Vanuatu: Accountability from the Subsistence Age to the Internet Age

Commentary: Vanuatu governments are not used to being held accountable. They act like they do not owe any explanation to the public about what they are doing. Rather than taking the initiative, successive Vanuatu governments seem to address significant issues only if they are forced by sustained public pressure in the private media to do so

Reduction of missed appointments at an urban primary care clinic: a randomised controlled study

<p>Abstract</p> <p>Background</p> <p>Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments.</p> <p>Methods</p> <p>We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile) reminder; 2. If no phone response: a Short Message Service (SMS) reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded.</p> <p>Results</p> <p>2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p < 0.005), and allowed to reallocate 28% of cancelled appointments. It also proved to be cost effective in providing a total net benefit of 1846. - EUR/3 months. A satisfaction survey conducted with 241 patients showed that 93% of them were not bothered by the reminders and 78% considered them to be useful. By multivariate analysis, the following characteristics were significant predictors of missed appointments: younger age (OR per additional decade 0.82; CI 0.71-0.94), male gender (OR 1.72; CI 1.18-2.50), follow-up appointment >1year (OR 2.2; CI: 1.15-4.2), substance abuse (2.09, CI 1.21-3.61), and being an asylum seeker (OR 2.73: CI 1.22-6.09).</p> <p>Conclusion</p> <p>A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders.</p

Identification of two new protective pre-erythrocytic malaria vaccine antigen candidates

<p>Abstract</p> <p>Background</p> <p>Despite years of effort, a licensed malaria vaccine is not yet available. One of the obstacles facing the development of a malaria vaccine is the extensive heterogeneity of many of the current malaria vaccine antigens. To counteract this antigenic diversity, an effective malaria vaccine may need to elicit an immune response against multiple malaria antigens, thereby limiting the negative impact of variability in any one antigen. Since most of the malaria vaccine antigens that have been evaluated in people have not elicited a protective immune response, there is a need to identify additional protective antigens. In this study, the efficacy of three pre-erythrocytic stage malaria antigens was evaluated in a <it>Plasmodium yoelii</it>/mouse protection model.</p> <p>Methods</p> <p>Mice were immunized with plasmid DNA and vaccinia virus vectors that expressed one, two or all three <it>P. yoelii </it>vaccine antigens. The immunized mice were challenged with 300 <it>P. yoelii </it>sporozoites and evaluated for subsequent infection.</p> <p>Results</p> <p>Vaccines that expressed any one of the three antigens did not protect a high percentage of mice against a <it>P. yoelii </it>challenge. However, vaccines that expressed all three antigens protected a higher percentage of mice than a vaccine that expressed PyCSP, the most efficacious malaria vaccine antigen. Dissection of the multi-antigen vaccine indicated that protection was primarily associated with two of the three <it>P. yoelii </it>antigens. The protection elicited by a vaccine expressing these two antigens exceeded the sum of the protection elicited by the single antigen vaccines, suggesting a potential synergistic interaction.</p> <p>Conclusions</p> <p>This work identifies two promising malaria vaccine antigen candidates and suggests that a multi-antigen vaccine may be more efficacious than a single antigen vaccine.</p

Adenovirus-5-Vectored P. falciparum Vaccine Expressing CSP and AMA1. Part B: Safety, Immunogenicity and Protective Efficacy of the CSP Component

