Protection of the environment.

The International Commission on Radiological Protection's (ICRP) system to protect the living components of the environment is designed to provide a broad and practical framework across different exposure situations. The framework recognises the need to be able to demonstrate an adequate level of protection in relation to planned exposure situations, whilst also providing an ability to manage existing and emergency situations in an appropriate way. In all three exposure situations, the release of radionuclides into the natural environment leads to exposures of non-human biota (wildlife), as well as having the potential for exposures of the public. How the key principles of the ICRP system of radiological protection apply in each of these exposure situations will be discussed. Using examples, we will demonstrate how the overall approach provides a mechanism for industry to assess and demonstrate compliance with the environmental protection objectives of relevant (national) legislation, and to meet stakeholder expectations that radiological protection of the environment is taken into consideration in accordance with international best practice. However, several challenges remain, and these will be discussed in the context of the need for additional guidance on the protection of the environment.

Nursing practice and global refugee migration: initial impressions from an Intergovernmental-Academic Partnership.

AIM: This report from the field describes impressions of the initial impact of bilateral, multi-sectoral field-based activities undertaken to strengthen International Organization for Migration/United Nations Migration Agency and US-based nurses' capacity to address complex clinical, social and cultural challenges experienced by refugees in resettlement. Authors comment on the defined and thorough health assessment process that refugees go through prior to resettlement, and focus on the essential nursing role in the health assessment process and continuum of care. The development of the interdisciplinary and collaborative partnership is described as well as next steps to move the partnership forward. BACKGROUND: In 2017, International Organization for Migration/United Nations Migration Agency and the University of Minnesota, guided by experts from the United States Centers for Disease Control and Prevention, began a unique bilateral Intergovernmental-Academic partnership to enhance the health care of refugees. A key component was to strengthen nursing care of refugees through the standardization of clinical practice and nursing leadership. SOURCES OF EVIDENCE: Listening sessions, direct interaction between International Organization for Migration/United Nations Migration Agency and US-based refugee resettlement stakeholders, patterns in resettlement. CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY: The report highlights the potential public health impact of a bilateral and collaborative initiative that develops and bridges key points in the migration and health trajectory of people with refugee status. Separated by geography, context and scope of work, health professionals in different roles in varied worldwide settings with a spectrum of resources may not fully understand the work of each other. Project activities were a platform through which US-based and internationally based nurses established mutuality, reciprocity and equity as partners. By strengthening systems and resources, the partnership reinforces the abilities of nurses who engage in this important work, to optimize health and wellbeing of people with refugee status.

Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000-17: a financial modelling study.

BACKGROUND: Estimates of government spending and development assistance for tuberculosis exist, but less is known about out-of-pocket and prepaid private spending. We aimed to provide comprehensive estimates of total spending on tuberculosis in low-income and middle-income countries for 2000-17. METHODS: We extracted data on tuberculosis spending, unit costs, and health-care use from the WHO global tuberculosis database, Global Fund proposals and reports, National Health Accounts, the WHO-Choosing Interventions that are Cost-Effective project database, and the Institute for Health Metrics and Evaluation Development Assistance for Health Database. We extracted data from at least one of these sources for all 135 low-income and middle-income countries using the World Bank 2019 definitions. We estimated tuberculosis spending by source and function for notified (officially reported) and non-notified tuberculosis cases separately and combined, using spatiotemporal Gaussian process regression to fill in for missing data and estimate uncertainty. We aggregated estimates of government, out-of-pocket, prepaid private, and development assistance spending on tuberculosis to estimate total spending in 2019 US$. FINDINGS: Total spending on tuberculosis in 135 low-income and middle-income countries increased annually by 3·9% (95% CI 3·0 to 4·6), from $5·7 billion (5·2 to 6·5) in 2000 to $10·9 billion (10·3 to 11·8) in 2017. Government spending increased annually by 5·1% (4·4 to 5·7) between 2000 and 2017, and reached $6·9 billion (6·5 to 7·5) or 63·5% (59·2 to 66·8) of all tuberculosis spending in 2017. Of government spending, $5·8 billion (5·6 to 6·1) was spent on notified cases. Out-of-pocket spending decreased annually by 0·8% (-2·9 to 1·3), from $2·4 billion (1·9 to 3·1) in 2000 to $2·1 billion (1·6 to 2·7) in 2017. Development assistance for country-specific spending on tuberculosis increased from $54·6 million in 2000 to $1·1 billion in 2017. Administrative costs and development assistance for global projects related to tuberculosis care increased from $85·3 million in 2000 to $576·2 million in 2017. 30 high tuberculosis burden countries of low and middle income accounted for 73·7% (71·8-75·8) of tuberculosis spending in 2017. INTERPRETATION: Despite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending. FUNDING: Bill & Melinda Gates Foundation.

Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years.

OBJECTIVE: To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload. DESIGN: Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB). SETTING: Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres. PARTICIPANTS: The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers. PRIMARY OUTCOME MEASURE: Volume and nature of surgical workload of different anaesthesia providers. RESULTS: Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%. CONCLUSION: Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.

The role of multilateral organizations and governments in advancing social innovation in health care delivery.

BACKGROUND: Despite great medical advances and scientific progress over the past century, one billion people globally still lack access to basic health care services. In the context of the 2030 Agenda for Sustainable Development social innovation models aim to provide effective solutions that bridge the health care delivery gap, address equity and create social value. This commentary highlights the roles of multilateral organizations and governments in creating an enabling environment where social innovations can more effectively integrate into health systems to maximize their impact on beneficiaries. MAIN TEXT: The integration of social innovations into health systems is essential to ensure their sustainability and the wide dissemination of their impact. Effective partnerships, strong engagement with and endorsement by governments and communities, regulations, trust and sometimes willingness are key factors to enhance system integration, replication and dissemination of the models. Three examples of social innovations selected by the Social Innovation in Health Initiative illustrate the importance of engaging with governments and communities in order to link, integrate and synergize their efforts. Key challenges that they encountered, and lessons learnt are highlighted. Multilateral organizations and governments increasingly engage in promoting and supporting the development, testing and dissemination of social innovations to address the health care delivery gap. They play an important role in creating an enabling environment. This includes promoting the concept of social innovation in health care delivery, spreading social innovation approach and lessons learnt, fostering partnerships and leveraging resources, convening communities, health system actors and various stakeholders to work together across disciplines and sectors, and nurturing capacity in countries. CONCLUSIONS: Multilateral organizations and local and national governments have a critical role to play in creating an enabling environment where social innovations can flourish. In supporting and disseminating social innovation approach, multilateral organizations and governments have a great opportunity to accelerate Universal Health Coverage and the achievement of the Sustainable Development Goals.

Comparing estimates of disability prevalence using federal and international disability measures in national surveillance.

BACKGROUND: The National Health Interview Survey (NHIS) is changing the annual inclusion of standardized disability identifiers, reinvigorating the priority to examine existing disability question sets. These sets include questions developed by the United States (U.S.) National Center for Health Statistics in conjunction with the U.S. Census Bureau (the American Community Survey questions, ACS) and United Nations (the Washington Group Short Set questions, WGSS), that are policy relevant, comparable across populations, and short enough to be included in censuses and surveys across countries. OBJECTIVE: To compare disability prevalence estimates from federal and international standardized disability questions across demographic factors. METHODS: Bivariate analysis of disability question sets asking adults about vision, hearing, ambulation, cognition, and self-care difficulties and demographic factors using secondary data from supplements in the 2010 and 2013-2015 NHIS. RESULTS: Our study found substantial and statistically significant differences in the percentage of disabilities (overall and by type) based on comparable ACS and WGSS questions across demographic categories. Dependent on response coding, WGSS-based disability prevalence was consistently and significantly larger or smaller than ACS-based disability prevalence. Overall disability prevalence using ACS and two different WGSS response combinations were 16.3% and 9.2% or 39.4%, respectively. CONCLUSION: ACS and WGSS measures identify predictably different sized populations of adults with disabilities. Further, with some exceptions, ACS and WGSS questions identify populations with disabilities with relatively consistent demographic factors. Additional research is recommended to understand the comparability of disability prevalence and health disparities and inequities people with disabilities experience when using these measures.

Funding blood safety in the 21st century.

