Articoli di riviste sul tema "National Centre for Disease Control and Public Health after L"

ObjectivesTo explore the association between non-high-density lipoprotein (non-HDL) and mortality risk, both short-term and long-term, in Chinese people.DesignA prospective cohort study.SettingThe National Basic Public Health Service (BPHS) in China.ParticipantsIncluding 621 164 elderly individuals around Hunan Province who underwent healthcare management receiving check-ups in China BPHS from 2010 to 2020. Exclusion criteria: (1) missing information on gender; (2) missing records of lipid screening; (3) missing information on key covariates; and (4) missing records of comorbidities (cardiovascular disease, hypertension, diabetes, cancer.)Primary and secondary outcome measuresThe study’s primary endpoint was all-cause and cause-specific mortality, sourced from Hunan’s CDC(Center for Disease Control and Prevention)-operated National Mortality Surveillance System, tracking participants until 24 February 2021.Results26 758 (4.3%) deaths were recorded, with a median follow-up of 0.83 years. Association between non-HDL and mortality was non-linear after multivariable adjustment, with the optimum concentration (OC) being 3.29 and 4.85 mmol/L. Compared with OC, the risk increased by 1.12-fold for non-HDL <3.29 mmol/L (HR: 1.12 (1.09 to 1.15)) and 1.08-fold for non-HDL ≥4.85 mmol/L (HR: 1.08 (1.02 to 1.13)) for all-cause mortality. Furthermore, there is also an increased risk of cardiovascular mortality (HRfor non-HDL <3.29: 1.10 (1.06 to 1.32) and HRfor non-HDL ≥4.85: 1.07 (1.01 to 1.14)). However, cancer mortality risk was significantly increased only for non-HDL <3.29 mmol/L (HR: 1.11 (1.04 to 1.18)). Non-optimum concentration of non-HDL had significant effects on both the long-term and the short-term risk of mortality, especially for risks of mortality for all-cause (log HR:0 .086 (0.038 to 0.134)), cardiovascular (log HR:0 .082 (0.021 to 0.144)), and cancer (log HR:0 .187 (0.058 to 0.315)) within 3 months. A two-sided value of p <0.05 was considered to be statistically significant.ConclusionsNon-HDL was non-linearly associated with the risk of mortality, and non-optimal concentrations of non-HDL significantly increased short-term mortality in elderly Chinese, which needs more attention for cardiovascular disease prevention.

Health surveillance is the ongoing, systematic use of routinely collected health data to guide public health action in a timely fashion. This paper describes the creation and growth of national surveillance systems in Canada and their impact on chronic disease and injury prevention. In 2008, the authors started a review process to retrace the history of the early development of national chronic disease surveillance in Canada from 1960 to 2000. A 1967 publication describes the history of the development of the Laboratory of Hygiene from 1921 to 1967. This review is a sequel to that paper and describes the history of the development of national chronic disease surveillance in Canada before and after the formation of the Laboratory Centre for Disease Control (LCDC).

Abstract Olanzapine is a thienobenzodiazepine class antipsychotic that strongly antagonises the 5-HT2A serotonin receptor, but acute poisonings are reported rarely. Symptoms of an overdose include disorder of consciousness, hypersalivation, myosis, and coma. Serum concentration higher than 0.1 mg/L is toxic, while concentration above 1 mg/L can be fatal. Here we report key data about 61 patients admitted to the National Poison Control Centre in Belgrade, Serbia over olanzapine poisoning in 2017 and 2018. The ingested doses ranged from 35 to 1680 mg, and time from ingestion to determination from two to 24 hours. In 34 patients olanzapine serum concentrations were in the therapeutic range and in 27 in the toxic range. In five patients they were higher than fatal, but only one patient died. The most common symptoms of poisoning were depressed consciousness (fluctuating from somnolence to coma), tachycardia, hypersalivation, hypotension, myosis, and high creatine kinase. All patients but one recovered fully after nonspecific detoxification and symptomatic and supportive therapy.

ObjectivesThis mixed-method study aimed to understand the effectiveness of linkage to biopsy and treatment in women with a high-risk mammography result (Breast Imaging Reporting and Data System, BI-RADS 4 and 5) in the national telemammography programme and to explore women’s experiences during this process.SettingQuantitative component: we collected and linked health data from the telemammography reading centre, the national public health insurance, the national centre for disease control and the national referral cancer centre. Qualitative component: we interviewed participants from different regions of the country representing diverse social and geographical backgrounds.ParticipantsQuantitative: women who underwent telemammography between July 2017 and September 2018 and had high-risk results (BI-RADS 4–5) were collected. Qualitative: women with a high-risk telemammography result, healthcare providers and administrators.Outcomes measuresQuantitative: we determined biopsy and treatment linkage rates and delays. Qualitative: we explored barriers and facilitators for obtaining a biopsy and initiating treatment.ResultsOf 126 women with high-risk results, 48.4% had documentation of biopsy and 37.5% experienced a delay of >45 days to biopsy. Of 51 women diagnosed with breast cancer, 86.4% had evidence of treatment initiation, but 69.2% initiated treatment >45 days after biopsy. Travelling to major cities for care, administrative factors and breast cancer misconceptions, among other factors, impeded timely, continuous care for breast cancer. A multidisciplinary and culturally tailored patient education facilitated understanding of the disease and prompt decision making about subsequent medical care.ConclusionsStrengthened breast cancer care capacity outside the capital city, standardised referral pathways, ensured financial support for travel expenses, and enhanced patient education are required to secure linkage to the breast cancer care continuum. Robust information systems are needed to track patients and to evaluate the programme’s performance.

Background: Rabies has been the subject of fear ever since the disease was recognized. Worldwide the number of deaths annually, due to rabies, is estimated to be between 35,000 to 50,000 approximately Rabies continues to be a major public health problem in Bangladesh killing an estimated 2000 people annually and 100,000 people receive post-exposure treatment in the country. In this regard the post-exposure treatment of animal bite cases is of prime importance. Materials and Methods: Communicable disease control(CDC) of, Directorate General of Health Services (DGHS) took the noble initiative to establish the national rabies elimination programme 2010 with an comprehensive approach of care for human and control of rabid animal. An expert group meeting for strategic plan and finalizing the guidelines for prevention and control of rabies cases was held in 2010, under CDC of DGHS to bring out uniformity in post-exposure treatment practices. . The participants in the meeting included practitioners managing anti-rabies clinics, laboratory medicine practitioners, policy makers, public health experts from both public and private sector. The guideline, which emerged out of consensus of expert groups, is summarized in this paper. Results: Until recently the Nervous Tissue Vaccine (NTV) was the mainstay for post-exposure prophylaxis in Bangladesh. As per WHO recommendations, the production and use of this reactogenic vaccine should be gradually phased out from our country. Modern, safe and effective anti-rabies Cell Culture Vaccines (CCVs) will be used for post-exposure prophylaxis in public sectors. The limitation is the high cost of this vaccine and also the cost and unavailability of Anti Rabies Immunoglobulin. WHO recommended the use of intra-dermal (ID) route of application of CCVs. Considering the recommendations of experts, results of clinical trials and international experience, experts of Bangladesh recommends ID regimen phase wise. In first phase, only Dhaka Infectious Disease Hospital will serve as Anti-rabies centre for ID regimen. After its successful implementation, ID regimen will spread out to Division and then to District level hospitals. National experts suggested and recommended the use of cost-effective vaccination schedules such as abbreviated multisite IM Zagreb protocol (4 dose, 3 visits) and updated Thai Red Cross (TRC) intradermal regimen(2-2-2-0-2) to phase out NTV and to make available modern rabies vaccine in public sector. Conclusion: This guideline will be extremely useful for the country to make rational use of modern rabies vaccine and phase out NTV by 2011. The guideline will be of immense use for better management of animal bite cases and availability and affordability of modern rabies vaccine will be of great help for physician to manage appropriately for preventing the deadly disease rabies. DOI: http://dx.doi.org/10.3329/jom.v12i2.7691 JOM 2011; 12(2): 153-159

BackgroundLong Covid (LC) refers to prolonged symptoms after Sars-CoV2 infection not explained by alternative diagnosis lasting 4-12 weeks as defined by the National Institute for Health and Care Excellence.Few studies explored LC in rheumatic diseases patients (RD) concluding that they present persistent symptoms after infection, although lacking a healthy control (HC) group.ObjectivesTo evaluate incidence and clinical features of LC on patients affected by Rheumatoid (RA) or Psoriatic arthritis (PsA) as well as infection’s influence on disease activity.MethodsA monocentric retrospective case-control study was conducted on consecutive outpatients affected by RA or PsA in Low Disease Activity or remission, referring to the Rheumatology Unit of University of Tor Vergata (Rome, Italy) between Sep ’21 - Sep ’22.Inclusion criteria: age ≥ 18 years, proven Sars-CoV2 infection between Jun ’21 – Jun ’22, 3 doses anti Sars-CoV2 vaccination, recovered for at least 12 weeks, diagnosis of PsA/RA before Feb ‘20.Exclusion criteria: symptoms explained by other diagnosis (as fibromyalgia, COPD ecc), hospitalization for Sars-CoV2.Patient were evaluated at 12 weeks after infection: demographic data, baseline comorbidities, ongoing therapy at infection and symptoms during and after infection were recorded; disease related data were recorded referred to the last clinical assessment too. Clinical features were compared among RA and PsA and with HC than among females and males patients.Results120 (60 PsA/60 RA) patients and 60 HC were enrolled (Table 1).Patients compared to HC reported higher incidence of dyspnoea during infection while at resolution: lower VAS general health (GH), higher asthenia, joint pain and higher incidence of dyspnoea, chest pain, sleep disturbances and depression. All patients continued their therapy during infection and no differences were found about baseline comorbidities and ongoing therapy.No statistical differences emerged between PsA and RA patients among them but when compared with HC both presented higher VAS fatigue, joint pain, lower GH and a longer duration of anosmia and anageusia after infection. Moreover, PsA presented higher incidence of chest pain after infection and headache during and after infection; RA reported higher incidence of chest pain and headache after infection and dyspnoea during and after. Regarding gender: females reported higher VAS disease activity, asthenia and higher incidence of joint pain, dyspnoea, depression and sleep disturbances at infection resolution. Lastly, female PsA patients presented higher DAPSA score after infection than man. Disease related items were compared before and after infection (Figure 1): statistical significant differences emerged regarding VAS disease activity, asthenia, joint pain and GH in RA and PsA patients.ConclusionHere, we documented that RD patients – particularly females - suffer from a higher burden after Sars-Cov2 infection showing statistical significant higher incidence of symptoms than HC and a worsening of disease activity although no disease flare were registered. Thus, LC carrying a significant burden is becoming an urgent health issue that needs immediate prioritization to prevent anothernational health disasterthat could be a further blow to health systems.References[1]National Institute for Health and Care Excellence, 2022[2]Leon L et al. Rheumatol Adv Pract. 2022[3]Di Iorio et al. Sem in arth and rheum, 55Table 1.*: p <0,05; **: p<0,01Total RDHCpPsaRAp PsA vs HCp RA vs HCMalesFemalesPPatients1206060604872Disponea during26,60%11,60%*20%33,30%-.22,90%35%- after25%8,30%**18,30%31,60%--14,50%38,3*Chest pain during24,10%16,60%-20%28,30%--20,80%31,60%- after12,50%0-10%15%***10,40%16,60%-Sleep disturbance43,30%16,60%**41,60%45%****27%65%** during after38,30%26,60%-35%41,60%--18,70%61,60%**Headache during42,50%28,30%-46,60%38,30%***39,50%53,30%- after21,60%11,60%-35%38,30%***14,50%31,60%-Depression after35,80%15%*35%36,60%--20,80%53,30%**Acknowledgements:NIL.Disclosure of InterestsNone Declared.

The pandemic of COVID-19 has afflicted every individual and has initiated a cascade of directly or indirectly involved events in precipitating mental health issues. The human species is a wanderer and hunter-gatherer by nature, and physical social distancing and nationwide lockdown have confined an individual to physical isolation. The present review article was conceived to address psychosocial and other issues and their aetiology related to the current pandemic of COVID-19. The elderly age group has most suffered the wrath of SARS-CoV-2, and social isolation as a preventive measure may further induce mental health issues. Animal model studies have demonstrated an inappropriate interacting endogenous neurotransmitter milieu of dopamine, serotonin, glutamate, and opioids, induced by social isolation that could probably lead to observable phenomena of deviant psychosocial behavior. Conflicting and manipulated information related to COVID-19 on social media has also been recognized as a global threat. Psychological stress during the current pandemic in frontline health care workers, migrant workers, children, and adolescents is also a serious concern. Mental health issues in the current situation could also be induced by being quarantined, uncertainty in business, jobs, economy, hampered academic activities, increased screen time on social media, and domestic violence incidences. The gravity of mental health issues associated with the pandemic of COVID-19 should be identified at the earliest. Mental health organization dedicated to current and future pandemics should be established along with Government policies addressing psychological issues to prevent and treat mental health issues need to be developed. References World Health Organization (WHO) Coronavirus Disease (COVID-19) Dashboard. 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Abstract This study aimed to describe the impact of the COVID-19 pandemic and related public health decisions on dental services. A retrospective study was conducted using secondary data on dental services (2019–2021). Data were obtained from the Latvian National Health Service and the Centre for Disease Prevention and Control and analysed using descriptive statistics and data visualisation methods. In the first wave of COVID-19, the frequency of routine dental services decreased by 81.6% at the patient level, which coincided with the restrictions imposed as public health measures. The amount of regular dental manipulations returned to its previous level immediately after lifting restrictions. Still, they decreased to a more moderate extent (not exceeding 25% decline) with the beginning of the second wave. We observed a decrease in all manipulations, regardless of their aerosol-generating risk, and no increase in preventive manipulations that could be performed without any physical contact. We conclude that the most significant decrease in the availability of services was directly linked to existing public health measures. It seems that these measures allowed time to adapt the clinics to the new sanitary requirements, further ensuring continuity of service provision.

Uganda has had repeated outbreaks of Rift Valley fever (RVF) since March 2016 when human and livestock cases were reported in Kabale after a long interval. The disease has a complex and poorly described transmission patterns which involves several mosquito vectors and mammalian hosts (including humans). We conducted a national serosurvey in livestock to determine RVF virus (RVFV) seroprevalence, risk factors, and to develop a risk map that could be used to guide risk-based surveillance and control measures. A total of 3,253 animals from 175 herds were sampled. Serum samples collected were screened at the National Animal Disease Diagnostics and Epidemiology Centre (NADDEC) using a competition multispecies anti-RVF IgG ELISA kit. Data obtained were analyzed using a Bayesian model that utilizes integrated nested Laplace approximation (INLA) and stochastic partial differential equation (SPDE) approaches to estimate posterior distributions of model parameters, and account for spatial autocorrelation. Variables considered included animal level factors (age, sex, species) and multiple environmental data including meteorological factors, soil types, and altitude. A risk map was produced by projecting fitted (mean) values, from a final model that had environmental factors onto a spatial grid that covered the entire domain. The overall RVFV seroprevalence was 11.39% (95% confidence interval: 10.35–12.51%). Higher RVFV seroprevalences were observed in older animals compared to the young, and cattle compared to sheep and goats. RVFV seroprevalence was also higher in areas that had (i) lower precipitation seasonality, (ii) haplic planosols, and (iii) lower cattle density. The risk map generated demonstrated that RVF virus was endemic in several regions including those that have not reported clinical outbreaks in the northeastern part of the country. This work has improved our understanding on spatial distribution of RVFV risk in the country as well as RVF burden in livestock.

Background: As malaria is among the leading public health problems globally as well as in India, early diagnosis and treatment of cases is one of the key interventions for its control and elimination. Present study was done to assess treatment-seeking behaviour and associated factors among malaria suspected patients.Methods: Present study was carried out at urban health and training center, Sagar, Madhya Pradesh. The hospital based prospective study by facility based identification of patients. Study was under taken from 1st Oct 2018 to 31st march 2019. All malaria suspected cases of fever cases who got tested for malaria. Purposive sampling technique. After a pilot study final questionnaire regarding treatment seeking behavior were used to collect information from 285 patients of fever data was analyzed in word excel 2007 using percentage and proportion.Results: In present study we found that out of 285 patients only 54 (18.94%) patient approached health facility within 24 hours. Majority of patient 93(32.63%) adopted self medication practice, 20.00% patient, who did nothing and waited for self resolution of fever. Majority of 39.82% answered mildness of disease as a reason for delay in getting treatment.Conclusions: A low proportion of malaria-suspected patients sought treatment within 24 h of fever onset compared to the national target. Awareness about the advantage early treatment-seeking need to be increased through health education and behavioural change communication.

Abstract Introduction In response to the Coronavirus 2019 (COVID-19) pandemic, vascular surgeons in the Veteran Affairs Health Care System have been undertaking only essential cases, such as advanced critical limb ischemia. Surgical risk assessment in these patients is often complex, considers all factors known to impact short- and long-term outcomes, and the additional risk that COVID-19 infection could convey in this patient population is unknown. The European Centre for Disease Prevention and Control (ECDC) published risk factors (ECDC-RF) implicated in increased COVID-19 hospitalization and case-fatality which have been further evidenced by initial reports from the United States Centers for Disease Control and Prevention. CDC reports additionally indicate that African American (AA) patients have incurred disparate infection outcomes in the United States. We set forth to survey the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database over a nearly 20 year span to inform ongoing risk assessment with an estimation of the prevalence of ECDC-RF in our veteran critical limb ischemia population and investigate whether an increased COVID-19 comorbidity burden exists for AA veterans presenting for major non-traumatic amputation. Materials and Methods The VASQIP database was queried for all above knee amputation (AKA) and below knee amputation (BKA) completed 1999–2018 after IRB approval (MIRB:#02507). Patient race and ECDC-RF including male gender, age &gt; 60 years, smoking status, hypertension, diabetes, chronic obstructive pulmonary disease, cancer, and cardiovascular disease were recorded from preoperative patient history. AKA and BKA cohorts were compared via χ2-test with Yates correction or unpaired t-test and a subgroup analysis was conducted between AA and all other race patients for COVID-19 comorbidities in each cohort. Results VASQIP query returned 50,083 total entries. Average age was 65.1 ± 10.4 years and 68.2 ± 10.5 years for BKA and AKA cohorts, respectively, (P &lt; .0001) and nearly all patients were male (99%). At least one ECDC-RF comorbidity was present in 25,526 (88.7%) of BKA and 17,558 (82.4%) of AKA patients (P &lt; .0001). AA BKA patients were significantly more likely than non-AA BKA patients to present with at least one ECDC-RF comorbidity (P = .01). Conclusions According to a large national Veterans Affairs database, there are high rates of ECDC-RF in veteran amputees. During the present crisis, management of these patients should incorporate telehealth, expedient discharge, and ongoing COVID-19 transmission precautions.

