Aflatoxigenic fungi species capable of aflatoxin production [124].
\r\n\t
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"55931",title:"A Focus on Aflatoxin in Feedstuffs: New Developments in Analysis and Detection, Feed Composition Affecting Toxin Contamination, and Interdisciplinary Approaches to Mitigate It",doi:"10.5772/intechopen.69498",slug:"a-focus-on-aflatoxin-in-feedstuffs-new-developments-in-analysis-and-detection-feed-composition-affec",body:'The four major aflatoxins are called B1, B2, G1, and G2 (Figure 1) based on their fluorescence under UV light (blue or green) and retention factors during thin-layer chromatography. AFB1 has been described as a potent natural carcinogen (classified in group 1; [1]) and is usually the major aflatoxin produced by toxigenic strains. However, other aflatoxins (e.g. AFM1, B2a, and G2a) have been described, particularly since biotransformation products of the mammalian degradative enzyme metabolism, is based on cytochromes. This biosynthetic pathway is shared by norsolorinic acid, an anthraquinone, and sterigmatocystin (STE), a mutagenic and tumorigenic dihydrofuran toxin. STE is a late metabolite in the aflatoxin pathway and is also produced as a final biosynthetic product by some species such as
Chemical structure of the four major aflatoxins and two natural metabolites. Bonds colored in red showcase the main differences among them.
Aflatoxins are difuranocoumarin derivatives produced by a polyketide pathway by many strains of
Section | Section | Section |
---|---|---|
Aflatoxigenic fungi species capable of aflatoxin production [124].
1, 2 Blue and green colors represent the type of aflatoxins the strain is capable of producing.
From the mycological perspective, there are phenotypic and genetic differences in the strains within each aflatoxigenic species and each strain display various toxigenic abilities. For example,
Several of the species above are important mycotoxin producers including aflatoxins, and like the genetic ability to make aflatoxin, contamination is highly variable. Crops can become contaminated with aflatoxin in the field before harvest, where it is usually associated with drought stress [14]; adding difficulty to this issue, storage conditions may favor mold growth. During storage, usually, the most important variables are the moisture content of the substrate and the relative humidity of the environment [15]. Aflatoxin contamination has been linked to increased mortality in farm animals and, thus, significantly lowering grain value as an animal feed and, thereafter, loss of productivity in the case of food-producing animals [16]. Milk products can also serve as a source of aflatoxin. When cows consume aflatoxin-contaminated feeds, they transform AFB1 into a hydroxylated form called AFM1. Cytochrome P450 enzymes convert aflatoxins to the reactive 8,9-epoxide form, which is capable of binding to both DNA and proteins [3, 4]. This metabolite is still considered carcinogenic and teratogenic and may affect young and newborn animals and reach human as a final consumption product. Unit operations during milk production usually have little to no effect over the AFM1. Although we will not explore AFM1 contamination in detail, we urge the reader to read a very thorough review regarding AFM1 in bovine milk written by Becker-Algeri and coworkers [17].
Aflatoxin is associated with both toxicity and carcinogenicity in human and animal populations [16]. There are substantial differences in species susceptibility. On the other hand, within a given species, the magnitude of the response is influenced by age, sex, weight, diet, and exposure to infectious agents [16]. The presence of other mycotoxins (most common co-occurrence of AF and ochratoxin A or AF and fumonisins) and pharmacologically active substances may reflect antagonistic, additive, or synergistic effects [18]. Sufficient availability of feed is combined with regulations and continuous surveillance programs to monitor contaminant levels and protect animal populations from significant aflatoxin ingestion. The scarcity of resources (both economic and food supply) may play a role in the use of contaminated feed.
Feed is defined as any goods or materials which are consumed by animals and contribute energy and nutrients to the animal’s diet [19]. Usually, it is divided into two categories, roughages and compound feed. Roughages comprise diets based on grass, silage, hay, legumes, bagasse and others. Equines and dairy cattle complete rations on occasion are complemented or based on roughages. In Costa Rica, for example, dairy cow diets are composed mainly of forage, including
On the other hand, compound feed is composed primarily of cereals (e.g. rice, wheat, barley, oats, rye, corn, sorghum, and millet), milling by-products (e.g. brans, hulls, pollards), and oil cakes (e.g. palm kernel, soybean, sunflower, rapeseed, peanut, linseed, cottonseed). Other feed ingredients include distillers dried grains. The components above (especially corn and corn by-products) are the most susceptible to aflatoxigenic fungi attack and therefore aflatoxin contamination [13]. The chemical composition, ingredients and nutritional quality of feed inherently influence the capability of fungi to inoculate and even make use of their genetic machinery available to produce aflatoxins within such a substrate. Hence, feed is especially susceptible to aflatoxin contamination.
A few papers have focused on this fact and examined some aspects relating aflatoxin contamination with nutritional analysis. For example, Hashimoto and coworkers analyzed 42 fish feed samples and found no association between pelletized and extruded feed and aflatoxin levels and no nutritional differences between both feed types [21]. However, they did acknowledge an aflatoxin/fumonisin co-occurrence of a 23.8%. Prabakaran and Dhanapal found that natural contamination observed in two Indian regions (220 and 15 μg kg−1) were connected with those areas where feeds were prepared with higher moisture (11.29–11.70 g/100g) and crude fat (4.62–4.64 g/100 g) [22]. Interestingly, the authors also demonstrated that when feed undergo autoclaving and then inoculated with a toxin-producing
The One Health approach highlights the kinship of human, animal, and environmental health and the importance of transdisciplinary and interdisciplinary efforts [29]. Hence, collaborative efforts under this tactic aim to help promote animal and human health. The challenges posed by mycotoxicosis, a foodborne illness that results from consumption of aflatoxin-contaminated food and feed, are more likely to be understood and mitigated through a One Health approach. Shenge and LeJeune reported that it is estimated that a third of global food supplies are contaminated with aflatoxins [30]. This value alone should be cause for concern, as fungal contamination is not only a source of disease for crops but also generate poor harvests, and impact the well-being of animals and humans; creating, even more economic losses when food producing animals are involved. Several aspects of mycotoxins remain unclear, and research is still needed regarding all areas affected by mycotoxins. Although few articles tackle the issue from a holistically standpoint, at least one conference paper presented by Sirma is focused explicitly on using One Health in mycotoxin analysis [31]. On the other hand, Magnussen and Parsi published an article which encompasses a health issue such as hepatocellular carcinoma within the aflatoxin convoluted problematic [32]. More recently, two papers have more specifically considered the issue from the One Health stance. Frazzoli and coworkers contemplated aflatoxin contamination anticipating environment, animal, and human interaction, and the feed and food link with emphasis to the carryover that occurs from the presence of aflatoxins in a feed to milk (i.e. AFM1) during the entire dairy chain [33]. On the other hand, Ogodo and Ugbogu considered the presence of aflatoxins in food industry, management and its relationship with hepatocellular carcinoma, linking a public health issue again with an agronomical one [34]. The latest effort in integrating the totality of the food chain is in the form of “MyToolBox”, a European Commission funded initiative joining knowledge from different sectors to improve risk management, reduce crop losses and its impacts, and provide safe options to treat toxin-contaminated batches [35]. The final objective of the initiative is to offer recommendations and practical measures to the end users along the food and feed chain in a web-based platform.
Food safety relies on the capability of laboratories to screen, detect, quantify, and confirm the presence of aflatoxins in different staple foods. Multiple methods have been designed over the years, the authors refer the reader to a good starting point to familiarize with the general principles and mechanisms involved in the main techniques used for aflatoxin analysis [36, 37]. For an ampler view regarding the recent developments in techniques for the detection of aflatoxins, we urge the reader toward the paper written by Yao and coworkers [38]. Herein, we will limit the discussion to techniques applied for the aflatoxin determination in feed, feed ingredients, and some selected related matrices as they lead the food chain.
Accurate mycotoxin analysis is paramount for feed and feed ingredients safety evaluation and epidemiology. Animal feed is at the beginning of the food chain, and any in-feed contaminants may reach the final consumer through food matrixes, such as eggs or meat products [39]. However, few methods are specialized for feeds, which can be noted by the sheer number of official methods for this kind of matrices. For example, AOAC only has three assays: 975.36 (Romer mini column), 989.06 (ELISA), and 2003.02 (liquid chromatography [LC]). Contrasting to the amount of approaches and principles available for other staple foods [40, 41].
Aflatoxin sampling is especially complicated since mold growth (and hence toxin distribution), in feed and grain, may not be homogenous. For example, not all the conditions for the production of toxins will be met in the totality of a silo; a storage grain system will reduce the toxin production with aw values below 0.70 [42]. Errors in sampling methodology carry costs intrinsically. Assuming only a section of a feed batch is contaminated, the composite and homogenized sample is vital. Failure in detecting the mycotoxin will generate adverse effects on farm animals which will be fed with said foodstuff. Sampling directly and only from a “hot zone” will unchain legal events that usually ends in the elimination of a whole feed batch, which is costly for feed manufacturers or importers/exporters [43]. On the other hand, research has demonstrated that the bulk of the variability in mycotoxin analysis comes from sampling [44]. Some papers have focused specifically on aflatoxin sampling. For example, Mallmann and coworkers sampled eight lots of corn using two different plans: manual, using sampling spear for kernels; and automatic, using a continuous flow to collect corn meal [43]. The authors concluded that automatic sampling introduces less analytical variation and it is more accurate than manual sampling. In contrast, Herrman and coworkers sampled Texan grain elevator establishments and determined that while sampling contributes to variability in measuring aflatoxin in grain, aflatoxin analysis using commercially available test kits was a major contributor to variation in aflatoxin test results among commercial food handlers [45].
Several authorities have issued sampling guidelines. The American Association of Feed Control Officials (AAFCO) recommendations for mycotoxin test object collection is detailed in Feed Inspector’s Manual for the member States [46]. Similarly, the European Commission has emitted the 2006/401/EC which lay down the sampling methods and analysis for the official control of the levels of mycotoxins in foodstuffs [47]. Food and Agriculture Organization of the United Nations (FAO) have developed a mycotoxin sampling tool (http://www.fstools.org/mycotoxins/). Berthiller and coworkers detailed other sampling and analysis methods that include other mycotoxins [48]. Lee and coworkers designed a statistically derived risk-based sampling plan for surveillance sample assignments of chemical and biological hazards using binomial probability distribution [49]. The authors found that the number of feed samples that exceeded legal thresholds for target analytes (aflatoxins, fumonisins,
Several companies have devoted their efforts in the fabrication of versatile products useful to isolate aflatoxins from samples. Different researchers have applied diverse approaches to obtain a clean extract, especially to inject into LC systems. For example, R-biopharm AG has two various methods available for the analysis of aflatoxins: RIDASCREEN® for total AF and AFB1 single analysis and AFLAPREP® an immunoaffinity column which delivers limits of detection as low as 0.007 ng AF mL−1 extract, and based on our laboratory experience, sample clean-up is capable and good recoveries are obtained. Noteworthy, R-biopharm also has an immunoaffinity column for sterigmatocystin.
Other laboratories have recently applied these concrete columns to monitor aflatoxin in food and feed [50, 51]. Multiple columns (e.g. AOF MS-PREP®) based on this same principle are also available. However, care must be taken as usually recoveries vary with regard with that of the single toxin column as competition for active sites may arise causing lower recoveries. Romer Labs® has also developed a wide range of detection and sample treatment techniques, including AgraStrip®, which are rapid, ready-to-use (qualitative total aflatoxin or quantitative WATEX) lateral flow devices ideal for on-site or surface testing with a limit of detection of 3.31 μg kg−1. AgraQuant® Aflatoxin/Aflatoxin B1 which are ELISA tests with sensitivities ranging from 1 to 3 μg kg−1 and FluoroQuant® quantitative fluorometric tests based on a solid-phase or immunoaffinity column clean-up. Romer Labs® has two immunochemical columns: Aflastar™ FIT and Aflastar™ R, the latter have been used in our laboratory and applied to feed aflatoxin monitoring with excellent results. Vicam has similar products ranging from strip tests (Afla-V, Afla-V aqua which has removed the use of hazardous organic solvents) to LC clean-up immunoaffinity columns (Afla B, AOZ HPLC [high-performance liquid chromatography]) approached vary from quick response, qualitative to quantitative. Immunoaffinity columns are a very attractive option for sample clean-up and concentration; however, it is important to consider that this approach not only has inherent drawbacks [52, 53] but also may increase laboratory analysis costs considerably.
