Free and simple GIS as appropriate for health mapping in a low resource setting: a case study in eastern Indonesia

Background: Despite the demonstrated utility of GIS for health applications, there are perceived problems in low resource settings: GIS software can be expensive and complex; input data are often of low quality. This study aimed to test the appropriateness of new, inexpensive and simple GIS tools in poorly resourced areas of a developing country. GIS applications were trialled in pilot studies based on mapping of health resources and health indicators at the clinic and district level in the predominantly rural province of Nusa Tenggara Timur in eastern Indonesia. The pilot applications were (i) rapid field collection of health infrastructure data using a GPSenabled PDA, (ii) mapping health indicator data using open source GIS software, and (iii) service availability mapping using a free modelling tool. Results: Through contextualised training, district and clinic staff acquired skills in spatial analysis and visualisation and, six months after the pilot studies, they were using these skills for advocacy in the planning process, to inform the allocation of some health resources, and to evaluate some public health initiatives.Conclusions: We demonstrated that GIS can be a useful and inexpensive tool for the decentralisation of health data analysis to low resource settings through the use of free and simple software, locally relevant training materials and by providing data collection tools to ensure data reliability

Defining Remoteness from Health Care: Integrated Research on Accessing Emergency Maternal Care in Indonesia<br />

The causes of maternal death are well known, and are largely preventable if skilled health care is received promptly. Complex interactions between geographic and socio-cultural factors affect access to, and remoteness from, health care but research on this topic rarely integrates spatial and social sciences. In this study, modeling of travel time was integrated with social science research to refine our understanding of remoteness from health care. Travel time to health facilities offering emergency obstetric care (EmOC) and population distribution were modelled for a district in eastern Indonesia. As an index of remoteness, the proportion of the population more than two hours estimated travel time from EmOC was calculated. For the best case scenario (transport by ambulance in the dry season), modelling estimated more than 10,000 fertile aged women were more than two hours from EmOC. Maternal mortality ratios were positively correlated with the remoteness index, however there was considerable variation around this relationship. In a companion study, ethnographic research in a subdistrict with relatively good access to health care and high maternal mortality identified factors influencing access to EmOC, including some that had not been incorporated into the travel time model. Ethnographic research provided information about actual travel involved in requesting and reaching EmOC. Modeled travel time could be improved by incorporating time to deliver request for care. Further integration of social and spatial methods and the development of more dynamic travel time models are needed to develop programs and policies to address these multiple factors to improve maternal health outcomes

The Vulnerability of Groundwater Resources to Climate Change in Timor-Leste. Prepared for the Australian Government Department of Climate Change and Enerfy Efficiency by B. Mayers, R. Fisher, T. Paul P. Wurm. A. Campbell, Research Institute for the Enviro

This report is part of a two part study of the vulnerability of Timor-Leste&rsquo;s ground water resources, and those who use them, to predicted climate change.In this part of the study by Charles Darwin University (CDU) we focus on potential impact and adaptive capacity to address the vulnerability of Districts to water availability, and provide recommendations for water management. The second part of the study, by Geosciences Australia and presented separately, investigates the biophysical vulnerability of Timor Leste (of the aquifers) to climate change.This report uses a mixed methods approach including:&bull; Review of current climate change predictions&bull; Review of information about aquifer characteristics, provided by the GA study&bull; Assessment of exposure of aquifers to pressure by groundwater users, by reviewing population distribution and growth&bull; Evaluation of adaptive capacity of groundwater users, using census data on indicators of wealth, and field interviews about use and management of water resources.Using these methods we identify priority areas for action in water management and current and potential adaptation options. These options link readily to the National Adaptation Programmes of Action for Timor-Leste (NAPA), and we have also ranked them broadly in terms of predicted cost of implementation.Timor-Leste is a small island developing state, located in the eastern part of the lesser Sunda Islands archipelago. Topography is rugged, with the central mountains of the island reaching altitudes of almost 3000m. The climate is monsoonal, and annual rainfall varies with elevation and aspect, from less than 1000mm in some coastal areas to over 2500mm in the wettest high altitude areas. Timor-Leste has a complex geology and much of the bedrock is sedimentary calcareous rock with shallow soils of low water holding capacity, high alkalinity and low nutrient content.According to the national census, in 2010 Timor-Leste had a population of 1.07 million. Population growth is high (2.4%), fertility rate is high (5.7 births for each fertile aged woman) and the population is relatively young (41% under 14 years, 54% between 15-66 years, and about 5% over 65 years).Already, water insecurity is widespread in Timor-Leste and is a major limitation of food security and livelihoods. Low-input agriculture is the main economic activity in Timor-Leste, with over 86% of households involved in subsistence farming. The main staple crops are rice, maize and cassava, with the limited rice production on the coastal plains fed by gravity irrigation and maize widely grown on the uplands.Geoscience Australia has classified aquifer types in Timor-Leste according to geology and &ldquo;prospectivity&rdquo;, i.e. potential flow rates or yields. The major aquifer types in Timor-Leste are:&bull; Sedimentary aquifers with intergranular porosity, which have potential to hold large amounts of groundwater. Alluvial sedimentary aquifers have potential to be high yielding aquifers, with higher yield associated with greater porosity where sediments are more well-sorted (e.g. Dili).&bull; Limestone karstic aquifers with fissured porosity are associated with many springs fed by groundwater and are sensitive to rainfall. In limestone areas, groundwater recharge, storage and yield are affected by the age of the system which determines whether fissures and channels have formed (e.g. in and around Baucau).&bull; Fractured rock aquifers with localised porosity are low yielding and usually only sufficient for household use and animal watering. There is little or no porosity and groundwater is stored in existing fractures, with new channels not becoming larger with time (e.g. Lequidoe in Aileu District).A substantial proportion (about 33%) of the population live on high yielding sedimentary aquifers, particularly on the coast, such as in Dili District, however, most of the population (44%) live on localised aquifers in the highlands (approximately equally on high yielding karst and low yielding localised fractured rock aquifers aquifers).Uncertainty in climate change projections for Timor-Leste is relatively high because Timor-Leste is a similar in size to the grid cells of the models used for projections, has variable topography and little climatic data with which to test the validity of the models that underpin the projections.The most recent climate projections for Timor-Leste have been published by the Pacific Climate Change Science Program (www.pacificclimatechangescience.org). These projections include:&bull; warming of average air and sea temperatures (by 0.4-1.0oC by 2030 under a high emissions scenario);&bull; decrease in dry season and increase in wet season rainfall;&bull; extreme rainfall events to occur more frequently;&bull; decrease in frequency and increase in high intensity cyclones;&bull; sea level rise will continue (by 6-15cm by 2030 under a high emissions scenario)&bull; ocean acidification will continue.Impacts of climate change are discussed within the following framework:Exposure of groundwater resources to climate change were derived from prospectivity of aquifers as determined by Geoscience Australia. Sensitivity of groundwater resources was mapped by overlaying relative aquifer yield and modelled annual rainfall. Areas along the central northern coast and in Oecussi are expected to be particularly sensitive. Sensitivity was also considered in terms of population pressures, both density and rate of change.Potential impacts of climate change were a function of expected exposure to climate change and sensitivity to those changes. High potential impact was identified in several areas on low yielding, localised aquifers: Liquica District, with low rainfall west of Dili; the Districts of Ainaro, Aileu, Bobonaro, and Ermera, with high and rapidly growing populations; Oecussi District, with high population growth and low rainfall. The major towns of Dili and Baucau can also be considered sites of high potential impacts because of high population densities and high population growth rates. This is despite having relatively high yielding aquifers: high yielding sedimentary aquifer in the case of Dili and high yielding fissured aquifer in the case of Baucau. In addition, the surrounding hills are underlain by low yielding fractured rock aquifers.Vulnerability to climate change is a product of potential impacts and adaptive capacity.High adaptive capacity can minimise the vulnerability of a community or nation in the face of high potential impacts. Adaptive capacity is influenced by many factors, including poverty, education, health and social capital. We derived some possible indicators of adaptive capacity using data from the national census and Demographic and Health Survey, and from field surveys at sites representing the main aquifer types. This investigation indicated higher vulnerability due to potentially low adaptive capacity in some Districts. Dili is wealthy compared with other Districts and this may represent relatively high capacity for adaptation. Other factors, such as implementation of some health programs and evidence of community management bodies, suggest high adaptive capacity in other Districts. Current adaptation strategies in some sites included cooperative management of water resources, moving temporarily when water sources became unavailable, carrying water, and collecting rainwater.In summary, the following adaptation options are recommended:1. Documentation and monitoring of ground water resources &ndash; to improve understanding of water availability;2. Integrated water harvesting and storage, and irrigation maintenance &ndash; to build local resilience and adaptive capacity;3. Agricultural diversification - to build resilience and adaptive capacity;4. Improving governance (policy and regulation) &ndash; to reduce waste and over use, to secure availability and access, and to increase adaptive capacity.The people of Timor-Leste face substantial challenges in coping with the variability of the current climate, and further challenges regarding the expected changes to climate and water availability. Options for adaptations to climate change should be considered in the context of food security and sustainable agriculture and natural resource management practices at community, landscape and national scales. The need for this broader framework is stipulated in the National Adaptation Programmes of Action for Timor-Leste (NAPA)

Analysis of a Fragmenting Sunspot using Hinode Observations

We employ high resolution filtergrams and polarimetric measurements from Hinode to follow the evolution of a sunspot for eight days starting on June 28, 2007. The imaging data were corrected for intensity gradients, projection effects, and instrumental stray light prior to the analysis. The observations show the formation of a light bridge at one corner of the sunspot by a slow intrusion of neighbouring penumbral filaments. This divided the umbra into two individual umbral cores. During the light bridge formation, there was a steep increase in its intensity from 0.28 to 0.7 I_QS in nearly 4 hr, followed by a gradual increase to quiet Sun (QS) values in 13 hr. This increase in intensity was accompanied by a large reduction in the field strength from 1800 G to 300 G. The smaller umbral core gradually broke away from the parent sunspot nearly 2 days after the formation of the light bridge rendering the parent spot without a penumbra at the location of fragmentation. The penumbra in the fragment disappeared first within 34 hr, followed by the fragment whose area decayed exponentially with a time constant of 22 hr. The depleted penumbra in the parent sunspot regenerated when the inclination of the magnetic field at the penumbra-QS boundary became within 40 deg. from being completely horizontal and this occurred near the end of the fragment's lifetime. After the disappearance of the fragment, another light bridge formed in the parent which had similar properties as the fragmenting one, but did not divide the sunspot. The significant weakening in field strength in the light bridge along with the presence of granulation is suggestive of strong convection in the sunspot which might have triggered the expulsion and fragmentation of the smaller spot. Although the presence of QS photospheric conditions in sunspot umbrae could be a necessary condition for fragmentation, it is not a sufficient one.Comment: Accepted for publication in ApJ; 15 pages, 15 figures, 1 tabl

A systematic review of the safety of topical therapies for atopic dermatitis

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75613/1/j.1365-2133.2006.07538.x.pd

Adolescent transport and unintentional injuries: a systematic analysis using the Global Burden of Disease Study 2019

Background: Globally, transport and unintentional injuries persist as leading preventable causes of mortality and morbidity for adolescents. We sought to report comprehensive trends in injury-related mortality and morbidity for adolescents aged 10–24 years during the past three decades. Methods: Using the Global Burden of Disease, Injuries, and Risk Factors 2019 Study, we analysed mortality and disability-adjusted life-years (DALYs) attributed to transport and unintentional injuries for adolescents in 204 countries. Burden is reported in absolute numbers and age-standardised rates per 100 000 population by sex, age group (10–14, 15–19, and 20–24 years), and sociodemographic index (SDI) with 95% uncertainty intervals (UIs). We report percentage changes in deaths and DALYs between 1990 and 2019. Findings: In 2019, 369 061 deaths (of which 214 337 [58%] were transport related) and 31·1 million DALYs (of which 16·2 million [52%] were transport related) among adolescents aged 10–24 years were caused by transport and unintentional injuries combined. If compared with other causes, transport and unintentional injuries combined accounted for 25% of deaths and 14% of DALYs in 2019, and showed little improvement from 1990 when such injuries accounted for 26% of adolescent deaths and 17% of adolescent DALYs. Throughout adolescence, transport and unintentional injury fatality rates increased by age group. The unintentional injury burden was higher among males than females for all injury types, except for injuries related to fire, heat, and hot substances, or to adverse effects of medical treatment. From 1990 to 2019, global mortality rates declined by 34·4% (from 17·5 to 11·5 per 100 000) for transport injuries, and by 47·7% (from 15·9 to 8·3 per 100 000) for unintentional injuries. However, in low-SDI nations the absolute number of deaths increased (by 80·5% to 42 774 for transport injuries and by 39·4% to 31 961 for unintentional injuries). In the high-SDI quintile in 2010–19, the rate per 100 000 of transport injury DALYs was reduced by 16·7%, from 838 in 2010 to 699 in 2019. This was a substantially slower pace of reduction compared with the 48·5% reduction between 1990 and 2010, from 1626 per 100 000 in 1990 to 838 per 100 000 in 2010. Between 2010 and 2019, the rate of unintentional injury DALYs per 100 000 also remained largely unchanged in high-SDI countries (555 in 2010 vs 554 in 2019; 0·2% reduction). The number and rate of adolescent deaths and DALYs owing to environmental heat and cold exposure increased for the high-SDI quintile during 2010–19. Interpretation: As other causes of mortality are addressed, inadequate progress in reducing transport and unintentional injury mortality as a proportion of adolescent deaths becomes apparent. The relative shift in the burden of injury from high-SDI countries to low and low–middle-SDI countries necessitates focused action, including global donor, government, and industry investment in injury prevention. The persisting burden of DALYs related to transport and unintentional injuries indicates a need to prioritise innovative measures for the primary prevention of adolescent injury. Funding: Bill &amp; Melinda Gates Foundation

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection