A costing exercise of provision of prevention of HIV transmission from mother to child services in Vietnam

Objectives. This dissertation focuses on estimating the cost of providing a minimum package of prevention of mother-to-child HIV transmission (PMTCT) in Vietnam from a societal perspective and discussing the issues of scaling-up the minimum package nationwide. ^ Methods. Through collection of cost-related data of PMTCT services at 22 PMTCT sites in 5 provinces (Hanoi, Quang Ninh, Thai Nguyen, Hochiminh City, and An Giang) in Vietnam, the research investigates the item cost of each service in minimum PMTCT packages and the actual cost per PMTCT site at different organizational levels including central, provincial, and district. Next, the actual cost per site at each organizational level is standardized by adjusting for HIV prevalence rate to arrive at standardized costs per site. This study then uses the standardized costs per site to project, by different scenarios, the total cost to scale-up the PMTCT program in Vietnam. ^ Results. The cost for HIV tests, infant formula, and salary of health workers are consistently found to be the biggest expenditures in the PMTCT minimum package program across all organizational levels. Annual cost for drugs for prophylaxis treatment, operating and capital, and training costs are not substantial (less than 5% of total costs at all levels). The actual annual estimated cost for a PMTCT site at the central level is nearly VND 1.9 billion or US$ 107,650 (exchange rate US$ 1 = VND 17,500) while the annual cost for a provincial site is VND 375 million or US$ 21,400. The annual cost for a district site is VND 139 million (∼US$ 8,000). ^ The estimated total annual cost to roll out the PMTCT minimum package to the 5 studied provinces is approximately US$ 1.1 million. If the PMTCT program is to be scaled-up to 14 provinces until 2008 and up to 40 provinces through the end of 2010 as planned by the Ministry of Health, it would cost the health system an approximate annual amount of US$ 2.1 million and US$ 5.04 million, respectively. The annual cost for scaling-up the PMTCT minimum package nationwide is around US$ 7.6 million. Meanwhile, the total annual cost to implement PMTCT minimum packages to achieve PMTCT national targets in 2010 (providing counseling service to 90% of all pregnant women; 60% of them will receive HIV tests and 100% of HIV (+) mother and their newborn will receive prophylaxis treatment) would be US$ 6.1 million. ^ Recommendations. This study recommends: (1) the Ministry of Health of Vietnam should adjust its short-term national targets to a more feasible and achievable level given the current level of available resources; (2) a detailed budget for scaling-up the PMTCT program should be developed together with the national PMTCT action plan; (3) the PMTCT scaling-up plan developed by the Ministry of Health should focus on coverage of high prevalence population and quality of services provided rather than number of physical provinces reached; (4) exclusive breastfeeding strategy should be promoted as part of the PMTCT program; and (5) for a smooth and effective rolling out of PMTCT services nationwide, development of a national training plan and execution of this plan must precede any other initiations of the PMTCT scaling-up plan. ^