Although the use of immunoaffinity approaches is appealing, LC-MS or LC-MS-MS techniques usually require chemically based solid phase extraction as several structurally different analytes are analyzed simultaneously. For example, as early as in 2006, Garon and coworkers developed an HPCL-MS/ESI+ approach to analyzing up to 11 mycotoxins (including AFB1) in corn silage using an Oasis® HLB cartridges and eluting with a mixture of methyl
Likewise, only a few methods have been described elsewhere, e.g. Shakir Khayoon and coworkers detailed an assay for the determination of aflatoxins in animal feeds and ingredients by LC with multifunctional column clean-up [56]. Biotage® Isolute Multimode® Columns were used to assess aflatoxins successfully. These particular columns have three mechanisms of action: strong cation exchange (R-SO3− H+), hydrophobic-based retention [−(CH2)17CH3], and weak anion exchange [(CH2)3N+(CH3)3Cl−]. Based on structural analysis of aflatoxins, not all these mechanisms play a role during their extraction. The authors report great results, i.e. the sensitivity of 0.10 and 0.06 ng g−1 for AFG1/AFG2 and AFB1/AFB2, respectively. Acetonitrile:water (9:1) mixture gave satisfactory recoveries for all aflatoxins (>85%).
Depending on the method and analytical instrumentation chosen for aflatoxin analysis, the extraction step can become a limiting stage of the overall assay. For example, liquid chromatography coupled with extensive treatment to obtain clean extracts before injection. MS-based approaches have an inherent advantage over classic ones. The detector can differentiate between two different mass/charge units even if chromatographic signals are overlapped. Hence, less intensive and straightforward sample preparation techniques, such as QuECheRS (quick, easy, cheap, effective, rugged and safe), dispersive liquid-liquid microextraction, or “dilute-and-shoot”, are employed [57].
Dzuman and coworkers optimized a QuEChERS method for the determination of 56
Dispersive liquid-liquid microextraction was applied by Campone and coworkers to the determination of aflatoxins in cereals such as corn, rice, and wheat [61]. Chloroform was selected as transfer solvent, whereas a methanol:water (8:2) was selected as an extraction mixture and a 2.5 enrichment factor was reported. Afzali and coworkers developed a method using dispersive liquid-liquid microextraction for the preconcentration of ultratrace amounts of AFB1, AFB2, AFG1, and AFG2; the authors validated several parameters as extraction solvent (chloroform), disperser solvent (acetonitrile), sample pH, and centrifugation time finally settling for a two-step approach [62]. Lai and coworkers used a microextraction method to concentrate 1.25 times aflatoxin B1, B2, and ochratoxin A with acetonitrile/water/acetic acid mixture as extraction solvent and chloroform as a disperser in rice samples [63]. Noteworthy, it is usual to these microextraction methods to be coupled with immunoaffinity column extraction as an additional step or to compare performance results among methods. Amirkhizi and coworkers used a dispersive liquid-liquid microextraction as a clean-up method before the quantitation of AFB1 in eggs (
Two multi-mycotoxin methods, a dilute-and-shoot LC-MS/MS method and a method based on multi-toxin immunoaffinity columns before LC-MS/MS, were used for the determination of mycotoxins in corn samples, which included integral and moldy grains, harvested in South Africa [67]. Arroyo-Manzanares and coworkers used acetonitrile as an extraction solvent for a “dilute-and-shoot” method for the determination of AFs in animal feed in combination with matrix-matched calibration [68].
Although less complex sample clean ups are very attractive to offer a swift response on a relatively low budget, care must be taken as high matrix interference (when injecting crude extracts) represent a limitation, so some sample treatment methods are usually a requirement. New approaches are continually being developed such as the method selected by Ates and coworkers which injected extracts directly into an automated turbulent flow sample clean-up system, coupled to an LC-HRMS (high-resolution mass spectrometry [Orbitrap]) system to screen up to 600 fungal metabolites to generate feed contaminant profiles [69]. On the other hand, Fabregat-Cabello and coworkers used multi-level external calibration using isotopically labeled internal standards, multiple and single level standard addition, one point isotopic internal calibration and isotope pattern deconvolution to compensate sample extracts, such as those from a feed, that demonstrate powerful matrix effects [70].
On the other hand, Hu and coworkers simplified immunoaffinity column analysis reducing sample extraction and toxin purification to one step and using microbeads coupled with monoclonal antibodies against AFB1, AFB2, AFG1, AFG2, zearalenone, ochratoxin A, STE, and T-2 toxin [71]. Eighty feed samples were successfully tested using this tactic. Zhao and coworkers described a method for analyzing 30 different mycotoxins (e.g. aflatoxins, ochratoxin A, trichothecenes, zearalenone, fumonisins, and citrinin) in animal feed, animal tissue, and milk [72]. The authors compared three extraction mixtures, different SPE cartridges, including Oasis HLB®, an amino cartridge, Oasis MAX®, and MycoSep® 226 multifunctional cartridge, and sorbents, including C18, chitin, carbon nanotubes, and florisil. The reader is referred to the review by Arroyo-Manzanares and coworkers who cite new techniques in sample preparation for mycotoxins [73].
Other technologies have helped perform easier and faster toxin analysis. Though, they are limited as to the amount of information that can be drawn from a sample. Recently, the International Crops Research Institute for the Semi-Arid Tropics (ICRISAT) developed the first portable low-cost (up to 2 USD) device designed for rapid detection of aflatoxins. On the other hand, this technology seems to need little to no technical experience to use. This development means that feed producers and farmers may take decisions on location saving unnecessary exposure to toxins and limit economic loss. Another cost-effective approach is based on a lateral flow device (immunodipstick) to assess as little as 5 μg kg−1 of AFB1 in swine feed. We consider this type of approach to be considerably useful to assess aflatoxin cross-contamination in surfaces at feed manufactories, farms, or even dedicated laboratories. Lee and coworkers developed a semi-quantitative one dot lateral flow immunoassay for AFB1 using a smartphone as a reading system with a sensitivity of 5 μg kg−1 [74]. The authors applied this method to whole corn and feed with great results.
With the widespread use of immunochemical based techniques, the development of new toxin-specific monoclonal antibodies with a very high selectivity are in need. Zhang and coworkers reported a new AFB1 monoclonal antibody (MAb) 3G1 obtained by immunizing Balb/c mice with aflatoxin B2a-Bovine serum albumin [75]. The approach rendered a highly sensitive immunochromatographic assay, a detection limit of 1 ng mL−1, showed no cross-reactivity with other aflatoxins and avoided providing false-positive results. The authors included during validation among other matrices, feedstuffs. Several conjugates and antibodies have been commercially developed for sample preparative purposes. Recently, ImmuneChem® has developed AFB1, and AFM1 bovine serum albumin and horseradish peroxidase immobilized antigens for anti-aflatoxin antibody assays. Rabbit and mouse antibodies-based sorbents are also available and can be utilized for detection and quantization of food-borne AFB1. The standard application of these antibodies is in ELISA test. The usage of monoclonal ELISA test was introduced to research practice early on assessing aflatoxin concentrations in the feed. For example, Banerjee and Shetty applied this technique to poultry feed [76]. Recent approaches have incorporated improvements on ELISA tests. For example, Rossi et al. developed an indirect competitive enzyme-linked immunosorbent assay (ic-ELISA) based on an anti-aflatoxin B1 monoclonal antibody [77]. The authors reported that the method was validated for aflatoxin screening in poultry feed samples obtaining detection limits and recoveries of 1.25 ng g−1 and 98% for broiler feed and 1.41 ng g−1 and 102% for laying hen, respectively, on both accounts. The method was also compared with HPLC results, and the authors found a high correlation with HPLC of 0.97 (broiler feed) and 0.98 (laying hen feed). Another research group developed an indirect competitive electrochemical ELISA for the determination of AFB1 in barley. The method used disposable screen-printed carbon electrodes and anti-AFB1 monoclonal antibodies (MAb) for immunosensor development. Cross-reactivity of AFG1 was found, and the authors demonstrated that the coated electrodes could be used for up to 1 month after their preparation when stored at 4°C. The limit of detection was found to be 90 pg mL−1, which translates to 0.36 μg kg−1.
Gold colloid strip tests have also become available for some matrixes and are somewhat popular. For example, Ateko Masinde and coworkers developed a colloidal gold-based immunochromatographic strip which they applied to the analysis of corn and rice [78]. In our context, these matrixes are relevant since both are common feed ingredients. More recently, Sun and coworkers developed a green method using anti-AFB1 antibody-coated gold colloids as probes in plant oils [79]. Noteworthy, the extraction is attained using water as a solvent. The authors reported a successful visual detection under 5 min with a sensitivity of 1.5 mg kg−1. The methods above are interesting since no professional training needs to be involved in applying them efficiently and can be used in the field.
AOAC HPLC-based assays are for aflatoxins are scarce. The one method available is 2003.02, which is designed for the determination of AFB1 in cattle feed. Although it can easily be used to quantitate each AF fraction and other feeds. This last method uses post-column derivatization (a standard approach for AF HPLC-based methods to enhance sensitivity; [80]) using a R-biopharm’s KOBRA® CELL, which principle is based on the electrochemical
In our laboratory, we have implemented an accredited assay (according to ISO/IEC 17025 requirements) based on the derivatization of AF using an aqueous I−/I2 solution with excellent results ([85], see Figure 2). We base our method on the fact that iodine/iodide is less oxidizing than other agents and easier to manipulate. The drawback of this approach is that high temperatures (95°C) must be used to obtain AF derivates swiftly (using a 0.14 mL reaction loop); this is not the case for bromine.
RP-HPLC analysis of aflatoxins using iodine/iodide-based derivatization. (A) 40 μg L−1 standard in methanol and 10 μL injection AF fractions in order of elution: AFG2(4.789), AFG1(6.069), AFB2(7.585), and AFB1(9.745). (B) Same method used to analyze a naturally contaminated corn sample with AFB2(7.565) and AFB1(9.723).
Noteworthy, at 365 and 455 nm as excitation and emission wavelengths, respectively, AFB2 and AFG2 show natural fluorescence when no derivatization is used, while the signal for the other two fractions is negligible. Both iodine and bromine generate fluorescent derivatives using an addition reaction, which introduces a halogen atom on the double bond of the dihydrofuran ring. The steric hindrance and electronic repulsion conferred by the halogens, which are spatially opposite to each other, render an aflatoxin molecule with far more torsion [−0.2812 (AFB1) vs. 2.9320 (AFB1I2), using an MM2 energy minimization]. Hence, favoring a more rigid structure, a fluorescence prone one (Figure 3).
3D structure minimized energy using MM2 calculations of (A) aflatoxin B1 (total energy of 48.2584 kcal mol−1) and (B) AFB1 after iodine addition (total energy of 53.8536 kcal mol−1); pink-colored beads represent non-bonding electron pairs.