Background: Infection prevention and control (IPC) programs are important to control the Lassa Fever (LF) outbreak. We reported IPC's status at the Federal Medical Centre, Owo, southwest Nigeria, before and after implementing the IPC program during a surge in the LF outbreak. Methods: We conducted a longitudinal observational study among five health care professionals at the Federal Medical Centre, Owo, between February 2019 and May 2019 using the IPC Assessment Framework (IPCAF). The tool has eight core components with a score of 0-100 per component and provided a baseline assessment of the IPC program and evaluation after three months. We interviewed relevant unit heads and IPC committee members in the first phase. In the second phase, we designed and implemented the IPC program, and in the third phase, we conducted a repeat interview similar to the first phase. The program initiated included training healthcare workers and providing relevant IPC items according to identified gaps and available funding. Results: We interviewed five health care professionals, two female nurses, and three male doctors responsible for organizing and implementing IPC activities at the Federal Medical Centre, Owo, with an in-depth understanding of IPC activities. The overall IPC level score increased from 318.5 at baseline to 545 at three months later. IPC improvements were reported in all the components, with IPC education and training [baseline (20), final (70)], IPC guidelines [baseline (50), final (92.5)] and monitoring/audits of IPC practices and feedback [baseline (40), final (82.5)] recording the highest improvements. Healthcare-associated infection [baseline (10), final (25)], and built environment, materials, and equipment for IPC [baseline (43.5), final (55)] had the least improvement. Poor motivation to adopt recommended changes among hospital staff were major issues preventing improvements. Conclusion: Promotion of IPC program and activities should be implemented at the Federal Medical Centre, Owo. References World Health Organization, WHO. Lassa fever. Available from: https://www.who.int/health-topics/lassa-fever/#tab=tab_1. [Accessed on 11 October 2020] Nigeria Centre for Disease Control. Lassa fever. Available from: https://ncdc.gov.ng/diseases/factsheet/47. [Accessed on 11 October 2020]. World Health Organization, WHO. Lassa fever. Available from: https://www.who.int/news-room/fact-sheets/detail/lassa-fever. [Accessed on 11 October 2020]. Ijarotimi IT, Ilesanmi OS, Aderinwale A, Abiodun-Adewusi O, Okon IM. Knowledge of Lassa fever and use of infection prevention and control facilities among health care workers during Lassa fever outbreak in Ondo state, Nigeria. Pan Afr Med J. 2018; 30:1-13. https://doi.org/10.11604/pamj.2018.30.56.13125 Mateer EJ, Huang C, Shehu NY, Paessler S. Lassa fever–induced sensorineural hearing loss: A neglected public health and social burden. PLoS Negl Trop Dis. 2018;12(2):1-11. https://doi.org/10.1371/journal.pntd.0006187 Ijarotimi I., Oladejo J., Nasidi A, Jegede O. Lassa fever in the State Specialist Hospital Akure, Nigeria: Case report, Contact tracing and outcome of hospital contacts. Int J Infect Trop Dis. 2016;3(1):20-28. https://doi.org/10.14194/ijitd.3.1.4 Ireye F, Ejiyere H, Aigbiremolen AO, Famiyesin OE, Rowland-Udoh EA, Ogeyemhe CO, Okudo I, Onimisi AB. Knowledge, attitude and infection prevention and control practices regarding Lassa fever among healthcare workers in Edo State, Nigeria. Int J Prev Treat. 2019;8(1):21-27. https://doi.org/10.5923/j.ijpt.20190801.03 World Health Organization. Infection prevention and control assessment framework at the facility level. 2018; 2016:1-15. Available from: https://www.who.int/infection-prevention/tools/core-components/IPCAF-facility.PDF?ua=1 [Accessed on 11 October 2020]. World Health Organization, WHO. Communicable disease surveillance and response systems - Guide to monitoring and evaluating. Epidemic and pandemic alert and response. Published online 2006:90. doi: rr5305a1 [pii] Ousman K, Kabego L, Talisuna A, Diaz J, Mbuyi J, Houndjo B, et al. The impact of Infection Prevention and control (IPC) bundle implementation on IPC compliance during the Ebola virus outbreak in Mbandaka/Democratic Republic of the Congo: A before and after design. BMJ Open. 2019;9(9):1-6. https://doi.org/10.1136/bmjopen-2019-029717 Nzinga J, Mbindyo P, Mbaabu L, Warira A, English M. Documenting the experiences of health workers expected to implement guidelines during an intervention study in Kenyan hospitals. Implement Sci. 2009;4(1):1-9. https://doi.org/10.1186/1748-5908-4-44. Ataiyero Y, Dyson J, Graham M. Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: A narrative review. Am J Infect Control. 2019 May;47(5):565-573. https://doi.org/10.1016/j.ajic.2018.09.014. Gilbert GL, Kerridge I. The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians’ perceptions of professional and cultural factors that influence doctors’ attitudes and practices in a large Australian hospital. BMC Health Serv Res. 2019; 19(212). https://doi.org/1186/s12913-019-4044-y.

BackgroundAlthough research indicates that a physically active lifestyle has the potential to prevent cognitive decline and dementia, the optimal type of physical activity/exercise remains unclear. The present study aimed to determine the cognitive benefits of a golf-training programme in community-dwelling older adults.MethodsWe conducted a randomised controlled trial between August 2016 and June 2017 at a general golf course. Participants included 106 Japanese adults aged 65 and older. Participants were randomly assigned to either a 24-week (90–120 min sessions/week) golf-training group or a health education control group. Postintervention changes in Mini-mental State Examination (MMSE) and National Centre for Geriatrics and Gerontology-Functional Assessment Tool scores were regarded as primary outcome measures. Secondary outcome measures included changes in physical performance and Geriatric Depression Scale (GDS) scores.ResultsA total of 100 participants (golf training, n=53; control, n=47) completed the assessments after the 24-week intervention period. The adherence to the golf programme was 96.2% (51/53 participants). Analysis using linear mixed models revealed that the golf training group exhibited significantly greater improvements in immediate logical memory (p=0.033), delayed logical memory (p=0.009) and composite logical memory (p=0.013) scores than the control group. However, no significant changes in MMSE, word memory, Trail Making Test or Symbol Digital Substitution Test scores were observed. In addition, no significant changes in grip strength, walking speed or GDS were observed.ConclusionsGolf-based exercise interventions may improve logical memory in older adults, but no significant changes in other cognitive tests. Further follow-up investigations are required to determine whether the observed effects are associated with delayed onset of mild cognitive impairment or Alzheimer’s disease in older adults.Trial registration numberUMIN-CTR UMIN000024797; Pre-results.

Abstract Background: T-cell activation plays a critical role in the pathogenesis of acute graft-versus-host disease (GVHD). Quiescent T cells utilize oxidative phosphorylation to generate ATP, whereas activated T cells utilize glycolysis, so use glycolysis inhibitor may be a metabolically regulator needed to control T cells induced GVHD. The mixed lymphocytes culture (MLC) was used as a model to evaluate the effect of treatment for GVHD in vitro. Glucolysis inhibitor 3-Bromopyruvic acid (3-BrPA), a glucolysis inhibitor, can effectively induce multidrug resistance leukemia cell lines apoptosis and enhanced chemotherapy-induced cytotoxity to leukemia cells. Objective : This study aimed to study the effects of glycolytic inhibitor 3-Bromopyruvate (3-BrPA) on the proliferation, the apoptosis, the T lymphocyte subsets and the contents of cytokine IL-4 and IFN-γ in mouse spleen cells harvested from mixed lymphocyte culture. Methods An one-way mixed lymphocyte culture system characterized by labeled responder cells with BALB/c mouse spleen cells (H-2kd) and stimulator cells with C57BL/6 mouse spleen cells (H-2kb) was established. With treatment of 3-BrPA at different concentrations (0-200 μmol/L), the CCK-8 method was applied for lymphoproliferation activity, flow cytometry for cell surface markers of CD3, CD4 and CD8, and ELISA method for the levels of cytokine IL-4 and IFN-γ in the supernatant. Results: The CCK-8 test revealed that 3-BrPA in middle or high concentrations (over IC 30, 20 μmol/L) displayed a dose-dependent inhibitory effect on T-cell proliferation of MLC system. The IC50 were 48.6、41.2 and 41.9 μmol/L after 24 h, 36 h and 48 h of culture, respectively. FCM test discovered that the inhibitory effect mainly occurred in the CD4+ cells. After 48 h of culture, the apoptosis rate of 0, 10, 20, 50 and 100 μmol/L group were 4.86±0.88%, 5.2±1.13%, 12.63±2.97%, 18.55±4.06% and 22.47±3.61%, respectively. With treatment of 20 or 50μmol/L 3-BrPA, the levels of IFN-γ decreased obviously to 243.37±15.64 ng/L and 164.25±20.14 ng/L, compared with the control group (277.61±18.46 ng/L). The levels of IL-4 increased mildly to 33.18±5.69 ng/L and 31.06±6.06 ng/L, compared with the control group (28.64±3.97ng/L). Thus, the IFN-γ/IL-4 ratio decreased significantly. Conclusions :The results indicated that 3-BrPA could inhibit T cells proliferation, induce apoptosis and contribute to the Th2 cytokine environment in murine mixed lymphocyte culture system. Disclosures Liu: National Natural Science Foundation of China (81270647, 81300445, 81200388): Research Funding; National High Technology Research and Development Program of China (863 Program) (2011AA020105): Research Funding; National Public Health Grand Research Foundation (201202017): Research Funding; Natural Science Foundation of Guangdong Province (S2012010009299): Research Funding; the project of health collaborative innovation of Guangzhou city (201400000003-4, 201400000003-1): Research Funding; the Technology Plan of Guangdong Province of China (2012B031800403): Research Funding; the project of the Zhujiang Science & Technology Star of Guangzhou city (2013027): Research Funding.

Background Sedentary behaviour is linked to increased risk of type 2 diabetes, cardiovascular disease, musculoskeletal issues and poor mental well-being. Contact (call) centres are associated with higher levels of sedentary behaviour than other office-based workplaces. Stand Up for Health is an adaptive intervention designed to reduce sedentary behaviour in contact centres. Objectives The objectives were to test the acceptability and feasibility of implementing the intervention; to assess the feasibility of the study design and methods; to scope the feasibility of a future health economic evaluation; and to consider the impact of COVID-19 on the intervention. All sites received no intervention for between 3 and 12 months after the start of the study, as a waiting list control. Design This was a cluster-randomised stepped-wedge feasibility design. Setting The trial was set in 11 contact centres across the UK. Participants Eleven contact centres and staff. Intervention Stand Up for Health involved two workshops with staff in which staff developed activities for their context and culture. Activities ranged from using standing desks to individual goal-setting, group walks and changes to workplace policies and procedures. Main outcome measures The primary outcome was accelerometer-measured sedentary time. The secondary outcomes were subjectively measured sedentary time, overall sedentary behaviour, physical activity, productivity, mental well-being and musculoskeletal health. Results Stand Up for Health was implemented in 7 out of 11 centres and was acceptable, feasible and sustainable (objective 1). The COVID-19 pandemic affected the delivery of the intervention, involvement of contact centres, data collection and analysis. Organisational factors were deemed most important to the success of Stand Up for Health but also the most challenging to change. There were also difficulties with the stepped-wedge design, specifically maintaining contact centre interest (objective 2). Feasible methods for estimating cost-efficiency from an NHS and a Personal Social Services perspective were identified, assuming that alternative feasible effectiveness methodology can be applied. Detailed activity-based costing of direct intervention costs was achieved and, therefore, deemed feasible (objective 3). There was significantly more sedentary time spent in the workplace by the centres that received the intervention than those that did not (mean difference 84.06 minutes, 95% confidence interval 4.07 to 164.1 minutes). The other objective outcomes also tended to favour the control group. Limitations There were significant issues with the stepped-wedge design, including difficulties in maintaining centre interest and scheduling data collection. Collection of accelerometer data was not feasible during the pandemic. Conclusions Stand Up for Health is an adaptive, feasible and sustainable intervention. However, the stepped-wedge study design was not feasible. The effectiveness of Stand Up for Health was not demonstrated and clinically important reductions in sedentary behaviour may not be seen in a larger study. However, it may still be worthwhile conducting an effectiveness study of Stand Up for Health incorporating activities more relevant to hybrid workplaces. Future work Future work could include developing hybrid (office and/or home working) activities for Stand Up for Health; undertaking a larger effectiveness study and follow-up economic analysis (subject to its success); and exploring organisational features of contact centres that affect the implementation of interventions such as Stand Up for Health. Trial registration This trial is registered as ISRCTN11580369. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 13. See the NIHR Journals Library website for further project information.

e24088 Background: Palliative care is patient and family-centered care provided to optimize the quality of life in serious illness, and is an essential health service under Universal Health Coverage. Given the burden of cancer and other chronic disease diseases along with demographic changes, the need for palliative care is growing in Turkey. This study aimed to review of the available scientific literature on palliative cancer care needs, models and outcomes Turkey. Methods: A comprehensive literature review was conducted with English and Turkish keywords in PubMed, Scopus, Embase, ScienceDirect, Web of Science, Google Scholar, The Turkish Academic Network and Information Centre databases, Turkish Ministry of Health documents, Turkish Council of Higher Education’s doctoral thesis, and renowned national and international palliative care as well as cancer conferences 01/ 2000 to 07/ 2020. Results: Out of 27489 papers identified, 320 met the criteria for inclusion. The main focus of these studies was; historical development in palliative care, legislative regulation, professional training, use of opioids, symptom management, care for patients, palliative care centers, public awareness, psychosocial support, and end of life ethics. The majority of this literature used descriptive design, although a few case-control, cohort, and randomized control trials were also found. Our analysis showed that the development of PC in Turkey can be divided into three period. The first (early initiatives, before 2000), the second (dissemination phase, 2000-2010), and the third stage (government & societial engagement, after 2010). Several studies also analyzed the barriers such as low public & professional awareness, disconnection from cancer care, the opioidfobia and the lack of trained palliative care providers. The lack of integration of palliative care to cancer care is a major challenge for palliative care implementation. Conclusions: This review presents the evidence of the significant progress in PC during the last 20 years and the opportunities for further progress. Bringing research into practice is needed for shaping the integration of palliative care to cancer care in Turkey. The stakeholders and policy makers should not neglect the need for PC under the current pressure of COVID-19 pandemic on health and economy.

Background: Evaluate the Tuberculosis (TB) surveillance system in the Ga West Municipality to determine if it is achieving its objectives, and to assess its attributes and usefulness.Design: Descriptive analysis of primary and secondary dataData source: Stakeholder interviews and record reviews on the objectives and operation of the surveillance system at all levels of the system.Intervention: We evaluated the system’s operation from 2011-2015 using the Centers for Disease Control and Prevention (CDC) updated guidelines for evaluating public health surveillance systems and the World Health Organisation (WHO) TB surveillance checklist for assessing the performance of national surveillance systems.Results: The TB surveillance system in the municipality was functional and operated at all levels for timely detection of cases, accurate diagnosis, and case management. The system improved management of TB/HIV co-infections. The average time taken to confirm a suspected TB case was one day. The registration of a confirmed case and subsequent treatment happen immediately after confirmation. The municipality detected 109 of 727 TB cases in 2015 (case detection rate=15%). The positive predictive value (PPV) was 6.4%. There was one diagnostic centre in the municipality. Private facilities involvement in TB surveillance activities was low (1/15).Conclusion: The Tuberculosis surveillance system in the Ga West Municipality is well structured but partially meeting its objectives. The system is timely, stable and acceptable by most stakeholders and useful at all levels. It has no major data quality issues. Private health facilities in the municipality should be well incorporated into TB surveillance.Keywords: tuberculosis, evaluation, surveillance system, system attributes, Ga WestFunding: This work was supported by Ghana Field Epidemiology and Laboratory Training Program (GFELTP), University of Ghana through the support of the West Africa Health Organization (Ref.: Prog/A17IEpidemSurveillN°57212014/mcrt) to B-YA

Background Adolescent physical activity levels are low and are associated with rising disease risk and social disadvantage. The Get Others Active (GoActive) intervention was co-designed with adolescents and teachers to increase physical activity in adolescents. Objective To assess the effectiveness and cost-effectiveness of the school-based GoActive programme in increasing adolescents’ moderate-to-vigorous physical activity. Design A cluster randomised controlled trial with an embedded mixed-methods process evaluation. Setting Non-fee-paying schools in Cambridgeshire and Essex, UK (n = 16). Schools were computer randomised and stratified by socioeconomic position and county. Participants A total of 2862 Year 9 students (aged 13–14 years; 84% of eligible students). Intervention The iteratively developed feasibility-tested refined 12-week intervention trained older adolescents (mentors) and in-class peer leaders to encourage classes to undertake two new weekly activities. Mentors met with classes weekly. Students and classes gained points and rewards for activity in and out of school. Main outcome measures The primary outcome was average daily minutes of accelerometer-assessed moderate-to-vigorous physical activity at 10 months post intervention. Secondary outcomes included accelerometer-assessed activity during school, after school and at weekends; self-reported physical activity and psychosocial outcomes; cost-effectiveness; well-being and a mixed-methods process evaluation. Measurement staff were blinded to allocation. Results Of 2862 recruited participants, 2167 (76%) attended 10-month follow-up measurements and we analysed the primary outcome for 1874 (65.5%) participants. At 10 months, there was a mean decrease in moderate-to-vigorous physical activity of 8.3 (standard deviation 19.3) minutes in control participants and 10.4 (standard deviation 22.7) minutes in intervention participants (baseline-adjusted difference –1.91 minutes, 95% confidence interval –5.53 to 1.70 minutes; p = 0.316). The programme cost £13 per student compared with control. Therefore, it was not cost-effective. Non-significant indications of differential impacts suggested detrimental effects among boys (boys –3.44, 95% confidence interval –7.42 to 0.54; girls –0.20, 95% confidence interval –3.56 to 3.16), but favoured adolescents from lower socioeconomic backgrounds (medium/low 4.25, 95% confidence interval –0.66 to 9.16; high –2.72, 95% confidence interval –6.33 to 0.89). Mediation analysis did not support the use of any included intervention components to increase physical activity. Some may have potential for improving well-being. Students, teachers and mentors mostly reported enjoying the GoActive intervention (56%, 87% and 50%, respectively), but struggled to conceptualise their roles. Facilitators of implementation included school support, embedding a routine, and mentor and tutor support. Challenges to implementation included having limited school space for activities, time, and uncertainty of teacher and mentor roles. Limitations Retention on the primary outcome at 10-month follow-up was low (65.5%), but we achieved our intended sample size, with retention comparable to similar trials. Conclusions A rigorously developed school-based intervention (i.e. GoActive) was not effective in countering the age-related decline in adolescent physical activity. Overall, this mixed-methods evaluation provides transferable insights for future intervention development, implementation and evaluation. Future work Interdisciplinary research is required to understand educational setting-specific implementation challenges. School leaders and authorities should be realistic about expectations of the effect of school-based physical activity promotion strategies implemented at scale. Trial registration Current Controlled Trials ISRCTN31583496. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information. This work was additionally supported by the Medical Research Council (London, UK) (Unit Programme number MC_UU_12015/7) and undertaken under the auspices of the Centre for Diet and Activity Research (Cambridge, UK), a UK Clinical Research Collaboration Public Health Research Centre of Excellence. Funding from the British Heart Foundation (London, UK), Cancer Research UK (London, UK), Economic and Social Research Council (Swindon, UK), Medical Research Council, the National Institute for Health Research (Southampton, UK) and the Wellcome Trust (London, UK), under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged (087636/Z/08/Z; ES/G007462/1; MR/K023187/1). GoActive facilitator costs were borne by Essex and Cambridgeshire County Councils.

Monitoring and assessment of the implementation of the National Program of Prevention, Treatment, Advancement and Control of Renal Insufficiency and Dialysis Development in the Republic of Serbia by 2020 has been implemented by the Institute of Public Health of Serbia "Dr Milan Jovanović Batut". As the mode of dialysis centres operation changed after the COVID-19 epidemic was proclaimed, whereby some centres started operating in the Covid-regime, while Covid-negative patients from these centres were rerouted to the closest dialysis centres with available capacities, the need for monitoring and assessing the conditions for the implementation of the chronic dialysis program was further emphasized. The purpose of this paper is to provide a retrospective analysis of the conditions for the implementation of a chronic dialysis program in healthcare institutions within, and outside of the Network Plan during the COVID-19 outbreak in the period from the beginning of the epidemic to 1 October 2021. For the purposes of this study, a special questionnaire was designed, which was filled in by dialysis centres. The questionnaire consisted of three parts pertaining to: a) implementation of infection prevention measures at the dialysis centre, b) availability of personal protection equipment and disinfectants at the dialysis centres during the COVID-19 pandemic and c) conditions for the provision of dialysis services to patients positive for, or suspected of, COVID-19 infection. In the observed period, as much as 39% of the dialysis centres were designated to receive patients from other healthcare institutions, which called for additional efforts in organising and pursuing transmission containment. Implementation of transmission prevention measures in the dialysis centres was maintained at a very high level (between 95.5 and 100%). Only 10-15% of dialysis centres reported occasional shortages of individual items from the personal protective equipment or disinfectant categories. Almost one in five dialysis centres received a higher number of patients during the outbreak than was the case in the pre-pandemic period. In that sense, it was difficult to maintain the necessary physical distance in an already limited space, and to organize work in shifts as human resources were restricted. In addition to the general documents pertaining to infectious disease transmission prevention and containment, a protocol needed to be elaborated to organize the operation of dialysis centres in an outbreak such as the one caused by the SARS-CoV-2 virus.