Background: A protective malaria vaccine will likely need to elicit both cell-mediated and antibody responses. As adenovirus vaccine vectors induce both these responses in humans, a Phase 1/2a clinical trial was conducted to evaluate the efficacy of an adenovirus serotype 5-vectored malaria vaccine against sporozoite challenge.\ud \ud Methodology/Principal Findings: NMRC-MV-Ad-PfC is an adenovirus vector encoding the Plasmodium falciparum 3D7 circumsporozoite protein (CSP). It is one component of a two-component vaccine NMRC-M3V-Ad-PfCA consisting of one adenovector encoding CSP and one encoding apical membrane antigen-1 (AMA1) that was evaluated for safety and immunogenicity in an earlier study (see companion paper, Sedegah et al). Fourteen Ad5 seropositive or negative adults received two doses of NMRC-MV-Ad-PfC sixteen weeks apart, at 1x1010 particle units per dose. The vaccine was safe and well tolerated. All volunteers developed positive ELISpot responses by 28 days after the first immunization (geometric mean 272 spot forming cells/million[sfc/m]) that declined during the following 16 weeks and increased after the second dose to levels that in most cases were less than the initial peak (geometric mean 119 sfc/m). CD8+ predominated over CD4+ responses, as in the first clinical trial. Antibody responses were poor and like ELISpot responses increased after the second immunization but did not exceed the initial peak. Pre-existing neutralizing antibodies (NAb) to Ad5 did not affect the immunogenicity of the first dose, but the fold increase in NAb induced by the first dose was significantly associated with poorer antibody responses after the second dose, while ELISpot responses remained unaffected. When challenged by the bite of P. falciparum-infected mosquitoes, two of 11 volunteers showed a delay in the time to patency compared to infectivity controls, but no volunteers were sterilely protected.\ud \ud Significance: The NMRC-MV-Ad-PfC vaccine expressing CSP was safe and well tolerated given as two doses, but did not provide sterile protection

Understanding Hydrologic Alteration of Mediterranean-Climate Streams Using a Functional Flows Approach

Rivers have a fundamental importance to human civilization and are considered the primary source of renewable freshwater supply for societies worldwide. Human prosperity depends heavily on surface water and the groundwater it replenishes, but this growth often comes with a heavy cost to river health. Rivers worldwide and particularly in arid climates have experienced profound levels of human alterations, particularly through damming, that affect flow patterns, channel form, and species composition. Functional flows theory offers a promising method to characterize ecologically-important aspects of flow and how changes to flow patterns may affect ecosystems. The goal of this dissertation is to quantify and understand hydrologic alteration of rivers and its ecological effects using a functional flows approach. This work validates functional flows as an effective strategy for ecological streamflow analysis with evidence that they can be used to differentiate California’s natural flow regimes, quantify streamflow response to climate change, and reveal the links between flow management and riparian forest health. Chapter 1 describes creation of a novel tool to quantify functional flow metrics for Mediterranean streamflow patterns using time series analysis methods. Chapter 2 characterizes climate-caused changes to streamflow in snowmelt-dependent regions of California, highlighting the importance of both temperature increase on functional flow change and human emissions levels on potential outcomes. Chapter 3 describes an ecohydrologic field study linking riparian cottonwood growth to functional flows and offers promising evidence that environmental flows can lead to measurable improvement in riparian forest productivity. This dissertation advances river science through the creation and implementation of new tools that can be used to balance human and ecological needs of streamflow

Projected Effects of Temperature and Precipitation Variability Change on Streamflow Patterns Using a Functional Flows Approach

Abstract Streamflow patterns are shifting with climate change, and these shifts pose increasing risk to freshwater ecosystems. These emerging changes must be linked with ecological functions of river systems to understand how climate change may affect freshwater biota. In this study we used a functional flows approach to analyze the ecological effects of changing streamflow patterns in snowmelt‐dominated watersheds of the Sierra Nevada mountains of California. Our climate change modeling method combined ensemble Global Climate Models (GCMs) and decision scaling methods to incorporate the effects of GCM‐projected changes in precipitation variability on streamflow patterns. Of climate parameters explored, air temperature causes the most change in functional flows, although precipitation variability compounds changes driven by air temperature. The greatest changes in ecologically‐relevant streamflow patterns manifest as longer and drier dry season conditions, earlier snowmelt recession, and higher‐magnitude peak flows. Although the directions of changes in functional flow metrics are largely consistent across models and watersheds, the magnitude of change depends strongly on human emissions levels. The analytical approach used in this study can serve as a model for integrating multiple approaches in hydroclimatic assessment of ecological change, and the results can help prioritize specific aspects of the flow regime for restoration efforts