Machado Trombete and coworkers validated a fluorescence-based method and compared three methods of extraction; the authors found chloroform to be the most efficient solvent [86]. Pre-column derivatization with trifluoroacetic acid was used to increase sensitivity (reaching 0.6 μg kg−1 as the limit of detection). Although the authors intended this method for wheat projected for human consumption, this matrix is a widely used as a feed ingredient in some countries. Horizon technologies introduced to the market a thermostatically controlled heated water chamber that facilitates the pre-column derivatization of aflatoxins with trifluoroacetic acid (XcelVap®). Cortés and coworkers also used a fluorescence-based method without derivatization using 360 nm as an excitation wavelength and 418–700 nm as excitation [87]. The method included aflatoxicol (a reduced derivate from AFB1; cyclopentanone moiety is converted to cyclopentanol) and also assessed the recovery of aflatoxins and aflatoxicol in poultry litter finding non-trivial levels of these contaminants. A relevant feature since poultry litter (urea, uric acid, and ammonium-rich by-products) has served on occasion as livestock feed. Interestingly, in a Waters Corporation application note, Benvenuti and coworkers used a fluorescence detector-based approach to quantitate aflatoxins B1, B2, G1, G2, and M1 without derivatization [88]. The authors used 365 nm as excitation wavelength and emission wavelengths 429 and 455 nm for AFM1/AFB2/AFB1 and AFG1/AFG2, respectively. Pickering Laboratories developed a fluorometric method using photochemical derivatization and
Pirestani and coworkers measured aflatoxins both in dairy cattle feeds and milk samples from the province of Esfahan, Iran [89]. The authors compared results from HPLC (bromine post-column derivatization) and ELISA. It was concluded that there was no significant difference between the values obtained by the two procedures. However, sensitivity and specificity were determined to be superior to that of ELISA. Gomes Pereira and coworkers also did analyze dairy cattle feed and milk from the Lavras, Minas Gerais region of Brazil [90]. In the case of cattle feed samples, the authors state they used an AOAC method but failed to specified which.
With the advent of confirmatory and multi-analyte techniques such as tandem MS (mass spectrometry) coupled to LC, a whole new span of methods has been described which include the “classic” toxins and other not-so-known ones into feed vigilance schemes. In 2012, Warth and coworkers described a multiple-toxin method based on LC-MS/MS that included several metabolites, a total of 63 analytes were tested in corn, groundnut, sorghum, and feed produced in Burkina Faso and Mozambique [91]. De Souza and coworkers reported a LC-MS/MS using ESI+ with a QTrap 4000 system, which was used to analyze 119 samples collected from poultry feed factory [92]. The researchers analyzed
Recently, Njumbe and coworkers reported a LC-MS/MS method that included 23 mycotoxins in different sorghum varieties, all analytes eluted under 14 minutes and stated a high sensitivity for all mycotoxins, specifically 2.5 and 5.0 μg kg−1 for AFB1/AFB2 and AFG1/AFG2, respectively [93]. Although sorghum, in some regions, has been substituted by other grains such as corn, it has seen a resurgence as a crop for feed in several parts, which is relevant since some grain production is not continuous throughout the year, and feed ingredient supplies are in high demand, and their availability is constrained. More interestingly, when the method was applied to a small subset of retailed samples from Belgium and Germany, 90% were positive for aflatoxin B1. Regarding food and feed monitoring, a very comprehensive review was written by Zhang and coworkers [94]. This report is unique since it cites the techniques used by the US FDA to assess mycotoxins in different staple foods including LC-FLD (fluorescence detector), MS, tandem MS, and HRMS. For example, a LC-MS/MS method including 11 different mycotoxins (e.g. aflatoxins), using stable isotope dilution, has been developed and validated in various matrixes (including cat/dog food, corn, feeds, and wheat flour). Samples were fortified using 13C-IS and prepared by solvent extraction. In general, the recoveries ranged from 70 to 120%, with RSDs < 20%. Limit of quantitation was calculated to be 0.005 μg kg−1 for AFB1. The method above applied in our laboratory based on LC-FLD with post-column derivatization renders a similar acuteness for AFB1 (limit of detection and quantification 0.005 and 0.15 μg kg−1, respectively) nonetheless our method had to be modified to include a ca. 200-fold concentration step. Lattanzio and coworkers used a similar approach to analyze cereal-based foods using as a clean-up strategy SPE [95]. Zhang and coworkers opted for a LC/MS/MS approach to analyze mycotoxins in feed using isotope dilution and circumventing the clean-up step altogether [96]. For a thorough review of chromatographic and spectrometric techniques used for mycotoxin analysis, we suggest the paper wrote by Li and coworkers [97]. Ok and coworkers recently opted to include aflatoxins and sterigmatocystin in the same analysis using tandem MS for their assay in sorghum and rice [98].
DDGs is an essential matrix since the shortage and costs of other corn-based feed ingredients have pushed toward their extensive use [99, 100]. As this is a residue from ethanol production, any mycotoxins initially found in the raw material may be concentrated. On the other hand, Oplatowska-Stachowiak and coworkers developed a UPLC/MS/MS method capable of analyzing as much as 77 mycotoxins and other fungal metabolites [101]. The method analyzed 169 DDGs samples produced from wheat, corn, barley and other grains. Aflatoxin contamination was frequently encountered in corn DDGs. In contrast, wheat and mixed DDGs showed none or very few contaminated samples. In a very exhaustive analysis of European feedingstuffs, Zachariasova and coworkers used a UHPLC–QtrapMS/MS. The authors found that forages showed the lowest mycotoxin incidence while the most diversity of detected mycotoxins. In contrast, the highest concentrations, was quantified in DDGs [99]. For example, AFB1 was found with a mean value and a maximum of 0.6 and 6.4 μg kg−1, respectively.
Another important feed ingredient is palm kernel cake, which is used as a source of protein and energy for livestock and occasionally used as poultry feed supplement. Yibadatihan and coworkers developed a LC/MS/MS ESI+ to analyze several toxins in palm kernel cake, including aflatoxins [102]. Recoveries ranged from 84 to 110, and the method sensitivity was calculated as 0.16 and 0.54 for AFB2/AFG2 and AFB1/AFG1, respectively. Twenty-five samples were analyzed using this approach, and a very high prevalence for aflatoxins (>85% samples tested positive for any of the fractions) was found. The lowest and highest concentrations found were 1.31 (for AFG1) and 78.38 (for AFG2) μg kg−1. As with DDGs, any toxin found in palm kernel raw material will probably be concentrated as the palm kernel is mechanically pressed to extract vegetable oil.
Finally, in a provoking research, Escrivá and coworkers assessed mycotoxin (including aflatoxins) contamination of rat feed [100]. Twenty-seven commercial Spanish rat feed was analyzed using a liquid chromatography equipped with a 3200 QTrapVR mass spectrometry system with a Turbo electrospray ionization interface. Considerable mycotoxin burden was found in feeds. For example, concentrations of AFB2 (21.61 μg/kg bw/day), and AFG2 (15.09 μg/kg bw/day) were calculated for the assayed feeds. Since laboratory animals are used as models in other research, these contaminants’ toxic effects may cause artifacts and confounding results. The authors detailed the feed composition listing each ingredient use during formulation, data that is usually overlooked during contaminant analysis. Feed composition plays a significant role in toxin pollution as the main ingredients may guide which contaminants will be more likely to be present [103]. McElhinney and coworkers developed a method for the determination of mycotoxins in grass silage [104]. In this case, they used a modified QuEChERS approach with almost no clean-up and an UHPLC/MS/MS technique. Polarity switch during the analysis permitted to assess both positive and negative ions. AFB1 detection limit was calculated to be 3 μg kg−1 DM. This relatively low sensitivity is usually the cost of a swift sample preparation and avoiding thorough clean-up steps. A similar approach was used by Dzuman and coworkers for the analysis of cereals, complex compound feeds, extracted oil cakes, fermented silages, malt sprouts, or DDGs using U-HPLC-HRMS [105].
An interesting earlier report made by Babu and Muriana stated that AF recovery was enabled by the use of primary polyclonal antibodies for AFB1 [106]. Said antibodies, were covalently attached to 2.8 μm diameter magnetic beads using a cross-linking agent and a secondary antibody for the toxin covalently linked to DNA oligonucleotides based on the
Another novel approach for the extraction, preconcentration, and determination of aflatoxins in animal feedstuffs was carried on recently by Zhao and coworkers who developed a novel two-step extraction technique combining ionic liquid-based dispersive liquid-liquid microextraction with magnetic solid-phase before HPLC coupled with FLD [66]. The ionic liquid 1-octyl-3-methylimidazolium hexafluorophosphate was used as the toxin-retrieval agent, and hydrophobic pelargonic acid modified Fe3O4 magnetic nanoparticles as an active sorbent.
Ramesh and coworkers used a high-performance thin-layer chromatography method that uses a stationary phase based on silica gel 60G F254 and a mobile phase that consisted of acetone:chloroform (1: 9),
Ren and coworkers used an immunochromatographic assay based on CdSe/Zn quantum dot beads, reaching values as low as 0.42 pg mL−1 AFB1 [112]. Quantum dots were prepared using poly(methyl methacrylate), poly(maleicanhydride-
Finally, new efforts to quantitate and detect mycotoxins should include emerging analytes, such as other
Isolation and identification of fungi, especially those with aflatoxigenic capabilities, is an analytical feature, during aflatoxin determination, which is seldom considered. These data may easily be contrasted with concentrations obtained by any of the analysis methods aforementioned. However, a few papers have indeed tackled the issue. Suganthi and coworkers used both ELISA (based on urea peroxide and the chromogen tetramethylbenzidine) and thin-layer chromatography (using a mixture of chloroform and acetone) to detect aflatoxins in animal feed and also isolated molds using Czapek Dox Agar medium [117]. In this case, the authors concluded that 80%
As stated before, research based on animal feeds is somewhat lacking and usually, the importance of this matrix within the food chain sometimes omitted. Although this chapter is devoted to aflatoxins and regulatory standards, till this day, target only specific toxins, evidence suggests that other mycotoxins, contaminants, residues, and xenobiotics interact with aflatoxins sometimes even enhancing their carcinogenic potential. We consider that aflatoxin monitoring programs should be implemented and reinforced to minimize the impact of aflatoxins on animals and humans. On the other hand, policy makers and officials should concentrate efforts and prioritize the incorporation of country-wise feed monitoring systems where currently there are none. Based on the data recollected here-in, sampling and surveying should focus especially on corn and corn products and pet food and full ruminant rations including balanced feed. From the zootechnical standpoint, evidence indicates that general nutritional formulations can be modified to minimize fungal and toxin contamination and hence animal health impacts and still cover the traditional nutritional needs. On the other hand, farmers may equivocally attribute productivity loss to toxin presence where none is found. As occasionally farm feed practices are based on the exploitation of residue from other agricultural activities (e.g. fruit processing wastes, poultry litter, alcohol product by-products [DDGs]), strict control of this type of samples should be kept. Aflatoxin toxicity occurs at very low concentrations. Therefore, sensitive and reliable methods for their detection are required. Sampling and analysis of aflatoxins are paramount. Failure to achieve a verifiable analysis can lead to erroneous conclusions or judgments; contaminated feedlots being accepted or satisfactory batches unnecessarily rejected. Thanks to technological advancements method for aflatoxin detection are continuously improving in sensitivity, repeatability, accuracy, efficiency, and with less and less waste. Data herein demonstrate that even in countries where expensive technology (e.g. LC-MS/MS) is scarce or not readily available, feed monitoring is possible. Efforts have been made to provide proficiency testing for laboratories (e.g. American Association of Feed Control Officials [AAFCO] and Laboratory of Government Chemist [LGC Standards]), which improve method accuracy bias and reliability. However, feed-based certified materials available are still few. Finally, considering the relevance of feed in the food chain safety, countries should implement and improve monitoring programs for aflatoxin in foodstuffs; these programs should contemplate risk management, One Health or “MyToolBox” approaches, and farm-to-fork models that include all stakeholders to mitigate the economic and health burden that aflatoxin contamination generates.
The author would like to thank Vicerrectoría de Investigación for the financial support.
In 2020, the most rigorous scientific study to date regarding the efficacy of Alcoholics Anonymous (AA) and other 12 step approaches were published [1]. Soon after, a sweeping review of scientific studies relative to Narcotics Anonymous (NA) was released [2]. Outcomes gleaned from these publications suggests substantial benefit to members of AA and NA both as an adjunct to professional treatment and as a stand-alone intervention for substance use disorder (SUD). Although valid criticisms exist regarding 12-step approaches, for those whom 12-step approaches work, they appear to work quite well. While alternatives to 12-step approaches are increasing, scientific information is limited. Thus, this chapter focuses primarily on 12 step-approaches.
The chapter begins with an introduction presenting demographic data, history of 12-step programs, and the fundamental philosophy of the 12-steps. Because AA and NA are the largest and most studied 12-step programs, most of this discussion is drawn from literature specific to these two programs. Additionally, there is a dearth of scientific literature pertaining to 12-step approaches and behavioral addictions. At present, there is only one behavioral disorder included in the DSM’s classification of Substance-related and Addictive Disorders [3], gambling disorder, so the chapter’s focus is 12-step approaches relative to substance use disorders. An introduction to the most common 12-step programs associated with behavioral addictions is also presented.
Substance use disorder mutual aid recovery has an intricate and complex history. Many mark the year 1935 as the birth of the mutual aid recovery movement as that is the year Alcoholics Anonymous was formed. According to White [4], the mutual aid recovery movement began centuries before in the late 1700s with Native American Recovery Circles. Section II presents a brief survey of the history of mutual aid groups, followed by a more pointed examination of the histories of AA and NA. A concise overview of common 12-step offshoots follows. The section concludes with a look at how 12-step approaches became integrated into professional addiction treatment services.
In section III, the philosophical underpinnings of the 12 steps and recovery-related activities associated with 12-step mutual aid recovery are described. According to research, those who participate in 12-step activities such as sponsorship, regular meeting attendance, and service have better outcomes regarding sustained abstinence [5, 6, 7, 8, 9].
Section IV presents the evidence surrounding 12-step mutual aid recovery. Beginning with an examination of several core elements that appear to support recovery, the section explores the efficacy and strengths of 12-step approaches as well as its criticisms and limitations.
The discussion continues in section V with a consideration of culture as it relates to 12-step approaches. One size does not fit all, and the spiritual or religious undertone of the 12 steps is likely the most cited barrier for those who prefer a secular approach to addiction recovery. In contrast, many are attracted to 12-step programs because of the emphasis on spirituality and a Higher Power. This and several additional cultural influences are explored.
Before the chapter concludes, recommendations are offered for integrating 12-step approaches into professional treatment services.
In 2011, there were 54 different 12-step programs [10]. Alcoholics Anonymous and Narcotics Anonymous are by far the largest. A strength of 12-step programs is their wide availability across the globe. Estimated membership in Alcoholics Anonymous is 2,077,374 individual members and 125,557 groups as of 2019 [11].
A 2014 AA membership survey [12] reported the following demographic information. Sixty-two percent of membership identified as male and 38% identified as female. A large majority of membership identified as white, 89%, 4% black, 3% Hispanic, 1% Native American, 1% Asian, and 2% identified as other. The average age of AA members is estimated at 50 years.
Members are introduced to AA from a variety of sources. Thirty two percent of members are introduced to AA by an AA member, and another 32% are introduced by a treatment facility. Thirty percent of AA members report being self-motivated to attend, and 27% are referred by a family member. Other referrals come through the criminal justice system (14%), and medical and behavioral health professionals (17%). Less common referrals include Al-anon/Alateen member, AA literature, employer, or colleague, newspaper/magazine/radio/tv, clergy, and the internet. The survey reported the average length of sobriety is 10 years, with a range between less than one year (27%) and over 20 years (22%). On average, members attend 2.5 meetings per week, and 82% reported having a sponsor.
Narcotics Anonymous released a membership survey more recently [13]. They report 77,000 meetings weekly in 144 countries across the globe. Compared to AA, NA’s membership is more diverse, with 70% identifying as White, 13% Black, 7% Hispanic, 4% multiracial, 2% Asian, 1% Indigenous, and 1% as other. In terms of gender, 58% identified as male and 42% as female. The average age of NA members is 46 years, with a range between less than 21 (1%) and over 60 (15%). The mean number of years clean is 8.32 years, with a range between less than 1 year (8%) and over 20 years (25%).
Most members are referred through other NA members (49%) and treatment of counseling services (45%). Other referral sources include family members, NA literature or an NA service effort, and AA members.
NA members reported using a variety of substances. Alcohol was the most common substance reported (73%), followed by cannabis (62%), cocaine (52%), opiates (38%), stimulants (38%), crack (31%), opioids (26%), tranquilizers (25%), hallucinogens (25%), prescribed medications (23%), ecstasy (17%), methadone or buprenorphine (14%), inhalants (11%), and other (14%).
It is important to note that these two surveys are
According to the addiction field’s leading historian, William White, the history of abstinence-based mutual aid recovery groups begins with the Native American recovery circles [4]. Between 1737 and 1840, Indigenous leaders such as Handsome Lake, Wagomend, and Paounhan had transformational experiences leading to sobriety. These transformations led to cultural and religious reformations, which included the rejection of alcohol. Spawned by the temperance movement, the 1800s saw a variety of mutual aid societies begin and end. These included the Washingtonians, The Red Ribbon Reform Club, the Drunkard’s Club, and several others. White further explicates that for those whose goal was moderation rather than abstinence, other groups formed such as Businessman’s Moderation Society in 1879. European temperance societies formed in the 1800s as well. For example, in 1851 the Order of Good Templars formed, and in 1877 Switzerland founded the Blue Cross. White also states that European culture, like American culture, formed mutual aid groups founded on moderate drinking rather than abstinence such as the German Order of Temperance, French Temperance Society, and the Irish New Ross Temperance Society.
In the early 1900s, many American mutual aid and treatment organizations failed, and this was partly influenced by prohibition. According to White, the absence of mutual aid groups in the early decades of the 20th century is notable, but in 1935, an historic meeting occurred between two self-defined hopeless alcoholics that revolutionized the treatment for people with alcohol use disorders and a host of other addictive behaviors across the globe [14]. Today, AA is the largest and longest running mutual aid group for alcohol use disorders in the world. Such a profound impact has been made by AA, that its co-founder, Bill Wilson, was recognized by Time Magazine as one of the most influential people of the Millennium [15]. A brief history of AA is provided next.
From the book Alcoholics Anonymous [16], affectionately known as the
In 1934, Bill W. sat alone drinking at his kitchen table when the telephone rang. He was greeted by an old high school friend and drinking buddy, named Ebby T., whom he had not spoken to in quite some time. He had heard his old friend was institutionalized due to chronic alcoholism. Ebby T. asked if he could visit Bill, and later that day the two men sat reminiscing about old times. Bill offered Ebby a drink, but he refused and told Bill that he
According to Alcoholics Anonymous [16], the process described by Ebby T. was the foundation of the Oxford group. A mostly non-alcoholic, non-denominational, Christian group. Its fundamental principles and beliefs were later expanded and revised into what are now known as the 12-steps of Alcoholics Anonymous.
After that fateful meeting with Ebby T., Bill went on yet another drinking binge that eventually landed him in Towns Hospital in New York with delirium tremens. Remembering his friend’s spiritual directions, he proceeded to take the steps as outlined by Ebby T. In Towns Hospital, 1934, Bill W. experienced his famous white light experience, never to drink again.
What happened in the following six months formalizes the beginning of AA. Upon release from Towns Hospital, Bill joined the Oxford Group. He and Ebby embarked on a mission to share this spiritual process with as many alcoholics as possible. A profound lesson was learned, which is the bedrock of AA.
After several month, Bill W. became very disheartened because although they had shared the message of recovery with with every alcoholic they met, none were able to maintain sobriety. Bill was ready to abandon their effort when Ebby emphasized that even though none of their recruits remained sober, he and Bill did. This is the crux of AA -
About six months after Bill’s spiritual experience in Towns Hospital, he went on a business trip to Akron Ohio, alone for the first time in his newfound sobriety. Bill walked through the lobby of the hotel, immediately spotting the hotel lounge. The old memories of drink ensued, and the familiar craving took root. He went to the lobby phone booth and found a church directory where he began frantically calling churches to see if one knew of an alcoholic with whom he could speak. At the end of the church directory, he found a possibility. A meeting was arranged by the wife of an Akron surgeon to speak with her husband as he was dying of alcoholism. Dr. Bob Smith had been a member of the Oxford Group where he had sought help for his alcoholism, but to no avail.
On June 10th, 1935, Bill W. and Dr. Bob Smith met for the first time. Bill shared his experience with a chronic and seemingly hopeless alcoholic condition (what it used to be like), the spiritual process that transformed him (what happened), and how his life unfolded moving forward (what it’s like now). The two men spoke for hours and agreed to work together to share their experience with other alcoholics who still suffered. From this point forward, Bill W. and Dr. Bob dedicated the rest of their lives to carrying the message of AA’s 12-steps to other alcoholics. After 2 and a half years of sobriety, in 1937 Ebby T. relapsed. He did regain sobriety and died sober in 1966.
With the publication of AA’s Big Book in 1939 and a flurry of articles published thereafter, AA’s growth blossomed. A defining moment in AA’s growth trajectory occurred in 1941 when Jack Alexander’s article,
Because the only requirement for membership in AA is a desire to stop drinking, and drug addicts were often shunned by AA, Narcotics Anonymous was formed. Unlike AA’s beginnings, NA’s first few decades were tumultuous, experiencing several starts and stops, and more than one version of the program [18].
Addicts Anonymous held its first meeting in 1947, but the Narcotics Anonymous we know today began in earnest in 1953, but nearly died in 1959 [18]. When this happened, Jimmy K. and two others started what became today’s NA with the
In his historical presentation of NA, William White [4] describes Jimmy K.’s addiction as one that progressed from sneaking tastes of paregoric and alter wine as a child to binging on whiskey and pills in adulthood. According to White, Jimmy K.’s addiction “left him bankrupt physically, mentally, and spiritually, and an abject failure as a man, a husband, and a father” [4], p. 335. As a result, he began attending AA in 1950, introducing himself as an alcoholic and addict. He had a passion for helping those with multiple addictions. Jimmy befriended Dorothy S. in AA, who like Jimmy, had multiple addictions. Together, with the help from Danny C in New York, they worked to establish the NA we know today.
Narcotics Anonymous utilizes the same 12 steps and 12 traditions developed by AA, with several adaptations specific to
Another point from which NA diverges from AA is that NA is a program of abstinence from all drugs [19], and NA does not differentiate between substances of misuse. Further, NA clearly considers alcohol a drug. Though for some, this may be a barrier to participation in NA. In nearly every NA meeting this section from the NA Basic Text is read:
Alcoholics Anonymous and Narcotics Anonymous also have offshoots for family members. Al-Anon, Alateen, and Nar-anon operate under the 12 steps and 12 traditions but are designed for those who love people with substance use disorders.
Though Alcoholics Anonymous and Narcotics Anonymous are by far the largest of the 12 step fellowships, numerous other groups have formed modeled after the AA prototype. The following section briefly introduces a few of its more common descendants.
Many twelve step programs have formed to treat both substance use disorders and behavioral addictions. In addition to AA and NA, several substance specific 12 step programs have followed: for example, Cocaine Anonymous, Heroin Anonymous, Marijuana Anonymous, and Nicotine Anonymous. Each AA derivative substitutes the word alcohol in the 12-step language for the substance or behavior the program addresses.
Although behavioral addiction is an unscientific term, many groups have formed to address a variety of compulsive behaviors. Gambling use disorder is the only exception and is classified in the DSM 5 as a Substance-Related or Other Addictive Disorder [3]. Gamblers Anonymous is one of the largest of the behavioral addiction 12 step programs. Gamblers Anonymous began in 1957 and “is a fellowship of men and women who share their experience, strength, and hope with each other that they may solve their common problem and help others to recovery from a gambling problem” [20].
Overeaters Anonymous formed to address a variety of compulsive eating behaviors. It is “a community of people who support each other in order to recover from compulsive eating and food behaviors. We welcome everyone who feels they have a problem with food” [21]. Overeaters Anonymous was founded in 1960 and currently has over 6500 groups in 75 countries, and an estimated 60,000 members worldwide.
Another well-known 12 step program is Codependents Anonymous program. “Codependents Anonymous (CoDA) is a 12 Step Fellowship for people seeking loving and healthy relationships” [22]. The concept of co-dependency has come under fire by feminist scholars. For example, Anderson [23] argued that the concept pathologizes and blames women. Yet, Melody Beattie’s 1986 bestseller,
The Minnesota Model, known as the fundamental philosophy of the well-known Hazelden Betty Ford Center, was born in 1949. It was one of the first facilities to provide therapeutic and human treatment for alcoholics and addicts [25]. Borrowing principles from Wilmar State Hospital and Alcoholics Anonymous, the model was replicated across the globe. So popular was the 12-step movement that by 1989, an estimated 90% of treatment facilities followed the Minnesota Model [26]. The core practices of the Minnesota Model included patient education on the 12 steps and the idea that addiction is a physical, mental, and spiritual disease [25]. Moreover, the model integrates the notion that alcoholics and addicts can stay sober best by helping one another as did Bill W. and Dr. Bob, the AA co-founders; thus, the beginnings of utilizing recovering alcoholics as lay counselors.
Before this section concludes, it is important to acknowledge one of the most utilized evidence-based models for addiction treatment, Twelve Step Facilitation Therapy or TSF. In the largest clinical trial of its kind, Project Match examined three of the most common evidence-based models for alcohol use disorder: cognitive behavioral therapy, motivational enhancement therapy, and TSF [27]. The purpose of the study was to learn if certain patients would have better outcomes with a specific therapeutic model compared to another. Overall, the study found that patient matching did not change outcomes and that all models were equally effective. Two exceptions should be noted. First, those with low levels of psychiatric comorbidities treated with TSF, experienced higher rates of days completely abstinent. Second, those who received TSF had higher rates of complete abstinence at year one. The next section will explore the 12-step philosophy, principles, and practices more fully.
When describing 12-step philosophy several core elements are emphasized: the 12-steps, 12 traditions, sponsorship, meeting attendance, service, and spirituality.
No discussion on the application of 12-step principles is complete without the perspective of those with lived experience. In addition to the author’s voice, this section integrates the voices of those who identify as persons in recovery. The section begins with the 12-steps and 12 traditions of the program.
We admitted we were powerless over alcohol—that our lives had become unmanageable.
Came to believe that a Power greater than ourselves could restore us to sanity.
Made a decision to turn our will and our lives over to the care of God as we understood Him.
Made a searching and fearless moral inventory of ourselves.
Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
Were entirely ready to have God remove all these defects of character.
Humbly asked Him to remove our shortcomings.
Made a list of all persons we had harmed and became willing to make amends to them all.
Made direct amends to such people wherever possible, except when to do so would injure them or others.
Continued to take personal inventory and when we were wrong promptly admitted it.
Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs [28].
The program is described as “a set of principles written so simply that we can follow them in our daily lives” [19], p. 9. A simple translation of the 12-step process is provided by a woman who attends both AA and NA:
Eddy G., a long-time member of NA, describes the purpose of the 12-traditions this way.
Our common welfare should come first; personal recovery depends upon A.A. unity.
For our group purpose there is but one ultimate authority—a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
The only requirement for A.A. membership is a desire to stop drinking.
Each group should be autonomous except in matters affecting other groups or A.A. as a whole.
Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.
An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.
Every A.A. group ought to be fully self-supporting, declining outside contributions.
Alcoholics Anonymous should remain forever nonprofessional, but our service centers may employ special workers.
A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.
Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films.
Anonymity is the spiritual foundation of all our Traditions, ever reminding us to place principles before personalities [28].
Sponsorship and carrying the message to the person who still suffers (step 12) are fundamental practices in 12-step communities. Sponsorship is the tradition of a more experienced, sober member of the program supporting a newer member along their recovery journey. “The heart of NA beats when two addicts share their recovery” [29].
Though the following sponsorship guidelines are not required, they are suggested. In general, sponsors and sponsees should be same sexed as to avoid romantic distraction. A limitation here is the assumption that all members are heterosexual. There is not an established guideline for those who identify as LGBTQ . Additionally, the sponsor should have experience in working the steps and have attained stable recovery. There is not a written standard in terms of length of sobriety or how far along in the step process a sponsor should be.
Dekkers, Vos, and Vanderplasschen [30] discovered mutual understanding facilitates connection, and connection was identified as a key theme supporting recovery in their qualitative study of NA members. A large study of over 1800 veterans showed that having a sponsor was one element that helped mediate positive outcomes among participants of 12-step programs [7]. According to NA, “the two-way street of sponsorship is a loving, spiritual, and compassionate relationship that helps both the sponsor and sponsee” [29]. Sponsorship may be considered analogous to the therapeutic alliance [31]. Contact with a sponsor and a strong sponsorship relationship contribute to increased 12-step participation and abstinence.
One often hears the maxim,
The value of meeting attendance is best described by an anonymous member of AA and NA.
It is important to note that research also indicates 12-step meeting attendance alone may be insufficient for the maintenance of recovery. Participation in activities such as sponsorship, service work, working the steps, etc. appears to increase positive benefits compared to meeting attendance alone. In a study of 303 young adults, 12 step meeting attendance and
As noted in the previous section, positive recovery outcomes increase with the addition of other recovery activities to meeting attendance, and service is one of the foundational elements of 12-step programs.
One long-term NA member described service in NA as follows.
Service work in 12 step programs encompasses a variety of activities. The more common tasks, other than sponsorship, include, opening and closing the meeting; setting up and putting away chairs; making coffee; holding positions such as group chairperson, treasurer, or secretary. Service may also include activities such as taking meetings into facilities where clients are unable to attend in the community. Treatment centers, jail and prison facilities are the most common. Service commitments might extend all the way to the level of world service. In keeping with the fundamental tenets of the program, all service positions are unpaid. According to the traditions of the 12-step programs, there are no dues or fees for memberships, there are no leaders, groups are self-supporting and autonomous, and 12 step mutual aid groups do not accept outside contributions. So entrenched are these principles, that guests attending an NA group are often explicitly asked not to contribute when the donation basket is passed at the meeting.
Why is service such an important component of 12-step programs? Two theoretical ideas are proposed: the helper therapy principle and the wounded healer archetype [34]. These theories suggest that one’s experience with addiction might be reduced through helping others. Further, by having addiction oneself, it may render the individual with special knowledge and insight that can be shared to help a person still struggling with addiction. This provides a logical segue into the final section of 12-step philosophy, spirituality.
While religion tends to be associated with an organized set of beliefs, practices, rules, and doctrines [35], 12-step programs’ clearly state the program “should remain forever non-professional… ought never be organized” [19], pp. 69–70, and is “not connected with any sect, denomination, politics, organization or institution” [36]. Yet, 12-step programs are unapologetically spiritual in nature. A common axiom cited in AA and NA meetings asserts
An entire chapter in AA Big Book is devoted to those who may struggle with organized religion and the concept of God – it is titled
If 12 step programs are not religious but rather
No academic endeavor is complete, however, without a critical examination. The next section will do just that.
While millions of people worldwide have found recovery from addiction through 12-step programs, millions more have found the program unhelpful. The science of addiction and recovery provides empirical evidence of the efficacy of 12-step approaches, but it equally shows there are multiple efficacious paths to recovery. One size does not fit all.
This section begins with the counterargument to the last section on spirituality. Likely the most frequently cited criticism to 12-step programs is its religious undertone. As noted in the history section of the chapter, AA and the 12-steps were birthed from a non-denominational Christian organization, the Oxford Group. Osten and Switzer argue that for those who identify as atheist, agnostic, or a non-Christian faith, 12-step programs might be challenging [39]. For example, multiple references to God, using the male pronoun, are found in the in 12-step literature. Step 3 of the 12-steps suggests
Building on this criticism, feminist writers have named several barriers to accepting the 12-step path for women and people of color [40, 41]. Not the least of which is the reference to God using the male pronoun in steps 3, 7, and 11, and throughout the AA literature. For women, there is a long and painful history of patriarchy, oppression, and subjugation. Thus, the idea of turning one’s life over to a male God may feel reminiscent of this history for some. Additionally, concepts of surrender, powerlessness, and turning one’s life over are not only difficult for some women to accept but may also be challenging for ethnic minorities. For groups who have experienced the horrors of genocide and slavery, such as Native Americans and African Americans, these ideas may be particularly difficult.
One anonymous 12-step member, a middle-aged woman in long-term recovery, understands this criticism and has experienced discrimination and oppression in a male-dominated, patriarchal society, but states she has not experienced the 12-step community as such (Anonymous NA member, personal communication, December 1st, 2020). She shared that the terms
Another criticism regarding language in AA and NA is related to stigma. Critics say that the tradition of introducing oneself in meetings as an “addict” or “alcoholic” places a negative label on the individual and perpetuates stigma and stereotypical views of people who have SUDs. Additionally, identifying oneself as their disorder is contradictory to strength-based and person-centered philosophies. A differing perspective is offered in Greene’s article:
For those who have difficulty adapting to the language in AA’s original literature, NA language may be more relevant to the present day, particularly newer NA publications and the latest edition of the NA Basic Text. However, the language of the 12-steps remains as originally written. Substitutes can be made in the language. For example, the male pronoun used in reference to God, may be substituted by a gender-neutral term. For example, dropping the male pronoun in the 11th step reads as follows:
For those who do not identify as Christian, the word God may be substituted with Allah, Jehovah, Yahweh, the generic phrase Higher Power, or whatever is true for the individual. It is important to understand that 12-tep programs do not require a belief in God. In fact, many agnostic and atheist AA groups exist and are growing rapidly. In AA, one might hear GOD referred to as a Group Of Drunks, while a group of sober alcoholics might be considered a higher power for whom to turn to for help. An interesting finding by Tonigan and colleagues found that belief in God is not necessary to experience benefit from AA, but those who identify as atheist or agnostic are less likely to attend meetings [45].
Another criticism should be highlighted. Some have found the language of the 12-steps reflects a tearing down rather than a building up process that emphasizes moral inventory and examination of one’s character flaws. Steps 4 through 7 best show this critique. These steps recommend critical self-examination, admission to the exact nature of wrongs to God and another person, followed by a willingness to let go of, and have God remove, such character defects and shortcomings. When asked about these criticisms, an NA member had this to say.
A major criticism is related to research. The tradition of anonymity in 12-step mutual aid recovery groups is an important aspect that attracts many to the program who otherwise may not attend. However, the lack of organization, anonymity, and the voluntary participation of members create methodological barriers to research. Additionally, survey research has inherent methodological flaws, particularly when studying members of 12-step programs. Self-selection bias is unavoidable, and this is particularly problematic as the voices of those who have not done well via 12-step mutual aid recovery may be missing and the voices of those doing well may be over-represented. Twelve-step attendees often come and go many times before they commit to sobriety or leave permanently. When evaluating the research literature, this criticism should not be overlooked.
Although 12-step meetings are more plentiful than alternative mutual aid recovery groups, availability is variable depending on geographic location. Meetings may be scant in rural areas and in some countries other than the U.S. Additionally, specialty meetings such as gender specific groups, LGBT groups, groups for adolescents, and groups for those who identify as atheist or agnostic are not available in all areas.
Depending upon which lens through which one views 12-step programs (member or researcher), the program’s 12 traditions are both strengths and limitations. From a members’ perspectives the traditions, as Eddy G. noted uphold the integrity of the program. But for researchers, anonymity, group autonomy, lack of professionalism and organizational structure, and their commitment to hold no opinion on outside issues, makes studying the program difficult. There is tremendous variability in how groups run and how one works the steps, for example.
