Single cell transcriptome defined as the entire RNA or polyadenylated products of RNA polymerase II on a cell can describe the gene regulation networks responsible for physiological functions, behaviours, and phenotypes in response to signals and microenvironmental changes. Single cell transcriptome/sequencing has the special power to investigate small groups of differentiating cells, circulating tumour cells, or tissue stem cells. A large number of factors may influence the extent of single-cell heterogeneity within a system. It is the opportunity that the single-cell sequencing can be used for the identification of genetic changes in rare cells, e.g. cancer and tissue stem cells, in clinical samples. The methodologies of single-cell sequencing have been improved and developed with the increase of the understanding and attention. The clinical research and application of the single cell sequencing analysis are expected to identify and validate disease-specific biomarkers, network biomarkers, dynamic network biomarkers. The single cell research and value will be also dependent upon the understanding of genomic heterogeneity, planning and design of study protocol, representative of selected and targeted cells, and sensitivity and repeatability of the methodology. The single cell sequencing can be used to develop new diagnostics, monitor disease progresses, measure responses to therapies, and predict the prognosis of patients, although there are still a large number of challenges and difficulties to be faced. It would be more values and specificities of the single cell sequencing to integrate with the function of cells, organs, and systems of the body, the clinical phenotypes of patients, and the description of clinical bioinformatics. Single cell transcriptome defined as the entire RNA or polyadenylated products of RNA polymerase II on a cell can describe the gene regulation networks responsible for physiological functions, behaviours, and phenotypes in response to signals and microenvironmental changes. Methods of single cell transcriptome analyses have been developed and significantly improved with advantages and disadvantages ,2. SinglSingle cell transcriptome/sequencing has the special power to investigate small groups of differentiating cells, circulating tumour cells, or tissue stem cells. Tang et al. defined the dynamic molecular changes with cell-fate changes during the conversion from the inner cell mass cells of blastocysts to pluripotent embryonic stem cells using RNA-Seq transcriptome analysis at the resolution of single cells . MoleculA large number of factors may influence the extent of single-cell heterogeneity within a system, e.g. the source of analyzed tissues, biological conditions or microenvironments of the individual cell. The single cell transcriptome was suggested to avoid, or at least reduce, the variability of clinical samples, in order to define new cell classifications, transitional states, biological distinctions, or biomarkers. Shalek et al. recently demonstrated that the inflammatory stimulus lipopolysaccharide could induce an extensive, previously unobserved, bimodal variation in mRNA abundance and splicing patterns in bone marrow-derived dendritic cells using single-cell RNA-Seq analysis . It indiIt is the opportunity that the single-cell sequencing can be used for the identification of genetic changes in rare cells, e.g. cancer and tissue stem cells, in clinical samples which may contain hundred cells in body fluids and biopsy with fine-needle. It seems that one of clinical applications of single-cell sequencing should be to understand the genomic profiling of copy number or sequence mutations in rare cells. The challenge in the identification and validation of therapeutic targets is to define the cell heterogeneity, especially to differ between cancer and pre-cancer cells, activated and non-activated inflammatory cells, or functional and non-functional cells, between sampling micro-regions, between cells at various stages, or between responses to therapy. For example, our previous studies on genetic comparison of mouse lung telocytes with mesenchymal stem cells and fibroblasts demonstrated that about 10-20% of genes expressed differently between 5 and 10 day cell culture of lung telocytes per se . It indiThe methodologies of single-cell sequencing have been improved and developed with the increase of the understanding and attention. The single cell sequencing is expected to detect the genomic heterogeneity in the primary disease and provide useful information for selecting therapies, monitoring the efficacy and efficiency of the therapy, predicting the potential outcomes of patients, if the disease would be monogenomic one which hardly exists in clinical practice. It is more important to consider the interactions between genes, proteins, cells, organs, as well as the critical role of the tissue microenvironment, when clinical studies are designed for the single cell sequencing analysis. Single-cell sequencing was evidenced to have the high sensitivity in the identification of rare chemoresistant clones in the primary cancer and to investigate questions of whether resistant clones were pre-existing in the primary cancer or appeared in response to therapies . The chaAnother potential or new hope is to develop new type cells for therapies by bioengineering or modifying targeted genes selected from the single cell sequencing. It believes that the construction of a phylogenetic tree of a human lifetime and the contribution of genetic heterogeneity to the organism can be defined and figured out by the single cell sequencing analysis of the different cells from endodermal, mesodermal, and ectodermal tissues from an individual. The sub-classification or new discovered populations of cell types can be found by gene expression profiles and epigenetic status, although the relationship between genome sequence, epigenetic status, and gene expression, and the functional capacity of the cell remain unclear . The newIn conclusion, the clinical research and application of the single cell sequencing analysis are expected to identify and validate disease-specific biomarkers, network biomarkers, dynamic network biomarkers. The single cell research and value will be also dependent upon the understanding of genomic heterogeneity, planning and design of study protocol, representative of selected and targeted cells, and sensitivity and repeatability of the methodology. The single cell sequencing can be used develop new diagnostics, monitor disease progresses, measure responses to therapies, and predict the prognosis of patients, although there are still a large number of challenges and difficulties to be faced. It would be more values and specificities of the single cell sequencing to integrate with the function of cells, organs, and systems of the body, the clinical phenotypes of patients, and the description of clinical bioinformatics.


After publication of the original article , the autIn addition to the study sponsors the Bill and Melinda Gates Foundation (grant number 48027) and MIDAS (grant number U01-GM087728), the authors gratefully acknowledge funding of the NTD Modelling Consortium by the Bill and Melinda Gates Foundation in partnership with the Task Force for Global Health. The views, opinions, assumptions or any other information set out in this article are solely those of the authors. The authors thank the data and safety monitoring committee, including Douglas Jabs, MD, MBA (chair), Antoinette Darville, MD, Maureen Maguire, PhD, and Grace Saguti, MD, who were generous with their time and advice and met before and during the study. The authors thank all of our colleagues in Niger at Programme National de Santé Oculaire who collected samples and data. This trial is registered at ClinicalTrials.gov, number NCT00792922. We also thank the NTD support center and the Task Force for Global Health.


The aim of this special issue is to focus on recent developments and achievements in the theory of function spaces, sequences spaces and their geometry, and compact operators and their applications in various fields of applied mathematics, engineering, and other sciences. The theory of sequence spaces is powerful tool for obtaining positive results concerning Schauder basis and plays a fundamental role in creating the basis of several investigations conducted in nonlinear analysis. The compactness is very often used in fixed point theory and its applications to the theories of differential, functional differential, integral, and integrodifferential equations.The research papers in this special issue cover various topics like geometry of Banach spaces, Schauder basis and dual spaces, sequence spaces and their topological and geometric properties, approximation of positive linear operators by matrix and nonmatrix methods, convergence and stability results for iterative process, applications of iterative methods to a nonlinear integral equation, Littlewood-Paley operators on Morrey spaces, matrix transformations between certain sequence spaces, measures of noncompactness and their applications in characterizing compact matrix operators, fixed point theorems and their applications, and so on.


Best papers of this conference were covered. PCO'2013 attracted participants from many countries and from across the PCO community in Europe and all over the world, for a meeting of vivid exchanges and lively debates. The PCO'2013 conference provided an excellent floor for investigators and practitioners to promote their newest advances in power, control, and optimization to the wider community of scientists and practitioners, for identifying research challenges for their fields, as well as promising research developments in theory, methods, and applications, and for fostering given and creating new interactions with colleagues from related research areas of modern PCO areas and their emerging applications.This special issue of this journal is devoted to the PCO global conference organized a successful conference in the research areas of power systems, control systems, and optimization in Prague, the capital of Czech Republic. This special issue focuses on best and high quality selected papers which were presented at the PCO global conference. Well-known and new methodologies and techniques of optimization were used to solve some of the complicated and hard problems in the areas of power systems, control systems, and optimization.Applications of optimization techniques are well known in the research areas of power systems, control systems, and computer science. The current trends on application of metaheuristics techniques are very popular among the researchers in the areas of power systems, control systems, and computer science across the globe. In this regard, the PCO'2013 and our special issue focused on new development and contribution of the current research to the body of the knowledge in the area of PCO. The topics included are (i) optimal power; (ii) optimal control; (iii) optimization; (iv) cams, gears, wheels, and valve optimization; (v) android phone, mobile, WiMax, and wireless communications; (vi) smart grid, microgrid, distribution, and chaotic systems; (vii) scheduling and assignment problems; (viii) healthcare, bioinformatics, and signal processing; and (ix) future energy planning and the environment.This special issue was open for interested authors in all power, control, and optimization areas, and they were welcome to submit their recent findings and best results. BothThe subjects of power, control, and pptimization as elaborated in our special issue are so closely related to the emerging questions and challenges on energy and electricity, from engineering, applied mathematics, operational research, computer science and data mining, education, and social sciences, both quantitatively and qualitatively, and they reach out very far and, eventually, to the living conditions of people on earth.


This article presents a history of the early electroencephalography (EEG) of psychopathy, delinquency, and immorality in Great Britain and the United States in the 1940s and 1950s. Then, EEG was a novel research tool that promised ground-breaking insights in psychiatry and criminology. Experts explored its potential regarding the diagnosis, classification, etiology, and treatment of unethical and unlawful persons. This line of research yielded tentative and inconsistent findings, which the experts attributed to methodological and theoretical shortcomings. Accordingly, the scientific community discussed the reliability, validity, and utility of EEG, and launched initiatives to calibrate and standardize the novel tool. The analysis shows that knowledge production, gauging of the research tool, and attempts to establish credibility for EEG in the study of immoral persons occurred simultaneously. The paper concludes with a reflection on the similarities between EEG and neuroimaging—the prime research tool in the current neuroscience of morality—and calls for a critical assessment of their potentials and limitations in the study of immorality and crime. Approximately 70 years later, modern neuroscience has appropriated immorality and delinquency as viable objects of research. Especially the emergence of neuroimaging technology in the last two decades facilitated research on the good, the bad, and the brain. According to some, a revolution in understanding morality is on its way  in 1952 was an attempt to homogenize classification. Among others, the definition of one particular mental disorder was arduous: psychopathy.Immorality has to be understood in context—as well as corresponding mental disorder concepts and their putative biological manifestations. Ideas on a hereditary, physiological, or neurological basis for anti-sociality, violence, and crime have a long and multifarious history Rafter, . In the “It is a confusing term; it is misleading, and it means nothing.” .


Environmental modification by anthropogenic actions, disordered urban growth, globalization of international exchange and climate change are some factors that help the emergence and dissemination of human infectious diseases transmitted by vectors. This review discusses the recent entry of three arboviruses in Brazil: Chikungunya, West Nile, and Zika virus, focusing on the challenges for the Country’s public health. The Brazilian population is exposed to infections caused by these three arboviruses widely distributed on the national territory and associated with humans. Without effective vaccine and specific treatment, the maintainance and integration of a continuos entomological and epidemiological surveillance are important so we can set methods to control and prevent these arboviruses in the Country. Infectious diseases have some peculiarities that distinguish them from other human diseases, such as the unpredictable and explosive character on a global level, transmissibility, close relationship with both the environment and human behavior, and the ability to be prevented and eradicatedIn addition to the interference and modification of ecosystems by human action, other factors are related to the emergence of arboviruses in those countries, such as disordered urban growth and processes of globalization and expansion of international exchange, as well as climatic changesGlobal warming is also an important factor in the transmission dynamics of pathogens to humans. Global temperature increase affects the mosquito vectors by reducing the development time of the larvae and, thus, increasing rapidly the population of adults. It also decreases the extrinsic incubation period, i.e., the time for the virus to reach the mosquito’s salivary gland, making it suitable to transmit this etiologic agentThe aim of this comment was to discuss the recent entry of the arboviruses Chikungunya (CHIKV), West Nile (WNV), and Zikavirus (ZIKV) in Brazil, focusing on the challenges for the Country’s public health.Alphavirus genus of the Togaviridae family. CHIKV was first isolated in 1952/1953, during an epidemic in East Africa (Tanzania and Mozambique). The term “Chikungunya” is derived from the Makonde language, spoken in some areas of northern Mozambique and southern Tanzania, which means “that which bends up”, referring to the posture gained by the patient due to severe arthralgiasChikungunya fever is caused by a virus that belongs to the ,This arbovirus did not receive much attention until 2005, when outbreaks struck some Indian Ocean islands, as the French island Reunion, where more than 240,000 people were infected and 203 diedAedes genus, such as the Aedes furcifer-taylori, e.g., and nonhuman primatesAedes (Stegomyia) aegypti and with humans. However, during the epidemic of Chikungunya in the Reunion island, low numbers of Ae. aegypti and high density of Aedes (Stegomyia) albopictus were found in the areaAe. albopictus, turning this mosquito into an excellent vector for humans in several areas where Ae. aegypti is absent,In Africa, the cycle of CHIKV occurs mainly in forested areas, involving wild mosquitoes of the Ae. aegypti and Ae. albopictus show high vector competence, which makes this arbovirus a potential threat to the CountryAt the end of 2013, the first case of local transmission of CHIKV was reported in the Americas, in the Caribbean region. Just a year later, at the end of 2014, South American countries, such as French Guiana, Venezuela, Colombia, Suriname, Paraguay, and Brazil had already reported the local circulation of CHIKV  Flavivirus genus of the Flaviviridae family. WNV was first isolated in a feverish woman in the West Nile district of Uganda, Africa, in 1937. Then, some outbreaks of this arbovirus were reported elsewhere in Africa, Middle East, Asia, and EuropeWest Nile fever is caused by a virus that belongs to the Flavivirus genus as etiologic agentThe entry of WNV in the West occurred in late August and early September 1999, in New York City, United States of America. The city had a human encephalitis outbreak, which indicated the presence of an arbovirus of the ,Most patients infected with WNV are asymptomatic, but the symptoms include fever, headache, nausea, and vomiting. Generally, the recovery is complete, but weakness and fatigue may last longer. Less than 1.0% of infected people develop the most aggressive form of the disease, showing severe neurological problems, such as meningitis and encephalitis, which may lead to death. Such manifestations are more common in older adults and immunosuppressed peopleAedes and Anopheles in Africa, Europe, and United States, undoubtedly, the Culex genus encompasses the main mosquito vectors of this arbovirus, including Cx. quinquefasciatusThe WNV cycle is maintained in nature by birds and mosquitoes, while humans and horses are considered final hosts, as they do not act as infectious sources for the vector,In South America, serological evidence of WNV was detected in horses and birds in Colombia, Venezuela, and Argentina. In Brazil, the first serological evidence of WNV activity occurred in 2009, in the Pantanal region, state of Mato Grosso do Sul, with the virus isolation in horsesFlavivirus genus of the Flaviviridae family, ZIKV was first isolated in rhesus monkeys, in 1947, in the Zika forest, Uganda. The isolation of ZIKV in humans was confirmed in Nigeria, but some serological evidence of human infection by this arbovirus have also been reported in other African countries, such as Egypt, Tanzania, Gabon, and Sierra Leone, as well as in Asian countries, such as India, Malaysia, Thailand, and IndonesiaAlso belonging to the ,,In 2015, Brazil reported the first autochthonous human cases of Zika, confirming the recent entry of this arbovirus in the Country. Bahia and Rio Grande do Norte were the first Brazilian states to report cases of ZIKV infectionAedes genus, Ae. aegypti being the main vector in Brazil. The symptoms of this arbovirus appear a few days after the mosquito bite, they last from three to 12 days and include low-grade fever, arthralgia, myalgia, headache, conjunctivitis, and maculopapular rash,,The most common form of ZIKV transmission is by the bite of infected female mosquitoes of the ,The emergence of arboviruses in places that were safe represents a potential challenge for public health in many ways.The recent entry of CHIKV, WNV, and ZIKV in Brazil and in other countries of the Americas exposes the population to the infection, once all individuals are susceptible; in addition, no vaccines are available as prophylactic method and no antiviral drugs are effective for the treatmentAe.aegypti and Cx. quinquefasciatus have wide distribution in Brazil and are extremely associated with humans and the urban environmentAe. albopictus is present in almost all national territoryAe.aegypti, for instance, new technologies have been used to control this dengue vector, Chikungunya, and Zika in Brazil, such as the release of genetically modified adults or mosquitoes infected by the Wolbachia bacteria. However, more research is required to confirm the effectiveness of these methodsThe noteworthy association of mosquito vectors with humans is also a challenge. Ae. aegypti and Cx. quinquefasciatus. Climate change also contributes to the proliferation of mosquito vectors. The increased rainfall frequency, which has been observed in some places, entails the accumulation of water in more containers, increasing the supply of natural or artificial breeding sites for female mosquitoes to deposit their eggs. On the other hand, the period of drought in certain areas forces people to store water in barrels or other artificial deposits, which serve as breeding sites for the proliferation and increase of vector populationsThe environment also represents an obstacle to the control of these vectors. Disordered urban growth, combined with the pollution of rivers and ditches, provides artificial oviposition sites for the proliferation and dissemination of mosquitoes, especially of Other relevant challenge for public health is the diagnosis of these new arboviruses. In Brazil, several arboviruses circulate, such as Mayaro (MAYV), Venezuelan Equine Encephalitis (VEEV), Eastern Equine Encephalitis (EEEV), Rocio (ROCV), and Dengue virus (DENV), which present many symptoms similar to those observed for CHIKV, WNV, and ZIKVFinally, despite the lethality of CHIKV and ZIKV being considered low, cases of coinfection with other arboviruses have been reported in patients from other continentsThe recent entry of new arboviruses challenges physicians, health professionals, and researchers to perform an active and ongoing investigation about specific symptoms and serology of vectors, etiological agents, and of environmental and social factors that may be associated with the epidemics and the emergence of new cases. Thus, the strengthening and integration of entomological and epidemiological surveillances is necessary, so we can set methods to control and prevent these diseases in the Country.


There is an error in the byline. Prof. Lin Yun-Feng should be included as the fourth author. The correct affiliation for Prof. Lin Yun-Feng should be #1: Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. The contributions to the manuscript are as follows: Conception and the design of the work, acquisition of data, or analysis or interpretation of data; final approval of the version to be published.


Influenza viruses cause annual epidemics of respiratory tract disease that affect all age groups. Many developing countries do not have an influenza surveillance system or adequate laboratory capacity for virus detection. The objective of this study was to describe the influenza surveillance systems in the different countries in the tropics and to identify outstanding research needs. A questionnaire was designed and sent to 52 NICs and MoHs in the different countries in tropical Asia and Africa to gather information on the surveillance systems, sentinel sites, specimen and data collection, and laboratory testing. Replies were received from 32 NICs and MoHs (61.5% response) – 17 were located in tropical Asia and 15 in Africa. There are 20 WHO recognized NICs in tropical Asia and 14 in tropical Africa, all with virus isolation and polymerase chain reaction (PCR) testing capacity. Of the Asian countries, only Hong Kong and Singapore reported that the patient population from the sites represents the broader community. In tropical Africa, only Senegal has sentinel sites distributed all over the country contributing to the geographic representativeness of the surveillance system. The rest of the countries in Africa have just established their influenza surveillance system in the past decade and are working toward geographic expansion of the ILI and SARI sites. Limited laboratory capacity or infrastructure to perform influenza surveillance makes difficult to justify the importance of influenza vaccine or other influenza control measures as a strategy for improving population health in the tropical region. Influenza is a highly communicable acute respiratory disease which affects populations for centuries . The infTo understand the different influenza surveillance systems in the different countries in the tropical region, a questionnaire was designed to gather information specifically on the surveillance system, sentinel sites, specimen and data collection, and laboratory testing. The questionnaire was sent to the different National Influenza Centers and/or Ministry of Health. Additional information was obtained either online from the Ministry of Health websites of the different countries. Annual reports and presentations made by the National Influenza Centers or Ministries of Health to International Conferences  were also included.Questionnaires were sent to 52 National Influenza Centers (NICs) and Ministries of Health (MOHs) in the different countries in Tropical Asia and Africa. Replies were received from 32 NICs and MOHs (61.5% response). In this study 32 countries were included among which 17 were located in tropical Asia. For Africa, only 15 countries were included. These were the countries whose National Influenza Centers responded to the questionnaires sent or responded by providing presentations or publications from the country.In Asia, the Tropic of Cancer runs from west to east through Saudi Arabia, United Arab Emirates, Oman, India, Myanmar, Southern China and Taiwan and the Tropic of Capricorn runs through Australia. Some 19 countries including 4 in the Middle East  are situated in the tropical region. India, in southern Asia, lies mostly in the tropics, and all countries of Southeast Asia are tropical countries. Places located in the Pacific including parts of Australia, Micronesia, the Marshall Islands, Kiribati, and most of the other island nations of Oceania in the South Pacific are also considered tropical.In tropical Asia, Singapore and Indonesia were the first countries to conduct influenza surveillance in the 70s. New Caledonia, Hong Kong, and Taiwan followed in the 1990s. All the rest started after 2000 with Laos, Bangladesh, and Sri Lanka starting in 2007. ILI and SARI surveillance have been initiated in all the countries in tropical Asia except for Malaysia and Cambodia. Malaysia currently focuses on ILI while Cambodia does ILI and ALRI (acute lower respiratory infection) surveillance. All countries publish their influenza surveillance data in WHO FluNet except for Saudi Arabia and Taiwan , Table 2In Africa, the Tropic of Cancer runs from west to east through the African countries Western Sahara, Mauritania, Mali, Algeria, Niger, Libya, Chad, and Egypt. The Tropic of Capricorn runs from west to east through the African nations Namibia, Botswana, South Africa and Mozambique. The only countries that cannot be called tropical are Morocco and Tunisia in the north and Lesotho, South Africa, and Swaziland in the South. The rest lie entirely or partly within the tropics.In West Africa, from only 2 countries conducting influenza surveillance in 2006, 6 additional countries have established a functional in-country surveillance system. Mauritania has just started Flu Surveillance. From only 1 functional WHO recognized National Influenza Centers in 1996 , there are now 4 NICs in the region . In Middle Africa only Cameroon, Angola, Central African Republic, and the Democratic Republic of Congo have functioning Influenza Surveillance systems. Chad, Equatorial Guinea, Gabon, and Sao Tome and Principe currently do not have Influenza Surveillance systems. In East Africa, the countries with Influenza Surveillance systems include Ethiopia, Tanzania, Kenya, Uganda, and Rwanda. All these countries have National Influenza Centers recognized by the WHO. In the Horn of Africa, only Ethiopia has a functioning Influenza Surveillance system. In Southern Africa, Madagascar, Mozambique, Zambia, and South Africa have Influenza Surveillance systems. There are 3 WHO-recognized National Influenza Centers in Southern Africa – 1 in Madagascar, and 2 in South Africa. South Africa is not included here as most of country is located outside of the tropics , Table 4There are 21 WHO-recognized National Influenza Centers in Tropical Asia: 3 in India, 2 in Vietnam, 2 in Malaysia, and 1 each in Bangladesh, Indonesia, Myanmar, Sri Lanka, Thailand, Cambodia, Hong Kong SAR, Taiwan, Fiji, Papua New Guinea, New Caledonia, Laos, The Philippines, and Singapore. Except for Maldives, Brunei, and East Timor, all of the countries in the Tropical region in Asia have Influenza Surveillance systems. There are 14 WHO-recognized National Influenza Centres in Tropical Africa: Cote d'Ivoire, Senegal, Ghana, Nigeria, Cameroon, DR Congo, Angola, Uganda, Rwanda, Sudan, Ethiopia, Kenta, Tanzania, and Madagascar.Human Influenza surveillance comprises of 2 components: Influenza-Like Surveillance (ILI) and Severe Acute Respiratory Infection (SARI). ILI and SARI surveillance have been initiated in all the countries in tropical Asia except for Malaysia and Cambodia. Malaysia currently focuses on ILI while Cambodia does ILI and ALRI (acute lower respiratory infection) surveillance. ILI and SARI surveillance have been initiated in all the countries in tropical Africa except for Cameroon and Senegal which only focus on ILI surveillance for the moment. The surveillance systems in tropical Asia and Africa use the existing World Health Organization (WHO) case definition for Influenza-like illness  and incoThere are 20 WHO recognized NICs in tropical Asia and 14 in tropical Africa. All with virus isolation and polymerase chain reaction (PCR) testing capacity. Previously the methods employed for virus detection were mainly virus isolation and the haemagglutination inhibition test. Subsets of the specimens undergo viral culture and characterization. The on-going presence of the highly pathogenic avian A (H5N1) influenza virus since early 2004 increased the need for PCR (polymerase chain reaction) as part of the diagnosis process in order to improve the accuracy and efficiency of testing. Virologists and laboratory technicians in the NIC of the countries have been trained overseas on influenza laboratory diagnosis and detection. For most of the NICs, epidemiologists are full-time employees. Relevant technical personnel have been trained by staff from the WHO or US CDC or Institut Pasteur.In terms of surveillance sites, for Asia, only Hong Kong and Singapore reported that the patient population from the sites represents the broader community. This is most probably due to the size of the state and the healthcare IT network and integrated surveillance system. For India, samples are representing almost all the regions in the country, but not the individual states. For archipelagos like The Philippines and Indonesia with more than 7,000 and 13,000 islands respectively, obtaining a truly representative sample may be a challenge. However, the majority of the population is concentrated on the major cities, i.e. Metro Manila and Java where several sentinel sites are located. The rest of the countries in Asia are working toward geographic expansion of the ILI and SARI sites. Maldives, Brunei and East Timor do not have a National Influenza Center.In tropical Africa, only Senegal has sentinel sites distributed all over the country contributing to the geographical representativeness of the surveillance system. The rest of the countries in Africa have just established their influenza surveillance system in the last decade and are working towards geographic expansion of the ILI and SARI sites. Several countries do not have the laboratory capacity or infrastructure to perform influenza surveillance. These countries include the following: Benin, Burundi, Cape Verde, Chad, Comoros, Djibouti, Equatorial Guinea, Eritrea, Gabon, Guinea, Guinea Bissau, Lesotho, Liberia, Malawi, Namibia, Botswana, Mauritania, Mauritius, Sao Tome and Principe, South Sudan, Seychelles, Somalia and Zimbabwe.The burden of influenza in the tropical Asia and Africa is still not fully understood. However there have been some studies to learn more, particularly in Thailand, Myanmar, and India. Philippines and Bangladesh are currently conducting burden of disease studies. Defining the epidemiology and burden of influenza is high on the priority list of the WHO Southeast Asian Region and Western-Pacific region 2011 Bi-regional Plan for Further Strengthening National Influenza Surveillance . In AfriRespiratory specimens  are collected early from ILI and SARI patients using established protocols. For most of the countries in tropical Asia and Africa, it is not feasible to collect specimens from all patients therefore systematic sampling is done. There is no generic number of specimens collected in each site and this depends on several factors like seasonality and attack rates , 13. MosAll NICs and MoHs in tropical Asia and Africa collaborate with the WHO. Initiatives for building national capacity in the countries in tropical Asia and Africa include cooperative agreements with the US Center for Disease Control and Prevention (CDC) in Atlanta, United States of America. In tropical Africa countries like Nigeria, DR Congo, Angola, Ethiopia, Kenya, Rwanda, Tanzania, Uganda, Zambia and Mozambique these agreements have been instrumental in the establishment and improvement of national influenza surveillance capabilities. In Ghana, Mali, Burkina Faso, and Togo influenza surveillance receive assistance from the CDC via the US Naval Medical Research Unit-3 (NAMRU-3).In some countries, the NICs are hosted within the International Network of Pasteur Institutes. In tropical Africa Cote d’ Ivoire, Senegal, Sierra Leone, Central African Republic, and Madagascar are part of the network. In tropical Asia Vietnam, Cambodia, and New Caledonia are part of the Institut Pasteur network. In tropical Asia, Saudi Arabia, Cambodia, Singapore, and Indonesia collaborate with NAMRU. Saudi Arabia collaborates with NAMRU-3 while the other Asian countries work with NAMRU-2.There are existing influenza surveillance systems in several countries in Asia and Africa. WHO and different organizations such as the US CDC, NAMRU, and Institute Pasteur lend support to National Influenza Centers and laboratories in Asia and Africa. Surveillance will allow determination of the rates of influenza and a description of the clinical characteristics of the disease. With such epidemiologic data, public health officials will have better data in order to formulate influenza control strategies for either seasonal or pandemic influenza. Most of the countries are working toward geographic expansion of the ILI and SARI sites. Very few countries in tropical Asia and Africa have the capacity to measure the diseases burden of influenza. About half of the countries in Africa still do not have the laboratory capacity or infrastructure to perform influenza surveillance. This makes it difficult to justify the importance of influenza vaccine or other influenza control measures as a strategy for improving population health. Governments have taken steps to identify and focus on gaps in knowledge as indicated by the increasing development of surveillance networks, the organization of scientific congresses such as the African Influenza Scientific Symposium, ANISE meetings and the WHO  meetings. Although these efforts have not yet resulted in a great increase in published manuscripts and data, this situation should change within the next few years. It is important to encourage national laboratories to publish results of their studies. Collaborations between countries should be strengthened for efficient utilization of laboratory services and capacities.


Department of Health and Human Services, the task force is an independent, nonfederal, unpaid panel of public health and prevention experts whose members are appointed by the Director of CDC. The task force provides information for a wide range of decision makers on programs, services, and policies aimed at improving population health. Although CDC provides administrative, research, and technical support for the task force, the recommendations developed are those of the task force and do not undergo review or approval by CDC.


Department of Health and Human Services, the task force is an independent, nonfederal, uncompensated panel of public health and prevention experts whose members are appointed by the Director of CDC. The task force provides information for a wide range of decision makers on programs, services, and policies aimed at improving population health. Although CDC provides administrative, research, and technical support for the task force, the recommendations developed are those of the task force and do not undergo review or approval by CDC.


The health systems in the Americas region are characterized by fragmentation and segmentation, which constitute an important barrier to expanding coverage, achieving integrated primary health care, and reducing inefficiency and discontinuity of care.An assessment of the human resources for health (HRH) programmes that have been implemented at the country level was developed as part of the measurement of the 20 HRH regional goals for 2007–2015, adopted in 2007 by the Pan American Sanitary Conference (CSPA).The exercise was a combination of academic research and the development/application of an advocacy tool involving policy makers and stakeholders to influence the decision-making in the development, implementation, or change of HRH programmes while building evidence through a structured approach based on qualitative and quantitative information and the exchange and dissemination of best practices.This paper covers the methodological challenges, as well as a summary of the main findings of the study, which included 15 countries: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama in the Central America, Dominican Republic in the Caribbean, Chile, Colombia, Ecuador and Peru in the Andean sub region, and Argentina, Paraguay, and Uruguay in the South Cone. Despite the different contexts, the results showed that the programmes evaluated faced common challenges, such as lack of political support and financial unsustainability.The evaluation process allowed the exchange and dissemination of practices, interventions, and programmes currently running in the region. A shared lesson was the importance of careful planning of the implementation of programmes and interventions. The similarities in the problems and challenges of HRH among the participating countries highlighted the need for a cooperation programme on the evaluation and assessment of implementation strategies in the Americas region. In the last decade, the central role of the workforce in improving the health sector has become evident. Several studies have identified signals in the relationship between the quantity and quality of workers and the expansion and qualification of access to health services. Despite this, however, there is still a crisis in the health workforce, characterized by a shortage of professionals, an inadequate skill mix, and an unequal distribution of professionals ,2.In response to this crisis, there is a growing demand for countries to develop and implement programmes for the management and planning of human resources for health (HRH). The interventions aim to confront complex issues, such as the migration of health professionals, the need to make the health system more responsive to demographic changes and the ageing population, and the challenge of ensuring the presence of professionals in remote and rural locations .Moreover, the failure of health system reforms has been associated with the failure to strengthen the policies, planning, and management of HRH early in the process. In a systematic review, significant gaps were found in knowledge about the way training, regulatory, financial, and organizational mechanisms affect the supply, distribution, and performance of health care workers. Additionally, the data available tend to come from high-income settings and may not apply to low- and middle-income countries (LMICs) .According to Peters et al. , despiteThis article describes the process and results of the evaluation of health human resources programmes developed through cooperation between the Pan American Health Organization (PAHO) and the Institute of Social Medicine, State University of Rio de Janeiro. The study covered 15 countries in Latin America Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama in the Central America, Dominican Republic in the Caribbean, Chile, Colombia, Ecuador and Peru in the Andean sub region, and Argentina, Paraguay, and Uruguay in the South Cone.The programmes’ evaluation started from concerns raised in the monitoring process of the 20 regional goals for human resources for health for 2007–2015 adopted by the Pan American Sanitary Conference in 2007 [The HRH programmes’ evaluation at the regional level could also allow sharing of information and trends, identifying emerging issues, and promoting opportunities for future collaboration. Because of this cooperation process, different partners can exchange information about best practices. The evaluation was developed not only as an academic research but also to contribute to changes and the improvement of HRH programmes and policies, by empowering and encouraging the creation of a network.The evidence and reflections presented in The World Health Report 2006  and the At the 27th Pan American Health Conference, 20 regional goals to be achieved by 2015 were established in the process of transforming health systems towards the renewal of primary health care and the integration of services. The goals were grouped according to the five critical areas mentioned in the Toronto Call to Action: 1) define policies and long-term plans, 2) improve the distribution of professionals, 3) regulate professional flows and migration, 4) create healthy work environments, and 5) establish links between training institutions and services .The Toronto Call to Action in 2005 and, thereafter, the Regional Goals for Human Resources for Health 2007–2015 have established a strategic framework to direct efforts in HRH management, recognizing the importance of HRH planning and guidance of health systems based on primary health care and universal coverage. To monitor the 20 regional goals, a methodology was developed that allowed establishing a baseline and identifying the needs and progress in every area covered in the goals, as well as recognizing the priorities to be addressed in the implementation of HRH public policies. The evaluation process of the HRH programmes analysed in this article is part of this context of international cooperation, information exchange, and dissemination of practices and interventions.The approach proposed had three main components, completed in accordance with the possibilities in the different countries included in the evaluation. The first step was to identify and list the programmes and interventions that each country has implemented or is implementing to address HRH recruitment, deployment, and retention concerns and problems. As a result, it has built an inventory of programmes to be analysed and studied in depth, resulting in evidence on the challenges in HRH management and policy.The second step started with a description of the programme, including the identification of indicators of programme results from government reports and other data sources. A programme description conveys the mission and objectives of the programme being evaluated. It should be sufficiently detailed to ensure understanding of the goals and strategies of the programme, its capacity to effect change, its stage of development, and how it fits into the larger organization and community. The description enables comparisons with similar programmes and facilitates attempts to connect programme components to their effects ,9.The aspects included in the programme description were need, expected effects, activities, resources, stage of development, context, and a logic model -13. A loTo obtain more details on the programme-implementation process and its results, a formal questionnaire was used to collect data from secondary sources but also to interview key informants. Additionally, the information gathered was used to complete a logic model for the purpose of identifying and linking all major components and mapping the process of programme implementation.In the third step of this study, a template was developed for the country report to put together all the information gathered and to analyse the processes and results of the programme in relation to the expected outputs and outcomes.The stages of the programme evaluation are interdependent; that is, the success of each step is dependent on the success of the step before it. Therefore, there was an effort to clearly define and agree on programme goals, activities, and indicators, trying to assure the stakeholder participation and acceptance. Figure Aprogrammeis defined as a long-term (more than 1 year) formal plan of action, with a sequence of actions that describe how a health system or service will operate, including details such as roles and responsibilities, planned expenditures, results, etc. Less formal, and generally shorter-term than a programme (one year and less), aninitiativeis defined as a coherent set of actions, activities or interventions that are linked to an ultimate goal and one or more policy or programme objectives and have certain resources  to meet the objectives and contribute to the achievement of the goal.The respective country authorities, along with the national offices of PAHO/WHO, selected the national assessment teams. To support these teams in the preparation, data collection, interviews, and so on, an agreement was made with the PAHO/WHO Collaborating Centre on Health Workforce Planning and Information at the Institute of Social Medicine at the University of the State of Rio de Janeiro (IMS/UERJ). This made possible the conduct of face-to-face and virtual meetings with national teams to support the programme evaluation process. Although the basic process and objectives were the same in all countries, it was possible to take into account the capabilities of each country and allow flexibility in the way they deepened their evaluation . For theAfter listing the programmes and initiatives, the following criteria were used to select the programmes to be evaluated: at least one HRH programme/initiative on HRH, effect (impact) on the health system, total amount of programme funding, scope of the programme (population and geographic area), temporary extension (over a year), and the availability of information.Results related to changing partner and stakeholder attitudes and behaviour as a factor for the successful development, implementation, and management of programmes were only marginally addressed.Although the studied countries differ significantly in their political, social, economic, and geographic contexts, the HRH programmes and initiatives showed that the actions of these countries have been directed to strengthening national health systems, oriented towards primary health care with universal and equitable coverage. Beyond that, many of the challenges faced in the implementation of human resource programmes are the same across countries; these include the difficulty of training HRH, the lack of political will and financial support, weak HRH information systems, fragile/weak HRH governance, and difficulties in hiring and retaining health professionals in the public sector and in their allocation in remote and rural areas.Issues related to the programme design were described as challenges by some countries. For instance, in Honduras, most of the programme development is not based on any previous design, and there is no regular discussion regarding the adaption of the programme to human resources training and the health needs of the population. Another example is Chile, where the biggest challenge for programme design is the appropriate planning of the project. In El Salvador, there is still little consistency between HRH programmes and health needs.The fragility of intermediate and long-term planning remains a challenge in achieving the overall HRH objectives in countries such as Costa Rica, Nicaragua, Ecuador, and Argentina. In El Salvador, Costa Rica, Guatemala, Honduras, Panama, Dominican Republic, and Argentina, programme implementation was described as a big challenge, especially when extending the programme to the national level.The lack of clarity of roles was identified by Paraguay and Honduras as a challenge in programme development. The need for different authorities to understand their new roles in the programme was mentioned in Honduras. In Paraguay, there is a need to clarify and improve the coordination among different actions, programmes, and institutions to avoid overlap or inattention. The overlapping of actions by different participants or institutions also exists in Panama. Challenges at the participant level were reported in El Salvador, Costa Rica, Guatemala, Honduras, Dominican Republic, Chile, and Panama.Low acceptance of the programme by professionals was reported in Guatemala, where medical specialty residents partially rejected the programme, and in the Dominican Republic, where doctors struggled to be evaluated on their performance. The resistance of professionals to changes in the health system was highlighted in El Salvador, whereas in Honduras, low adherence to the changes by the community was found, in addition to resistance among professionals.In Guatemala, the Health Secretary was considered as a key player, whereas in Nicaragua, the importance of an integrated approach to planning HRH policies was stressed. In Argentina and Paraguay in Mercosur and in Chile, Ecuador, and Peru in the Andean region, the importance of the planning process was also highlighted. Peru cited the value of planning in expanding the access and coverage of health care.The countries identified the importance of community participation and an intersectoral approach in implementing HRH programmes. Guatemala, Chile, and Peru emphasized the importance of a common vision among stakeholders and cooperation among technical and academic institutions towards the establishment of a shared responsibility among stakeholders. In El Salvador, intersectoral work (interagency cooperation), albeit slow, was reported to be effective.The set of programmes presented are aligned with the five challenges of the Toronto Call to Action. Tables In seven countries, the analysed programme is related to the first challenge of the Toronto Call to Action: “To define policies and long-term plans on human resources”. From this viewpoint, El Salvador has established a planning process for organizing primary health care and a programme for training managers. These programmes were made possible by strengthening the institutional capacity with the establishment of the Department of Human Resources Development.All the countries have addressed the second challenge of the Toronto Call to Action to “place the right people in the right places” through initiatives and programmes related to professional training. Almost all the countries have made efforts to increase the number of specialists in different medical fields and to strengthen primary health care (PHC), indicating the concern of local governments with the training of health professionals and technicians.Cierre de Brechas plan in Chile provided funding for the training of medical specialists who were committed to provide public health services in areas with critical shortages. The Sistema Nacional de Acreditación de Residencias del Equipo de Salud programme in Argentina involves the establishment of minimum requirements for the medical residency system, with places and priorities defined according to regional needs. Panama, Guatemala, Costa Rica, Peru, Ecuador, and Colombia also presented programmes aimed at training specialists to meet the needs of the population.The Formación de Técnicas Universitários de Partería programme meets the challenge of reducing maternal and neonatal deaths by training people to integrate health teams in their own communities.The strengthening of PHC or its implementation through HRH training was related to programmes in the eight countries in the Central American region. In Guatemala, the The third challenge of the Toronto Call to Action focused on the regulation of health worker flows and migration. This evaluation found seven countries trying to address the HRH self-sufficiency issue in HRH policy.Ecuador Saludable, Vuelvo Por Ti, began in 2012 and aimed to promote the return of health professionals who were abroad to cover gaps in critical specialties and areas. A website was initiated for registering professionals working abroad who were interested in returning to the country; these professionals were offered professional stability and specialization programmes. By the end of 2013, about 700 professionals had been hired through the programme, and the experience brought by these professionals was highlighted for its contribution in enriching the sector.Ecuador was the only country that developed a programme directly related to the migration of health professionals. The said programme, Five countries addressed the fourth challenge of the Toronto Call to Action, which addressed the need to “promote healthy work environments and commitment to the institutional mission of ensuring quality health services for the entire population”. Ecuador targets 80% of health workers by 2017 with its labour stability plan, whereas Uruguay started in 2012 a programme to reform medical services, with the aim of improving the quality of care, prioritizing primary care, and enhancing the quality of life of medical professionals.Seven countries assessed programmes related to the fifth challenge, which involves developing interaction mechanisms between training institutions and health services to improve the training of health workers (Target 17). For instance, in 2012, the Dominican Republic developed a programme in agreement with the Universidad Autónoma de Santo Domingo, aiming to train human resources based on the primary health care model.Because the “Toronto challenges” are correlated, the evaluation naturally found that the programmes are also connected to more than one challenge, thus reinforcing the correlation.Communication mechanisms and changes in organizational culture were identified as a development strategy in Argentina and El Salvador, particularly when it comes to managing the HRH. Regarding budget support, Honduras, Ecuador, Argentina, and Chile reported that support in terms of resources facilitates the implementation of programmes. The importance of information as support was identified in Ecuador, Argentina, and El Salvador.Costa Rica reported that the implementation of the programme taught them the importance of the nursing profession. Honduras identified as interesting the lesson that the empowerment of health workers is a key factor in the implementation of a new health delivery model because of their management capacity.The Central American countries highlighted the importance of training in strengthening primary health care. In El Salvador, Costa Rica, and Honduras, the need to promote closer ties between health training and practice was emphasized. In Guatemala, the need to strengthen supervision to improve the quality of training programmes was stressed. Training health professionals was also a challenge in Argentina, Chile, Panama, and Ecuador.The lack of health professionals with adequate skills and competences, especially in PHC, was described as a challenge in Belize, Honduras, and Paraguay. Aiming to increase health coverage and ensure the quality of training and services, 14 of the 15 countries had programmes and initiatives to promote integration between educational institutions and health services, with the specific goal of improving the skills, capabilities, and training of doctors, nurses, and other technical professionals focused on primary health care and different specialties.Argentina, Uruguay, and Ecuador also cited the lessons learned regarding staff training, but these were not assessed in this study.In Central America, Dominican Republic identified IT development as a good practice that allows the systematization of administrative and financial procedures concerning staff contracts. Costa Rica recognized the importance of professional regulation and a competitive recruitment process. Peru, Paraguay, and El Salvador reported good practices related to changes in health care, including comprehensive care, the importance of teamwork, and community and family health models. The importance of teamwork was also reported in El Salvador. Meanwhile, Paraguay cited employment status and compensation as ways to reduce moonlighting.Lack of financial sustainability and challenges regarding the availability of information for the planning, implementation, or continuity of the programme were also identified. Difficulties related to the programme budget was highlighted and described in El Salvador, Belize, Costa Rica, Guatemala, Honduras, Panama, Ecuador, Chile, Argentina, and Uruguay. Such financial constraint was responsible for restricting the maintenance and expansion of programmes and for obstructing the establishment and implementation of a national HRH policy.Just as decisions related to HRH cannot be considered only by using economic criteria, so without adequate funding, it is not possible to address the health needs of the population, achieve the agreed-on goals, and guarantee the remuneration of health workers. For instance, in Costa Rica, there is an understanding that there are insufficient financial resources to address the health needs of the population and strengthen HRH. Honduras does not have a defined budget for human resources development. Ecuador had to postpone the first payments to those health workers who returned to the country from abroad, causing huge dissatisfaction. Further, Uruguay limited the number of new areas in the training programme due to lack of financial resources. Because of the weakness of the processes and the difficulty of developing projects or of integrating programmes within health systems, programmes and projects often develop in isolation, dependent on the availability of donor funds and without connection to the system as a whole.In many countries, such as Argentina, Guatemala, and El Salvador, the need to establish work agreements with educational institutions was mentioned. In addition, the identification of key stakeholders and the creation of institutional spaces of negotiation  can compensate for the lack of cooperation between these institutions and the lack of involvement of key partners in HRH programmes.The study results showed that the lack of supporting data and information remains a critical challenge for El Salvador, Costa Rica, Guatemala, Honduras, Dominican Republic, Chile, Argentina, and Paraguay. For instance, the importance of improving the data quality and of training staff on data collection tools was mentioned in Paraguay, whereas, in Argentina, local managers had difficulty updating the HRH data regularly.An increase in the use of virtual platforms in distance training programmes was observed. For instance, in Argentina, this sort of technology has been used to train professionals and tutors in a virtual campus for public health.In Costa Rica and Chile, retaining health professionals in the public sector was reported as a challenge, whereas El Salvador mentioned the burden of migration and high turnover of HRH. The difficulty of retaining health professionals in rural areas was also a challenge in Panama, El Salvador, and Paraguay. In Belize, this challenge is exacerbated because of the geography, low-population density, and scattered population, which make it even more difficult to organize health care services in remote and inaccessible areas. Difficulties in ensuring access to health services, increasing coverage, reducing waiting times, providing health care 24 h a day, and decreasing PHC gaps were considered as challenges in Nicaragua, El Salvador, Dominican Republic, and Ecuador.The concerns found in this research are similar to the ones noted by Ranson  and DussUnderstanding the nature of policy implementation and looking at this process can shed light on the barriers to and facilitators of more effective implementation . TherefoImplementation is an ongoing process of decision-making by key actors, who work in complex policy and institutional contexts and face pressures from interested as well as opposing parties. As such, the motivation, flow of information, and balance of power and resources among stakeholders influence the policy-implementation processes .In this study, most of the challenges involved in several phases and elements along the programme-to-action continuum were related to planning and programme design, stakeholder engagement, context, resources, and operational issues, which shape the decisions and actions at various levels.The initial stages of HRH programme development, such as the design and implementation planning, are crucial processes. According to Bhuyan et al. , the proAnother key issue in programme implementation is the involvement of and coordination with the stakeholders. These stakeholders include the groups or individuals responsible for the implementation, the people affected by the programme, and the officials and professionals accountable for achieving the programme goals. The involvement of stakeholders in the implementation can be challenging because this often requires “joint actions” in response to new partnerships that did not exist previously ,19.The insufficient commitment of key participants to implement programmes also emerged as a challenge. In some cases, stakeholder groups and organizations are not always committed to the same outcomes and must reach an agreement to support the implementation. As the programme implementation unfolds, additional stakeholders may find themselves being affected by the changes and may seek to also insert themselves into the process .To be feasible, HRH planning and implementation require the involvement of stakeholders, along with a solid financial basis and the necessary resources, such as time, skills, technology, equipment, information, and others. The programme descriptions highlighted situations in which a mismatch existed between the planned activities and the resources available for their implementation.Intersectionality was identified as a key issue for HRH planning to provide comprehensive and quality health services. Most of the programmes analysed seemed quite comprehensive, in terms of including training institutions, ministries of health, professional associations, and community associations as key stakeholders in the process of changing and reforming health systems and delivery models.Other difficulties in implementing HRH programmes include the following: lack of motivation for teamwork, unqualified recruitment mechanisms, outdated laws, unregulated health services provision, absence of impact measurement on the quality of care programmes, unmonitored activities, low educational level of candidates from rural communities, and nursing workload (rotating and moonlighting schedules).Although some of the initiatives and programmes evaluated were related to health training and labour management, almost all the countries considered success to be related more to the achievement of changes in the health delivery model and the reduction of HRH and health inequalities. Despite the current challenges, the countries have made progress in increasing the coverage of primary health care especially in the most vulnerable areas, providing vocational training, and strengthening the planning and establishment of a national human resources policy.This study provides information on a set of HRH programmes currently being developed in the region, including the challenges and lessons learned by each country at the national and regional levels. The value of evaluation as an institutional practice is a factor that was noted by all the countries and that needs to be promoted. The study results’ are consistent with the findings from other studies and authors -22.It is interesting to note that, although much is being done towards the achievement of health care goals, the gap between what can be done and what is being done is increasing. The success in reducing this gap will be determined largely by the successful development of the health workforce in alignment with the improvement of health systems, including on health system governance and financing.The relevance and importance of the evaluation process and the need for its institutionalization should also be emphasized, having shown its benefits and proven its relevance, as well as the need to enhance international cooperation in this area .


Robert Kissling , a pillaThe fondest of memories return; they remind the authors, his colleagues, and friends that it was with this attitude that the viral disease programs of CDC were established and have been maintained through the years. Bob, as an eminent virologist and a leader of CDC’s viral disease programs, left a permanent legacy.Born in Toledo, Ohio, Bob attended Otterbein College, was awarded a DVM and an MSc from the College of Veterinary Medicine, Ohio State University, and then spent a year at the graduate school of the University of California at Davis. In 1947, the year after CDC was founded, he joined the US Public Health Service and began a long and distinguished career with CDC, then known as the Communicable Disease Center.The 1950s was a period of great progress in field and laboratory research in virology and at CDC’s Virus and Rickettsia Section in Montgomery, Alabama. Bob began collaborative studies of the natural history, epidemiology, and pathogenesis of vectorborne viral encephalitides and began a career-long interest in rabies research; CDC developed an outstanding reputation in these areas, not the least because of Bob’s contributions. While in Montgomery, Bob married Martha Eidson, his laboratory technician, and they had 3 children.In 1958, Bob and guest researcher Robert Goldwasser succeeded in adapting the then-new immunofluorescence methodology to detect rabies viral antigen in brain specimens of animals suspected of being rabid  and the emergence of increasingly sophisticated approaches to virus research, virus detection and identification, and the means to guide CDC’s mission of disease prevention and control. Two new diseases are exemplary of the importance of his work, Marburg hemorrhagic fever and Lassa fever.In 1967, cases of hemorrhagic fever occurred among laboratory workers in Germany and Yugoslavia who were processing kidneys for cell culture; the kidneys were from African green monkeys that had been imported from Uganda. A new virus, Marburg virus, was isolated from patients and monkeys, first in Germany but shortly thereafter at CDC. From the beginning, it was realized CDC must have the capacity to deal with this virus and that Marburg virus was dangerous, calling for the best biocontainment of the day. CDC borrowed a mobile containment laboratory from the National Institutes of Health; the containment level provided was about what would be called Biosafety Level 2+ today. The work was led by Bob (As understood clearly by Bob, the Marburg virus episode had to be the impetus for the development of permanent biocontainment facilities at CDC. A glove port cabinet line laboratory was constructed, which opened in 1968. Completion of the laboratory coincided with the emergence of Lassa fever in West Africa. Early work on Lassa virus elsewhere was terminated after 1 person died and another nearly died; all virus stocks were sent to CDC. Under Bob’s leadership, Tom Monath and others set to work to develop diagnostic systems and uncover the natural history and reservoir host of Lassa virus (Retiring to a farm north of Atlanta in 1973, Bob and Martha were at last able to bird-watch, farm a bit, and enjoy the wildflowers. Martha died in 1999 and Bob, whose health was declining, moved to North Carolina to enjoy his children, grandchildren, and great-grandchildren. A gentleman of common sense, practical sense, he was always polite, always helpful, always willing to teach, and greatly respected by his peers. Bob Kissling was one of the giants of CDC.


After publication of the original article  it was bThe original Funding information contains an incorrect number. The original sentence reads as:This work was supported by a Grant-in-Aid  from the Japanese Ministry of Education, Culture, Sports, Science and Technology.The revised sentence, with the correct number reads as follows:This work was supported by a Grant-in-Aid  from the Japanese Ministry of Education, Culture, Sports, Science and Technology.26861729.Please note that the number 60615798 should instead be


Postgraduate medical education is founded on a tradition of service and education and is grounded in the realities of the twenty-first century. The very nature of the postgraduate enterprise is evolving in front of us all, and this is having a wide-ranging impact in a variety of areas. At stake is both the delivery of quality patient care and the preparation of the next generation of competent physicians. The engagement of the medical profession is an essential part of this reformation.One of the fundamental questions facing contemporary medicine is how best to organize the work hours of physicians who are undergoing clinical training. The postgraduate medical education of the physicians we refer to as “residents” is recognized by those within and outside medicine as an enterprise dedicated to preparing new physicians to enter independent practice. It is a time of great commitment for all involved – to learning, to patient care, and to the professional development of future leaders of health care teams. It is also a period that can be experienced through a number of perspectives: that of the residents and the patients they care for, the faculty who teach them, the training programs that support their progress, the certifying bodies that ultimately endorse them for entry into practice, and the administrators in the teaching hospitals where residents learn to balance their dual roles as learners and service providers on a health care team. These perspectives differ and diverge, and they also, ultimately, lead to the inherent tensions within residency in the modern era: education versus service, supervision versus autonomy, and quantity versus quality of care, among many others.Throughout much of the world, the hours that residents work have gradually decreased since the 1980s. This change has accelerated within the past five years with recent legislative and regulatory changes in Europe, the United States, Canada, and other jurisdictions. The question of how long residents should work has been the subject of heated discussion within the profession and among the broader public for almost three decades.BMC Medical Education arose from symposia on the topic of resident duty hours held at the annual International Conference on Residency Education in 2010 and 2011. These symposia, entitled respectively “Duty hours across borders” and “Solutions across borders,” took place as the most recent round of duty hour reforms were announced and implemented in the United States, the United Kingdom, and Canada, and both symposia included presentations by many of the authors of papers included in this issue. Importantly, these sessions provided an international forum to explore the challenges that can arise as a result of – and potential solutions to – changing duty hours, a dialogue we have capitalized on with this special issue.The impetus for this special issue of To accurately interpret the published data, it is essential to understand the historical context and the specifics of prior duty hour regulations.Early in the twentieth century, residents in North America actually resided in hospitals, providing after-hour “on-call” medical services as part of their training . Until tThe impetus to restrict duty hours varied from jurisdiction to jurisdiction. An initial catalyst for change in North America was the death of a college student, Libby Zion, in 1984 . ConcernAlso in 2011, in Canada, the province of Quebec ruled that shifts of 24 hours or more contravened both the provincial and national charters of rights and freedoms. As a result, duty hour schedules in the province were limited to no more than 16 continuous hours.In the European Union (EU), the movement to limit resident duty hours followed a somewhat different path. The European Working Time Directive (EWTD) was implemented in 1998, establishing the right of EU workers not to be required to work excessively long hours. This affected a number of professions, including those in the health sector. In the United Kingdom, doctors in training were exempted from these restrictions until 2004. Beginning in that year, hours for doctors in training were gradually reduced, finally reaching in 2009 a maximum of 48 per week, with no more than 13 consecutive hours of work .Resident work hours have also decreased in Australia and New Zealand over the past 20 years. As in Europe, the major driver of this change has been resident well-being rather than patient safety.A detailed survey of the current state of duty hour limits across these jurisdictions can be found in this issue in Sir John Temple’s paper “Resident duty hours around the globe: where are we now?” This issue examines the impact of changing resident duty hours through a number of lenses. Changes to the hours that residents work can be expected to have different effects on resident satisfaction and well-being, medical education, teaching faculty, patient safety, and the structure of health care delivery in teaching hospitals. These effects may vary by jurisdiction, reflecting differences in the structures of both health care delivery and medical education systems.BMC Medical Education, we felt it essential that these perspectives be reflected and explored. An international panel of expert authors provides historical and current perspectives across different domains of medical education and health service delivery. The crucial voice of residents is well represented from a range of jurisdictions. The result is a rich array of distinct scholarly perspectives on this important topic.The challenges and solutions may also differ between specialties, as the nature of practice and learning differs. As we assembled this special issue of The first set of papers in this issue address the intersection of duty hours with patient safety , residenThis special issue culminates with a discourse on the important issue of finding our way forward. Three solutions-focused papers explore strategies for adapting to changing resident duty hours. These articles examine how to improve continuity of care , a new mAs the editors of this special edition, we are pleased to be sharing the fruits of our international journey of residency education. These perspectives from around the globe articulate commonalities and differences from which we can learn and develop new ideas. We thank the authors for thoughtful contributions that describe their realities and solutions, and we hope that you will find the result thought-provoking, insightful, and valuable.Supplement Co-Editors:Dr. Kevin Imrie, MD, FRCPCPhysician-in-Chief, Sunnybrook Health Sciences CentreVice-Chair, Education, Department of Medicine, University of Toronto Professor of Medicine, University of TorontoDr. Christopher Parshuram, MB, ChB, D.Phil.Physician, Critical Care ProgramSenior Scientist, Child Health Evaluative Sciences, The Research Institute, Hospital for Sick ChildrenAssociate Professor Paediatrics, Critical Care, Health Policy, Management & Evaluation Faculty, Centre for Quality Improvement and Patient Safety, University of TorontoDr. Jason Frank, MD, FRCPCDirector, Specialty Education, Strategy, and Standards, Office of Specialty Education, The Royal College of Physicians and Surgeons of CanadaAll authors contributed to the concept, drafts, and revisions of this manuscript. All approved the final version.The supplement co-editors and authors declare that they have no competing interests.


Diabetes is a chronic disease, which deteriorates the quality of life of patients and reduces the life span. In the treatment of diabetes, first behavioral methods are used, then oral anti-diabetic drugs, then, in the course of the disease progress, a combined therapy (non-insulin plus insulin) and finally, solely insulin therapy. Unfortunately, many patients are afraid of including insulin for the treatment. By delaying the proper therapy, patients expose themselves to the increased risk of complications due to the macro- and microvascular pathologies. The prevention, prediction and minimalizing of the short- and long-term complications is a main focus of health care and it is at the front of the activities of many local and global organizations .Our two years long study (2011-2012) on the quality of life of the out clinic patients in Wroclaw suffered from the diabetes type 2, revealed the following: 1 quality of life was highest in patients treated with oral anti-diabetic drugs and the lowest in patients treated with insulin, only, and 2. general physical health of patients was worse than the general mental health. Moreover, we stated that the patients are more prone to develop depression than the general population. Besides of treatment method, within the factors that influence the quality of life, we found: age, disease duration, gender, obesity and presence of other diseases, including diabetes complications.One of the frustrating for patient complication, problematic in the treatment, is development of the diabetes foot, which is very often leading to the amputation, which in turn, shorten the patients’ life. Therefore, remote monitoring of the feet condition may allow for due to time medical intervention.Prevention of the complication as diabetic food may be possible by assessing the conditions for the pathology development. We expect that the local temperature distribution, as well as podobarographic data differ in healthy population and diabetes patients. Multi-institutional clinical study will help to gather enough data which may be exploited for finding the predictive factors of diabetic foot development. In patients already suffering from this complication, it could be possible to react promptly in order to prevent amputation. Such an approach will allow treating patients individually, simultaneously in the most economic way.


There are some missing grant numbers in the funding statement for this article. Please refer to the correct funding statement below:This work was supported by grant No. 8107513, No. 81370744, and No. 30901279 from National Natural Science Foundation of China . The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


Dr. Bruno Medeiros is not included in the author byline. He should be listed as the eleventh author and affiliated with Division of Hematology, Stanford University School of Medicine, Stanford, CA, USA. The contributions of this author are as follows: Conceived and designed the experiments, performed the experiments, and analyzed the data.


Dr. Constance Travers should be included in the author byline instead of the Acknowledgments. He should be listed as the seventh author, and his affiliation is #1: Abt Associates, Boulder, Colorado, United States of America. The contributions of this author are as follows: Conceived and designed the experiments, analyzed the data, and wrote the manuscript.