virus ( table table ). the proportion of influenza positive cases varied between different age groups with a higher proportion of influenza a detected in the - year-old group ( %) than other age groups (p = . ; table ). significantly, the pandemic influenza a (h n ) pdm was more often detected in patients aged - (p = . ) and - (p = . ) years than in other age groups. seasonal a/h n was predominant in patients aged - years ( %; p = . ) and was the only influenza a subtype detected among patients who were years or older. ili was observed throughout every year with irregular peak activity occurring twice annually during the months of; may and november in ; may and october in ; april/august, october in ( figure ) . however, the number of patients/samples enrolled was not consistent. influenza a virus was detected predominantly in and correlated with the ili peak. the first cases of pandemic influenza a (h n ) pdm were only confirmed in may. during the ili peak, the influenza positivity rate was % in may and % in november with the pandemic influenza strain, the most subtype detected. the pandemic virus remained predominant between october and april (figure ). during the ili peaks in , the influenza positive rate ranged from % to % with the predominance of influenza b virus activity in may representing % of all virus detected ( / ). the second peak was correlated to the seasonal influenza a/h n activity in october with % of viruses detected ( / ). from october , there was a co-circulation of influenza type a and type b with low activity of pandemic strain until september while the seasonal influenza a/h n was detected throughout the year . fever ( %), cough ( %), and rhinorrhea ( %) were the major symptoms for all age groups although sore throat ( %) and headaches ( %) were also recorded ( table ). ili patients who tested positive for influenza were more likely to present with cough (p = . ) and headaches (p = . ) but were less likely to present with difficulty breathing (p = . ) compared to those who tested negative for the influenza virus. among symptoms, only cough was more common in patients testing positive for influenza a than those who tested positive for influenza b (p = . ). rhinorrhea was more common in patients with seasonal a/h n than in those with pandemic influenza a (h n ) pdm (p = . ). due to the lack of ili surveillance in togo, there was no information about the epidemiology of ili or influenza viruses until . the first samples collected were processed in may and the presence of pandemic influenza a(h n ) pdm virus was confirmed in togo one year after the novel pandemic influenza occurred in mexico (april ). this is the first report that describes the epidemiology of influenza in togo using data from the ili sentinel surveillance system. during the two and half year period of ili sentinel surveillance, influenza viruses were detected in ( %) of samples. the average percentage positive in this study was higher than the positivity rate observed in other african countries between and [ ] . however, during the same timeframe, other countries in the temperate climate region: madagascar ( %), morocco [ ] . there are several reasons to explain the difference in the percentage positive observed between countries including the temporal distribution of these viruses, the sample collection method, the number of samples collected and the geographical distribution of sentinel sites. most of our data includes post pandemic influenza a (h n ) pdm ; this is a different picture compared to other african countries ( ) ( ) ( ) ( ) ( ) and to the south american region. the sample collection method was different from one country to another. in our study, we used two swabs (one oro-pharyngeal and one nasopharyngeal) for each enrolled patient and put both swabs in the same cryotube, thereby increasing the viral load and enhancing rt-pcr detection while in some other countries samples were collected either with nasopharyngeal [ ] or oro-pharyngeal swab only [ , ] . in addition, the number of samples tested in most of the other countries was quite high compared to our sample numbers and they were collected from many sites ranging from only to as many as . we only used two sentinel sites as our catchment area. the influenza positivity rate varied by year with the highest rate obtained in . since the number of samples collected during this year was very low ( samples) than the two subsequent years, the rate could be influenced. nevertheless, our percentage positive was similar to that of ghana and rwanda in africa [ ] and that of taiwan [ ] , but at different periods of time. table distribution of influenza viruses confirmed and ili patients influenza a was predominant in with pandemic influenza a (h n ) pdm in our study; this observation was similar to that of other countries in west africa [ ] . however, in , the situation was different in other subregions with predominance of influenza b in central/south and north africa [ , ] and seasonal influenza a/h n in east africa [ ] . this difference could be explained by the fact that circulation of pandemic influenza a (h n ) pdm was delayed in west africa and occurred one year after it was predominantly circulating in other african subregions [ , ] . while two years is not sufficient time for an adequate description of the seasonality of influenza virus transmission, we did observe trends in the lomé commune region. the influenza b virus showed a peak activity during the rainy seasons (may and october) and the pandemic influenza a (h n ) pdm was more frequent during the long dry season while the seasonal a/h n was detected across both seasons. although the seasonality of influenza viruses in african countries is not yet clear, we observed that our trends were similar with the influenza peaks, which have often been associated with the rainy season activity in other tropical countries [ ] [ ] [ ] . in our study, influenza cases were highest ( %) in the - year age group but also high among other age groups, with lowest percent positive ( . %) among - and > years ( . %). this distribution is consistent with the observation in the study conducted in countries of africa during to and in peru [ , , ] in which young children and adults were shown to have the highest influenza viral disease. contrary to our study, a study from venezuela [ ] showed higher detection rates in - year olds. the percentage positive of influenza a was significantly higher in ili patients in the - age groups. therefore, we found that pandemic influenza a (h n ) pdm was detected significantly among - years old. this finding is consistent with other studies in the african region [ , , ] that have found that pandemic influenza a (h n ) pdm is most commonly identified in school-age children and young adults. while pandemic influenza a (h n ) pdm appeared more often in older children, seasonal influenza a/h n appeared more likely to infect adults in the - year-age category. our finding was similar to the observation from a study conducted in peru [ ] , where the author found that the seasonal influenza a/h n virus was detected with adults of to years. in conclusion, our results are consistent with studies from africa and south american regions which observed that seasonal influenza a/h n affected a wide range of age groups with predominantly to years old while the pandemic influenza a (h n ) pdm and influenza b virus infections occurred more frequently among older children and young adults. we observed that clinical symptoms were associated with influenza viruses. the influenza type a was more frequently detected than type b in patients presenting with cough and rhinorrhea. this result is consistent with the observation of a study from venezuela [ ] . in contrast with this study were pandemic influenza a (h n ) pdm was associated with ili patients with cough, our study showed that ili patients with rhinorrhea were associated with seasonal a/h n . our study had some limitations. our data were collected only from sites in an urban area in the capital city of togo and could not be generalized to the population. the percent influenza positivity and age distribution of positive cases were influenced by the low number of samples collected which may be attributable to the non availability of a physician to collect nasal and orpharyngeal swabs. the low number of samples may have also contributed to the high positivity rate. in addition, this low proportion may not be representative to better describe the distribution of influenza cases in the age groups. physician time limitations were due to the time consumption and their workload (number of patients viewed in consultation at the outpatients' department). children were over-represented in this study thus introducing a bias, as the number of adults was not comparable to children under years old. some possible reasons to explain this bias include the fact that the military health service has three units but only the family health care center was functional when added as a site in december . because this unit is a pediatric health center, the high number of children enrolled from this site can account for the observed figures. at the hôpital de bè site, we observed that many patients, mostly adults were not enrolled as ili patients due to the lack of recorded fever (≥ °c), suggesting that we should be considering history of fever as one of the enrollment criteria for ili. this study focused exclusively on outpatients thus limiting our ability to examine the severity of the influenza viruses in hospitalized cases. since our influenza surveillance system had challenges in collecting samples of severe acute respiratory infection (sari) and the lack of data on hospitalizations with patient follow-up we excluded discussions on sari from this study. to improve our influenza surveillance system, it will be necessary to expand the system in other regions by including sari surveillance for severe disease to give a complete picture of influenza burden and epidemiology in our country. these data provided information on the epidemiology of influenza in the lomé commune region in the capital city of togo. some efforts are needed to allow better understanding of influenza burden and epidemiology by expanding sentinel sites in other regions and including sari surveillance. future studies will also be focused on identifying the etiologic agents for the % of ili cases that were negative for influenza viruses. retrospective analyses of these stored samples will be necessary to identify other respiratory viruses circulating, including respiratory syncytial virus (rsv), coronaviruses, human metapneumovirus (hmpv) and rhinoviruses. who: the global burden of disease: update who: influenza fact sheet available the global impact of influenza on morbidity and mortality seasonality of influenza in the tropics: a distinct pattern in northeastern brazil epidemiology and seasonality of respiratory tract virus infections in the tropics who: affected areas with confirmed cases of h n avian influenza who: pandemic (h n ) epidemiology and factors associated with fatal cases preparedness for highly pathogenic avian influenza pandemic in africa who regional office for africa: integrated disease surveillance in the african region: a regional strategy for communicable diseases influenza in africa: uncovering the epidemiology realities and enigmas of human viral influenza: pathogenesis, epidemiology and control who: recommended composition of influenza virus vaccines for use in the southern hemisphere influenza season manual for the laboratory diagnosis and virological surveillance of influenza who: cdc protocol of real time rt-pcr for detection and characterization influenza a (h n ) pdm virus influenza surveillance in countries in africa influenza-like illness sentinel surveillance in peru influenza surveillance among children with pneumonia admitted to a district hospital in coastal kenya challenges of establishing routine influenza sentinel surveillance in ethiopia nationwide surveillance of influenza during the pandemic ( - ) and post-pandemic ( - ) periods in taiwan sentinel surveillance for influenza-like illness, severe acute respiratory illness and laboratory-confirmed influenza in kinshasa, democratic republic of congo pandemic influenza a virus subtype h n circulation in west africa epidemiological and virological influenza survey in dakar, senegal: - influenza in outpatient ili case-patients in national hospital-based surveillance seasonality of influenza in brazil: a traveling wave from the amazon to the subtropics sentinel surveillance of influenza-like illness in two hospitals in influenza viruses in nigeria, results from the first months of a national influenza sentinel surveillance system implementation of influenza-like illness sentinel surveillance in togo we would like to thank all sentinel staff at the hôpital de bè and the military health services for their essential role in the ili sentinel surveillance. we are grateful to the ministry of health and the division of epidemiology for their support and coordination. we would like also express our sincere thanks to the team of the national influenza reference laboratory for their efforts in collecting samples, clinical data and detection by rt-pcr of influenza viruses. we wish to thank mr koffi akolly, field epidemiologist for designing the map of the figure . the influenza sentinel surveillance was successful established with the technical and financial support of cdc and namru- . we are grateful also to cdc reviewers for their precious analyses and revision of this paper prior it's submission for publication. the authors have declared that no competing interests exist.authors' contributions im contributed to the study design, statistical analyses of data and wrote the paper. kb and edl contributed to the study design, interpreted analysis and review the manuscript. awh and tat contributed in the study design and review the manuscript. tnn, gnd, wt and pjk provide technical advice for study protocol, methodology, revised critically the manuscript for important scientific content and have given final approval for the version to be published. zi and kk were involved in literature review and revising the manuscript. abk contributed to the facilitation of the project, participated in its design, coordination and review the paper. all authors read and approved the final manuscript. key: cord- - kxszvha authors: imai, hissei; matsuishi, kunitaka; ito, atsushi; mouri, kentaro; kitamura, noboru; akimoto, keiko; mino, koichi; kawazoe, ayako; isobe, masanori; takamiya, shizuo; mita, tatsuo title: factors associated with motivation and hesitation to work among health professionals during a public crisis: a cross sectional study of hospital workers in japan during the pandemic (h n ) date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: kxszvha background: the professionalism of hospital workers in japan was challenged by the pandemic (h n ) . to maintain hospital function under critical situations such as a pandemic, it is important to understand the factors that increase and decrease the willingness to work. previous hospital-based studies have examined this question using hypothetical events, but so far it has not been examined in an actual pandemic. here, we surveyed the factors that influenced the motivation and hesitation of hospital workers to work in japan soon after the pandemic (h n ) . methods: self-administered anonymous questionnaires about demographic character and stress factors were distributed to all employees at three core hospitals in kobe city, japan and were collected from june to july, , about one month after the pandemic (h n ) in japan. results: of a total of questionnaires distributed, ( . %) valid questionnaires were received. . % (n = ) of workers had strong motivation and . % (n = ) had strong hesitation to work. demographic characters and stress-related questions were categorised into four types according to the odds ratios (or) of motivation and hesitation to work: some factors increased motivation and lowered hesitation; others increased motivation only; others increased hesitation only and others increased both motivation and hesitation. the strong feeling of being supported by the national and local governments (multivariate or: motivation; . ; ci . - . , hesitation; . ; ci . - . ) and being protected by hospital (multivariate or: motivation; . ; ci . - . , hesitation; . ; ci . - . ) were related to higher motivation and lower hesitation. here, protection included taking precautions to prevent illness among workers and their families, providing for the care of those who do become ill, reducing malpractice threats, and financial support for families of workers who die on duty. but . % of the respondents answered protection by the national and local government was weak and . % answered protection by the hospital was weak. conclusions: some factors have conflicting effects because they increase both motivation and hesitation. giving workers the feeling that they are being protected by the national and local government and hospital is especially valuable because it increases their motivation and lowers their hesitation to work. the professionalism of hospital workers was challenged by the pandemic (h n ) . to maintain the function of hospitals under high risk conditions in the future, it is important to clarify the factors that promote or hinder a professional attitude in actual situations. historically, the professionalism of medical workers has been tested by various events such as hiv, ebola hemorrhagic fever, the tokyo sarin gas attack, sars and so on. among these events, sars raised the question of how professionals should respond in public emergencies. sars spread to countries, where it infected people and killed (mortality rate: . %). most hospitals continued to serve the public, but at least one hospital in china ceased to function because of mass absence of its workers [ ] . many people in the public were afraid of what would happen if infections like sars occurred on a pandemic scale. after the sars crisis, various studies were carried out, in which hospital workers were asked how they would respond to a hypothetical pandemic infection. in germany, % of nurses, doctors, medical students and hospital officials answered that they might be absent from work during a pandemic to protect themselves and their families [ ] . in the united states, . % of local public health workers reported that they would probably not work during a future influenza pandemic [ ] and . % of health care employees would be unwilling to work during a sars pandemic [ ] . in singapore, . % of primary care physicians would not look after patients infected with avian influenza [ ] . in canada, % of family physicians indicated that they would be unwilling to help in a pandemic infection if their help was requested by the public health department [ ] . overall around or % of health care-related workers showed a hesitation to work during a future infection pandemic regardless of their culture. on june , , who declared the h n influenza infection a pandemic. on may , our hospital admitted the first patient that had been domestically infected with the h n influenza virus in japan. in the following two weeks, people who suspected that they had h n influenza infection came to our hospitals and were released as outpatients and an additional patients who we suspected as having h n were admitted. of these, were diagnosed as having an h n influenza infection after they were admitted. kobe city medical center general hospital had admissions who were suspected to be h n -positive, including patients who were subsequently diagnosed with h n . kobe city medical center west hospital had admissions including patients diagnosed with h n afterward. the peak was may and the number of patients coming to our outpatient unit for h n infection on that day was . on may , the mayor of kobe city declared the emergency had subsided. on june , the outpatient unit for h n infection was closed. to the best of our knowledge, no studies have evaluated hospital workers' willingness to work and the factors that influence their decisions in a real pandemic. individuals interacting within a social setting are known to be subject to intrinsic and extrinsic motivation, and are often manipulated or managed to strategically meet societal and/or organizational goals [ , ] . professionals, who are traditionally granted a high degree of autonomy, may be particularly sensitive to incentives and disincentives, of whatever nature [ ] . a hospital-based study suggested that the willingness of workers to respond to an influenza pandemic is powerfully influenced by their perceptions of threat and efficacy [ ] . professional conduct of physicians is affected by incentives and disincentives [ ] [ ] [ ] [ ] [ ] [ ] . from these points of view, the willingness to work is thought to be a function of the conflicting factors of motivation (incentives), and hesitation (disincentives). to maintain willingness of hospital workers and improve hospital function in critical situations, it is important to understand the factors that motivate hospital workers to work and that discourage them from working. after our experience with the h n influenza pandemic, we investigated the attitudes of workers in kobe area hospitals about willingness to work in a pandemic and the factors that influence them by using questionnaire. this survey was approved by the kobe city medical center general hospital ethical review board. participation in this survey was voluntary. we conducted the study at kobe city medical center general hospital ( beds), kobe city medical center west hospital ( beds) and nishi-kobe medical center ( beds), which compose kobe city hospital organization and are tertiary teaching hospitals in kobe city. all three hospitals accepted h n influenza patients starting march , , when the first domestically infected patient visited kobe city medical center general hospital. paper-based self-administered anonymous questionnaires were personally handed to all employees or placed in their mail boxes from june , and were collected from collecting boxes in the participating hospitals till july , , which is about one month after the peak of the h n outbreak in kobe city. when this survey was conducted, the level of the pandemic was phase in the world and the number of patients in japan was growing, but the alert to the infection was downgraded as information accumulated that the virulence was not strong. by june , , our hospitals returned to their normal practice. the questionnaire explained its purpose and stated that the results would be published, and respondents would remain anonymous. the first item asked for approval to use the responses in the survey. answers without this approval were omitted from the analysis. the questionnaire contained items that addressed sociodemographic characteristics, perceived stress associated with the h n event, and motivation and hesitation to work during the event (additional file ). the personal characteristics included gender, age, job and working place (the ward for h n , the outpatient department for h n , emergency outpatient unit, headquarter and others). the stress-related questions were as follows: anxiety about being infected; anxiety about infecting family; anxiety of being infected during commuting; lack of knowledge about infectiosity and virulence; lack of knowledge about prevention and protection; feeling of being protected by national and local government; feeling of being protected by hospital (the protection include taking all reasonable precautions to prevent illness, providing for the care of those who do become ill, reducing malpractice threats for those working in high-risk emergency situations and providing reliable compensation for the families of those who die while fulfilling this duty and attenuating the duty of hospital workers not to become a patient him or herself and so on); anxiety about compensations; burden of increase quantity of work; burden of change of quality of work; physical exhaustion; mental exhaustion; insomnia; elevated mood; feeling of being avoided by others; feeling of being isolated; feeling of having no choice but to work due to obligation; burden of child care including lack of nursery. these are the essential items from previous studies on sars [ , ] and hypothetical infection pandemics [ , , , ] and hypothetical symptoms during crises. the respondents used a -point likert scale ( ; "never", ; "rarely", ; "sometimes", ; "always") to respond to the questions about how often they felt about the items. the responses of how often they felt motivation and hesitation to work were also scored by a -point likert scale as above. the jobs of hospital workers were classified into three categories: ( ) clinical staff (doctors and nurses); ( ) clinical technical/support staff (radiological technologists, clinical laboratory technicians, pharmacists, dieticians, social workers, physical therapists, occupational therapists and speech therapists); and ( ) non-clinical staff (office workers, clinical clerks, guards, janitors and others). working places were categorised into the highrisk places (the ward and the outpatient department for h n influenza infection, emergency outpatient unit and headquarter) and the low-risk places (others). we were unable to determine how many workers in high risk places actually came in contact with h n patients, but all such workers could have come in contact with h n patients and they recognized this. responses to the stress-related questions and motivation and hesitation to work were dichotomized into responses with a score two or less (weak) and all other (strong) responses. bivariate and multivariate logistic regression models (adjusted for age, gender, job and working place) were used to compute odds ratios (or) to evaluate the association of personal characteristics variables and stress-related items with self-described motivation and hesitation to work. spss ( . j: tokyo) was used for data capturing and analysis. we sent out a total of questionnaires. we received a total of valid questionnaires ( . % clinical technical/support staff had higher motivation (multivariate or: . ; ci . - . ) than clinical staff without any significant difference in hesitation. working at a high-risk facility was related to higher motivation than working at a low-risk facility (multivariate or: . ; ci . - . ) without any significant difference in hesitation ( table ). the associations between stress-related questions and or are shown in table . among the items with significant difference between the responses to the stress-related questions with strong scores and those with weak scores, ors that are over . or under . are indicated as follows; "being protected by the national or local government" (multivariate or: motivation; . ; ci . - . , hesitation; . ; ci . - . ) and "being protected by hospital" (multivariate or: motivation; . ; ci . - . , hesitation; . ; ci . - . ) were associated with higher motivation and lower hesitation. . % responded that the protection from the national and local governments was weak and . % responded that the protection provided by their hospital was weak. "elevated mood" was associated with higher motivation without any significant difference in hesitation (multivariate or: . ; ci . - . ). the items with higher motivation without any significant difference in hesitation were "burden of child care including lack of nursery" (multivariate or: . ; ci . - . ). the items with higher motivation and hesitation were "anxiety about being infected" (multivariate or: motivation; . ; ci . the percentage of workers that considered childcare to be a burden was significantly higher among females ( . %) than males ( . %). although some studies have examined professionalism or willingness to work in a hypothetical pandemic or high-risk infection and one study examined the hospital absentee rate during an actual h n pandemic [ ] , as far as we know, our survey is the only one that evaluated hospital workers' willingness to work and the influencing factors following an actual pandemic infection. our study was focused on the factors associated with willingness. the results show that willingness has conflicting aspects. that is, factors that raise motivation do not necessarily lower hesitation: some factors raise both motivation and hesitation. we found factors were categorised into four types according to their influence on the or of motivation and hesitation to work. that is, some factors increased the or of motivation and lowered the or of hesitation, other factors increased the or of motivation only, other factors increased the or of hesitation only, and others increased the or of both motivation and hesitation. this is important because understanding factors that cause or reduce conflict is necessary to find ways to support professionalism of hospital workers in a highrisk environment. a limitation of our study is the non-response bias as a result of the . % response rate. however, the total number of subjects was large and their demographics to the population as a whole that did not make noticeable difference. the most important factors are ones that resolve conflicting emotions and promote willingness, that is, increase motivation and lower hesitation. above all, the various types of protection that workers receive from the national and local governments and from their hospitals (e.g. protecting them from getting sick and from malpractice suits) needs improvement. the physicians, nurses and others in the ward for h n and the outpatient department for h n were provided with protection suits, n masks, goggles and antiviral prophylaxes but many of them felt that they were not strongly protected by the national and local government and hospitals. there were no plans about what they should do or how they would be reimbursed in case they became infected and the governments provided no encouraging words to the hospitals. in a study of the use of the antiviral oseltamivir as a prophylactic [ ] , employees who worked in high risk places at kobe city medical center general hospital (kcgh) took oseltamivir from may to may , . only % took the medicine for the full ten days. the others stopped taking it for a variety of reasons, including side effects, anxiety about the drug, failure to remember taking it, or because the virulence of h n seemed weak. the fact that governmental and hospital protection increased motivation and lowered hesitation suggests that positive intervention in these fields will have the strongest impact on reducing non-illness-related absenteeism. therefore, the protection of hospital workers by governments and hospitals should be emphasized [ ] [ ] [ ] . samuel et al. [ ] suggested that two major factors are involved in instilling employees sense of ethical obligations to treat patients during a crisis. first is an expectation of some reciprocal social obligations. for example, in preparation for epidemics, communities or employers should take all reasonable precautions to prevent illness among health care workers and their families, provide for the care of those who do become ill, reduce or eliminate malpractice threats for those working in high-risk emergency situations and provide reliable compensation for the families of those who die while fulfilling this duty. second, the duty of physicians should be attenuated but not eliminated, by his or her responsibility in order to prevent them from becoming patients [ ] . work can be attenuated by reducing working time, by restricting the number of patients, by assigning physician to a place with lower workload or by shifting them to jobs with lower risk. in order for workers to fulfil their duties, they need to feel safe. the feeling of safety will be strong when the safety is provided by their organizations. but, in addition to these measurements, there is a need for frequent communication between individual workers and their organization or governments. encouragement from organizations or governments would also support workers mentally. in the present study, increased motivation and less hesitation was noted in middle-aged and male workers. age and gender were also examined in two studies that presented hospital workers with a hypothetical influenza pandemic in the united states [ ] and a hypothetical sars pandemic in singapore [ ] . these studies found no age or gender difference in the willingness to work, which is inconsistent with our results. this discrepancy may be partly because people in management positions have a strong sense of responsibility, and in our hospitals, many of the management positions are held by males in their s and s. another reason for the discrepancy is that our study was based on a real pandemic and the others were based on hypothetical pandemics. as for gender, studies of physicians' burnout have indicated that females feel more stress than males in the workplace [ , ] . as a result, extra measures should be taken to alleviate the stress of female workers during stressful events, such as by providing childcare services. factors that increase motivation only may not always be good because they could result in overfatigue in the long run. paradoxically, we found that working in a place of high risk and demands for unaccustomed work increased motivation. a canadian study of senior practitioners with reputations for resilience indicated that making a unique contribution, and receiving privileges and rewards are central to building resilience, although the burden of increased workload was found to lower the level of satisfaction [ ] . in view of these results, working in a place of high risk with new work may be considered as a special contribution by hospital workers. technical/support staffs were especially motivated, perhaps because, in addition to the above reason, they usually had little direct contact with patients and thus had lower perceived levels of risk. reducing the factors that cause hesitation only will reduce the barrier to work in high-risk situations. such stress factors include a lack of knowledge about prevention and protection, the burden of increased quantity of work, the feeling of being avoided by others, and the burden of childcare without childcare facilities. examples of such measures include work sharing or rotation of duty. sharing of duties and increasing the number of people who work in high-risk places will provide workers with more concrete knowledge about prevention and protection, lighten their workload, promote a sense of unity and reduce the sense of isolation. reducing factors that increase both motivation and hesitation should be given high priority, as these factors can result in the conflict among hospital workers in the long term, although in the short term they may cancel each other out. in the present study, many of the respondents had strong fears of being infected ( . % of respondents), infecting family ( . %), feeling of having no choice but to work due to obligation ( . %) and anxiety about compensation in case of being infected ( . %). during an infection pandemic, it is to some degree inevitable to feel exhausted and isolated and to worry about becoming infected. but a study said that mitigation strategies that include options for preferential access to either antiviral therapy, protective equipment, or both for the employee as well as his or her immediate family will have the greatest impact [ ] . our hospitals provided all protective measurements listed above to the employee but not to his or her immediate family. the measurement should include protection of employees' family, which might support their motivation and reduce hesitation. in addition, government and hospital managers should develop plans to compensate and treat workers that become infected and to help workers meet their obligations. this would also increase the feeling of protection given by the hospital and the various levels of government. although our survey was related to an influenza pandemic, most of the questions used here have generalizability to other high-risk situations. further studies are needed to test the external validity of our results. we found that there are factors which influence motivation and hesitation to work in an influenza pandemic. some factors have conflicting effects that increase both motivation and hesitation. giving workers the feeling that they are being protected by the national and local governments and by their hospital is especially valuable because it increases their motivation and lowers their hesitation to work. this can be achieved by not only providing protective materials and compensation but also by frequently communicating with and encouraging workers. we should prepare for severer and longer infection pandemic as soon as possible. additional file : questionnaire asian medics stay home, imperiling respirator patients. the new york times influenza pandemic and professional duty: family or patients first? a survey of hospital employees local public workers' perceptions toward responding to an influenza pandemic health care workers' ability and willingness to report to duty during catastorophic disasters a crosssectional study of primary-care physicians insingapore on their concerns and preparedness for an avian influenza outbreak enhancing public health response to respiratory epidemics employee reward london: institute of personnel and development understanding organizations london: penguin books sociological approaches to health and medicine london: croom helm characterizing hospital workers' willingness to report to duty in an influenza pandemic through threat-and efficacybased assessment preserving the physician-patient relationship in the era of managed care financial incentives for physician in hmos: is there a conflict of interst general practitioners and the new cotract: promoting better health through financial incentives sulmasy d: physicians, cost control, and ethics extreme risk -the new corporate proposition for physicians economic incentive in community nursing: attraction, rejection or indifference? human resources for health the experience of the sars outbreak as a traumatic stress among frontline healthcare workers in toronto: lessons learned the immediate psychological and occupational impact of the sars outbreak in a teaching hospital healthcare workers' attitudes to working during pandemic influenza: a qualitative study which health care workers were most affected during the spring h n pandemic? use of oseltamivir for prevention of novel influenza a(h n ) infection in healthcare personnel: treatment compliance and incidence of adverse events severe acute respiratory syndrome and its impact on professionalism: qualitative study of physicians' behaviour during an emerging healthcare crisis the lessons of sars ethics and sars: lessons from toronto physician responsibilities in epidemics risk perception and impact of severe acute respiratory syndrome(sars) on work and personal lives of heslthcareworkers in singapore women in medicine: stresses and solusions well-being in residency training: a survey examining resident physician satisfaction both within and outside of residency training and mental health in alberta building physician resilience mitigating