BACKGROUND: Since 2000, there has been an historic increase in international development assistance, including blood safety projects. The result has been increased blood donations and infectious disease screening in many beneficiary countries. A comprehensive examination of international development assistance for blood safety has yet to be completed. STUDY DESIGN AND METHODS: This report examines publicly available information, including donor agency websites and databases and data from the 2008 and 2012 World Health Organization Global Database on Blood Safety. RESULTS: Between 2000 and 2015, from $602.4 million to $2.1 billion in international development assistance was allocated to blood safety programs worldwide, mostly as part of the global response to the human immunodeficiency virus/acquired immunodeficiency syndrome epidemic. The US President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria were responsible for the majority of blood safety funding, which peaked in 2010 and declined through 2015. CONCLUSION: Between 2000 and 2015, countries with high burdens of human immunodeficiency virus/acquired immunodeficiency syndrome received funding and technical assistance to improve national laboratories, increase blood component production, and strengthen clinical practice. Global trends in international development assistance at large, including aid for blood safety, suggest that funding will not rebound.

[Prescription of Yellow Fever Vaccine: The Experience of the International Vaccination Centre of the Loures-Odivelas Health Centre Group]. / Prescrição da Vacina Contra a Febre Amarela: Experiência do Centro de Vacinação Internacional do Agrupamento de Centros de Saúde Loures-Odivela.

INTRODUCTION: Yellow fever is a vector-borne disease in sub-Saharan Africa and tropical South America regions which is preventable by an effective and safe vaccine. In some cases, it may cause serious adverse effects and should therefore be prescribed only to individuals at risk of exposure to the yellow fever virus or those traveling to countries requiring proof of vaccination. The aim of this study was to analyze the prescriptions of yellow fever vaccine, based on travel destination and type of referring consultation, according to the international recommendations of the World Health Organization. MATERIAL AND METHODS: The database of the International Vaccination Centre of the International Vaccination Centre of the Loures-Odivelas Health Centre Group was used to analyze data concerning the year of 2016. Travelers who were prescribed and administered the yellow fever vaccine were grouped based on travel destination and type of referring consultation (travelers' medical consultations or non-specialist consultations). RESULTS: A total of 517 yellow fever vaccines were administered, with the highest proportion in female (53%) and in individuals aged 40 - 49 years (20.7%). One hundred and thirteen (22.6%) of the 499 individuals with known-destinations were travelling to non-endemic/non-epidemic countries and a greater proportion of those were prescribed in non-specialist consultations (27.3%) than in travel medicine consultations (8.8%). DISCUSSION/CONCLUSION: The highest percentage of yellow fever vaccines that were administered to individuals travelling to non-endemic/non-epidemic countries were prescribed in non-specialist consultations.

Introdução: A febre amarela é uma doença de transmissão vetorial que ocorre na África Subsaariana e na América do Sul tropical, e é evitável por uma vacina eficaz e segura. Nalguns casos pode causar efeitos adversos graves, devendo ser prescrita apenas a indivíduos em risco de exposição ao vírus ou que viajem para países que exigem prova de vacinação. O objetivo deste estudo foi analisar a prescrição da vacina contra a febre amarela, de acordo com o destino da viagem e o tipo de consulta de referenciação, segundo as recomendações internacionais da Organização Mundial de Saúde. Material e Métodos: Foi analisada a base de dados existente no Centro de Vacinação Internacional do Agrupamento de Centros de Saúde Loures-Odivelas, referente a 2016. Foram estudados os registos dos viajantes a quem foi prescrita e administrada a vacina contra a febre amarela, de acordo com o destino da viagem e o tipo de consulta de referenciação (consulta de medicina do viajante ou consulta não especializada). Resultados: Foram administradas no total 517 vacinas contra a febre amarela, em maior proporção em indivíduos do sexo feminino (53%) e em indivíduos dos 40 aos 49 anos de idade (20,7%). Dos 499 indivíduos que tinham destino conhecido, 113 (22,6%) tinham como destino países não endémicos/não epidémicos, com uma maior proporção de prescrições em contexto de consultas não especializadas (27,3%) do que em consultas de medicina do viajante (8,8%). Discussão/Conclusão: A maior percentagem de vacinas contra a febre amarela administradas a indivíduos que tiveram como destino países não endémicos/não epidémicos foram prescritas numa consulta não especializada.