Abstract Background The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors. Purpose Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort. Method This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Result(s) During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p&lt;0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity. Conclusion(s) Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding below: Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE. Disclosure of Interest C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared

Background:Multisystem inflammatory syndrome in children (MIS-C) was recognized during the 2020 pandemic of SARS-CoV-2. Because of the relative rarity current knowledge is limited, especially in the European Caucasian population.Objectives:To report the epidemiology, clinical and laboratory characteristics of patients with MIS-C in a nationwide cohort study in Slovenia.Methods:This is a nationwide prospective cohort study of all consecutive patients with MIS-C, admitted from the beginning of epidemics to 31st December 2020 to University Medical Centre Ljubljana, Slovenia, the only tertiary care pediatric rheumatology center in the country. The inclusion criteria were meeting the CDC criteria for MIS-C. Infection with SARS-CoV-2 was confirmed in all patients by positive antibodies for SARS-CoV-2. Data were collected from the patients’ medical records. Data on the COVID-19 epidemics in Slovenia were collected from National Institute of Public Health. Population data were provided by the Statistical Office of the Republic of Slovenia.Results:Twenty-three patients with MIS-C were diagnosed nationwide in Slovenia, all of them in the second wave of epidemics from 14th September to 31st December 2020. All patients were Caucasian and the estimated prevalence of MIS-C was 5.8/100 000 persons younger than 19 years of age. Detailed analyses were available in 20 patients of which 14 were boys (70 %), median age was 12.4 years (4 months to 17.7 years). Two patients (10 %) were treated in the intensive care unit and none of the patients died. Troponin was elevated in 15/20 (75 %) patients during the disease course, and 7/15 (47 %) of these had normal troponin level at admission. The serum level of troponin closely followed the serum level of CRP. Six out of 20 (30 %) patients had elevated pancreatic enzymes in the second week of the disease after treatment was already given,and one patient developed asymptomatic acute pancreatitis with serum lipase level reaching the maximum of 25μkat/L. All patients had elevated levels of D-dimer with no signs of thrombosis. Five patients (5/20; 25 %) had pleural effusions and five patients (5/20, 25 %) had ascites. Half of the patients (10/20; 50 %) had hepatosplenomegaly and eight (8/20; 40 %) had mesenterial lymphadenopathy. Three patients (3/20; 15 %) had radiologic signs of cholecystitis. Two patients had thickened lung parenchyma. All patients received IVIG and systemic glucocorticosteroids. Because of resistant or organ threatening disease 4 patients (4/20, 20%) received high dose methylprednisolone pulse therapy. Biologic therapy with anakinra was started in 2 patients. Nineteen patients (19/20, 95%) received acetylsalicylic acid and prophylactic anticoagulation was prescribed in 15/20 (75%) of patients.The mean follow up was 50 days (14 – 122). At the last follow-up visit all patients had normal laboratory parameters of inflammation, troponin, pro-BNP, d-dimer values and normal heart function.Table 1.Clinical characteristics.n (%)Fever n (%)20 (100)Fever duration (days) [ min; max]5.9 [4; 8]Headache8 (40)Lymphadenopathy15 (75)Chest pain6 (30)Tachycardia16 (80)Gastrointestinal involvement19 (95)•Abdominal pain16 (80)•Vomiting11 (55)•Diarrhoea9 (45)•Loss of apetite18 (90)Cough7 (35)Skin and mucous involvement14 (70)•Rash12 (60)•Palmar/plantar oedema3 (15)•Lip and mouth changes12 (60)•Bilateral conjunctivitis14 (70)Myocarditis19 (95)Conclusion. A very high incidence of MIS-C, estimated 5.8/100 000 persons under the age of 19 with a predominantly cardiac involvement but very good outcome was noted in European Caucasian population in a nationwide cohort study in Slovenia. Attention to newly described pancreatic involvement should be raised.Conclusion:A very high incidence of MIS-C, estimated 5.8/100 000 persons under the age of 19 with a predominantly cardiac involvement but very good outcome was noted in European Caucasian population in a nationwide cohort study in Slovenia. Attention to newly described pancreatic involvement should be raised.Disclosure of Interests:None declared

ABSTRACT Finger millet (Eleusine coracana (L) commonly known as ragi is an important crop used for food, forage and industrial products. Finger millet has a wide ecological and geographical adaptability and resilience to various agro-climatic adversities hence, it is highly suited to drought condition and marginal land and requires low external input in cultivation.. Farmers participatory field demonstrations of ragi variety Arjun and Bhairabi were conducted at two villages ie Pedawada of Malkangiri block and MPV -1 of Kalimela block of Malkangiri district, comprising 40 farmers in cluster approach in Kharif 2018 and 2019 , by Krishi Vigyan Kendra, Malkangiri , in South Eastern Ghat Zone of Odisha . Conducting front line demonstrations on farmer’s field help to identify the constraints and potential of the finger millet in the specific area as well as it helps in improving the economic and social status of the farmers. Observation on growth and yield parameters were taken and economic analysis was done. The final seed yield was recorded at the time of harvest and the gross return in (Rs ha -1) was calculated based on prevailing market prices. The results from the demonstration conclusively proved that finger millet variety Arjun (OEB-526) recorded the higher yield ( 18.8 q ha-1) , followed by Bhairabi ( 15.3 q ha-1) and farmer’s traditional variety Nali Mandia ( Dasaraberi) recorded an average yield of (8.6 q ha-1 ) . HYV Finger millet variety Arjun with proper nutrient management and plant protection measures gave 118 % higher over farmer’s practices. The technological and extension gap was 1.9 q ha-1 and 12.07 q ha-1 respectively. Similarly, technological index was 8.2 percent. The benefit cost ratio was 2.4 and 1.9 in case of Arjun and Bhairabi respectively and in case of farmer’s variety Nali Mandia it was 1.4. Hence the existing local finger millet variety can be replaced by HYV Arjun ans Bhairabi , since it fits good to the existing rainfed farming situation for higher productivity. By conducting front line demonstrations on millet on large scale in farmer’s field, yield potential of finger millet can be enhanced largely which will increase in the income level of farmers and improve the livelihood condition of the farming community. Introduction Among small millets, finger millet (Elusine coracana L,) locally known as Ragi/Mandia is the most important crop grown in tribal districts of Odisha and it is the staple food of the tribals. It was originated about 5000 years ago in east Africa (possibly Ethiopia) and was introduced into India, 3000 years ago (Upadhyaya et al., 2006) and it is highly suited to drought condition and marginal land and requires low external input in cultivation. Millet is a collective term referring to a number of small seeded annual grasses that are cultivated as grain crops, primarily on marginal lands in dry areas in temperate, subtropical and tropical regions (Baker, 1996). Nutritionally finger millet is superior to major cereal crops and rich source of micronutrients such as calcium, phosphorous, magnesium and iron. And it has several health benefits. Finger millet grains contain higher amount of proteins, oils and minerals than the grains of rice, maize or sorghum (Reed et al., 1976). Vadivoo and Joseph (1998) mentioned finger millet grains contain 13.24% moisture, 7.6% protein, 74.36% carbohydrate, 74.36% carbon, 1.52% dietary fiber, 2.35% minerals, 1.35% fat and energy 341.6 cal/100g. (Joshi and Katoch, 1990; Ravindran, 1991). It is a rich source of micronutrients such as calcium, phosphorus, magnesium and iron. Cysteine, tyrosine, tryptophan and methionine are the right spectrum of amino acids found in finger millet protein (Rachie, 1975). The increase in global temperature leads to climate changes that directly affect crop production and increase people's hunger and malnutrition around the world.. With regard to protein (6-8%) and fat (1-2%) it is comparable to rice and with respect to mineral and micronutrient contents it is superior to rice and wheat (Babu et al., 1987). It is also known for several health benefits such as anti-diabetic, anti-tumerogenic, atherosclerogenic effects, antioxidant, which are mainly attributed due to its polyphenol and dietary fiber contents. Being indigenous minor millet it is used in the preparation of various foods both in natural and malted forms. Grains of this millet are converted into flours for preparation of products like porridge, puddings, pancakes, biscuits, roti, bread, noodles, and other snacks. Besides this, it is also used as a nourishing food for infants when malted and is regarded as wholesome food for diabetic's patients. Diversification of food production must be encouraged both at national and household level in tandem with increasing yields. Growing of traditional food crops suitable for the area is one of the possible potential successful approaches for improving household food security. Malkangiri is one of the seven districts where a flagship programme called “Special Programme for Promotion of Millets in Tribal Areas of Odisha (hereafter, Odisha Millets Mission, (OMM)” has been launched by Department of Agriculture and Farmers Empowerment, Odisha in order to revive millets in rainfed farming systems and household consumption. It was started in kharif 2017 in four blocks of the district, namely Chitrakonda, Korkunda, Mathili and Khairiput. The Government of Odisha launched Odisha Millets Mission (OMM) also known as the Special Programme for Promotion of Millets in Tribal Areas of Odisha in 2017 to revive millets in farms and on plates. The aim was to tackle malnutrition by introducing millets in the public distribution system (PDS) and other state nutrition schemes. The focus is on reviving millets in farms and putting it on plates.” Millet, a nutritious and climate-resilient crop, has traditionally been cultivated and consumed by tribal communities in the rainfed regions of southern Odisha. Technology gap, i.e. poor knowledge about newly released crop production and protection technologies and their management practices in the farmers’ fields is a major constraint in Ragi production. So far, no systematic approach was implemented to study the technological gap existing in various components of Ragi cultivation. Awareness of scientific production technology like HYV of ragi, seed treatment with fungicide, use of insecticide and bio-fertilizers, is lacking in Malkangiri district which were a key reason for low productivity. The production potential could be increased by adopting recommended scientific and sustainable management production practices with improved high yielding varieties and timely use of other critical inputs. Objective The field experiment was undertaken to study the performance of three finger millet varieties Local Mandia (Nali Mandia), Bhairabi and Arjun in rainfed upland situation in kharif season. The present investigation was undertaken to evaluate the field performance of newly released finger millet varieties Arjun and Bhairabi under rainfed condition. The demonstrations were carried out in Malkangiri district covering two villages like Pedawada and MPV-6 to find out the existing technological and extension gap along with technology index with an objective to popularize the ragi varieties having higher yield potential. Material and methods The study was carried out in operational area of Krishi Vigyan Kendra (KVK), Malkangiri during Kharif season in the year 2018 and 2019. The study was under taken in Malkangiri and Kalimela blocks of Malkangiri district of Odisha and the blocks were selected purposefully as Finger millet is the major cereals crop grown in large area in Kharif season. The demonstrations were conducted in two different adopted villages Pedawada and MPV-6 in cluster approach. The Front Line Demonstration (FLD) is an applied approach to accelerate the dissemination of proven technologies at farmer’s fields in a participatory mode with an objective to explore the maximum available resources of crop production and also to bridge the productivity gaps by enhancing the production in national basket.The necessary steps for selection of site and farmers and layout of demonstrations etc were followed as suggested by Choudhary (1999). Forty numbers front line demonstrations on HYV Ragi were conducted in two clusters comprising 40 numbers of farmers. All the participating farmers were trained on various aspects of Ragi production technologies and recommended agronomic practices and certified seeds of Ragi variety Arjun and Bhairabi were used for demonstration. The soil of demonstration site was slightly acidic in reaction (pH-5.0 to 5.25) with sandy loam in texture and EC was 0.134 (dS m −1). The available nitrogen, phosphorus and potassium was between 214 .00, 22 .00, 142 .00 (Kg ha−1) respectively with 0.48 (%) Organic Carbon. The crop was sown in under rainfed condition in the first to second week of July. The crop was raised with recommended agronomic practices and harvested within 4th week of November up to 2nd week of December. Krishi Vigyan Kendra ( KVK), Malkangiri conducted front line demonstration with HYV varieties like Bhiarabi and Arjun and farmer’ local var Dasaraberi as check Finger millet Variety Arjun (OEB-526) is having Maturity duration 110 days and average yield 20.7q/ha with moderate resistance to leaf, neck and finger blast and brown seed and Bhairabi is a HYV of Ragi with Maturity duration 110 days and average yield 17.6 q/ha. Moderate resistance to leaf, neck blast and brown seeded and protein content 81%. Local variety Dsaraberi or Nali Mandia is having 105 days duration and drought tolerant variety used as farmers variety as local check . The technologies demonstrated were as follows: Popularization of high yielding Ragi variety, Seed treatment with Trichoderma viride @ 4g kg-1 seed , Line sowing with, soil test based fertilizer application along with need based plant protection measures. The field was ploughed two times and planking was done after each plugging, Need based plant protection measures were taken; along with soil test based fertilizer application was done with fertilizer dose 40:30:60 kg. N: P2O5: K2O kg ha -1. In case of local checks existing practices being used by farmers were followed. The observations were recorded for various parameters of the crop. The farmers’ practices were maintained in case of local checks. The field observations were taken from demonstration plot and farmer’s plot as well. Parameters like Plant height, number of fingers per plant, length of finger , no of fingers per year, 1000 seed weight and seed yield were recorded at maturity stage and the gross returns (Rs ha -1 ) were calculated on the basis of prevailing market price of the produce. The extension gap, technology gap, technology index along with B: C ratio was calculated and the data were statistically analyzed applying the statistical techniques. Statistical tools such as percentage, mean score, Standard deviation, co-efficient of variation, Fisher‘s “F” test, were employed for analysis of data. The farmer’s practices (FP) plots were maintained as local check for comparison study. The data obtained from intervention practices (IP) and famers practices (FP) were analyzed for extension gap, technological gap, technological index and benefit cost ratio study as per (Samui et al., 2000) as given below. Technology gap = Pi (Potential yield) - Di (Demonstration yield) Extension gap = Di (Demonstration Yield) - Fi (Farmers yield) Technology index = X 100 Result and Discussion The results obtained from the present investigation are summarized below. The Table 1 depicts the major differences observed between demonstration package and farmer’s practices in ragi production in the study area. The major differences were observed between demonstration package and farmer’s practices were regarding recommended varieties, seed treatment, soil test based fertilizer application, keeping optimum plant population by thinning, weed management and plant protection measures. The data of Table 1 shows that under the demonstrated plot only recommended high yielding variety, proper weeding and optimum plant population maintaining by thinning and the farmers used herbicides and the farmers timely performed all the other package and practices. It was also observed that farmers were unaware about balanced fertilizer application, seed treatment, and use of fertilizers application and maintenance of plant population for enhancing the yield. Majority of the farmers in the study area were unaware about use of weed management practices. The findings are in corroborated with the findings of (Katar et al., 2011) From the Table 2 it was revealed that in the district Malkangiri the productivity of finger millet was 6.38 (q ha-1) as compare to state average productivity 8.67 (q ha-1), but there exists a gap between potential yield and farmers yield, which can be minimized by adoption High yielding varieties with improved management practices. The productivity of finger millet was very low in the district as the crop is mostly grown along the hillsides on sloppy land on light textured soil. It was also coupled with negligence in adoption of improved varieties no input like fertilizers use and no plant protection measures and improper method and time of sowing. However, there is a wide gap between the Potential and the actual production realized by the farmers due to partial adoption of recommended package of practices by the growers. Several constraints contributed to yield fluctuation on Ragi production, including: unreliable rainfall; lack of high yielding variety ,disease tolerant varieties; pests and diseases incidence; low producer prices; poor agronomic practices; and lack of institutional support (Bucheyeki et al., 2008; Okoko et al., 1998). One of the central problems of ragi production and processing in this district is due to an uncertain production environment owing to rain fed cultivation, the low resource base of smallholder farmers and processors, and no scope for post harvest management and value addition facilities and poor marketing facility. The results clearly indicated from the Table 3 that the positive effects of FLDs over the existing practices. HYV Ragi Arjun recorded higher yield 18.8(q ha-1) followed by Bhairabi 15.53 (q ha-1) which was 21 % more and the yield performance of these two HYV varieties was higher than the farmer’s variety. This is due to higher of panicle length, more number of tillers and more number of fingers per panicle in HYV of ragi as compared to local variety. The results are in conformity with the findings of (Tomar et al. , 2003). The results clearly indicated the positive effects of FLDs over the existing practices towards enhancing the productivity. It is revealed form table 4 that, as the calculated ‘F’ value at α=0.05 level was found to be larger than table value, indicating significant difference in yield between farmer’s variety and recommended varieties. There was significant difference between average yield of ragi under Farmers practice (FP) and Recommended practice (RP) in variety Arjun under this demonstration. It was concluded that the yield of these HYV ragi varieties was significantly higher as compared to farmer’s variety. The economics and B:C ratio of farmers practice and Demonstration practice has been presented in Table 6. From the table it was revealed that Benefit: Cost ratio (B:C) was recorded to be higher under demonstrations against control treatments during all the years of experimentation. The cost of cultivation in HYV variety was higher due to more labour cost involved in transplanting and also it included cost of fertilizers and plant protection chemicals and also net returns was higher as compared to farmer’s practice. The B: C ratio was found to be 2.4 in case of variety Arjun as compared to 1.9 in case of variety Bhairabi. The results on economic analysis indicated that HYV ragi Arjun and Bhairabi performed better than local variety Ragi. The HYV variety Arjun recorded higher gross return upto Rs 54,332 and followed by Bhairabi Rs 44,289 per ha which was significantly higher than farmers practice and it was due to higher productivity of varieties under demonstration. Conclusion The results revealed that in Malkangiri district finger millet variety Arjun rerecorded highest yield followed by Variety Bhirabi with proper package and practices under rainfed upland condition. From the above study it was concluded that use of finger millet varieties like Arjun or Bhairabi with scientific methods and technological practices of can reduce the technological gap and enhance the productivity in the district. Yield improvement in Finger Millet in the demonstration was due to use of HYV seed and scientific management practices adopted by the farmers. Yield of Finger Millet can be increased to a great extent by conducting effective front line demonstrations in larger area with proven technologies. Finger millet is one of future smart food crop of India and can be grown in the drought condition. This crop is rich in nutrient for food insecurity and within few years because of increase in population of world and depletion of area of production.. The principal reasons of lower productivity of finger millet in the district Malkangiri were lack of knowledge among the farmers about cultivation of HYV finger millet varieties and improper fertilization, late season sowing and severe weed infestation in crop at critical stages. From the above findings, it can be concluded that use of scientific methods of Finger millet cultivation can reduce the technology gap to a considerable extent thus leading to increased productivity of millets in the district. Moreover, extension agencies in the district need to provide proper technical support to the farmers through different educational and extension methods to reduce the extension gap for better production. Acknowledgments The OUAT Bhubaneswar and ICAR-ATRI Kolkata, is acknowledged for financial support to the research program. Conflicts of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. References: Babu, B. V.; Ramana, T.; Radhakrishna, T.M. Chemical composition and protein in hybrid varieties of finger millet. Indian J. Agric. Sci. 1987, 57(7), 520-522. Biplab, M.; Samajdar, T. Yield gap analysis of rapeseed-mustard through Front Line Demonstration. Agricultural Extension Review. 2010, 16-17. Bucheyeki, T. L.; Shenkalwa, E. M.; Mapunda, T. X.; Matata, L.W. On-farm evaluation of promising groundnut varieties for adaptation and adoption in Tanzania. African Journal of Agricultural Research. 2008, 3(8), 531-536. Chandra, D.; Pallavi S C.; Sharma A.K. Review of Finger millet (Eleusine coracana (L.) Gaertn): A power house of health benefiting nutrients. Food Science and Human Wellness. 2016, 5( 3), 149-155. Choudhary, B. N. Krishi Vigyan Kendra - a guide for KVK managers. Division of Agricultural Extension, ICAR, 1999, 73-78. De Onis M.; Frongillo E.A.; Blossner, M. “Is malnutrition declining? An analysis of changes in levels of child malnutrition since, 1980.” Bulletin of the World Health Organization. 2000, 1222–1233. Gull, A.; Jan, R.; Nayik, G. A.; Prasad, K.; Kumar, P. Significance of Finger Millet in Nutrition, Health and Value added Products: A Review. Journal of Environmental Science, Computer Science and Engineering & Technology, JECET. 2014, 3(3), 1601-1608. Gupta, S .M.; Arora, S.; Mirza, N.; Pande, A.; Lata, C.; Puranik, ; Kumar, J.; Kumar, A. Finger Millet: A “Certain” Crop for an “Uncertain” Future and a Solution to Food Insecurity and Hidden Hunger under Stressful Environments. Frontiers on Plant Sci. 2017, 8, 643 Joshi, H. C.; Katoch, K. K. Nutritive value of millets: A comparison with cereals and pseudocereals. Himalayan Res. Dev. 1990, 9, 26-28. Kande, M.; Dhami, N B.; Subedi, N.; Shrestha, J. Arjun. Field evaluation and nutritional benefits of finger millet (Eleusine coracana (L.) Gaertn.) 2019. Katare, S.; Pandey, S.K.; Mustafa, M. Yield gap analysis of Rapeseed-mustard through front line demonstration. Agriculture update. 2011, 6(2), 5-7. Lupien, J.R. Sorghum and millets in human nutrition. FAO, ICRISAT. At: ao.org. 1990, 86. Mohanty, B. Odisha Millet Mission: The successes and the challenges. 2020. 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USDA, USA. 1976. Samui, S K.; Maitra, S.; Roy, D K.; Mandal, A. K.; Saha, D. Evaluation of front line demonstration on groundnut. Journal of Indian Society of Coastal Agricultural Research. 2000, 18(2), 180-183. Singh, J.; Kaur, R..; Singh, P. Economics and Yield gap analysis of Front Line Demonstrations regarding Scientific practices of Indian Mustard in district Amritsar. Indian Journal of Economics and Development. 2016, 12(1a), 515. Singh, P.; Raghuvanshi. R. S. Finger millet for food and nutritional security. African Journal of Food Science. 2012, 6(4), 77-84. Srivastava, P.P.; Das, H.; Prasad, S. Effect of roasting process variables on hardness of Bengal gram, maize and soybean. Food Sci. Technol. 1994, 31(1), 62-65. Tomar, L. S.; Sharma, B. P.; Joshi, K. Impact of front line demonstration of soybean in transfer of improved technology. Journal of Extension Research. 2003, 22(1), 139. Upadhyaya, H.D.; Gowdaand C.L.L.; Reddy, V.G. Morphological diversity in finger millet germplasm introduced from Southern and Eastern. African Journal of SAT Agriculture Research. 2007, 3(1). ejournal.icrisat.org. Vadivoo, A.S.; Joseph, R. Genetic variability and diversity for protein and calcium contents in finger millet (Elusine coracona (L.) Gaertn) in relation to grain color. Plant Foods for Human Nutrition Dordrecht. 1998, 52, 353-364. Department of Botany, Avinashilingam Institute for Home Science and Higher Education for Women, Deemed University, Coimbatore, TN, 641 043, India.

Abstract STUDY QUESTION Are maternal serum phthalate metabolite, phenol and paraben concentrations measured at 10–17 weeks of gestation associated with male infant genital developmental outcomes, specifically cryptorchidism, anogenital distance (AGD), penile length and testicular descent distance, at birth and postnatally? SUMMARY ANSWER Maternal serum bisphenol A (BPA) concentration at 10–17 weeks of gestation was positively associated with congenital or postnatally acquired cryptorchidism, and n-propyl paraben (n-PrP) concentration was associated with shorter AGD from birth to 24 months of age. WHAT IS KNOWN ALREADY Male reproductive disorders are increasing in prevalence, which may reflect environmental influences on foetal testicular development. Animal studies have implicated phthalates, BPA and parabens, to which humans are ubiquitously exposed. However, epidemiological studies have generated conflicting results and have often been limited by small sample size and/or measurement of chemical exposures outside the most relevant developmental window. STUDY DESIGN, SIZE, DURATION Case–control study of cryptorchidism nested within a prospective cohort study (Cambridge Baby Growth Study), with recruitment of pregnant women at 10–17 postmenstrual weeks of gestation from a single UK maternity unit between 2001 and 2009 and 24 months of infant follow-up. Of 2229 recruited women, 1640 continued with the infancy study after delivery, of whom 330 mothers of 334 male infants (30 with congenital cryptorchidism, 25 with postnatally acquired cryptorchidism and 279 unmatched controls) were included in the present analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS Maternal blood was collected at enrolment, and serum levels of 16 phthalate metabolites, 9 phenols (including BPA) and 6 parabens were measured using liquid chromatography/tandem mass spectrometry. Logistic regression was used to model the association of cryptorchidism with serum chemical concentrations, adjusting for putative confounders. Additionally, offspring AGD, penile length and testicular descent distance were assessed at 0, 3, 12, 18 and 24 months of age, and age-specific Z scores were calculated. Associations between serum chemical levels and these outcomes were tested using linear mixed models. MAIN RESULTS AND THE ROLE OF CHANCE Maternal serum BPA concentration was associated with offspring all-type cryptorchidism both when considered as a continuous exposure (adjusted odds ratio per log10 μg/l: 2.90, 95% CI 1.31–6.43, P = 0.009) and as quartiles (phet = 0.002). Detection of n-PrP in maternal serum was associated with shorter AGD (by 0.242 standard deviations, 95% CI 0.051–0.433, P = 0.01) from birth to 24 months of age; this reduction was independent of body size and other putative confounders. We did not find any consistent associations with offspring outcomes for the other phenols, parabens, and phthalate metabolites measured. LIMITATIONS, REASONS FOR CAUTION We cannot discount confounding by other demographic factors or endocrine-disrupting chemicals. There may have been misclassification of chemical exposure due to use of single serum measurements. The cohort was not fully representative of pregnant women in the UK, particularly in terms of smoking prevalence and maternal ethnicity. WIDER IMPLICATIONS OF THE FINDINGS Our observational findings support experimental evidence that intrauterine exposure to BPA and n-PrP during early gestation may adversely affect male reproductive development. More evidence is required before specific public health recommendations can be made. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by a European Union Framework V programme, the World Cancer Research Fund International, the Medical Research Council (UK), Newlife the Charity for Disabled Children, the Mothercare Group Foundation, Mead Johnson Nutrition and the National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre. Visiting Fellowship (J.M.): Regional Programme ‘Jiménez de la Espada’ for Research Mobility, Cooperation and Internationalization, Seneca Foundation—Science and Technology Agency for the Region of Murcia (No. 20136/EE/17). K.O. is supported by the Medical Research Council (UK) (Unit Programme number: MC_UU_12015/2). The authors declare no conflict of interest.

Our studies have indicated that the relative concentration of Se or Hg to As in urine and blood positively correlates with percentage of inorganic arsenic (% Inorg-As) and percentage of monomethlyarsonic acid [% MMA (V)]. We also found a negative correlation with percentage of dimethylarsinic acid [% DMA (V)] and the ratio of % DMA (V) to % MMA (V). In another study, we found that a group of proteins were significantly over expressed and conversely other groups were under-expressed in tissues in Na-As (III) treated hamsters. Introduction.Inorganic arsenic (Inorg-As) in drinking water.One of the largest public health problems at present is the drinking of water containing levels of Inorg-As that are known to be carcinogenic. At least 200 million people globally are at risk of dying because of arsenic (As) in their drinking water1-3. The chronic ingestion of Inorg-As can results in skin cancer, bladder cancer, lung cancer, and cancer of other organs1-3. The maximum contamination level (MCL) of U.S. drinking water for arsenic is 10 ug/L. The arsenic related public health problem in the U.S. is not at present anywhere near that of India4, Bangladesh4, and other countries5. Metabolism and toxicity of Inorg-As and arsenic species.Inorg-As is metabolized in the body by alternating reduction of pentavalent arsenic to trivalent form by enzymes and addition of a methyl group from S-adenosylmethionine6, 7; it is excreted mainly in urine as DMA (V)8. Inorganic arsenate [Inorg-As (V)]is biotransformed to Inorg-As (III), MMA (V), MMA (III), DMA (V), and DMA (III)6(Fig. 1). Therefore, the study of the toxicology of Inorg-As (V) involves at least these six chemical forms of arsenic. Studies reported the presence of 3+ oxidation state arsenic biotransformants [MMA (III) and DMA (III)] in human urine9and in animal tissues10. The MMA (III) and DMA (III) are more toxic than other arsenicals11, 12. In particular MMA (III) is highly toxic11, 12. In increased % MMA in urine has been recognized in arsenic toxicity13. In addition, people with a small % MMA in urine show less retention of arsenic14. Thus, the higher prevalence of toxic effects with increased % MMA in urine could be attributed to the presence of toxic MMA (III) in the tissue. Previous studies also indicated that males are more susceptible to the As related skin effects than females13, 15. A study in the U.S population reported that females excreted a lower % Inorg-As as well as % MMA, and a higher % DMA than did males16. Abbreviation: SAM, S-adenosyl-L-methionine; SAHC, S-adenosyl-L-homocysteine. Differences in susceptibility to arsenic toxicity might be manifested by differences in arsenic metabolism among people. Several factors (for examples, genetic factors, sex, duration and dosage of exposure, nutritional and dietary factors, etc.) could be influence for biotransformation of Inorg-As,6, 17 and other unknown factors may also be involved. The interaction between As, Se, and Hg.The toxicity of one metal or metalloid can be dramatically modulated by the interaction with other toxic and essential elements18. Arsenic and Hg are toxic elements, and Se is required to maintain good health19. But Se is also toxic at high levels20. Recent reports point out the increased risk of squamous cell carcinoma and non-melanoma skin cancer in those treated with 200 ug/day of selenium (Nutritional Prevention of Cancer Trial in the United States)21. However, it is well known that As and Se as well as Se and Hg act as antagonists22. It was also reported that Inorg-As (III) influenced the interaction between selenite and methyl mercury23. A possible molecular link between As, Se, and Hg has been proposed by Korbas et al. (2008)24. The identifying complexes between the interaction of As and Se, Se and Hg as well as As, Se, and Hg in blood of rabbit are shown in Table 1. Influence of Se and Hg on the metabolism of Inorg-As.The studies have reported that Se supplementation decreased the As-induced toxicity25, 26. The concentrations of urinary Se expressed as ug/L were negatively correlated with urinary % Inorg-As and positively correlated with % DMA27. The study did not address the urinary creatinine adjustment27. Other researchers suggested that Se and Hg decreased As methylation28-31(Table 2). They also suggested that the synthesis of DMA from MMA might be more susceptible to inhibition by Se (IV)29 as well as by Hg (II)30,31 compared to the production of MMA from Inorg-As (III). The inhibitory effects of Se and Hg were concentration dependent28-31. The literature suggests that reduced methylation capacity with increased % MMA (V), decreased % DMA (V), or decreased ratios of % DMA to % MMA in urine is positively associated with various lesions32. Lesions include skin cancer and bladder cancer32. The results were obtained from inorganic arsenic exposed subjects32. Our concern involves the combination of low arsenic (As) and high selenium (Se) ingestion. This can inhibit methylation of arsenic to take it to a toxic level in the tissue. Dietary sources of Se and Hg.Global selenium (Se) source are vegetables in the diet. In the United States, meat and bread are the common source. Selenium deficiency in the US is rare. The US Food and Drug Administration (FDA) has found toxic levels of Se in dietary supplements, up to 200 times greater than the amount stated on the label33. The samples contained up to 40,800 ug Se per recommended serving. For the general population, the most important pathway of exposure to mercury (Hg) is ingestion of methyl mercury in foods. Fish (including tuna, a food commonly eaten by children), other seafood, and marine mammals contain the highest concentrations. The FDA has set a maximum permissible level of 1 ppm of methyl mercury in the seafood34. The people also exposed mercury via amalgams35. Proteomic study of Inorg-As (III) injury.Proteomics is a powerful tool developed to enhance the study of complex biological system36. This technique has been extensively employed to investigate the proteome response of cells to drugs and other diseases37, 38. A proteome analysis of the Na-As (III) response in cultured lung cells found in vitro oxidative stress-induced apoptosis39. However, to our knowledge, no in vivo proteomic study of Inorg-As (III) has yet been conducted to improve our understanding of the cellular proteome response to Inorg-As (III) except our preliminary study 40. Preliminary Studies: Results and DiscussionThe existing data (Fig. 1) from our laboratory and others show the complex nature of Inorg-As metabolism. For many years, the major way to study, arsenic (As) metabolism was to measure InorgAs (V), Inorg-As (III), MMA (V), and DMA (V) in urine of people chronically exposed to As in their drinking water. Our investigations demonstrated for the first time that MMA (III) and DMA (III) are found in human urine9. Also we have identified MMA (III) and DMA (III) in the tissues of mice and hamsters exposed to sodium arsenate [Na-As (V)]10, 41. Influence of Se as well as Hg on the As methyltransferase.We have reported that Se (IV) as well as mercuric chloride (HgCl2) inhibited As (III) methyltransferase and MMA (III) methyltransferase in rabbit liver cytosol. Mercuric chloride was found to be a more potent inhibitor of MMA (III) methyltransferase than As (III) methyltransferase30. These results suggested that Se and Hg decreased arsenic methylation. The inhibitory effects of Se and Hg were concentration dependent30. Influence of Se and Hg in urine and blood on the percentage of urinary As metabolites.Our human studies indicated that the ratios of the concentrations of Se or Hg to As in urine and blood were positively correlated with % Inorg-As and % MMA (V). But it negatively correlated with % DMA (V) and the ratios of % DMA (V) to % MMA (V) in urine of both males and females (unpublished data) (Table 3). These results confirmed that the inhibitory effects of Se as well as Hg for the methylation of Inorg-As in humans were concentration dependent. We also found that the concentrations of Se and Hg were negatively correlated with % Inorg-As and % MMA (V). Conversely it correlated positively with % DMA (V) and the ratios of % DMA (V) to % MMA (V) in urine of both sexes (unpublished data). These correlations were not statistically significant when urinary concentrations of Se and Hg were adjusted for urinary creatinine (Table 3). Interactions of As, Se, Hg and its relationship with methylation of arsenic are summarized in Figure 2. Sex difference distribution of arsenic species in urine.Our results indicate that females have more methylation capacity of arsenic as compared to males. In our human studies (n= 191) in Mexico, we found that females (n= 98) had lower % MMA (p<0.001) and higher % DMA (p=0.006) when compared to males (n= 93) (Fig. 3). The means ratio of % MMA (V) to % Inorg-As and % DMA (V) to %MMA (V) were also lower (p<0.05) and higher (p<0.001), respectively in females compared to males. The protein expression profiles in the tissues of hamsters exposed to Na-As (III).In our preliminary studies40, hamsters were exposed to Na-As (III) (173 pg/ml as As) in their drinking water for 6 days and control hamsters were given only the water used to make the solutions for the experimental animals. After DIGE (Two-dimensional differential in gel electrophoresis) and analysis by the DeCyder software, several protein spots were found to be over-expressed (red spot) and several were under expressed (green spot) as compared to control (Figs. 4a-c). Three proteins (one was over-expressed and two were under-expressed) of each tissue (liver and urinary bladder) were identified by LC-MS/MS (liquid chromatography-tandem mass spectrometry).DIGE in combination with LC-MS/MS is a powerful tool that may help cancer investigators to understand the molecular mechanisms of cancer progression due to Inorg-As. Propose a new researchThese results suggested that selenium (Se) as well as mercury (Hg) may influence the methylation of Inorg-As and this influence could be dependent on the concentration of Se, Hg and/or the sex of the animal. Our study also suggested that the identification and functional assignment of the expressed proteins in the tissues of Inorg-As (III) exposed animals will be useful for understanding and helping to formulate a theory dealing with the molecular events of arsenic toxicity and carcinogenicity.Therefore, it would be very useful if we could do a research study with combination of Inorg-arsenic, Se, and Hg. The new research protocol could be the following:For metabolic processing, hamsters provide a good animal model. For carcinogenesis, mouse model is well accepted. The aims of this project are: 1) To map the differential distributions of arsenic (As) metabolites/species in relation to selenium (Se) and mercury (Hg) levels in male and female hamsters and 2) To chart the protein expression profile and identify the defense proteins in mice and hamsters after As injury. Experimental hamsters (male or female) will include four groups. The first group will be treated with Na arseniteNa-As(III), the second group with Na-As (III) and Na-selenite (Na-Se (IV)], the third group with Na As (III) and methyl mercuric chloride (MeHgCl), and the final group with Na-As (III), Na-Se (IV), and MeHgci at different levels. Urine and tissue will be collected at different time periods and measured for As species using high performance liquid chromatography/inductively coupled plasma-mass spectrometry (HPLC/ICP-MS). For proteomics, mice (male and female) and hamsters (male and female) will be exposed to Na-As (III)at different levels in tap water, and control mice and hamsters will be given only the tap water. Tissue will be harvested at different time periods. TWO dimensional differential in gel electrophoresis (2D-DIGE) combined with liquid chromatography-tandem mass spectrometry (LC-MS/MS) will be employed to identify the expressed protein. In summary, we intend to extend our findings to: 1) Differential distribution of As metabolites in kidney, liver, lung, and urinary bladder of male and female hamsters exposed to Na-As (III), and combined with Na-As (III) and Na-Se (IV) and/or MeHgCl at different levels and different time periods, 2) Show the correlation of As species distribution in the tissue and urine for both male and female hamsters treated with and without Na-Se (IV) and/or MeHgCl, and 3) Show protein expression profile and identify the defense proteins in the tissues (liver, lung, and urinary bladder epithelium) in mice after arsenic injury. The significance of this study: The results of which have the following significances: (A) Since Inorg-As is a human carcinogen, understanding how its metabolism is influenced by environmental factors may help understand its toxicity and carcinogenicity, (B) The interactions between arsenic (As), selenium (Se), and mercury (Hg) are of practical significance because populations in various parts of the world are simultaneously exposed to Inorg-As & Se and/or MeHg, (C) These interactions may inhibit the biotransformation of Inorg-As (III) which could increase the amount and toxicity of Inorg-As (III) and MMA (III) in the tissues, (D) Determination of arsenic species profile in the tissues after ingestion of Inorg-As (III), Se (IV), and/or MeHg+ will help understand the tissue specific influence of Se and Hg on Inorg-As (III) metabolism, (E) Correlation of arsenic species between tissue and urine might help to understand the tissue burden of arsenic species when researchers just know the distribution of arsenic species in urine, (F) The identification of the defense proteins (over-expressed and under-expressed) in the tissues of the mouse may lead to understanding the mechanisms of inorganic arsenic injury in human. The Superfund Basic Research Program NIEHS Grant Number ES 04940 from the National Institute of Environmental Health Sciences supported this work. Additional support for the mass spectrometry analyses was provided by grants from NIWHS ES 06694, NCI CA 023074 and the BIO5 Institute of the University of Arizona. Acknowledge:The Authorwantsto dedicate this paper to the memory of Dr. H. VaskenAposhian and Dr. Mary M. Aposhian who collected urine and bloodsamples from Mexican population. The work was done under Prof. H. V. Aposhian sole supervision and with his great contribution. References NRC (National Research Council). Arsenic in Drinking Water. Update to the 1999 Arsenic in Drinking Water Report. National Academy Press, Washington, DC. 2001. Gomez-Caminero, A.; Howe, P.; Hughes, M.; Kenyon, ; Lewis, D. R.; Moore, J.; Mg, J.; Aitio, A.; Becking, G. Environmental Health Criteria 224. Arsenic and Arsenic Compounds (Second Edition). 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ObjectiveThis paper analyzes emergency department syndromic data in the Centers for Disease Control and Prevention’s (CDC) National Syndromic Surveillance Program’s (NSSP) BioSense Platform to understand trends in suspected heroin overdose.IntroductionOverdose deaths involving opioids (i.e., opioid pain relievers and illicit opioids such as heroin) accounted for at least 63% (N = 33,091) of overdose deaths in 2015. Overdose deaths related to illicit opioids, heroin and illicitly-manufactured fentanyl, have rapidly increased since 2010. For instance, heroin overdose deaths quadrupled from 3,036 in 2010 to 12,989 in 2015. Unfortunately, timely response to emerging trends is inhibited by time lags for national data on both overdose mortality via vital statistics (8-12 months) and morbidity via hospital discharge data (over 2 years). Emergency department (ED) syndromic data can be leveraged to respond more quickly to emerging drug overdose trends as well as identify drug overdose outbreaks. CDC’s NSSP BioSense Platform collects near real-time ED data on approximately two-thirds of ED visits in the US. NSSP’s data analysis and visualization tool, Electronic Surveillance System for the Notification of Community-based Epidemics (ESSENCE), allows for tailored syndrome queries and can monitor ED visits related to heroin overdose at the local, state, regional, and national levels quicker than hospital discharge data.MethodsWe analyzed ED syndromic data using ESSENCE to detect monthly and annual trends in suspected unintentional or undetermined heroin overdose by sex and region for those 11 years and older. An ED visit was categorized as a suspected heroin overdose if it met several criteria, including heroin overdose ICD-9-CM and ICD-10-CM codes (i.e., 965.01 and E850.0; T40.1X1A, T40.1X4A) and chief complaint text associated with a heroin overdose (e.g., “heroin overdose”). Using computer code developed specifically for ESSENCE based on our case definition, we queried data from 9 of the 10 HHS regions from July 2016-July 2017. One region was excluded due to large changes in data submitted during the time period. We conducted trend analyses using the proportion of suspected heroin overdoses by total ED visits for a given month with all sexes and regions combined and then stratified by sex and region. To determine significant linear changes in monthly and annual trends, we used the National Cancer Institute’s Joinpoint Regression Program.ResultsFrom July 2016-July 2017, over 72 million total ED visits were captured from all sites and jurisdictions submitting data to NSSP. After applying our case definition to these records, 53,786 visits were from a suspected heroin overdose, which accounted for approximately 7.5 heroin overdose visits per 10,000 total ED visits during that timeframe. The rate of suspected heroin overdose visits to total ED visits was highest in June 2017 (8.7 per 10,000) and lowest in August 2016 (6.6 per 10,000 visits). Males accounted for a larger rates of visits over all months (range = 10.7 to 14.2 per 10,000 visits) than females (range = 3.8 to 4.7 per 10,000 visits). Overall, compared to July 2016, suspected heroin overdose ED visits from July 2017 were significantly higher for all sexes and US regions combined (β = .010, p = .036). Significant increases were also demonstrated over time for males (β = .009, p = .044) and the Northeast (β = .012, p = .025). No other significant increases or decreases were detected by demographics or on a monthly basis.ConclusionsEmergency department visits related to heroin overdose increased significantly from July 2016 to July 2017, with significant increases in the Northeast and among males. Urgent public health action is needed reduce heroin overdoses including increasing the availability of naloxone (an antidote for opioid overdose), linking people at high risk for heroin overdose to medication-assisted treatment, and reducing misuse of opioids by implementing safer opioid prescribing practices. Despite these findings, there are several limitations of these data: not all states sharing data have full participation thus limiting the representativeness of the data; not all ED visits are shared with NSSP; and our case definition may under-identify (e.g., visits missing discharge diagnosis codes and lacking specificity in chief complaint text) or over-identify (e.g., reliance on hospital staff impression and not drug test results) heroin overdose visits. Nonetheless, ED syndromic surveillance data can provide timely insight into emerging regional and national heroin overdose trends.ReferencesWarner M, Chen LH, Makuc DM, Anderson RN, Minino AM. Drug poisoning deaths in the United States, 1980-2008. NCHS Data Brief 2011(81):1-8.Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2016;65(5051):1445-1452.Spencer MRA, F. Timeliness of Death Certificate Data for Mortality Surveillance and Provisional Estimates. National Center for Health Statistics 2017.Richards CL, Iademarco MF, Atkinson D, Pinner RW, Yoon P, Mac Kenzie WR, et al. Advances in Public Health Surveillance and Information Dissemination at the Centers for Disease Control and Prevention. Public Health Rep 2017;132(4):403-410.

Photo by Mika Baumeister on Unsplash INTORDUCTION In March of 2022, New Jersey Governor Phil Murphy announced that the state would no longer mandate face masks for students, staff, and visitors at schools and childcare centers. Two-thirds of New Jersey residents already supported this decision.[1] Soon after, Princeton University led the way in learning to live with the virus by making the use of masks optional in most situations. At a time when vaccination rates were already high and Omicron hospitalization rates were falling, the decision to relax mask mandates was the right call. Yet, Rutgers University has extended its mask mandate for the rest of the academic year, with no stated endpoint. In a university-wide email, Executive Vice President and Chief Operating Officer Antonio Calcado announced: The university has been clear that the science and data would guide our path forward with respect to the health and safety of our community… Use of appropriate face coverings will still be required in all teaching spaces (classrooms, lecture halls, seminar rooms, etc.), teaching labs, computer labs, buses, libraries, and clinical facilities.[2] Despite the university’s purported commitment to follow “the science and data,” there has been a noticeable lack of transparency regarding the scientific rationale and official endpoint for this extension of the mask mandate. Given the same set of scientific data available, these neighboring universities came to opposite conclusions on the need for continued mask mandates. Notably, the Rutgers mask mandate continues to require students to mask in libraries but not in crowded cafeterias. These discrepancies have led to understandable frustration among members of the Rutgers community. In response, the Rutgers student newspaper objects to “the sense of optics” and “the lack of clear communication,” resulting in “confusion,” arguing that the university administration “needs to be more transparent” and “must communicate and explain the policy changes more effectively.”[3] At a time when trust in public health institutions is at an all-time low, Ava Kamb warns that a lack of transparent messaging can reduce public trust even further.[4] Instead, Kamb argues that public health mandates should use the least restrictive means necessary in order to promote health and civil liberties at the same time. The ethical question is whether university mask mandates should be relaxed. I argue that the use of face masks by healthy individuals has uncertain benefits, which potential harms may outweigh, and should therefore be voluntary. ANALYSIS Rutgers intends “the science and data” to guide its path forward. As such, it is worth revisiting the controversial science behind mask mandates. From 2019 to 2020, systematic reviews by the World Health Organization (WHO) and Cochrane Acute Respiratory Infections concluded that the use of face masks by healthy individuals in the community lacks effectiveness in reducing viral transmission based on moderate-quality evidence.[5] Neither study concerned COVID-19 specifically. Since then, the only two randomized controlled trials of face masks published during the pandemic found little to no benefit.[6] Yet, the Centers for Disease Control and Prevention (CDC) cite many observational and modeling studies (based on empirical assumptions) which suggest that community masking is beneficial.[7] These studies support a larger benefit associated with masking, but they use less reliable research methods. Based on these non-randomized data and mechanistic plausibility, WHO’s current position is also supportive of community masking recommendations. But without high-quality evidence, it is difficult to justify a requirement rather than a recommendation. It may be useful to draw an ethical distinction between a recommendation and a mandate in public health. A public health recommendation does not generally undermine individual autonomy because individuals have the choice to follow the recommendation. I argue that recommendations may be justified by a lower standard of proof or a lesser expected benefit precisely because they do not violate individual autonomy. On the other hand, a public health mandate demands compliance using the threat of penalty. To ethically justify an infringement of autonomy, strong evidence that demonstrates a significant health benefit should support a public health mandate. While the recommendation to use masks in accordance with personal preference may be a reasonable precaution—particularly for vulnerable individuals—the higher standards of evidence and benefit that would ethically justify mask mandates have not been met. Notwithstanding, one might argue the precautionary principle justifies mask mandates. For example, Chinese CDC Director-General George Gao, medical researcher Trisha Greenhalgh, and others espouse such a view.[8] The precautionary principle holds that it is better to be safe than sorry. In the context of COVID-19, the principle has been used to advocate for public health measures which lack high-quality evidence. Accordingly, it might be thought that it is safer to implement potentially ineffective mask mandates than to risk forgoing a lifesaving benefit. Yet, the precautionary principle is an ill-defined concept that is philosophically problematic. Health economist Jay Bhattacharya and epidemiologist Sunetra Gupta argue that the precautionary principle cuts both ways because a public health mandate without high-quality evidence has both potential benefits and potential harms.[9] If the precautionary principle can justify implementing mask mandates due to the risk of forgoing possible benefit, then it might also be able to justify not implementing mask mandates due to the risk of potential harm caused by the intervention. It is commonly thought that there is little to lose from the use of face masks, but this is not necessarily true. According to WHO, CDC, and the European Centre for Disease Prevention and Control (ECDC), the harms of face masks may include headaches, difficulty breathing, skin lesions, difficulty communicating, a false sense of security, environmental pollution, impaired learning, delayed psychosocial development, and disadvantages for individuals with cognitive or mental disorders.[10] These include both potential and observed harms drawn from the scientific literature. Yet, the negative side effects of masks remain significantly under-investigated. For example, there is emerging mechanistic evidence that prolonged mask use or reuse increases both inhaled and environmental microplastics, the long-term effects of which are unknown.[11] The harms related to communication, learning, and psychosocial development are particularly problematic for educational institutions, whose mission is to promote these very things. It is, therefore, possible that masks have done more harm than good. While many observational studies and models support the potential benefits of masks, some interpret these studies to mean that masks clearly work. However, the limited body of randomized data paints a less optimistic picture and cannot be used to rule out an increase in infection from masks.[12] Other types of studies, less reliable research methods, do rule this out and support masking. Bhattacharya and Gupta would argue that it is safer to encourage voluntary, evidence-based interventions than to foist these potential harms upon individuals for the sake of uncertain benefits. It remains unclear whether and to what extent the use of face masks by healthy individuals in the community influenced COVID-19 mortality. However, it is clear to me that community masking does not meet the higher standard of evidence necessary to justify a mandate and that mask use is associated with potential harm. The already tenuous case for masks continues to weaken with a mixed body of evidence, the availability of effective pharmaceuticals, and widespread natural immunity to COVID-19. If public health should aim for the least restrictive means necessary to promote health while respecting civil liberties, then the extension of burdensome mask mandates which lack high-quality evidence is ethically problematic. CONCLUSION Given the current state of COVID-19, a university mask mandate for a low-risk population with high levels of immunity is not justified. In times of fear and uncertainty, higher education institutions ought to make reasoned policy decisions guided by “the science and data.” It would seem that, of the universities that mandated masks, Princeton has emerged as a national leader in mask policy while Rutgers lags behind. Schools across the nation should take note. - [1] Rutgers University Eagleton Institute of Politics. Two-thirds of New Jerseyans agree with lifting school mask mandate, most comfortable returning to normal; half think NJ has done “just right” on pandemic. Accessed May 14, 2022. https://eagletonpoll.rutgers.edu/wp-content/uploads/2022/03/Rutgers-Eagleton-Poll-COVID-March-7-2022.pdf [2] Calcado AM. Return to Campus Update – January 31, 2022. Accessed May 14, 2022. https://coronavirus.rutgers.edu/changes-related-to-covid-19-protocols [3] The Daily Targum. Rutgers’ new mask policies are more than confusing. Accessed May 14, 2022. https://dailytargum.com/article/2022/04/editorial-rutgers-new-mask-policies-are-more-than-confusing [4] Kamb A. The false choice between public health and civil liberties. Voices in Bioethics 2020;6. doi:10.7916/vib.v6i.6297. [5] World Health Organization Global Influenza Programme. Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza. Geneva: World Health Organization; 2019; Jefferson T, Del Mar CB, Dooley L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews 2020;11(CD006207). doi:10.1002/14651858.CD006207.pub5. [6] Abaluck J, Kwong LH, Styczynski A, et al. Impact of community masking on COVID-19: A cluster-randomized trial in Bangladesh. Science 2022;375(6577):eabi9069. doi:10.1126/science.abi9069. (intervention reduced symptomatic seroprevalence by 9.5%; 95% confidence interval = [0.82, 1.00].); Bundgaard H, Bundgaard JS, Raaschou-Pedersen DET, et al. Effectiveness of adding a mask recommendation to other public health measures to prevent SARS-CoV-2 infection in Danish mask wearers: A randomized controlled trial. Ann Intern Med 2021;174(3):335-343. doi:10.7326/M20-6817. (trial was conducted in a setting where mask wearing was uncommon and the findings were inconclusive; 95% confidence interval = [0.54, 1.23].) [7] U.S. Centers for Disease Control and Prevention. Science Brief: Community Use of Masks to Control the Spread of SARS-CoV-2. Accessed May 14, 2022. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html [8] Zimmerman A. The precautionary principle in mask-wearing: When waiting for explicit scientific evidence is unwise. Voices in Bioethics 2020;6. doi:10.7916/vib.v6i.5896. (supporting the use of masks early in the pandemic arguing that the harms of masking in the short term were unlikely to be severe or to outweigh the benefits.); Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the public during the COVID-19 crisis. BMJ 2020;369:m1435. doi:10.1136/bmj.m1435. [9] Bhattacharya J. On the Catastrophic Misapplication of the Precautionary Principle. Accessed May 14, 2022. https://collateralglobal.org/article/misapplication-of-the-precautionary-principle; Gupta S. A Betrayal of the Precautionary Principle. Accessed May 14, 2022. https://collateralglobal.org/article/a-betrayal-of-the-precautionary-principle [10] World Health Organization. Mask use in the context of COVID-19: Interim guidance, 1 December 2020. Accessed May 14, 2022. https://apps.who.int/iris/handle/10665/337199; U.S. Centers for Disease Control and Prevention; European Centre for Disease Prevention and Control. Using face masks in the community: First update - Effectiveness in reducing transmission of COVID-19. Accessed May 14, 2022. https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-face-masks-community-first-update.pdf [11] Li L, Zhao X, Li Z, et al. COVID-19: Performance study of microplastic inhalation risk posed by wearing masks. J Hazard Mater 2021;411:124955. doi:10.1016/j.jhazmat.2020.124955; Ma J, Chen F, Xu H, et al. Face masks as a source of nanoplastics and microplastics in the environment: Quantification, characterization, and potential for bioaccumulation. Environ Pollut 2021;288:117748. doi:10.1016/j.envpol.2021.117748; Chen X, Chen X, Liu Q, et al. Used disposable face masks are significant sources of microplastics to environment. Environ Pollut 2021;285:117485. doi:10.1016/j.envpol.2021.117485. [12] Bundgaard et al. (inconclusive with a 95% confidence interval = [0.54, 1.23]).

Coronavirus disease 2019 (COVID-19) is primarily a respiratory virus and there is no evidence of transfusion transmission for COVID-19;1, 2 however, estimation of the seroprevalence rate of antibodies to severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2) in blood donors’ population reflects the progression of the epidemic in the region. It is unclear how many people have contracted the virus since only symptomatic cases have been registered. For this reason, and as a part of the National Centre for Disease Control preparedness plan to combat the spread of the COVID-19 infection in the Tobruk region, eastern Libya, we conducted a cross-sectional study between January 15 to February 15, 2021, six months after the identification of the first confirmed COVID-19 case in the region on 23 July 2020. 3

In early June 2018, an increase in non-travel-related cases of Legionella non-pneumophila Legionnaires’ disease (LD) was observed in Sweden and a national outbreak investigation was started. Outbreak cases were defined as notified confirmed or probable cases of L. non-pneumophila LD, with symptom onset after 1 April 2018. From April to August 2018, 41 cases were reported, 30 of whom were identified as L. longbeachae. We conducted a case–control study with 27 cases and 182 matched controls. Results from the case–control study indicated that gardening and handling commercial bagged soil, especially dusty dry soil, were associated with disease. L. longbeachae was isolated in soils from cases’ homes or gardens, but joint analysis of soil and human specimens did not identify any genetic clonality. Substantial polyclonality was noted between and within soil samples, which made finding a genetic match between soil and human specimens unlikely. Therefore, whole genome sequencing may be of limited use to confirm a specific soil as a vehicle of transmission for L. longbeachae. Handling soil for residential gardening was associated with disease and the isolation of L. longbeachae in different soils provided further evidence for Legionella non-pneumophila infection from soil.

Photo by Mufid Majnun on Unsplash INTRODUCTION In 2007, the Nuffield Council of Bioethics introduced the “Intervention ladder” as a guiding framework[1] to evaluate the impact on individual liberty of various public health measures. One criticism of the ladder is that it reflects a narrow view of liberty, yet other researchers adapted the intervention ladder to incorporate a more autonomy-based view. Recently, academics and public health officials have used intervention ladders as guides in framing policies, particularly COVID-19 pandemic policies.[2] Analyzing the Indian COVID-19 vaccination drive under these two ladders can illuminate the concepts of liberty underlying those ladders and help determine the best framework on a philosophical basis. ANALYSIS l. Case Study: The Indian COVID-19 Vaccination Drive On January 16, 2021, India attempted a public vaccination drive.[3] The drug regulatory body Central Drugs Standards Control Organization (CDSCO) approved two vaccines, Covishield and Covaxin, for emergency use.[4] The approval was granted despite a clear lack of phase 3 clinical trial data for both of these vaccines.[5] Covishield, produced by the Serum Institute of India, is the Indian variant of the Astra-Zeneca vaccine that has shown an average efficiency of 70.4 percent after trials in the UK.[6] Covaxin, manufactured by Bharat Biotech in collaboration with the Indian Council of Medical Research (ICMR) National Institute of Virology, was developed and manufactured in India. [7] Covishield relied on the safety and efficacy data from large trials conducted in Brazil, South Africa, and the UK with 24,000 participants and a small cohort for the Indian study. Covaxin was given approval based only on phase-1 trial data. [8] An article published in The Lancet called for further efficacy data from the Covaxin study.[9] The officials associated with Bharat Biotech, as well as the Indian Council of Medical Research, maintained that fast production of the vaccine does not indicate a compromise in safety, even though they had little data to produce.[10] However, transparency is key to vaccination policy, which requires public participation. The media reported that the Covaxin clinical trials compromised research integrity by providing a monetary incentive of around 7 euros, to research subjects. People’s University, a private medical college, and hospital, recruited survivors of the Bhopal Gas tragedy for the Covaxin study. The participants were told that they were being provided a vaccine against COVID-19 without clarifying that data was being collected for their clinical study. There was no record of informed consent from these participants for the Covaxin study.[11] The media reported the death of a 42-year-old individual who received his first dose on December 23, 2020. [12] Although it was reported that the cause of death was not linked to the vaccine, the death added to vaccine hesitancy. The vaccines were provided for free to the frontline healthcare workers with no choice on which vaccine the recipients would receive.[13] Similarly, in the US, some people do not have a choice between Pfizer or Moderna. In the UK and the US, data from phase 3 trials are known with a periodic follow-up after the administration of the second dose.[14] The WHO developed a tracking system for COVID-19 vaccine recipients which was updated on March 19, 2021, to reflect the results of Covaxin phase 3 trials.[15] India eliminated choice although the two vaccines approved for emergency use did not have the depth of research that those used elsewhere had. The intervention ladder, discussed below, which uses proportionality and the harm principle to justify the lack of choice between the vaccines in the UK and the US, should not be applied to India’s vaccination policy. ll. The Nuffield Intervention Ladder The foundational principle underlying the Nuffield Intervention Ladder is Mill’s conception of individual liberty from the prominent work, On Liberty.[16] However, the Council recognizes that the intervention ladder is conceived on a broader interpretation of Mill’s liberty, using the principle of proportionality as a tool for justification i.e., the desired effect from the intervention is proportional to the loss incurred in liberty.[17] As shown in Table 1, an ideal intervention that is least infringing would then be no intervention at all. An intervention that would be more difficult to justify would be one that significantly restricts individual liberty. Intuitively, eliminating occupies the topmost rung on the ladder. The metaphor of the ladder suggests that as one climbs up the rungs of the ladder, stronger justifications would be required. Table 1: Examples of interventions at each level of the intervention ladder adapted and improvised from the Nuffield Council of Bioethics Report, 2007. A voluntary vaccination policy is one public health intervention that is acceptable and justifiable in terms of the principle of proportionality as well as Mill’s Harm Principle, with emphasis on diminishing individual liberties when actions might result in harm to others.[18] Although a vaccination policy in the context of a global pandemic seems justifiable through the lens of the intervention ladder, the Indian modus operandi is unique because of inherent problems with the original conception of the intervention ladder. By pausing to elaborate and reflect on the Indian context as a case study, we can demonstrate that individual liberty should not be the sole variable in framing justifiability. lll. Critiquing the Nuffield Intervention Ladder & Adding a Precautionary Approach In his paper, ‘Snakes and Ladders: State Interventions and the Place of Liberty in Public Health Policy’, Angus Dawson criticizes the intervention ladder’s focus on individual liberty,.[19] and its inability to account for the different treatment of incentives and disincentives and the role of information. Public health institutions require public participation to restrict the infectious spread of COVID-19. The lack of transparency and minimal information surrounding the vaccines have been a major hurdle in increasing public participation. It is contradictory to think that the public does not require information about interventions and have the ability of self-determination to guide them, when in fact self-determination presupposes possession of relevant information. A voluntary vaccination policy can be seen as sitting on either the lowest rung (providing information) or the rung of enabling choice, as a vaccination campaign does both. However, in India, the precautionary principle should also be applied as providing the choice should not permit ‘harm’. The precautionary principle holds that anything that poses a risk to human health or the environment should be avoided or accompanied by precautionary measures. In India, because the clinical trials were smaller and there is less proof of safety and efficacy, a vaccination requirement, or a public health campaign to encourage vaccination violates the principle. The proportionality principle governing the intervention ladder only requires that the benefits of the intervention justify the restrictions on liberty. The intervention ladder should prevent requiring healthcare worker vaccination without a choice of vaccine because a free choice requires transparency and more information than is available from the small early-stage clinical trials. Actions surrounding the vaccines in India do not reflect proper precaution or a proportionate and thus acceptable restriction on liberty. If there is no ability to choose between the two possible vaccines, then they should not be mandatory for healthcare workers. The Indian government and its officials have urged healthcare worker compliance by invoking the seriousness of the pandemic and the alarming rates of mortality rather than providing transparent data pursuant to the regulatory mechanisms of the vaccine clinical trial. For a healthcare worker, the duty to provide service and a stronger obligation to do so in the time of a pandemic already imposes certain restrictions on their liberty. The lack of choice in opting for a preferred vaccine puts it on a higher rung on the intervention ladder and thus requires stronger justifications. This case study reveals how the same public health intervention falls on different rungs of the intervention ladder depending on the target group in consideration. Or to put this simply, choice is contextual. Table 2: The ethical values at stake when it comes to “choice” lV. An Autonomy-Based Intervention Ladder Liberty and autonomy differ slightly: liberty revolves around the constraints on the ability to act, whereas autonomy stresses on the independence and the authenticity of the willingness to act.[20] It is thus possible for an individual to be autonomous but unfree, as can be seen from the inability to opt for a preferred vaccine.[21] Figure 1 shows an adapted schematic of an autonomy-based intervention ladder as proposed by Griffiths et al. Figure 1: An adapted schematic of the autonomy-based intervention ladder proposed by Griffiths, P.E and West, C. In comparing the original intervention ladder with their proposal, we see that the autonomy-based model allows for a negative scale in terms of its effects on autonomy. Thus, on this ladder, actions can be autonomy-enhancing or autonomy-diminishing. Such a model challenges the one-directional view of the ladder and rearranges interventions on a scale that ranges from negative to positive. A few interventions that were shown to have restrictive effects on liberty now have reinforcing effects when viewed through the lens of autonomy. Thus, providing information and educating can be seen as positive reinforcements for autonomous choice rather than infringing on individual liberty. The autonomy-based intervention ladder requires the State to implement interventions and design policies in a manner that reinforces autonomy. Information and education allow individuals to be free and equal participants in public health discourses. As seen in the original intervention ladder restricting choice, as well as eliminating it, still fall in the negative, autonomy-infringing side of the ladder. Thus, requiring stronger justifications for their implementation. The only difference between the two is the manner in which the new model ensures the availability of a choice when the precautionary, as well as the proportionality principle, have not been met to a sufficient extent. Ensuring choice and exercising it becomes much more relevant in making people autonomous. The frontline worker thus can opt for a vaccine they prefer. Thereby, helping them navigate the moral conundrum of opting to get vaccinated, easing their moral burden. It also places strict vigilance over regulatory mechanisms that are involved in clinical trials since the burden of proof now involves providing information as a clear operational motive. This ameliorates public tendencies of hesitancy can be alleviated in this respect. An autonomy-based intervention ladder is not in conflict with Mill’s conception of liberty since Mill himself does not automatically assume a cost to liberty when the State seems to employ public education campaigns to inform the public.[22] CONCLUSION The original intervention ladder was conceived to remedy the hurdles that a traditional liberal landscape brings in implementing a public health intervention and to protect individual liberties. The intervention ladder assumes an inverse relationship between public health and freedom. Rethinking the intervention ladder from a different perspective allows a proper role of the dissemination of information, recognizing that consent relies on information. An autonomy ladder acts as a starting point for rethinking public health and how it can foster autonomy as well as impede it. By focusing on autonomy, the benefits that can be gained from educational and informational campaigns are viewed as reinforcing autonomy. Autonomy is vital to liberty. COVID-19 has brought a unique set of ethical issues that have questioned conventionally accepted frameworks and calls for a substantive, alternative approach to public health ethics. [1] Nuffield Council on Bioethics, “Public Health: Ethical Issues.” Nuffieldbioethics.org, Nov 13, 2007. www.nuffieldbioethics.org/publications/public-health. Accessed 9 May 2021. [2] Giubilini A, The Ethics of Vaccination [Internet]. Cham (CH): Palgrave Pivot; 2019. Chapter 3, “Vaccination Policies and the Principle of Least Restrictive Alternative: An Intervention Ladder.” 2018 Dec 29, 2018. www.ncbi.nlm.nih.gov/books/NBK538385/. [3] Dash, Sachinta. “India Begins Its COVID-19 Vaccination Drive — Here’s a Look at How the World’s Largest Vaccine Rollout Is Set to Take Place.” Business Insider India, January 16, 2021, www.businessinsider.in/india/news/india-will-begin-its-covid-19-vaccination-drive-tomorrow-heres-everything-you-need-to-know/articleshow/80281740.cms. Accessed 9 May 2021. ‌ [4] Special Correspondent, “Coronavirus | India Approves COVID-19 Vaccines Covishield and Covaxin for Emergency Use,” The Hindu, January 3, 2021, www.thehindu.com/news/national/drug-controller-general-approves-covishield-and-covaxin-in-india-for-emergency-use/article33485539.ece. Accessed 9 May 2021. ‌ [5] Thiagarajan, Kamala, “Covid-19: India Is at Centre of Global Vaccine Manufacturing, but Opacity Threatens Public Trust.” BMJ, January 28, 2021. www.bmj.com/content/372/bmj.n196, 10.1136/bmj.n196. [6] Thiagarajan, Kamala. [7] Bharat Biotech, “COVAXIN - India’s First Indigenous Covid-19 Vaccine | Bharat Biotech.” www.bharatbiotech.com/covaxin.html. [8] Prasad, R. “Coronavirus | Vaccine Dilemma — to Take or Not to Take Covaxin.” The Hindu, January 15, 2021, www.thehindu.com/sci-tech/health/vaccine-dilemma-to-take-or-not-to-take-covaxin/article33577223.ece. [9] Ella, Raches, et al. “Safety and Immunogenicity of an Inactivated SARS-CoV-2 Vaccine, BBV152: A Double-Blind, Randomised, Phase 1 Trial.” The Lancet Infectious Diseases, vol. 21, no. 5, January 21, 2021, pp. 637–646, www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30942-7/fulltext, 10.1016/S1473-3099(20)30942-7. [10] Thiagarajan, Kamala. [11] Thiagarajan, Kamala. ‌ [12] Nichenametla, Prasad. “Bhopal Volunteer’s Death Unrelated to Covaxin, Says Bharat Biotech.” Deccan Herald, 9 Jan. 2021, www.deccanherald.com/national/bhopal-volunteers-death-unrelated-to-covaxin-says-bharat-biotech-937199.html. [13] Thiagarajan, Kamala. ‌ [14] Thiagarajan, Kamala. ‌ [15] World Health Organization, “Draft Landscape of COVID-19 Candidate Vaccines.” www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines. Accessed 9 May 2021. ‌ [16] John Stuart Mill. On Liberty. 1859. S.L., Arcturus Publishing Ltd, 1859. [17] Nuffield. “Public Health: Ethical Issues.” [18] John Stuart Mill. On Liberty. p 13. [19] Dawson, Angus J. “Snakes and Ladders: State Interventions and the Place of Liberty in Public Health Policy.” Journal of Medical Ethics, vol. 42, no. 8, May 23, 2016, pp. 510–513, 10.1136/medethics-2016-103502. [20] Griffiths, P.E., and C. West. “A Balanced Intervention Ladder: Promoting Autonomy through Public Health Action.” Public Health, vol. 129, no. 8, August 2015, pp. 1092–1098, pubmed.ncbi.nlm.nih.gov/26330372/, 10.1016/j.puhe.2015.08.007 [21] Thaler, Richard H, and Cass R Sunstein. Nudge: Improving Decisions about Health, Wealth, and Happiness. London, Penguin Books, 2008. ‌ [22] Griffiths, P.E., and C. West.

The World Health Organization (WHO) declared a COVID-19 pandemic last March 11, 2020.1,2 According to the WHO Director General, “In the past two weeks, the number of cases of COVID-19 outside China has increased 13-fold, and the number of affected countries has tripled. There are now more than 118,000 cases in 114 countries, and 4,291 people have lost their lives. Thousands more are fighting for their lives in hospitals.” Soon after, Metro Manila was placed on a complete lockdown which started on March 15, 2020 and continues up to the time of this writing.2 So, what exactly is this COVID-19 pandemic? Will it be changing how we live our lives as healthcare professionals? What will be our role in taking care of patients with COVID-19? These and many other related questions require immediate answers as we face the threat of COVID-19. The WHO was first informed of cases of pneumonia of unknown cause in Wuhan City, China near the end of 2019. A novel coronavirus was identified as the cause by Chinese authorities and was initially named 2019-nCoV.3,4 This was later revised to COVID-19 (coronavirus disease of 2019) and the virus that causes it called SARS-CoV-2 (severe acute respiratory syndrome-coronavirus 2). In the first global epidemic caused by the “first” SARS coronavirus in 2003, the Philippines had a total of only eight confirmed patients. All the cases had contact with a nurse aide who had returned from Toronto, Canada where she got it. The index case and her father eventually died from SARS while the rest recovered.5 But, with COVID-19, at the time of writing this editorial, there were approximately 1,611 weekly cases with 112 weekly deaths in the Philippines and appears to be an increasing trend.6,7 By mid-March 2020, the WHO European Region had become the epicenter of the epidemic, reporting over 40% of globally confirmed cases. As of 28 April 2020, 63% of global mortality from the virus was from the Region, according to the WHO.3 There is much that we need to know about SARS-CoV-2, the virus that causes COVID-19. It belongs to the same family of coronavirus that causes SARS, MERS (Middle East Respiratory Syndrome), and even the common cold.3 Early studies report that SARS-CoV-2 was most often detected in respiratory samples from patients in China. However, live virus was also found in feces.8 It is thought that transmission mainly occurs through the respiratory route, probably as droplets, but extra respiratory sources may also be important. Risk factors for severe illness remain uncertain but old age and comorbidities such as cardiovascular disease, liver disease, kidney disease or malignant tumors, have emerged as likely important factors. There are no proven effective specific treatment strategies, and the risk-benefit ratio for commonly used treatments such as corticosteroids is not clear.7,8 COVID-19 may also cause damage to other organs such as the heart, the liver, and the kidneys, as well as to organ systems such as the blood and the immune system. Patients die of multiple organ failure, shock, acute respiratory distress syndrome, heart failure, arrhythmias, and renal failure.9,10 Among the WHO’s current recommendations, people with mild respiratory symptoms should be encouraged to isolate themselves, and social distancing is emphasized, and these recommendations apply even to countries with no reported cases.3,11 However, such measures could drastically affect the economy with impact on work practices as well as commercial establishments which depend on people’s patronage.12,13 Moreover, the psychological and mental burden that isolation and quarantine can bring about should also be considered. 14,15 For those in the academe, adjustments and quick transition to online learning strategies will need to be made.16 This will also affect how scientific research is done, particularly as we try to learn more about COVID-19.17 The longer the pandemic lasts, and the longer these measures need to be implemented, the more significant will the effects be on the economic and mental well-being of the people. There has certainly been a rush to get more information about COVID-19.18 Although well-intended in most cases, this has resulted into an “infodemic” with some erroneous or unscientific information about COVID-19. 19-21 Even mainstream scientific publications have not been spared by such faulty information. 22,23 Health professionals, therefore, who will be using the information found in these publications will need to be more vigilant in making sure that the data are properly collected and interpreted. We need to constantly update ourselves as new information becomes available.24-26 As in many viral diseases, the best way to combat COVID-19 could be vaccination. Based on the experience with developing vaccines for the other coronaviruses such as the ones causing SARS, MERS and even the common colds, the development of an effective vaccine against COVID-19 may be challenging.27-30 Even if one were to be quickly developed, having the resources needed to make enough vaccines for potentially all inhabitants of our planet are also staggering. And then of course, once a vaccine is available, each country would have to device its own vaccination strategy and all of its accompanying logistic considerations. And then there is the cost of such a vaccine. As a third world country, would the Philippines be able to afford enough vaccines for its citizens? Pending availability of an effective vaccine, one would need to look at actual treatment of COVID-19 patients. In the short-term, it may be possible to repurpose some of the currently available drugs we use for treating other viruses.31-33 In order to help address these, some wide-ranging initiatives have been set up. In March 2020, the UK Research and Innovation (UKRI) Medical Research Council and the UK National Institute of Health Research (NIHR) started the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial.34,35 It is the world’s largest clinical trial into treatments for COVID-19, with more than 40,000 participants across 185 trials sites in the UK. It is led by the University of Oxford. At about the same time, the WHO also announced the start of an international randomized and adaptive clinical trial SOLIDARITY which will also be looking at potential treatments for COVID-19. 36,37 The Philippines is set to participate in the SOLIDARITY trial.38 Use of personal protective equipment (PPEs) similar to how we have used them against Ebola and other viruses could also be beneficial.39 But similar to developing capacity for making enough vaccines, the ability to make enough PPEs, especially the disposable ones and bring these to where they are needed could also be additional challenges. In the Philippines, as in many other parts of the world, many healthcare workers report insufficient availability of PPEs which puts them at risk of getting COVID-19 from their patients.40,41 There are many more questions needing answers that we will need to deal with as we confront COVID-19. And, most likely, there will also be new challenges that can arise as the pandemic evolves. The combined efforts of the scientific and political communities will need to be engaged if we hope to successfully deal with this emergency. Joven Jeremius Q. Tanchuco, MD, MHA Professor, Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines Manila Clinical Professor, Division of Pulmonary Medicine, Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila REFERENCES WHO Director-General's opening remarks at the media briefing on COVID-19 [Internet]. 11 March 2020 [cited 2020 Apr 15]. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020. Metro Manila to be placed on 'lockdown' due to COVID-19 [Internet]. [cited 2020 Apr 15]. Available from: https://cnnphilippines.com/news/2020/3/12/COVID-19-Metro-Manila-restrictions-Philippines.html Cucinotta D, Vanelli M. 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Background: Outbreaks of Lassa fever (LF) in Nigeria have become more frequent, with increasing more healthcare worker infections. Prevention of infection is dependent on strict compliance to infection prevention and control (IPC) practices in treatment centres where patients are managed. Objective: To evaluate IPC practices during an ongoing LF outbreak in the two major tertiary hospitals serving as the referral LF treatment centres in the north-central region of Nigeria. Methods: This cross-sectional survey was carried out by the IPC subteam of the National Rapid Response Team of the Nigeria Centre for Disease Control (NCDC) deployed to Plateau State, north-central Nigeria during the 2019 LF outbreak. Information on IPC in these facilities was collected using the NCDC viral haemorrhagic fevers (VHFs) isolation and treatment facility IPC survey tool. Results: Both treatment centres had national VHF IPC isolation guidelines and few health workers had received IPC training. In both centres, there were no clearly demarcated entry points for staff going into clinical areas after putting on personal protective equipment, and there were also no standard operating procedures in place for reporting occupational exposure of staff to infected blood or body fluids in both centres. Discussion: The LF treatment centers located in Plateau State during the 2019 LF outbreak were not fully implementing the national VHF IPC guidelines. Periodic assessments of IPC are recommended for proper management of cases and effective control of LF in the State.

Abstract Background COVID-19 has highlighted the importance of preparedness and response systems when faced with a pandemic. The rapid spread of the disease throughout Europe raised questions about the capacity of the European Union (EU) and its Member States to combat serious cross-border threats to health. This article provides an overview of institutional arrangements for pandemic preparedness before the COVID-19 pandemic and outlines the changes proposed by the European Health Union (EHU) framework. Methods A systematic review of relevant EU law, EU policy documents and the scientific literature was conducted. EUR-lex, PubMed, Web of Science core collection and Google Scholar databases were searched for relevant records published after the year 2000. The proposed new regulatory framework was extracted from the EHU legislative package. The results were organized according to the Public Health Emergency Preparedness Logic Model. Results The main EU bodies involved in preparedness and response are the European Centre for Disease Prevention and Control (ECDC), the European Commission and the Health Security Committee (HSC). The proposed changes of the EHU focus on strengthening the auditing capabilities of the ECDC, increasing the scope of EU action in managing medical countermeasures, and further formalizing the HSC. Conclusions The proposal takes bold steps to address technical and political issues of preparedness and response; whereas, on the latter point, it is likely that amendments to the proposal will not address long-standing challenges in preparing for and coordinating national responses to a future EU-wide pandemic.

On 5 April 2022, the United Kingdom reported an increase of cases of severe acute hepatitis of unknown aetiology in children, several needing hospitalisation and some required liver transplant or died. Thereafter, 35 countries reported probable cases, almost half of them in Europe. Facing the alert, on 28 April, Portugal created a multidisciplinary Task Force (TF) for rapid detection of probable cases and response. The experts of the TF came from various disciplines: clinicians, laboratory experts, epidemiologists, public health experts and national and international communication. Moreover, Portugal adopted the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) case definition and recommendations. By 31 December 2022, 28 probable cases of severe acute hepatitis of unknown aetiology were reported: 16 male and 17 aged under 2 years. Of these cases, 23 were hospitalised but none required liver transplant or died. Adenovirus was detected from nine of 26 tested cases. No association was observed between adenovirus infection and hospital admission after adjusting for age, sex and region in a binomial regression model. The TF in Portugal may have contributed to increase awareness among clinicians, enabling early detection and prompt management of the outbreak.

Abstract Background In November 2020, similar to other European countries, Portugal implemented a tiered restrictions system to control the COVID-19 pandemic. We aimed to compare the COVID-19 growth rate across tiers to assess the effect of a tiered restrictions system in Portugal, using models with different times between tiers assessment. Our hypothesis was that being in a higher tier brings a faster deceleration in the growth rate than being in a lower tier. Methods The national database of notified COVID-19 cases and publicly available data were used to analyse the effect of the tiered restrictions system on the COVID-19 incidence growth rate. The tiers were based on the European Centre for Disease Control risk classification: moderate, high, very and extremely high. We used a generalised mixed-effects regression model to estimate the growth rate ratio (GRR) for each tier, comparing the growth rates of higher tiers using moderate tier as reference. Three models were fitted using different times between tiers assessment, separated by 14 days. Results We included 156 034 cases. Very high tier was the most frequent combination in all the three moments assessed (21.2%), and almost 50% of the municipalities never changed tier during the study period. Immediately after the tiers implementation, a reduction was identified in the municipalities in high tier (GRR high tier: 0.90 [95%CI: 0.79; 1.02]) and very high tier (GRR very high tier: 0.68 [95%CI: 0.61; 0.77]), however with some imprecision in the 95% confidence interval for the high tier. A reduction in very high tier growth rate was identified two weeks (GRR: 0.79 [95%CI: 0.71; 0.88]) and four weeks (GRR: 0.77 [95%CI: 0.74; 0.82]) after the implementation, compared to moderate tier. In high tier, a reduction was also identified in both times, although smaller. Conclusions We observed a reduction in the growth rate in very high tier after the tiered restriction system was implemented, but we also observed a lag between tiered restriction system implementation and the onset of consequent effects. This could suggest the importance of early implementation of stricter measures for pandemic control. Thus, studies analysing a broader period of time are needed.

Abstract Background COVID-19 pandemic provides a unique opportunity to learn the challenges encountered by public health emergency preparedness systems, both in terms of problems encountered and adaptations during and after the first wave, as well as successful responses to them. Results This work draws on published literature, interviews with countries and institutional documents as part of a European Centre for Disease Prevention and Control project that aims to identify the implications for preparedness measurement derived from COVID-19 pandemic experience in order to advance future preparedness efforts in European Union member states. The analysis focused on testing and surveillance themes and five countries were considered, namely Italy, Germany, Finland, Spain and Croatia. Our analysis shown that a country’s ability to conduct testing at scale was critical, especially early in the pandemic, and the inability to scale up testing operations created critical issues for public health operations such as contact tracing. Countries were required to develop new strategies, approaches, and policies under pressure and to review and revise them as the pandemic evolved, also considering that public health systems operate at the national, regional, and local level with respect to testing, contact tracing, and surveillance, and involve both government agencies as well as private organizations. Therefore, communication among multiple public and private entities at all levels and coordination of the testing and surveillance activities was critical. Conclusion With regard to testing and surveillance, three capabilities that were essential to the COVID-19 response in the first phase, and presumably in other public health emergencies: the ability to scale-up testing, contact tracing, surveillance efforts; flexibility to develop new strategies, approaches, and policies under pressure and to review and revise them as the pandemic evolved; and the ability to coordinate and communicate in complex public health systems that operate at the national, regional, and local level with respect and involve multiple government agencies as well as private organizations.

Objectives: Real-time data analysis during a pandemic is crucial. This paper aims to introduce a novel interactive tool called Covid-Predictor-Tracker using several sources of COVID-19 data, which allows examining developments over time and across countries. Exemplified here by investigating relative effects of vaccination to non-pharmaceutical interventions on COVID-19 spread.Methods: We combine &gt;100 indicators from the Global COVID-19 Trends and Impact Survey, Johns Hopkins University, Our World in Data, European Centre for Disease Prevention and Control, National Centers for Environmental Information, and Eurostat using random forests, hierarchical clustering, and rank correlation to predict COVID-19 cases.Results: Between 2/2020 and 1/2022, we found among the non-pharmaceutical interventions “mask usage” to have strong effects after the percentage of people vaccinated at least once, followed by country-specific measures such as lock-downs. Countries with similar characteristics share ranks of infection predictors. Gender and age distribution, healthcare expenditures and cultural participation interact with restriction measures.Conclusion: Including time-aware machine learning models in COVID-19 infection dashboards allows to disentangle and rank predictors of COVID-19 cases per country to support policy evaluation. Our open-source tool can be updated daily with continuous data streams, and expanded as the pandemic evolves.

Abstract Background Infection surveillance is a key element of infection prevention and control activities in the aged care sector. In 2017, a standardised infection surveillance program was established for public residential aged care services in Victoria, Australia. This program will soon be expanded to a national level for all Australian residential aged care facilities. It has not been evaluated since its inception. Methods The current study aimed to evaluate the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Aged Care Infection Indicator Program (ACIIP), to understand its performance and functionality. A mixed methods evaluation was performed using the Updated Guidelines for Evaluating Public Health Surveillance Systems developed by the United States Centers for Disease Control and Prevention as a framework. VICNISS staff who coordinate and manage the ACIIP were invited to participate in interviews. Residential aged care staff who use the program were invited to participate in a survey. Document analysis was also performed. Results Four VICNISS staff participated in the interviews and 38 aged care staff participated in the survey. The ACIIP is stable and able to be adapted quickly to changing definitions for infections. Users found the system relatively easy to use but have difficulties after the long intervals between data entry year on year. VICNISS staff provide expert guidance which benefits users. Users appreciated the benefit of participating and many use the data for improving local practice. Conclusions The ACIIP is a usessful state-wide infection surveillance program for aged care. Further development of data validation, IT system capacity and models for education and user support will be required to support future scalability.