absenteeism in hospital workers during a pandemic pre-publication history the pre-publication history for this paper can be accessed here factors associated with motivation and hesitation to work among health professionals during a public crisis: a cross sectional study of hospital workers in japan during the pandemic (h n ) we thank the three hospitals for their assistance in this survey. authors' contributions hi was the lead writer and worked on the content development and distribution of the survey instrument. km coordinated the three hospitals survey protocol. ai, km and nk developed survey instrument content and distributed of the survey instrument at kobe city medical center general hospital. ka and km, and ak, mi and st distributed the survey instrument and cooperated data analysis at kobe city medical center west hospital and west kobe medical center respectively. tm provided guidance on whole process. all authors read and approved the final manuscript. the authors declare that they have no competing interests. key: cord- -vi dms authors: hanvoravongchai, piya; adisasmito, wiku; chau, pham ngoc; conseil, alexandra; de sa, joia; krumkamp, ralf; mounier-jack, sandra; phommasack, bounlay; putthasri, weerasak; shih, chin-shui; touch, sok; coker, richard title: pandemic influenza preparedness and health systems challenges in asia: results from rapid analyses in asian countries date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: vi dms background: since , asia-pacific, particularly southeast asia, has received substantial attention because of the anticipation that it could be the epicentre of the next pandemic. there has been active investment but earlier review of pandemic preparedness plans in the region reveals that the translation of these strategic plans into operational plans is still lacking in some countries particularly those with low resources. the objective of this study is to understand the pandemic preparedness programmes, the health systems context, and challenges and constraints specific to the six asian countries namely cambodia, indonesia, lao pdr, taiwan, thailand, and viet nam in the prepandemic phase before the start of h n / . methods: the study relied on the systemic rapid assessment (sysra) toolkit, which evaluates priority disease programmes by taking into account the programmes, the general health system, and the wider socio-cultural and political context. the components under review were: external context; stewardship and organisational arrangements; financing, resource generation and allocation; healthcare provision; and information systems. qualitative and quantitative data were collected in the second half of based on a review of published data and interviews with key informants, exploring past and current patterns of health programme and pandemic response. results: the study shows that health systems in the six countries varied in regard to the epidemiological context, health care financing, and health service provision patterns. for pandemic preparation, all six countries have developed national governance on pandemic preparedness as well as national pandemic influenza preparedness plans and avian and human influenza (ahi) response plans. however, the governance arrangements and the nature of the plans differed. in the five developing countries, the focus was on surveillance and rapid containment of poultry related transmission while preparation for later pandemic stages was limited. the interfaces and linkages between health system contexts and pandemic preparedness programmes in these countries were explored. conclusion: health system context influences how the six countries have been preparing themselves for a pandemic. at the same time, investment in pandemic preparation in the six asian countries has contributed to improvement in health system surveillance, laboratory capacity, monitoring and evaluation and public communications. a number of suggestions for improvement were presented to strengthen the pandemic preparation and mitigation as well as to overcome some of the underlying health system constraints. background "world 'well prepared' for virus" is the title of a news article from the bbc on april , a day the world health organization (who) raised the level of influenza pandemic alert from phase to phase [ ] . the article cited a high-level who officer who commented that "the international community is better prepared than ever" to handle the potential influenza pandemic, because several years of preparation for avian flu had helped countries build up stockpiles of antiviral drugs globally. on the same day, a spokesman for the who regional office for the western pacific declared that "asia is better prepared and in a better position than others" citing experience in management of and response to the severe acute respiratory syndrome (sars) outbreak which affected the region in [ ] . having established a large antiviral stockpile and/or having experience with sars does not necessarily mean that a country is well equipped to face an influenza pandemic. preparedness is a complex phenomenon which involves many aspects, including disease surveillance, case management, command and control, and community containment [ ] . earlier studies on the completeness of national pandemic influenza preparedness plans in several regions reveal that many challenges and important gaps in preparedness remain [ ] [ ] [ ] [ ] [ ] [ ] . besides, these studies show that the level of preparedness varies hugely across and within regions. the situation in developing countries is the most worrisome as their public health infrastructure is often weak with severe shortage in financial, human, and technical resources [ , [ ] [ ] [ ] . since , asia-pacific, particularly southeast asia, has received substantial attention because of the anticipation that it could be the epicentre of the next pandemic. there has been active investment in preparedness strategy and planning in many countries by both domestic and international players. despite such strong interest and investment, a review of strategic pandemic preparedness plans in asia in and a report on regional preparedness published by the united nations system influenza coordinator (unsic) in reveals that the translation of these strategic plans into operational plans is still lacking in many countries in the region [ , ] . this paper presents the results from a rapid situation analysis (rsa) of health system and pandemic preparedness in six countries of the asia-pacific region prior to the h n / epidemic. taiwan had extensive experience with the sars outbreak, with over confirmed cases. viet nam, thailand, and indonesia also had sars cases (albeit fewer than taiwan) and, together with lao pdr and cambodia, have had human avian influenza cases. besides, endemicity of the influenza subtype h n is found in poultry in these five countries. the objectives of this rapid situation analysis are to describe the pandemic preparedness programmes and the health systems context in which these programmes have been established, and to identify challenges and constraints specific to the six countries. it is a part of a bigger project, the asiaflucap project, which aims to evaluate health system capacity in these countries in response to different phases of influenza pandemic. the study was conducted in the second half of with funding support from the european union and the rockefeller foundation. this study relies on the systemic rapid assessment (sysra) toolkit which is a systematic approach for gathering information about structures and modes of operation from complex health systems [ ] . it builds on the sysra framework, a conceptual and analytical framework initially developed by atun et al. to evaluate health systems and communicable disease control programmes [ , ] . the sysra analytical framework provides a conceptual, analytical framework and tool to evaluate health interventions that takes into account disease programmes, the general health system, and the wider sociocultural and political context. for the purpose of this study, this framework was adapted to pandemic influenza. our sysra toolkit comprises of two core elements: (i) the 'health systems element' and (ii) the 'pandemic preparedness programme element' (figure ). the health systems element focuses on structures and functionality of an overall health system (horizontal level). the 'pandemic preparedness programme element' assesses the specific pandemic influenza programme components embedded within a health system (vertical level). for each element, the components under review are: external context; stewardship and organisational arrangements; financing, resource generation and allocation; healthcare provision; and information systems. the study was conducted in the second half of . for each of the rsa modules qualitative and quantitative data were collected based on a review of published data, documentation and interviews with key informants in each country. as a first step, secondary data and documentation was reviewed and summarised for each country in order to determine what information was available and what data was lacking. afterwards, an interview team consisting of members (public health specialists) familiar with the health system and pandemic management programme in the country conducted interviews with key informants using a predefined semi-structured questionnaire, focusing especially on gaps identified in the initial literature review. the questions explored past and current patterns of health programme response, changes in pandemic response and other historical information about outbreak management. while conducting the interviews, additional qualitative and quantitative information were collected through an iterative process of information gathering. key informants were selected on the basis of their expertise in a broad range of health system and pandemic programme components. they were chosen from all administrative levels and from different institutions to provide a triangulated view of the health system and of the pandemic management programme. field visits occurred between october to december with up to key informants being interviewed in each country. no remuneration was provided to the informants. the lists of field researchers and the affiliations and roles of the key informants from each country are provided in the country case study reports available publicly accessible on the website: http://www.cdprg.org/publications. ethi-cal approval for this project was obtained from all participating countries. the scope of this study is limited to health system and health service response and preparation for pandemic influenza. non-health sector preparation and mitigation efforts are beyond the scope of this analysis. the choice of the six countries is based on an historical assessment that they would likely be at the epicentre of an influenza pandemic, the incidence of h n in poultry, and their experience with sars. the country contexts in the six study countries vary considerably. the political systems include republic (taiwan and indonesia), constitutional monarchy (thailand and cambodia), and socialist republic (vietnam and lao pdr). the level of economic development based on world bank's classification ranges from low income with high agricultural share (lao pdr, cambodia, and viet nam), middle income (thailand and indonesia) to industrialized and high income (taiwan). there is, however, similarity in that all countries enjoyed relative political stability (except recently in thailand) and continuous economic growth over the past decade preceding the current global economic crisis. health systems in the six countries vary in regard to the current health status and epidemiological profile, the level of health care resource, health financing mechanisms and health service provision patterns (table ) . • current health status and epidemiological profile taiwan shows a pattern of industrialized economies post epidemiological transition with low mortality, high life expectancy, and high disease burden from chronic diseases. in contrast to taiwan, lao pdr and cambodia have lower life expectancy with high morbidity and mortality from communicable diseases. • level of healthcare resources the level of health system resources reflects the level of economic development. taiwan has a high level of health spending and high density of hospital beds and health workforce per capita. on the other end of the spectrum, cambodia and lao pdr have low health spending and very low health facility and health workforce density. external resources are a significant source of health financing in cambodia and lao pdr. • health financing mechanisms only taiwan and thailand have universal coverage of health insurance. indonesia and viet nam have a number of health insurance schemes such as social security scheme and government employee health insurance for different sectors of the population. lao pdr and cambodia relied mainly on out-of-pocket payments with recent development of community financing. lao pdr is developing social security insurance. • health service provision health service provision patterns in the six countries are mixed. the private sector plays a major role in tai- wan. in both thailand and viet nam, the public sector has an extensive network of public health facilities. however, a significant proportion of population is increasingly using private sector health care providers such as drug stores and private clinics as their first source of health care. in indonesia, lao pdr, and cambodia, the availability of health facilities is quite limited as seen in the density of hospital beds which is at per , or less. one indicator of health service access is the proportion of skilled birth attendance. the statistics in shows that the proportion was over % in thailand and viet nam, around two-third in indonesia, nearly % in cambodia and less than % in lao pdr in . all countries in this study have experienced an outbreak of sars or avian influenza in humans ( table ) . during the sars outbreak, taiwan was severely affected with casualties. there were , nine, and two confirmed cases in vietnam, thailand and indonesia respectively [ ] . for avian and human influenza (ahi), more than human cases have been reported each in viet nam and indonesia, in thailand, eight in cambodia, and two in lao pdr. there were no ahi cases in taiwan. all six countries have developed national governance on ahi and pandemic preparedness. they all have national pandemic preparedness plans and ahi response plans. however, the governance arrangements and the nature of the plans differ across the countries. moreover, the operational procedures as well as strategic directions vary. this section presents the preparedness arrangements in regard to governance and stewardship, financial resources, other resources, and health service provision in the study period. • in all countries, the pandemic preparedness committees were headed by the president or prime minister or his/her representative. in indonesia, lao pdr, and thailand the national pandemic preparedness plans and the ahi response plans were integrated together with ahi response plan as a part of pandemic preparedness plan. the other countries had separated plans for pandemic preparedness from the ahi response plans. at the central/national level, there were three main patterns of pandemic preparedness governance. first, as in lao pdr and indonesia, a special coordination unit (national ahi coordination office (nahico) which recently changed its name to national emerging infectious diseases coordination office (neidco) in lao pdr, and national committee for ai control and pandemic preparedness (komnas) for indonesia) was established specifically to coordinate ahi and pandemic related activities as a priority programme (vertical policy approach). second, in vietnam, the governance relies on existing governance structure e.g. responsible agencies only. third, in cambodia, taiwan and thailand, pandemic preparedness is situated as part of programmes on disaster preparedness and mitigation so the preparation for pandemic is framed within the national disaster response. there was also a difference in the governance in regard to the level of responsibility. this reflects the existing governance structure and the nature of devolution of governing power in the country. in cambodia, lao pdr, taiwan, thailand, where resource allocation decisions are centralized, the budget allocation towards ahi and pandemic preparedness programmes was also decided mostly at central level. in indonesia and viet nam, central authority was important but local authorities also played crucial roles in the decision and priority setting of the level of pandemic preparedness investment in their regions. nevertheless, in all countries the operational activities of pandemic preparation at the local level were allocated to/integrated within the network of existing government bodies. • financial resource data on government and external spending for ahi and preparedness are not readily available and our best estimate shows that most countries spent around usd per capita per year or less on these activities (table ) . whereas the level of to the disease was highest in and , it declined in . funding solely or mostly originated from central budget, except in indonesia and viet nam where the local source of funding was also important, and to a lesser extent in thailand. all countries but cambodia, had discretionary budget for local level administration to use on ahi and pandemic preparation. external resources have been substantial for low income countries, particularly lao pdr and cambodia. almost the entire budget for ahi and pandemic preparedness activities in lao pdr and cambodia was provided by external donors and international organizations. indonesia also drew in a significant amount of external funding for ahi and pandemic preparedness, accounting for almost one-fourth of total budget. there was no external financial support for taiwan and less than percent in thailand. no data was available for vietnam. • other resources: human resource, vaccine, drugs, technology in all six countries, pandemic preparedness activities at the operational level relied on existing healthcare workforce in the public sector. hence human resources available for ahi are reflective of the health workforce situation in public health system. shortage of highly skilled workers was a major problem in all developing countries, especially in relation to physicians and nurses. in regard to specific knowledge and skills for pandemic influenza, additional trainings were provided to specific sections of the workforce in all countries, particularly to those working in surveillance, case detection, and infection control. most, except taiwan and viet nam, did not have a plan for surge capacity of health care workers during pandemic time. moreover, there is a question over potential absenteeism among existing workforce at the time of pandemic. all countries have strengthened their laboratory investigation capacity to prepare for the potential pandemic. all, except lao pdr, had biosafety level (bsl ) laboratory capacity and can conduct virus sequencing. these five countries were also capable of immuno-fluorescence assay (ifa) and reverse transcription-polymerase chain reaction (rt-pcr). only taiwan had the capacity to produce pre-pandemic vaccine and has a plan to increase its capacity towards pandemic vaccine production by . indonesia, thailand, viet nam had plans, or were in the process of conducting research, towards developing their pandemic vaccine production capacity. taiwan, thailand, and indonesia had local capacity to produce antiviral drugs from chemical entities. all countries had stockpiles of antivirals and personal protective equipment (ppe) but the size of the stockpiles varied across countries. in taiwan, the national stockpile was enough to treat % of population and there is a plan to increase this stockpile if necessary. the national stockpiles of thailand and indonesia covered approximately % of their population while in cambodia the national stock in phnom penh was enough for . % of the population ( , doses). we were unable to estimate the size of the stockpiles in lao pdr and viet nam from key informants or reviewed documents. in most countries, the antiviral stockpiles were located at both central level and at hospital and local health authorities. in addition to national stockpiles, there was an asean regional stockpile in singapore. • health service health service preparedness for pandemic influenza highly concentrated on surveillance and rapid containment activities in all countries but taiwan. the surveillance systems were mainly facility and community based surveillance systems where suspected cases are reported to the central level authority for further investigation and note: * only budget for adb cdc regional project; # government budget only containment. several channels for case reporting have been set up including telephone hotline, sms, email and websites. all countries except lao pdr also conducted laboratory surveillance of samples from influenza-like-illness cases. the surveillance system for pandemic influenza in the five countries with history of ahi focused on poultry related cases. when there were animal cases of avian influenza in the neighbourhood, patients with influenzalike illness with history of poultry contacts would be specially monitored. in these countries active collaboration between human and animal health sectors to conduct joint surveillance was reported. also, surveillance rapid response teams (srrts) have been set up at both central level and local level based on existing capacity, to be readily available for field investigation when there is a suspected case. in countries with shortage of qualified human resources, the surveillance and response capacity at local level remains a major challenge. only taiwan and viet nam had explicit plans for surveillance and response in time of pandemic. all countries have assigned referral hospitals to take care of ahi cases in the pre-pandemic phases. a model hospital preparedness plan has been developed in most countries to be used by their health facilities in time of pandemic. hospital surge capacity (extra beds) has been planned in all countries but lao pdr and cambodia. similar to surveillance and response, only taiwan and viet nam had an explicit staff surge capacity plan. lao pdr and taiwan had additional plans to use volunteer in time of pandemic. in regard to case management, the focus was mainly on ahi cases. clinical treatment guidelines for ahi infection have been developed in all countries. training on clinical management of ahi cases has been conducted with patient isolation and antiviral treatment as the main instruments. in all countries there was a policy to provide antiviral prophylaxis to ahi contacts. however, there was no clear rationing policy on antiviral distribution in case of pandemic. all countries (except taiwan which has not reported any case) have provided free care to all ahi patients thus far. in the five countries where human cases have been reported, most infected patients arrived at hospital after their symptoms had developed for several days. in these countries, a patient generally seeks self medication or informal/private primary-care providers as his/her first contact point and only visit public health facilities when the symptoms are severe. this is compounded by the relative lack of health care facilities in lower resource countries like cambodia and lao and the high use of private care facilities in cambodia. there were active public health education efforts in all countries. in the countries with ahi cases, most of the messages and materials were related to the handling of livestock and basic health hygiene such as hand washing, protection when sneezing/coughing. the main strategy of public health education was to focus on the prevention of avian influenza transmission (e.g. use chicken as a mascot, etc). very few messages were on pandemic influenza. a number of simulation exercises have been conducted in all six countries. most of the exercises were table-top style where relevant officers discuss and manage a hypothetical pandemic situation in a round-table manner. for example, thailand had at least one table-top exercise at the central level and in each province. viet nam has conducted many simulations for ahi preparedness at national, provincial and district level as well as at airport and borders. there were also a few regional (multi-country) table-top exercises coordinated by the world health organization and one table-top exercise by the mekong basin disease surveillance network (mbds). only indonesia and taiwan had full-scale exercises involving real field activities. indonesia's full-scale exercise in bali in april was the first of its kind in the world. taiwan's full-scale exercise at its national airport focused on its response to the arrival by plane of a suspected h n case. most exercises reveal that management and coordination between various players, including non-health sector players, constitutes a major weakness in preparedness. a criticism common to all six countries is that most simulations exercises have focused on early containment but not on pandemic preparedness in later phases. the preparation for mitigation efforts at more advanced stages of a pandemic was quite limited in most countries. they have identified various channels for risk communication to the public. however, only taiwan had clear operation procedures to sustain service provision and resource mobilization when widespread pandemic occurs. the researchers also found that knowledge/skills for pandemic preparation at local level were more limited than central level staff. the rapid analyses in six asian countries show a strong link between the health system functions and pandemic preparation. in all countries, the health system context shapes how pandemic preparedness in the country is carried out. from the rsa we found that the interfaces/linkages between health system contexts and pandemic preparedness programmes are particularly strong in three areas: governance and stewardship, resources, and service provision. the arrangements and strength of governance and stewardship of pandemic preparedness programme follow those of the general health system. in well-established health systems, pandemic preparedness is integrated within existing mechanisms, notably within the national disaster preparedness framework. in countries with a weak healthcare system, new vertical programme had to be established to manage and coordinate pandemic preparedness and response. the nature of pandemic governance also depends on the existing political context. decentralized countries have greater challenges to deal with during both outbreaks and pandemics. in a decentralized system like in indonesia, the level of political commitment could affect the level of investment in pandemic preparedness in that region/area as seen in the contrasting difference between bali and jakarta. in jakarta, where political interest on pandemic is low, the planned table-top simulation exercise was postponed because of the lack of budget while in bali, a full-scale exercise was carried out with strong support from all sectors. the political and historical context also shapes the pandemic preparedness process. for example, the political crisis in thailand in resulted in frequent changes of minister of public health and several postponements of national pandemic preparedness committee meetings. in taiwan, pandemic preparation is high on national political agenda because of its previous history of sars outbreak and casualties as well as a perceived threat of bioterrorism. the level of resource available for pandemic preparedness depends on the level of economic and health system development of the country. the amount of financial investment in preparedness activities and stockpiling of drugs and equipments is dependent on the level of budget availability. countries with low financial resource need to rely on external funding for their pandemic preparedness activities. the series of h n outbreaks which have occurred in the region since combined to the heightened global interests in averting a pandemic have allowed many low resource countries to draw in financial resources to support their preparation especially for surveillance and early detection. however, there are questions about the sustainability of these external resources given the current global economic recession and other public health priorities in donor countries themselves. such resources might also be much more difficult to mobilize during pandemic time. similarly, the shortage of highly skilled workers in the general health system has been raised as a major limitation of the preparedness planning and response in many of these countries. this situation could be even more serious in pandemic time when a number of staff may become ill with the disease and some of them may be absent due to the fear of infection. health service provision for ahi control relies primarily on the existing provider system. the main strategy used in all countries but taiwan is to focus on early detec-tion and containment. investment was made into rapid response team and surveillance mechanisms with attention to the linkages between poultry infection and human cases. this strategy may be driven by several factors. the emergence of human cases of h n may have led each of the five countries to strongly assume that outbreaks of human-to-human transmission could start within their own country. moreover, the potential threat of the h n pandemic also drew external funding whose main interest may have been to rapidly contain avian influenza outbreaks within the region, hence investment in surveillance and case detection. besides, the lack of internal resources may have yield to limited investment in pharmaceutical interventions such as antiviral and vaccine stockpiling. the who pandemic classification system into various phases could have also influenced countries into investing first in preparedness for the earlier phases and to delay preparedness for the later phases, although phases will remain fluid during a pandemic as the h n / has demonstrated. investment in pandemic preparedness activities has contributed to the strengthening of health system functions in many countries specifically in regards to surveillance, laboratory capacity, monitoring and evaluation, and public communication. regionally, there has been active cooperation through the surveillance network in the mekong basin through the mekong basin disease surveillance network (mbds). these health system functions could be useful for other diseases beyond pandemic response. however, the low investment in clinical care in relation to other health services may be a big challenge for these countries, especially if a pandemic is to expand beyond the early containment phase. the outbreak of influenza h n / and its spread globally also raises many important questions on how prepared these asian countries are for global pandemic influenza. the underlying assumption that the pandemic would start from avian influenza virus mutation within the country led to heavy investment on surveillance and case detection mechanisms in the five developing countries. these mechanisms were designed primarily for ahi with reliance on poultry contact history in the surveillance and case detection operational guidelines and unlikely to be effective for early-detection and containment of pandemic influenza now that human-to-human transmission has been observed without an animal tracer. the pandemic response strategy and the surveillance and case detection protocols in these countries need to be transformed to accommodate this changing circumstance. it is also important to translate existing pandemic response and mitigation plans into operations particu-larly at the subnational level as local administration and communities need to be active and ready for these plans to be effective. limited stockpiles of the antivirals, covering % or less of the population in all countries other than taiwan, raise the issue of drug allocation when a large-scale highimpact pandemic occurs. the world health organization recommended countries to stockpile antivirals for % of their population but this is obviously not feasible financially for many developing countries [ , ] . similarly, it is already clear with the h n / outbreak that when the pandemic vaccine is developed its availability will be limited [ ] . explicit rationing or prioritization policy for the medicines and vaccines is necessary and should be developed to avoid ethical and political conflicts that may arise [ ] [ ] [ ] . the ongoing threat of pandemic influenza with humanto-human transmission also calls for a revision/reposition of public education campaigns that were shown to be focusing on animal to human transmission in many southeast asian countries. the message requires adjustment from current emphasis on animal handling hygiene to respiratory health hygiene and when to seek medical care. the current treatment strategy to rely on a referral hospital system may also need to be adjusted towards community level surge capacity and the use of volunteers to support the system in time of pandemic. simulation exercises with phase hypothetical scenarios could be useful as a test of the level of preparedness especially with actors from non-health sector. for the preparation to be effective and sustainable, the interventions need not only focus on the influenza related activities. our study shows that health systems provide important context towards the success of the responses. the effort to strengthen pandemic preparedness should also be done in such a way that also strengthens health systems. three areas of improvement based on our findings of strong linkages between pandemic preparation and health systems in governance and stewardship, health system resource, and service provision are highlighted here. firstly, the governance and stewardship of ahi and pandemic preparedness should be integrated into the broader disaster preparedness system. taiwan benefited from more resources from higher level of economic development but comprehensive and multisectoral responses with commitment from all levels also resulted from high political interest and a systematic approach to preparedness using disaster and bioterrorism response system. national ownership of the preparedness activities is particularly important especially in low resource countries where external funding is prominent. the allocation decision of pandemic related investment should be harmonised and aligned with national systems and priorities. secondly, the scarcity of health care resources particularly in rural areas was shown to hamper the preparation for the pandemic as well as the responses to other diseases. scaling up health system capacity such as health workforce and health care infrastructure is necessary and should be decided based on evidence together with effective planning. for example, the countries can benefit from the asiaflucap project's ongoing analysis of health system resource gaps to effectively respond to pandemic. nevertheless, investment in health workforce and health care infrastructure should avoid disease-specific focus and contribute to overall system strengthening [ ] . a number of tools and proposed actions for scaling up disease specific capacity that also promote health system strengthening are increasingly available [ ] [ ] [ ] . lastly, in service provision the preparedness strategy also needs to address the prominent role of the private sector. private providers are the first contact point for health care in many countries. in many countries where the linkage of information system between public and private sector does not exist, the surveillance system may not be able to detect the cases early enough before it has already spread. treatment success could also be lower and the fatality rate could be higher if the patients present themselves late to public health care system where antiviral medicines are prescribed. the pandemic and disaster responses could also tap into the capacity of private nonprofit network and volunteers to support the scaling up of necessary responses. better planning and coordination between public and private sector health providers and is necessary and should be strengthened. this study contains a number of limitations. first, the rapid nature of the analysis was useful for simplicity, speed, and limited cost but it also limits the extent and the depth of the analyses. this limitation is alleviated by the way the questionnaires and data collection procedures were designed. published and grey literature documents were reviewed prior to and after field visits to prepare and verify the data received from the interviews. second, there are potential biases from key informants' selection. these were mitigated by including resource persons from different health system levels and sectors to allow for the triangulation of results from various sources. additionally, the data collection including interviews was carried out by both external and local experts to balance the views and to provide systematic, robust, contextual understanding. third, the scope of the analysis is limited to pandemic influenza and the health systems. other competing health care needs and priorities were assessed to a limited extent in the analysis of health care context. relative importance of those needs could influence how health systems respond to pandemic influenza, which could add to the complexity of the analysis. additionally, a pandemic could create adverse social events beyond health impacts and interrupts essential services such as food logistics or water and electricity supply systems. our study did not explore multisectoral responses or the continuity of essential services beyond the health sector, which is important and deserves further careful evaluation. additional research should be conducted to shed more light into pandemic preparation in these asian countries. a number of research activities are now going on as part of the asiaflucap project. these include the analyses of health system capacity and resource distribution in the country, scenario development for identification of resource requirements at different stages of a pandemic, and stakeholder analyses to better understand the political context and relationship between actors. future research may include the implications of pandemic preparedness on health systems e.g. financial trend, health workforce burden, the economic analyses of resource needed to fill the capacity gaps, and so on. the study in late prior to the h n / epidemic shows that the health system context influences how the six countries have been preparing themselves for a pandemic. the level and form of pandemic preparedness depend on existing health systems arrangements particularly its governance, resource, and existing service provision patterns. the political and historical context of previous epidemics shaped the priority given to pandemic preparation in a country. countries with limited domestic resources rely heavily on external funding for