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FosteringChinasIncreasingEngagementinGlobalHealth

FengCheng,LucyChen,DavidGold,etal()

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PublicObjectionstoEnvironmentalTobaccoSmokeamongAdultsinHawaii

MiaoxuanZhang,RebekahRodericks,StephanieLee,etal()

EffectiveRecoveryofInfectiousHumanEnterovirusfromEnvironmentalWatersforTheirApplication

forWaterQualityMonitoring ZiWang,SiSun,ChristinaConnel,etal()

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TheRoleofEarlyLifeNutritioninObesityPrevention ColinBinns,MiKyungLee,RongxianXu()

GlobalHealthJournalVolNo Mar

Contents

Preface YoumeiFeng()

ResearchonSpecialTopics/Subjects

APACPHandPublicHealthEducationinChina BoWang,LimingLi()

ChinaandGlobalHealth:ConceptandFuture MinghuiRen,GuopingLu()

GlobalHealthPolicy:EffortsforPromotingHealthEquity QingyueMeng()

TheAnalysisofNewPracticesofSinoAfricanHealthCooperation XuJi,GuopingLu,LinaZhao()

FosteringChinasIncreasingEngagementinGlobalHealth FengCheng,LucyChen,DavidGold,etal()

PolicyAnalysis

ComparativeResearchonTobaccoControlPolicybetweenUSAandChina

DanCui,TianGan,ZongfuMao,etal()

PublicObjectionstoEnvironmentalTobaccoSmokeamongAdultsinHawaii

MiaoxuanZhang,RebekahRodericks,StephanieLee,etal()

LaborataryResearch

EffectiveRecoveryofInfectiousHumanEnterovirusfromEnvironmentalWatersforTheirApplication

forWaterQualityMonitoring ZiWang,SiSun,ChristinaConnel,etal()

ResearchReview

ImplementationResearch:aBriefIntroductionofaKeyResearchFrameworkinGlobalHealth

JingGu,YuantaoHao()

BibliometricAnalysisofMultidrugresistantTuberculosisLiteratureatHomeandAbroad

ChaoyuYing,XiaodongTan,BeiLiu,etal()

TheItalianRegionalHealthcarePerformanceEvaluationSystem:AReviewandCommentary

HaoLi,TingfangLiu,SipingDong()

TheRoleofEarlyLifeNutritioninObesityPrevention ColinBinns,MiKyungLee,RongxianXu()

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APACPHandPublicHealthEducationinChina

BoWang,LimingLi

ChineseAcademyofMedicalSciencesHealthscienceresearchcenter,BeijingChina;

ChineseAcademyofMedicalSciences/BeijingUnionMedicalCollege,Beijing,China

Abstract:Firstly,anintroductionofAPACPH,includingthemissionandobjectives,organizationalstructure,main activities,majorfunding sourcesand extraordinaryleaders,was provided ThecontributionofAPACPHtoChinaspublichealth,intermsofregionalcollaborationandcommunication,

training and faculty/students exchanges,research cooperation and communication, emergencypreparednessanddisastermanagement,andPublicHealthEducationReform,wasdescribedSecondly,

thedevelopmentprocess,characteristicsandreformofChinaspublichealtheducationweresummarizedFinally,futurecooperationbetweenAPACPHandChinawasexpected

Keywords:APACPH;publichealtheducation;publichealtheducationaccreditation

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ChinaandGlobalHealth:ConceptandFuture

MinghuiRen,GuopingLuDepartmentofInternationalCooperation,NationalHealthandFamilyPlanningCommission,Beijing,China

Abstract:GlobalizationissweepingeverycornerHealthissueshave becomethecoreofglobaldevelopmentandareamongimportantnontraditionalsecurityissuesNocountriescandealwithitalone,

andthereisaneedtotakecoordinatedactionwithdiverseresourcesandtoworkonglobalhealthcooperativelyChinasexperienceofitsownhealthcaredevelopmentprovidesvaluablevisionsandthoughtsforglobalhealthChinahasbeentheimportantstateactorofglobalhealthinbilateral,multilateral,theregionalandgloballevelsAtpresent,itisnecessaryforChinatoengageintheglobalhealthandconducttheresearchonglobalhealthstrategyfromanewandfullperspective

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NewYork:RockefellerFoundation,

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GlobalHealthPolicy:EffortsforPromotingHealthEquity

QingyueMengPekingUniversityChinaCenterforHealthDevelopmentStudies,Beijing,China

Abstract:HealthequityandpromotionisoneofthemostimportantaimofglobalhealthdevelopmentHealthpolicydevelopmentfromglobalperspectiveplayscriticalroleininfluencinghealthandpromotedevelopmentoftheglobalhealthsubjectOverthepastthreedecades,healthequityhasbeencenteredthedevelopmentandpolicyaimsbymanyinternationalorganizations,especiallytheUNsystem,whichisreflectedfromtheprimaryhealthcare,theMillenniumDevelopmentGoals,anduniversalhealthcoverageThisarticleintroducesthemainglobalhealthpolicies

Keywords:Globalhealth;healthpolicy;equity

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[]HopelessAfrica,theEconomist[]http://

wwweconomistcom/node/[]Thehopefulcontinent Africarising TheEconomist

[]http://wwweconomistcom/node/[]InternationalMonetaryFund(IMF),Worldeconomicandfi

nancialsurveys Worldeconomicoutlook(),Washing

ton DC, http://wwwimforg/external/pubs/ft/

weo///pdf/textpdf[]RalucaBChinaandtheUScourtAfricaYaleGlobalOn

line, http://yaleglobalyaleedu/content/chinaand

uscourtafrica[]RalucaBChinaandtheUScourtAfricaYaleGlobalOn

line, http://yaleglobalyaleedu/content/chinaand

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cahttp://wwwwhitehousegov/sites/default/files/

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world///content_htm[]JohnPB,GeorgeI,MwangiK,etalTopfivereasonswhy

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Institution Washington DC, http://

wwwbrookingsedu/research/reports///africaprior

ityunitedstates[]KatherineB,DavidB,NellieB,etalGlobalHealthPolicyin

theSecondObamaTerm,CenterforStrategicandInterna

tionalStudies/Rowman & Littlefield Washington DC,

http://csisorg/publication/globalhealthpolicysec

ondobamaterm[]TheUnitedStatesgovernmentglobalhealthinitiativeStrat

egydocuments http://wwwcdcgov/globalhealth/

ghi/pdf/ghistrategypdf[]http://wwwusaidgov/wherewework/africa[]VictorC,LucyC,HealtherAC,etal Thechangingland

scapeofglobalhealthdiplomacy,CenterforStrategicandIn

ternational Studies/Rowman & Littlefield Washington

DC,http://csisorg/publication/changinglandscape

globalhealthdiplomacy[]EricJBeyondinvestment,politicalengagementcalledfor:

JapanurgedtoplaymorevisibleroleoncontinentTheJapan

times Tokyo, http://wwwjapantimescojp/news/

///national/japanurgedtoplaymorevisiblerole

oncontinent/UwnKbKcEM[]MinistryofForeignAffairsofJapanYokohamaDeclaration

:HandinhandwithamoredynamicAfrica Tokyo,

http://wwwmofagojp/region/pagee_html[]EmilieGLeJapondfendsespositions,LeMondediploma

tique, http://wwwmondediplomatiquefr///

GUYONNET/[]BenjaminSJapansglobalhealthdiplomacy:Internationali

zationofpublichealth CSISreport,Washington DC,

http://csisorg/publication/changinglandscapeglob

alhealthdiplomacy[],

,,[]BenjaminSJapansglobalhealthdiplomacy:Internationali

zationofpublichealth CSISreport,Washington DC,

[]RaydenL,Sayako K,Osamu K,etal Reinvigorating

Japanscommitmenttoglobalhealth:challengesandoppor

tunitiesLancet,,:[]BenjaminSJapansglobalhealthdiplomacy:Internationali

zationofpublichealth CSISreport,Washington DC,

[]KatherineB,HarukoS,AyakaF,etalJapansglobalhealth

policy:Developingacomprehensiveapproachinaperiodofe

conomicstressCenterforStrategicandInternationalStud

ies/Rowman&LittlefieldWashingtonDC,http://

csisorg/publication/japansglobalhealthpolicy[]BenjaminSJapansglobalhealthdiplomacy:Internationali

zationofpublichealth CSISreport,Washington DC,

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TheAnalysisofNewPracticesofSinoAfricanHealthCooperation

XuJi,,GuopingLu,LinaZhao

PekingUniversityGlobalHealthInstitute,Beijing,China;

TheMinistryofHealthHumanResourlesDevelopmentLeuter,Beijing,China;

MinistryofHealthandFamilyPlanningCommissionDepartmentofInternationalCooperationDepartment,Beijing,China

Abstract:Overthepastyears,theAfricancontinentisundergoingahugetransformationAlthoughtheregionasawholeisstillconfrontingmanyeconomicandsocialchallenges,particularlyinachievingtheUNMillennium DevelopmentGoals,itisundeniablethat AfricaisontherighttrackThispapersystematicallyreviewstherecentinitiativesinthearenaofglobalhealthmadebytheUnitedStatesandJapan,thetwomajorplayersininternationalhealthdevelopmentaidandfurtheranalyzeshowChinawillrespondtothosechangingsituationandcontinuetoconductpragmatichealthcooperationwithAfricancountriesthroughscientificdecisionmakingprocess,comprehensivemarketforces,innovationinhealthassistancemechanismanddiversityofhealthcooperationpatterns,etc,soastoenhancethebreadthandthedepthofChineseSouthSouthhealthcooperation