ObjectiveTo assess the formation and function of a joint committee of the Ahmadu Bello University (ABU) and the Ahmadu Bello University Teaching Hospital (ABUTH) to prevent and control EVD in Zaria and the North West sub region of Nigeria.IntroductionThe Ebola Virus Disease (EVD) outbreak in West Africa was unprecedented in spread and its attendant response. There were over 15 000 confirmed cases and over 9 000 suspected cases. The response to the outbreak was massive within Africa and beyond. The outbreak in Nigeria affected 19 people and led to 7 deaths (CFR 37%).There were more than 891 contacts of these cases under surveillance as at 23rd September 2014. Nigeria was declared EVD free by the World Health Organization in October 2014.Nationwide there was targeted preparedness to prevent and control EVD. In Zaria, this led to the formation of a joint committee of the Ahmadu Bello University (ABU) and the Ahmadu Bello University Teaching Hospital (ABUTH) to prevent and control EVD in Zaria and the sub region as a whole.MethodsA joint multidisciplinary committee was formed by ABU and ABUTH with representatives from the Department of Community Medicine, Internal Medicine, Nursing sciences, Veterinary Public Health, Medical Microbiology, Mass Communication, Directorate of Public Affairs ABU Zaria, General Administration and Management services division ABUTH, the University Health Services and the Centre for Disease Risk Management under the Department of Geography. Four subcommittees were created steered by the main committee. The subcommittees were Surveillance; Case Management; Infection Control and Social and Mass mobilization subcommitteesResultsThe committee conducted seminars and trainings in case management, surveillance and infection control. Mass media campaigns included radio jingles production and airing as well as production of flyers and posters on EVD prevention and control. There was a phone in live radio programme. Screening exercise for raised temperature was conducted using laser thermometers at main entry points. A case of suspected EVD was managed who turned out to be a case of dengue haemorrhagic fever.ConclusionsThe committee was enriched by its multidisciplinary nature and a blueprint for the control and prevention of EVD was developed in line with national and global standards. The committee was hampered with lack of funds to implement fully the blueprint for the prevention and control of EVD in Zaria and its environs. The committee transformed into the ABU/ABUTH Epidemic Preparedness and Response Committee after the outbreak was over to address other emerging epidemics.ReferencesABU/ABUTH Joint Committee For The Prevention And Control Of Ebola Virus Disease (ABUPACE) Blueprint For Prevention And Control Of Ebola Virus Disease In ABU/ABUTH Zaria 2014. Pages 1-44World Health Organization. WHO declares end of Ebola outbreak in Nigeria www.who.int/mediacentre/news/statements/2014/nigeria-ends-ebola/en/

Abstract Background Mobile health interventions hold the prospect to support risk factor and lifestyle modification and are readily scalable in healthcare systems. Purpose We aim to assess whether text messaging program can improve glycemic control in high-risk patients with coronary heart disease (CHD) and diabetes mellitus (DM). Methods The study was a multi-centre randomised clinical trial conducted at 34 clinics in China. 502 individuals with both CHD and DM were recruited and randomly assigned to either the text messaging intervention (n=251) or control group (n=251). The control group received 2 thank-you messages per month in addition to usual care. The intervention group received 6 messages per week for 6 months. Messages provided educational and motivational information related to glucose monitoring, BP control, physical activity and lifestyle recommendations. The primary outcome was change in glycemic hemoglobin (HbA1C) from baseline to 6 months. Results Follow-up rate was 99%. At 6 months, HbA1C was significantly lower in intervention group compared to control group (mean HbA1C 6.7% vs. 7.2%, P<0.001), with a mean change of −0.2% and 0.1% from baseline, respectively (mean absolute change −0.3% [95% CI −0.5 to 0.1]; P=0.003). Significantly more participants in intervention group achieved a HbA1c<7% (69.3% vs. 52.6%; P=0.004), and change in FBG was larger in intervention group (−0.5 vs. 0.1 mmol/L; P=0.011). No differences in SBP, LDL-C, BMI and physical activity were observed. Almost all patients reported messages to be easy to understand (97.1%) and useful (94.1%). Table 1. Primary and Secondary Outcomes Analyses at 6 Month Follow-up Parameter Intervention (N=251) Control (N=251) Mean Difference in Change P value for Baseline 6 Months Mean Change Baseline 6 Months Mean Change (95% CI) Difference in Change Primary Outcome HbA1C level, %, mean (SD) 6.9 (1.4) 6.7 (1.3) −0.2 (1.0) 7.1 (1.4) 7.2 (1.5) 0.1 (1.1) −0.3 (−0.5, −0.1) 0.003 Secondary Outcomes HbA1C level<7%, No. (%) 155 (62.0%) 174 (69.3%) – 139 (56.1%) 132 (52.6%) – 1.2 (1.1, 1.3)a 0.004 FBG, mmol/L, mean (SD) 8.1 (2.7) 7.5 (2.7) −0.5 (2.5) 8.5 (3.0) 8.6 (3.3) 0.1 (3.1) −0.6 (−1.1, −0.2) 0.011 SBP, mmHg, mean (SD) 135.9 (18.4) 134.7 (18.7) −1.4 (17.1) 135.9 (18.1) 132.2 (17.7) −3.5 (17.8) 2.4 (−0.8,5.5) 0.144 LDL-C, mmol/L, mean (SD) 2.6 (0.8) 2.5 (0.7) −0.1 (0.7) 2.6 (0.8) 2.5 (0.8) −0.1 (0.7) 0 (−0.1, 0.1) 0.828 BMI, mean (SD) 26.4 (3.2) 26.3 (3.5) −0.1 (2.1) 26.3 (3.2) 26.0 (3.4) −0.4 (2.5) 0.3 (−0.1, 0.7) 0.213 Physical activity (MET min/wk), 1386 1386 177 1386 1386 322 −70.7 0.784 median (IQR) (693–3066) (918–3612) (2840) (693–3066) (693–3002) (2635) (−574.9, 433.5) Conclusion Use of a simple, culturally sensitive mobile text-messaging program could be an effective and scalable way to improve disease self-management among patients with CHD and DM. Acknowledgement/Funding Research Special Fund for Public Welfare Industry of Health (201502009) from the National Health and Family Planning Commission of China

Speaking to WHO personnel who are based in all states/UTs in India, via video conference in April 2020, Dr Harsh Vardhan, Union Minister for Health & Family Welfare said, “WHO is an important partner in our ght against the COVID-19. I really value guidance and contributions made by the WHO in containing spread of COVID-19 across the country.” The WHO Country Ofce for India (WCO India) has been working closely with the Government of India (GoI) to step-up preparedness and response measures for COVID-19, including surveillance and contact tracing, laboratory testing, risk communications and community engagement, hospital preparedness, infection prevention and control, and implementation of containment plan at all three levels of the health system – national, state and district. The entire eld presence, including the National Public Health Surveillance Project, consisting of more than 2000 personnel has been fully re-purposed to support the government to overcome this challenge. At the national level, WCO India is providing technical support to the Ministry of Health & Family Welfare (MoHFW) through the Joint Monitoring Group (JMG) and working closely with National Centre for Disease Control (NCDC), Indian Council of Medical Research (ICMR), National Disaster Management Authority and NITI Aayog. WHO teams are also supporting National and State Governments in ensuring essential health services such as immunisation, reproductive maternal newborn child and adolescent health (RMNCAH), non-communicable diseases and priority communicable diseases are available. Thus the investigator would like to take up the present study to assess the knowledge and attitude regarding use of contraception methods among female students. Objectives Of The Study: 1. To assess the knowledge regarding covid -19 amongadoloscent students. Method: The research approach adopted for the study was quantitative evaluative and the research design wasdescriptive survey design. By using non-probability, purposive sampling 100 adoloscent students from D. Y. PATILJunior college, Kolhapur. Structured knowledge questionnaire was used to assess the knowledge of adoloscent students regarding covid -19.The data was collected on socio demographic variables and knowlwdge questionnaire on Covid-19.After obtaining permission from the principals of junior colleges, Data were analyzed by using mean, median, mode, standard deviation, range. Results: After analysis of knowledge scores among 100 adoloscent students regarding covid -19 .Maximum number of 88 (88%) adolescent students had average knowledge and minimum 12 (12%) adolescent students had good knowledge While 0 (0%) adolescent students had poor knowledge Among 100 adolescent student. Interpretation And Conclusion: The present study revealed that Overall test of knowledge regarding the Covid -19 among adolescent students was average.

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Slovenian Research Agency Ministry of Health, Republic of Slovenia. Background Cardiac rehabilitation (CR) is a complex intervention, providing supervised exercise training, risk factor control, and secondary prevention. Centre-based outpatient CR provides the necessary structure to accomodate the delivery of several preventive interventions, but the quality of secondary prevention may vary. The present study sought to assess the impact of CR on the improvement and between-center variation of the quality of secondary prevention. Methods Data were extracted from the Slovenian National CR Registry for patients who completed CR between 2017 and 2020. A composite quality score (CQS) was calculated adjudicating one point for each of the following: non-smoking status, body mass index &lt;25 kg/m2, systolic blood pressure &lt;130 mmHg, low-density lipoprotein (LDL) cholesterol &lt;1.4 mmol/L, antiplatelet therapy, and high-potency statin/combined lipid-lowering therapy. Predictors of CQS improvement were assessed using mixed-effects ordinal logistic regression model acknowledging the hierarchical nesting of patients within centres. Results A total of 1,952 patients from 5 centres were included (mean age 59.4±10.8 years; 22% women). Mean CQS improved from 3.16±1.11 to 3.53±1.21 (p&lt;0.001), with CR associated with an OR 1.72 (95% confidence interval [CI] 1.49-2.00) for CQS improvement (Figure). Improvement of CQS was also positively associated with increasing number of sessions &gt;12 (e.g., OR 6.06 [3.29-11.14] for 12-24 sessions) and total number of co-morbidities (OR 1.40 [95%CI 1.33-1.48]), and negatively associated with male sex (OR 0.78 [95%CI 0.65-0.92]), high cardiac risk (OR 0.83 [95%CI 0.68-0.99]), age &gt;60 years (e.g., OR 0.62 [95% CI 0.41-0,94] for age group 60-69 years), and referral diagnosis other than STEMI (e.g., OR 0,56 [95%CI 0.39-0,72] for non-infarction coronary artery disease). Random-effects partitioning attributed 68.8% of variance to patient-level factors and 19.8% to between-center variability. Conclusions Centre-based CR is associated with improved quality of secondary prevention; factors affecting quality improvement range from patient-level (e.g., age and sex) to mode of provision (e.g., number of sessions). Up to one fifth of the variation, however, can be attributed to between-center variationm.

Abstract Background The first half of 2020 has been marked as the era of COVID-19 pandemic which affected the world globally in almost every aspect of the daily life from societal to economical. To prevent the spread of COVID-19, countries have implemented diverse policies regarding Non-Pharmaceutical Intervention (NPI) measures. This is because in the first stage countries had limited knowledge about the virus and its contagiousness. Also, there was no effective medication or vaccines. This paper studies the effectiveness of the implemented policies and measures against the deaths attributed to the virus between January and May 2020. Methods Data from the European Centre for Disease Prevention and Control regarding the identified cases and deaths of COVID-19 from 48 countries have been used. Additionally, data concerning the NPI measures related policies implemented by the 48 countries and the capacity of their health care systems was collected manually from their national gazettes and official institutes. Data mining, time series analysis, pattern detection, machine learning, clustering methods and visual analytics techniques have been applied to analyze the collected data and discover possible relationships between the implemented NPIs and COVID-19 spread and mortality. Further, we recorded and analyzed the responses of the countries against COVID-19 pandemic, mainly in urban areas which are over-populated and accordingly COVID-19 has the potential to spread easier among humans. Results The data mining and clustering analysis of the collected data showed that the implementation of the NPI measures before the first death case seems to be very effective in controlling the spread of the disease. In other words, delaying the implementation of the NPI measures to after the first death case has practically little effect on limiting the spread of the disease. The success of implementing the NPI measures further depends on the way each government monitored their application. Countries with stricter policing of the measures seems to be more effective in controlling the transmission of the disease. Conclusions The conducted comparative data mining study provides insights regarding the correlation between the early implementation of the NPI measures and controlling COVID-19 contagiousness and mortality. We reported a number of useful observations that could be very helpful to the decision makers or epidemiologists regarding the rapid implementation and monitoring of the NPI measures in case of a future wave of COVID-19 or to deal with other unknown infectious pandemics. Regardless, after the first wave of COVID-19, most countries have decided to lift the restrictions and return to normal. This has resulted in a severe second wave in some countries, a situation which requires re-evaluating the whole process and inspiring lessons for the future.

Objective: Diabetes is a major risk factor for vascular disease in the general population. We investigated the prevalence of diabetes and glycemic control in the Chinese adult population. Methods: We conducted a cross-sectional survey in a nationally representative sample of 98,658 Chinese adults aged ≥18 years in 2010. After an overnight fast, participants without known diabetes underwent an oral glucose-tolerance test (OGTT) using 75 g anhydrous glucose dissolved in water. Previously diagnosed diabetes was determined on the basis of self-report. Undiagnosed diabetes was defined as a hemoglobin A1c (A1c) ≥ 6.5% or fasting plasma glucose (FPG) ≥126 mg/dl (7.0 mmol/l) or 2-h plasma glucose (2-h PG) ≥200 mg/dl (11.1 mmol/l) during an OGTT according to the 2010 American Diabetes Association criteria. Pre-diabetes was defined as FPG 100-125 mg/dl (5.6-6.9 mmol/l) or 2-h PG 140-199 mg/dl (7.8-11.0 mmol/l) or A1c 5.7-6.4%. Prevalence was calculated by weighting sampling factors derived from China population census data in 2010 to obtain national estimates. Results: Prevalence of self-reported diabetes was estimated to be 3.5% in the Chinese population aged ≥18 years (3.6% in men and 3.4% in women) or 34.2 million persons (18.0 million men and 16.3 million women). Prevalence of undiagnosed diabetes was 8.1% (8.5% in men and 7.7% in women) or 79.6 million persons (42.5 million men and 37.1 million women), and the prevalence of pre-diabetes was 50.1% (52.1% in men and 48.1% in women) or 493.4 million persons (260.1 million men and 233.3 million women). The prevalence of diabetes was higher in urban (14.3%) than in rural (10.3%) residents, and higher in persons who were older, heavier, and living in economically developed areas. The proportion of controlled (A1c <7.0%) was 42.8% among self-reported diabetes (42.3% in men and 43.4% in women) in the general population in China. Conclusions: Our study shows that the prevalence of diabetes in the general population in China is much higher than previously reported. More troublesome, 7 out of every 10 diabetic patients are undiagnosed. Among self-reported diabetes, 3 out of 5 were poorly controlled. Our findings indicate that diabetes has become a major public health problem in China and suggest an urgent need to develop national strategies for prevention and treatment of diabetes.

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [6] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm [7] Center for Disease Control and Prevention. (2021, October). Estimated HIV incidence and prevalence in the United States 2015–2019. https://www.cdc.gov/hiv/pdf/group/racialethnic/hispanic-latino/cdc-hiv-group-hispanic-latino-factsheet.pdf [8] Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [9] CDC. (2020). [10] CDC. (2020). [11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. (2021, November 2). Mission, Work, and Impact | NHSC. https://nhsc.hrsa.gov/about-us [52] Elam, C. L., & Wagoner, N. E. (2012). Legacy Admissions in Medical School. AMA Journal of Ethics, 14(12), 946–949. https://doi.org/10.1001/virtualmentor.2012.14.12.ecas3-1212

Abstract Background Left ventricular ejection fraction (EF) is an independent predictor of adverse outcomes after myocardial infarction (MI). However, contemporary data from the PCI era of MI therapy on trajectories and determinants of EF are scarce. Purpose The present study aimed to describe the epidemiology of systolic dysfunction and EF recovery among consecutive patients hospitalized for their first MI. Methods Data from a single-centre prospectively-designed AMBITION registry of consecutive patients hospitalized for MI between years 2017 and 2021 at a large tertiary cardiology centre were utilized. Results Out of 1593 patients in the registry, 1065 were hospitalized for MI type I and had no previous history of heart failure (HF) or coronary artery disease. Revascularisation was performed in 93.5% of patients: 901 (84.6%) underwent PCI, 89 (8.4%) CABG and 6 (0.6%) both. At discharge, EF&lt;40% was present in 238 (22.3%), EF 40–50% in 326 (30.6%) and EF &gt;50% in 501 (47.0%), respectively. Patients with EF&lt;40% were more often those who suffered subacute and anterior STEMI, had higher heart rate at admission and higher maximal troponin level, and more often HF signs requiring intravenous diuretic therapy (Table 1). In the multivariate Cox analysis, EF&lt;40%, together with age, glomerular filtration rate, glycemia level, clinical signs of HF, and atrial fibrillation were associated with increased mortality risk. Among subjects with EF&lt;40%, the control follow-up EF determined on a median 153 days (IQR 101–407) after discharge was available in 166 patients. Among these, systolic function recovered to EF&gt;50% in 38 (22.9%) and improved to EF 40–50% in 45 (27.1%). Improvement in systolic function to EF&gt;40% was predicted by lower severity of coronary artery atherosclerosis (GENSINI score), by higher discharge EF, by the lower leukocyte count, the absence of atrial fibrillation during MI hospitalization and glycemia level (Table 2). Recovery of systolic function was associated with lower mortality risk (log-rank p=0.012). Conclusion In the current era of primary coronary intervention, only 22% of patients after the first MI have EF below 40%. Of them, EF improves in 50%, and full recovery is observed in 23% of patients. Severity or coronary atherosclerosis, inflammatory response to MI, atrial fibrillation and glucose metabolism may all affect EF recovery. These observations provide novel therapeutic targets for EF recovery. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health, Czech Republic

Abstract Background Randomised control trials have demonstrated direct positive and causal associations of 24-hr measurements of urinary sodium excretion on blood pressure. However, prospective studies, which often used spot (not 24-hr) measurements of urinary sodium, have reported J-shaped associations with higher risks of cardiovascular disease (CVD) at sodium intake &lt;4 g/day. The reasons for the discrepant results are not fully understood, but have prompted some to question the World Health Organisation's recommendations to restrict sodium intake to &lt;2.3g/day. Purpose We examined the effects of within-person variability in spot urinary sodium (UNa) measurements on immediate and delayed associations of UNa with blood pressure at baseline and at resurvey, and with incident cardiovascular disease in the UK Biobank (UKB). Methods Baseline spot urine samples were measured in 502,619 adults at baseline and in 20,346 participants who were resurveyed at 4 years after baseline. Linear regression was used to assess associations of baseline UNa measurements with systolic blood pressure (SBP; mmHg) at baseline and at resurvey. Cox regression was used estimate the associations between baseline measures of UNa with incident CVD events (recorded from linkage with hospital records). All analyses were adjusted for confounders and corrected for regression dilution bias. Results After excluding participants with prevalent diseases, the primary analyses involved 386,060 adults who were followed-up for a median of 7.8 years, during which ∼13,000 CVD events occurred. Estimated mean (SD) urinary sodium excretion was 77.4 mmol/L (SD 44.4, IQR = 42.8–103.7 mmol/L), and mean SBP/DBP were 137.5/82.3 (SD 18.5/10.1) mmHg, respectively. Within-person variability in UNa was high, with a self-correlation of 0.35 at 4 years between measurements. After adjustment for confounders and correction for regression dilution bias, a 100 mmol/L higher UNa was associated with an immediate 3.2 mmHg higher SBP (95% confidence interval [CI]: 2.8–3.6) in cross-sectional analyses (Figure 1). However, the corresponding associations of baseline UNa with SBP at resurvey was completely attenuated (p=0.20). The predicted risk of CVD was 1.06 (95% CI 1.06–1.07, p&lt;0.001) for a 3.2 mmHg higher SBP, but the observed risk for a 100 mmol/L higher UNa was 0.95 (95% CI 0.82–1.10, p=0.47) (Figure 1). Conclusions While spot measurements of UNa were strongly associated with immediate effects on SBP, the magnitude of within-person variability in UNa precluded detection of associations with SBP several years after baseline or with risk of CVD. The extreme within-person variability in spot UNa may explain the discrepant results of the trials and observational studies of sodium and blood pressure. Figure 1. Spot UNa with SBP and CVD in UK Biobank Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Core funding from the Medical Research Council-Population Health Research Unit, British Heart Foundation

ObjectiveIdentify and document strategies that enhance the value of syndromic surveillance (SyS) data and information for the response, recovery, mitigation and preparedness needs of local and state emergency management professionals in the U.S.IntroductionIntense stress can severely degrade one’s ability to process and utilize new kinds of information.1 This psychological phenomena may partially explain why epidemiologist are challenged to communicate and establish the value of SyS information with emergency management professionals (EMPs). Despite the timely and useful insights that SyS data and methods can provide, it is very difficult to convey what these data are when EMPs and epidemiologists are working to make intense, highly-scrutinized and high-consequence emergency decisions. If state and local authorities want emergency plans and responses that benefit from the powerful insights that SyS can provide, epidemiologists need to learn how to best report information and establish a strong rapport before emergencies strike.Over the past ten months, ISDS’s NSSP’s Syndromic Surveillance and Public Health Emergency Preparedness, Response and Recovery (SPHERR) Committee has worked to identify gaps, potential best practices, document use cases, and identify tools for integration of SyS data in EM activities. During SPHERR practice exchange meetings, SyS professionals have consistently cited effective communication between SyS staff and emergency preparedness staff as a top priority in integrating SyS more fully into all phases of emergencies.MethodsParticipants will engage in an interactive and guided discussion that identifies and documents effective strategies and tools to communicate SyS information in ways that provide EMPs with useful, actionable and valuable insights. As a prompt and further framing device, examples or use cases will be gathered from participants based on health conditions of interest; i.e., Infectious Disease, Environmental Exposures, Injury, Mental Health Conditions, Health Care Utilization, and Exacerbations of Chronic Disease Conditions.4 Examples presented or discussed by SPHERR will also be used as prompts. The authors will use grouping and appreciative inquiry techniques to facilitate this round table discussion, and document the lessons learned. The discussion will inquire and analyze communication methods that participants use, or plan to use for conveying relevant SyS insights to EMPs during each phase of the emergency management cycle. Examples by preparedness phase are included below.During the preparedness phase, establishing SyS/Emergency management relationships can identify ways in which SyS information can address gaps in emergency management capabilities. Ongoing relationships and inclusion of SyS information in exercises helps ensure that this information is incorporated and effectively utilized in emergency management.During the response, SyS data can be used to monitor changes in the number of emergency department (ED) visits, increases in emergency-related syndromes, timing of impacts to EDs, and relative impact by geographical location of EDs. Displacement of populations during mass-care events can also be examined. Conducting surveillance for emergency-related key-words in ED reports can facilitate targeted surveillance for outcomes of interest. SyS data can also be used to screen for potential cases of disease, so that interventions can be targeted effectively. Example use cases of how SyS information has informed event responses will be discussed.During recovery from the emergency, SyS data can be used to track population displacement, as populations return to the area affected by the emergency. It can also be used to track ED visits, to determine when/if they return to pre-event levels. Secondary effects of the emergencies (such as carbon monoxide poisoning, flood-water contaminated food, HazMat events or suicidal ideation/attempts) can also be examined.SyS data can help in mitigation activities to prevent emergencies, reduce the chance of their occurrence, or reduce their damaging effects by monitoring ED data for patterns of syndrome presentations, or clusters of syndromes which could indicate a potential outbreak or event of public health significance. For diseases with typical seasonal patterns, SyS data can be used as an indicator of the beginning of the season, so that public health disease prevention messages and other interventions can be timed more effectively. Historical SyS data can also be examined to identify patterns of presentations that occurred before an outbreak is recognized, to increase the index of suspicion for these patterns in future surveillance.ResultsAt the end of the discussion, roundtable participants will possess a matrix of strategies and tools that they can customize to better utilize SyS in have tools and templates customized to communicate the value of SyS information in addressing hazards, vulnerabilities and threats faced by their communities.ConclusionsIntegration of SyS data into a highly functioning surveillance system facilitates rapid identification and characterization of potential threats, enhances health and medical situational awareness and increases the evidence base for making emergency management decisions.The importance of integrating surveillance data into emergency management and of effective and timely communication of this data to enhance situational awareness and share surveillance information with emergency managers has been repeatedly cited in both CDC Guidanceand in after-action reports for real-world events.This roundtable will help ensure that participants have the knowledge to effectively communicate SyS to EM personnel and ensure that this potentially life-saving information is integrated into all phases of emergency management.References1. Bourne, L, Yaroush, R. Stress and Cognition: A Cognitive Psychological Perspective. Moffett Field (CA): National Aeronautics and Space Administration; September 2003 155 p. Report Number (Nasa/CR-2003-212282), p.6.2. Arroyo-Barrantes, S, RodrIguez,M, Perez, R, editors (Pan American Health Organization). Information management and communication in emergencies and disasters; manual for disaster response teams. 2009 Washington, (DC): Area on Emergency Preparedness and Disaster Relief. 138 p. Report Number NLM HV553.3. Kahn, A., Kosmos, C, Singleton, C. Public Health Preparedness Capabilities: National Standards for State and Local Planning. Atlanta (GA); March 2011 252 p. Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention.4. Final Recommendation: Core Processes and EHR Requirements for Public Health Syndromic Surveillance. International Society for Disease Surveillance; Jan 2011 69 p.5. A Primer for Understanding the Principles and Practices of Disaster Surveillance in the United States (1st ed.). Centers for Disease Control and Prevention (CDC). Atlanta (GA): CDC; 2016.6. Uscher-Pines, L, Farrell, C, Babin, S, Cattani, J, Gaydos, C., Hsieh, Y, Rothman, R, Framework for the development of response protocols for public health syndromic surveillance systems: Case studies of 8 U.S. States, Disaster Med Health Prep. 2009 Jun 3 (S1), S29-36.7. Monitoring Health Effects of Wildfires Using the BioSense System—San Diego County, California, October 2007, Centers for Disease Control and Prevention. Atlanta (GA). MMWR 2008 57(27); 741-747.8. Morbidity surveillance after Hurricane Katrina---Arkansas, Louisiana, Mississippi, and Texas, September 2005. Centers for Disease Control and Prevention. Atlanta (GA). MMWR 2006; 55;727-31

To Rodica, who died first / To Mircea, who continues me [I]In his book Picturing Health and Illness: Images of Identity and Difference, Sander L. Gilman argues that during the nineteenth century the healthy norm perceived as ugly not only those who were deformed, but also those who were ill, ageing, and/or experienced different bodily “loss of function” (53). In the nineteenth century, how much was medicine responsible for defining ugly as ill, deformed, and getting old, versus beautiful as healthy, and then, for the sake of the community’s health, firmly promoting these ideas? Furthermore, with the rise of photographic art, medicine was able to manipulate and control these ideas even more efficiently. According to Deborah Lupton, “The new technology of photography that developed from the mid-nineteenth century became a valuable strategy in the documentation of patterns of disease and illness, and the construction of the sites of dirtiness and contagion” (30). This essay focuses on the skin’s narrative as it presents its story when photographed. William Yang takes photos of his good friend, Allan, who is dying of AIDS. Of interests here is to discuss/approach the photographic art not from its scopophilic angle, that is, not from its perverse and pleasurable voyeuristic angle, but to analyze it side-by-side with Drew Leder’s notion of the “the remaining body.” He believes that in states of severe pain, one’s body “dys-appears,” “from the Greek prefix signifying ‘bad,’ ‘hard,’ or ‘ill,’” and he gives as example the English word “dysfunctional” (84). Yang’s photos offer variations of the “body that remains,” and, as we shall see, of the body that gradually did not remain. Through his work, Yang approaches visually the theme of the ars moriendi of the entropic body in pain as reminder of its mortal, gradually disabling fabric. [II] In the section of his work dedicated to AIDS, Gilman discusses only a collection of posters that have circulated in mass-media, which he researched at the National Library of Medicine at Bethesda, Maryland. Gilman thinks these posters function as the “still images of illness” (174). In other words, he believes these posters may have had an impact on the lay community, although not the intensified, urgent one, as he would have hoped. Because Gilman did not include a single photo of a patient dying of AIDS — although he understood this lack — I juxtapose one of the posters from his book with Yang’s photos taken of his dying friend, Allan, from his project entitled Sadness: A Monologue with Slides. Here I discuss the impact of Allan’s increasingly emaciated body versus the static, almost ineffective quality of the poster in order to consider the idea according to which “AIDS victims are living sculptures. … Both subject and object of art … they combine with their disease to overcome the narcissism of human consciousness. … It is an art of continuous transformation of subject into object and object into subject” (Siebers 220-21). Yang is an Australian artist with Chinese parentage. The images presented in this section originally appeared in print in Thomas W. Sokolowski’s and Rosalind Solomon’s collection of essays entitled Portraits in the Time of AIDS. According to the editors, Yang presented them as “monologues with slide projection in the theatre” (34) because the main actor of this one-man show is dying of AIDS. Yang’s work consists of seventeen slides with short texts written underneath them. In an attempt to respect the body that is dying, the texts are not recited, but the readers/spectators read them subvocally. The brilliance of this piece resides in its hushed tone, which parallels the act of dying when the patient’s body and mind become more and more tacit and lifeless. From one photo to another, and from one text to another, we discover Allan, although we never quite get to know him. The minitexts relate Allan’s story: how he was hospitalized at St. Vincent’s, known as “the AIDS ward” (35); how he decided to return home, into a studio shared with a dealer; how AIDS first attacked his lungs, and so he had to keep next to him “a large cylinder of oxygen as he was often out of breath” (37); how AIDS then affected his sight, and he developed a condition known as “CytoMegalo Virus — C.M.V. Retinctus” that gradually “destroyed the retina” of his eyes (39); how he decided “to go off medication” (46); and, how, finally “he went into a coma. I saw a nurse give him a glass of water but the water just ran out of his mouth” (50). To look at these photos time and time again is to be reminded of Albert Einstein’s vision of the passenger trapped in the train running with the speed of light. That passenger could not sense all that was happening in the train, and especially outside of it, because time moves in its cosmic, non-human, slippery dimension, and thus sensation could not profusely permeate his body. Juxtaposing Einstein’s vision with Allan’s decaying body, I read the latter’s body as if it were coiled up inside his mind just like a snail covers a part of its body under its hard shell. The photos are presented rapidly with no entr-acte in between; in a matter of minutes, time and space seem to collapse. There is no time for a prolonged reminiscence of Allan’s spent life. Allan is dying now, and he does not have time to remember his life. He barely has time to feel his body, a touch, or a kiss on his face, which seems to Yang “to have caved in” (47). Through this work, not only does Yang capture the disturbing moments of a friend dying, but he also touches on the “epidermis” of despair. This “epidermis” is both endotopic and exotopic, meaning that it starts within the patient and then it radiates/extends to his relatives and friends. Yang’s images of Allan dying give the impression that his body levitates, jutting out into space — but unfortunately without much meaning. On the other hand, the posters advertised for AIDS are simple, if not quite embarrassing and disrespectful given the gravity of this illness. They rarely touch on any aspects related to the illness itself, as they allude more to the immorality of homosexual acts. Gilman explains part of the rationale involved in the process of not presenting people dying of AIDS as follows: The image of the ‘positive’ body or the body with AIDS is strictly controlled in the world of the public health poster. Nowhere is an image of the ‘ugly’ or diseased body evoked directly, for any such evocation would refer back to the initial sense as a ‘gay’ disease. … Mens non sana in corpore insano cannot be the motto. For representing the ill body as a dying body is not possible. Such a body would point to ‘deviance from the norm’ in the form of illness. And this association with homosexuality and addiction labeled as illness must be suppressed. … All these images are images not of educating, but of control. (162) The poster chosen for illustration reads “LOVE AIDS PEOPLE,” with AIDS used as a verb and not as a noun; nonetheless, the construction’s subtlety is rather counterproductive. To a certain extent, this poster can be related to Michelangelo Merisi Caravaggio’s The Incredulity of Saint Thomas (1601-02). There, the Apostle touches the actual wound because he needs tactile proof to accept its existence. The act of touching, as well as the skin open by the wound, reveal the fact that “Skin lacks the depth, the interiority we want it to give us. … The flesh we crave as confirmation of our forms cannot do anything but turn us forever out even as we burrow into the holes we find there” (Phelan 42). But the poster presented below brings into focus verbally (therefore propagandistically) how one’s body might be destroyed because of AIDS. Furthermore, the symbol of the arrow is a recurrent motif in the art representing AIDS, especially in light of its religious association with the martyrdom of Saint Sebastian (see for example David Wojnarowicz art works which offer a personal interpretation of the martyrdom of Saint Sebastian). But if LOVE AIDS PEOPLE, and if gay men identify themselves with a martyr, then they might easily fall target to this twisted logic and think of themselves as victims. As Larry Kramer notes, gay men are tragic people partly because they feel responsible for an illness that has been affecting both the homosexual and heterosexual communities: “The continuing existence of HIV is essential for the functioning of the totalitarianism under which gay people now live. It works like this: HIV allows ‘them’ to sell us as sick. And that kills off our usefulness, both in our minds — their thinking we are sick — and in the eyes of the world — everyone thinking we are sick” (65).Gay men have always been a target since, allegedly, they are a menace to the institution of marriage, procreation, and to morality in general. Endocrinology studies have been conducted on gay men, but their results have not been able to say with certainty why some people prefer to engage in homosexual rather than heterosexual acts. According to Jennifer Terry, earlier studies from the 1930s aimed at determining distinct somatic features of homosexuals for the most part failed to produce any such evidence. Most of them focused on the overall physical structure of bodies, measuring skeletal features, pelvic angles and things like muscle density and hair distribution. (144) (Another useful resource is Holt N. Parker’s 2001 article “The Myth of the Heterosexual: Anthropology and Sexuality for Classicists.”) How and by whom are our sexual identities created? Does the presence of one specific anatomical organ delimit one person’s sexual identity? We have been trained into believing that there are only two genders, male and female, partly because of our binary way of thinking. Needless to say, just as in one color there are degrees of its intensity and saturation, so there are in us verbal, behavioral, and sexual tendencies that could make us look and act more or less masculine or feminine. Even more productive is to note the importance of power (control) and the erotic in our lives considering that the photos (and the minitexts) presenting Allan seem insufficient to initiate a dialogue by themselves. Because the eroticized body is what dies, that is, what is put at risk or could become powerless because of AIDS. The body that cannot touch and be touched anymore; the body that cannot control its needs and desires; and, ultimately, the body that is deprived of its pleasures and thus loses its erotic self. Therefore, AIDS is not only a way to redefine our erotic life, but also becomes a reason to question our hygiene practices. Elizabeth Grosz points out that “erotic pleasures are evanescent, they are forgotten almost as they occur” (195). But when erotic pleasures are controlled, as seems to be the case because of AIDS, have we intervened in such a manner as to program our intercourse? Admittedly, AIDS is predominantly linked with one’s sexuality and, hence, it could make one feel too self-aware about one’s needs, as well as rigid and self-conscious in an (intimate) act which, in essence, is all about losing oneself, being uninhibited. In the end, Allan’s sense of identity seems to be imprinted only in the camera’s objective lens. After he died, as Yang remembers, “I read his diaries […]. AIDS was a tragedy that was for sure, but as well he had an addictive personality and his day to day life was full of desperation. I hadn’t realize the extent of this and it came as a shock. Yet there were moments of clarity when his fresh test for life shone” (51). Yang does not say more about Allan’s intimate writings and, as he suggests, it was quite surprising for him to discover a richer, more intimate dimension of his friend. Still, until Allan’s diaries will be released to the public to offer us a more palpable view on his life, we rely exclusively on the selections of photos and minitexts accomplished by Yang, thus being aware that, no matter how exquisite they are, they could only say a few things about this enigmatic patient.[III] After exposing Allan’s gradually collapsing body, we may want to analyze to which extent is dying/death something that reveals our self-centricity. It is by now a truism to say that death is the final moment of our embodiment to which we are denied access. Nonetheless, we cannot stop thinking about (our) death, and the last passage of this essay proposes its own reflection on this subject. Norbert Elias argues that each one of us is a homo clausus (Latin for “closed, self-sufficient being”). He believes that this condition is a consequence of our living an advanced phase in our individualized life. Surprisingly, he relates this self-sufficiency to the ritual of dying. He believes that in highly industrialized societies, a patient may benefit from the most recent technical and medical equipment, but that that person usually dies alone, meaning without his family/relatives around him. On the other hand, as he goes on to argue, “families in less developed states … often go hand in hand with far greater inequalities of power between men and women. [The dying] take leave of the world publicly, within a circle of people most of whom have strong emotive value for them, and for whom they themselves have a such a value. They die unhygienically, but not alone” (87). Elias does not explore this idea in depth, so we are left to wonder what he meant by dying unhygienically, or if he thought that method was better in coping with death. Also, he never mentioned the exact countries/regions he had in mind when he made that remark; therefore, we are left unsatisfied by his comment. Nonetheless, as Elias reminds us, it is important to remember that the traditional death rituals were and are intimate moments (and they should remain like this). The homo clausus idea may be linked with a body that is reaching its final embodiment, and hence becoming a closing-in-itself body. However, how does a body transact and/or negotiate the moments of its final embodiment? The process of sinking in one’s body, to which I refer, is not a visually, aurally, or especially olfactorily pleasant experience. Our deceitful memory misdirects our emotional brains by indicating which subsystem is still functional and open and which has become useless, that is, closed. In this light, we should redefine Elias’s idea by saying that what appears to be a monolithic structure — a body: closed, sealed, and/or self-contained — is in fact a very fluid body; that death does not reveal our self-centricity because that reasoning may generate an absurd idea, namely, we die alone because we have spent a life alone. Consequently, the dying body becomes the margin par excellence, which, because it is completely out of control, does not stop from leaking and/or emitting smells. This theory is confirmed by a study conducted on dying patients, Dying Process: Patients' Experiences of Palliative Care (2000), where Julia Lawton notes that “on a number of occasions, staff kept aromatherapy oil burners running throughout the day and night in an attempt to veil the odour of excretia, vomit and rotting flesh. … I observed that smell created a boundary around a patient, repelling others away” (135). One has to close one’s eyes to vaguely imagine what it must feel like for the medical personnel to keep the vigil of the dying bodies. Nonetheless, the lay community is exposed to photographs of the dying only on rare occasions. According to Gilman, these images are not made public because “The classical model of ‘healthy/beauty’ and ‘illness/ugliness’ is part of a cultural baggage that accompanies any representation of the ill or healthy body” (118-19). While the skin is endowed with the capacity of regenerating itself after it has been wounded, thus effacing time, a photograph of a dying body seems to efface one’s memory of one’s accumulated experiences. Such a photograph makes its contents (that is, the time, location, personal context of the shooting) disappear since its details will eventually fade away. As a corollary, the absent body effaces its photographed version, leaving it few chances to be remembered. The theme of the ars moriendi, as presented in this essay, has demonstrated that what dies is not only one’s body, but also the echoed memory of its erotic self. ReferencesElias, Norbert. The Loneliness of Dying. New York: Blackwell, 1985. Gilman, Sander. Picturing Health and Illness: Images of Identity and Difference. Baltimore: Johns Hopkins UP, 1995. Grosz, Elizabeth. Space, Time, and Perversion: Essays on the Politics of Bodies.New York: Routledge, 1995. Kramer, Larry. The Tragedy of Today’s Gay. New York: Penguin Group, 2005. Lawton, Julia. Dying Process: Patients' Experiences of Palliative Care. New York: Routledge, 2000. Leder, Drew. The Absent Body. Chicago: University of Chicago Press, 1990. Lupton, Deborah. The Imperative of Health: Public Health and the Regulated Body. Thousand Oaks, California: Sage Publications, 1995. Peggy Phelan. Mourning Sex: Performing Public Memories. New York: Routledge, 1997. Siebers, Tobin. The Body Aesthetic: From Fine Art to Body Modification. Ann Arbor: University of Michigan Press, 2000. Jennifer Terry. “The Seductive Power of Science in the Making of Deviant Subjectivity.” Posthuman Bodies. Eds. Judith Halberstam and Ira Livingston. Bloomington : Indiana University Press, 1995: 135-162. Yang, William. “Allan from Sadness: A Monologue with Slides.” Portraits in the Time of AIDS. Eds. Thomas W. Sokolowski and Rosalind Solomon. New York: Grey Art Gallery & Study Center, 1988: 34-51.

ObjectiveWeekly numbers of deaths are monitored to increase the capacity to deal with both expected and unusual (disease) events such as pandemic influenza, other infections and non-infectious incidents. The monitoring information can potentially be used to detect, track and estimate the impact of an outbreak or incident on all-cause mortality.IntroductionThe mortality monitoring system (initiated in 2009 during the influenza A(H1N1) pandemic) is a collaboration between the Centre for Infectious Disease Control (CIb) of National Institute for Public Health and the Environment (RIVM) and Statistics Netherlands. The system monitors nation-wide reported number of deaths (population size 2017: 17 million) from all causes, as cause of death information is not available real-time. Data is received from Statistics Netherlands by weekly emails.MethodsOnce a week the number of reported deaths is checked for excess above expected levels at 2 different time-lags: within 1 and 2 weeks after date of death (covering a median 43% and 96% of all deaths respectively). A weekly email bulletin reporting the findings is sent to the Infectious Disease Early Warning Unit (at CIb) and a summary of results is posted on the RIVM website. Any known concurrent and possibly related events are also reported. When excess deaths coincide with hot temperatures, the bulletin is sent to the Heat Plan Team (also at RIVM). Data are also sent to EuroMOMO which monitors excess mortality at a European level. For the Dutch system baselines and prediction limits are calculated using a 5 year historical period (updated each July). A serfling-like algorithm based on regression analysis is used to produce baselines which includes cyclical seasonal trends (models based on historical data in which weeks with extreme underreporting have been removed. Also periods with high excess mortality in winter and summer were removed so as not to influence the baseline with previous outbreaks).ResultsIncreased mortality started two weeks after the influenza epidemic started and remained increased during the remainder of the influenza epidemic except for a drop in week 52 (coinciding with Christmas holidays) (Figure 1). Excess mortality was primarily observed in persons 75 years or older. Cumulative excess mortality was estimated at 7,503 deaths occurring during the 15 weeks of the 2016/2017 influenza epidemic (week 48 of 2016 through week 10 of 2017) and at 8,890 during the total winter season (44 weeks running from week 40 up to week 20 of the next year).ConclusionsIn terms of number of deaths during the winter season (weeks 40-20 the next year) and during the influenza epidemic (weeks 48-10), the 2016/2017 season in the Netherlands was of high severity compared with the previous five seasons. Mortality was only higher in the 2014/2015 season when the longest influenza epidemic was recorded of 21 weeks.