pandemic preparation activities. the fragmentation of health information and referral systems in some countries particularly in relation to linkage with private sector providers constitutes a challenge in synergistic pandemic response. pandemic preparation in the six asian countries has contributed to improvement in health system surveillance, laboratory capacity, monitoring and evaluation and public communications. however, preparation for pandemic mitigation in countries with low health system resources is still rather limited. with the emergence of h n / , the previous preparation in the five developing countries based on the ahi model of poultry to human transmission became less relevant. if a pandemic is to expand beyond the early containment phase it will be a big challenge for these countries whether their health system will have enough capacity to effectively respond. a number of suggestions for improvement were presented to strengthen the pandemic preparation and mitigation as well as to overcome three areas of the underlying health system constraints -governance and stewardships, resources, and service provision. the heightened public interest and awareness on the ongoing pandemic could be mobilized towards more investment in health systems. world 'well prepared' for virus afp: swine flu: asia 'better prepared' to tackle outbreak world health organization: who checklist for influenza pandemic preparedness planning pandemic influenza preparedness in the asia-pacific region how prepared is europe for pandemic influenza? analysis of national plans progress and shortcomings in european national strategic plans for pandemic influenza pandemic influenza preparedness in africa is a profound challenge for an already distressed region: analysis of national preparedness plans pandemic influenza preparedness in latin america: analysis of national strategic plans. health policy plan summary report of the sars expert committee major issues and challenges of influenza pandemic preparedness in developing countries avian and pandemic influenza: progress and problems with global health governance. global public health meeting the challenge of influenza pandemic preparedness in developing countries coordination of avian and human influenza activities. a report produced for the un system influenza coordinator a toolkit for rapid assessment of health systems and pandemic influenza preparedness and response: systemic rapid assessment toolkit (sysra). london, london school of hygiene and tropical medicine world health organization: guide to rapid assessment and response (tg-rar) a framework and toolkit for capturing the communicable disease programmes within health systems tuberculosis control as an illustrative example world health organization: summary of probable sars cases with onset of illness from uk department of health: agreements secured for pre-pandemic vaccine for the uk prioritization strategies for pandemic influenza vaccine in countries of the european union and the global health security action group: a review priority setting for pandemic influenza: an analysis of national preparedness plans antiviral resistance during pandemic influenza: implications for stockpiling and drug use overcoming health-systems constraints to achieve the millennium development goals task force on human resources for health financing: what countries can do now: twenty-nine actions to scale-up and improve the health workforce scaling up in international health: what are the key issues? health policy & planning the asiaflucap project is funded by a grant from the european commission # this paper benefits from the comments received from the participants of the ubud workshop on health system resource for pandemic preparation between - february . we are grateful to the three reviewers -mahomed patel, oscar mujica, and hitoshi oshitani -who provided extremely helpful comments to improve the manuscript. excellent administrative support from nicola lord and wasamon sabaiwan is greatly appreciated. rc has received funding from f hoffmann-la roche, various governments, and the european commission. key: cord- - s e authors: sun, mei; xu, ningze; li, chengyue; wu, dan; zou, jiatong; wang, ying; luo, li; yu, mingzhu; zhang, yu; wang, hua; shi, peiwu; chen, zheng; wang, jian; lu, yueliang; li, qi; wang, xinhua; bi, zhenqiang; fan, ming; fu, liping; yu, jingjin; hao, mo title: the public health emergency management system in china: trends from to date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: s e background: public health emergencies have challenged the public health emergency management systems (phemss) of many countries critically and frequently since this century. as the world’s most populated country and the second biggest economy in the world, china used to have a fragile phems; however, the government took forceful actions to build phems after the sars outbreak. after more than one decade’s efforts, we tried to assess the improvements and problems of china’s phems between and . methods: we conducted two rounds of national surveys and collected the data of the year and , including all provincial, municipal, and county cdcs. the municipal and county cdcs were selected by systematic random sampling. twenty-one indicators of four stages (preparation, readiness, response and recovery) from the national assessment criteria for cdc performance were chosen to assess the ten-year trends. results: at the preparation stage, organization, mechanisms, workforce, and stockpile across all levels and regions were significantly improved after one decade’s efforts. at the readiness stage, the capability for formulating an emergency plan was also significantly improved during the same period. at the response stage, internet-based direct reporting was . %, and coping scores were nearly full points of ten in . at the recovery stage, the capabilities were generally lower than expected. conclusions: due to forceful leadership, sounder regulations, and intensive resources, china’s phems has been improved at the preparation, readiness, and response stages; however, the recovery stage was still weak and could not meet the requirements of crisis management and preventive governance. in addition, cdcs in the western region and counties lagged behind in performance on most indicators. future priorities should include developing the recovery stage, establishing a closed feedback loop, and strengthening the capabilities of cdcs in western region and counties. since the early twenty-first century, frequently appearing public health emergencies such as severe acute respiratory syndrome (sars), middle eastern respiratory syndrome, and ebola have threatened population health and social stability [ ] . this has critically challenged the public health emergency management systems (phemss) of many countries [ ] , especially developing countries. the global community quickly reached a consensus on the development of the phemss [ ] . in , the th world health assembly (wha) adopted the revised international health regulations, which instructed the world health organization (who) member states to collaboratively confront public health emergencies of global concern. a world health report in also focused on global public health security in the twenty-first century. the ebola outbreak in - has pushed the process of who reform into high gear [ ] , giving top priority to changes in the who's emergency operations and a need to build resilient health systems that can withstand epidemics. china has the largest population and the second biggest economy in the world. china has played an increasingly important role in preventing and controlling the global spread of epidemics in recent years and gradually changed from aid recipient to aid donor [ ] . china used to have a fragile phems; however, the sars outbreak exposed many weaknesses and problems [ ] , such as an ineffective response system, lagging epidemiological field investigation and laboratory testing skills, and inaccurate and untimely information communication. these aroused the public's horror and international community's blame. the central government urged governments at different levels to make political commitments and take forceful actions to build the phems. after more than one decade's efforts, what are the trends of china's phems? what are the improvements and remaining problems? what are the implications for china and global health security? in recent years, the development of phems has received increased attention in the literatures. some researchers expressed the importance of phems and the progress after sars qualitatively [ , ] . others quantitatively accessed the trends using regional data, usually at a certain level or within a certain province or city [ ] [ ] [ ] [ ] . time spans were restricted to early-phase usually around [ ] . to our knowledge, little evidence could tell the differences that happened in china's phems in this decade. based on two national surveys in and , we previously reported that resource allocation of cdcs increased and the general completeness of phems improved between and [ ] . however, what measures phems carried out and how it changed still remained unclear. this paper will attempt to answer these questions specifically. this article consists of the follows. the next section provides details on methodology,including sampling, indicator selection and measurements, data collection, and data analysis methods. the third section shows the results, followed by discussion corresponding to the results. the final section is about conclusion and policy implications. the survey methods have previously been published [ ] . briefly, we conducted two rounds of cross-sectional surveys in and . the two surveys were retrospective and selected the same agencies in the two rounds. the survey of collected the data from to , and the survey of collected data of . we conducted a multistage sampling to select cdcs at different administration levels, selected all provincial cdcs and used systematic random sampling to select municipal and county cdcs. as governmental funding is the most critical control point of public health emergency management for the cdcs [ ] ,we used "governmental funding to cdcs per thousand people" as a basis to determine sample size [ ] . a sample size of municipal and county cdcs was calculated based on the following formula [ ] . where n is the number of the minimal sample size; αis the probability of type i error, and β is the probability of type ii error, here α = . ,β = . ; u α and u β are standard normal distribution values corresponding to α and β respectively;σis the population standard deviation, hereσ = . yuan; δ is the allowable error. for municipal cdcs, δ = . yuan, σ = . yuan. for county-level cdcs, δ = . yuan, σ = . yuan ( u.s. dollar = . yuan). the municipal and county level cdcs were all selected through random sampling. the sampling process was conducted based on the national standard coding (gb coding, the corresponding administrative regional code which is unique for each city or county [ ] ). we used a computergenerated random number to identify the first institution, and then selected every third municipal cdc and every sixth county level cdc. finally, we selected provincial cdcs, municipal cdcs, and county cdcs. the study was approved by the former ministry of health (moh) in china and reviewed by the medical research ethics committee at the school of public health of fudan university. we selected twenty-one indicators associated with the phems from the national assessment criteria for cdc performance. based on the crisis management theory which was commonly used in the field of public emergency management [ , ] , the whole process was divided into four stages including preparation, readiness, response and recovery [ ] . according to the framework, we grouped the indicators into stages and capabilities. table showed the features, units and measurements of these indicators. according to the national regulations on public health emergency management [ ] , each sampled cdc graded five public health emergencies handled in the year before the survey with the full mark of points for each indicator; at cdcs where the total numbers of handled public health emergencies were fewer than five, all public health emergencies were graded instead. the bureau of disease prevention and control of the former moh approved and organized two rounds of field surveys, and provincial health departments coordinated data collection. a pilot survey was conducted to ensure validity and reliability. after receiving uniform training from the moh, the provincial quality supervisors trained investigators from sampled cdcs in their corresponding provinces. the investigators collected relevant data from sampled cdcs and submitted the completed questionnaires to their provincial quality supervisors via e-mail or cd-rom. simultaneously, paper copies with official stamps were submitted. the second round of survey data were obtained from national disease control and prevention performance evaluation platform. the quality control process was set up and carried out by the platform with backend logic judgments and audit procedures. as the final step of quality control in both surveys, research group rechecked data and contacted cdcs with abnormal or absent values via email or phone. finally, the overall response rate was . % in and . % in . we established a dataset using excel (microsoft redmond wa). we only used the data of the year and for analysis. after data cleaning and sorting, descriptive analysis and statistical tests were performed using spss . (ibm spss, chicago, il, usa). we used establishing organization comprised building an emergency response office and forming a leadership group and an expert panel. table ). the capability for building mechanisms in terms of information sharing and on-site treatment increased by . % and . %, respectively. increasing by . %, response-material deployment mechanism gained the highest growth rate. municipal cdcs had the highest percentages, followed by provincial and county cdcs. the central region not only had the highest percentages, but also experienced the highest growth rate. average number of emergency response personnel per cdc increased from in to in , which was significant. in , provincial cdcs had the highest number of personnel (n = ), followed by municipal (n = ) and county (n = ) cdcs. moreover, the average number decreased from eastern (n = ) to western regions (n = ) ( table ). the percentage of fully stockpiling emergency resources significantly increased from . % in to . % in . provincial cdcs had the highest percentage ( . %) in and increased by . %, whereas county cdcs had the lowest percentage ( . %) in and increased by . %. nevertheless, the average percentage at each administrative level did not meet the corresponding performance assessment criteria. average percentages of fully stockpiling emergency resources decreased from eastern ( . %) to western ( . %) regions. the mean percentage of formulating emergency plan increased from . % in to . % in , statistically significantly increasing by . %. provincial cdcs had the highest percentage ( . %) in , and the difference between municipal ( . %) and county cdcs ( . %) was not significant. cdcs in central region had the highest percentage ( . %), followed by western ( . %) and eastern ( . %) regions ( table ). the average length of emergency response training increased from . days per person in to . days per person in ; however, this . % increase was not statistically significant. provincial cdcs had the highest average length of response training ( . days per person), followed by municipal and county cdcs (table ) . comparing the statistics in and , the average times of exercises did not change with statistical significance. in , county cdcs had higher average times of exercises than did municipal ( . ) and provincial ( . ) cdcs; nevertheless, only provincial cdcs had increased average times of exercises during the past decade. from regional perspective, the average times of exercises decreased from western ( . ) to eastern ( . ) regions (table ). there were . % and . % of disease surveillances conducted per month and per week in , respectively. compared with statistics in , frequencies of daily, weekly, and monthly surveillance analysis increased, among which weekly surveillance analysis increased with statistical significance. meanwhile, the frequencies of disease surveillance analysis per ten days, quarter, and year decreased with statistical significance ( table ). according to "contingency rules of paroxysmal public health events", public health emergency events are classified into four levels (i, ii, iii and iv), with severity decreasing from level i to level iv. in , there were public health emergencies directly reported via the disease surveillance information management system, which accounted for . %.the percentage of timely reporting by county cdcs emergency levels in was presented in table . moreover, the average scores for indicators of coping capability were high in (table ). the average scores for capabilities at recovery stage were lower than those for capabilities at response stage. the average score for data archiving was . , then followed by those for data analyzing ( . ) and concluding ( . ) ( table ). the main findings indicated that china had made significant progress in the four stages after a decade's efforts, especially in preparation, readiness, and response stages. this has been demonstrated by other researches [ , ] . the average percentages of cdcs with an emergency response office, a leadership group and an expert panel were . %, . % and . % in , respectively. this suggests that a phpm system with better leadership has been established in china. soon after the sars outbreak, chinese governments at different levels were urged to establish a sars headquarters at cdcs to shoulder the responsibilities of unified leadership and command during public health emergencies. the emergency response law of the people's republic of china issued in formally and strongly stipulated the establishment of the emergency management system that urged unified leadership, comprehensive coordination, categorized management, graded responsibility, and territorial management. the capability for building mechanisms comprised of information sharing, on-site treatment and response-material deployment increased to more than % in . boosted by the sars outbreak in , various authorities consecutively issued a series of regulations that standardized the phems in terms of macro-level management, professional categories, disposal processes, etc. from the perspective of macro-level management, regulations included emergency management [ ] , organizational establishment [ ] , coordination mechanisms [ ] , etc. from the perspective of professional categories, regulations standardized the responses to nuclear accidents [ ] , infectious disease outbreaks [ ] , etc. from the perspective of disposal processes, regulations clearly guided emergency response plans [ ] , exercising [ ] , information reporting [ ] , etc. another notable foundation is that the growth of resources including workforce and stockpile was . % and . %, respectively. since , intensive investments by governments have contributed to the improvements on the following aspects. first, funding for cdcs across different levels changed from balanced allocation to full fiscal funding after . total income governmental funding increased from . % in to . % in [ ] . second, cdcs' staff were overall more educated. the percentage of staff with bachelor degree or higher increased from . % in to . % in [ ] . last, the total value of fixed assets of all cdcs increased from . billion cn ¥ in to . billion cn¥ in [ ] . available research showed that the quantity and quality of emergency staff, governmental-funding level, and fixed assets played important roles in improving the implementation of cdcs' capabilities in the phems [ ] . a firm leadership, a favorable mechanism and sufficient resources are the key elements of a well-developed phpms [ ] . it is undeniable that the phems' achievements in the past decade are remarkable. china's active and constructive contributions have been highly valued by the global community; for example, china's response to h n in was recognized as "exemplary" by the who [ ] . the three leading guarantees of china could be referenced by developing and other underdeveloped countries. however, to cope with future challenges in global health security, the following aspects require strengthening. first, preventive governance is necessary. the recovery stage capabilities were the weakest, which is far from achieving the standard of full recovery including sustainability, resilience after crisis and feedback to preparationstage. the prediction, communication, and social services during and after emergencies require improvement. second, balanced development at different regions and levels is very important. county cdcs in the front lines [ ] had the weakest capabilities. one possible reason was that the relevant policies including contingency plan, work specifications, and guidelines were not instructive and operable enough for county cdcs [ ] . another reason was an inequitable distribution of personnel in urban and rural areas [ ] . available data showed that compared with county cdcs, a greater number of personnel with degree higher than bachelor worked at provincial and municipal cdcs [ ] . additionally, the governmental funding per staff for county cdcs in was . million cn¥, which was much lower than the funding at municipal and provincial cdcs ( . and . million cn¥, respectively) [ ] . from the perspective of regional disparity, cdcs in western region were the weakest. reasons include that it had the poorest fiscal capacity to fund cdcs; a limited personnel size; and an inadequate stockpile in terms of working budget, timely reserves, and prompt delivery [ ] . third, the application of new technologies should keep pace with science and technology development. for example, the disease surveillance systems need to be integrated with the use of standard data formats and allow the public health community to respond more quickly to public health threats [ ] . a stockpile management and tracking system could also be designed and used to manage stockpiles across different levels and regions [ ] . the available assessment indicators are relatively narrower in comparison with those such as the capability nearly half the indicators were binary ("yes" or "no"), so the quality of policy implementation and accountability could not be judged. although logic judgments and audit procedures were conducted, recall bias may still exist. despite these limitations, the main contribution of this paper are the findings based on the data from two rounds of national field surveys conducted in to in china. we believe that this contribution is theoretically and practically relevant because the lessons china's government learned from the sars outbreak provide an emergency response framework that can be employed by developing countries. since the sars outbreak, china has built an effective phems and achieved comprehensive progress and improvements at preparation, readiness, response, and recovery. nevertheless, lacks of conceptual crisis management and preventive governance, disparities across regions and levels, and insufficient application of new technologies remain. future priorities should be to develop the recovery stage, establish a closed-feedback loop between recovery and preparation stages, and strengthen capability-building cdcs in western areas through increasing governmental funding and improving the quality of response personnel. the guarantees of leadership, regulations, and resources provide useful references for other developing countries. this survey was administered in the collaboration with national health commission of the people's republic of china (the former ministry of health), and the data ownership belongs to former moh. we just got the admission of certain data fields to analyze, so we are sorry that we cannot provide basic data. authors' contributions ms participated in study design and conception, data acquisition, data analysis, manuscript drafting, and funding acquisition. nx participated in data analysis and manuscript drafting. cl, yw and ll participated in data acquisition. dw participated in data analysis. jz participated in discussion and manuscript revision. my, yz, hw, ps, zc and jy participated in the design and conceptualization of the study, acquisition of data, and data interpretation. jw, yl, ql, xw, zb, mf, and lf participated in the interpretation and acquisition of data. mh participated in the design and conceptualization of study, acquisition of data, revising of the manuscript, acquisition of funding, and supervision. all authors read and approved the final manuscript. the study was approved by the medical research ethics committee at the school of public health of fudan university. the access to the survey data used in this study was approved by the national health commission of the people's republic of china (the former ministry of health). this study didn't involve human participants and there was no data collected from humans or animals. consent to participate for patients were not applicable. not applicable. the authors declare that they have no competing interests. springer nature remains neutral with 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family planning commission of the people's republic of china. statistical yearbook of china's health and family planning emergency capability construction of institution of disease prevention and control updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group development of the inventory management and tracking system (imats) to track the availability of public health department medical countermeasures during public health emergencies key: cord- -jm qmpeg authors: mao, suling; huang, ting; yuan, heng; li, min; huang, xiaomei; yang, changxiao; zhou, xingyu; cheng, xiuwei; su, qian; wu, xianping title: epidemiological analysis of local covid- clusters in sichuan province, china date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: jm qmpeg background: this study was intended to investigate the epidemiological characteristics of covid- clusters and the severity distribution of clinical symptoms of involved cases in sichuan province, so as to provide information support for the development and adjustment of strategies for the prevention and control of local clusters. methods: the epidemiological characteristics of local clusters of covid- cases in sichuan province reported as of march , were described and analyzed. information about all covid- clusters and involved cases was acquired from the china information system for disease control and prevention and analyzed with the epidemiological investigation results taken into account. results: the clusters were temporally and regionally concentrated. clusters caused by imported cases from other provinces accounted for . %; familial clusters accounted for . %; the average attack rate was . %, and the average secondary attack rate was . %; the median incubation period was . d; a total of cases met the criteria for incubation period determination, and in the cases, the incubation period was > d in . % ( / ). a total of confirmed cases were reported in the clusters. ten cases were exposed before the confirmed cases they contacted with developed clinical symptoms, and the possibility of exposure to other infection sources was ruled out; two clusters were caused by asymptomatic carriers; confirmed cases mainly presented with fever, respiratory and systemic symptoms; a gradual decline in the severity of clinical symptoms was noted with the increase of the case generation. conclusions: population movement and gathering restrictions and strict close contact management measures will significantly contribute to the identification and control of cases. transmission during the incubation period and asymptomatic infections have been noted. studies on the pathogenicity and transmissibility in these populations and on covid- antibody levels and protective effects in healthy people and cases are required. so absence of stringent and effective prevention and control could have resulted in serious social consequences. we analyzed the epidemiological characteristics of covid- clusters in sichuan, intended to provide information support for the development and adjustment of local prevention and control strategies. the epidemiological characteristics of local covid- clusters in sichuan reported as of march , and confirmed cases involved in these clusters were described and analyzed using a cross-sectional study design. in accordance with requirements in the guidance for corona virus disease : prevention, control, diagnosis and management [ ] , information about all covid- clusters and cases should be reported to the china information system for disease control and prevention. in this study, information about all local clusters was exported from sub-module "emergency public reporting system" and data about related confirmed cases and asymptomatic carriers from sub-module "infectious disease management information system". based on epidemiological investigation results, transmission chains were constructed and case generations were determined, followed by a comprehensive analysis. this study has covered all local clusters and all confirmed cases and asymptomatic carriers in the clusters, so sampling was not involved. confirmed cases with missing clinical information were not included into the analysis. confirmed cases, asymptomatic carriers and clusters were identified according to the definitions in the guidance for corona virus disease : prevention, control, diagnosis and management [ ] . a cluster outbreak indicated that more than two confirmed cases or asymptomatic carriers were found within days in a small area (such as a family, a building site, a work unit), and there was a possibility of human-to-human transmission caused by close contact or by exposure to infectious source together. all confirmed cases were divided into mild cases (the clinical symptoms are mild and no pneumonia manifestation can be found in imaging); ordinary cases (with symptoms like fever and respiratory tract symptoms, and pneumonia manifestation can be seen in imaging); and severe cases (respiratory distress, rr ≥ breaths/min; pulse oxygen saturation (spo ) ≤ % on room air at rest state; arterial partial pressure of oxygen (pao )/oxygen concentration (fio ) ≤ mmhg. the date of onset for a confirmed case was defined as the date of first appearance of clinical symptoms self-reported in field epidemiological investigation. the date of onset for an asymptomatic carrier was defined as the date on which a positive covid- pathological test was obtained with respiratory tract or other feasible samples. the attack rate was defined as the number of cases divided by the number of exposed persons, where the number of cases was the total number of confirmed cases involved in a transmission chain. as both secondgeneration (g ) and third-generation (g ) cases were identified from close contacts of cases of the previous generations, if any g case developed in a cluster, the number of exposed persons was the number of close contacts of first-generation (g ) cases plus the number of g cases; if any g case developed in a cluster, the number of exposed persons was the number of close contacts of g cases plus the number of close contacts of g cases resulting in the g cases plus the number of g cases; and so forth. the secondary attack rate was defined as the number of second-and later-generation cases divided by the number of exposed persons, where the number of exposed persons was calculated using the aforementioned algorithm except that the number of g cases was not included. the incubation period was determined based on confirmed cases that had been exposed for a single time in transmission chains, whose exposure and onset time were clearly known and in whom other factors potentially responsible for their infection were ruled out. cases for the determination of the attack rate, the secondary attack rate and the incubation period included confirmed cases and asymptomatic carriers. a family dinner was defined as a dinner attended by two or more families. epidemiological characteristics of clusters and demographic and clinical characteristics of confirmed cases were descriptively analyzed. attack rates, secondary attack rates and clinical types of cases and constituent ratios of symptoms were compared using χ test for constituent differences. the regional distribution map in fig. was created by geocoding all covid- clusters and matching them to the city-level layers of polygon and point by administrative codes with the use of arc-gis software. on january , , the first local covid- cluster was reported in sichuan. on january , , a level- public health emergency response was launched, followed by the successive execution of multiple measures with respect to infection sources, routes of transmission and susceptible populations to effectively reduce population movement and gatherings and strengthen the management of close contacts. main measures and the timeline are shown in fig. . on january , , the first local covid- cluster was reported. a total of clusters were reported in january and in february. the daily number of clusters peaked on january , (n = ) and gradually declined after february , . a total of ( . %) clusters were reported as of february , . temporal distribution of cluster reports is shown in fig. . among the clusters, ( . %) were caused by imported cases, and in the infection source of the first case was unknown. the clusters had involved prefectures and districts/counties (fig. ) . chengdu had the largest number of clusters (n = ), followed by dazhou (n = ), nanchong (n = ) and guang'an (n = ). clusters in the four prefectures accounted for . % ( / ) of the total in the province. households were the primary exposure place in the reported clusters, accounting for . % ( / ); living in the same household was the primary form of exposure, accounting for . % ( / ). clusters caused by exposure in multiple places and in multiple forms accounted for . % (fig. ) . significantly more clusters were caused by family gatherings in february than in january (p = . ) ( table ) . in the clusters, a total of confirmed cases were reported, accounting for . % ( / ) of the total in the whole province; among these confirmed cases, were local confirmed cases resulting from clusters, accounting for . % ( / ); the male/female ratio was : , the mean age was . years ( month- years), and patients years of age or above accounted for . % ( / ); involved were ( . %) g cases, ( . %) g cases and ( . %) g cases ( table ); . % ( / ) had a history of travel or residence in wuhan, and . % ( / ) had a history of travel or residence in other provinces except wuhan. the constituent ratios of cases with a history of travel or residence in both wuhan (p < . ) and other provinces except wuhan (p = . ) were higher in g cases were higher in g and g cases, and the differences were statistically significant ( table ) . the confirmed cases were clinically typed as follows: . % ( / ) were ordinary, . % ( / ) were mild, and . % ( / ) were severe; no death occurred. with the increase of the transmission generation, the number of ordinary cases gradually decreased, with a significant difference noted overall (p = . ); a significant difference was found between g and g cases in the constituent ratio of ordinary cases (p = . ). no apparent between-generation difference was found in the constituent ratios of mild or severe cases (fig. ) . among .the number of cases with fever showed a declining trend overall with the increase of transmission generation (p = . ), and significant differences were noted between g and g cases (p = . ) as well as g cases (p = . ) in terms of the constituent ratio of cases with fever. no statistically significant difference was found between generations in other symptoms (fig. ) . among the clusters, g cases were identified in ( . %) and g cases in ( . %); a total of confirmed cases (including asymptomatic carriers) were reported, and on average each cluster resulted in . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) cases; the average attack rate was . % ( . - %), and the average secondary attack rate was . % ( . - . %). starting from february , , we expanded the time window of close contact tracing to cover days prior to the appearance of clinical symptoms in primary confirmed cases or prior to the obtainment of a positive nucleic acid test in primary asymptomatic carriers. attack rates and secondary attack rates before and after this time point were compared, and it was found that, following the expansion of the time window of close contact tracing, both the attack rate and the secondary attack rate increased, with statistical differences identified ( table ) . among the cases, . % ( / ) had been exposed to confirmed cases. in . % ( / ) of such cases, the exposure to the confirmed cases occurred at or after onset of the disease in them. in cases (involved in clusters), the exposure occurred before the confirmed cases they contacted with developed clinical symptoms, and they had been exposed only once while the possibility of exposure to other infection sources could be ruled out. the median time of exposure was d ( - d) prior to disease onset in the confirmed cases they contacted with, and the mean was . d; . % ( / ) of the cases were exposed within d prior to disease onset in the confirmed cases they contacted with. of confirmed cases, the median interval between hospital visit and onset was d ( - d), the median interval between confirmation and onset was d ( - d), and the median interval between isolation and confirmation was − d (− - d). twenty-eight cases met the criteria for incubation period determination (involved in clusters). the average incubation period was . d, the median incubation period was . d ( - d) and the incubation period was > d in . % ( / ). in the clusters, a total of asymptomatic carriers (all were identified during medical observation of close contacts) were reported, including males and females. the mean age was . years ( months- years); and patients years of age or above accounted for . % ( / ). involved were ( . %) g cases, ( . %) g cases and ( . %) g cases. in one cluster, one g case (severe) was found to have spread the disease to one g case (mild) and one g case (asymptomatic). two clusters were caused by asymptomatic carriers and, in both clusters, only g cases developed, including one (asymptomatic) to two (confirmed) transmission in one cluster and one (asymptomatic) to one (confirmed) transmission in another cluster. the possibility of other infections was ruled out in all g cases. by the end of the two clusters, the g asymptomatic carriers had not presented with clinical symptoms or imaging abnormalities. our analysis of covid- clusters in sichuan reveals that the majority of clusters were reported before february and occurred in four regions of sichuan, and three-fourth of the clusters were caused by importations from other provinces including wuhan. the study also found that the proportion of cases with a history of travel or residence in wuhan was significantly higher in g cases than in secondary cases and the clusters mainly occurred in households with a greater proportion in february than in january. these characteristics were similar to clusters in other provinces in china [ ] . the above characteristics of covid- clusters were supposed to be related with several factors. firstly, the epidemic happened during the spring festival in china, when large numbers of people in china returned home for family reunion or visited their friends or relatives, forming a population shift peak, particularly in the midlate january. secondly, chengdu, the capital of sichuan province, as a rapidly growing metropolis in west china, has well-developed transport infrastructure including highways, railways and airlines, which facilitated the spread of the disease [ ] ; big data analysis also showed that chengdu was ranked the top in terms of inflow of people from wuhan [ ] [ ] [ ] ; dazhou and guang'an, located in the northeast of sichuan, are adjacent to chongqing, which was relatively hardly hit by the epidemic among provinces other than hubei in china [ ] . finally, on january , , sichuan launched a level- public health emergency response [ , ], followed by the successive execution of multiple measures with respect to infection sources, routes of transmission and susceptible populations, effectively reducing population movement and gatherings and strengthening the management of close contacts. specifically, on january , , the administration for market regulation, the health commission and the department of commerce of sichuan province jointly issued a document [ ] for strengthening the supervision of dinner gatherings; on january , , the people's government of sichuan province issued an order [ ] requiring suspension of massive gatherings and business of recreational places and banning dinner gatherings. on february , , the provincial headquarters for emergency response issued a notice on strengthening the supervision of dinner gatherings in rural areas [ ] , banning dinner gatherings involving two or more families. the above measures have effectively reduced people's gatherings including festival celebrations and company dinner parties. however, still a minority of people, following traditional customs, organized and participated in family dinners and entertainment activities with inadequate protection during the chinese new year, resulting in the familial clustering characteristic of the epidemic. the attack rate of covid- clusters in our study was slightly lower than . % in a study located in shenzhen [ ] . the interval between hospital visit and onset was shorter than that reported in hunan [ ] ; related data were not available from other provinces. the study also showed that the attack rate and the secondary attack rate were significantly higher after february , than before; cases were mainly confirmed during the isolation period and asymptomatic carriers were identified in the management of close contacts, which suggested that the intensive close contact management measures in sichuan including expansion of the close contact tracing time window to cover d prior to the presence of clinical symptoms (or positive test for asymptomatic carriers) in the confirmed cases they contacted with, implemented from february , , and the conduct of nucleic acid testing at both the start and the end of quarantine of close contacts, implemented from february , , might have contributed to the discovery and control of cases and the reduction of spread. the median incubation period in the limited cases in sichuan was corresponding to the finding in other studies in china that the incubation period in the majority of cases was < d, but being longer than the median incubation period reported in other studies ( - d) [ ] [ ] [ ] [ ] [ ] . it was also found that the proportion of cases with an incubation period > d was higher than that reported in a study in henan ( . %) [ ] . ten cases exposed before the confirmed cases they contacted with presented with clinical symptoms, of which most cases exposed within d prior to disease onset, and these cases had been exposed only once and other potential sources of infection could be ruled out, suggesting covid- is possibly transmittable during the incubation period, similar to a report in zhejiang [ ] . at the same time, the majority of cases involved in the clusters exposed within days prior to onset of the disease in confirmed cases they contacted with, suggesting covid- , like influenza, is possibly contagious at the end of the incubation period or tracing back to d prior to disease onset in seeking close contact could miss earlier infections in the incubation period. what's more, two clusters caused by asymptomatic carriers indicated covid- could be transmitted by asymptomatic infected persons, as is similar to the report in henan [ ] . nevertheless, the asymptomatic carriers had only caused a small number of g cases, indicating the transmissibility in this population may be limited. the above two populations cannot be effectively identified and thus are of special public health significance for sustained transmission of covid- [ ] ; due to limited available data, the transmissibility of the disease cannot be analyzed, and studies on its pathogenicity and transmissibility in these populations are awaited. main presentations of confirmed cases involved in the clusters in sichuan included fever, respiratory and systemic symptoms, basically corresponding to the reported clinical characteristics of covid- cases, and no characteristic clinical symptom was seen [ , [ ] [ ] [ ] [ ] . in clusters, the proportion of ordinary cases and cases with fever decreased with the increase of the case generation, suggesting that the severity of clinical symptoms might gradually lighten with the development of the epidemic. this corresponded to reports that, in the initial period of the epidemic, cases were mainly severe and the case fatality rate was high [ ] and, in the later period of the epidemic, cases were mainly mild [ ] . this is possibly because the virus will maintain moderate virulence during passage and evolution for the purpose of long-time reproduction in human and the infection was limited to the upper respiratory tract [ ] . in addition, it was reported that antibody levels would not last long, and repeated infection was common [ , ] . however, limited data are available and further studies on covid- antibody levels and protective effects are awaited for investigating whether post-infection antibody levels will decline following the mitigation of covid- clinical symptoms or whether repeated infection will occur as a result of the short-term maintenance of antibody levels. the findings in the study are subject to several limitations. on the one hand, as only cases exposed only once were included, the cases calculated for the incubation period was limited. on the other hand, pcr detection of respiratory tract specimens was carried out once each time when close contacts were isolated and released, and the isolation period was days. if an asymptomatic carrier recovered spontaneously during the isolation period, the attack rate might be underrated due to the missing count of cases. in conclusion, our study demonstrated the comprehensive epidemic situation of covid- in sichuan province and confirmed the infectivity during the incubation period and asymptomatic infection, providing a reference for decision makers to formulate and adjust control measures. abbreviations who: world health organization; covid- : coronavirus disease; rr: respiratory rate; spo : pulse oxygen saturation; pao : arterial partial pressure of oxygen; fio : fraction of inspiration o ; g : first generation; g : second generation; g : third generation; pcr: polymerase chain reaction funding this study was supported by the science and technology department of sichuan province (grant no. yfs ). the funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. this study was consulted to the ethics committees of sichuan center for disease control and prevention. ethics approval was not available because all data were collected as part of public health emergency surveillance following the laws of the people's republic of china on the prevention and treatment of infectious diseases. we also did not include any data of patients' personal information and therefore ethical approval was not required and waived off written informed consent. not applicable. director-general's opening remarks at the media briefing on covid- national health commission (nhc) of the prc, national administration of traditional 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patients in henan, china presumed asymptomatic carrier transmission of covid- potential presymptomatic transmission of sars-cov- advances on presymptomatic asymptomatic carrier transmission of covid- clinical features of patients infected with novel coronavirus in wuhan epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus disease (covid- ) in china offline: -ncov outbreak-early lessons molecular virology. th ed. chaoyang district: people's medical publishing house medical microbiology. th ed. chaoyang district: people's medical publishing house clinical and immunological assessment of asymptomatic sars-cov- infections publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we salute and thank all personnel engaged in the prevention, control, diagnosis and treatment of covid- in sichuan province. the authors declare that they have no competing interests. key: cord- - fuiind authors: lee, albert; chuh, antonio at title: facing the threat of influenza pandemic - roles of and implications to general practitioners date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: fuiind the pandemic of h n influenza, compounded with seasonal influenza, posed a global challenge. despite the announcement of post-pandemic period on august by thewho, h n ( ) virus would continue to circulate as a seasonal virus for some years and national health authorities should remain vigilant due to unpredictable behaviour of the virus. majority of the world population is living in countries with inadequate resources to purchase vaccines and stockpile antiviral drugs. basic hygienic measures such as wearing face masks and the hygienic practice of hand washing could reduce the spread of the respiratory viruses. however, the imminent issue is translating these measures into day-to-day practice. the experience from severe acute respiratory syndrome (sars) in hong kong has shown that general practitioners (gps) were willing to discharge their duties despite risks of getting infected themselves. sars event has highlighted the inadequate interface between primary and secondary care and valuable health care resources were thus inappropriately matched to community needs. there are various ways for gps to contribute in combating the influenza pandemic. they are prompt in detecting and monitoring epidemics and mini-epidemics of viral illnesses in the community. they can empower and raise the health literacy of the community such as advocating personal hygiene and other precautious measures. gps could also assist in the development of protocols for primary care management of patients with flu-like illnesses and conduct clinical audits on the standards of preventive and treatment measures. gps with adequate liaison with public health agencies would facilitate early diagnosis of patients with influenza. in this article, we summarise the primary care actions for phases - of the pandemic. we shall discuss the novel roles of gps as alternative source of health care for patients who would otherwise be cared for in the secondary care level. the health care system would thus remain sustainable during the public health crisis. the outbreak of novel influenza a (h n ) has caused a global challenge since the first case was identified on april . within nine weeks, all six who regions of the world were affected [ ] . the impact of this pandemic is compounded by the ageing population in many countries and the new epidemics of "non-communicable diseases" [ ] . more than , laboratory-confirmed cases from countries were identified by october [ ] . although who announced the post-pandemic period on august , h n ( ) virus would continue to circulate as a seasonal virus for some years and national health authorities should remain vigilant during the immediate post pandemic period due to unpredictable behaviour of the virus (who pandemic h n briefing note ) . a semi-quantitative study in australia reported that additional daily presentations to general practice surgeries would be - presentations per day [ ] . one of us (al) serving in public primary care setting had to re-organise some designated clinics in the catchment area to manage patients with influenza-like illnesses. however, such venture induced an increase in workload demand of other clinics for chronic illnesses, subsequently leading to double burden of diseases. another author (ac) working in a private primary care setting in the community experienced around % increase in workload demand for influenza-like presentations. if a new outbreak occurs, increase in patient load will be inevitable. should the presentations, risks of complications, and the infectivity of the new influenza pandemic be different, the situation could be much worse. how should we build up the spare capacity to prepare for and respond to the pandemic if it arises again? our capability of responding to the pandemic most countries have contingency planning. the royal college of general practitioners in the uk, for example, has issued clear guidelines for the management and control of pandemic influenza [ ] . however, the less developed countries are experiencing difficulties in putting these guidelines in operation owing to inadequate stockpiles of antiviral drugs to go beyond rapid containment in supporting the mitigation efforts [ ] . for the south-east asian countries, the hospital bed capacity and medical personnel might not have the capacity to care for sudden surges of large number of patients [ ] . during the early phase of the pandemic in may , concerns of the delay in launching of the uk national flu line were raised in an article published in the british medical journal. the line acted as the main route for the public to get advice and access to antiviral treatment [ ] . widespread community transmission of an infectious disease could overwhelm our health care system globally. close collaboration with functional components of public health such as home-based care and primary health care is therefore indispensable [ ] . absenteeism amongst health care workers could pose another threat to the health care system with the prolonged periods of a pandemic. a us-based survey found that nearly half of the health care workers might fail to report for duties during an influenza pandemic, particularly the technical and supporting staff [ ] . another study reported that % of german health care workers might remain absent from work in order to protect themselves [ ] . results from uk study on randomly selected healthcare workers suggest that absenteeism could be as high as % at any point during a pandemic [ ] . it has been estimated that a general practitioner (gp) might expect to see new cases per week for an average list size, which would rise to at the height of the pandemic if % of other gps were sick [ ] . however, these studies were done prior to the h n pandemic, and the data analyses were based on an h n situation which might not be valid to be extrapolated for the h n pandemic [ , ] . an uk study on how gps responded to an influenza pandemic revealed that at least one-quarter of the respondents would respond poorly to such a pandemic [ ] . non-urban gps were less prepared to an influenza pandemic as compared to urban gps and also less likely to be aware of pandemic preparedness plans. an article authored by jennings et al outlined the multistrategic approach to pandemic preparedness which would be categorised as non-pharmaceutical (public health) and pharmaceutical measures [ ] . the former is aimed to reduce the social impacts such as social distancing by prompt case isolation, household quarantine, and closure of school and workplaces. responce of health services with increasing number of possible flu cases and the existing care of other patients, risk communication, data collection and surveillance, and basic respiratory hygiene practices are all important public health measures. the pharmaceutical measures included vaccination, anti-viral medications, stockpiling of vaccines and drugs and co-ordinated effort in distribution. this would involve pre-pandemic vaccination and treatment of cases for secondary prevention. although vaccination for h n is now available, it does not entail overall willingness to accept. a study in hong kong amongst , health care workers showed that the overall willingness to accept pre-pandemic h n vaccine was only . % during a who influenza pandemic alert phase [ ] . no significant change in the level of willingness to accept vaccine was observed despite an escalation to alert phase [ ] . public health measures would be more effective with close collaboration between public health authorities and gps. gps in uk were generally praised on their dedication and efforts during the pandemic [ ] . most of the influenza cases were diagnosed clinically by gps, not virologically in the laboratories [ ] . the royal college of general practitioners closely liaised with health authorities and external agencies in the battle against h n influenza [ ] . daily updates were sent to their college members, and formal guidelines were in place specifically for gps in england [ ] and scotland [ ] . moreover, gps had access to a dedicated email address flu@rcgp.org.uk for enquiries and support. preventive interventions are more effective in primary care setting which are not related to any one disease or organ system [ ] . effective primary care integrates vertical care concerning the management of specific diseases from primary to tertiary care as well as horizontal care with emphasis on addressing the needs of individuals, families and the community [ ] . this is particularly important for preparing and responding to a pandemic of influenza. although routine long term implementation of some physical measures to interrupt or reduce the spread of respiratory viruses could be difficult, a systematic review showed that simple and inexpensive interventions could be effective in reducing the spread of respiratory viruses [ ] . good infection control (comprising policies and procedures to prevent or minimise the risk of transmission) is a well known cornerstone of disease management and should be the focus of general practice management of respiratory outbreaks [ ] . gps should be in excellent position to self-demonstrate as well as educating patients on the pertinence and efficacies of hygienic measures. the imminent issue now is how to translate these basic personal hygienic measures into day-to-day practice. gps possess unique skills to empower patients, and patients felt that they are better helped and more understood by gps [ ] . gps are in excellent positions to translate national guidelines into public health educationand put the daily lives of patients into context. they could also help to improve the health literacy of the community on infection control. gps in hong kong played this role during sars. the hong kong medical association established doctors' network amongst gps in different districts to support the local communities [ ] . if gps could play the role of health educators on preventive controls and the reinforcement of personal hygiene and other precautious measures in the community and serve as reliable resource persons to share and disseminate information to the community, the well subjects would thus be reassured. their important role of gps providing psycho-social support to the community during health crises is unique. gps are prompt in detecting and reporting epidemics and mini-epidemics of viral illnesses [ , ] . the epidemiological data obtained in primary care represents the best proxy measurements of the day-by-day prevalence of ailments in the community. gps can also assist in the development of protocols for primary care management of patients with flu-like illnesses in accordance to national guidelines to avoid missing cases while at the same time preventing panics in the community. a study conducted in hong kong revealed that gps were amongst the first group of doctors performing clinical audits in their practice in order to improve the structures, processes, and outcomes of their services [ ] . gps could play the frontier role in management of patients with influenza without complications to allow unexpectedly large numbers of ill patients to be managed in the community. gps could support the continuity of health care provision by acting as alternate source of health care for those patients who would otherwise attend specialist outpatient clinics, accident and emergency departments [ ] , or be hospitalised. moreover, gps are trained as generalists, so they can manage a diverse range of health problems. in some countries fully trained gps are capable of providing counselling to patients, their families, and alerted members in the community. pharmaceutical measures for pandemic preparedness include the provision of vaccines particularly during the pre-pandemic period, and anti-viral drugs for treatment of cases as well as secondary prevention for selective cases. although it was expected that the australian health management plan for pandemic influenza (ahmppi) would enable frontline australian gps to maintain a central role during the swine flu pandemic, their task was rendered extremely difficult owing to deficiencies in the implementation of ahmppi [ ] . this included resource supply failures, time-consuming administrative burdens, delays in receiving laboratory test results and approval for providing oseltamivir to patients, and a lack of clear communication about policy changes as the situation progressed [ ] . better consultation with front-line clinicians, particularly gps, is crucial; and this must occur as a matter of high priority. different countries have initiatives for gps to play their roles during the flu pandemic [ , ] . of specific interest is the "flu champion" in some australian practices, which actively advocates educational activities, promotes vaccinations, and ascertains the availability of antiviral medications [ ] . gps in the uk can access influenza vaccines subject to their clinical discretion during serious periods of the pandemic [ ] . no effort was spared to assure that gps would continue their services during the pandemic [ ] . the outbreak of sars in hong kong exposed the lack of support and guidance for gps and other primary healthcare professionals during a public health crisis [ , ] . despite fear, anxiety and uncertainty, gps in hong kong demonstrated their willingness and commitments to discharge their duties as healers [ ] . a study showed that . % of gps aspired deeper involvements in the war against sars in the community -as educators ( . %), as gatekeepers ( . %), utilising rapid diagnostic tests ( . %), and administering vaccines when available ( . %) [ ] . some gps expressed their wish to "share the government's outpatient burden and/or outreach services at elderly homes", and one doctor had volunteered to serve in a sars screening clinic [ ] . in terms of public health measures taken by gps, more measures were taken by gps in hong kong when compared to those in toronto [ ] . as the outbreaks were larger in scale and occurred at the community level in hong kong, the sense of vulnerability for possible infection in gps should be higher in hong kong. however gps in private practice voluntarily incurred negative commercial initiatives such as sharing patient loads, supplying appropriate protective barriers including expensive masks, delivering lectures in school and community centres, and being medical advisors for deprived members of the society such as inmates in elderly homes. those initiatives would become public health actions with public health authorities drawing up the action plans for the gps. the sars experience also revealed that patients were also unnecessarily referred to secondary care because of ineffective communications and the unavailability of some investigations to gps. valuable health care resources were thus inappropriately matched to community needs [ ] . this would put even heavier burdens on the health care system during the outbreak of influenza. if the public health authorities would work more closely with gps with more rapid communications in clinical information, epidemiological update and results of investigations, gps being the first point of contact for most patients in the health care system would provide better, comprehensive and continuing care during the public health crisis. studies in singapore, australia and uk all showed the willingness of gps to provide professional services during pandemic [ , ] . the findings were in sharp contrast to the sarcastic remarks by dawes in an editorial "caring for patient is a moral imperative during a pandemic influenza outbreak. i wouldn't be much of a human being if i closed up and headed for the hill." [ ] . however the motivation was also altruistic as gps participating in the australian study did not have stockpiles of antiviral or personal protective equipments within their own practices [ ] . they also believed that most appropriate setting to manage these patients was within gp practices and the government had a duty of care to stockpile on behalf of the gps. public health authorities would make good use of the public health initiatives currently in place in order to strengthen the roles of gps within the system. reassurance of well subjects, the assessment and management of patients unwell with influenza, the continuous care of unaffected patients, and the attendance to the psychological consequences of the disaster were defined by an australian study as key roles of gps during pandemic [ ] . gps should provide optimal management for patients without flu-like illnesses, empower self care of patients, and act as alternate sources of health care for stable patients from secondary care. the ultimate goal is to enable gps to relieve the workload of overwhelmed secondary care setting during the flu pandemic. the framework for general practice by nori and william described how to establish an effective level of infection control for different stages of outbreak [ ] . table summarises the primary care actions for different components at the different pandemic phases ( ) ( ) ( ) as defined by who [ ] . the framework of table goes beyond infection control at clinic level. it also covers measures to handle the suspected cases and close contacts, advice to patients returning from high risk areas, and the identification of high risk cases. this framework also enables the primary care system to play a leading role to sustain the health care services during the pandemic so that the health care system can cope with a large influx of patients with influenza like illnesses without jeopardising the care of chronic illnesses patients. primary health care should be more proactive as an alternate sources of health care for hospital patients with stable conditions, developing of protocol for self management for certain illnesses, acting as resource persons for patient health education in the community and providing leadership to re-organise the local resources meeting the local health care needs. it is highly crucial that such primary care action plan should be made readily available to gps not only during but also before a pandemic. all levels of primary care professionals from administrators to individual gp surgery professionals and allied health professionals should be alerted to the existence and elements of these action plans. when resources including time and manpower are available, mini-drills could be conducted in surgeries to investigate the practicalities and logistical barriers of these actions. we also recommend conducting clinical audits to assess the structure, processes and outcomes of these primary care actions. what should be the next step? the success of primary care in handling emerging health crises prompts us to re-conceptualise primary care as the foundation of care for all people rather than the mere provision of basic services for the lower strata of the society [ ] . this is particularly important for developing countries where the delivery of primary care is usually more fragmented, rendering the entire health care system more vulnerable to the emergence of an influenza pandemic. the roles of gps should also be broadened to take up greater share of patient care in the entire health care system, particularly the co-ordination of triage systems for suspected cases, disease prevention and health promotion, improvement of health literacy of the community, alternate sources of care for patients in secondary care, surveillance, and close monitoring of suspected cases and/or close contacts. clinical audits should be conducted to assess whether the actions are being implemented effectively and to identify barriers of implementing such actions in order to enact remedial solutions. we are convinced that implementation of the table roles of general practitioners in preparing for and responding to pandemics phase phase - running and coordination co-ordination of triage system for suspected cases. liaison with national/local health authority for prioritisation of primary health care during pandemic. standardisation of procedures in handling suspected cases and cautious cases. chair of gp network participates and gives advice in national/sub-national crisis committee. action plan to avoid cross infection of suspected cases and other patients. co-ordination of care at primary care level for large influx of influenza patients and patients with other illness. co-ordination of other sectors to care for large number of ill patients. provide local leadership in rational use of multi-sectoral resources in meeting the local health needs and demand. identify the vulnerable and at risk groups for necessary 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to two surgeries of a private family physician in hong kong? hong kong practitioner how to minimize inappropriate utilization of accident and emergency departments: improve the validity of classifying the general practice cases amongst the a&e attendees the general practice experience of the swine flu epidemic in victoria-lessons from the front line ongoing h n vaccination arrangements primary care trusts, nhs. primary care pandemic continuity agreement, pandemic influenza service continuity planning, tees primary care services primary care during the sars outbreak (letter) how did general practitioners protect themselves, their staff and their families during the severe acute lee and chuh bmc public health respiratory syndrome epidemic in hong kong? primary care physicians in hong kong and canada -how did their practices differ during the sars epidemic? a cross-sectional study of primary-care physicians in singapore on their concerns and preparedness for an avian influenza outbreak the general practitioner's response to pandemic influenza: a qualitative study infection prevention and control during health care for confirmed, probable, or suspected cases of pandemic (h n ) virus infection and influenza-like illnesses pre-publication history the pre-publication history for this paper can be accessed here cite this article as: lee and chuh: facing the threat of influenza pandemic -roles of and implications to general practitioners the authors would like to express sincere thanks to alpha lee for his kindest assistance in editing the manuscript. authors' contributions al is a general practitioner and an academic in the field of general practice and public health. his ideas of the paper come from researching, working experience with who as temporary advisor on many occasions, training of health professionals in disease prevention and health promotion, review of current evidence, and experience as general practitioner in different settings. ac is a general practitioner and an academic in general practice. his ideas of the paper come from researching, community services, training of health professionals, review of current literature, and experience as a general practitioner. both are authors of the paper and contributed to initial idea, and to the serial drafts and agreed the final submission. the author declares that they have no competing interests. key: cord- - fu blu authors: lazarus, ross; yih, katherine; platt, richard title: distributed data processing for public health surveillance date: - - journal: bmc public health doi: . / - - - sha: doc_id: cord_uid: fu blu background: many systems for routine public health surveillance rely on centralized collection of potentially identifiable, individual, identifiable personal health information (phi) records. although individual, identifiable patient records are essential for conditions for which there is mandated reporting, such as tuberculosis or sexually transmitted diseases, they are not routinely required for effective syndromic surveillance. public concern about the routine collection of large quantities of phi to support non-traditional public health functions may make alternative surveillance methods that do not rely on centralized identifiable phi databases increasingly desirable. methods: the national bioterrorism syndromic surveillance demonstration program (ndp) is an example of one alternative model. all phi in this system is initially processed within the secured infrastructure of the health care provider that collects and holds the data, using uniform software distributed and supported by the ndp. only highly aggregated count data is transferred to the datacenter for statistical processing and display. results: detailed, patient level information is readily available to the health care provider to elucidate signals observed in the aggregated data, or for ad hoc queries. we briefly describe the benefits and disadvantages associated with this distributed processing model for routine automated syndromic surveillance. conclusion: for well-defined surveillance requirements, the model can be successfully deployed with very low risk of inadvertent disclosure of phi – a feature that may make participation in surveillance systems more feasible for organizations and more appealing to the individuals whose phi they hold. it is possible to design and implement distributed systems to support non-routine public health needs if required. timely identification and subsequent reaction to a public health emergency requires routine collection of appropriate and accurate data about the occurrence and location of cases of illness. there is substantial interest in using rou-tinely collected electronic health records to support both the detection of unusual clusters of public health events and the response to public health threats detected by other means. such data are also useful to reduce an initial alert level, if it is clear that no unusual illness clusters exist in a community. ideally, such systems operate automatically and include sensitive and specific statistical surveillance software and alerting systems. these are often referred to as syndromic surveillance systems [ , ] , because they typically rely on the non-specific signs and symptoms that may provide the earliest evidence of a serious public health threat, such as anthrax or sars. many syndromic surveillance systems gather potentially identifiable, individual patient-level encounter records. these records are typically collected without name or address, but they do contain enough identifiers to allow re-identification in some circumstances. the potential for re-identification is greatest when records are collected from ambulatory settings or health systems that supply a unique identifier that allows the very useful identification of repeated visits over time. the risk of disclosing sensitive information that can be linked to the individual also increases when the health care facility provides more than occasional care. in the united states, the health insurance portability and accountability act [ ] (hipaa) specifically exempts transfer, use and retention of identifiable electronic personal health information (phi) to support public health activities. this exemption also applies to syndromic surveillance activities, although hipaa was developed before large volumes of such data concerning individuals who are not suspected of having a reportable condition were being used for public health purposes in the absence of any known public health emergency. despite the exemption, data providers may be unwilling to offer identifiable data for surveillance purposes in the face of increasing awareness of the potential costs of inadvertent disclosure or inappropriate use of phi. additionally, their patients may object to their providing it. these concerns are common to many developed countries and under these circumstances, designs that minimise the risk of inadvertent disclosure may be needed in order to gain the cooperation of data custodians, for surveillance systems to be feasible. the focus of this paper is on one such design, in which initial data aggregation is performed to decrease the risk of any phi being inadvertently disclosed, before the aggregate data is centralised for subsequent statistical analysis. although the system we describe is currently operating in the united states and many of the implementation details are specific to that context, some of the conceptual issues we describe and some of the lessons we have learned may be directly relevant to public health practice in other countries. while it is possible to centrally collate and process deidentified records, there is a potential problem with statistical inference if multiple records from the same individual are not distinguished. this problem arises because many statistical analysis techniques applicable to surveillance, such as generalised linear mixed models [ ] (glmm), depend on the assumption that observations are statistically independent. inference based on this assumption using ambulatory care encounter data will likely be biased if the model cannot distinguish observations from multiple encounters during a single course of illness from a single individual patient. although the extent of this bias has not been quantified, the problem is clearly illustrated by real data. in more than half of the individuals with multiple lower respiratory syndrome encounters over a four year period from one large ambulatory care practice, a second encounter with the same syndrome was noted less than days after the first encounter [ ] . our approach to this problem of statistical independence is to aggregate multiple encounters from a single individual into "episodes" of illness, and is described in more detail below. reliably automating this aggregation requires that every patient's records be uniquely