An epidemiologic evaluation of a worksite based intervention

The healthcare industry spends billions on worker injury and employee turnover. Hospitals and healthcare settings have one of the highest rates of lost days due to injuries. The occupational hazards for healthcare workers can be classified into biological, chemical, ergonomic, physical, organizational, and psychosocial. Therefore, interventions addressing a range of occupational health risks are needed to prevent injuries and reduce turnover and reduce costs. ^ The Sacred Vocation Program (SVP) seeks to change the content of work, i.e., the meaningfulness of work, to improve work environments. The SVP intervenes at both the individual and organizational level. First the SVP attempts to connect healthcare workers with meaning from their work through a series of 5 self-discovery group sessions. In a sixth session the graduates take an oath recommitting them to do their work as a vocation. Once motivated to connect with meaning in their work, a representative employee group meets in a second set of five meetings. This representative group suggests organizational changes to create a culture that supports employees in their calling. The employees present their plan in the twelfth session to management beginning a new phase in the existing dialogue between employees and management. ^ The SVP was implemented in a large Dallas hospital (almost 1000 licensed beds). The Baylor University Medical Center (BUMC) Pastoral Care department invited front-line caregivers (primarily Patient Care Assistants, PCAs, or Patient Care Technicians, PCTs) to participate in the SVP. Participants completed SVP questionnaires at the beginning and following SVP implementation. Following implementation, employer records were collected on injury, absence and turnover to further evaluate the program's effectiveness on metrics that are meaningful to managers in assessing organizational performance. This provided an opportunity to perform an epidemiological evaluation of the intervention using the two sources of information: employee self-reports and employer administrative data. ^ The ability to evaluate the effectiveness of the SVP on program outcomes could be limited by the strength of the measures used. An ordinal CFA performed on baseline SVP questionnaire measurements examined the construct validity and reliability of the SVP scales. Scales whose item-factor structure was confirmed in ordinal CFA were evaluated for their psychometric properties (i.e., reliability, mean, ceiling and floor effects). CFA supported the construct validity of six of the proposed scales: blocks to spirituality, meaning at work, work satisfaction, affective commitment, collaborative communication, and MHI-5. Five of the six scales confirmed had acceptable measures of reliability (all but MHI-5 had α>0.7). All six scales had a high percentage (>30%) of the scores at the ceiling. These findings supported the use of these items in the evaluation of change although strong ceiling effects may hinder discerning change. ^ Next, the confirmed SVP scales were used to evaluate whether the intervention improved program constructs. To evaluate the SVP a one group pretest-posttest design compared participants’ self-reports before and after the intervention. It was hypothesized that measurements of reduced blocks to spirituality (α = 0.76), meaning at work (α = 0.86), collaborative communication (α = 0.67) and SVP job tasks (α = 0.97) would improve following SVP implementation. The SVP job tasks scale was included even though it was not included in the ordinal CFA analysis due to a limited sample and high inter-item correlation. Changes in scaled measurements were assessed using multilevel linear regression methods. All post-intervention measurements increased (increases <0.28 points) but only reduced blocks to spirituality was statistically significant (0.22 points on a scale from 1 to 7, p < 0.05) after adjustment for covariates. Intensity of the intervention (stratifying on high participation units) strengthened effects; but were not statistically significant. The findings provide preliminary support for the hypothesis that meaning in work can be improved and, importantly, lend greater credence to any observed improvements in the outcomes. (Abstract shortened by UMI.)^

HPV vaccine coverage in Texas counties: An application of multilevel, small area estimation

Health departments, research institutions, policy-makers, and healthcare providers are often interested in knowing the health status of their clients/constituents. Without the resources, financially or administratively, to go out into the community and conduct health assessments directly, these entities frequently rely on data from population-based surveys to supply the information they need. Unfortunately, these surveys are ill-equipped for the job due to sample size and privacy concerns. Small area estimation (SAE) techniques have excellent potential in such circumstances, but have been underutilized in public health due to lack of awareness and confidence in applying its methods. The goal of this research is to make model-based SAE accessible to a broad readership using clear, example-based learning. Specifically, we applied the principles of multilevel, unit-level SAE to describe the geographic distribution of HPV vaccine coverage among females aged 11-26 in Texas.^ Multilevel (3 level: individual, county, public health region) random-intercept logit models of HPV vaccination (receipt of ≥ 1 dose Gardasil® ) were fit to data from the 2008 Behavioral Risk Factor Surveillance System (outcome and level 1 covariates) and a number of secondary sources (group-level covariates). Sampling weights were scaled (level 1) or constructed (levels 2 & 3), and incorporated at every level. Using the regression coefficients (and standard errors) from the final models, I simulated 10,000 datasets for each regression coefficient from the normal distribution and applied them to the logit model to estimate HPV vaccine coverage in each county and respective demographic subgroup. For simplicity, I only provide coverage estimates (and 95% confidence intervals) for counties.^ County-level coverage among females aged 11-17 varied from 6.8-29.0%. For females aged 18-26, coverage varied from 1.9%-23.8%. Aggregated to the state level, these values translate to indirect state estimates of 15.5% and 11.4%, respectively; both of which fall within the confidence intervals for the direct estimates of HPV vaccine coverage in Texas (Females 11-17: 17.7%, 95% CI: 13.6, 21.9; Females 18-26: 12.0%, 95% CI: 6.2, 17.7).^ Small area estimation has great potential for informing policy, program development and evaluation, and the provision of health services. Harnessing the flexibility of multilevel, unit-level SAE to estimate HPV vaccine coverage among females aged 11-26 in Texas counties, I have provided (1) practical guidance on how to conceptualize and conduct modelbased SAE, (2) a robust framework that can be applied to other health outcomes or geographic levels of aggregation, and (3) HPV vaccine coverage data that may inform the development of health education programs, the provision of health services, the planning of additional research studies, and the creation of local health policies.^

Pollen record from Kleiner Mochowsee, Germany

A Holocene pollen diagram from Kleiner Mochowsee (northern Niederlausitz, East Germany) shows pine as an important constituent of the woodland south of the Schwielochsee. Oak woodland was widespread since the Atlantic. Betula lost its importance at the end of the Preboreal. Fagus is represented continuously in the pollen record since the Atlantic, Carpinus since the Subboreal. However, the two latter tree species remain without great importance throughout the whole pollen record. The poor sandy soils are furthermore reflected by the low values of Corylus during the Boreal, comparable to other records from Berlin and its surrounding area. The 'classical' elm decline could be shown for the Niederlausitz, radiocarbon dates assume a contemporaneous age for this event with other records from northern Germany. Only small-scaled human impact is indicated in prehistoric times, during the migration period it seems to have ceased completely. Later, in the Medieval, deforestation and tillage can be shown. Secale was cultivated since the early Medieval; an accompanying weed flora appeared at the same time. Cultivation of Fagopyrum and Linum usitatissimum could be shown for the late Medieval times.

Methane concentrations in the central North Sea

We investigated dissolved methane distributions along a 6 km transect crossing active seep sites at 40 m water depth in the central North Sea. These investigations were done under conditions of thermal stratification in summer (July 2013) and homogenous water column in winter (January 2014). Dissolved methane accumulated below the seasonal thermocline in summer with a median concentration of 390 nM, whereas during winter, methane concentrations were typically much lower (median concentration of 22 nM). High-resolution methane analysis using an underwater mass-spectrometer confirmed our summer results and was used to document prevailing stratification over the tidal cycle. We contrast estimates of methane oxidation rates (from 0.1 to 4.0 nM day**-1) using the traditional approach scaled to methane concentrations with microbial turnover time values and suggest that the scaling to concentration may obscure the ecosystem microbial activity when comparing systems with different methane concentrations. Our measured and averaged rate constants (k') were on the order of 0.01 day**-1, equivalent to a turnover time of 100 days, even when summer stratification led to enhanced methane concentrations in the bottom water. Consistent with these observations, we could not detect known methanotrophs and pmoA genes in water samples collected during both seasons. Estimated methane fluxes indicate that horizontal transport is the dominant process dispersing the methane plume. During periods of high wind speed (winter), more methane is lost to the atmosphere than oxidized in the water. Microbial oxidation seems of minor importance throughout the year.

Pore water chemistry of ODP Sites 201-1225, 201-1226 and 201-1231

High-resolution analyses of the oxygen isotope ratio (18O/16O) of dissolved sulfate in pore waters have been made to depths of >400 meters below seafloor (mbsf) at open-ocean and upwelling sites in the eastern equatorial Pacific Ocean. d18O values of dissolved sulfate (d18O-SO4) at the organic-poor open-ocean Site 1231 gave compositions close to modern seawater (+9.5 per mil vs. Vienna-standard mean ocean water, providing no chemical or isotopic evidence for microbial sulfate reduction (MSR). In contrast, the maximum d18O values at Sites 1225 and 1226, which contain higher organic matter contents, are +20 per mil and +28 per mil, respectively. Depth-correlative trends of increasing d18O-SO4, alkalinity, and ammonium and the presence of sulfide indicate significant oxidation of sedimentary organic matter by sulfate-reducing microbial populations at these sites. Although sulfate concentration profiles at Sites 1225 and 1231 both show similarly flat trends without significant net MSR, d18O-SO4 values at Site 1225 reveal the presence of significant microbial sulfur-cycling activity, which contrasts to Site 1231. This activity may include contributions from several processes, including enzyme-catalyzed equilibration between oxygen in sulfate and water superimposed upon bacterial sulfate reduction, which would tend to shift d18O-SO4 toward higher values than MSR alone, and sulfide oxidation, possibly coupled to reduction of Fe and Mn oxides and/or bacterial disproportionation of sulfur intermediates. Large isotope enrichment factors observed at Sites 1225 and 1226 (epsilon values between 42 per mil and 79 per mil) likely reflect concurrent processes of kinetic isotope fractionation, equilibrium fractionation between sulfate and water, and sulfide oxidation at low rates of sulfate reduction. The oxygen isotope ratio of dissolved pore water sulfate is a powerful tool for tracing microbial activity and sulfur cycling by the deep biosphere of deep-sea sediments.

Scaling up the production of biogenic magnetite nanoparticles

Although there are numerous examples of large-scale commercial microbial synthesis routes for organic bioproducts, few studies have addressed the obvious potential for microbial systems to produce inorganic functional biomaterials at scale. Here we address this by focusing on the production of nano-scale biomagnetite particles by the Fe(III)-reducing bacterium Geobacter sulfurreducens, which was scaled-up successfully from lab-scale to pilot plant-scale production, whilst maintaining the surface reactivity and magnetic properties which make this material well suited to commercial exploitation. At the largest scale tested, the bacterium was grown in a 50 L bioreactor, harvested and then inoculated into a buffer solution containing Fe(III)-oxyhydroxide and an electron donor and mediator, which promoted the formation of magnetite in under 24 hours. This procedure was capable of producing up to 120 g biomagnetite. The particle size distribution was maintained between 10 and 15 nm during scale-up of this second step from 10 ml to 10 L, with conserved magnetic properties and surface reactivity; the latter demonstrated by the reduction of Cr(VI). The process presented provides an environmentally benign route to magnetite production and serves as an alternative to harsher synthetic techniques, with the clear potential to be used to produce kg to tonne quantities.

In-situ geotechnical measurements with the dynamic penetrometer Nimrod on the continental shelf off the Coromandel Peninsula, New Zealand

We tested the ability of a small dynamic penetrometer, Nimrod, to infer geotechnical properties of sediment mixtures in the inner shelf. The penetrometer is light and easy to operate, and its operation by scuba divers ensures a greater degree of precision than ship-based penetrometer deployments. We have studied selected positions along a sorted bedform (~ 100 m wide) on the continental shelf off the Coromandel Peninsula close to Tairua, North Island of New Zealand, and additionally took sediment samples at the exact positions of penetrometer impact, also by scuba divers. The derived dynamic penetrometer signatures (i) measured deceleration of the probe and estimated quasi-static bearing capacity as a measure of sediment strength, (ii) reflected changes in grain-size distribution ranging from very fine to very coarse sands, and (iii) revealed the uppermost seafloor stratification (top layer 2-6 cm) potentially being an indicator for sediment dynamics. In this manner, the device proved to be suitable for spatially fine-scaled surveys using divers' support and might deliver complementary information about sediment dynamics, in this case sorted-bedform maintenance.

Mineral composition and experimental results from XRD analyses of sediments from ODP Leg 190 sites

X-ray diffraction analyses of the clay-sized fraction of sediments from the Nankai Trough and Shikoku Basin (Sites 1173, 1174, and 1177 of the Ocean Drilling Program) reveal spatial and temporal trends in clay minerals and diagenesis. More detrital smectite was transported into the Shikoku Basin during the early-middle Miocene than what we observe today, and smectite input decreased progressively through the late Miocene and Pliocene. Volcanic ash has been altered to dioctahedral smectite in the upper Shikoku Basin facies at Site 1173; the ash alteration front shifts upsection to the outer trench-wedge facies at Site 1174. At greater depths (lower Shikoku Basin facies), smectite alters to illite/smectite mixed-layer clay, but reaction progress is incomplete. Using ambient geothermal conditions, a kinetic model overpredicts the amount of illite in illite/smectite clays by 15%-20% at Site 1174. Numerical simulations come closer to observations if the concentration of potassium in pore water is reduced or the time of burial is shortened. Model results match X-ray diffraction results fairly well at Site 1173. The geothermal gradient at Site 1177 is substantially lower than at Sites 1173 and 1174; consequently, volcanic ash alters to smectite in lower Shikoku Basin deposits but smectite-illite diagenesis has not started. The absolute abundance of smectite in mudstones from Site 1177 is sufficient (30-60 wt%) to influence the strata's shear strength and hydrogeology as they subduct along the Ashizuri Transect.

Marine meso-herbivore consumption scales faster with temperature than seaweed primary production, supplementary material

Respiration of ectotherms is predicted to increase faster with rising environmental temperature than photosynthesis of primary producers because of the differential temperature dependent kinetics of the key enzymes involved. Accordingly, if biological processes at higher levels of complexity are constrained by underlying metabolic functions food consumption by heterotrophs should increase more rapidly with rising temperature than photo-autoptrophic primary production. We compared rates of photosynthesis and growth of the benthic seaweed Fucus vesiculosus with respiration and consumption of the isopod Idotea baltica to achieve a mechanistic understanding why warming strengthens marine plant-herbivore interactions. In laboratory experiments thallus pieces of the seaweed and individuals of the grazer were exposed to constant temperatures at a range from 10 to 20°C. Photosynthesis of F. vesiculosus did not vary with temperature indicating efficient thermal acclimation whereas growth of the algae clearly increased with temperature. Respiration and food consumption of I. baltica also increased with temperature. Grazer consumption scaled about 2.5 times faster with temperature than seaweed production. The resulting mismatch between algal production and herbivore consumption may result in a net loss of algal tissue at elevated temperatures. Our study provides an explanation for faster decomposition of seaweeds at elevated temperatures despite the positive effects of high temperatures on algal growth.

Geophysical mapping of the sediment architecture in the Orkhon Valley, Mongolia

Ground penetrating radar (GPR) and capacitive coupled resistivity (CCR) measurements were conducted in order to image subsurface structures in the Orkhon Valley, Central Mongolia. The data are extended by information from drill cores to the entire transects distinguishing different sedimentary environments in the valley. The Orkhon Valley is part of the high sensitive Steppe region in Central Mongolia, one of the most important cultural landscapes in Central Asia. There, archaeological, geoarchaeological and sedimentological research aims to reconstruct the landscape evolution and the interaction between man and environment during the last millennia since the first settlement. In May 2009 and 2010 geophysical surveys have been conducted including transects with lengths between 1.5 and 30 km crossing the entire valley and a kilometre-scaled grid in the southern part of the investigation area. The geoelectrical and GPR data revealed the existence of two layers characterized by different resistivity values and radar reflectors. The two layers do not only represent material contrasts, but also reflect the influence of sporadic permafrost which occurs in several areas of Mongolia. The results help to reconstruct the evolution of the braided Orkhon River and therefore give important hints to understand the environmental history of the Orkhon Valley.