Keywords:USandJapan;globalhealthstrategy;southsouthhealthcooperation

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GlobalHealthJournalVolNoMar

FosteringChinasIncreasingEngagementinGlobalHealth

FengCheng,,LucyChen,DavidGold,MyThuanTran,AlexBowlesTsinghuaUniversityResearchCenterofPublicHealth,Beijing,China;

GlobalHealthStrategies,Beijing,China;

BeijingUniversityInstituteforGlobalHealth,Beijing,China;

GlobalHealthStrategiesInitiatives,NewYork,USA

Abstract:ChinahasbeenactivelyparticipatinginglobalhealthissuesThispapermadeanoverallreviewofChinasdevelopmentinbothdomesticandglobalhealthChinascontributionstoglobalhealtharediscussedintermsofforeignassistance,humanresourcesandinfrastructure,theuseofdrugs,politicalcommitment,etcThechallengesChinaisconfrontingarealsodiscussedsoastobetterfosterChinasengagementinglobalhealth

Keywords:GlobalHealth;ForeignAssistance;SouthSouthCollaboration;Challenges;China

Received:;Revised:

PaperpresentedatthethAPACPHConferencehostedbySchoolofPublicHealthatWuhanUniversity,October,

Author:FengCheng,professorofresearchcenterforpublichealth,TsinghuaUniversity&vicepresidentofGlobalHealthStrategies(GHS);LucyChen,executivedeputydirector,Instituteforglobalhealth,PekingUniversity;DavidGold,principalofGlobal

HealthStrategies(GHS);MyThuanTran,directorofGlobalHealthStrategies(GHS);AlexBowles,seniorassociateofGlobal

HealthStrategies(GHS)

CorrespondingAuthor:FengCheng,researchcenterforpublichealth,TsinghuaUniversity& GlobalHealthStrategies(GHS)Email:

fchengglobalhealthstrategiescom

Introduction

AsChinahassolidifieditsstandingasaglobal

power,ithasrapidlyincreaseditsforeign,withanestimatedannualgrowthofbetweenand[]Healthfocusedassistanceremainsasmall,

thoughgrowing,partofChinasoverallassistancebudgetNonetheless,asChinaincreasinglybringsresourcesandinnovationtosupporthealthindevelopingcountries,ithasthepotentialtomakeasignificantimpactonhealthglobally

Chinaseffortsarepartofthegrowinginfluence

ofemergingeconomiesinglobalhealthCountriesincludingIndiaandBrazilwithanincreasedfocusonSouthSouthcooperationarebringingnewapproachesandresourcestoimprovethehealthofpeopleworldwide Asthebudgetsoftraditionalglobalhealthdonorscontinuetocomeunderpressure,

theseeffortsareincreasinglyimportantChinaisuniquelypoisedtoadvanceglobalhealth

efforts,drawing from its significant domestichealthachievements,productionofhighquality,

lowcosthealthtechnologiesandenormousinvestmentinresearchanddevelopment Atthesametime,ensuringChinaspotentialasaglobalhealth

partnerisfullyrealizedandcontinuedpoliticalcommitmentfromChinasleadersisneededTheGovernmentofChinarecognizedinthatChinahasalongwaytogoinprovidingforeignaid,

andpromisedtooptimizethecountrysforeignaidstructure,improvethequalityofforeignaid andimprovethepertinenceandeffectivenessofforeignaid[]Internationalorganizationsandtraditional

globalhealthdonorscanhaveakeyroleinsupportingChinasefforts

DomesticHealthAchievementsOfferKeyLessons

Chinahasmadedramaticprogressagainstitsownpublichealthchallenges,evenwitharelativelylowpercapitaGDPThecountrymetMDGaheadofschedule,reducingchildmortalityfrom

per,livebirthsintoin[]IthasachievedMDGandhasmadeprogressagainstMDGChinasuccessfullycontrolledandpreventedarangeofinfectiousdiseasesIteliminatedpolioin(andswiftlydealtwithreimportationofthevirusin),eliminatedlymphaticfilariasisin,andnearlyeliminated malariaandschistosomiasis

ChinahasstrengtheneditshealthsystemtoreachbothurbanandruralareasIn,Chinaembarkedonreformingitshealthsectortoexpanduniversalcoverageofhealthservicesandinsuranceby,representingthegreatestexpansionofhealthcarecoverageandaccesstheworldhaseverseen

Chinasdomestichealthprogresscanprovidevaluable modelsfordevelopingcountriesfacingsimilarchallengesOneimportantfactorofChinassuccessinreducingchildmortalityisimprovingaccesstoimmunizationthroughitsNationalImmunizationProgram,alongwithadvancesincoldchainmanagementandsurveillancesystemsChinahasbeguntoshareitsexpertisethroughbilateraltechnicalassistancetootherdevelopingcountriesfacingsimilarchallenges

Quality Health Technologies andImprovingAccess

Chinas pharmaceutical industry, startingfromscratch,hasgrownfromaweak,centrallyplannedsectortoastrong,marketorientedoneSincetheReformandOpeningup,thepharmaceuticalsectorhasbeenoneofthefastestgrowingindustries Chinahasinvestedheavilyinresearchanddevelopmentandisnowthesecondbiggestinvestorin R&Dintheworld,afterthe UnitedStates[]Chinesecompanieshavebeenasourceofhighquality,lowcosttechnologiesandareincreasinglybringinginnovativetechnologiestomarketthatcouldsubstantiallyimproveaccessindevelopingcountries

Oneimportantexampleofthishasbeenantimalarialdrugs,asChinaistheworldslargestproducerofartemisininAnotherexampleisSinoimplantII,alowcost,longactinginjectablecontraceptive,whichhashelpedtodrivepricesdownforwomenincountrieswhereaccesstoreproductivehealthservicesislimited TheShangRingisalowcostmalecircumcisiontoolthatcanreducetheriskofHIVinfection,whichmakesithighlysuitableforlowincomecountrieswithhighHIVprevalenceBothSinoimplantandtheShangRingareawaitingWHOprequalification,whichwillclearthepathforpurchasebyinternationalagencies

ChinesecompaniesmanufactureallvaccinesinitsNationalImmunizationProgram,ensuringareliabledomesticsupplyofvaccinesInOctober,thefirstChinesemanufacturedvaccineachieved WHO prequalification,markinga milestoneinChinasentryintotheglobalmarketforvaccinesThevaccineprotectspeoplefromJapaneseEncephalitis,adiseasethataffectsmanypoorcommunitiesacrossAsiaBymeetingtheinternationalqualitystandard,thevaccinecannow bepurchasedbyinternationalorganizationssuchastheGAVIAllianceandUNICEFfordeliveryto

lowresourcecountriesSignificantly,theChinesemanufacturerhasembracedaprinciplefundamentaltoglobalequityknownas tieredpricing,

promisingtoprovidethelowestpricestothepoorestcountriesAnumberofothervaccinesareseekingWHOprequalificationoverthenextfewyears,

includingoralpoliovaccine,rotavirus,pneumococcalconjugate,seasonalfluandmeningitis

HumanResourcesandInfrastructure

Chinashealthassistanceisrootedinrecognitionoftheessentialrolethathumanresourcesplayinhealth,anditseffortsfocusonhelpingsupportsustainablehealthsystemsinlowincomesettingsSince,Chinahassent morethan,healthworkersincludingdoctorsandnursestocountriesinAfricaandadozencountriesacrossAsiathroughitsChineseMedicalTeamsprogram[]Tobuildlocalcapacity,Chinasoverseasmedicalteamsalsotrainincountrystaff

Chinahashistoricallyprovidedassistanceformuchneededhealthinfrastructureinseveraldevelopingcountriesincluding hospitalsand malariacenters,andhassupportedpharmaceuticalfactoriesinvariouscountriesinAfrica

PoliticalCommitmenttoStrengthenChinasGlobalHealthEfforts

Overthepastyear,Chinasgovernmentandprivatesectorhaveengagedinfurthereffortstosupporthealthinothercountries,particularlyontheAfricancontinent TheMinisterialForumonChinaAfrica Health Development in AugustbroughtmorethanAfricanheathministersandanumberofglobalhealthleaderstoBeijingThisForum wasthefirstmeetingofhealthministersunderthe Forum on ChinaAfrica Cooperation(FOCAC),highlightingtheimportanceofhealthinthefutureofChinaAfricarelations

ParticipantsatthemeetingagreedtotheBeijing Declaration,whichidentifiedareas whereChinacanbringitsexpertiseandresourcestoaddressparticularhealthissues,suchasmalariacontrol,schistosomiasis,HIV/AIDS,reproductivehealthandimmunization The Declarationalsohighlightedeffortsthatcouldsupportsustainability,suchasaddressinghealthworkershortagesandincreasingpartnershipsonresearchandtechnologytransfer

ChallengesforGlobalHealthEfforts

OnechallengeisthatChinadoesnothaveasingleoverarchingbodythatcoordinatesitsaidInstead,severalagenciesanddepartmentsinChinashareresponsibilityforChinashealthassistancebudgetsandactivities TheyaretheMinistryofCommerce(MOFCOM),theNationalHealthandFamilyPlanningCommission(NHFPC),andtheMinistryofForeignAffairs(MOFA)Eachministryhasdifferentinterestsandpriorities,andlackofcoordinationcaninhibitefficiency,efficacyandtransparency