identifiable. to support the national demonstration bioterrorism surveillance program (ndp), we developed a system in which no phi leaves the immediate control of the data provider, and only aggregate data is transferred to the datacenter [ , ] . each data provider performs initial aggregation of the phi within their own existing, secured data processing environment, producing data that is aggregated beyond the point where any individual patient is identifiable. since data processing is distributed to the site of data collection rather than being performed at one central location, we describe this as a distributed processing surveillance system. although this particular aspect of our work has briefly been mentioned in previous publications [ , , [ ] [ ] [ ] , we present it in greater detail here, because we believe that it represents a potentially valuable alternative surveillance system design option that deserves more explanation and wider debate than it has received to date. the basic principle of distributed processing is simple. rather than collecting all needed identifiable, individual phi records centrally for statistical processing, all phi is pre-processed remotely, and remains secured, under the direct control of the data provider. only aggregate data are transferred to the central datacenter for additional statistical processing, signal detection, display and distribution. at an appropriate level of aggregation, the risk of inadvertent phi disclosure becomes very small, and may prove acceptable to data custodians and to individual patients. although this risk is never completely absent, it is certainly decreased in aggregate data, making this approach far more acceptable to data providers in our experience, than the more traditional approach of centralized collection of directly identifiable phi. before describing our distributed system, we briefly review the more familiar model of centralized aggregation and processing of phi for surveillance. in the more traditional type of system, individual patient records, often containing potentially identifiable information, such as date of birth and exact or approximate home address, are transferred, usually in electronic form, preferably through some secured method, to a central secured repository, where statistical tools can be used to develop and refine surveillance procedures. one of the main benefits of this data-processing model is that the software and statistical methods can be changed relatively easily to accommodate changes in requirements, because they only need to be changed at the one central location where analysis is taking place. as long as appropriate details have been captured for each individual encounter of interest, the raw data can be re-coded or manipulated in different ways. only one suite of analysis code is needed, and because it is maintained at a single, central location, costs for upgrading and maintenance are small. inadvertent disclosure of phi is always a potential risk with centralized systems. even where minimally identifiable data are stored in each record, the probability of being able to unambiguously identify an individual increases as multiple, potentially linkable records for that individual accrue over time. rather than gathering identifiable phi information into a central repository for analysis, a distributed system moves some of the initial data processing, such as counting aggregated episodes of care (see below), to the site where the data is being collected. this aggregation minimizes the number of individuals who have access to phi and diminishes the risk of inadvertent phi disclosure from the sur-distributed processing model and data flow figure distributed processing model and data flow. veillance system, while still allowing effective use of the information of interest. the focus of this report is on the model used to collect surveillance data while providing maximum protection for phi, so the statistical methods we use in the ndp, which have been described elsewhere [ ] are not discussed further here. data flows for the ndp are illustrated in figure . data pre-processing, detection of repeated visits by the same patient for the same syndrome, and data aggregation is performed using a custom software package, written, maintained, and distributed by the ndp datacenter. data providers maintain complete control of the security of their own phi and also maintain control over the operation of the data processing software, which runs on one of their secured workstations. since the pre-processing takes place within a secured environment under the control of the data provider, there is no need for the individual patient identifiers to be divulged to the datacenter. in the case of the ndp [ ] , the only data that is centrally collated consists of counts of the number of new episodes of specific syndromes over a defined time period (currently set at each hour period ending at midnight), by geographic area (currently, -digit zip code area). more detailed definitions of "syndromes" and "new episodes" are provided below. table illustrates the data transferred from each data provider each day to the datacenter for statistical processing, reporting and alerting. note that the although this data does not contain any obvious identifiers such as date of birth or gender, there is always a risk that a specific individual might be identifiable using additional data, and that this risk is greatest in zip codes with very small populations. all source code required to build the data processing software is provided to the data provider at installation and whenever the software is updated, so that the local information services staff can check that there are no "backdoors" or other ways the distributed software could compromise the security of their systems. all information transferred to the datacenter is stored in text files (in xml format) and can be readily accessed by local staff to ensure that no phi is being transmitted. participating data providers have near real-time icd codes for every encounter, usually assigned by clinicians at the time of the encounter. since much acute infectious disease manifests as broad suites of nonspecific symptoms, we monitor syndromes -respiratory, lower gastro-intestinal (gi), upper gi, neurological, botulism-like, fever, hemorrhagic, skin lesions, lymphatic, rash, shock-death, influenza-like illness and sars-like illness. all syndromes except influenza-like illness and sars-like illness were defined by a working group led by cdc and department of defense [ ] . individual icd codes are used to aggregate encounters into one of these syndromes. the definitions (icd code lists) of of these syndromes are available [ ] . the definitions comprising the other two syndromes were developed in consultation with both cdc and the massachusetts department of public health. our surveillance algorithms [ ] require statistically independent observations and are based on new episodes of syndromes. our goal was to distinguish health care encounters that were related to ongoing care for any given episode of acute illness from the initial encounter that indicated the start of a new episode of a syndrome of interest. the derivation of the specific method for identifying first encounters for an episode of illness has been described in more detail elsewhere [ ] . we define a new episode to begin at the first encounter after at least a day encounter-free interval for that specific patient and that specific syndrome. if there has been any encounter for that specific syndrome for the same individual patient within the previous days, the current encounter is regarded as part of the usual ongoing care for the original encounter that signalled the start of an episode of illness of that syndrome. the start of a new episode for a different syndrome can occur during ongoing encounters for any given specific syndrome -ongoing encounters during an episode are counted as new episodes only if they are outside (i.e. at least days since the last encounter)of an existing episode of the matching syndrome. as will be described later, all ongoing encounters within any syndrome are recorded, and are visible through reports under the control of the data provider, but they do not contribute to the counts that are sent to the datacentre for analysis. all of this processing requires consistent and unique patient identifiers for all encounters. we use the local patient master index record number for this purpose in the software that we provide, but these identifiers are not required once the processing is complete, and they remain under the complete control of the providers. the distributed software requires the data providers to extract information about encounters of interest (daily, in our case) and convert it into the uniform format used by our distributed software. this kind of uniform representation is required for any multi-source surveillance system and is not peculiar to the distributed model we have adopted. in practice, we found that data providers could easily produce text files containing data as comma separated values in the format which we specified, and which the distributed software has been written to process. however, this requires dedicated programming effort that was supported with resources from the ndp grant. our project receives support from the cdc, so we are required to comply with relevant cdc standards. although the data being transferred to the datacenter is arguably not identifiable phi because of the high level of aggregation, we use the public health information network messaging system [ ] (phinms), a freely available, secure, data transfer software suite developed by the cdc, to transfer aggregate data. a phinms server operates at the datacenter and each data provider operates a phinms client, using a security certificate supplied by the datacenter for encryption and authentication. phinms allows fully automated operation at both the datacenter and at each data provider. phinms communicates over an encrypted channel and usually requires no special modification to the data provider firewall, since it is only ever initiated by an outgoing request (the data provider always initiates the transfer of new data) and uses the same firewall port and protocol (ssl on port ) as commercially encrypted services such as internet banking. phinms is reasonably robust to temporary connectivity problems, as it will try to resend all messages in the queue until they are delivered. data transmission is one of the least problematic aspects of maintaining this system. we provide automatic installation software and it runs more or less instantaneously and transparently, without intervention in our experience. no training is needed as the process is fully automated. all data is transferred to the datacenter in the form of extensible markup language (xml) since this is a flexible machine-readable representation and is easy to integrate with phinms. we used the python [ ] language for the development of the distributed software package. this choice was partially motivated by the fact that python is an open-source language and thus freely distributable, partly by our very positive experience with python as a general purpose application development language, and partially because in our experience, python can be installed, and applications reliably run without any change to source code, on all common operating systems (including linux, unix, macintosh and windows), making it easy for the datacenter to provide support for systems other than windows pc's. it is also a language with extensive support for standards such as xml, and securely encrypted internet connections. in addition, our existing web infrastructure has been built with the open-source zope [ ] web application framework, which is written mostly in python. a major design goal for our distributed software was that it should offer potentially useful functions for the data provider. this was motivated by our desire to encourage data providers to look at their own data in different ways that might not only help them manage the data more efficiently, but might also help them to more easily identify errors. in our experience, the task of maintaining a system like the one we have developed is far more attractive and interesting to the staff responsible at each participating institution if they gain some tangible, useful and immediate benefits. in addition, easy access to data flowing through our software is useful for ensuring transparency and to facilitate security auditing by each data provider. the distributed software optionally creates reports that show one line of detailed information about each of the patient encounters that was counted for the aggregate data for each day's processing. these reports are termed "line lists" and were designed to support detailed reporting of encounter level data, so that a data provider can quickly make this information available in response to a public health need. two versions are available, one with and one without the most specific identifying details, such as patient name and address. these standard line lists are used most often to support requests by public health agencies for additional information about the individual cases that contribute to clusters identified in the aggregate data. these lists are never transmitted to the datacenter but may be used to support public health officials investigating a potential event. when unexpectedly high counts of particular syndromes are detected in geographically defined areas, the datacenter automatically generates electronic alerts, which are automatically routed to appropriate public health authorities. for example, in massachusetts, electronic messages are automatically sent to the massachusetts alert network within minutes of detection, where they are automatically and immediately forwarded to the appropriate public health personnel for follow up. available alert delivery methods in the massachusetts system range from email through to an automated telephone text-to-speech delivery system. responders can configure the alert delivery method for each type of alert they have subscribed to. this alerting system is independent of our distributed system, but in practice, the ready availability of reports in electronic format containing both fully and partially identifiable clinical data for all cases comprising any particular period or syndrome makes the task of the clinical responder much simpler whenever a query is received from a public health official. electronic reports, containing clinical information and optionally, full identifiers for all encounters can be generated as required, at the provider's site, from where they can immediately be made available to public health agencies. in the ndp's current operational mode (see figure ), a public health official calls a designated clinical responder to obtain this information. table ). the "narrow" version, which contains fewer identifiers, provides each patient's five-year age group instead of date of birth and does not include the physician id or medical record number (table ) . at the provider's discretion, the clinical responder can provide the "narrow" list corresponding to the cases of interest to the public health department. if on this basis public health officials decide that further investigation is warranted, they can call the clinical provider and request a review of medical records, identifying the cases of interest by date and an index number (unique within date) in the narrow line list. the clinician finds the medical record number by looking up the date and index number in the wide line list and then accesses the record itself through the usual hmo-specific means. resources to support clinical responders were provided through our ndp grant to participating data providers. it would be straightforward to send detailed lists of encounters that are part of clusters directly to the relevant health department whenever the datacenter detects an event and sends an automated alert to a health department. we have not implemented this feature because all the participating health plans prefer to have an on-site clinical responder participate in the initial case evaluation with the public health agency. it would also be simple to allow designated public health personnel to initiate requests for specific line lists, even when no alert has occurred. public health officials may, on occasion, wish to inspect the line lists to search for specific diagnoses that do not occur frequently enough to trigger an alert for their syndrome, but may be meaningful in the context of information that arises from other sources. although not currently implemented in the ndp, it would be feasible to allow a remote user to perform adhoc queries on the encounter data maintained by the health plan. examples of these queries include focused assessment of disease conditions affecting subsets of the population or specific diagnoses. this type of direct query capability is currently used at some of the same participating health plans to support the cdc's vaccine safety datalink project [ ], a surveillance system that supports post-marketing surveillance of vaccine safety [ ] . this distributed data model supports active surveillance and alerting of public health agencies in five states with participating data providers. the system has proven to be workable, and it supports the syndromic surveillance needs of the participating health departments. there are fixed costs such as programming to produce the standard input files, installation and training, associated with adding each new data provider, so we have focussed our efforts on large group practices providing ambulatory care with substantial daily volumes of encounters, completely paperless electronic medical record systems, and substantial technical resources, since these enable us to capture large volumes of transactions with each installation. relatively large numbers of encounters are needed to ensure that estimates from statistical modelling are robust. applying a distributed architecture to surveillance from multiple smaller practices may enable appropriately large numbers of encounters to be gathered, but may prove infeasible because of costs and lack of appropriate internal technical support and because of heterogeneity in the way icd codes are recorded and assigned by each data provider. once the programming for standard input files is completed, installation and training take approximately one day total, usually spread out over the first two weeks. nearly all problems are related to providers getting the standard file format contents exactly right, and to transferring these to the the distributed architecture currently in use by the ndp allows clinical facilities to provide the aggregated information needed to support rapid and efficient syndromic surveillance, while maintaining control over the identifiable phi and clinical data that supports this surveillance. the system provides support for the clinical providers to respond quickly to public health requests for detailed information when this is needed. in our experience, such requests involve only a tiny fraction of the data that would be transferred in a centralized surveillance model, providing adequate support for public health with minimal risk of inadvertent disclosure of identifiable phi. we believe this design, in which patients' clinical data remains with their own provider under most circumstances, while public health needs are still effectively met, conforms to the public's expectations, and so will be easier to justify if these surveillance systems come under public scrutiny. many of the details of our approach are specific to the united states context, but the general principle of using distributed processing to minimise the risk of inadvertent phi disclosure is of potential utility in other developed countries, although the specifics of our implementation may be less useful. the benefit of decreased risk of inadvertent phi disclosure from our approach entails three principal disadvantages compared with routine, centralized collection of identifiable data. first, a clinical responder with access to the locally stored phi data must be available to provide case level information when a cluster is detected. it would be technically straightforward to provide detailed information for relevant cases automatically when signals are detected. we deliberately did not implement this feature in the current system, since the participating health plans expressed a strong preference for direct involvement in this process. the second disadvantage is the need to pre-specify the syndromes, age groups, and other data aggregation parameters in advance, since changing these requires the distribution of a new release of the aggregation software. in practice, we have addressed this by means of configura-distributed software screen, showing results (synthetic data) after daily processing of encounter records figure distributed software screen, showing results (synthetic data) after daily processing of encounter records. tion data for syndrome categories read from a text file as the application loads, so the application code itself does not need alteration. this limitation could be largely overcome by creating a remote query capability to support ad hoc queries on identifiable data that remains in the control of the provider. the third disadvantage is the technical challenge of maintaining distributed software that must reliably process data that the programmers are not permitted to examine. while the software can be exhaustively tested on synthesized data, we have occasionally encountered subtle problems arising from previously unnoticed errors in the input data. our experience suggests that when writing this kind of distributed application, extensive effort must be devoted to detecting and clearly reporting errors in the input data before any processing takes place. an archive of python source code for the distributed software will be made available by the corresponding author upon request. unfortunately no resources are available to provide technical or other support outside the ndp. in summary, we have implemented a near real-time syndromic surveillance system that includes automated detection and reporting to public health agencies of clusters of illness that meet pre-specified criteria for unusualness [ ] . this system uses a distributed architecture that allows the participating health care provider to maintain full control over potentially identifiable phi and health encounter data. the distributed software loads simple text files that can be created from the data stored in virtually any proprietary emr system. it sends summary data suitable for signal detection algorithms via a freely available messaging system, to a datacenter that can manipulate the aggregated information and combine it with data from other providers serving the same geographic region, and which automatically generates and sends alerts when unusual clusters of syndromes are identified. the distributed software also facilitates efficient access to fully identified patient information when needed for following up a potential event. using automated medical records for rapid identification of illness syndromes (syndromic surveillance): the example of lower respiratory infection national bioterrorism syndromic surveillance demonstration program us department of health & human services: health insurance portability and accountability act a generalized linear mixed models approach for detecting incident clusters of disease in small areas, with an application to biological terrorism syndromic surveillance using minimum transfer of identifiable data: the example of the national bioterrorism syndromic surveillance demonstration program use of automated ambulatory-care encounter records for detection of acute illness clusters supported by u /ccu from the centers for disease control and prevention/massachusetts department of public health public cooperative agreement for health preparedness and response for bioterrorism and rfa-cd- - , center of excellence in public health informatics, from the centers for disease control and prevention. figure originally appeared in an article in the mmwr supplement [ ] the author(s) declare that they have no competing interests. rl wrote the first draft of the manuscript after extensive discussions with ky and rp. ky and rp both made substantial intellectual contributions during the evolution of the submitted manuscript. ky prepared figure and all of the tables.publish with bio med central and every scientist can read your work free of charge the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /pre pub key: cord- -dmkdsy r authors: seglem, k. b.; Ørstavik, r.; torvik, f. a.; røysamb, e.; vollrath, m. title: education differences in sickness absence and the role of health behaviors: a prospective twin study date: - - journal: bmc public health doi: . /s - - -y sha: doc_id: cord_uid: dmkdsy r background: long-term sickness absences burden the economy in many industrialized countries. both educational attainment and health behaviors are well-known predictors of sickness absence. it remains, however, unclear whether these associations are causal or due to confounding factors. the co-twin control method allows examining causal hypotheses by controlling for familial confounding (shared genes and environment). in this study, we applied this design to study the role of education and health behaviors in sickness absence, taking sex and cohort differences into account. methods: participants were two cohorts of in total norwegian twins born to (older cohort, mean age at questionnaire = . , . % women), and to (younger cohort, mean age at questionnaire = . , . % women). both cohorts had reported their health behaviors (smoking, physical activity and body mass index (bmi)) through a questionnaire during the s. data on the twins’ educational attainment and long-term sickness absences between and were retrieved from norwegian national registries. random (individual-level) and fixed (within-twin pair) effects regression models were used to measure the associations between educational attainment, health behaviours and sickness absence and to test the effects of possible familial confounding. results: low education and poor health behaviors were associated with a higher proportion of sickness absence at the individual level. there were stronger effects of health behaviors on sickness absence in women, and in the older cohort, whereas the effect of educational attainment was similar across sex and cohorts. after adjustment for unobserved familial factors (genetic and environmental factors shared by twin pairs), the associations were strongly attenuated and non-significant, with the exception of health behaviors and sickness absence among men in the older cohort. conclusions: the associations between educational attainment, health behaviors, and sickness absence seem to be confounded by unobserved familial factors shared by co-twins. however, the association between health behaviors and sickness absence was consistent with a causal effect among men in the older cohort. future studies should consider familial confounding, as well as sex and age/cohort differences, when assessing associations between education, health behaviors and sickness absence. supplementary information: supplementary information accompanies this paper at . /s - - -y. high levels of sickness absence are a growing concern in many industrialized countries. norway has one of the highest sickness absence rates with approximately % of working days lost over the past decade [ ] . sickness absence increases considerably across age, and women have a higher level than men [ ] . for an individual, staying away from work when ill is often necessary to ensure good health. long term sickness absence can, however, also have a negative impact on a person's health, and is a risk factor for permanent disability and lifelong exclusion from the labor market [ , ] . despite sickness absence being more than a measure of morbidity, e.g. influenced by the nature of one's work [ , ] and sociopolitical structures [ ] , there is a clear education gradient in sickness absence that parallels the well-known education gradient in health. individuals with lower educational attainment, a key dimension of socioeconomic status, are at higher risk of sickness absence and labor market exclusion [ ] . studies of education and sickness absence borrow largely from theoretical perspectives on the widely studied "education-health gradient" [ ] , thus positing that educational attainment has a causal effect on sickness absence [ , ] . an important mechanism, partly explaining education differences in health, is differences in health behaviors [ , ] . knowledge about the influence of health behaviors on sickness absence is limited [ ] [ ] [ ] [ ] [ ] [ ] [ ] , but lifestyle or health behaviors have been documented as one explanation for socioeconomic differences in sickness absence [ , , , , ] . the etiological processes underlying the association between education, health behaviors and sickness absence is poorly understood, but results from some studies indicate that these associations may be confounded by unobserved familial factors, i.e. genetic and/or environmental factors shared by co-twins [ , ] . education is considered as an important individual determinant of later medically confirmed sickness absence [ , , ] . individuals with higher educational level have lower levels of sickness absence than those with lower educational level, indicating better health and worklife functioning [ ] . education is typically completed by early adulthood, while other indicators of socioeconomic status, such as occupational class and income, are determined later [ , ] . compared to income, educational attainment is a stronger socioeconomic determinant of sickness absence in societies where differences in income levels are relatively low, such as in nordic countries [ , ] , which is why we focus on education in the present study. furthermore, education differs from other socio-economic indicators in that it primarily indicates differences in non-material resources such as general knowledge, and health literacy, which maylead to healthier behaviors [ ] . the importance of lifestyle or health behaviors for sickness absence has been studied to a limited degree only. much of the evidence focuses on single health behaviors, is based on relatively small sample sizes and findings have been mixed [ ] [ ] [ ] [ ] [ ] [ ] . however, a large observational study of cohorts from france, finland, and the uk found that lifestyle-related factors including bmi, physical activity, smoking and alcohol consumption were all associated with sickness absence [ ] . two previous studies have investigated whether lifestyle or health behaviors explain educational differences in sickness absence [ , ] . a population-based study among year olds in finland, found that lifestyle factors including smoking, physical exercise, sleeping problems, alcohol consumption and obesity altoghether explained about % of the educational differences in sickness absence, with a stronger effect among women [ ] . a study of workers in six companies in the netherlands, found that overweight/ obesity explained % of educational differences, after working conditions and perceived general health was accounted for [ ] . together, these studies indicate that lifestyle-related factors play a role in the mechanisms through which education affects sickness absence. however, these studies were observational, thus, inferences about causality could not be made. there is increasing appreciation that health behaviors do not co-occur within individuals by chance, but that they tend to cluster. those who smoke cigarettes are more likely to drink excessive amounts of alcohol and less likely to eat healthy and be physically active [ ] [ ] [ ] [ ] . poor health behaviors are also more prevalent among individuals with less education [ ] . instead of targeting specific health behaviors, some argue that multiple behaviors need to be targeted, in order for interventions to have an effect on health [ , ] . a previous randomized trial showed that an intervention involving physical exercise, health advice and smoking cessation had an effect on sickness absence [ ] . other intervention studies limited to physical exercise [ ] and overweight [ ] alone, did not appear to have any effects. based on the evident clustering of health behaviors and that the sum of several health behaviors seems more important for sickness absence than a particular health behavior, we use a health behavior index in the present study to focus on broad explanations for the role of health behaviors. recently, a growing body of studies using causal inference designs failed to fully support the hypothesis that socio-economic status exerts a causal effect on health [ ] [ ] [ ] [ ] . the co-twin control method represents one such design, where the aim is to mimic a counterfactual situation: monozygotic (mz) twin pairs are genetically identical while dizygotic (dz) pairs share on average % of their genes, just like other siblings. if raised together, both share their family environment. in the co-twin control method, the size of associations between exposure and outcome is compared with the corresponding within mz (and dz) associations. for example, if educational attainment statistically predicts sickness absence in the population, and we find a similar effect among mz-twins with different levels of educational attainment (within pair analyses), this supports that educational attainment is causally related to sickness absence. if, on the other hand, we observe that the populationbased association disappear in the within pair analyses, the initial association is probably due to confounding by unmeasured confounding by genes or shared environmental factors. subgroup analyses within mz and dz twins pairs allow to differentiate between confounding due to genes or shared environment. a previous twin study of young norwegian adults based partly on the same data as the present study [ ] showed that within dz twins, the effect of education on sickness absence was attenuated. within mz twins, who share both the family environment and all of their genes, the effect of education on sickness absence was negligible and reduced to non-significance, indicating that mainly genetic influences explained the association between education and sickness absence in young adulthood. in an older sample of middle-aged swedish twins, samuelsson and colleagues [ ] found that the association between education and disability pensioning, a construct strongly related to sickness absence, was also confounded by familial factors. in contrast, a twin study of health behaviors and risk for disability pensioning found an effect independent of familial factors [ ] . in this paper, we aim to add to the existing literature on educational and health behavior differences in sickness absence, by employing a co-twin control design. based on previous findings [ , ] , we hypothesized that educational attainment and health behaviors are independent predictors of sickness absence, and that health behaviors partly explain educational differences in sickness absence. we further hypothesized, based on previous twin studies [ , , ] , that the association between education and sickness absence would not be consistent with a causal explanation, but that the association between health behaviors and sickness absence would. due to well-known sex and age differences in level of sickness absence, but limited knowledge of causal factors underlying these differences [ ] , we will explore the effects by age/birth cohort and sex subgroups. information from three norwegian registries was linked using national identity numbers. the first was the norwegian twin registry, comprising information on , twins born between and and between and , respectively. for the present study, we selected two cohorts of twins. the older cohort was born between and and had completed a health questionnaire between and (median = ). the younger cohort of twins was born between and and had completed a similar health questionnaire between and . the mean age of the two cohorts when answering the questionnaires was . years and . years, respectively. the second registry (the historical-event database) contained information on each twin's sickness absence and employment. the third registry contained information about each twin's highest completed education (the norwegian educational database). sickness absences were retrieved for the period to , ensuring that the twins had completed the health questionnaires before the first recorded sickness absence. we excluded participants who had fewer than working days registered throughout the year follow-up period. for the older cohort, only same-sex twins were available. among the final sample of twins, there were complete pairs ( monozygotic (mz) male, dizygotic (dz) male, mz female, dz female, and unlike-sex twin pairs) and single twins. questionnaire items and genotyping of a subsample determined zygosity [ ] . in this longitudinal, population-based twin study, we employed a co-twin control design. the basics of this design is explained in the introduction. the regional committee for medical and health research ethics (case / ) approved of the study. we computed sickness absence taking the ratio of sickness absence days to contracted working days, ranging from to %. the mandatory norwegian insurance scheme covers sickness absences exceeding days and up days during a calendar year. we excluded sickness absences granted for problems or illnesses related to "pregnancy, childbearing, family planning" [ ] since those were relevant for women in the younger cohort only. data on educational attainment was available annually from to from the norwegian educational database administered by statistics norway. here the norwegian standard classification of education [ ] distinguished eight levels, ranging from "no education" to "ph.d. or equivalent". we simplified this classification by merging technical diplomas with undergraduate levels and ph.d.s with master degrees, resulting in five educational levels. to ensure completeness, we used data from when the youngest participants were years old. health-related lifestyle factors were based on selfreported information. leisure-time physical activity ("how often do you exercise?") included categories of never, less than once a week, one to two times per week and three times per week or more. categories were reverse coded prior to analyses, so that higher score reflects less physical activity. body mass index (bmi) was used as a proxy indicator for diet or overeating [ , ] . bmi was calculated based on weight ("how much do you weigh?") and height ("how tall are you?"). we first categorized bmi as underweight (lower than . kg/ m ), normal weight ( . - . kg/m ), overweight ( . - . kg/m ), and obesity ( . kg/m or higher). due to few individuals in the underweight and obese categories and a u-shaped association with sickness absence, we dichotomized bmi into normal weight ( ) versus not ( ) . smoking was assessed with the questions "do you currently smoke?" and "if you quit smoking, how old were you then?". we