This section ends with two additional strengths of 12-step programs – the first is cost. Membership in 12-step mutual aid programs is free. There are no membership dues or fees, no professionals, and the only requirement for membership is a desire to stop drinking or using [19]. The program is totally self-supported by its members’ contributions collected at each meeting. A dollar or two is typical, but not required. Newcomers and those who do not identify as members are usually asked not to contribute. Finally, healthcare costs are substantially reduced for those who participate in 12-step programs. In their systematic review, Kelley and colleagues demonstrated higher healthcare cost savings for individuals treated with AA or Twelve Step Facilitation (TSF) compared to those treated in an outpatient facility utilizing CBT, or no AA/TSF exposure [1]. Further, for those with a poor prognosis, AA/TSF had higher cost savings compared to Motivational Enhancement Therapy.
The final and maybe most important strength of the program discussed here concerns science. Several 12-step activities are supported by research. Though provision of a comprehensive review is not possible here, two empirically supported activities are highlighted. The first, helping others, is the primary purpose of the 12-step programs and is underscored in Tradition five, “Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.” Supported by a substantial scientific literature, personal well-being is enhanced by helping behaviors [46, 47, 48, 49], and 12-step mutual aid recovery is founded on the principle of service. A common evidence-based practice for SUDs, contingency management [50], where rewards and incentives are provided to help reinforce abstinence and other health promoting behaviors, is exemplified in nearly every 12-step meeting. Through the chip system in AA or the key tag system often used in NA, members are recognized with a different colored chip or key tag for each marker of recovery, typically followed by a round of applause from the group. For example, if an NA member achieves 30 days of continued abstinence, they receive an orange key tag, 60 days is green, 90 days is red, blue is for 6-months, green for 9-months, and a glow in the dark key tag is awarded for one year clean. For members who attain multiple years of recovery, they often receive a special medallion.
Culture has been defined as “a community or society. It structures the way people view the world. It involves the particular set of beliefs, norms, and values concerning the nature of relationships, the way people live their lives, and the way people organize their environments” [51], p.11. Additionally, culture includes the many cultural identities one holds in terms of ethnicity, gender, sexual orientation, age, socioeconomic status, geographic region, etc. Narcotics Anonymous is one of the most culturally diverse mutual aid programs, and this seems to be generalizable across the globe [2]. An important question to consider is this: Are there cultural considerations relative to 12-step philosophy and who may, and may not, fare well with the approach?
A key element of cultural beliefs, values, and norms is spirituality. In addition to examining spirituality as cultural element, this discussion provides a contradictory view of a primary criticism of 12-step programs, the religious and spiritual undertones. Abraham Maslow, noted psychologist and theorist, said “the spiritual life is part of the human essence. It is a defining characteristic of human nature, without which human nature is not fully human.” In a large survey conducted by the Pew Research Center, nearly 90% of survey respondents reported belief in God or a Universal Spirit [52]. Spirituality and religion seem to be in the fabric of many cultures. Based on data from the Higher Power Project, Dossett suggests that helping professionals need not be wary of referring individuals and families to 12-step programs, and in fact may want to consider supporting individuals and families in seeking recovery through 12-step programs [53]. Participants in the HHP consistently report the notion of “autonomous and personal construction of a Higher Power which works for them” [53], p. 380. Koenig [35] underscores the importance of allowing individuals to define spirituality for themselves. Findings consistently show that those who attend 12-step meetings regularly and actively participate in the program have better substance use and quality of life outcomes [53, 54].
While much of the criticism of 12-step programs surrounds language that may be interpreted as oppressive, a substantial literature exists that contradicts the criticisms. Though a comprehensive cultural review is not possible here, the following discussion highlights several population groups that have historically experienced oppression or may experience unique issues in terms of SUD recovery. The author would be remiss to fail to mention that culture is subjectively experienced, and there are substantial differences within groups as well as between groups. Maintaining cultural humility [55] is always recommended. The discussion that follows highlights several special population groups and associated findings relative to 12-step recovery: African Americans, Native Americans, women, adolescents, and LGBTQ populations.
In general, African American communities highly value spirituality and religion. Consequently, the topic of spirituality provides a smooth transition into the examination of the African American culture relative to 12-step programs. Peavy, Garret, Doyle, and Donovan compared outcomes of 12-step facilitation treatment between African American and Caucasian stimulant users and found treatment was equally effective for both groups [56]. One study found that African Americans were just as likely to attend and benefit from 12-step group attendance as their White counterparts and were slightly more likely to remain abstinent [57]. Another study explored spirituality among African American men attending a methadone maintenance program. The group of 25 men all reported a group focused on spirituality would be preferable to treatment as usual [58]. Given the spiritual foundation of 12-step programs, African American individuals with SUDs may derive great benefit from AA/NA.
While valid criticisms exist relative to women and 12-step programs, there is also substantial literature to support the efficacy of 12-step approaches for women. As highlighted in the introduction, women make up approximately 42% of NA membership and 38% of AA’s membership. According to some authors, 12-step programs are equally effective for women and people of color compared to their European-Male counterparts. For example, Hillhouse and Fiorentine found that women were just as likely to attend 12-step groups and recover as their White male counterparts [57]. Data were analyzed from the Los Angeles Target Cities Evaluation Project (n = 356), inclusive of 26 outpatient programs. Participants were followed for 2-years. At each of three follow-up points in the study, over 50% of participants identified as female, and no statistically significant differences were found between men and women. Moreover, approximately 35% of women reported weekly attendance at a 12-step meeting, and 30% of men reported weekly attendance. Men and women were equally likely to be abstinent at the 2-year follow-up, but women were slightly more likely to be abstinent from alcohol than were men; however, this finding was not statistically significant. Further, women and men were equally likely to dropout, 33.1% and 33.2% respectively. As a bridge into the next section, gender difference was compared among a sample of urban Native American individuals with SUDs as well, and none were found. Men and women in this sample experienced AA-related benefits equally, and 12-step meeting attendance helped to explain increased abstinence for both groups. For those who prefer gender specific 12-step meetings, there is availability in many areas.
There are more than 566 recognized Native American tribes in the U.S., and as a cultural group, Native Americans have experienced significant historical trauma and harms relative substance use and addiction. Some of the highest rates of substance use disorders are found among this population group. For example, SAMHSA reports that American Indian/Native Alaskans have the highest rates of alcohol misuse compared to other cultural groups [51]. Because a frequently cited value of this community is spirituality, 12-step mutual aid groups may be effective for Native Americans with SUDs [26]. However, research is quite limited specific to the efficacy of 12-step programs among Indigenous populations.
Although there has been speculation that cultural factors may render 12-step programs less effective for Native Americans, some studies have contradicted that assumption. One study, longitudinal in design, compared 12-step group attendance, attrition, and abstinence outcomes between urban Native Americans and White Americans [59]. The authors found no significant differences between meeting attendance and abstinence outcomes at 3-, 6-, and 9-month follow-ups. Decreased drinking intensity and increased abstinence was associated with greater meeting attendance for both groups. Interestingly, Native American participants were less likely to decrease meeting attendance. A more recent study relative to benefits experienced by urban Native Americans who attended AA also found benefit for those who attended 12-step groups relative to positive drinking outcomes [60].
Before concluding this section, the Wellbriety Movement deserves mention. It is described as “a sustainable grassroots movement that provides culturally based healing for the next seven generations of Indigenous people” [61]. Though an oversimplification, Wellbriety is an integration of traditional 12-step philosophy and Native cultural practices, such as the Medicine Wheel. Currently, an estimated 175 Wellbriety meetings exist in the U.S.
As a cultural group, adolescents with SUDs likely have the strongest need for social connection, and one benefit of 12-step program involvement is just that - mutual aid group communities provide instant access to sober social support. Multiple studies show that adolescents benefit from 12-step program involvement [5, 33, 62, 63, 64]. Because teens are more susceptible to peer influence and identification, they appear to benefit more from youth-focused 12-step groups, and like adults, teens seem to have improved SUD outcomes with increased participation in 12-step-activities [64, 65]. There are several barriers for adolescents noted in the literature: lack of transportation, resistance to the 12-steps, and the idea of powerlessness [65]. Kingston, Knight, Williams, and Gordon build on ideas set forth by Nash: adolescents may not only reject the notion of powerlessness but also the idea of a Higher Power [66]. Overall, however, there is substantial research to support the consideration of 12-step models for treating adolescents with SUDs [1, 2, 65, 67].
Given the fact that as a cultural group, sexual minorities have high rates of substance misuse and SUDs, it is surprising that so little research exists specific to this population and 12 step recovery programs. In fact, SAMHSA suggests this cultural group has about a 30% prevalence rate of SUDs [68]. As a cultural group, sexual minorities tend to be highly stigmatized, which may contribute to higher rates of SUDs. For this reason, 12-step groups specific to the LGBTQ population are steadily increasing. For clients wishing to attend an LGBTQ specific AA group, Gay and Lesbian AA (GaL-AA) is an excellent resource and provides a meeting list for all LGBTQ AA meetings nationwide [69]. Narcotics Anonymous does not have an equivalent resource, but an internet search will locate LGBTQ NA meetings.
Nearly half of people with an SUD also have a co-morbid psychiatric condition [70]. According to SAMHSA, people with SUDs are twice as likely than the general population to experience mood and anxiety disorders, and anti-social and conduct disorders [71]. Further, about 50% of those diagnosed with schizophrenia will develop an SUD over their lifetime. So, how do those with co-occurring disorders fare in 12-step programs? According to Project Match, those with more psychiatric severity did less well in 12-step approaches compared to cognitive behavioral interventions [27].
Mutual aid groups utilizing the 12-step framework and specific to those with co-occurring SUDs and mental health disorders are becoming more common. One such group, Double Trouble in Recovery (DTR), seems to provide an extra layer of comfort and emotional safety for members when sharing about both conditions, SUD, and mental illness [72, 73, 74]. Dual Recovery Anonymous (DRA) is a similar program that also follows the 12-steps. There are meetings located in each of the United States as well as Australia, Canada, Iceland, India, and New Zealand [75]; yet there is an absence of scholarly literature relative to its efficacy. The factors that appear to support recovery via 12-step affiliation for those with co-morbid conditions are identification, emotional safety, social support, and increased abstinence [72, 73, 74]. Because this group tends to have higher rates of relapse [76], referral to these specialty groups in addition to traditional 12-step groups is suggested.
With such a strong literature supporting the efficacy of 12-step programs for individuals with SUDs, inclusion of 12-step approaches in the menu of therapeutic options for clients is warranted. From their comprehensive review on Narcotics Anonymous, White and colleagues underscore three salient findings [2]:
Much like Duncan and colleagues describe allegiance to a therapeutic model as an important factor influencing therapeutic outcomes [77], clinicians’ beliefs regarding 12-step recovery matters, and may influence client participation and outcomes.
Successful linkage is crucial. Utilize assertive connection strategies rather than passive ones.
When clients are linked with 12-step groups while in treatment, their post-treatment attendance and participation increases.
Integrate 12-step recovery as a topic for psychoeducation in group or individual sessions.
Clinicians should educate themselves about 12-step programs, not just via academic literature, but attendance at
Reach out to local AA and NA communities and coordinate to bring a meeting to your facility, or to locate individual members willing to come in and speak to clients and patients at your facility.
Place 12-step literature and meetings lists in the waiting area of your facility or in your office.
As appropriate, integrate 12-step group attendance into the change plan.
Utilize Twelve Step Facilitation (TSF) in your agency among other evidence-based models.
Monitor mutual aid group attendance as a relapse prevention technique rather than a punitive strategy.
With individuals for whom 12-step approaches are not a good fit, refer to alternative mutual aid groups (SMART, Women for Sobriety, Moderation Management, Dharma Recovery, and many others). Though the empirical evidence is still lacking for 12-step alternatives, similar mechanisms of action are likely at work.
As the chapter closes, it ends where it began, with the most rigorous scientific studies to date, and the main findings are presented here. Kelley and colleagues [1] examined 12-step mutual aid groups and professional therapeutic models based on 12-step philosophy, such as Twelve Step Facilitation (TSF), and their impact on SUD-related outcomes: “abstinence, reduced drinking intensity, reduced alcohol-related consequences, alcohol addiction severity, and healthcare cost offset” [1], p. 1. Twenty-seven studies and 10,536 study participants are included in the review.
The main findings for manualized AA/TSF intervention groups follow. Compared to the clinical intervention groups (e.g., CBT), AA/TSF participants demonstrated higher rates of complete abstinence, and this effect held over time. Further, AA/TSF interventions performed equally to the clinical intervention relative to percentage of days abstinent, but at 24 months performed better. AA/TSF appears to be equally effective to comparison groups in terms of longest period of abstinence. Another equal comparison was shown regarding intensity of drinking and number of drinks per drinking day. For alcohol-related consequences, AA/TSF does just as well as comparison groups, and may also perform equally in terms of reducing alcohol use severity, with one study showing better outcomes for AA/TSF.
Findings for non-manualized 12-step interventions are just as good. At 3 to 9 months follow-up, AA/TSF appears to perform as well as comparison groups in terms of the proportion of individuals completely abstinent but may perform slightly better than the clinical intervention for percentage of days abstinent. Regarding drinking intensity and percentage of heavy drinking days, AA/TSF also performed as well as the clinical intervention.
The review conducted by White and colleagues asked, “what is known about Narcotics Anonymous from the standpoint of science?” [2], p. 3. Included in their review were 232 studies. Though the scientific literature on NA needs more rigorous and methodologically sound study, so far it appears to mirror the evidence of AA’s efficacy. Researchers from this review concluded that participation in NA contributes to increased abstinence and decreased substance use. Physical, mental, and spiritual health is improved, and improvement in overall social functioning seems to occur for many members. Decreased healthcare costs, increased self-esteem, improved coping, increased pro-recovery social networks, and decreased depression and anxiety are also benefits experienced by some NA members. Additionally, participation in activities such as reading NA literature, working the steps, service, and sponsorship appear to extend the benefits. According to the review, diverse sub-groups of people with SUDs may also benefit from NA; in particular, people of color, women, adolescents, and those with co-occurring mental health conditions.
The evidence for the efficacy of 12-step interventions is compelling. Not only is the research compelling, but 12-step programs also have an interesting history. Millions of individuals have experienced addiction recovery through 12-step pathways and have intimately experienced its transformational power. Organizations are unsustainable without leaders, structure, organization, funding, profits, or grants. Yet, the 12 traditions include ideas such as these: the program should have no leaders, no initiation dues, or fees; the program should remain forever non-professional; and, the program ought never be organized. Even so, and for over 85 years, 12-step programs across the globe have helped millions of people achieve recovery. It is unfathomable the 12-step movement has thrived without a traditional organizational structure. The 12-step organizational structure is built on spiritual principles, 12-steps, and the fundamental idea of one addict/alcoholic helping another. The 12-step movement revolutionized professional treatment services and has been tested across numerous populations. Scientific literature consistently demonstrates 12-step interventions to be equal in efficacy compared to common evidence-based models, and sometimes they perform even better than the intervention for which they are compared. 12-step groups can serve as an adjunctive service to professional addiction treatment to extend treatment benefits; and for some, 12-step groups may be the primary mode of intervention. In addition to its demonstrated efficacy, 12-step meetings are abundant, making accessibility a minimal concern. Finally, because 12-step meetings are free, it is quite cost-effective. In closing, clinicians should consider adding 12-step interventions to their clinical toolbox if they have not already done so. The science is out.
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\n\nWhen ordering our books from the countries listed below, please provide an alternative mailing address. For any further assistance, please contact us at orders@intechopen.com.
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\n\nInspect your order carefully when it arrives. Any problems should be immediately reported to orders@intechopen.com.
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\n\nOur books are available at our direct Print Sales Department and through selected representatives throughout the world.
\n\nBooks International
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Currently, there are many commercial Geographic Information System (GIS) or statistics software offering spatial interpolation functions, such as inverse distance weighted (IDW), kriging, spline, and others. To date, there is no “rule of thumb” on the most appropriate spatial interpolation techniques for certain situations, though general suggestions have been published. Many studies rely on quantitative assessment to determine the performance of spatial interpolation techniques. Most quantitative assessment methods provide a numeric index for the overall performance of an interpolated surface. Although it is objective and convenient, there are many facts or trends not captured by quantitative assessments. This study used 2D visualization and 3D visualization to identify trends not evident in quantitative assessment. This study also presented a special case, a closed system in which all interpolated surfaces should sum up to 100%, to demonstrate the interaction between interpolated surfaces that were created separately and independently.",book:{id:"5241",slug:"applications-of-spatial-statistics",title:"Applications of Spatial Statistics",fullTitle:"Applications of Spatial Statistics"},signatures:"Yi-Hwa (Eva) Wu and Ming-Chih Hung",authors:[{id:"181853",title:"Dr.",name:"Yi-Hwa",middleName:null,surname:"Wu",slug:"yi-hwa-wu",fullName:"Yi-Hwa Wu"}]},{id:"69962",doi:"10.5772/intechopen.90039",title:"Nanosatellites and Applications to Commercial and Scientific Missions",slug:"nanosatellites-and-applications-to-commercial-and-scientific-missions",totalDownloads:1617,totalCrossrefCites:8,totalDimensionsCites:17,abstract:"In the past two decades, a silent revolution has taken place in the space domain, leading to what today is known as “New Space.” We have passed from a selected group of countries, space agencies, and big industries building, launching, and operating satellites and other spacecrafts, of a scenario in which many universities and research institutes can do it. The key of this was the definition of the “CubeSat” standard, back to 1999. In 2013, it all took off on the commercial Earth Observation sector with the first launches from two companies that are now running 100+ CubeSat constellations for optical imaging or weather prediction, with very low revisit times. Today, the same revolution is taking place in the fields of Telecommunications, and Astronomical Scientific missions. In this chapter, the evolution of the space sector is briefly revised until the arrival of the CubeSats. Then, the CubeSat intrinsic limitations are discussed as they are key to understand the development and current situation of the CubeSat sector. NASA and ESA strategies are also presented. The chapter concludes with a summary of the technology roadmap to enable the next generation of CubeSat-based missions, including satellite constellations or federations, formation flying, synthetic apertures…",book:{id:"9246",slug:"satellites-missions-and-technologies-for-geosciences",title:"Satellites Missions and Technologies for Geosciences",fullTitle:"Satellites Missions and Technologies for Geosciences"},signatures:"Adriano Camps",authors:[{id:"299991",title:"Prof.",name:"Adriano",middleName:null,surname:"Camps",slug:"adriano-camps",fullName:"Adriano Camps"}]},{id:"67603",doi:"10.5772/intechopen.86596",title:"The Color of Water from Space: A Case Study for Italian Lakes from Sentinel-2",slug:"the-color-of-water-from-space-a-case-study-for-italian-lakes-from-sentinel-2",totalDownloads:1135,totalCrossrefCites:8,totalDimensionsCites:10,abstract:"Lakes are inestimable renewable natural resources that are under significant pressure by human activities. Monitoring lakes regularly is necessary to understand their dynamics and the drivers of these dynamics to support effective management. Remote sensing by satellite sensors offers a significant opportunity to increase the spatiotemporal coverage of environmental monitoring programs for inland waters. Lake color is a water quality attribute that can be remotely sensed and is independent of the sensor specifications and water type. In this study we used the Multispectral Imager (MSI) on two Sentinel-2 satellites to determine the color of water of 170 Italian lakes during two periods in 2017. Overall, most of the lakes appeared blue in spring and green-yellow in late summer, and in particular, we confirm a blue-water status of the largest lakes in the subalpine ecoregion. The color and its seasonality are consistent with characteristics determined by geomorphology and primary drivers of water quality. This suggests that information about the color of the lakes can contribute to synoptic assessments of the trophic status of lakes. Further ongoing research efforts are focused to extend the mapping over multiple years.",book:{id:"7304",slug:"geospatial-analyses-of-earth-observation-eo-data",title:"Geospatial Analyses of Earth Observation (EO) data",fullTitle:"Geospatial Analyses of Earth Observation (EO) data"},signatures:"Claudia Giardino, Kerttu-Liis Kõks, Rossano Bolpagni, Giulia Luciani, Gabriele Candiani, Moritz K. Lehmann, Hendrik Jan Van der Woerd and Mariano Bresciani",authors:[{id:"292340",title:"Dr.",name:"Claudia",middleName:null,surname:"Giardino",slug:"claudia-giardino",fullName:"Claudia Giardino"},{id:"300416",title:"Ms.",name:"Kerttu-Liis",middleName:null,surname:"Kõks",slug:"kerttu-liis-koks",fullName:"Kerttu-Liis Kõks"},{id:"300418",title:"Dr.",name:"Rossano",middleName:null,surname:"Bolpagni",slug:"rossano-bolpagni",fullName:"Rossano Bolpagni"},{id:"300419",title:"Dr.",name:"Giulia",middleName:null,surname:"Luciani",slug:"giulia-luciani",fullName:"Giulia Luciani"},{id:"300420",title:"Dr.",name:"Gabriele",middleName:null,surname:"Candiani",slug:"gabriele-candiani",fullName:"Gabriele Candiani"},{id:"300421",title:"Dr.",name:"Moritz K.",middleName:null,surname:"Lehmann",slug:"moritz-k.