True Dopers or Negligent Athletes? An Analysis of Anti-Doping Rule Violations Reported to the World Anti-Doping Agency 2010-2012.

BACKGROUND: The sanction that an athlete receives when an anti-doping rule violation has been committed depends on the specific circumstances of the case. Anti-doping tribunals decide on the final sanction, following the rules of the World Anti-Doping Code. OBJECTIVES: To assess the athletes' degree of fault based on the length of sanctions imposed on them to feed policy-related discussions. METHODS: Analysing data from the results management database of the World Anti-Doping Agency for anonymous information of anti-doping rule violations in eight selected sports covering the years 2010-2012. RESULTS: Four out of ten athletes who committed an anti-doping rule violation received a suspension that was lower than the standard. This is an indication that tribunals in many instances are not convinced that the athletes concerned were completely at fault, that mitigating circumstances were applicable, or that full responsibility of the suspected violation should not be held against them. Anabolic agents, peptide hormones, and hormone modulators lead to higher sanctions, as do combinations of several anti-doping rule violations. CONCLUSIONS: This first analysis of information from the World Anti-Doping Agency's results management database indicates that a large proportion of the athletes who commit anti-doping rule violations may have done this unintentionally. Anti-doping professionals should strive to improve this situation in various ways.

Haemophilia care in Europe - A survey of 37 countries.

INTRODUCTION: The European Haemophilia Consortium (EHC) is an international non-profit organization representing 45 national patients' organizations in Europe. Every 3 years, the EHC circulates a survey to its national member organizations to assess the state of haemophilia care. AIM: The purpose of this exercise is to ascertain information about the organization of haemophilia care and treatment availability at national levels. Furthermore, the survey provides a basis from which the EHC are able to monitor the unmet need and stability of care/treatment access in the individual member countries. PATIENTS AND METHODS: Surveys are distributed to EHC member organizations in English and Russian. Patient organizations are encouraged to share the survey with local clinicians to ensure accuracy of responses. The data collected are in part consistent to provide a longitudinal overview for treatment access, but topical items are included such as ageing. Subsequently, completed surveys are transposed into a database for analysis and reporting. RESULTS: Thirty-seven responses were received from the 45 countries approached, representing an 82% response rate from members. Findings suggest increased access to treatment and some improvement in certain areas of care. However, access to treatment has declined or remained largely unchanged in some countries. CONCLUSION: The survey has been a successful exercise in enabling a greater understanding of the current Haemophilia care landscape across Europe. However, there remain unmet needs in various aspects of patient care, and specific examples include psychosocial care and general preparedness for an ageing haemophilia population.

Examining Pediatric Cases From the Clinical Research Office of the Endourological Society Ureteroscopy Global Study.

OBJECTIVE: To evaluate the characteristics and outcomes of ureteroscopy (URS) in children treated in several hospitals participating in the Clinical Research Office of the Endourological Society (CROES) Study, and to present the overall results of pediatric URS compared with adults. PATIENTS AND METHODS: The CROES Study collected data on consecutive patients treated with URS for urolithiasis at each participating center over a 1-year period. The collected prospective global database includes data for 11,885 patients who received URS at 114 centers in 32 countries. Of these URS-treated patients, 192 were ≤18 years old. RESULTS: Of the 114 centers participating in the study, 42% had conducted pediatric URS. Among the pediatric cases, 7 were infants, 53 were small children, 59 were school-aged children, and 73 were adolescents. A considerable number (37%) of the pediatric cases had previously undergone URS treatment. No differences in the surgical outcomes of the adults and children were reported. The URS-treated children had a greater number of positive preoperative urine cultures when compared with adult cases treated. A semirigid scope was used in the vast majority of pediatric cases (85%). According to the present data, within the group of URS-treated children, the younger the child, the more readmissions occurred. CONCLUSION: URS is as efficient and safe in children as it is in adults. The data suggest that readmissions among URS-treated children are associated with age, with the likelihood of readmissions greater among younger age groups.

Global Pattern of Nasopharyngeal Cancer: Correlation of Outcome With Access to Radiation Therapy.

PURPOSE: This study aimed to estimate the treatment outcome of nasopharyngeal cancer (NPC) across the world and its correlation with access to radiation therapy (RT). METHODS AND MATERIALS: The age-standardized mortality (ASM) and age-standardized incidence (ASI) rates of NPC from GLOBOCAN (2012) were summarized, and [1-(ASM/ASI)] was computed to give the proxy relative survival (RS). Data from the International Atomic Energy Agency (IAEA) and the World Bank were used to assess the availability of RT in surrogate terms: the number of RT equipment units and radiation oncologists per million population. RESULTS: A total of 112 countries with complete valid data were analyzed, and the proxy RS varied widely from 0% to 83% (median, 50%). Countries were categorized into Good, Median, and Poor outcome groups on the basis of their proxy RS (<45%, 45%-55%, and >55%). Eighty percent of new cases occurred in the Poor outcome group. Univariable linear regression showed a significant correlation between outcome and the availability of RT: proxy RS increased at 3.4% (P<.001) and 1.5% (P=.001) per unit increase in RT equipment and oncologist per million population, respectively. The median number of RT equipment units per million population increased significantly from 0.5 in the Poor, to 1.5 in the Median, to 4.6 in the Good outcome groups, and the corresponding number of oncologists increased from 1.1 to 3.3 to 7.1 (P<.001). CONCLUSIONS: Nasopharyngeal cancer is a highly treatable disease, but the outcome varies widely across the world. The current study shows a significant correlation between survival and access to RT based on available surrogate indicators. However, the possible reasons for poor outcome are likely to be multifactorial and complex. Concerted international efforts are needed not only to address the fundamental requirement for adequate RT access but also to obtain more comprehensive and accurate data for research to improve cancer outcome.

The indirect impact of antiretroviral therapy: Mortality risk, mental health, and HIV-negative labor supply.

To reduce the burden of the HIV/AIDS epidemic, international donors recently began providing free antiretroviral therapy (ART) in parts of Sub-Saharan Africa. ART dramatically prolongs life and reduces infectiousness for people with HIV. This paper shows that ART availability increases work time for HIV-negative people without caretaker obligations, who do not directly benefit from the medicine. A difference-in-difference design compares people living near and far from ART, before and after treatment becomes available. Next we explore the possible reasons for this pattern. Although we cannot pinpoint the mechanism, we find that ART availability substantially reduces subjective mortality risk and improves mental health. These results show an undocumented economic consequence of the HIV/AIDS epidemic and an important externality of medical innovation. They also provide the first evidence of a link between the disease environment and mental health.

International Variation in Female Breast Cancer Incidence and Mortality Rates.

BACKGROUND: Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer-related death among women worldwide. Herein, we examine global trends in female breast cancer rates using the most up-to-date data available. METHODS: Breast cancer incidence and mortality estimates were obtained from GLOBOCAN 2012 (globocan.iarc.fr). We analyzed trends from 1993 onward using incidence data from 39 countries from the International Agency for Research on Cancer and mortality data from 57 countries from the World Health Organization. RESULTS: Of 32 countries with incidence and mortality data, rates in the recent period diverged-with incidence increasing and mortality decreasing-in nine countries mainly in Northern/Western Europe. Both incidence and mortality decreased in France, Israel, Italy, Norway, and Spain. In contrast, incidence and death rates both increased in Colombia, Ecuador, and Japan. Death rates also increased in Brazil, Egypt, Guatemala, Kuwait, Mauritius, Mexico, and Moldova. CONCLUSIONS: Breast cancer mortality rates are decreasing in most high-income countries, despite increasing or stable incidence rates. In contrast and of concern are the increasing incidence and mortality rates in a number of countries, particularly those undergoing rapid changes in human development. Wide variations in breast cancer rates and trends reflect differences in patterns of risk factors and access to and availability of early detection and timely treatment. IMPACT: Increased awareness about breast cancer and the benefits of early detection and improved access to treatment must be prioritized to successfully implement breast cancer control programs, particularly in transitioning countries.

A cross-sectional study of indications for cesarean deliveries in Médecins Sans Frontières facilities across 17 countries.

OBJECTIVE: To review the major indications for cesareans performed by Médecins Sans Frontières (MSF) personnel from the Operational Center Brussels. METHODS: A retrospective study was undertaken of all singleton cesarean deliveries from 2008-2012 for which indications were recorded. Location of project, age of patient, type of anesthesia, and duration of operation were also recorded. RESULTS: A total of 14 151 singleton cesarean deliveries were identified from 17 countries. Among the 15 905 indications recorded, the most common was failure to progress or cephalopelvic disproportion (4822 [30.3%]), followed by previous uterine scar (2504 [15.7%]), non-reassuring fetal status (2306 [14.5%]), and fetal malpresentation (1746 [11.0%]). Other indications were placenta or vasa previa (794 [5.0%]), uterine rupture (676 [4.3%]), hypertensive disorders (659 [4.1%]), placental abruption (520 [3.3%]), pre-rupture (450 [2.8%]), and cord prolapse (365 [2.3%]). CONCLUSION: Indications for cesareans in MSF settings differ from those in higher-income countries. Further investigation is needed for adequate emergency obstetric care coverage.

Natural vitamin C intake and the risk of head and neck cancer: A pooled analysis in the International Head and Neck Cancer Epidemiology Consortium.

Evidence of associations between single nutrients and head and neck cancer (HNC) is still more limited and less consistent than that for fruit and vegetables. However, clarification of the protective mechanisms of fruit and vegetables is important to our understanding of HNC etiology. We investigated the association between vitamin C intake from natural sources and cancer of the oral cavity/pharynx and larynx using individual-level pooled data from ten case-control studies (5,959 cases and 12,248 controls) participating in the International Head and Neck Cancer Epidemiology (INHANCE) consortium. After harmonization of study-specific exposure information via the residual method, adjusted odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated using unconditional multiple logistic regression models on quintile categories of 'non-alcohol energy-adjusted' vitamin C intake. In the presence of heterogeneity of the estimated ORs among studies, we derived those estimates from generalized linear mixed models. Higher intakes of vitamin C were inversely related to oral and pharyngeal (OR = 0.54, 95% CI: 0.45-0.65, for the fifth quintile category versus the first one, p for trend<0.001) and laryngeal cancers (OR = 0.52, 95% CI: 0.40-0.68, p for trend = 0.006), although in the presence of heterogeneity among studies for both sites. Inverse associations were consistently observed for the anatomical subsites of oral and pharyngeal cancer, and across strata of age, sex, education, body mass index, tobacco, and alcohol, for both cancer sites. The inverse association of vitamin C intake from foods with HNC may reflect a protective effect on these cancers; however, we cannot rule out other explanations.

The development of education indicators for measuring quality in the English-speaking Caribbean: how far have we come?

Education evaluation has become increasingly important in the English-speaking Caribbean. This has been in response to assessing the progress of four regional initiatives aimed at improving the equity, efficiency, and quality of education. Both special interest groups and local evaluators have been responsible for assessing the progress of education and providing an overall synthesis and summary of what is taking place in the English-speaking Caribbean. This study employed content analysis to examine the indicators used in these education evaluation studies since the declaration of the Caribbean Plan of Action 2000-2015 to determine these indicators' appropriateness to the Caribbean context in measuring education progress. Findings demonstrate that the English-speaking Caribbean has made strides in operationalizing quality input, process, and output indicators; however quality outcome indicators beyond test scores are yet to be realized in a systematic manner. This study also compared the types of collaborative partnerships in conducting evaluation studies used by special interest groups and local evaluators and pinpointed the one that appears most suitable for special interest groups in this region.

Should mortality data for the elderly be collected routinely in emergencies? The practical challenges of age-disaggregated surveillance systems.

Data on the elderly are rarely collected in humanitarian emergencies. During a refugee crisis in South Sudan, Médecins Sans Frontières developed a prospective mortality surveillance system collecting data for those aged ≥50 years and found that the elderly were dying at five times the rate of those aged 5-49 years. Practical and ethical issues arose. Were reported ages accurate? Since no baseline exists, what does the mortality rate mean? Should programmatic changes be made without evidence that these would reduce the elderly mortality rate? We outline issues to be addressed to enable informed decisions on response to elderly populations in emergency settings.