categorized smoking status as current or past smoker ( ) and non-smoker ( ). the internal-consistency reliability for the three health behavior variables was low as expected, i.e. kr- = . . a health behavior composite score was computed using principal component analysis (pca) of the three health behavior measures, and saving the factor scores (i.e., standardized, weighted sum score). the kaiser-meyer-olkin (kmo) measure verified the sampling adequacy for the analysis, kmo = . , and all kmo values for individual items were > . which is above the acceptable limit of . [ ] . bartlett's test of sphericity χ ( ) = . , p = < . , indicated that correlations between items were sufficiently large for pca. the items clustered on one component with an eigenvalue over kaiser's criterion of and explained . % of the variance. factor loadings were . for bmi, . for physical activity and . for smoking. higher score reflects less healthy behaviors, i.e. an unhealthy lifestyle. sex referred to that which was assigned at birth (men = , women = ), and was together with cohort (birth year) available from the norwegian twin registry. models included observations with complete information on all model variables. number of missing cases are reported in table . we performed the analyses using stata se version [ ] . careful inspection of scatterplots showed that education, health behaviors and sickness absence were linearly related. in the first set of analyses, the associations of education and health behaviors with sickness absencewere assessed with random-effects generalized least squares (gls) regression using the twins as individuals. standard errors and cis were adjusted for dependence between twins in pairs using robust variances (stata command xtreg, option re). we first estimated a model including the effects of education, sex and cohort on sickness absence, then added the effect of the health behavior composite. sex and cohort differences were examined using two-and three-way interaction terms. we finally calculated to what extent the association between education and sickness absence were reduced when health behaviors were included in the regression equation. secondly, we repeated the analyses using within twin pair models, by running fixed-effects models separately for monozygotic and dizygotic twins (stata command xtreg, option fe). this approach separates the effects of familial and genetic confounding, respectively. an attenuation of estimates in dz twin pairs would indicate familial (genes and or shared environment) confounding while further attenuation in mz twin pairs would suggest genetic confounding [ ] . models were run for the full sample and subgroups of sex and cohorts . descriptives table provides descriptive statistics for each cohort and sex. in the older and younger. cohorts, . % versus . % had higher education (beyond upper secondary),, t ( ) = − . , p < . . men scored higher on the health behavior composite, indicating more unhealthy behaviors, than women in both the older, t ( ) = . , p < . , and in younger cohort, t ( ) = . , p = . . the older cohort scored higher on unhealthy behaviors t ( ) = . , p < . . the overall incidence of any sickness absence was . %, i.e. a majority of participants were granted sickness absence during the years to . a total of . % of all working days between and were lost to sickness absence. there was a lower sickness absence proportion among men ( . % in the older cohort and . % in the younger cohort, t ( ) = . , p < . ) than among women ( . % in the older cohort and . % in the younger cohort, t ( ) = . , p < . ). figure shows a bar graph of educational attainment differences in annual mean sickness absence proportion in the follow-up years from to among women and men in the older and younger cohort. in the total sample, the difference in sickness absence varied from . % among those with lowest education (primary/ lower secondary) to . % among those with the highest level (master's degree or higher). despite differing levels of sickness absence, there was a clear negative relationship with educational attainment in all subgroups. table shows the results of the random-effect models predicting proportion of sickness absence from educational attainment and health behaviors for the total sample, including tests of interaction with sex and cohort. educational attainment was standardized to be directly comparable to health behaviors. the first model shows the association between education and sickness absence adjusted for birth cohort and sex, and accounting for twin dependency. the regression coefficient indicates that as educational attainment increased by one standard deviation (sd), the mean annual sickness absence proportion decreased with . percentage points. in unstandardized units, and more comparable to the raw data in fig. , the coefficient was − . ( % ci: − . , − . ), indicating that with each increasing level in educational attainment, sickness absence decreased with . percentage points. this means that based on the general sickness absence proportion of . %, one sd increase in education reduces sickness absence by %, while each increase in education level reduces sickness absence with %. the between r-squared for model indicated that % of the individual variation in sickness absence was explained. in the second model we added the health behavior composite. this resulted in a % reduction in the education-sickness absence coefficient, indicating a small degree of overlap and potential mediation. yet, both education and health behaviors showed unique statistically significant contributions. based on the general sickness absence proportion of . %, one sd increase in unhealthy behaviors was prospectively associated with . percentage points or a % increase in sickness absence. the between r-squared for the model was . , indicating that the composite of health behaviors only explained an additional % of the individual variation in sickness absence. models and include two-way interactions to investigate whether there were statistically significant sex and cohort effects in the education gradient in sickness absence. results indicated no interaction effects. model shows a stronger effect of health behaviors on sickness absence among women than men, and model a weaker effect of health behaviors in the younger than the older cohort. there were no statistically significant three-way interactions. to better understand how education and health behaviors are associated and since health behaviors are generally regarded as mediators of the effect of education on sickness absence, we ran an additional model predicting health behaviors from educational attainment for the whole sample, adjusting for birth year and sex, and accounting for twin dependency (not shown in table). next, we tested sex and cohort differences in table shows the associations between education, health behaviors, and sickness absence within dz and mz twin pairs for the total sample. in dz pairs, the association between education and sickness absence remained, i.e. higher education was associated with lower sickness absence. this association was slightly attenuated when adding health behaviors in model , but health behaviors did not show a statistically significant association with sickness absence. within mz pairs, the association of both education and health behaviors with sickness absence was small and not statistically significant. figure shows the standardized regression coefficients for the associations between all main variables for the total sample and within mz pairs (full adjustment of familial confounders) presented as a mediation model. this shows that the association of health behaviors and educational attainment with sickness absence was confounded by familial (shared environmental and/or genetic) factors. the association between educational attainment and health behaviors, on the other hand, was attenuated, yet remained statistically significant after control for familial factors. next, we ran fixed-effect models for each sex and cohort group separately (see figures s a-d in the online supplementary material). fixed-effects models were run with dz and mz twin pairs combined to increase statistical power when running analyses in subgroups. results were similar as for the fixed-effect model in the total sample, but with some exceptions. the most notable and robust difference was found between the cohorts in the association between educational attainment and health behaviors. in the older cohort the educationhealth behaviors association almost disappeared after adjusting for familial factors. in contrast, the educationhealth behaviors association in the younger cohort was somewhat attenuated and remained statistically significant (women: β = −. , p = . , men: β = −. , p < . ). we checked the robustness of this association by running analyses within mz twins only, confirming the results (women: β = −. , % ci = − . , − . , p = . ; men: β = −. , % ci = − . , − . , p = . ). due to the similar results for women and men in the younger cohort, we combined the sexes to increase statistical power. in the younger cohort, the association between education and health behaviors was similar in mz and dz twins (β = −. , % ci = − . , − . , p = . and β = −. , % ci = − . , − . , p = . , respectively), indicating partial confounding by mainly shared environmental factors. another exception was the association between health behaviors and sickness absence, which among men in the older cohort was enhanced and statistically significant in the within mz twin analyses (β = . , % ci = . , . , p = . ). to validate our findings, we performed several robustness checks. we reran the analyses with years of education (m = . , sd = . , range = - ) obtained from national registry data, yielding essentially the same results as with five educational levels (see tables s and s in the online supplementary material). second, we computed separate analyses for those who had completed their highest education before participating in the health study, to ensure temporal alignment. the analyses yielded essentially the same results (see tables s and s ). since more participants in the younger cohort had not completed their highest level of education before participating in the health study ( . %), we ran table within-twin pair associations between education, health behaviors and sickness absence in the total sample education and health behaviors were standardized prior to model entry additional models to check whether this affected the results in the younger cohort ( figures s a and b) . no substantial differences were found. the key findings of the present study were that on the population level, educational attainment and health behaviors were prospectively associated with sickness absence among both women and men, as well as older and younger cohorts. controlling for genetic and shared environmental factors, however, showed that these associations appeared to be confounded by familial factors and were therefore probably not causal. one exception was the association between health behaviors and sickness absence among men in the older cohort. these findings are an important contribution to the sickness absence literature, suggesting that a larger focus on the role of genetic mechanisms is warranted. the main findings are subsequently discussed. the findings that low educational attainment and poor health behaviors were associated with higher levels of sickness absence replicates previous observational studies (e.g. , ) . in addition to both education and health behaviors exerting main effects on sickness absence, there was also a degree of overlap between them. as previously shown in other studies [ , ] , we found that the effect of education on sickness absence was reduced once health behaviors were controlled for. this is in line with theories of health behaviors being mediators in the education-health outcome link [ , ] . however, our analyses of within-twin pair differences might give reason to reconsider these interrelationships. adjusting for factors shared by co-twins reduced the associations between education and sickness absence and between health behaviors and sickness absence (except for men in the older cohort). the reduction of the educationsickness absence association in the younger cohort sample has previously been documented [ ] . our study confirms these findings for an even longer follow-up time of years, until the year , when the younger cohort have reached the ages - , as well as extending these findings to hold also for the older cohort with follow-up until retirement age. we are not aware of any other previous twin studies that investigated whether the interrelationships between education, health behaviors and sickness absence are consistent with causal hypotheses. however, our results are consistent with a previous twin study of disability pensioning in sweden, showing that the association between education and disability pensioning is confounded by familial factors [ ] . another swedish twin study showed that the association between a combination score of health behaviors and disability pensioning was unclear [ ] . this could reflect that ropponen and svedberg combined alcohol consumption, which they found to have a protective effect, together with tobacco use and low physical activity, found to be risk factors. previous studies have found a u-shaped association between alcohol use and sickness absence, with abstainers and high level users having more sickness absence [ , ] . at the same time, alcohol use shows a more complex and heterogeneous pattern of association with socio-economic status (ses) than many other public health challenges, with higher ses often being associated with higher alcohol consumption [ ] . different ways of operationalizing and combining health behaviors make comparisons across studies complicated. nevertheless, knowledge of how various health behaviors interact in different groups or contexts is important for researchers and policy makers in the hope of improving health-related behaviors and reduce sickness absence in the population. in the present study, results indicated a causal link between health behaviors and sickness absence among men in the older cohort. in the younger cohort, health behaviors may not have had enough time to exert an effect on fig. all standardized coefficients from regression models with total sample adjusted for sex, cohort and twin dependency (first line) and within mz twins (second line). coefficients for sickness absence regressed on health behaviors (higher score indicates less healthy behaviors) was additionally adjusted for educational attainment health or sickness absence. why health behaviors did not seem to have a causal link to sickness absence among women in the older cohort, however, is more difficult to explain. one suggestion is that there may be selection effects, as the older cohort belongs to a generation where women typically stayed more at home. therefore it may have been easier for these women than the men to reduce their participation in or exit the labour force if experiencing health problems. however, women in the older cohort had higher levels of sickness absence, indicating that such selection effects were not overriding. another observation is that men in the older cohort showed more unfavourable health behaviours as measured by the composite and higher bmi in particular. this could indicate that sickness absence due to lifestyle diseases may be more prevalent among older men than women. this is consistent with previous observational studies showing that obesity is particularly associated with sickness absence due to digestive and circulatory diseases [ ] , and that several health behaviors, including smoking and bmi, has shown stronger associations with medically confirmed sickness absence among men than women [ ] . we also examined whether the association between education and health behaviors was consistent with a causal explanation. interestingly, the association between educational attainment and health behaviors was only partly confounded and remained statistically significant after familial control in the younger cohort, but not the older. this shows that education and health behaviors have become more causally related in younger cohorts. this corresponds to previous studies in the us showing that health behaviors exert a stronger impact on the education gap in mortality at younger than older ages [ ] , and that risky health behaviors have become more concentrated among more recent cohorts of individuals with lower education [ ] . this could be due to improved quality of education, more health campaigns and interventions from health authorities, or it could be due to sociocultural mechanisms leading to clustering of better or worse health behaviors in the upper and lower end of socioeconomic positions. the latter explanation also fits with the increasing socioeconomic segregation seen in populations of many industrialized countries [ ] . the strengths of this study include the prospective study design, the long follow-up period, the fact that we relied on high-quality registry data regarding exposure and outcome, and the genetically informative design that captured population data covering the entire age span of the norwegian working population. furthermore, in the present study, persons with at least employment days, and regardless of the hours of employment, during the -year follow-up period were included. with these wide inclusion criteria, we are likely to include persons who only work part-time due to health reasons and persons who fall out of the labour market for various reasons. by including all persons who are eligible for sickness absence benefits some time during follow-up, we include a broader segment of the population, which we believe make the findings more generalizable with regard to sickness absence in the population. the limitations of the study are first, that despite being able to use twin pairs as optimal matching of cases and controls, not all putative factors could be controlled for in this study. while the within-pair estimates are free from confounding from genetic and shared environmental facors, these estimates may be biased by non-shared confounders [ ] . for example, health problems early in life in one twin may explain why this twin has lower education as well as poorer health behaviors such as lower physical activity. second, sickness absence is a complex construct and our study has taken into account only some influential factors. risk factors specific to work, family situation attributable to the person or work-home interference, as well as psychological trait factors may be important and should be considered when interpreting our findings. third, due to restrictions in data accessibility we were only able to follow the twins until . there has (except from the current situation with covid- ) however, been no major changes in patterns of sickness absence or levels of employment since. fourth, we only had available information on long term sickness absence, i.e. at least days. we therefore do not know if the same results apply for short term sickness absence. finally, the results may not be generalizable to all settings, and are best generalizable to nordic and european countries with similar welfare schemes, attitudes and cultures of health behaviors. to conclude, both educational attainment and health behaviors were independently associated with level of sickness absence, but these associations were strongly confounded by familial factors. based on these findings, interventions aiming to increase educational attainment or improve overall health behaviors, despite their potential importance in improving public health, might not be the best strategy to reduce the rate of sickness absence. future studies investigating education and health behaviors as predictors of sickness absence need to take familial confounding into account, as well as consider variations between sex and age/cohort groups. supplementary information accompanies this paper at https://doi.org/ . /s - - -y. additional file . oecd economic surveys: norway risk factors for sick leave-general studies sickness absence as a risk factor for job termination, unemployment, and disability pension among temporary and permanent employees is there an association between long-term sick leave and disability pension and unemployment beyond the effect of health status?-a cohort study sickness absence as a measure of health status and functioning: from the uk whitehall ii study explaining socioeconomic differences in sickness absence: the whitehall ii study more and better research needed on sickness 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the gap gets bigger: changes in mortality and life expectancy, by education socioeconomic segregation in european capital cities. increasing separation between poor and rich sibling comparison designs: bias from non-shared confounders and measurement error publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations data on zygosity on the twins used in this study was obtained from the norwegian twin registry, the norwegian institute of public health. we are very grateful to the twins for their participation. the raw data is confidential and cannot readily be shared. data may be shared with researchers obtaining permissions from the norwegian twin registry, statistics norway, and the regional committees for medical and health research ethics. the study was approved by the regional committees for medical and health research ethics (reference number: / rek sør-øst d). written informed consent was obtained from participants born - . for participants born - an exemption from the duty of confidentiality, cf. the norwegian health research act, was approved by the regional committees for medical and health research ethics. not applicable. the authors declare that they have no competing interests. key: cord- - rpbsj authors: wessel, lindsay; hua, yi; wu, jianhong; moghadas, seyed m title: public health interventions for epidemics: implications for multiple infection waves date: - - journal: bmc public health doi: . / - - -s -s sha: doc_id: cord_uid: rpbsj background: epidemics with multiple infection waves have been documented for some human diseases, most notably during past influenza pandemics. while pathogen evolution, co-infection, and behavioural changes have been proposed as possible mechanisms for the occurrence of subsequent outbreaks, the effect of public health interventions remains undetermined. methods: we develop mean-field and stochastic epidemiological models for disease transmission, and perform simulations to show how control measures, such as drug treatment and isolation of ill individuals, can influence the epidemic profile and generate sequences of infection waves with different characteristics. results: we demonstrate the impact of parameters representing the effectiveness and adverse consequences of intervention measures, such as treatment and emergence of drug resistance, on the spread of a pathogen in the population. if pathogen resistant strains evolve under drug pressure, multiple outbreaks are possible with variability in their characteristics, magnitude, and timing. in this context, the level of drug use and isolation capacity play an important role in the occurrence of subsequent outbreaks. our simulations for influenza infection as a case study indicate that the intensive use of these interventions during the early stages of the epidemic could delay the spread of disease, but it may also result in later infection waves with possibly larger magnitudes. conclusions: the findings highlight the importance of intervention parameters in the process of public health decision-making, and in evaluating control measures when facing substantial uncertainty regarding the epidemiological characteristics of an emerging infectious pathogen. critical factors that influence population health including evolutionary responses of the pathogen under the pressure of different intervention measures during an epidemic should be considered for the design of effective strategies that address short-term targets compatible with long-term disease outcomes. the findings highlight the importance of intervention parameters in the process of public health decision-making, and in evaluating control measures when facing substantial uncertainty regarding the epidemiological characteristics of an emerging infectious pathogen. critical factors that influence population health including evolutionary responses of the pathogen under the pressure of different intervention measures during an epidemic should be considered for the design of effective strategies that address short-term targets compatible with long-term disease outcomes. epidemics of infectious diseases have been observed throughout history, with substantial variability in their dynamical patterns. the influenza pandemic is a notorious case documented as the most devastating epidemic with over million deaths and multiple outbreaks in many geographic areas worldwide [ , ] . distinct pandemic infection waves were recorded with an to week interval; the latter were more severe than the first and were associated with the majority of deaths [ , ] . although several factors may be involved, such as the effect of seasonal changes, demographics, and evolution of the virus, the true mechanism by which subsequent waves occur is not fully understood. nor is it clearly understood how different control measures and strategies for deployment of limited health resources may interfere with disease dynamics and the occurrence of later infection waves. recent epidemiological and modelling studies have attempted to provide explanatory theories for the mechanisms of multiple outbreaks of an infectious pathogen capable of establishing an epidemic [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . spontaneous behavioural changes (e.g., a change in the number of contacts due to modified behaviour of susceptible individuals) have been shown to affect the course of infection events and produce subsequent outbreaks in an epidemic episode [ ] . this has been further investigated through modelling "concerned awareness" of individuals that may result in contagion dynamics of fear and disease [ ] , and the implementation of public health control measures (e.g., social distancing) that may interfere with the individuals' contact patterns during the epidemic [ ] . co-infection has also been suggested as a possible explanation for multiple infection outbreaks as a result of increased transmissibility in coinfected individuals and non-synchronicity in the time course of the two co-circulating infections [ ] . other possible mechanisms include transient post-infection immunity and evolutionary changes that may occur in the characteristics of the infectious pathogens [ , , ] . in this study, we consider the occurrence of multiple infection waves of a pathogen from a public health perspective, and develop mathematical models to investigate how intervention measures may affect the transmission dynamics in a population. specifically, we are interested in exploring the impact of changes in policy-relevant parameters on the patterns of disease spread during the course of an epidemic. these parameters may reflect the effectiveness of intervention strategies (e.g., treatment or isolation of infected cases) in reducing disease transmission, or their epidemiological consequences (e.g., emergence of drug resistance), and may therefore play an important role in determining the outcome of disease control activities. the significance of this work thus relates to the process of public health decision-making, in particular when confronting the emergence of a novel infectious disease with substantial uncertainty regarding the epidemiological characteristics of the invading pathogen. for the purpose of this investigation, we develop both mean-field and stochastic epidemiological models that describe the transmission dynamics of a disease in the population, and incorporate treatment and isolation of infected cases as control measures. we parameterize these models to simulate the spread of influenza as a case study, and determine the impact of control parameters on disease dynamics. we illustrate the occurrence of multiple infection waves associated with different treatment levels and the development of drug resistance in the population under the scenario of limited capacity for treatment and isolation of infectious individuals. we compare the results obtained by simulating the mean-field model with those observed in the stochastic model, and discuss our findings in the context of epidemiology and public health. to formulate the models for describing disease epidemic, we assume that the population is initially entirely susceptible to the infectious pathogen. it is assumed that the infection can be treated with drugs, but the pathogen may develop resistance during the course of treatment with potential for transmission. since resistance emergence may impose fitness cost on pathogen replication and transmission [ ] , we assume that the drug-resistant pathogen is less transmissible than the drug-sensitive pathogen. treatment is assumed to reduce transmissibility of the drug-sensitive infection, but remains ineffective against drug-resistant infection. we also assume that the recovery from infection confers immunity to re-infection with either drug-sensitive or resistant pathogens. considering epidemics with relatively short time-courses, we ignore the effect of recruitment, natural death, and other demographic variables of the population. with the assumption of homogeneous mixing, we divide the population into classes of susceptibles (s); individuals exposed (not yet infectious) to sensitive (e) and resistant (e r ) infections; untreated individuals infected with sensitive (i) and resistant (i r ) infections; treated individuals infected with sensitive (i t ) and resistant (i t,r ) infections; isolated individuals infected with either sensitive or resistant infection (j); and recovered individuals (r). figure shows the movements of individuals between these classes during the course of an epidemic. with parameters described in table , the dynamics of the mean-field model can be mathematically expressed by the following system of differential equations: ). ( ) details of the model in its stochastic form are provided in the appendix. a key parameter in disease epidemiology is the basic reproduction number of the invading pathogen, commonly denoted by r , which is the average number of new infections generated by a single infected case introduced into an entirely susceptible (non-immune) population [ ] . the quantity r can be used to estimate the growth rate of an epidemic (during the initial phase) and the total number of infections (final size of the epidemic) [ ] . when public health interventions are implemented, the reproduction number of disease is affected by parameters that determine the effectiveness of control measures; and we therefore introduce the control reproduction number ( r c ) to evaluate the impact of such parameters on transmissibility of the pathogen and epidemic dynamics. applying a previously established method [ , ] , for model ( ) where s is the size of the susceptible population at the onset of the outbreak. in the absence of treatment and isolation, r c reduces to the basic reproduction number of the sensitive pathogen, given by r = bs /g. using the expression for r c s in ( ), one can easily calculate the critical value p * at which r c s = , and therefore the spread of the sensitive infection can be contained for p >p * . rewriting r c s in terms of r , the value p * is given by however, the spread of disease caused by the sensitive pathogen cannot be controlled if r exceeds the threshold r * = (g + a)/δ t qg, which results in p * > . since ≤ q ≤ , for parameter values used in simulations (table ) , disease control becomes infeasible if r > . . similarly, there is a critical value p r * at which r c r = , and the spread of the resistant pathogen is contained if which highlights the importance of isolation for controlling the spread of resistant infection. to simulate the models, we considered influenza infection as a case study, for which emergence and spread of drug-resistance during an outbreak can result from treatment of infected individuals. we assumed that the epidemic is triggered by a drug-sensitive influenza virus, and investigated the role of several key model parameters in changing the epidemic patterns and generating multiple waves of infection. these parameters include the fractions of infected individuals identified for treatment or isolation, and the basic reproduction number of disease which varies within the estimated range published in the literature (table ) . since public health resources may be limited during an epidemic, we [ , , ] baseline values of the parameters used for simulations of the models with sources from published literature. for a given value of r , the baseline transmission rate b can be calculated using the expression r = bs /g. also defined a parameter (t c ) as the capacity for treatment of infected individuals including those who are isolated (i.e., the percentage of the total population that can be treated). to illustrate various scenarios, we initially seeded a susceptible population of size s = , with e = individuals exposed to the sensitive virus, and assumed that treatment can result in the emergence of resistance with the relative transmissibility δ r = . during the outbreak. other parameter values are given in table . the mean-field model was simulated for a number of scenarios to show the occurrence of multiple infection waves during an epidemic episode ( figure ). these simulations indicate that variation in the transmissibility of the pathogen (determined by r ), as well as parameters that govern the effectiveness of control measures can significantly impact the epidemic profile, leading to sequences of infection waves with different magnitudes and time-courses. to explore the causes of these multiple outbreaks, we plotted time-courses of treated and untreated sensitive (black curves) and resistant infections (red curves), corresponding to epidemic profiles in figures a- d. as illustrated in figures a- b , a large scale use of treatment (combined with isolation) suppresses the spread of the sensitive infection quickly, but leads to the emergence and spread of resistance that causes the first wave of infection. due to the limited capacity of treatment and isolation (run-out scenario), a second wave of infection follows as a result of wide-spread resistance (red curves), which declines once a sizable portion of the susceptible population is infected and the level of susceptibility reduces below a threshold that is sufficient to block the transmission of the resistant pathogen with reduced fitness. however, this level of susceptibility may still be above the threshold required for disease containment, and therefore the sensitive pathogen can cause the third wave of infection (black curves). as the reproduction number of the sensitive infection increases (figures c- d) , higher treatment levels are required for the resistant infection to prevail and cause a significant outbreak [ ] . for a reduced level of treatment and a higher transmissibility of the sensitive virus, corresponding to the epidemic profile in figure c , we observed two infection waves, both of which are caused by the spread of the sensitive virus, with generation of very few cases of resistant infection. in this scenario, run-out occurs before epidemic is contained, and a second infection wave takes place. similar dynamics can occur with two subsequent waves of resistant infections for a significantly higher treatment level (figure d) . however, the second wave that occurs after the treatment capacity is fully dispensed (run-out scenario) leads to a major reduction in susceptibility of the population; thereby ending the epidemic. these simulations indicate that multiple infection waves could occur due to limited resources for treatment/isolation of infected cases, the ways that such resources are deployed during the outbreak, the evolutionary responses of the pathogen to control measures (e.g., emergence of drug resistance), or a combination thereof. we performed further experiments with small changes in these parameters, and observed significant influences on the epidemic dynamics that can be associated with the elimination or creation of an infection wave. it is worth noting that the above scenarios can take place even for sufficient drug stockpiles for which run-out does not occur, if a policy for adaptation (e.g., reduction) of treatment at the population level is implemented due to wide-spread drugresistance [ ] . for comparison purposes, we simulated the stochastic version of the model using a markov chain monte carlo method and observed sequences of infection waves for different sets of parameter values (see appendix). consistent with previous observations [ ] , the stochastic model displays a later peak time of infection waves (with lower magnitudes) than the homogeneous mean-field model. this depends not only on the treatment level, but also on other parameters involved in the spread of sensitive and resistant infections, such as the reduction in the potentially infectious contacts and the fitness of resistance. furthermore, stochastic effects can play a significant role in determining disease dynamics even during the outbreak well past the initial establishment phase of the epidemic. this is illustrated in figure c of the appendix that the epidemic dies out after the first outbreak in the stochastic model; whereas a second wave of infection takes place in the mean-field model with a larger magnitude compared to the first outbreak. in addition to parameters pertaining to the nature of disease and effectiveness of interventions, the number of infected cases at the onset of an epidemic can greatly influence the dynamics of disease. our simulations (figure ) indicate that small changes in the initial number of infections may result in different epidemic profiles exhibiting more than one infection wave. this suggests that the true dynamics of an emerging disease (with unknown initial number of infections) may not be predicted with certainty, even when reliable estimates of other pathogen-related and intervention parameters are available. stellar advances in the prevention and management of infectious diseases have been achieved since the great influenza pandemic of . yet, emerging pathogens often inflict incalculable devastation to humanity. the global mobilization with rapid international transportation between populations makes the impact of such diseases even more dramatic with potential socioeconomic upheaval. this was recognized in with the appearance of severe acute respiratory syndrome (sars) as the first major infectious disease threat of the st century [ ] , and was recently experienced with the worldwide spread of a swine-origin influenza a virus h n , that led the world health organization to declare this virus as the cause of an influenza pandemic on june , [ ] . public health responses to the emergence of new diseases often involve difficult decisions on optimal use