-lehmann",fullName:"Moritz K. Lehmann"},{id:"300423",title:"Dr.",name:"Mariano",middleName:null,surname:"Bresciani",slug:"mariano-bresciani",fullName:"Mariano Bresciani"},{id:"305861",title:"Dr.",name:"Hendrik",middleName:"Jan",surname:"Van Der Woerd",slug:"hendrik-van-der-woerd",fullName:"Hendrik Van Der Woerd"}]},{id:"70180",doi:"10.5772/intechopen.90115",title:"The Impact of Space Radiation Environment on Satellites Operation in Near-Earth Space",slug:"the-impact-of-space-radiation-environment-on-satellites-operation-in-near-earth-space",totalDownloads:1238,totalCrossrefCites:6,totalDimensionsCites:10,abstract:"Energetic particles and electromagnetic radiation (EM) from solar events and galactic cosmic rays can bombard and interact with satellites’ exposed surfaces, and sometimes possess enough energy to penetrate their surface. Among other known effects, the scenario can cause accelerated orbit decay due to atmospheric drag, sporadic and unexplainable errors in functions of sensitive parts, degradation of critical properties of structural materials, jeopardy of flight worthiness, transient and terminal health hazard to both onboard passengers and astronauts, and sometimes a catastrophic failure that can abruptly end satellite mission. The understanding of the dynamics of the space radiation environment and associated effects is critically important for satellites design and operation in ionospheric plasma environment, in which satellites are designed to function. In this chapter we review some satellite anomalies associated with the space radiation environment and conclude with mitigation effort that can reduce such impact.",book:{id:"9246",slug:"satellites-missions-and-technologies-for-geosciences",title:"Satellites Missions and Technologies for Geosciences",fullTitle:"Satellites Missions and Technologies for Geosciences"},signatures:"Victor U. J. Nwankwo, Nnamdi N. Jibiri and Michael T. Kio",authors:[{id:"94563",title:"Dr.",name:"Nnamdi",middleName:null,surname:"Jibiri",slug:"nnamdi-jibiri",fullName:"Nnamdi Jibiri"},{id:"300878",title:"Dr.",name:"Victor",middleName:null,surname:"Nwankwo",slug:"victor-nwankwo",fullName:"Victor Nwankwo"},{id:"310318",title:"Dr.",name:"Michael",middleName:null,surname:"Kio",slug:"michael-kio",fullName:"Michael Kio"}]},{id:"64204",doi:"10.5772/intechopen.81955",title:"GIS and Remote Sensing for Mangroves Mapping and Monitoring",slug:"gis-and-remote-sensing-for-mangroves-mapping-and-monitoring",totalDownloads:2341,totalCrossrefCites:6,totalDimensionsCites:9,abstract:"Malaysia is one of the few South East Asian counties with large tracts of mangroves. They provide ecosystem goods and services to the environment and the surroundings regarding shoreline stabilization, storm protection, water quality maintenance, micro-climate stabilization, recreation, tourism, fishing and supply of various forest products. Despite extensive distribution of the mangroves, threats posed by different land use activities are inevitable. Therefore, knowledge on mangroves distribution and change is importance for effective management and making protection policies. Although remote sensing (RS) and geographic information system (GIS) has been widely used to characterize and monitor mangroves change over a range of spatial and temporal scales, studies on mangroves change in Malaysia is lacking. Effective mangrove management is vital via acquiring knowledge on forest distribution and changes to establish protection policies. This chapter will elaborate technically how GIS and RS were utilized to identify, map, and monitor changes of mangroves ecosystem in Malaysia. It also highlights how GIS can enhance the current governance and regulations related to forestry in Malaysia.",book:{id:"7362",slug:"geographic-information-systems-and-science",title:"Geographic Information Systems and Science",fullTitle:"Geographic Information Systems and Science"},signatures:"Hamdan Omar, Muhamad Afizzul Misman and Samsudin Musa",authors:[{id:"264176",title:"Dr.",name:"Hamdan",middleName:null,surname:"Omar",slug:"hamdan-omar",fullName:"Hamdan Omar"},{id:"272549",title:"Mr.",name:"Muhamad Afizzul",middleName:null,surname:"Misman",slug:"muhamad-afizzul-misman",fullName:"Muhamad Afizzul Misman"},{id:"272550",title:"Dr.",name:"Samsudin",middleName:null,surname:"Musa",slug:"samsudin-musa",fullName:"Samsudin Musa"}]}],mostDownloadedChaptersLast30Days:[{id:"73592",title:"A Review of the Machine Learning in GIS for Megacities Application",slug:"a-review-of-the-machine-learning-in-gis-for-megacities-application",totalDownloads:905,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"Machine learning (ML) is very useful for analyzing data in many domains, including the satellite images processing. In the remote sensing data processing, ML tools are mainly founded out a place for filtering, interpretation and prediction information. Filtering aims at removing noise and performing transformations, which is vital segment of data processing as useful performance of data validation. An interpretation is significant part of it as the stage of objects classification depends of existing task for solution. Prediction is performed to estimate precise values of underlying parameters or future events in the data. It can be used successfully above achievements in a variety of areas. An urbanization is one of the spheres of advance technology application where highly need to collect appropriate data for understanding of challenges facing society. The process of urbanization becomes very important problem, thanks to city expansion. Each city is a complicated system. It consists of various interactive sub-systems and is affected by multiple factors, including population growth, transportation and management policies. To understand the driving forces of the urban structure change, the satellite-based estimates are considered to monitor these changes, in long term. GIS (geographic information system) is equivalent to methods related to the use of geospatial information. Besides, the increasing application of ML techniques in various fields, including GIS, is undeniable. Thus, the chapter attempts to review the application of ML techniques in GIS with a focus on megacities and theirs features fixing/identification and solution.",book:{id:"9381",slug:"geographic-information-systems-in-geospatial-intelligence",title:"Geographic Information Systems in Geospatial Intelligence",fullTitle:"Geographic Information Systems in Geospatial Intelligence"},signatures:"Nasim Tohidi and Rustam B. Rustamov",authors:[{id:"59174",title:"Dr.",name:"Rustam B.",middleName:null,surname:"Rustamov",slug:"rustam-b.-rustamov",fullName:"Rustam B. Rustamov"},{id:"317547",title:"Dr.",name:"Nasim",middleName:null,surname:"Tohidi",slug:"nasim-tohidi",fullName:"Nasim Tohidi"}]},{id:"64204",title:"GIS and Remote Sensing for Mangroves Mapping and Monitoring",slug:"gis-and-remote-sensing-for-mangroves-mapping-and-monitoring",totalDownloads:2336,totalCrossrefCites:6,totalDimensionsCites:9,abstract:"Malaysia is one of the few South East Asian counties with large tracts of mangroves. They provide ecosystem goods and services to the environment and the surroundings regarding shoreline stabilization, storm protection, water quality maintenance, micro-climate stabilization, recreation, tourism, fishing and supply of various forest products. Despite extensive distribution of the mangroves, threats posed by different land use activities are inevitable. Therefore, knowledge on mangroves distribution and change is importance for effective management and making protection policies. Although remote sensing (RS) and geographic information system (GIS) has been widely used to characterize and monitor mangroves change over a range of spatial and temporal scales, studies on mangroves change in Malaysia is lacking. Effective mangrove management is vital via acquiring knowledge on forest distribution and changes to establish protection policies. This chapter will elaborate technically how GIS and RS were utilized to identify, map, and monitor changes of mangroves ecosystem in Malaysia. It also highlights how GIS can enhance the current governance and regulations related to forestry in Malaysia.",book:{id:"7362",slug:"geographic-information-systems-and-science",title:"Geographic Information Systems and Science",fullTitle:"Geographic Information Systems and Science"},signatures:"Hamdan Omar, Muhamad Afizzul Misman and Samsudin Musa",authors:[{id:"264176",title:"Dr.",name:"Hamdan",middleName:null,surname:"Omar",slug:"hamdan-omar",fullName:"Hamdan Omar"},{id:"272549",title:"Mr.",name:"Muhamad Afizzul",middleName:null,surname:"Misman",slug:"muhamad-afizzul-misman",fullName:"Muhamad Afizzul Misman"},{id:"272550",title:"Dr.",name:"Samsudin",middleName:null,surname:"Musa",slug:"samsudin-musa",fullName:"Samsudin Musa"}]},{id:"67603",title:"The Color of Water from Space: A Case Study for Italian Lakes from Sentinel-2",slug:"the-color-of-water-from-space-a-case-study-for-italian-lakes-from-sentinel-2",totalDownloads:1129,totalCrossrefCites:8,totalDimensionsCites:10,abstract:"Lakes are inestimable renewable natural resources that are under significant pressure by human activities. Monitoring lakes regularly is necessary to understand their dynamics and the drivers of these dynamics to support effective management. Remote sensing by satellite sensors offers a significant opportunity to increase the spatiotemporal coverage of environmental monitoring programs for inland waters. Lake color is a water quality attribute that can be remotely sensed and is independent of the sensor specifications and water type. In this study we used the Multispectral Imager (MSI) on two Sentinel-2 satellites to determine the color of water of 170 Italian lakes during two periods in 2017. Overall, most of the lakes appeared blue in spring and green-yellow in late summer, and in particular, we confirm a blue-water status of the largest lakes in the subalpine ecoregion. The color and its seasonality are consistent with characteristics determined by geomorphology and primary drivers of water quality. This suggests that information about the color of the lakes can contribute to synoptic assessments of the trophic status of lakes. Further ongoing research efforts are focused to extend the mapping over multiple years.",book:{id:"7304",slug:"geospatial-analyses-of-earth-observation-eo-data",title:"Geospatial Analyses of Earth Observation (EO) data",fullTitle:"Geospatial Analyses of Earth Observation (EO) data"},signatures:"Claudia Giardino, Kerttu-Liis Kõks, Rossano Bolpagni, Giulia Luciani, Gabriele Candiani, Moritz K. Lehmann, Hendrik Jan Van der Woerd and Mariano Bresciani",authors:[{id:"292340",title:"Dr.",name:"Claudia",middleName:null,surname:"Giardino",slug:"claudia-giardino",fullName:"Claudia Giardino"},{id:"300416",title:"Ms.",name:"Kerttu-Liis",middleName:null,surname:"Kõks",slug:"kerttu-liis-koks",fullName:"Kerttu-Liis Kõks"},{id:"300418",title:"Dr.",name:"Rossano",middleName:null,surname:"Bolpagni",slug:"rossano-bolpagni",fullName:"Rossano Bolpagni"},{id:"300419",title:"Dr.",name:"Giulia",middleName:null,surname:"Luciani",slug:"giulia-luciani",fullName:"Giulia Luciani"},{id:"300420",title:"Dr.",name:"Gabriele",middleName:null,surname:"Candiani",slug:"gabriele-candiani",fullName:"Gabriele Candiani"},{id:"300421",title:"Dr.",name:"Moritz K.",middleName:null,surname:"Lehmann",slug:"moritz-k.-lehmann",fullName:"Moritz K. Lehmann"},{id:"300423",title:"Dr.",name:"Mariano",middleName:null,surname:"Bresciani",slug:"mariano-bresciani",fullName:"Mariano Bresciani"},{id:"305861",title:"Dr.",name:"Hendrik",middleName:"Jan",surname:"Van Der Woerd",slug:"hendrik-van-der-woerd",fullName:"Hendrik Van Der Woerd"}]},{id:"66971",title:"Introductory Chapter: Geographic Information Systems and Science",slug:"introductory-chapter-geographic-information-systems-and-science",totalDownloads:1020,totalCrossrefCites:1,totalDimensionsCites:1,abstract:null,book:{id:"7362",slug:"geographic-information-systems-and-science",title:"Geographic Information Systems and Science",fullTitle:"Geographic Information Systems and Science"},signatures:"Cláudia M. Viana, Patrícia Abrantes and Jorge Rocha",authors:[{id:"145918",title:"Ph.D.",name:"Jorge",middleName:null,surname:"Rocha",slug:"jorge-rocha",fullName:"Jorge Rocha"},{id:"149241",title:"Prof.",name:"Patricia",middleName:null,surname:"Abrantes",slug:"patricia-abrantes",fullName:"Patricia Abrantes"},{id:"192917",title:"Dr.",name:"Cláudia",middleName:"M.",surname:"Viana",slug:"claudia-viana",fullName:"Cláudia Viana"}]},{id:"70180",title:"The Impact of Space Radiation Environment on Satellites Operation in Near-Earth Space",slug:"the-impact-of-space-radiation-environment-on-satellites-operation-in-near-earth-space",totalDownloads:1236,totalCrossrefCites:6,totalDimensionsCites:10,abstract:"Energetic particles and electromagnetic radiation (EM) from solar events and galactic cosmic rays can bombard and interact with satellites’ exposed surfaces, and sometimes possess enough energy to penetrate their surface. Among other known effects, the scenario can cause accelerated orbit decay due to atmospheric drag, sporadic and unexplainable errors in functions of sensitive parts, degradation of critical properties of structural materials, jeopardy of flight worthiness, transient and terminal health hazard to both onboard passengers and astronauts, and sometimes a catastrophic failure that can abruptly end satellite mission. The understanding of the dynamics of the space radiation environment and associated effects is critically important for satellites design and operation in ionospheric plasma environment, in which satellites are designed to function. 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He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}},{id:"338856",title:"Mrs.",name:"Nur Alvira",middleName:null,surname:"Pascawati",slug:"nur-alvira-pascawati",fullName:"Nur Alvira Pascawati",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universitas Respati Yogyakarta",country:{name:"Indonesia"}}},{id:"441116",title:"Dr.",name:"Jovanka M.",middleName:null,surname:"Voyich",slug:"jovanka-m.-voyich",fullName:"Jovanka M. Voyich",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Montana State University",country:{name:"United States of America"}}},{id:"330412",title:"Dr.",name:"Muhammad",middleName:null,surname:"Farhab",slug:"muhammad-farhab",fullName:"Muhammad Farhab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"349495",title:"Dr.",name:"Muhammad",middleName:null,surname:"Ijaz",slug:"muhammad-ijaz",fullName:"Muhammad Ijaz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}}]}},subseries:{item:{id:"95",type:"subseries",title:"Urban Planning and Environmental Management",keywords:"Circular economy, Contingency planning and response to disasters, Ecosystem services, Integrated urban water management, Nature-based solutions, Sustainable urban development, Urban green spaces",scope:"