Chinasgreatpromiseasasourceofhealthtechnologiesislimitedbycontinuingchallengeswithqualitycontrol WhilemostChineseproductsareofhighquality,doubtsoverqualityandsafetysometimesunderminetheiracceptance CounterfeitorpoorqualitydrugsproducedinChinaandothercountriesthreatenrealharminsomeinstancesResolvingthisissuewillrequireaddressinganinterlockingsetofproblemsincludinglaxregulatoryregimesandtheroleoftheprivatesectorButtherecentprequalificationoftheChinesemadeJapaneseEncephalitisvaccineaugurswellforthefuture

Finally,Chinahastraditionallyconductedaidthroughbilateralagreements,ratherthanfinancingmultilateralssuchastheGAVIAllianceortheGlobalFundThisalignswithmanyotheremer

FengCheng,etal:FosteringChinasIncreasingEngagementinGlobalHealth

gingeconomygovernments,suchasBrazilandIndia,whichdonthewtostandarddonorrecipientframeworksbutinsteadexploredifferentdevelopmentassistancemodelsChinaspreferenceforbilateralagreementsislikelytoremain,althoughitsengagementwithmultilateralsisexpanding,includingdonationstoUNICEF,theGlobalFundandtheWHOInrecentyears,ChinahaswelcomedthesupportofinternationalorganizationssuchasWHO,UNAIDS,UNFPAandUNICEFinshapingChinaAfricahealthcollaboration

ThisincreasingengagementwithinternationalorganizationsandsystemsmustalsoincludeChinesebusinesses Chinesepharmaceuticalcompaniesarestillfocusingalmostexclusivelyonthedomesticmarket ThismeanstheywillneedsomesupporttomeetinternationalstandardsforWHOprequalificationofdrugsandvaccinesalongandcomplexprocess,withlanguagebarriersacontinualchallenge

Conclusion

Chinasexperienceinbuildingandoperatinghealthdeliverysystemsinlowincomesettings,

combinedwithitsprogressinhealthproductdevelopmentandmanufacturing,makeitideallyplacedtocollaboratewithvariouspartnersinimproving

globalpublichealthChinasengagementinglobalhealthisapowerfulforcethatcanprovidenewfundingandinnovativetechnologiesandapproaches Byseekingtodevelopacoherentglobalhealthstrategy,theChinesegovernmentisdemonstratingitscommitmenttofurtheritsinfluenceonglobalhealthTheinternationalcommunityhasanimmenseopportunitytosupporttheseeffortsTomoveforward,Chinaneedstoengageinglobalhealthdebates,tobetterunderstandthehealthneedsofpartnercountriesandcoordinateitsowneffortsmoreeffectively ContinuedadvocacycanhelpencouragetheChinesegovernmenttoaddressthechallengesidentifiedabove,expanditsengagementandalignitsprioritiestoeffectivelysupporttheglobalcommunityinmeetingpressinghealthchallenges

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():(NongovernmentalOrgnization,NGO).CDC,CDC,.NGO.

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[]CentersofDiseaseControlandPreventionBehavioralRisk

FactorSurveillanceSystem[]http://wwwcdcgov/

brfss/[]CDCPrevalenceandtrendsdatatobaccouseAdultswho

arecurrentsmokersOfficeofSurveillance,Epidemiology,and

LaboratoryService[]http://appsnccdcdcgov/

BRFSS/listasp? catTU&yr&qkey&state

All[]

:

,:[]CentersofDiseaseControlandPreventionBehavioralRisk

FactorSurveillanceSystem[]http://wwwcdcgov/

brfss/[]CentersforDiseaseControlandPrevention DataSource/

MethodologyOfficeofSurveillance,Epidemiology,andLa

boratoryService[]http://appsnccdcdcgov/

statesystem/help/help_methodologyaspx[][

]http://wwwnotcorgcn/jcpg/gs//t_

htm[]DavidWC,PhilipBSmokefreelawsandbarrevenuesin

CaliforniathelastcallHealthEconomics():

[]CentersforDiseaseControlandPreventionStatesmokefree

lawsforworksites,restaurants,andbarsUnitedStates,

MMWR Morbidityand Mortality WeeklyRe

port,,():[]MichelleD,RichardLB,StantonAGChippingawayatto

baccotraditionsintobaccocountry:tobaccoindustrypolitical

influenceandtobaccopolicymakinginNorthCarolina

CenterforTobaccoControlResearchandEducation

SchoolofMedicine[]GlobalSmokeFreePartnership:

[]http://wwwglobals mokefreepartner

shiporg[]SmokefreeTransportationChronology[]http://no

smokeorg/documentphp?id[],

[]http:// wwwrmdbwgovcn/

//html[]CentersofDiseaseControlandPrevention[]Leg

islationhttp://wwwcdcgov/tobacco/data_statistics/by_

topic/policy/legislation/[]TheSettlingStatesMasterSettlementAgreement[]//

[]wwwnotcorg

cn/zcfg/fzjcycyw//t_html[]:,

[]NorthAmericanquitlineconsortium Whocallsquitlinesin

theUnitedStates? :[]

[]http://wwwtobaccogov

cn/html//_nhtml[]CaliforniaSmokers Helpline[]http://www

californiasmokershelplineorg/[],[

]http://wwwgovcn/rexian/rxjsjsp[][]http://

wwwbjorg/NewsViewaspx? NewsID[]Anationalactionplanfortobaccocessation:preventing

milliondeaths,helpingmillionsmokersquit[]ht

tp://wwwctriwiscedu/Researchers/researchers_national_ac

tion_planhtm[]AmericanlungassociationProvidingfederalcoverageforcessa

tionservices[]http://wwwlungorg/stopsmok

ing/tobaccocontroladvocacy/federal/cessationcoveragehtml[][

]http://wwwmohgovcn/ publicfiles/business/html

,:

files/wsb/pzcjd//htm[],,,

,():[]PubliclawJune,Familysmokingpreventionand

tobaccocontrolact[][]ht

tp://wwwchinaacccom/new//////zh

htm[]

[]http://wwwtobaccochinacom/law/nation/wu/

/_shtml[]

[]http://wwwcatcprcorgcn/indexaspx?

menuid&typearticleinfo&lanmuid&infoid&lan

guagecn[]TheSettlingStatesMasterSettlementAgreement

[]

[]http://wwwsaicgov

cn/fldyfbzdjz/zcfg/xzfg//t_html[][]http://wwwgovcn/

xwfb///content_htm[]NJenniferR,MichaelS Useofcorporatesponsorshipasa

tobaccomarketingtool:areviewoftobaccoindustrysponsor

shipintheUSA, TobaccoControl():

[],,()[]CDCLegislationexcisetaxcigarette[]http://

appsnccdcdcgov/statesystem/ComparisonReport/Compari

sonReportsaspx? TopicID&MeasureIDReport

Detail[]WHO:

:

ComparativeResearchonTobaccoControlPolicybetweenUSAandChina

DanCui,TianGan,ZongfuMao,JayEMaddock

WuhanUniversityGlobalHelthInstitute,Wuhan,China;

GuangdongCenterforDiseaseControlandPrevention,Guangzhou,China

Abstract:ThisarticlecomparedthepolicyandmeasuresoftobaccocontrolbetweenChinaandUSAaccordingtotheMPOWERstrategyofWHOandtriedtofindtheexperiencesandadvicesfortobaccocontrolinChinaComparingthedifferencesbetweenChinaandUSAinresponsiblemanagement,managedobjects,managedcontentandhistoricaldevelopmentaccordingtotheMPOWERstragegy,wefoundimportantproblemsoftobaccocontrolinChinabysearchingtheinformationofpolicyandmeasuresoftobaccocontrolinChinaandUSAonthewebFirstly,therehadnotbeenacontinuous,nationalwidemonitoringsystemfortobaccoprevalenceSecondly,therewasnolawforsmokefreeinthenationallevelThelocalbylawwasnotclearandwithalighterpunishmentThirdly,therewasnoeffectivehelpforquittingsmokingFourthly,thehealthwarningsshowedoncigarettepackagingwerenotobviousandthesentencewasnotseriousenoughFifthly,tobaccoenterpriseenhancedtheircorporateimagethroughtherecessiveandindirectadvertisement Sixthly,thetobaccotax wastoolowtoreducethetobaccoconsumption

Keywords:Tobaccocontrol;MPOWERStrategy;comparativeresearth

GlobalHealthJournalVolNoMar

PublicObjectionstoEnvironmentalTobaccoSmokeamongAdultsinHawaii

MiaoxuanZhang,,RebekahRodericks,StephanieLee,JayEMaddock,

UniversityofHawaiiatManoaOfficeofPublicHealthStudies,Honolulu,USA;

WuhanUniversityGlobalHealthInstitute,Wuhan,China

Abstract:CreatingsmokefreeenvironmentcanreducetheharmfuleffectoftobaccosmokeforbothsmokersandnonsmokersInitiatingbehaviorstoavoidsecondhandsmokemaybeagoodwaytopromoteorencourageasmokefreeenvironmentBinarylogisticregressionwasusedtoanalyzearandomdigitdialedtelephonesurveywith,adultresidentsofHawaiiCurrentsmokersweretheleastlikelytoobjecttoenvironmentaltobaccosmokefrombothstrangersandfriendsAmongformersmokersandnonsmokers,significantpredictorsofaskingstrangersnottosmokearoundthemwere:beingNativeHawaiianandFilipino,goodgeneralhealthstatus,lowerhouseholdincome,youngerage,positivesocialnorms,disagreeingthatitisokayforpeopletosmokeinoutdoorpublicplaces,andhavingchildrenSimilarly,statisticallysignificantpredictorsofavoidingsecondhandsmokefromafriendwasbeingNativeHawaiianorFilipino,lowerhouseholdincome,youngerage,negativeattitudestowardssmoking,andhavingchildrenThisstudyindicatesthatchangesinpeoples

psychosocialconstructstowardsecondhandsmokemaybeimportanttocreatesmokefreeenvironments

Keywords:Secondhandsmoke;hawaii;smokefreepolices

Received:;Revised:

Author:MiaoxuanZhang,researchstaffofofficeofPublicHealthStudies,UniversityofHawaiiatManoa;RebekahRodericks,juniorfac

ultyofOfficeofPublicHealthStudies,UniversityofHawaiiatManoa;StephanieLee,studentofOfficeofPublicHealthStudies,

UniversityofHawaiiatManoa;JayEMaddock,professorofOfficeofPublicHealthStudies,UniversityofHawaiiatManoa

CorrespondingAuthor:JayEMaddock,OfficeofPublicHealthStudies,UniversityofHawaiiatManoaEmail:jmaddockhawaiiedu

Introduction

TheWorldHealthOrganization(WHO)predictsthatby,tobaccowillberesponsibleformorethanmilliondeathsworldwideeachyear[]Thisismorethantuberculosis,HIV/AIDS,andmalariacombined[]Evenamongnonsmokers,exposuretosecondhandsmokehasabroadrangeof serious health consequences[]Secondhandsmokeexposureincreasestheriskoflungcancer,

strokeandcoronaryheartdisease[]IntheUnitedStates,secondhandsmokecausesabout,lungcancerdeathsand,heartdiseasedeathseachyear[]Tobaccoisresponsibleforanestimatedcasesofsuddeninfantdeathsyndrome,,lowbirthweightbabies,,pretermdeliveriesand,episodesofchildhoodasthmaannuallyintheUnitedStates[]Theonlywaytofullyprotectindividualsfromtheharmfuleffectsofsecondhandsmokeistocreate smokefreeenvironments[]

Twentytwopercents ()oftheworldspopulation,agedandolder,aresmokersNonsmokingisbecomingthestandardpatternofbehaviorandsecondhandsmokingexposurehasalsodecreasedinrecentyears[]Thedecreaseinexposuretosecondhandsmokeoverthelastyearsisduetothegrowingnumberoflawsbanningsmokinginworkplacesandpublicplaces,anincreaseinthenumberofhouseholdsandresidencesthatenforcesmokefreerules,andadecreaseinadultandyouthsmokingrates[]

InHawaii,betweento,theproportionofpeoplelivinginhomeswheresmokingisnotallowedincreasedfromtoandthepercentageofadultswhodonotallowsmokingintheirfamilycarsincreasedfromto[]InitiatingbehaviorstoavoidsecondhandsmokemaybeagoodwaytopromoteorencourageasmokefreeenvironmentOnemethodistodirectlyasksmokersnottosmokearoundthemHowever,

noteveryoneiscomfortableenoughtoconfrontastrangertorequestthisLinandotherresearchershavestudiedcontributingfactorsassociatedwithavoidanceofsecondhandsmokeandfoundthatselfefficacy wasthestrongestfactorassociatedwithavoidanceofsecondhandsmoke[]Studieshaveshownthatknowledge,attitude,gender,

familysmokingbehavior,andselfefficacypredictavoidanceofsecondhandsmoke[,]HoweverlittleisknownaboutaskingstrangersversusfriendsandfamilymemberstoavoidsmokingItisimportanttonotethatafriendandastrangerplaydifferentsocialrolesandmayhavedifferentpredictorsofbehaviorThegoalsofthisstudywereto:assesstheprevalenceofsmokefreepolicesinhouseholdsandvehiclesinHawaii;assesstheprevalenceofsecondhandsmokeavoidancebehaviorwhenthesmokerisaknownfriendorastranger;andtounderstand the predictors of secondhand smokeavoidancebehaviorofstrangersandfriendsamongHawaiiresidents

Methods

DatacollectionDataforthisstudywerecollectedaspartof

theongoingevaluationoftheHealthyHawaiiInitiative,astatewidesocialecologicalprogram designedtoincreasephysicalactivity,improvenutritionandreducetobaccouseamongtheresidentsofHawaii[]In,acrosssectionalrandomdigitdialedtelephonesurveywasconductedamongHawaiiresidentsagedto Overthecourseoftheyear,,adultswerecontactedbytelephoneAmongthese,,residentsagedtocompletedthetelephonesurveyThisresearchincluded,landlinebasedsurveysand,cellphonebasedsurveysInthisstudy,WestVarwasusedtogenerateweightsTheweightingvariableswereage,gender,householdsize,

andextentofcellphoneuse(iecellonly,landlineonly,cellmajority,landlinemajority)AlldatareportedinthisstudywasweightedusingthesevariablesMeasuresDemographics

Participants wereaskedaseriesofdemographicquestions,includingage,gender,maritalstatus,education,income,ethnicidentification,

generalhealthstatusandnumberofhouseholdmembersThepresenceofchildreninthehouseholdwasassessedbysubtractingthenumberofmembersagedyearsandolderfromthetotalnumberofpeopleinthehousehold Forethnicidentification,CaucasianandPortuguesewerecategorizedasWhite,whileChinese,Japanese

andKoreanwereclassifiedasEastAsianFormaritalstatus,marriedandnotmarriedbutlivingwithpartnerwereidentifiedasNotsingleWidowed,Separated,DivorcedandNevermarriedwereidentifiedasSingleSecondhandSmokeAvoidance

Participantswereaskedifinthepastthree

months,theyhadaskedastranger,friendorsomeonetheyknownottosmokearoundthemReponsestoeachofthethreequestionswereeitheryesornoSmokingRelatedAttitudes

Participantswereaskedseveralquestionstoassesstheirattitudesandbeliefsaboutsmoking

(Table)Theirresponseswerecategorizedaccordingtoapointscale(stronglydisagree;

disagree;neitheragreenordisagree;agree;stronglyagree)Fortheanalysis,theresponsesweredichotomizedintotwocategories,agreeordisagree,andexcludedtheneutralresponse

TablePublicObjectionstoEnvironmentalTobaccoSmokefromstrangersandfriendsbysmokingstatus

N Askingstrangers P Askingfriends P

Total

Smokingstatus

Currentsmoker

Formersmoker

Neversmoker

SmokefreepolicesinhomesandcarsParticipantswereaskedwhichstatementbest

describeshow smokingishandledinsideyourhome?HavingasmokingfreepolicyathomewasindicatedbytheparticipantstatingthatSmokingisnotallowedanywhereinsidemyhomeParticipantswerecategorizedasnothavingasmokefreepolicyiftheychoseeitherofthefollowingstatements,Smokingisallowedinsomeplacesorsometimes,orTherearenorulesaboutsmokinginsidemyhome[]ParticipantswereaskedtoindicatewhichstatementbestdescribedhowsmokingishandledintheircarsAsmokefreepolicyincarswasidentifiediftheparticipantsaid,NooneisallowedtosmokeinmycarParticipantswerecategorizedasnothavingasmokefreepolicesincarsiftheychoseanyofthefollowingthreestatements,Onlyspecialguestsareallowedtosmokeinmycar,Peopleareallowedtosmokeinmycarifthewindowsareopen,orTherearenorulesaboutsmokinginmycarParticipantswhosaidthattheydidnothaveacarweretreatedasmissing[]SmokingStatus

Currentandformersmokerswereidentifiedif

theyrespondedYestothequestion,HaveyoueversmokedcigarettesinyourentirelifeandrespondedYesorNotothequestion,Doyoucurrently smoketobacco?respectively NeversmokerswereidentifiediftheyansweredNotobothofthequestionsFormersmokersansweredyestothefirstquestionandnotothesecondDataanalysis

DatawereanalyzedusingSPSSforWindowsInthedescriptiveanalysis,chisquaretestswereusedtotestforassociationsbetweensecondhandsmokeavoidancebehaviorfromstrangersandfriends,demographicfactorsandsmokingvariablesLogisticregressionwasusedforthebinaryanalysisofsecondhandsmokeavoidancebehaviorfromstrangersThefullmodelconsistedofallsignificantvariablesfromthechisquareanalyses,includingethnicity,selfreportedgeneralhealthstatus,education,income,maritalstatus,gender,

age,thepresenceofchildreninthehome,thebeliefthatpeopleshouldnotsmokeinoutdoorpublicplaces,thebeliefsthatallhomesandcarsinHawaiishouldbesmokefree,thatsecondhandsmokeseriouslyharmsnonsmokers,andthesocialnormsthatmostofmyfriends(orpeopleinmycommu

MiaoxuanZhang,etal:PublicObjectionstoEnvironmental

TobaccoSmokeamongAdultsinHawaii

nity)thinksmokingisdisgusting

Results

DescriptionofStudyParticipantsTheaverageageofparticipantswasyears

(SDyears)andparticipantsweremaleFourethnicgroupscomposedofthesample:White(),NativeHawaiian(),

Filipino()andEastAsian()Educationalattainmentwashigh,with havingahighschooldegreeand havingsomecollege/collegedegreeLessthanhalfofrespondents()reportedthepresenceofchildreninthehouseholdFormaritalstatus,halfofparticipants()weremarriedornotmarriedbutlivingwithparent Morethanhalf()oftheparticipantshaveasmokefreepolicyinhome,andoftheparticipantshaveasmokefreepolicyintheircarsAlmostallparticipants()participantsagreedsecondhandsmokeseriouslyharmsnonsmokersandsaiditisnotokaytosmokeindoorsMorethanhalf()ofparticipantsagreethatallhomesandcarsinHawaiishouldbesmokefreeThecompositionofparticipantsbysmokingstatuswascurrentsmoker,formersmokerandneversmokerTabledisplaysthefrequencyofobjectionofenvironmentaltobaccosmokebystrangersandfriendsbysmokingstatusCurrentsmokersweretheleastlikelytoobjecttobothstrangerandfriendssmokingaroundthem

Overall,oftherespondentshaveaskedastrangernottosmokearoundtheminthepastthreemonths,andoftherespondentshaveaskedsomeonetheyknownottosmokearoundtheminthepastthreemonthAdditionally,ofthosewhoavoidedsecondhandsmokefromastrangeralsoavoidedsecondhandsmokefromafriendSimilarly, ofthosewithavoidedsecondhandsmokefromfriendalsoavoidedsecondhandsmokefromstrangersTabledisplayscorrelatesof

publicobjectionstosmokehandsmokeexposureTablepresentstheoddsratios(OR),and

associatedconfidenceintervals(CI),andPvaluefromthefinallogisticregressionmodelassessingobjectiontosecondhandsmokefrom astrangeramongformerandneversmokers

TablepresentstheOR,andassociatedCI,andPvaluefromthefinallogisticregressionmodelassessingobjectiontosecondhandsmokefromafriendamongformerandneversmokers

Discussion

ThisstudyfoundthatofHawaiiresidentshaveasmokefreepolicyintheirhome,

whichissimilartotheprevalencereportedbytheHawaiiStateBRFSS()[]Thestudyalsofoundthat ofHawaiiresidentshaveasmokefreepolicyincars,whichissimilartotheprevalencereportedbytheHawaiiStateBRFSS()[]Thisstudywasthefirsttoreportthat oftheHawaiiresidentsavoidedsecondhandsmokefromstrangersandofresidentsavoidsecondhandsmokefromfriendinthepastthreemonthsFormerandneversmokersareofparticularinterestbecausetheyaremorelikelyto influence social norms around secondhandsmokeexposureTheyarethelargestgrouppeoplereportingobjectiontosecondhandsmokeHowever,mostpeoplestilldonotasksmokersnottosmokearoundthem UnivariateanalysisfoundthatcorrelatesofavoidingsecondhandsmokebehaviorvariedsomewhatbetweenastrangerandafriendCorrelatesincommonincludedethnicity,

generalhealthstatus,maritalstatus,educationlevel,householdincome,ageMostoftheirfriendsthinksmokingisdisgustingMostofthepeopleintheircommunitythinkthatsmokingisdisgusting,

itisokayforpeopletosmokeinindoorpublicplaces,allhomesandcarsin Hawaiishouldbesmokefree,andchildreninthehome

TableCorrelatesofpublicobjectionstoenvironmentaltobaccosmokeN Fromstranger Fromfriends

N P N PTotal Ethnicity

White NativeHawaiian Filipino EastAsian Other

GeneralHealthExcellent Verygood Good Fair Poor

MaritalstatusNotsingle Single

EducationHighschoolorless Collegeorless Grandschool

Householdincome, ,~, ,~, ,

GenderMale Female

Age~ ~

IthinksmokingisdisgustingDisagree Agree

Mostofmyfriendsthinksmokingisdisgusting

Disagree Agree

Mostofthepeopleinmycommunitythinkthatsmokingisdisgusting

Disagree Agree

SmokefreepolicesinhomeYes No

SmokefreepolicesincarYes No

Itisokayforpeopletosmokeinindoorpublicplaces

Agree Disagree

Itisokayforpeopletosmokeinoutdoorpublicplace

Agree Disagree

AllhomesandcarsinHawaiishouldbesmokefree

Agree Disagree

Second hand smoke seriouslyharmsnosmokers

Agree Disagree

ChildreninhomeNo Yes

MiaoxuanZhang,etal:PublicObjectionstoEnvironmental

TobaccoSmokeamongAdultsinHawaii

TableLogisticregressionmodelforaskingastrangernottosmokearoundyouamongformerandneversmokersN OR CI P

EthnicityWhite NativeHawaiian Filipino EastAsian Other

GeneralHealthExcellent VeryGood Good Fair Poor

Householdincome, ,~, ,~, ,

Age~years ~years

Mostofthepeopleinmycommunitythinksmokingisdisgusting

Disagree Agree

ItisokayforpeopletosmokeoutdoorpublicplaceDisagree Agree

ChildreninhomeNo Yes

TableLogisticregressionmodelforaskingafriendnottosmokearoundyouamongformerandneversmokersN OR CI P

EthnicityWhite NativeHawaiian Filipino EastAsian Other

Householdincome, ,~, ,~, ,

Age~years ~years

ItisokayforpeopletosmokeoutdoorpublicplaceDisagree Agree

AllhomesandcarsinHawaiishouldbesmokefreeDisagree Agree

DoyouhavesmokefreepoliciesinyourcarYes No

ChildreninhomeNo Yes

Inbinarylogisticregressionanalysesofformerandneversmokers,statisticallysignificantpredictorsofavoidingsecondhandsmokefromastrangerwereNativeHawaiianandFilipinoethnicities,verygoodandgoodselfreportedgeneralhealthstatus,lowerhouseholdincome,youngerage,agreeingthatmostofthepeopleinmycommunitythinksmokingisdisgusting,disagreeingthatitisokayforpeopletosmokeinoutdoorpublicplaces,andhavingchildrenSimilarly,statisticallysignificantpredictorsofavoidingsecondhandsmokefromafriendincludedbeingNativeHawaiianorFilipino,

lowerhouseholdincome,youngerage,disagreeingthatitisokayforpeopletosmokeinoutdoorpublicplaces,agreeingallhomesandcarsinHawaiishouldbesmokefree,andhavingchildrenDemographicandsocialeconomicstatus

FilipinosandNativeHawaiians,lowerhouseholdincome,andyoungeragewerepredictorsforobjectingtosecondhandsmokefrombothstrangersandfriendsAccordingtoHawaiiStateDepartmentofHealthdata,FilipinomaleshavethehighestsmokingrateinHawaii(),followedbyNativeHawaiianfemales()[]Individualswithlowerincomesand/oreducation,theunemployed,theunmarried,andyoungpeoplereportthehighestsmokerates[,]Peoplefromdemographicgroupswithhighersmokingratesaremorelikelytohavehadagreaterchanceofbeingexposedtosecondhandsmoke,thus,alsomakingthemmorelikelytoaskasmoker(eitherastrangerorfriend)nottosmokearoundthemDillonsresearchalsoshowedthatyoungwomeninparticular,werecomfortableaskinganyonetostopsmokingbecausetheyfelttheywereentitledtobefreefrom secondhand smoke exposure However,

manyotheryoungwomensaidtheywerenotatallcomfortableaskingsomeonetostopsmokingnearthemduetosocialconstraints[]Smokingrelatedattitudeandsocialvariables

Thosewhoagreethatmostofthepeopleintheircommunitythinkthatsmokingisdisgusting

anddisagreethatpeopleshouldsmokeinoutdoorpublicplacesweremorelikelytoaskastrangernottosmokearoundthemThosewhodisagreethatitisokayforpeoplesmokeinoutdoorpublicplaces,

agreedthatallhomesandcarinHawaiishouldbesmokefree,andhadasmokefreepolicyintheircarweremorelikelytoaskfriendsnottosmokearoundthemTheseresultsshowthatpeoplewhowanttocreatesmokefreeenvironmentsaremorelikelytoaskothers,eitherstrangersorfriends,

nottosmokearoundthemThiscanalsobesupportedbyotherstudiesthatsuggestattitudecanbeapredictorofanindividualsbehavior[,,],andamorepositiveattitudetowardavoidingsecondhandsmokeisaprerequisiteforsuccessfulsecondhandsmokeavoidance[]AnencouragingfindingisthatthepresenceofchildreninthehouseholdwaslinkedtoagreaterlikelihoodofavoidingsecondhandsmokefrombothstrangersandfriendsLimitations

Thelowresponseratemayhaveaffectedtheresults CautionshouldbeusedingeneralizingthesefindingstotheentirestateofHawaiiSecondly,thisstudywasbasedonatelephonesurvey,

excludingHawaiiresidentswithoutaphoneSurveyquestionsonlyincludedquestionsregardingsecondhandsmokeavoidancebehavior,anddidnotincludesecondhand smokeexposure questionsThus,itispossiblethatrespondentswhoindicatedthattheydidnotaskothersnottosmokewerenotexposedtosecondhandsmokeatall

Acknowledgements

ThisstudywasfundedbytheHawaiiTobaccoSettlementSpecialFundthroughacontractfromtheHawaiiDepartmentofHealthtoDr Maddock

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GlobalHealthJournalVolNoMar

EffectiveRecoveryofInfectiousHumanEnterovirusfromEnvironmentalWatersforTheirApplication

forWaterQualityMonitoring

ZiWang,SiSun,,ChristinaConnell,YuananLu,UniversityofHawaiiatManoaDepartmentofPublicHealthSciences,Honolulu,USA;

WuhanUniversityGlobalHealthInstitute,Wuhan,China

Abstract:HumanentericvirusesarecurrentlybeingtestedasalternativeindicatorsforenhancedmonitoringofrecreationalwaterqualityLaboratorymethodsfortheeffectiveconcentrationandmolecularbaseddetectionofentericvirusesfromenvironmentalwatershaverecentlybeenreportedHowever,inordertoestablishapracticalmonitoringsystemusingentericvirusesasindicators,thereisaneedtodevelopoptimizedmethodsfortheeffectiverecoveryofinfectiousvirusesfromenvironmentalwatersInthisstudy,usingPoliovirusasasurro

gatemodel,differentlaboratoryconditionsfortheeffectiveconcentrationandelutionofinfectiousvirusesfromenvironmentalwaterswerecomparativelytestedandanalyzedElutionwithbeefextractinmMglycinewasshowntobethemosteffectivebufferformaximalviralrecovery()Inaddition,itwasfoundthatshakingconcentratedfilterswiththeelutionbufferisamoreeffectiverecoverymethodthandirectelutionthroughthefilters(p)Ourfindingshavedemonstratedthatinfectiousvirusescanbeeffectivelyconcentratedandelutedforinvitrodetection,supportingthenotionthathumanentericvirusesmayindeedbeutilizedaspracticalindicatorsfortheeffectiveassessmentofrecreationalwaterquality

Keywords:Humanentericvirus;recoveryofinfectiousvirus;viralinfectivityassay;watermonitoring

Received:;Revised:

PaperpresentedatthethAPACPHConferencehostedbytheSchoolofPublicHealthatWuhanUniversity,October,

Author:ZiWangChristinaConnell,studentofDepartmentofPublicHealthSciences,UniversityofHawaiiatManoa;SiSun,studentof

DepartmentofPublicHealthSciences,UniversityofHawaiiatManoaandWuhanUniversityGlobalHealthInstitute;YuananLu,

professorofDepartmentofPublicHealthSciences,UniversityofHawaiiatManoaandWuhanUniversityGlobalHealthInstitute

CorrespondingAuthor:YuananLu,DepartmentofPublicHealthSciences,UniversityofHawaiiatManoaEmail:yuananhawaiiedu

Introduction

Millionsofgallonsoftreatedanduntreatedwastewateraredischargedintotheworldsoceanseveryday[]Duetonegativeimpactssuchasincreasedoccurrenceoffecaloralwaterbornediseases,thisisapublichealthconcernStudieshaveshownthatfecalcontaminationhasbeenthemain

causeofwaterborneillness,affectingmorepeoplegloballythanothertypeofinfectiouswaterbornediseases[]Arecentarticledemonstratedthatthenumberofviraloutbreakshasactuallyincreasedoverthepastyears[]Inordertoreduceandeliminatehealthrisksandenhanceprotectionofthepublicfromrecreationalwaterborneillnesses,itisofcrucialimportancetoregularlymonitorwaterqualityusingeffectivemethods[]

Currently,theassessmentofrecreationalwaterqualityisprimarilydependentonthegrowthbasedcountingandmeasurementoffecalindicatorbacteria(FIB),whichincludeEcoli,enterococci,fecalcoliform,andtotalcoliformbacteria[,]SincetheestablishmentandenforcementbyEPAin[],theFIBsystemhasbeenwidelyusedformonitoringwaterqualityoverthepasttwodecadesDetectionmethodsfortheseFIBarerelativelysimple,rapid,inexpensive,andwellstandardizedforwideapplication[,]Inaddition,epidemiologicalstudieshaveshownthatthedetectionofFIBcouldindicatethepresenceofpotentialfecalpathogens[],andexposuretoelevatedleveloftheseFIBislinkedwithincreasedriskofcontractinggastrointestinaldiseases[]However,severalmajorlimitationsareassociatedwithFIBmonitoringsystemForinstance,theirsourceisnotsolelylimitedtohumanfeces[],andimpropercorrelationbetweenfecalpathogensandwaterborneillnessincidentsexists[]FIBpersistandevenmultiplyintheenvironmentaftersecretionfromtheirhost,yieldinginaccurateestimationsoftruefecalpollutionlevels[]Inaddition,bacterialindicatorsoftenfailtoreliablyreflectthepresenceofpathogenicviruses[,],potentiallyleadingtoviralrelatedoutbreaksofwaterbornediseasefromwatersthateithermetthestateorlocalbacterialwaterqualitycriteriaorwerefreeofindicatorbacteria[,]Clearly,bacterialindicatorscannotbesolelyreliedupontoaccuratelyassessmicrobialwaterquality

Tofacilitatemoreaccuratemonitoringofrecreationalwaterqualityandimprovedprotectionofthepublicfromwaterbornediseases,humanentericvirusesarepresentlybeingtestedasalternativeindicatorsfor enhanced water quality monitoring[,]Humanentericvirusesarethemaincause of most recreational waterborne illnesses[]Overtypesofviralpathogensmaybepresentedinsewageimpacted water[]Virusesareabletosurvivelongerthanindicatorbacteriain

bothfreshandmarinewaterenvironmentsandaregenerallymoreresistantthanFIBduringconventionalwastewatertreatmentprocesses[]Recentpublicationshaveshownthatunderoptimizedlaboratoryconditions,lownumbersofentericvirusescanbeefficientlyconcentratedfromenvironmentalwaters,andeffective molecularbased protocolshavebeendescribedforthesensitivedetectionofseveraltypesofhumanentericviruses,includinghumannoroviruses,adenovirus,enterovirus,andfecalindicatorvirusmalespecificRNAcoliphage(FRNAC)[,]Tofacilitatethepracticalestablishmentofusinghumanentericvirusesforenhancedwaterqualitymonitoring,thisstudyfocusesonthedevelopmentofoptimizedlaboratoryconditionsfortheeffectiverecoveryofinfectiousvirusesfromenvironmentalwaters,usingpoliovirustypeasanenteroviralrepresentative

Materialsandmethods

CellsGreen Africa monkey kidney Vero cells

(ATCC,Manassas,VA,Cat,No CCLTM)

wereusedforpropagationandtitrationofinfectiouspoliovirusinthisstudyCellswereculturedandmaintainedwithMEMmedium(MinimumEssentialMedium Eagle,Manassas,VA ),

heatinactivatedFBS (fetalbovineserum,

HyClone,UT)and PSsolution (U/mlpenicillin,U/mlstreptomycinsulfate)inTCcmcellcultureflasks(GreinerBioOne,Germany)at withahumidified CO,andpassedeverydaysbytrypsinizingwithtrypsinversinesolution (SigmaAldrich,MO)Allcellcultureoperationswereconductedinsideacellculturebiosafetyhood(SterilGARDIIIAdvanceandTheBakerCompany,Sandford,ME)Poliovirustype

ViralisolatesAlaboratorystrainofpoliovirustypeoriginallyobtainedfromDrPhilipCLoh(UniversityofHawaiiatManoa)wasusedinthis

studyasamodelvirusforlaboratoryprocedureoptimization Alltheviralpropagationand viralquantificationassayswereperformedinacellculturebiosafetyhood (LabconcoPurifierClassIIBiosafetyCabinetDeltaSeries,Labconco,MO)

equippedwithaUVsterilizationlampViralstock Vero cellsattheirexponential

growthphasewereharvestedusingtrypsinEDTAsolutionandindividualcellsuspensionswereseededintoTCcmflasksAfterahrincubationandcellgrowth,cellmonolayersformedintheflaskswereinfectedwithmlofPoliovirusatMOIofInfectedcultureswereincubatedatandthentransferredtofreezerwhenofthecellsshowedcytopathiceffects(CPE)Theflaskswereremovedfromthefreezerandcompletelythawedatroomtemperature,thenstoredinfreezeragainAftermorefreezethawcycles,theculturemediumwascollectedfromtheflasksandcelldebriswasremovedthroughcentrifugationat,rpm (Beckman)forminutesRecoveredsupernatantwastransferredintomLcentrifugetubesatmL/vial,andaliquotsofviruswerestoredin andusedaviralstockforthisstudy

PlaqueassayQuantificationofinfectiouspolioviruswasconductedbyusingaplaqueassaywithmethylcelluloseusedasoverlaymediumInbrief,

Verocellsatexponentialgrowthphasewereharvestedandseededintowellplatesat

cells/wellFollowingthehrincubationatandtheformationofacellmonolayer,thecellmediumwasdiscardedandtheVerocellmonolayerwasrinsedtwicewithMEMatmL/wellPoliovirussolutiontobetitratedwasfolddiluted(upto)withMEMcontainingnoFBS,andeachdilutedviruswasinoculatedintotheplateatmL/wellandthreewellperdilutionmLofMEMwasaddedtoonewellasanegativecontrolTheplatewasincubatedatforhrsforviraladsorptionTheplatewasgentlyrocked

fromsidetosideeveryminutestoallowanevendistributionofinfectiousvirusesResidualviralsolutionwasremovedfromthewellsaftertheadsorptionandmL/wellofoverlaymediumconsistingofMEMwithFBSand Agarwasadded(Sparks,MD,USACat No)Theplatewasincubatedattoallowtheformationofvirusinducedplaques Atdaywhenplaquesbecamereadilyvisible,crystalvioletstainingsolution[gcrystalvioletdissolvedinmLformaldehyde w/w (SigmaAldrich,

StLouis,Mo)andmlddHO)]wasaddedtoeachwellatmL/well,andtheplatewasstainedatroomtemperatureforhrsandthenvigorouslywashedwithtapwaterViralplaqueswerecountedandviraltiterwascalculatedasfollows:

Viraltiter(plaqueunits/mL) plaquescountedxdilutionfactorxinoculumfactor(mL)

WatersamplepreparationToestablishoptimizedlaboratorymethodsfor

theeffectiveconcentrationandrecoveryofinfectiousvirusesfromseawater,mLofpoliovirusstock(FPU/mL)wasspikedintoliterofqualifiedseawater (from Waikikiaquarium,

Honolulu)togenerateafinalconcentrationofFPU/mLSeawaterwasthensupplementedwithMgClsolutiontoreachafinalconcentrationofmMandpassedthroughnegativelychargedtypeHAfiltermembranes(mmindiameter,

MilliporeCorporation,MA)withumporesizeasdescribedpreviously(Tongetal)ThemembraneswerethenrinsedwithmlofmM HSO(pH)toremovecations,followedbyviruselutionwithvariousbuffersandproceduresFiltrationelutionvsshakingelution

TwotypesofviruselutionprocedureswerecomparativelytestedinthisstudyForviruselutionthroughfiltration,concentratedviruswaselutedfromthemembranesbyaddingmLoftheelutionbufferAfterminutesincubationatroomtemperature(),concentratedviruswase

ZiWang,etal:EffectiveRecoveryofInfectiousHumanEnterovirusfromEnvironmentalWatersforTheirApplicationforWaterQualityMonitoring

lutedandcollectedintoasterileflaskRecoveredviruswascentrifugedatrpmforminandtiteredbyplaqueassayasdescribedaboveForviralelutionthroughtheshakingmethod,membraneswereremovedfromthefiltrationunitandtransferredtomLcentrifugetubescontainingmlofselectedelutionbuffer ThesemLcentrifugetubeswereshakenonavortexadaptercombinedwithananalogvortex mixer(VWR,CAT No,USA)atspeedforminutesatRecoveredviruswasthencentrifugedatrpmforminSupernatantwascollectedandtheviraltitrationtestwasappliedElutionbuffers

Todetermineanoptimizedlaboratoryprocedurefortheeffectiverecoveryofinfectiousvirusesfromconcentratedmembranes,threedifferentelutionbufferswerecomparativelytestedinthisstudy,includingmMNaOH (pH),BeefextractinMglycine(pH),andMKHPOinMNaCl(pH)FortheNaOHelutionbuffer,mLofXTEbuffer(pH)andLmM HSO(pH)wereaddedintotheflaskstoneutralizeNaOH

Inaddition,threeselectedconcentrationsforeachelutionbufferweretested,includingNaOHsolutionatmM,mM,andmM;,,

andofbeefextractsolution;andKHPOatmM,mM,andmMOptimalshakingtime

Once the membraneshaking method wasfoundtobemoreeffectivethandirectfiltrationinvirusrecovery,acomparativetestwasperformedtodetermineanoptimalshakingtimeforviruselutionAtotalofdifferenttimepointsweretestedrangingfrommintominInthistest,thefiltermembranewastransferredintoamLcentrifugationtubecontainingmlofselectedelutionbufferandshakenonavortexmixeratspeedasdescribedaboveAteachselectedtimepoint,mLoftheeluentwassampledfromthecentrifugationtubeandtestedforviralrecoveryusingthevi

ralplaqueassaySamplespretreatment

Priortoperformingtheviralplaqueassays,

allelutedvirussampleswerepretreatedwithantibioticincubation medium (AIM)containingxMEM with U/mL Penicillin, U/mLstrptomycin,ug/mLAmphotericinB,and

g/mLGentamicinataratioof(v/v)andincubatedatforhrsEachtestwasconductedinthreeindependentexperimentalassaysAlso,eachviraldilutionwastestedintriplicatewellstoensurereliableexperimentaldataDataanalysis

ByusingSPSSsoftware,onewayANOVAwasperformedtoallplaqueassaydata,withapvalue

Results

Inthisstudy,alaboratorystrainofPoliovirustypewasusedasaprototypeentericvirusfortheestablishmentofoptimizedlaboratoryconditionsfortheefficientrecoveryofinfectiousvirusesfromenvironmentalwatersPoliovirusreplicatesinVerocellsrapidly,andviralinducedcytopathiceffectoftenbecomeapparentwithinhrspostinfection(Figure)ThetiterofthePoliovirusstockgeneratedforthisstudywasquantifiedusingaviralplaqueassay performedin eitherorwellplatesFigureshowsthetypicalplaqueformationofpoliovirusinfectedVerocellsinawellplate,showingastronglinearcorrelationbetweenthevirusdilutionandthenumberofvirusinducedplaquesininfectedcells

Comparativeanalysisofthetwoelutionmethodswiththreebuffersshowedmixedresults AsshowninFigure,thefiltrationmethodmediatedarecoveryrateofinfectiouspoliovirus,showingnosignificantdifferenceinvirusrecovery(p)amongthreeelutionbuffers PolioviruselutionfromtheconcentratedmembraneappearedtobemoreeffectivewhenNaOHandKHPO

A B

A)PriortopoliovirusinfectionandB)poliovirusinfectedVerocellsatpostinfectionhoursshowingviralinducedCPEOriginalmagnification:xFigurephotomicrographsofpoliovirusinfectionofseededinTCcmflasksVerocells

C

10-5

10-4

10-6 10-7

10-3

FigurePlagueassayshowingPoliovirusinducedplaqueformationinVerocellsinwellplateandalinearreductionofplaquenumberswithviraldilution

bufferswereused,whiletheshaking methodismoreeffectivewhenBEsolutionwasusedAlthoughshakingthemembraneinKHPObufferresultedinnodetectionofinfectiousvirus,thiselutionmethodworksextremelywellwithbeefextract,asmorethanofinfectiousviruswasrecoveredusingtheestablishedlaboratoryprocedures

Toestablishoptimizedconditionsforeffectiveviruselutionusingthemembraneshakingmethod,

eachbufferwastestedatthreedifferentconcentrationsAsshowninFigure,BEwasthemosteffectiveelutionbufferfortherecoveryofinfectiouspoliovirusfrom concentrated membranesDecreased()orincreased()concentration

NaOH BE KH PO2 4

100

80

60

40

20

0

Elution Buffer

Filtration-ElutionShaking Elution

Reco

very

Rat

e (%

)

FigureComparisonoftwoelutionmethodsfortheireffectiveelutionofinfectiouspolioviruseswithselectedbuffers

ofbeefextractresultedindecreasedvirusrecoveryfromtheconcentratedmembrane Approximately ofinfectiousPolioviruswasrecoveredwithNaOHwhenmMconcentrationwasused,whileincreasedNaOHbufferconcentrationtomMandmMresultedindecreasedviralrecoveryInthisstudy,shakingelutionwiththreedifferentconcentrationsofKHPObuffersrangingfrommMtomMresultedinnorecoveryofinfectiouspoliovirus(Figure)

3%

1%

5%

120

100

80

60

40

20

0

1mM

1mM

5mM

5mM10mM

10mM

Beef ExtractNaOHKH PO2 4

Elution Buffer Concentrations

Reco

very

Rat

e (%

)

FigureEffectofdifferentconcentrationsofselectedelutionbuffersontherecoveryofinfectiouspoliovirusesfromconcentratedmembranebyshakingmethod

Todeterminetheoptimizedshakingtimeformaximalrecoveryofinfectiousvirusfromconcentratedmembranes,shakingtimesrangingfrom min wereexamined bytestingsamplestakenfromtheselectedtimepointsforviralinfec

ZiWang,etal:EffectiveRecoveryofInfectiousHumanEnterovirusfromEnvironmentalWatersforTheirApplicationforWaterQualityMonitoring

tivityAsshowninFigure,overinfectiousviruswasrecoveredwhenthemembranewasshakenwith BE;recoveryofinfectiousvirusincreasedwithshakingtimeupuntilmin()Recoveryofinfectiousvirusdroppedwhenshakingtimeincreasedto minanddecreasedtowhentheconcentratedmembranewasshakenforhrs

120

100

80

60

40

20

0

Reco

very

Rat

e (%

)

10 20 30 60 90 120Shaking Time (min)

FigureEffectofshakingtimeontherecoveryofinfectiouspolioviruseswithBeefExtract

Discussion

Humanentericviruses,themainetiologicalagentsinmostswimmingassociatedillnesses,arecurrentlybeingconsideredasalternativeindicatorsforhumanoriginfecalcontaminationinaquaticenvironments[,,,,]ComparedtotheFIB,

enteric viruses are more resistantto currentwastewatertreatmentprocesses[],morestableintheaquaticenvironment,andabletomaintaininfectivityforalongertime[,,,,]Inaddition,

theirlowinfectiousdoseandstringenthostspecificitywithnoreplicationintheaquaticenvironmentarealsoadvantageouswhenconsideringentericvirusesforenhancedmonitoringofrecreationalwaterforsafety[,]

Rapiddetectionofhumanentericvirusesfrom

environmentalwatersiscurrentlyconductedusingPCRandquantitativeRTPCR[,,,]Recentreportshaveindicatedthatseveralentericviruses,

includingbothRNAandDNAviruses,canbeveryeffectivelydetectedfrom bothfreshand marinewatersusingnewlyestablishedprotocols[,,]Thesereportscollectivelysuggestthatitispossibletodetectevenlownumbersofhumanentericvirusesfromenvironmentalwatersbyemployinghighlysensitivetechniques

However,duetotheirinabilitytodifferentiateinfectiousfromnoninfectiousvirusparticles,molecularbasedmethodscanonlybeusedforpreliminaryandpresumptivewaterquality monitoringAlthoughasfewasoneinfectiousviralparticlemaybeabletocausehumanillness[],positiveviraldetectionbyPCRbasedmethodsalonemaynotnecessarilyindicatethepresenceofinfectiousvirusoratruehealthriskThus,inordertoaccuratelyassesshealthriskassociatedwithwatersamplespositiveforviruses,afollowupviralinfectivitytestisessential

Several methods werecomparativelytestedandanalyzedfortheireffectiveconcentrationandmaximizedrecoveryofinfectiousvirusesfromenvironmentalwatersComparisonoftwoviralelutionmethodsusingpoliovirusasamodelrevealedthatdirectfiltrationelutionrecoveredonlyofinfectiousvirusesfromspikedwater,whichissignificantlylowerthantherecoveryrateobtainedbyshakingelution()TheminuteshakingofconcentratedmembranesinelutionbufferappearedtogreatlyenhanceviralelutionfromthemembraneAmongthethreeselectedelutionbufferstestedinthisstudy,beefextractinMglycinewasdeterminedtobethemosteffective,incomparisonwithNaOHandKHPOThesefindingsareconsistentwithpreviousreports[,]Thisstudyalsodemonstratedthatshakingtimecanbeverycriticalforeffectivevirusrecovery;extendedshakingtime(overhr)didnotresultinanyincreasebutactuallyreducedtherecoveryofinfec

tiouspoliovirusThisobservationmaybeattributedtophysicaldamagetothemembrane,subjectingviralparticlestoprecipitationwithmembranedebris

Althougheffectiveconcentrationandelutionareknowntobelimitingfactorsforthefeasibilityofutilizingentericvirusesforwaterqualitymonitoring,therehavebeensomereportsofviralconcentrationfrom waterusingvariousapproaches,

includingtheadsorptionelutionmethod,precipitation method, and ultracentrifugation method[,,]However,fewstudieshavebeenconductedfocusingonconcentratinginfectiousvirusesfromrecreationalwaters[]Katayamaetalreportedaviralrecoveryashighas[];however,thisdetectionwasnotforinfectiousvirususinganinfectivityassaybutforaviralgeneusingqPCRTherefore,tothebestofourknowledge,

thevirusconcentrationandelutionmethodswereestablishedinthisstudyItrepresentedthemosteffectiverecoveryofinfectiousvirusesfromenvironmentalwatersandcouldbeusefultoenvironmentalmicrobiologistsasavaluabletoolforwiderangeofapplications

Itshouldbeemphasizedthatsinceviralinfectivityassaysforcertainvirusescanbetimeconsumingandtechnicallydemanding,cellculturebasedviraldetectionshouldbeconductedonlyasafollowupmethodforwatersamplesthattestspositiveusing molecularmethodsItisalsoknownthatsomeentericviruses,suchasnorovirus,currentlylacksusceptiblecellculturesystems;therefore,aneedexiststodevelopinvitrocellcultureorotherbiologicalsystemsfortheeffectivedetectionofthesehumanentericviruses

Acknowledgement

ThisworkwassupportedinpartbygrantsfromtheCentersforOceansandHumanHealth(COHH)program,theNationalInstitutesofEnvironmentalHealthSciences(PES)and

theNationalScienceFoundation (OCEandOCE),andthe HawaiicommunityFoundation(ADVC)

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[]PetersDH,TranNT,AdamTImplementationResearchinHealth:APraticalGuideAllianceforHealthPolicyandSystemResearch,WorldHealthOrganization,

[]RemmeJH,AdamT,BecerraPosadaF,etalDefiningresearchtoimprovehealthsystemsPLoS Medicine,,():

[]ThornicroftG,LemppH,TansellaMTheplaceofimplementationscienceinthetranslationalmedicinecontinuumPsychologicalMedicine,,():

[]HarrisJR,CheadleA,HannonPA,etalAframeworkfordisseminatingevidencebasedhealthpromotionpracticesPreventingChronicDisease,,:E

[]Glasgow RE,VogtTM,BolesSMEvaluatingthepublic

healthimpactofhealthpromotioninterventions:theREAIMframeworkAmericanJournalofPublicHealth,,():

[]DamschroderLJ,AronDC,KeithRE,etalFosteringimple

mentationofhealthservicesresearchfindingsintopractice:aconsolidatedframeworkforadvancingimplementationscienceImplementationScience,,

[]ZwarensteinM,TreweekS,GagnierJJ,etalImprovingthereportingofpragmatictrials:anextensionoftheCONSORTstatementBMJ,,:a

[]CurranGM,BauerM,MittmanB,etalEffectivenessimplementationhybriddesigns:combiningelementsofclinicaleffectivenessandimplementationresearchtoenhancepublichealthimpactMedicalCare,,():

[]FairallLR,BachmannMO,ZwarensteinMF,etalStreamliningtasksandrolestoexpandtreatmentandcareforHIV:randomisedcontrolledtrialprotocol,Trials,,:

[]FairallL,BachmannMO,LombardC,etalTaskshiftingofantiretroviraltreatmentfromdoctorstoprimarycarenursesinSouthAfrica(STRETCH):apragmatic,parallel,clusterrandomisedtrialLancet,,():

[]UebelK,GuiseA,GeorgeuD,etalIntegratingHIVcareintonurseledprimaryhealthcareservicesinSouthAfrica:asynthesisofthreelinkedqualitativestudiesBMCHealthServicesResearch,,:

[]MadonT,HofmanKJ,KupferL,etalPublichealthImplementationscienceScience,,():

ImplementationResearch:aBriefIntroductionofaKeyResearchFrameworkinGlobalHealth

JingGu,YuantaoHaoSunYatsenUniversitySchoolofPublicHealth,Guangzhou,China

Abstract:Inthedevelopmentofglobalhealth,implementationresearch,whichconsistsofabroadcategoryofmethodsfocusingonturningeffectivehealthinterventionsintohealthpractices,isreceivingmoreand moreattentionImplementationresearchinChina,however,isstillinitsearlystageofdevelopmentInthispaper,weintroducedthebackground,concept,theoreticalframeworkandanexampleofimplementationresearchFurthermore,wesummarizedthedifficultiesinthedevelopmentofimplementationresearch worldwide,andtheaspects needto bestrengthenedin orderto startimplementationresearchinChina

Keywords:Implementationresearch;globalhealth;concept;framework;methods

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,,():[]LiH,BarsantiS,BoniniABuildingChinasmunicipalhealth

careperformanceevaluationsystem:A Tuscanperspective

InternationalJournalforQualityinHealthCare;():

[]ScalzoAL,DonatiniA,OrzellaL,etalItaly:Healthsystem

reviewHealthSysteminTransition;():[]LaboratorioManagementeSanitIlsistemadivalutazione

dellaperformancedellasanittoscanaReportPisa:Ediz

ioniETS,

TheItalianRegionalHealthcarePerformanceEvaluationSystem:AReviewandCommentary

HaoLi,,TingfangLiu,SipingDong,

ScuolaSuperioreSantAnna,InstituteofManagement,Pisa,Italy;

WuhanUniversitySchoolofPublicHealth,GlobalHealthInstitute,Wuhan,China;

TsinghuaUniversityHospitalManagementInstitute,Beijing,China;

TheMinistryofHealthHospitalManagementInstitute,Beijing,China;

WuhanUniversitySchoolofPoliticalScienceandPuldicAdministration,Wuhan,China

Abstract:Regionalhealthcareperformanceevaluationsystemcanoptimizehealthcareresourcesallocationonregionalbasisandimprovethequality,efficiencyandequityofhealthcareservicesprovided,thusfacilitatinghealthstatusimprovementofaregion TheadventofhospitalmanaginginstitutionsandinstitutionsofcommunityhealthservicecentersinChinamakesitpossibletoconductregionalhealthcareperformanceevaluation However,ChinastilllacksofrelevantsupportingtheoriesandpracticesandthereforeneedstolearnfrominternationalexperienceAstheTuscanexperienceinItalyisagoodexampleandhassomeimplicationstobuildChinasownregionalhealthcareperformanceevaluationsystem,inthispaper,theTuscanregionalhealthcareperformanceevaluationsystemisanalyzedindetailforitssystemdevelopmentandaspectstobeimprovedItcanserveasChinasreferencetodevelopitsownregionalhealthcareperformance