of health resources over very short timelines. such decisions are further confounded by substantial uncertainties regarding the epidemiological characteristics of the novel infectious pathogen, the effectiveness of public health intervention strategies, and the evolutionary responses of the pathogen under the pressure of control measures [ ] . from a population health perspective, it is therefore imperative to look beyond short-term targets and account for long-term disease outcomes in strategy development and implementation. this is particularly important for preventing multiple infection outbreaks that may result from imprudent use of resources or unintended adverse consequences of disease containment strategies. given the historical evidence for the occurrence of multiple infection waves [ , , ] , several modelling studies have attempted to provide explanatory theories for these events in a single epidemic course [ , , , [ ] [ ] [ ] . in this study, we developed mean-field and stochastic models to investigate possible causes of sequential outbreaks from a public health perspective. our results show that epidemic dynamics can be substantially affected by factors that influence policy design and implementation (e.g., treatment level or isolation of infected individuals), and parameters that determine the effectiveness and consequences of control measures (e.g., reduction in infectiousness due to treatment or emergence of drug-resistance). furthermore, the initial number of infections can influence disease outcomes. while mean-field and stochastic models may exhibit similar epidemic behaviour, we also observed differences in their predictions in terms of the speed with which disease spreads through the population (with further delay in the peak time of outbreaks in the stochastic model); the magnitudes of infection outbreaks; and more importantly, the occurrence of infection waves (see appendix). the latter is particularly influenced by stochastic effects, in addition to the structure of contact patterns and heterogeneity in population interactions [ ] . previous work [ , ] provides a solid foundation for extension of this study through the development of network dynamical models of disease transmission in which heterogeneous contacts between individuals are accounted for. in this study, we simplified the models and included compartments corresponding to some possible stages of a disease; yet we understand that different pathogens may cause infections with different clinical manifestations and infectiousness periods. for example, influenza is known to have a short latent period of less than days before becoming infectious [ ] , followed by a pre-symptomatic infection during which disease can be transmitted without showing clinical symptoms; however, the latent period of sars is estimated to be longer and may be comparable to the duration of a complete course of influenza infection [ ] . it is also well-documented that influenza can be table of the main text with: (a) r = . , p = . , q = . , t c = . % (three infection waves); (b) r = . , p = . , q = . , t c = % (two infection waves); and (c) r = . , p = . , q = . , t c = % (one infection wave). black and red curves correspond respectively to the sensitive (untreated and treated: i + i τ ) and resistant (untreated and treated: i r + i t,r ) infections. blue curves illustrate the corresponding scenarios for the total number of infections (i + i t + i r + i t,r ) during epidemic simulated in the mean-field model. in all simulations, initial number of infected cases is e = . transmitted in asymptomatic form without developing clinical symptoms [ ] ; while evidence for asymptomatic transmission of sars is rather scant. these discrepancies in infection stages of human diseases, combined with the ability of the pathogens to overcome the pressures that are applied to limit their replication and spread, can profoundly impact not only the feasibility and effectiveness of control measures, but also the dynamics of disease over the course of an epidemic. our study highlights these considerations for further investigation, while demonstrating possible mechanisms for the occurrence of multiple infection waves in a single epidemic. future research in this direction should address some limitations of the present study, including a systematic exploration of parameter space to characterize which intervention parameter regimes are more likely to give rise to sequences of infection outbreaks, and to determine the sensitivity of model outputs (epidemic dynamics) on parameter changes. although models considered here are simulated for influenza infection as a case study, understanding the interplay between intervention parameters, evolutionary responses of the pathogens, and epidemic dynamics remains a critical objective of public health for many diseases [ ] , including hiv, tuberculosis, malaria, and several bacterial infections. such diseases often share common features, including the emergence and prevalence of drug resistant pathogens under the pressure of drug treatment. the initial rise of resistance is generally associated with fitness costs that make the resistant pathogen less capable of competing with the sensitive pathogen (as the dominant competitor) in a given host population [ ] . however, evolutionary mechanisms (e.g., compensatory mutations [ ] ) may improve the fitness of resistant pathogens, and therefore intervention measures may result in further selection of resistance, as has been documented for the global spread of seasonal influenza drug resistance that appears to be associated with fitness enhancement processes [ ] . this suggests that future modelling efforts should integrate factors that govern pathogen-host interactions with the mechanisms of disease epidemiology to guide public health in devising novel and effective means of infection control. with the same population compartments as defined in the mean-field model described in the main text, we develop a stochastic model for disease transmission dynamics to investigate the epidemic patterns with random effects. we consider time t as a continuous variable, and define the following random vector for ) that represents changes that occur to the random vector at Δt units of time. we define the transition probability as , the function Θ(·) describes the status of an individual in a subpopulation (i.e., Θ(·) = - : an individual leaves the subpopulation; Θ(·) = : no changes occur to the individuals' status in the subpopulation; Θ(·) = : an individual enters the subpopulation). we assume that Δt is sufficiently small, so that at most one change of status can occur during the time interval Δt, which can be viewed as a markov chain process. the resulting stochastic model can be described as a continuous time markov model, with the transition probabilities given in table . for simulating the stochastic model, we used the markov chain monte carlo method, with an initial e( ) = exposed individuals to sensitive infection in a population of s = , susceptibles. a key parameter in these simulations is the step-size of the monte carlo method. using a fixed step-size requires a large number of steps to guarantee that the transitions between subpopulations take place and disease transmission can occur, which is computationally very demanding in terms of both timing and resources. to reduce such a computational load, we implemented an adaptive step-size method [ ] to estimate the transition time to the next event (Δt) by calculating the sum of the frequencies of all possible events, given by h = b(i + δ t i t )s(t) + δ r b(i r + i t,r )s(t) + ( p)µ e (e + e r ) + pqµ e (e + e r ) + ai t + p( q)µ e (e + e r ) + g(i + i r + i t,r + j + i t ). then, by choosing Δt = u /h, where u is uniform distribution in the interval [ , ], we ordered all possible events as an increasing fraction of h and generated another uniform deviate (u [ , ]) to determine the nature of the next event. for the convergence of the results, we ran these simulations for samples, and considered the average of sample realizations of the stochastic process to generate infection curves. we ran stochastic simulations with parameter values given in table to illustrate the possibility of multiple infection waves for different scenarios with variation in the basic reproduction number, fractions of treated and isolated ill individuals, and the capacity for treatment and isolation. figure a shows that, since the transmission of the sensitive infection is largely blocked by a high treatment level, resistance emerges and causes the first infection wave of the outbreak. the second wave of resistant infections follows after the capacity of treatment and isolation (t c ) is exhausted, and declines when susceptibility of the population falls below a certain threshold that is sufficient to end the resistant outbreak (red curve). however, due to higher fitness of the sensitive infection, a third wave of outbreak occurs which results in depletion of the susceptible population to levels sufficient for ending the epidemic (black curve). we observed similar behaviour in the mean-field model, as illustrated by the blue curve in figure a . when treatment level is reduced by a significant margin, generated resistant infection is out-competed by the sensitive infection which has a higher fitness advantage (figure b) , and only outbreaks of the sensitive infection occur; the second wave takes place after the capacity of treatment is fully dispensed (black curve). while, the mean-field model also produces similar results (blue curve), we observed differences in the behaviour of the stochastic model. a small reduction in the fraction of isolated individuals leads to the elimination of the second wave in the stochastic model, while mean-field model still produces a second wave with even a larger magnitude than the first wave of the outbreak ( figure c ). this suggests that not only are stochastic effects important during the early stages of disease outset, but they also can play a critical role in shaping the epidemic well beyond the establishment phase of the disease. influenza pandemic planning influenza: the mother of all pandemics potential impact of antiviral drug use during influenza pandemic a comparative evaluation of modelling strategies for the effect of treatment and host interactions on the spread of drug resistance quantifying social distancing arising from pandemic influenza coupled contagion dynamics of fear and disease: mathematical and computational explorations turning points, reproduction number, and impact of climatological events for multi-wave dengue outbreaks coinfection can trigger multiple pandemic waves spontaneous behavioural changes in response to epidemics qualitative analysis of the level of crossprotection between epidemic waves of the - influenza pandemic rna viruses mutations and fitness for survival verlag; . . van den driessche p, watmough j: reproduction numbers and subthreshold endemic equilibria for compartmental models of disease transmission antiviral resistance during pandemic influenza: implications for stockpiling and drug use management of drug resistance in the population: influenza as a case study incubation periods of acute respiratory viral infections: a systematic review population-wide emergence of antiviral resistance during pandemic influenza containing pandemic influenza at the source strategies for containing an emerging influenza pandemic in southeast asia modelling strategies for controlling sars outbreaks world now at the start of influenza pandemic world health organization modelling of pandemic influenza: a guide for the perplexed the effect of population structure on the emergence of rug resistance during influenza pandemics factors that make an infectious disease outbreak controllable gaining insights into human viral diseases through mathematics the role of compensatory mutations in the emergence of drug resistance the genesis and spread of reassortment human influenza a/h n viruses conferring adamantane resistance the interplay between deterministic and stochasticity in childhood diseases ):s . submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution developed mean-field model and performed simulations: lw, sm. developed stochastic model and performed simulations: yh, sm. designed the study and wrote the paper: jw, sm. all the authors have read the final version of the paper and approved it. the authors declare that they have no competing interests. recovery from treated infectionrecovery from treated sensitive infectionincrease in treated resistant infection key: cord- - x zrfw authors: cherrie, mark p. c.; nichols, gordon; iacono, gianni lo; sarran, christophe; hajat, shakoor; fleming, lora e. title: pathogen seasonality and links with weather in england and wales: a big data time series analysis date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: x zrfw background: many infectious diseases of public health importance display annual seasonal patterns in their incidence. we aimed to systematically document the seasonality of several human infectious disease pathogens in england and wales, highlighting those organisms that appear weather-sensitive and therefore may be influenced by climate change in the future. methods: data on infections in england and wales from to were extracted from the public health england (phe) sgss surveillance database. we conducted a weekly, monthly and quarterly time series analysis of pathogen serotypes. each organism’s time series was forecasted using the tbats package in r, with seasonality detected using model fit statistics. meteorological data hosted on the medmi platform were extracted at a monthly resolution for – . the organisms were then clustered by k-means into two groups based on cross correlation coefficients with the weather variables. results: examination of . million infection episodes found seasonal components in / ( %) organism serotypes. salmonella showed seasonal and non-seasonal serotypes. these results were visualised in an online rshiny application. seasonal organisms were then clustered into two groups based on their correlations with weather. group had positive correlations with temperature (max, mean and min), sunshine and vapour pressure and inverse correlations with mean wind speed, relative humidity, ground frost and air frost. group had the opposite but also slight positive correlations with rainfall (mm, > mm, > mm). conclusions: the detection of seasonality in pathogen time series data and the identification of relevant weather predictors can improve forecasting and public health planning. big data analytics and online visualisation allow the relationship between pathogen incidence and weather patterns to be clarified. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. seasonality can be defined as increased or decreased observations that display a periodic pattern (e.g. week, month, quarter) of occurrence between years [ ] . microbial pathogens tend to be defined as microorganisms that can cause disease in humans and other organisms [ ] . reviews of their seasonality have been published previously [ ] . seasonal drivers are already known to produce annual peaks for a number of infectious diseases, including malaria [ ] , west nile virus [ ] , and cholera [ ] , as well as several pathogens transmissible by contact such as influenza [ ] , respiratory syncytial virus [ ] and meningococcal meningitis [ ] . seasonality may be explained by a mixture of factors including climate, social, behavioural, agricultural, environmental, stochastic changes in immune populations, and other drivers. in addition, weather can influence vector abundance, pathogen survival and host characteristics (e.g. behaviour and immune susceptibility) [ ] . the mathematical approaches to modelling have been reviewed [ ] . several studies have investigated the effects of weather and climate on pathogens in england and wales. salmonella enteritidis incidence was shown to increase by . % ( %ci; . - . ) for every °c rise over a °c threshold [ ] . similarly, campylobacter prevalence was associated with temperature in the previous weeks [ ] while other studies found little association [ ] . a systematic approach to the analysis of the potential seasonality of common pathogen serotypes and their associations with multiple weather variables is required to help narrow the focus on candidate pathogens in addition to those that have been studied in depth previously. the current analysis is well placed to address this gap given the rich data now available on a broad number of pathogens and meteorological factors. the aim of the analysis was to use several data mining techniques to identify pathogens that display a seasonal component, and describe their associations with meteorological factors as an aid to future analytical work (including forecasting) and public health planning. infectious disease data from england and wales were collected by public health england (phe) (formerly the health protection agency and before that the public health laboratory service) through a voluntary reporting system, whereby hospital laboratory records are transferred to regional epidemiology units, processed and added to the labbase national surveillance database [ ] . to avoid duplication by organism and patient, each record has a unique identifier called the organism patient illness record (opie). if a record is sent with the same patient and organism information within days ( weeks for mycobacterium spp.), then these cases are merged to ensure a single opie for the entire duration of the episode. the second generation surveillance system (sgss-formerly labbase ) voluntary national surveillance database holds records on , , reportable human infectious cases spanning from the st week in to the nd week in for root organisms and serotypes. pathogen counts were recorded at a weekly level in the database. the analysis for individual serotypes was restricted to complete years, from to , with serotypes greater than cases (above quartile one, i.e. top % in terms of total count), as a time series model could not be automatically estimated with fewer cases (n = ). we aggregated the data to a monthly level and linked with national meteorological data held on the medical and environmental data mash-up infrastructure project (medmi) platform [ ] . the analysis was performed at a national scale due to multiple factors at a local level that act as noise to obfuscate the relationship between infectious disease and weather [ ] . a range of meteorological data for the uk was downloaded from the medmi platform [ ] at a km by km resolution for - ; full details on methods used to generate data are provided elsewhere [ ] . the variables were monthly weather summaries that included: mean sunshine duration (hours per day), mean temperature (°c), mean daily maximum temperature (°c), mean daily minimum temperature (°c), mean vapour pressure (hpa), mean sea level (msl) pressure (hpa), rain ≥ mm (days), rain ≥ mm (days), total rainfall (mm), mean wind speed at a height of m (knots), mean relative humidity (%), snow lying over % of ground (days), ground frost measured as grass minimum temperature below °c (days), and air frost measured as air minimum temperature below °c (days) (additional file : figure s ). the data were imported into arcmap (esri, redwoods, ca) and aggregated (arithmetic mean) for england and wales, which enabled linkage with the infectious disease time series data. descriptive statistics were generated for the organisms including total count, crude prevalence rate per month, peak month and plots of time-series patterns (for gastro-intestinally acquired infections and those from respiratory transmission). we applied a two stage automated analysis to: a) detect seasonality and b) identify correlations with weather variables. the first stage was the seasonality detection analysis, undertaken in rstudio (ver . . ). description of the forecast package, which was used extensively in the analysis to automatically detect seasonal patterns, has been detailed elsewhere [ ] . briefly, the pathogen time series data were decomposed via box cox transformations into trend, seasonal and irregular components, which were used to forecast the time series into the future [ ] . the algorithm automatically selects model parameters such as trend (with or without a dampening parameter) and noise (arma (p,q) process) using model fit statistics (i.e. minimising akaike information criteria (aic)). a tbats model, as described above, was fitted for each organism serotype (with a non-zero count) using the weekly periodicity (i.e. the most granular temporal resolution available). the models were re-run with data aggregated at monthly and quarterly periodicities to investigate seasonality at different temporal aggregations [ ] . each time the model would provide a logical output (i.e. true/false) as to whether the model fit improved with the inclusion of the seasonal component (i.e. consistent repeating pattern over time). this is because the algorithm fits two models, seasonal and non-seasonal, and selects the seasonal model if the aic is lower than the non-seasonal model (heuristically, it selects the model that results in the best combination of good fit and lower number of parameters). to limit the seasonality definition to those whose model fit was significantly better with the addition of the seasonal component, we calculated the difference between the seasonal and non-seasonal aic (Δ i = aic nonseasonal − aic seasonal ) and excluded organisms with aic difference greater than , as suggested as a suitable cut-off by burnham and anderson [ ] . the pathogens at a monthly resolution with aic difference greater than were used in subsequent analysis with weather variables. for the second stage, we aggregated the pathogen incidence data to monthly resolution so that they were able to be merged with the weather variables previously processed to monthly values by the national climate information centre. the time series' for each of the weather variables was shown to be stationary (no significant trend from year to year) by using the augmented dickey-fuller (af) test (p < . ) and kwiatkowski-phillips-schmidt-shin (kpss) test (p > . ). we tested each pathogen time series in the same way. some were found to be non-stationary and differenced (once or twice, depending on results of af and kpss tests). cross correlation coefficients were generated between cases and weather variables for the month that they were recorded and then by the meteorological values lagged by month. the correlation coefficients were then used as input to the k-means clustering method. two clusters were generated in order to narrow the focus on those correlated with weather. the terminology for discussing the correlation coefficients was as follows: very weak (r = - . ), weak (r = . - . ), moderate (r = . - . ), strong ( . - . ) and very strong (r = . - . ). seasonality and weather correlation results were summarised and discussed in terms of differences between weather variables and within the most common genus for which serotypes were available (salmonella). supplementary to the time series analysis, an rshiny app was developed to display the results and aid future hypothesis generation. the user can filter the pathogens by seasonality, prevalence and serotype. once an individual serotype is selected, a range of descriptive information is available: wikipedia description, total number of cases, time series plot, month plot of crude rate per , (england and wales population), decomposition of time series, tbats model forecast and weather scatterplot. the weekly data on . million pathogen infections in england and wales from to were examined systematically. the minimum number for an organism to be in the database during the time period was once per week. the maximum number of cases for week was for chlamydia trachomatis. there was a non-normal distribution of total cases, from one case for organisms to , , for chlamydia trachomatis. the median number of total cases was (interquartile range quartile -quartile ; - , ). the organisms with the highest number of serotypes were salmonella (n = ) and streptococcus (n = ), although most of these had very low counts. figure shows a heat map of z-scores of crude rates by month ( fig. shows non-salmonella pathogens, and fig. shows only the salmonella genus). the months with the fewest high pathogen rates for the majority of organisms were december ( . %) and february ( . %). the months with the highest number of high pathogen rates were more evenly spread out over the summer and autumn, with july, august, september and october being the highest months for . % of the organisms. the seasonality of gastro-intestinally acquired infections (fig. ) , and pathogens acquired through respiratory transmission (fig. ) , differed substantially. the gastro-intestinal pathogens showed different distributions, with most bacteria having higher rates in summer, some viruses had higher rates in winter (e.g. norovirus, rotavirus) and others were more common in the summer (enteroviruses). some of the pathogens associated with travel overseas had a late summer increase (thought to reflect the period when people return from summer holidays). the respiratory pathogens predominated in the winter months (e.g. coronavirus, influenza, respiratory syncytial virus (rsv)). however, several of the bacterial pathogens were more frequent in warmer months (e.g. bordetella, coxiella, legionella). we detected significant seasonality in organisms using tbats models at varying periodicities ( / ; %) (additional file : table s ); with varying links with weather (additional file : figure s ). two k-means clusters (identified as the optimum number of k) were generated from the cross correlation coefficients with weather variables and represented groups of pathogens that had similar correlations with weather variables (fig. ) . the two groups were characterised by their relationship with the weather variables (additional file : table s ). group had mean positive correlations with higher temperature (min, mean, max), sunshine and vapour pressure; whilst the group had positive mean correlations with lower temperature variables (snow lying, ground frost, air frost), precipitation (rain days over mm, rain days over mm and rainfall), mean in group , pathogens had highest correlations with relative humidity (n = ) and ground frost (n = ) (additional file : figure s ). there was at least one pathogen with the highest correlation for each meteorological variable. summary information on seasonality and links with weather, by temperature cluster group are presented in table . group consisted of organisms, of which were from the salmonella genus. parvovirus b had a moderate correlation with sunshine (mean r = . ), followed by salmonella enteritidis with sunshine (r = . ) and salmonella typhimurium with vapour pressure (r = . ). group consisted of pathogens of which only two genus (influenza and trychophyton) had more than one serotype. rsv had strong correlations with air frost (r = . ), followed by moderate correlations between human metapneumovirus (hmpv) with relative humidity (r = . ) and rubella virus with lying snow (r = . ). we were interested in how the correlation coefficients varied between the weather variables that measured the same phenomenon (e.g. min, max, mean temperature). in general, there were slight differences between the different measures of temperature. the mean difference in correlation coefficients between minimum and maximum temperature was . with standard deviation of . . hmpv and rotavirus showed the largest difference between the temperature variables (comparing min temp and max temp). hmpv recorded a . higher coefficient for maximum temperature, whereas rotavirus recorded a . higher coefficient for minimum temperature. similar associations with temperature were found with vapour pressure and sunshine, although they tended to be relatively weaker when taking the mean for all of the pathogens there were also similar moderate inverse correlations with ground frost, air frost and snow lying days. for influenza a, days with lying snow had a higher correlation than the other weather variables (r = . ). notable differences in correlations between pathogens and the precipitation variables (comparing days with over mm of rain compared to days with over mm of rain), included plesiomonas shigelloides with a . higher correlation with days over mm and rsv with a . higher correlation with days over mm of rain. salmonella serotypes featured heavily with varying strength and pattern of seasonality detected. salmonella enteritidis and salmonella typhimurium had the strongest associations with meteorological variables. the remaining salmonella serotypes were split between being weakly correlated (n = ) and very weakly correlated (n = ). there is some reason to believe that the epidemiological causes of seasonality in most salmonellas is similar ( / ; % belong to group ) and the association with temperature might be linked to growth in prepared foods. in addition, the strength of association in linking the seasonality or temperature to cases will be limited to the number of isolates in each serogroup. because of this the salmonellas were grouped into four groups ( . salmonellas causing enteric fever that are usually acquired overseas (s. typhi/s. paratyphi); . seasonal salmonellas; . strains showing no evidence of any seasonality and . the remaining strains where there are insufficient numbers to determine seasonality). the remaining strains included serotypes that had so few isolates that seasonality could not be determined. when grouped thus, the seasonality of the seasonal salmonellas ( ) resembled that of the remaining strains ( ), while the overall seasonality of serotypes that individually showed little evidence of seasonality were not obviously seasonal when combined (fig. ) . the seasonality of groups and showed a high degree of correlation using data averaged over the -year period (r = . ; fig. b ). we have systematically examined a large number of human infectious disease pathogens for seasonality, and detailed potential links with weather in england and wales. this was made possible by utilising time series and clustering algorithms that can detect patterns in the data without supervision. this can lead to greater research efficiency by defining a focus for further investigations. we found that of the most prevalent organisms displayed seasonality, classified into two groups due to their association with month lagged meteorological variables. within these groups, there were well-known seasonal pathogens such as rsv, campylobacter and salmonella, as well as other less studied organisms such as aeromonas. the limitations of the big-data approach in this analysis meant that it was not possible to undertake analysis on causative weather factors on pathogen incidence. behavioural determinants that correlate with season and weather may explain the correlations found. for example, school closures for holidays can reduce transmission and therefore cases of influenza [ ] , outdoor eating, when the temperature is higher increases risk of salmonella, undercooking, raw meat contamination and recreational activities on water, are more likely to occur in summer, are associated with campylobacter [ ] . in separate work we are looking at methods to separate out the weather parameters from seasonality (and the associated behavioural determinants) using local weather data linkage, as described in 'recommendations for future research' [ ] . the study was limited by the temporal and spatial aggregation of the data, and therefore we were unable to investigate the effect of day-to-day weather in regions of england and wales. the results of the analysis were also dependent on the time-period used. for example, c. difficile have been reported to have a strong seasonal pattern previously using hospital episode statistics from england from to [ ] ; however we did not find a strong seasonal component in our study period. in our analyses, c. difficile displayed a peak in and then reduced in prevalence and seasonality. therefore, the results are presented with a caveat that the correlation coefficients with weather were sensitive to the time-period under analysis and would be expected to differ in a pathogen-dependent manner. the surveillance methods for collecting data changed over the years, with many pathogens having separate expert surveillance datasets that are independent of this data and some periods of enhanced surveillance or poor surveillance. there have also been periods where an intervention (e.g. vaccination) had been introduced, as well as those where the surveillance had improved (e.g. fungal infections; hospital infections), although we were unable to systematically account for these changes in the current analysis. furthermore, the data were lab-confirmed and therefore do not represent milder unreported or undiagnosed cases which may display a different pattern of seasonality. finally, we could not ascertain concomitant pathogens as they were not readily extractable from the database. the analysis was limited as it only considered a month lag effect and did not consider time-varying confounders. lag effects can vary for different environmental exposures. for example sunshine will induce -hydroxy-vitamin d production (the major circulating form of vitamin d) in human skin; -hydroxy-vitamin d will lag sunshine exposure by up to months due to metabolism within the body [ ] . also, the life-cycle of the pathogen or vector varies between organisms producing a lag between weather exposure and clinical manifestations of pathogen and subsequent laboratory diagnosis [ ] , but this has not been addressed in the current study. lag effects may be more pronounced for organisms that are indirectly rather than directly associated with weather [ ] , for example weather conditions that precede mosquito larvae growth do not immediately result in malaria transmission, due to development of both mosquito and pathogen being highly complex [ ] . however, given that the analysis was undertaken at a monthly resolution some short-term lagged correlations would be captured. the primary strength of the analysis is the large infectious disease dataset, which is nationally representative and has information on a wide range of pathogens. we have shown how a well-known clustering algorithm (k-means) can be applied to these data to classify pathogens by their relationship with weather variables. we have utilised a number of weather parameters from the medmi database, which allowed for subtle differences in correlation to be illustrated. the use of two methods to detail seasonal patterns was also a strength of the analysis. the advantages of using a tbats model is that it automatically selects fourier terms and other aspects of the model, whilst allowing for seasonality to change over time. wavelet analysis could be used to test for the robustness of the findings in future analysis. by sub-setting the data on the basis of seasonality detected using the difference in model fit statistics between a 'seasonal' and 'non-seasonal' model, it was less likely that the correlations with climate in the following analysis were spurious. this is akin to defining an exclusion criterion in the design of an epidemiological study to reduce the effect of bias. having detailed the strengths and limitations of the current analysis, in the following sections we aim to explain the results in relation to previously published work under headings based on the explanations for seasonality outlined by grassly and fraser [ ] . the data linkage was at the england and wales level which has certain advantages (reducing noise in the data), however public health applications often require predictions at a variety of smaller scales [ ] . analysis at a local level would complement the results presented here by showing the context in which national level predictors hold. in addition our analyses should be undertaken in different national contexts, as some pathogens shown to be non-seasonal in this context (e.g. polio, p. vivax) will be highly seasonal in non/under-vaccinated endemic regions. in particular, between salmonella serotypes, there was a clear hierarchy of strength of correlation with weather. the high prevalence of salmonella enteritidis (n = , ) and salmonella typhimurium (n = , ) contributed to high seasonality for these serotypes and strong associations with temperature and the auto-correlated sunshine and vapour pressure. the examination of salmonella data showed some of the limitations that can constrain the comparison of weather and infectious disease data. while most salmonella serotypes were seasonal, this could not be demonstrated for most of these until they were combined together with similar serotypes showing some evidence of more cases in summer months. the serotypes that showed no evidence of seasonality may be associated with contamination from reptiles kept as pets [ ] . such exposure is thought to be relatively less seasonal in its occurrence compared to foodborne salmonellosis. typhoid and paratyphoid infections in england and wales are usually associated with travel abroad, particularly to the indian subcontinent, and this is in the late spring and early autumn [ ] . temperature was most often used to explain any relationship between climate and pathogens previously [ , ] . however, there must be careful consideration of the measure of temperature used as shown in our analysis of influenza a and b. influenza a was most strongly correlated with extreme weather events (i.e. snow lying days), which may indicate specific circumstances around these events that are important for transmission of the pathogen (i.e. temperature of below °c with moisture in the air). we also found that other temperature-related variables showed consistent associations with various pathogens. vapour pressure has been used previously in a study investigating the effect of meteorological variables on the risk of legionnaires' disease in switzerland [ ] . vapour pressure may have such strong associations with several infectious diseases such as influenza [ ] , because it represents a set of meteorological parameters, i.e. warm, humid and wet conditions. similar inferences were made in a study of rsv activity in the netherlands, which found that humidity and temperature combined explained more variability than these parameters individually [ ] . this may be due to the dual impact of increased contact from lower temperature and increased immunosusceptibility associated with by higher relative humidity [ ] . the approach here was probably not optimal for linking waterborne diseases to rainfall because of the local linkage needed, as there are significant variations by geographic region. weather can influence pathogen prevalence indirectly through exerting pressure on vector abundance. we found both dengue and plasmodium falciparum had a seasonal pattern (although for dengue it was so weak that it was excluded at stage ) and for the latter weak correlation with max temperature. this can be explained by rising temperatures increasing mosquito distributions and causing seasonal peaks in dengue virus and plasmodium falciparum (i.e. the parasite responsible for cases