Management of Delphi study regarding the development of ongoing behavioral risk factor surveillance system in the Republic of Moldova

Nicolae Testemitsanu Department of Social Medicine and Health Management, Nicolae Testemitsanu State University of Medicine and Pharmacy, Chisinau, the Republic of Moldova, Institute of Cardiology, Chisinau, the Republic of MoldovaBackground: Implementation of ongoing behavioral risk factor surveillance system (BRFSS) can improve prevention and control of noncommunicable diseases (NCDs) in the Republic of Moldova. Delphi study regarding the development of ongoing behavioral risk factor surveillance system in the Republic of Moldova contributes to evidence-based credible model of implementation in order to support National Strategy on Noncommunicable Diseases Prevention and Control for the period 2012-2020. The article has highlighted the aspects of designing Delphi survey which should be considered for making sense of consensus. Material and methods: The study used Delphi techniques to achieve in an effective way experts’ consensus in terms of development of ongoing BRFSS in the Republic of Moldova. Results: The research found that Delphi panelists similarly trained and competent in the area of knowledge related to the target issue contributed to achievement of the consensus agreement for all items in discussion regardless the national or international affiliation. Conclusions: Well-designed Delphi panel are important for effective and reasonable survey management in terms of achieving feasible consensus agreement to support effective decision-making for further development

Considerations on the development of functionality of noncommunicable diseases surveillance system in the Republic of Moldova

Introducere. Decesele premature cauzate de bolile netransmisibile ar putea fi reduse, în mare măsură, prin reducerea factorilor de risc modificabili. OMS a declarat dezvoltarea continuă a funcţionalităţii sistemului de supraveghere ca una din condiţiile-cheie pentru asigurarea realizării ţintei strategice globale (nr. 1) de reducere relativă de 25% a mortalităţii premature, cauzate de bolile netransmisibile către anul 2025 („25×25”). În Republica Moldova, supravegherea și monitorizarea factorilor de risc modificabili nu este, deocamdată, sistematică și integrată, nefiind nici parte componentă a Sistemului Informaţional Medical Integrat în resursele informaţionale de stat. În acest context, studiul și-a propus drept obiectiv general evidenţierea premiselor existente de dezvoltare a funcţionalităţii sistemului de supraveghere a factorilor de risc pentru bolile cardiovasculare și alte boli netransmisibile din Republica Moldova. Material și metode. S-a efectuat un studiu de sinteză a cadrului de politici de la nivel global și naţional, însoţit de evaluarea bunelor practici internaţionale, privind experienţa de supraveghere funcţională a factorilor de risc, testată în timp. Rezultate. Au fost identificate reperele conceptuale privind abordarea actuală în lume în vederea supravegherii factorilor de risc pentru bolile netransmisibile: (1) cooperarea internaţională; (2) asigurarea conformităţii capacităţii naţionale prin determinarea priorităţilor locale în acord cu principiul de cost-eficienţă maxim posibilă; (3) colaborare intersectorială și multisectorială, în special, la nivelul sistemului de sănătate, centrat pe asistenţa medicală primară, ca sector de primul contact cu populaţia. În paralel, rezultatele studiului au evidenţiat progresele Republicii Moldova, în vederea fortificării capacităţii naţionale privind răspunsul pentru bolile netransmisibile, elaborării strategiilor naţionale în coerenţă cu cele globale, asigurării consolidării cooperării intersectoriale și multisectoriale, optimizării resurselor instituţionale și umane în sistemul de sănătate sub aspect al prevenţiei și controlului bolilor netransmisibile. Concluzii. În Republica Moldova există premize pentru dezvoltarea funcţionalităţii sistemului de supraveghere a factorilor de risc, determinate de progresele realizate, alături de rezerve de perspectivă, privind continua îmbunătăţire prin ajustarea bunelor practici internaţionale.Introduction. According to World Health Organization (WHO) strategies, premature deaths due to noncommunicable diseases could be reduced substantially by reducing modifiable risk factors. WHO declared the continuously development of the surveillance system’s functionality as one of the key conditions in reaching the global strategic target (no. 1) on 25% relative reduction of premature mortality due to noncommunicable diseases by 2025 (“25×25”). In the Republic of Moldova, surveillance and monitoring of modifiable risk factors is not systematic nor integrated, being neither part of the Integrated Medical Information System within the state information resources. In this context, the study had as a general objective: to highlight the existing prerequisites for the development of the functional surveillance system for cardiovascular disease and other noncommunicable disease risk factors in the Republic of Moldova. Material and methods. A review study of the global and national policy framework was performed, accompanied by the evaluation of good international practice on risk factors surveillance functionality, proven over time. Results. Conceptual milestones on current global approaches to the surveillance of noncommunicable disease risk factors have been identified: (1) international cooperation; (2) ensuring national capacity compliance by determining local priorities in accordance with the principle of maximum possible cost-effectiveness; (3) cross-sectoral and multisectoral collaboration, particularly at the level of health system, focused on primary health care, as the sector of first contact with the population. In parallel, the study results highlighted the progress of the Republic of Moldova in strengthening national capacities to respond to noncommunicable disease challenges, to develop national strategies coherent with global ones, to ensure consolidation of cross-sectoral and multisectoral cooperation, to optimise institutional and human resources within the health system in order to prevent and control noncommunicable diseases. Conclusions. There are prerequisites in the Republic of Moldova to develop the functional risk factor surveillance system, determined by the accomplished progress along with some perspective limitations regarding continuous improvement through good international practice adjustment

Burden, cost of disease and optimization of clinical practice of human cystic echinococcosis in Mongolia

Our goal was to facilitate prevention and control of cystic echinococcosis (CE) in Mongolia by measuring the disease burden and societal cost, investigating the zoonotic linkages, and identifying the key challenges in clinical management of CE with proposed improvement. The disease is caused by the larval stage of Echinococcus granulosus sensu lato, and transmitted between dogs and various species of ungulates and also transmitted to humans. In humans, large cystic lesions can occur, mainly in the liver and lungs. Mongolia is one of the areas most affected by CE. The numbers of dogs and livestock are high, and a nomadic herding lifestyle is commonly practiced in most parts of the country. However, existing health services in Mongolia for CE barely reach the targeted populations, and CE cases are only detected at a late stage. For adequate diagnosis and treatment, herders must often travel hundreds of kilometers. Surgical procedures and hospitalization, travel costs, and lifelong disability following complicated surgeries are common for most patients. There is very limited information on infection in livestock populations due to the lack of public slaughterhouses and animal surveillance tools in the country. We collected data on human CE cases from hospital records, statistical departments, and ultrasound examination records. Estimates of the reported incidence were used to calculate disability-adjusted life years (DALYs). To estimate the economic cost, we interviewed 65 patients who had CE surgery. The societal cost, including direct medical, direct non-medical and indirect costs, was estimated. We investigated the zoonotic linkages using the data of surgical CE cases and the livestock population of four species, including sheep, goats, cattle, and camels. To support the statistical analysis, samples were collected from CE infected animals in an endemic province. The subspecies identification, genetic diversity and haplotype network analysis were conducted. To understand the current clinical management of CE, we organized Focus Group Discussions (FGD), surveyed health professionals using a questionnaire. The ultrasound cyst images were reviewed by international experts to critically contrast current national practice with WHO-Informal Working Group on Echinococcosis (WHO-IWGE) guideline. Key challenges and further potential improvements were discussed during a workshop with Mongolian and international experts to reach consensus for standardization of clinical practice. The incidence of surgical cases, diagnosed cases, and total cases including undiagnosed cases was estimated to be 2.2 per 100 000, 15 per 100 000 and 60 per 100 000 person-years, respectively. The DALY was estimated to be 11461 for total cases including undiagnosed cases and 3017 for diagnosed cases. The total societal cost due to human CE is USD 2.7million which equals 0.024% of total gross domestic product (GDP). The cost decreases to USD 0.3million when the productivity loss of undiagnosed and diagnosed cases is excluded. The impact on the household economies is high for surgical cases where 76% of the direct cost is paid by the patients. In total out-of-pocket expense, the cost of albendazole contributed most. US images of 84 patients were staged and assessed for interrater-agreement. The average raw agreement was 77.2%. Unweighted Kappa coefficient and weighted Kappa was 0.57 and 0.59, respectively. Mean proportion of images judged as stages CE1, CE2, CE3a, CE3b, CE4 and CL were 0.59, 0.01, 0.19, 0.08, 0.03 and 0.11 respectively. 40 cysts met the inclusion criteria of treatment modality analysis. The mean proportion of cases with a single cyst assigned to medical, percutaneous treatment, surgery and watch & wait were 52.5% (95% CI 42-65), 25.8% (95% CI 15-30), 5.1% (95% CI 0-10) and 3.3% (95% CI 0.0-10), respectively. 13.3% (95% CI 5–25) of cysts were staged as CL and therefore assigned to further diagnostic requirement. The incidence of surgical CE cases increased by a factor of 1.71 for one interquartile range increment in the density of the camel population. No significant association was observed with other livestock species. The samples collected from 96 camels and 15 goats in an endemic region showed a CE prevalence of 19.7% and 6.7%, respectively. All livestock CE were caused by E.granulosus s.l. G6/7 (formerly identified as E.granulosus canadensis G6/7) of the of the E. granulosus s.l. complex. Four haplotypes were identified within the livestock samples, two of which had not been previously reported. A common haplotype was identified between humans, camels, goats, and a wolf, all of which were within the same geographical area. A mixed infection of E. granulosus s.l. G6/G7 with different haplotypes in the intermediate host was identified first time. This is the first estimate of the burden and societal cost of human CE in Mongolia. Mongolia has a substantial proportion of the population suffering from cystic echinococcosis. The disease causes a significant amount of loss to society and household economy. Access to fully equipped treatment centers is limited by geographic distance and economic resources. Availability of albendazole is sparse,and the price is high. WHO-IWGE guidelines are not implemented for allocating patients within the four treatment options based on CE cyst staging, with the result that all CE patients are referred for surgical treatment. This creates an unnecessary high-risk approach for patients who could either be treated with albendazole or percutaneously or observed. Our study revealed evidence that camels play an important role contributing to human CE in Mongolia, which is a critical information for further control and prevention of CE

Economie agrara si dezvoltare rurala - realitati si perspective pentru Romania

The present volume is the collection of the conference papers presented on The 12th International Symposium Agricultural economics and rural development. Realities and perspectives for Romania, organized by The Research Institute for Agrarian Economy and Rural Development during 17 November 2021 of September, in Bucharest, Romania. The main aim of this symposium was both to present the newest research results and findings in field of agricultural and rural development research and, also to encourage the direct implementation of these results in practice by creating a strong cooperation between academicians and researchers with the field experts and investors

From Endgame to Long Game: A Multi-Method Analysis of Immunization, Integration, and Equity During Outbreak Response and Recovery in Low- and Middle-Income Countries

Background: Achieving and sustaining high levels of equitable immunization coverage during and after outbreaks remains a major public health challenge for many health systems in low- and middle-income countries (LMICs). Objectives: The objectives of this dissertation are to (1) describe vaccine delivery challenges that emerge during the last mile of outbreak response; (2) explore how routine immunization programs recover from epidemics; and (3) characterize the relationship between integrated vaccine delivery and equitable vaccination coverage. The ultimate goal of this investigation is to inform how decision-makers in LMICs might strengthen or reform vaccination systems to increase equitable immunization coverage. Methods: Paper 1 presents a conceptual framework of last mile challenges in vaccine delivery during outbreaks, based on a scoping literature review and key informant interviews. Paper 2 presents a comparative case study analysis of post-epidemic routine immunization challenges in Haiti and Liberia. Paper 3 applies group-based trajectory modeling to describe longitudinal trends in vaccination equity in 78 LMICs and examine associations between integrated vaccine delivery and equity. Results: In Paper 1, we find that last mile challenges in vaccine delivery may be conceptualized in terms of geography, epidemiology, target populations, and health system considerations, and span the domains of governance and leadership, surveillance, health workforces, program implementation, vaccine uptake, and population immunity. In Paper 2, we find that embedding in-country expertise within outbreak response structures, respecting governmental autonomy and self-determination, aligning post-epidemic recovery plans and policies, and integrating response assets into systems for routine care resulted in more equitable levels of immunization coverage. In Paper 3, we report positive associations between integrated vaccine delivery and both geographic and socioeconomic vaccination equity in select settings reporting high baseline levels of vaccination inequity. Conclusions: The health system challenges associated with achieving and sustaining high levels of equitable immunization coverage differ between pre-, post-, and inter-outbreak periods. Strengthening linkages within and between relevant health system components can help address these challenges in LMICs. Further research is needed to characterize the barriers and facilitators of equitable vaccine delivery in these settings

Understanding the clinical harms that contribute to morbidity among people who inject drugs

People who inject drugs (PWID) experience a range of clinical harms that contribute to morbidity and increase their risk of mortality. The literature has largely focused on the epidemiology of blood borne viruses (BBVs) in this population; however, other mental and physical conditions affect PWID that significantly impact quality of life. There are gaps in our understanding of the clinical profiles of PWID beyond the risk of BBVs which this thesis aims to address. This thesis employs various study designs to broaden our understanding of the clinical profiles of PWID. Firstly, three systematic reviews were conducted to synthesise the evidence and generate estimates of injecting frequency, non-fatal overdose, and mental health problems (i.e., depression, post-traumatic stress disorder [PTSD], suicidality, and non-suicidal self-harm) among PWID. Second, latent class analyses were performed using cross-sectional data from a national sentinel sample to examine profiles and correlates of PWID reporting recent injecting-related injuries and diseases (IRID). Finally, a large, linked cohort of people engaged in opioid agonist treatment (OAT) from 2001 to 2017 in New South Wales was analysed to examine the impact of OAT on hospitalisations for injecting-related diseases. Several key findings emerged from this thesis. Findings from the systematic reviews indicated that most PWID are injecting daily or more frequently and approximately one in five have experienced a recent non-fatal overdose. Fewer studies were identified that assessed mental disorders and self-harm among PWID; however, pooled estimates across studies suggested that perhaps nearly half of PWID have current severe depressive symptomology, and 22.1% have previously attempted suicide. The latent class analyses identified risk factors that may contribute to PWID experiencing more severe and multiple IRID, namely recent needle re-use and thrombophlebitis. Finally, there is a modest protective association between OAT retention and injecting-related diseases; however, hospitalisations for these diseases are increasing. These findings highlight several important areas for future research, and for clinical and public policy action. Namely, when we consider the healthcare needs of this population, we must consider this broad spectrum of pathology. Continued research into effective interventions that improve PWID health as well as expanding accessibility of existing interventions are crucial future steps

Emerging Threats of Synthetic Biology and Biotechnology

Synthetic biology is a field of biotechnology that is rapidly growing in various applications, such as in medicine, environmental sustainability, and energy production. However these technologies also have unforeseen risks and applications to humans and the environment. This open access book presents discussions on risks and mitigation strategies for these technologies including biosecurity, or the potential of synthetic biology technologies and processes to be deliberately misused for nefarious purposes. The book presents strategies to prevent, mitigate, and recover from ‘dual-use concern’ biosecurity challenges that may be raised by individuals, rogue states, or non-state actors. Several key topics are explored including opportunities to develop more coherent and scalable approaches to govern biosecurity from a laboratory perspective up to the international scale and strategies to prevent potential health and environmental hazards posed by deliberate misuse of synthetic biology without stifling innovation. The book brings together the expertise of top scholars in synthetic biology and biotechnology risk assessment, management, and communication to discuss potential biosecurity governing strategies and offer perspectives for collaboration in oversight and future regulatory guidance

Linkage to care following HIV diagnosis in Europe

Background: Attendance for clinical care promptly after diagnosis with human immunodeficiency virus (HIV) is important; delayed linkage to care and treatment has implications for the health of the individual and the public. In this thesis, I have explored entry into care in the World Health Organization European Region with an aim to inform and optimise public health monitoring. Methods: I utilised data from the literature and HIV surveillance data from Europe and England, Wales and Northern Ireland (EW&NI) to describe linkage to care and risk factors for poor linkage. I carried out a key informant survey of national HIV surveillance focal points to understand the context within which linkage occurs in Europe and investigate the current capacity of countries to monitor linkage to care for public health purposes. Results: Overall, 38/53 countries from Europe were able to contribute routinely collected CD4 data to this, the first European estimate of linkage to care; 80% of included HIV diagnoses made between 2014 and 2016 were ever linked to care, 73%-92% within three months of diagnosis. However, linkage varied widely by region. Several groups were identified as being at higher risk of delayed linkage to care: people who acquired HIV through injecting drug use or heterosexual contact (Europe), people of younger age at diagnosis (Western Europe), migrants (Western Europe), people who had a higher first CD4 count (Western Europe) and people diagnosed outside of sexual health clinics (EW&NI). The survey identified a number of barriers to using surveillance data to monitor linkage to care, but ultimately validated the use of CD4 as a proxy for care entry. Conclusion: The findings of this thesis have implications for public health action and have informed the development of monitoring of linkage to care at the European Centre for Disease Prevention and Control and Public Health England

Driving Manufacturing Systems for the Fourth Industrial Revolution

It has been a long way since the aroused of the Industry 4.0 and the companies' reality is not already align with this new concept. Industry 4.0 is ongoing slowly as it was expected that its maturity level should be higher. The companies´ managers should have a different approach to the adoption of the industry 4.0 enabling technologies on their manufacturing systems to create smart nets along all production process with the connection of elements on the manu-facturing system such as machines, employees, and systems. These smart nets can control and make autonomous decisions efficiently. Moreover, in the industry 4.0 environment, companies can predict problems and failures along all production process and react sooner regarding maintenance or production changes for instance. The industry 4.0 environment is a challenging area because changes the relation between humans and machines. In this way, the scope of this thesis is to contribute to companies adopting the industry 4.0 enabling technologies in their manufacturing systems to improve their competitiveness to face the incoming future. For this purpose, this thesis integrates a research line oriented to i) the understanding of the industry 4.0 concepts, and its enabling technologies to perform the vision of the smart factory, ii) the analysis of the industry 4.0 maturity level on a regional industrial sector and to understand how companies are facing the digital transformation challenges and its barriers, iii) to analyze in deep the industry 4.0 adoption in a company and understand how this company can reach higher maturity levels, and iv) the development of strategic scenarios to help companies on the digital transition, proposing risk mitigations plans and a methodology to develop stra-tegic scenarios. This thesis highlights several barriers to industry 4.0 adoption and also brings new ones to academic and practitioner discussion. The companies' perception related to these barriers Is also discussed in this thesis. The findings of this thesis are of significant interest to companies and managers as they can position themselves along this research line and take advantage of it using all phases of this thesis to perform a better knowledge of this industrial revolution, how to perform better industry 4.0 maturity levels and they can position themselves in the proposed strategic scenarios to take the necessary actions to better face this industrial revolution. In this way, it is proposed this research line for companies to accelerate their digital transformation.Já existe um longo percurso desde o aparecimento da indústria 4.0 e a realidade das empresas ainda não está alinhada com este novo conceito. A indústria 4.0 está em andamento lento, pois era esperado que o seu nível de maturidade fosse maior. Os gestores das empresas devem ter uma abordagem diferente na adoção das tecnologias facilitadoras da indústria 4.0 nos seus sistemas produtivos para criar redes inteligentes ao longo de todo o processo produtivo com a conexão de elementos do sistema produtivo como máquinas, operários e sistemas. Estas redes inteligentes podem controlar e tomar decisões autónomas com eficiência. Além disso, no ambiente da indústria 4.0, as empresas podem prever problemas e falhas ao longo de todo o processo produtivo e reagir mais cedo em relação a manutenções ou mudanças de produção, por exemplo. O ambiente da indústria 4.0 é uma área desafiadora devido às mudanças na relação entre humanos e máquinas. Desta forma, o objetivo desta tese é contribuir para que as empresas adotem as tecnologias facilitadoras das indústria 4.0 nos seus sistemas produtivos por forma a melhorar sua competitividade para enfrentar o futuro que se aproxima. Para isso, esta tese integra uma linha de investigação orientada para i) a compreensão dos conceitos da indústria 4.0, e suas tecnologias facilitadores para realizar a visão da fábrica inteligente, ii) a análise do nível de maturidade da indústria 4.0 num setor industrial regional e entender como as empresas estão enfrentando os desafios da transformação digital e suas barreiras, iii) analisar a fundo a adoção da indústria 4.0 numa empresa e entender como essa empresa pode atingir níveis mais elevados de maturidade, e iv) o desenvolvimento de cenários estratégicos para ajudar as empresas na transição digital, propondo planos de mitigação de riscos e uma metodologia para desenvolver cenários estratégicos. Esta tese destaca várias barreiras à adoção da indústria 4.0 e também traz novas barreiras para a discussão acadêmica e profissional. A perceção das empresas em relação a essas barreiras também é discutida nesta tese. As descobertas nesta tese são de grande interesse para empresas e gestores, pois podem-se posicionar ao longo desta linha de investigação e aproveitá-la utilizando todas as fases desta tese para obter um melhor conhecimento desta revolução industrial, como obter melhores níveis de maturidade da indústria 4.0 e possam posicionar-se nos cenários estratégicos propostos por forma a tomar as ações necessárias para melhorar o envolvimento nesta revolução industrial. Desta forma, propõe-se esta linha de investigação para que as empresas acelerem a sua transformação digital