of malaria) [ , ] , in the countries where the infection was likely acquired. other native vector-borne diseases were shown to be associated with weather in the current analysis. for example, borrelia burgdoferi, which infects ticks and causes lyme disease, had a strong correlation with sunshine. borrelia burgdoferi infected tick distribution was previously shown to correlate with season and rainfall in scotland [ ] . there is evidence to suggest that weather is a driver of faecal-oral infectious diseases, through the increased survival of pathogens in the environment [ ] . in addition to rotavirus, which have enhanced survival at low temperature, the current analysis has identified that aeromonas (a.sp, a. hydrophilia, a. sobria), bacillus (b. cereus, b. sp), coxsackie b, cryptosporidium sp., giardia lamblia, listeria monocytogenes and shigella sonnei may flourish under higher temperatures. respiratory infections transmitted by aerosols are similarly influenced by changes in weather. the high correlations between astrovirus, hmpv, mycoplasma pneumoniae, moraxella catarrhalis, neisseria meningitidis and rsv, and weather may be due to low temperatures causing increased survival and transmission or it could be lower levels of uv in the darker winter months. further work is needed to determine if specific weather thresholds control seasonality. weather may indirectly affect pathogen prevalence through host behaviour. salmonella is highest in summer months which may in part be due to changes in food handling by humans during those months [ ] . pasturella multocida, which is caused by scratches or bites from domestic animals, was shown to be highest in july in the current analysis. injuries caused by a cat or dog were shown to peak in summer in bologna, italy [ ] , which may be due to more time spent outdoors. as mentioned vector abundance will create higher incidence for certain infectious diseases such as malaria, dengue fever and cholera, which are then found to be higher in other countries due to travel behaviour. for example, uk travellers returning from countries with poor sanitation, typically india and pakistan, in summer months, have an increased risk of cholera due to the seasonal effects on the pathogen growth conditions in these other countries [ ] . several infectious diseases are more prevalent in immune-compromised individuals. previously it was found that patients (most of whom have medication, fluid or blood transferred using a central line catheter) were at increased risk of bloodstream infections caused by acinetobacter spp., escherichia coli, enterobacter cloacae, klebsiella spp., and pseudomonas aeruginosa during summer [ ] . we found associations between higher ambient temperature and enterobactor (e. sp., e. clocae, other named, e. agglomerans (pantoea agglomerans), stenotrophomonas maltophilia, acinetobacter baumannii, psuedomonas putida and pleisiomonas shigelliodes. mechanisms for seasonality in nosocomial infections need to be examined further to highlight whether meteorological factors are responsible for the primary infection, complications, or both [ ] . mystery of seasonality: getting the rhythm of nature what is a pathogen? a question that begs the point seasonal infectious disease epidemiology a weather-driven model of malaria transmission west nile virus cholera dynamics and el niño-southern oscillation dynamical resonance can account for seasonality of influenza epidemics the transmission dynamics of groups a and b human respiratory syncytial virus (hrsv seasonality and cross-protection climate drives the meningitis epidemics onset in west africa methods to assess seasonal effects in epidemiological studies of infectious diseasesexemplified by application to the occurrence of meningococcal disease the effect of temperature on food poisoning: a time-series analysis of salmonellosis in ten european countries campylobacter epidemiology: a descriptive study reviewing million cases in england and wales between climate variability and campylobacter infection: an international study evaluation of a national microbiological surveillance system to inform automated outbreak detection medmi: the medical & environmental data mash-up infrastructure project climate change and human infectious diseases: a synthesis of research findings from global and spatio-temporal perspectives the generation of monthly gridded datasets for a range of climatic variables over the uk automatic time series forecasting: the forecast package for r modifiable temporal unit problem (mtup) and its effect on space-time cluster detection model selection and multimodel inference: a practical information-theoretic approach the impact of regular school closure on seasonal influenza epidemics: a datadriven spatial transmission model for belgium association between the ambient temperature and the occurrence of human salmonella and campylobacter infections challenges in developing methods for quantifying the effects of weather and climate on water-associated diseases: a systematic review clostridium difficile infection seasonality: patterns across hemispheres and continents -a systematic review vitamin d status and its adequacy in healthy danish perimenopausal women: relationships to dietary intake, sun exposure and serum parathyroid hormone time series regression model for infectious disease and weather climate change and dengue: a critical and systematic review of quantitative modelling approaches the ecology of climate change and infectious diseases seasonal patterns of infectious diseases prevalence of salmonella spp., and serovars isolated from captive exotic reptiles in new zealand enteric fever (typhoid and paratyphoid) england, wales and northern ireland. in: travel and migrant health seasonality and the dynamics of infectious diseases meteorological factors and risk of community-acquired legionnaires' disease in switzerland: an epidemiological study absolute humidity modulates influenza survival, transmission, and seasonality variation of respiratory syncytial virus and the relation with meteorological factors in different winter seasons respiratory syncytial virus activity and climate parameters during a -year period environmental determinants of ixodes ricinus ticks and the incidence of borrelia burgdorferi sensu lato, the agent of lyme borreliosis incidence of injuries caused by dogs and cats treated in emergency departments in a major italian city seasonality in gram-negative and healthcare-associated infections not applicable. availability of data and materials data are available in the medmi database [ ] and can be visualised on the medmi rshiny app: https://thebest.shinyapps.io/seasonalpathogen/.authors' contributions gn conceived the study. mc undertook the analysis and data visualisation under the guidance of gn, with feedback throughout by cs, gl, sh and lf. the manuscript was prepared by mc and edited with important contributions from cs, gn, gl, sh and lf. all authors read and approved the final manuscript. we received permission to use the sgss pathogen count data from public health england. not applicable. european centre for environment and human health, university of exeter medical school, truro, england.received: october accepted: august in this large database of infectious diseases in england and wales, we have provided an analysis of the seasonality of common pathogens and their correlation with meteorological data. this is extremely important given the context of future climate changes. pathogens within the identified should be investigated further using the proposed meteorological variable, following recommendations proposed by imai and colleagues [ ] . in particular, future studies should be undertaken at finer spatial and temporal aggregations, using pathogen specific confounders and investigating a variety of lag effects and non-linear associations. additional file : figure s . time series plots of meteorological variables. (png kb) additional file : table s . weekly, monthly and quarterly breakdown of pathogen seasonality. (csv kb) additional file : figure s the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -yj uwiu authors: el morr, christo; layal, manpreet title: effectiveness of ict-based intimate partner violence interventions: a systematic review date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: yj uwiu background: intimate partner violence is a “global pandemic”. meanwhile, information and communication technologies (ict), such as the internet, mobile phones, and smartphones, are spreading worldwide, including in low- and middle-income countries. we reviewed the available evidence on the use of ict-based interventions to address intimate partner violence (ipv), evaluating the effectiveness, acceptability, and suitability of ict for addressing different aspects of the problem (e.g., awareness, screening, prevention, treatment, mental health). methods: we conducted a systematic review, following prisma guidelines, using the following databases: pubmed, psycinfo, and web of science. key search terms included women, violence, domestic violence, intimate partner violence, information, communication technology, ict, technology, email, mobile, phone, digital, ehealth, web, computer, online, and computerized. only articles written in english were included. results: twenty-five studies addressing screening and disclosure, ipv prevention, ict suitability, support and women’s mental health were identified. the evidence reviewed suggests that ict-based interventions were effective mainly in screening, disclosure, and prevention. however, there is a lack of homogeneity among the studies’ outcome measurements and the sample sizes, the control groups used (if any), the type of interventions, and the study recruitment space. questions addressing safety, equity, and the unintended consequences of the use of ict in ipv programming are virtually non-existent. conclusions: there is a clear need to develop women-centered ict design when programming for ipv. our study showed only one study that formally addressed software usability. the need for more research to address safety, equity, and the unintended consequences of the use of ict in ipv programming is paramount. studies addressing long term effects are also needed. intimate partner violence includes physical violence, sexual violence, stalking, and psychological harm inflicted by a current or former partner or spouse [ ] . violence against women (vaw) has been described as a "global pandemic" by the united nations [ ] . it is considered both a violation of women's human rights [ ] and a public health issue [ ] . in low-and middle-income countries, violence against women is widespread and often involves pregnant women [ , ] . however, violence against women occurs in high-income countries as well [ , ] . nearly one in three women have experienced intimate partner violence or sexual violence [ ] ; therefore, it is important to disseminate as widely as possible the knowledge and tools related to ipv prevention and to intervention to empower the women subjected to ipv. information and communication technologies (ict) present an opportunity for such dissemination. ict are being adopted at unprecedented rates in high-income as well as low-and middle-income countries [ ] . moreover, the use of the internet , mobile phones, and smartphones [ , [ ] [ ] [ ] [ ] [ ] [ ] for health purposes has been well documented in research. it has been used to address chronic disease management [ , ] , mental health challenges [ , ] , and hospital readmissions [ ] , encompassing applications that target the public (i.e., public health informatics), interactions between patients and healthcare professionals, and applications for individual use through smartphone apps (i.e., consumer health informatics). however, little is known about the use of icts in the context of violence against women, and only a few articles on the subject have been published recently [ , , ] . at the same time, there is a solid increase in phone ownership and access to the internet in low-and-middle-income countries [ ] , which suggests the possibility of implementing ict-based interventions to address ipv in these countries. recent systematic reviews showed that the efficacy of ict-based mobile apps for health (mhealth) is still limited, as research in the field lacks long-term studies and existing evidences of impact are inconsistent [ ] . also, mhealth in the domain of violence against women (vaw) showed an abundance of apps addressing one-time emergency or avoidance solutions, and a paucity of preventative apps, which indicates the need for studies addressing data security, personal safety, and efficacy of interventions using apps to address vaw [ ] . by extension, investigating the situation of ict in ipv seems a necessary step. given the existing ipv interventions challenges, the evidence demonstrating effectiveness of online interventions in health, the rise of research on online ipv interventions, the risks inherent in ict use for ipv programming, it is important to synthesize the available evidence regarding the use of ict-based ipv interventions. to our knowledge, there is no systematic review of such work. to address this knowledge gap, we initiated a systematic review of literature on ict-based ipv interventions. the study objectives were to examine whether ict could become acceptable for effective ipv interventions, we reviewed the literature on the use of ictbased interventions to address ipv issues. the questions that guided us in examining the were as follows: ( ) "what type of objectives did ict based interventions tried to address?", ( ) "were ict based interventions effective in addressing ipv?", and ( ) "what type of strategies did they implement to mitigate ict risks (e.g. safety, data security)". the results will inform future ict-based ipv interventions. in total, articles were identified, among which articles were duplicates. out of the unique articles, were excluded based on the content of their abstracts. the inclusion criteria were then applied to the remaining articles after reading their full text. four articles were then excluded, and articles were kept for analysis [ , (fig. ) . table (see appendix) lays out the studies in terms of population, intervention, comparison groups, and outcomes (pico). table presents the authors, publication year, study country, study type, recruitment space, theme, outcomes, sample size, sample size per arm, control group, and the type of ict used for the studies. out of the , ( %) took place in north america ( studies ( %) in the united states and ( %) in canada), study ( %) took place in australia, and ( %) in new zealand. most studies focused on women with potential vulnerability to, past experience of, and/or current experience of intimate partner violence, with the exception of one [ ] , which included both men and women as study participants. four studies included women who were pregnant [ , , , ] ; two of these studies included women up to months postpartum who had history of ipv [ , ] . two studies focused on women with a history of ipv and who were active substance(s) users [ , ] , and study on women who were at risk of hiv through unprotected intercourse [ ] . out of the , studies ( %) were solely desktop-or laptop-based [ , , , , , , , - , , , - , - ] , studies ( %) were solely tablet-based [ , ] , study ( %) used computer and telephone [ ] , study ( %) used tablet and telephone [ ] , ( %) implemented a kiosk system [ ] and ( %) were not reported and supposed any type of ict [ , , ] . table shows the characteristics of the included studies. the studies included randomized controlled trials ( two-arm and four three-arm studies), four pre-post designs, two cross-sectional studies, two prospective studies, and one diagnostic case-control study (i.e. retrospective data with known disease-positive and disease-negative cases [ ] ). control groups varied widely, and wait-list controls were used in five rct studies [ , , , , ] . four studies allowed control groups to access websites with static, or non-interactive, or non-tailored content [ , , , ] , while two studies used irrelevant information for control groups [ , ] , seven control groups used faceto-face (or paper-based self-reported) screening [ , , , , , , ] , four had the intervention group play the role of control (i.e. pre-post design) [ , , , ] , and three studies had no control groups [ , , ] . the sample size in the rct studies varied extensively from participants to a high of . the interventions implemented had various foci. ict was used for screening and disclosure in ( %) of the studies. five studies ( %) aimed at ipv prevention, four ( %) studies used ict to address the mental health of female victims of ipv, and two ( %) studies used ict to provide support for decision aid. only one ( %) study assessed mainly the suitability of ict for use in an ipv context. the studies had five types of interventions and varied study settings. in terms of settings, studies were conducted in medical services facilities [ , , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ] such as emergency departments, clinics, community health centers, trauma treatment centers, and family practices. six studies were conducted in the community [ , , , , , ] , four in social services facilities [ , , , ] , and one in legal services facilities [ ] . the studies represent a range of uses of ict in the context of ipv, addressing screening and disclosure, ipv prevention, ict suitability, empowerment and support, and women's health. in three studies, ipv screening using ict was found to be as effective as using the usual face-to-face/paper method [ , , ] . one study reported that computerized screening was more sensitive and less or similarly specific compared to face-to-face staff screening [ ] . one study reported high self-disclosure of ipv using computers vs in person ipv screening with health professionals; out of female patients who participated in both screening methods. ( %) patients out of the disclosed some form of ipv in person compared to ( %) who disclosed ipv via a computer. out of those patients, ( %) also disclosed ipv to their doctors in person and patients ( %) disclosed via a computerized tool but not with the doctor [ ] . one study that included african american women in a women, infants, and children (wic) services setting found that women were less likely to disclose ipv using a computerized intervention than in person [ ] . a study that used a tablet for disclosure during perinatal home visitation found the tablet to be a conduit through which interpersonal connection between women and home visitors was facilitated [ ] . one study found that women were more likely to disclose ipv using ict, leading to higher rates of screening and disclosure [ ] . one study reported that . % of women disclosed using the ict intervention, and only . % women disclosed using usual care [ ] . another study found that implementing ict-based disclosure in an emergency department was successful and reliable [ ] . two studies addressed ipv prevention [ , ] . one study showed that % of the participating women who used ict were less likely to report experiencing physical ipv at a follow-up ( months later), % were less likely to report ipv with injury, and % were less likely to report severe sexual ipv [ ] . the study by braithwaite et al., which targeted both males and females using ict, reported less physical aggression committed by females at postintervention, as well as less physical aggression committed by both males and females at a -year follow up; also, the study showed a large reduction in expected counts for female-and male-perpetrated physical aggression at the year follow-up ( and %, respectively) [ ] . our systematic review showed that ict has been used to address two aspects in the lives of some women experiencing ipv: substance use and mental health. six studies used online tools to address the mental health of women experiencing ipv [ , , , , , ] . depression was measured in five studies [ , , , , ] , anxiety was measured in three [ , , ] and stress in two [ , , ] . in all studies, mental health showed improvement compared to intervention. one study reported that women found it easier and safer to report drug use and partner abuse through a computer than in person [ ] . the study by hassija et al. addressed the treatment of ipv-related trauma through video conferencing, and found the method effective at reducing post-traumatic stress disorder (ptsd) symptoms, with high users' satisfaction [ ] . ict was used to empower women by enabling them to create safety and action plans and by providing them with tools for enhanced decision making and self-efficacy. three studies focused on women creating a safety and/or action plan in the event of a future partner abuse incident [ , , ] , with two interventions providing additional local resources [ , ] . in one study, % of the participating women who used ict reported leaving their abusive partner within the year [ ] , and in another study % of the participating women reported the intention to make changes in regard to their ipv within days to months [ ] . moreover, in a single study focused on using online tools to teach participants about behaviours and/or actions related to safety [ ] , researchers reported a % significant increase in safety behaviours for the ict-based intervention group, compared to a % increase for the control waitlist [ ] . in addition, a study reported that participants found using a computer survey to disclose ipv safer than a face-to-face survey [ ] . in terms of decision-making and self-efficacy, two studies reported that more than % of the participants acquired general skills through the ict-based interventions [ ] , and two other studies reported that participants gained decision-making skills through the ict-based interventions [ , ] . additionally, using their new skills, women experienced lower decisional conflicts and had an overall less difficult time deciding on their actions [ , ] . only study has a formal testing for the usability of ict software as a major focus using the systems usability scale [ ] . the results indicate high satisfaction with the software usability. table (appendix) summarizes the outcomes measured by each study. our review revealed a wide variation among studies in terms of outcomes measured for studies that address the same focus. in total, measurement tools were used in the studies (see table in appendix). among the studies that address screening and disclosure, five studies used a simple disclosure count [ , , , , ] . two studies used non-validated questionnaires [ , ] , and two studies used the partner violence screen (pvs) and the abuse assessment screen (aas) [ , ] . three studies had no common outcome measurement tools. the four studies [ , , , ] that focus on mental health used eight different outcome measurement tools; only the ptsd checklist (pcl) was common to two studies [ , ] . in terms of suitability of ict, the systems usability scale (sus) was used in one study only to assess software usability [ ] . out of the five studies [ , , , , ] focusing on ipv prevention, three studies [ , , ] used the revised conflict tactics scale (cts ). the two studies that addressed support [ , ] had no common measurement tools. our review revealed the emerging nature of ict use in ipv research. while there is a growing interest in the use of ict in ipv interventions, there are virtually no studies examining its challenges. while most of the studies used ict to enhance screening and increase the disclosure rate, few studies targeted ipv prevention and even fewer aimed at improving support. suitability of ict was seldom assessed in a formal way using a validated usability scale (e.g. systems usability scale) or methodology [ ] . in addition, while most of the studies used rct design, the number of arms, the population, the control groups used, the sample sizes, and the outcome measures varied widely among the studies, which makes it hard to compare those results. with the exception of two large sample sizes that were used in two non-rct studies (one that accessed electronic health records for an artificial intelligence application [ ] , and another that used the emergency department [ ] ), the sample sizes per arm were generally low. the sample size per arm was less than in four studies. only six studies had a sample size per arm between and , and only four studies had a sample size per arm between and . this suggests that the current ict-based ipv interventions have limited generalizability and comparability-especially because only six studies were conducted in the community. twenty-three ( %) of the studies were conducted in north america, ( %) of which were in the united states, which is an additional limitation to the generalizability of the findings since they lack diversity in terms of ethnicity, race, language, and cultural backgrounds. diversity is crucial in ipv. research shows that foreign-born immigrant as well as indigenous women are more likely to experience ipv [ , ] and intimate partner homicide than other women [ , ] ; hence, addressing diversity in ipv is critical. it is encouraging that one recently published rct protocol laid out a plan for culturally tailored intervention targeting immigrant, refugee, and indigenous survivors of ipv [ ] . technology is costly in terms of hardware, software and data plan costs. consequently, while access to ict by women experiencing ipv is a challenge in high income countries, including the united states [ , ] , it is even more difficult in low-and middle-income countries (lmics). this creates inequity in access to technology, and a digital divide among women subject to ipv. this inequity challenge and its impact on outcomes has long been observed in electronic health (ehealth) [ , ] and needs to be addressed in ictbased ipv interventions; it was not addressed in the studies covered by our review. also, involvement of users in software design is a well-known need that is effective in producing software that works for users and aligns with their priorities and is suitable for their environments [ , [ ] [ ] [ ] [ ] [ ] . hence, involving women experiencing ipv in the research team and in the ict software design process is paramount to ensure usability and accessibility of the software and as a matter of equity [ ] . there is a lack of research in this area in the studies covered by our review. a recent study protocol is promising that ict will ensure lower access barriers [ ] , which is the traditional unchecked point of view; this is another demonstration of the need to shed a critical light on the use of ict for women experiencing ipv, analyzing equity as well as the safety and ethical challenges involved. our review shows that studies [ , , , , , , , ] reported that women found ict interventions suitable for ipv disclosure; three of those studies found it particularly suitable in terms of confidentiality, usefulness, and satisfaction [ , , ] . stigma is an important factor associated with intimate partner violence [ ] limiting agency in help-seeking for ipv [ ] ; ict seems to be a tool that provide an opportunity for women subject to ipv. with the exception of one in which participants preferred a face-to-face discussion [ ] , ipv disclosure through ict was found to be most appropriate in most of the studies compared to face-to-face disclosure and was perceived as non-judgemental and more anonymous than face-to-face discussion, which facilitated more disclosure. the increase in phone ownership and internet access in low-and middle-income countries [ ] , coupled with the ability to use ict to target individuals through health informatics tools that targets individuals (i.e. consumer health informatics) [ ] such as apps, makes ict a flexible tool to address ipv in multiple languages, embedding different cultural cues, and overcoming the cultural stigma related to disclosing ipv from the convenience of a personal ict device (e.g. cell phone, smart phone). simple ict tools such as cell phones are available in rural areas and proved to be successful tools in the health domain (e.g. chronic disease management) [ ] [ ] [ ] . however, it is important to note that one challenge of ict-based interventions is that only women with basic literacy and it knowledge can benefit; also, some victims may not have access to ict, and some abusers may restrict their partners' access to ict. therefore, in addition to the traditional security considerations related to the use of ict, such as maintenance of privacy [ ] and confidentiality [ ] , there are ethical issues related to the unintended consequences of ict [ , ] , including safety risks. in the ipv domain, sharing cell/smart phones at home or with neighbors is a common practice [ , ] , which might increase the risk of ipv if the perpetrators notice that women are using these devices to address ipv [ ] . the studies covered by this review were located in high income countries; there is little to no examination of the problem of access to ict (i.e. cost), nor of the risks inherent in the use of ict (e.g. sharing devices, ability to access browsing history) in addressing ipv programming in a variety of contexts. ethical challenges related to the safety of women increase when women are sharing cell/smart phones with perpetrators; in such contexts special considerations should be taken care of, including "safety by design" [ ] . safety challenges involved in the use of ict in health have recently attracted much attention [ , ] . moreover, recent reflections related to the ethical challenges of using web-based rct show the need to equip participants with information about internet safety [ ] ; likewise, identifying and managing safety risks within ictbased ipv research remains a perspective to be explored. this raises ethical questions related to the use of ict, for example in the case of referral embedded in the ipv programming, as was the case in three studies included in this review [ , , ] . poor quality services are well documented in low-resource and rural areas [ ] , so referring women to such services might have negative consequences for them. while this is not an ict issue, ict facilitates communication of information and has the potential to exacerbate current challenges. this is part of the well-known unintended consequences of the use of information technology in health [ ] [ ] [ ] . of the studies that explicitly mentioned their settings, were in urban settings, only three were in urban and suburban areas, and two were in suburban settings, suggesting a need to test ict use for ipv in rural settings [ , ] and uncover any particularities compared to the urban context. it is also worth noting that our systematic review has not included search terms regarding the user of ict tools to address ipv for women with disabilities. however, in a quick assessment, when we searched in pubmed for research that addresses the use of ict to address violence in the context of women with disabilities, our search revealed only two papers [ , ] . the use of ict to address ipv for this particular group of women is important to address in a separate study, as ict accessibility may be challenging for women with certain types of disabilities, especially since there is evidence that ipv occurs at higher rates in this population compared to the general population [ ] [ ] [ ] [ ] [ ] [ ] , and that ict can play a major role in empowering people with disabilities [ ] . the use of ict tools to address ipv for women with disabilities, and the accessibility of these tools, remains an important area for future studies. moreover, our review indicated that there is a paucity of research addressing ict use for ipv prevention and ipv treatment. there is a clear need for more research on ictbased interventions to prevent ipv and to address post-ipv challenges, such as mental illness and the integration and coordination of mental and social services (e.g., employment, housing), which has never been addressed in the reviewed literature. in this context, virtual communities may play an important role in integrating and coordinating mental health services and social services [ ] . while the studies showed different aspects of ict use for ipv, a more integrative approach can be taken if researchers approach ipv using a virtual community framework. a virtual community (vc) is defined as a community of individuals cooperating using online tools to attain an objective [ ] . health vcs have been used in healthcare to provide patients with education, health education, and remote support; that proved to be an enabling and empowering factor, which allowed patients to become active participants in managing their health conditions [ , ] . support was not provided solely by health professionals; instead, health vcs connected individuals with common experiences (e.g., similar health conditions), which enabled them to interact and mutually support each other [ ] . healthcare providers could provide validated evidence-based health information, coupled with strategies for effective chronic disease management [ ] [ ] [ ] . ample evidence exists demonstrating that virtual tools are effective and efficient for addressing health issues experienced by patients with various health conditions (chronic kidney disease, pulmonary hypertension, cancer) [ , [ ] [ ] [ ] . there is also ample evidence that health vcs are effective in engaging individuals managing their own health condition [ , ] . moreover, vcs can be patient-centred, customizable to individual preferences, and responsive to individuals' needs and values [ ] . in terms of mental health, an important factor for women experiencing ipv, vcs provide a secure, private way for women to communicate privately and securely and to access information tailored to their situation in a personalized manner. this privacy facilitates access and assists in overcoming stigma, especially for women from visible minority groups [ ] . vcs have a proven potential to engage participants [ ] . there is ample evidence that health vcs are associated with positive mental and social benefits, such as reduced loneliness and increased emotional well-being, self-esteem, and self-empowerment [ , , ] . it is important to explore an integrative approach to ict-based intervention in ipv using vcs, especially since vcs enable a community dimension that facilitates mutual support and empowerment among its members (e.g., abused women). in a study that screened for ipv, while women preferred computerized over face-to-face disclosure, computerized screening did not increase prevalence, so ict did not lead to increase in disclosure. also, when women disclosed by answering paper-based questionnaires, the self-completed paper-based questionnaires had less missing data collected than both computer-based and face-to-face interviews [ ] , which shows the advantage of having for paper-based screening (i.e. less missing data). likewise, while ict allowed considerably higher ipv detection, this did not always lead to charting for ipv or to a follow-up by treating physicians [ ] ; more research is needed to understand the factors, such as continuing medical education [ ] , that increase the chances of charting and follow-up. detection is not enough. we have noted above the lack of research regarding equity, safety, and the ethical challenges involved in the use of ict, as well as the lack of culturally, ethically, and racially sensitive ict programs. ict might be able to support and enhance more traditional on-the-ground program delivery; however, ensuring that effective ictbased interventions reach the most vulnerable in equitable, ethical, and safe ways remains a research agenda to be undertaken. current results suggest that face-to-face and paperbased approaches should not be discarded, and that the computer-based software design must be user-centred and must follow usability principles [ , ] . limiting the search to english language is one of the limitations of this study. another limitation was the difficulty to compare the results, since the tools used to measure the same outcome varied widely between the studies. various questionnaires were used to detect ipv, assess decisional conflict, assess mental health challenges, assess treatment efficacy, and assess different primary and secondary outcomes. an illustrative example is the varied questionnaires that researchers used to measure ipv [ , , , , , , [ ] [ ] [ ] , which included the use of an artificial neural network to identify ipv automatically via analysis of the notes stored in the electronic health records [ ] . our review shows that there are limits for comparing the effectiveness of the interventions in terms of mental health (e.g., reduction in stress, anxiety, or depression levels), given the great variety of mental-healthrelated measurement tools that have been used. the evidence reviewed suggests that ict-based interventions have the potential to be effective in spreading awareness about and screening for ipv. ict use show promise for reducing decisional conflict, improving knowledge and risk assessments, and motivating women to disclose, discuss, and leave their abusive relationships. however, there is lack of homogeneity among the studies' outcome measurements, and the sample sizes, the control groups used (if any), the type of interventions and the study recruitment space. the use of ict-based interventions seems to be an attractive option for disseminating awareness and prevention information [ ] , due to the wide availability of ict (including simple mobile phones) in both high-income and low-and middle-income countries. ict may also present an opportunity to deliver culturally sensitive multilingual interventions using consumer health informatics. however, there is a clear need to develop womencentred ict design when programming for ipv. our study showed only one study that formally addressed software usability. moreover, research directly addressing safety, equity, and ethical challenges in using ict in ipv programming are virtually non-existent; the need to find answers to equity, and the unintended consequences of the use of ict use for ipv programming is necessary. in this context, virtual communities may play an important role in providing a sense of community and in integrating and coordinating the services around women experiencing ipv. future longitudinal follow-ups could help determine the long-term effects of the use of ict in ipv programming. 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springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge the work of kanchi uttamchandani in searching for some of the articles. authors' contributions ml contributed in searching for articles, analysing their content, completing a first categorization of themes. ce contributed to searching for articles and analysing their content, comparing ml results with his, he finalized the themes, interpreted the results, designed and populated the figures and tables and wrote the current version of the paper. ce supervised and coached ml during the process. all authors read and approved the manuscript. not applicable. data sharing not applicable to this article as no datasets were generated or analysed during the current study.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests.