Differences between field epidemiology and clinical epidemiology.
\r\n\tThe objective of this book is to provide a state-of-the-art review of the use of timber in building construction from various perspectives, including manufacturing, fabrication, modeling, design, and construction of residential and other types of buildings. Of special interest will be contributions related to new developments in timber technologies, design, construction, testing, sustainability, LCA, building envelope, and the performance of timber buildings in natural and man-made hazard conditions.
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Memari",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/12057.jpg",keywords:"Wood, Lumber, Timber Industry, Home Building, Glue-Laminated Wood, Cross-Laminated Timber, Plywood, Fire Resistance, Sustainability, Fabrication, Panelized/Modular, Material Properties",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 31st 2022",dateEndSecondStepPublish:"June 28th 2022",dateEndThirdStepPublish:"August 27th 2022",dateEndFourthStepPublish:"November 15th 2022",dateEndFifthStepPublish:"January 14th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"6 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Memari is a Professor and Bernard and Henrietta Hankin Chair in Residential Building Construction in the Departments of Architectural Engineering and Civil and Environmental Engineering. During his 30 years of teaching in structural engineering, his research focused on the behavior of structural, architectural, and enclosure components of residential and commercial buildings under natural hazard loading and environmental conditions. He has published over 300 publications.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"252670",title:"Prof.",name:"Ali",middleName:null,surname:"M. Memari",slug:"ali-m.-memari",fullName:"Ali M. Memari",profilePictureURL:"https://mts.intechopen.com/storage/users/252670/images/system/252670.jpg",biography:"Dr. Memari is a Professor and Bernard and Henrietta Hankin Chair in Residential Building Construction in the Departments of Architectural Engineering and Civil and Environmental Engineering at Penn State, and Director of The Pennsylvania Housing Research Center. 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This way, it allows carrying out an integral management of the epidemiology, both communal and individual, which will finally result in preventive medicine and public health
\nClinical epidemiology has its application peak in the solution of treatment and management of diseases, contributing the identification of risk factors to certain illnesses and being to date the fundamental part of Evidence Based Medicine, and for that it becomes important the teaching of clinical epidemiology, for it will aid in the education of professionals with judicious capacity and rational use of the best alternatives in diagnostic and treatment, by means of a critical evaluation of the literature [5], as well as helping to stimulate the training of researchers, because it’s implied that the execution of the clinical epidemiology will lead to the development of research [6].
\nResearch development makes it necessary to use tools that will make research more efficient, such as GoogleDocs, ZOGO, OneNote, which allow to write and edit online texts, or scientific literature search engines that will let us find evidence for the sustain of our activities in the healthcare systems, and in some cases without even looking for them, like with the applications from Google Reader and the RSS/XML, or obtaining portals dedicated to Evidence Based Medicine, or programs such as the statistical calculator Epidat which can simplify our statistical analysis, without even mentioning the multiple statistical softwares available [7].
\nOther concepts to consider are social epidemiology, which have been gaining ground these last decades and backing up the analysis of the social determinants of health status. This approach has generated big expectation for its integration and multidisciplinary character, but it’s not free of skepticism that relates it with the idealism of a politics’ strategic instrument [8].
\nHowever, social epidemiology, like field of clinical epidemiology, is based on the positivist paradigm and uses the statistical methods as analysis foundation. Besides, it is important to mention that currently, it has been generated a whole new research line based on the approach of the social determinants, where it is critical the usage of multilevel statistical models and new technologies that pose a new challenge to young researchers [9].
\nAccording to what it is stated, the current medical science tendency is focused in the generation of evidence that contributed in its development and has an impact in the patients’ health. This approach, of EBM, is expressed mainly in the care, in relation to drugs and medical devices, though it is admitted that community interventions through Public Health deserve to be recognized as significant events that have had an impact in the population’s health [10]. In this way, it is necessary to recognize the existence of research that s directed to make evidence of the impact of Public Health’s diverse activities.
\nEvidence Based Public Health keeps the cause-effect logic, and allows adding the determinants of health, such as lifestyles, culture and environment, to the scientific context that often is what characterizes the good or bad execution of an intervention. Evidence Based Public Health is a new tendency that is joining efforts to offer the best information for an efficient politics decision making [11]. When it is oriented to the research of a population’s health issues whether in the community or the hospital sphere, it contributes remarkably to the solution of very different local and regional realities, thus making a progress in Public Health, especially in out developing countries.
\nEpidemiology is an old discipline with roots on scientific and rational structures, based on experience, on what is real. It is of great importance for Public Health and its impact for clinical medicine has risen in the last decades [12].
\nThe comparison between clinical epidemiology and field epidemiology may demonstrate similarities and differences that can result in a contribution to their final application, which is their common desire: the people’s health.
\nField epidemiology’s primary function is to identify the cause or source of infectious diseases’ outbreaks, containing its dissemination and organizing the infected patients’ treatment as soon as possible [3].
\nInformation obtaining and action are done «in the field», on the ground, namely, in the epidemic territory, there being a dominance of practice over theory. During an outbreak, the field epidemiologist works long hours until he has control over the outbreak. Another specific feature is that it is not only executed by doctors, but also by other specialties professionals, such as nurses, veterinarians, biologists, technicians, etc. [3].
\nThe Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET), founded in 1997 and currently located in 53 countries around the world, aims to strengthen, at an international level, the field epidemiologists’ capacity for Public Health [13]. In Peru, is has been developed the Field Epidemiology Residency Program (PREC), in order to train professionals in different specialties to act in their respect jurisdictions, challenging the lack of epidemiology specialists.
\nThis national Program had 4 stages: I Introduction to Epidemiology (2 months), II Basic Epidemiology (4 months), III Intermediate Epidemiology (6 months) and IV Specialized Epidemiology (12 months). The designated participants for each Regional Health Direction started to take the classes in their own offices, taught by specialists from the General Epidemiology Office and professors from a macro regional level University’s headquarters with on line tutoring, as well as field practices. Stages II and III were carried out in the University’s headquarters and the selection of the participants to continue on to the next stages were done with a pyramidal system, according to weighted averages and additional exams. The last stage was carried out only Lima-Peru, though it was still open to other provinces [14].
\nIt is discussed that field epidemiology would tend to action without a theoretical framework. This tendency would be based on its most direct reference: the Epidemic Intelligence Service (EIS) of the Center for Disease Control and Prevention (CDC) from the USA government, administrative body of military origin related to the intelligence service, which gives them a more attractive image than a function, closer to a secret agent directed towards the action, the protection of a community against a germ invasion, the avoidance of social alarm and insecurity on the population [4]. Field epidemiology executes its intervention on a daily basis in micro spaces, generally institutional: schools, restaurants, elderly residencies, hospitals whose services can present outbreaks, and uses conventional methods [15].
\nThacker SB and Buffington J., who belong to the CDC, call field epidemiology as the 21st century applied epidemiology, based on the philosophy of ‘learn by doing’, supervised by experienced epidemiologists on field research, database analysis, vigilance system evaluation, presenting and publishing scientific research and answering to public questions. On the other hand, it has to be directed toward action regarding the main Public Health problems, the reduction of social inequality, having a greater consideration for psychosocial elements of the illness process, the incorporation of contents and methods from social sciences and working in multidisciplinary teams [16].
\nIn the case of field or applied epidemiology, which is also denominated general epidemiology, it has as a feature the use of epidemiologic methods for the prevention of diseases and promotion of health in the populations, to achieve in an effective way the Public Health objectives, trying to apply a primary prevention.
\nIn 1938, Jean Paul coined the term clinical epidemiology, and defined it as: ‘a new basic science for preventive medicine’. Therefore, the practical application of clinical epidemiology is a key part of Evidence Based Medicine and clinical decision making [17]. Clinical epidemiology is a discipline that puts into practice the epidemiologic principles into the clinical environment, focusing on patients [18]. What characterizes it is the combination of epidemiologic methods with the objectives of social clinical activity, which are, a good diagnostic and treatment of the ill. The knowledge is integrated with what is obtained from a good bibliographic research and critical reading of scientific reading [1]. It is currently considered the cornerstone of Evidence Based Medicine.
\nClinical epidemiology is based mainly on its clinical trials, examining the diagnostic methods, discussing the prognosis, taking part in the evolution of treatments, trying to organize a controlled and randomized study opposite to sick people getting placebos or another indicated drug [1].
\nTruthfully, it was difficult to distinguish this activity from what would later be called as Evidence Based Medicine (EBM), term introduced in 1992 by the same group that, years before, had founded the discipline called Clinical Epidemiology (CE) [2].
\nHowever, both disciplines: field epidemiology and clinical epidemiology share the same methodology and tool, the difference relies on the place where these are applied (Table 1).
\n\n | \n
Differences between field epidemiology and clinical epidemiology.
The current medical approach must contemplate the application of clinical epidemiology in health establishments, for the benefit of patients, given that epidemiologic research, with its analytical designs and clinical trials, allow the progress in treatments and managements, as well as defining the quality of auxiliary exams ever more sophisticated by means of the test of tests design and its economic approach (cost-benefit, cost-utility, cost-effectiveness), without forgetting the general population. It is in the community where field epidemiology is applied, the descriptive studies of the population’s health situation with its analytical approaches to the Situational Health Analysis, the study of epidemic outbreaks and their respective intervention, as well as the posing of hygiene measurements and global prevention for a better quality of life and disease prevention. This way, an integral management is being carried out, both communal and individual, which will finally result in preventive medicine and public health.
\nDavid Sackett drew attention over the need to integrate the evidence with the clinical experience and the value of patients in the clinical decision making, referring to it as Clinical Epidemiology and defining it as: ‘
Clinical epidemiology aims for the production and identification of valid tests, and to its logical extension. It is EBM, which aims for the rational use of evidence in the individual diagnosis and treatment of patients [17]. Clinical Epidemiology represents the way in which classic epidemiology, traditionally directed to general strategies in the public health of communal groups,
Uses of Clinical Epidemiology.
Clinical epidemiology has perform a center role in 5 recent evolutions (some say revolutions) on the healthcare area: evidence generation, critical evaluation, efficient storage and recovery, evidence based medicine and evidence synthesis (Table 2).
\n\n | \n
Evolution of the Clinical Epidemiology (Sackett DL. 2000).
The effect of using epidemiologic principles has not been simply to improve the usage of clinical judgment and to eliminate the implicit element of epistemology from clinical reasoning. Arthur Elstein declared that decades of psychological research in decision making has demonstrated that: clinical judgment from experts was not as expert as we thought it was, that knowledge transference was more limited than we expected, and that judgment errors are not limited to medicine students nor are eradicated by experience, so that, them being the cognitive errors inherent to clinical reasoning, they can be aggravated through the dependency called ‘experts opinion’ [21].
\nIn 1992, Sackett DL. and Col. decided to substitute the term ‘Clinical Epidemiology’ for ‘Evidence Based Medicine’, meaning that every medical action of diagnosis, prognosis and therapy must be sustained in quantitative, solid proofs, based on the best epidemiologic and clinical research [21]. Thereby, Sacket DL., in one of the first definitions of EBM, he mentioned: ‘conscious, explicit and reasonable use of the best current evidence to make decisions regarding the care of individual patients’ [5].
\nSackett DL. mentions the dichotomous existence between the science of epidemiologic reasoning and the art of intuitive judgments of clinical epidemiology. He realized that the application of these epidemiologic principles (plus a bit more of biostatistics) to the beliefs, judgments and intuitions that make up for the art of medicine can considerably improve the accuracy and effectiveness of diagnosis and prognosis [21]. The practice of EBM means to integrate the individual clinical experience with the best external clinical evidence available from systematic research, and recently, in a paper published on 2000, it is described as: ‘the integration of the best research evidence, of clinical experience and the patients’ values’ [5]. Meanwhile, Cuestas E. defines it as ‘the discipline that takes care of the study of the happening of medical decisions regarding its determinants’ [22].
\nBroadly, clinical epidemiology takes care of the event of patients’, which range from the appearance of the disease to its result in the form of healing, sequels or death. Therefore, the study subjects are ill people who are normally found in health establishments, and their contribution is relevant, especially for diagnosis and secondary and third prevention of the disease.
\nClinical epidemiology can be divided into descriptive and analytical. The descriptive part is focused on the variation of clinical prognosis, whereas the analytical is focused on the reasons for this variation, that is to say, the main predictors for the prognosis, diagnosis and treatment, which are key concepts in the clinical epidemiology and the practice of clinical medicine (Figure 2). Also, demographic epidemiology is largely directed to the general population, whereas clinical epidemiology is more focused on the individual [23] (Figure 1).
\nActual medicine, clinical medicine and clinical epidemiology
The EBM is driven by the need of confront the surplus of information and the medical practice, the patient’s demand for the best diagnosis and treatment, y by the cost control, being known that the world tendency is the rise of costs in healthcare, leading to a stimulus of the critical evaluation of laboratory tests as an attempt for the best use of the limited resources. That means to realize a cost-benefit analysis [5]. In the last years, clinical epidemiology has become ‘very important’ for the health system, due to the need to perform evaluations in the quality of care, patient’s security, health economy and resource usage areas. All these aspects are based on clinical epidemiology’s thinking [23].
\nNowadays, there have been many misunderstandings about EBM, which arise because it has been adopted by functionaries and academicians in Public Health, and by health managers, who for better or for worse, are ‘too far from patients’, giving interpretations like ‘they remain sitting comfortably in their desks’, ‘they manage abusively and without a criteria, telling clinical doctors how to treat the patients in cost-effective ways’…; points of view far from what was originally planned for the integral approach of clinical practice and clinical epidemiology [24].
\nInteractions of the Clinical Epidemiology.
But we also need to bear in mind that the EBM is not a ‘cookbook’, like some think, for it requires the integration of the best external evidence with the individual professional experience and the patient’s choice; the clinical evidence may inform but cannot substitute the individual clinical experience. This knowledge is necessary to evaluate if the external evidence can be applied to the individual subject to decide how to improve the patient’s clinical results (Figure 3). In the same manner, the use of EBM as a ‘cost reducing’ medicine is a misunderstanding, because doctors who practice the EBM, identify and apply the more efficient interventions to achieve the best in terms of patient’s quality of life, might increase the cost of healthcare instead of reducing it [5].
\nClinical Medicine, Clinical Epidemiology and EBM have been widely promoted as an improvement in patient’s healthcare [25]. For that, doctors must be capable of showing the patient the therapeutic options for a shared decision making [26], using the results obtained in clinical studies [27]. Then it becomes important to correctly interpret the results of a study, to transmit appropriately this information to the patients, and to take the best diagnostic and therapeutic decisions.
\nThrough systematic reviews and meta-analysis, as well as clinical practice guidelines, important progress has been made in the search of scientific literature, evaluation and synthesis. Terms such as ‘likelihood ratio’ or ‘number needed to harm’ are used commonly in medical journals [28]. In medical literature it is also used many epidemiologic risk indicators to present the results on the effectiveness of a therapeutic intervention. Between the most used are: relative risk (RR), relative risk reduction (RRR), absolute risk reduction (ARR), hazard ratio (HR) and number needed to harm (NNH). These entire indicators represent different ways to express the same result [29].
\nStudies done at the beginning of the decade showed that practicing doctors had a limited comprehension of numerical data given by the research results [5,30]. In Estellat C’s study, the highest proportions of correct answers were the questions about relative risk reduction (87.7%), sensibility (84.6%) and specificity (80%), whereas the lowest proportions were for the calculus and use of likelihood ratio (16.9% and 9.2% respectively), and the interpretation of the kappa coefficient (19.2%). Though more than 80% of the respondents were able to calculate the sensibility or the specificity of a diagnostic test, only 32% was capable of using it in a clinical context. In the same way, the 30% correctly defined the likelihood ratio, but a percentage lower than 10% was able to use it to approximate the post-test probability of a disease [31].
\nIn the same study, the subjects that had had previous training in statistics, epidemiology or critical evaluation of medical literature scored significantly higher than those who did not have this training. The average score (highest score being 7) was of 5.9 (IC95% 5.3-6.5) and 4.5 (IC95% 4.0-5.0), respectively (p<0.01). Therefore, their capacity to interpret quantitative data from medical scientific literature may be limited, which can deplete the information given to the patient for the decision making [31]
\nThe practice of EBM requires the comprehension of five tasks: (1) building of a clinical question, structured on the patient’s problem, (2) the acquisition of skills o search in medical literature and obtain the best evidence available, (3) critical evaluation of the evidence, (4) the application and integration of evidence to the patient’s healthcare and (5) the evaluation (how to evaluate the process of helping the patient?) [32,33], which have taken EBM to be now part of the undergraduate teaching and the graduate activities of continuous medical education in various countries all over the world [34].
\nFor example, in France, the critical evaluation of a medical article is part of the national residence exam, and for that, most the schools of medicine have incorporated it in their curricula as a formal training in clinical epidemiology. However, in the teaching hospitals most doctors tend to ignore clinical epidemiology and EBM, mainly because it requires the knowledge and comprehension of epidemiology and statistics technical terms, which makes its understanding complex to some, whether for self-sufficiency or lack of interest [34].
\nThis way, when the risk indicators used to inform the results of clinical trials were evaluated in students and residents, it was found that 19.4% didn’t recognize any of the indicators and 81.4% wasn’t able to calculate them. The relative risk reduction was the most recognized indicator (55.2%), followed by ‘number need to harm’ (51.6%), absolute risk reduction (26.6%) and hazard ratio (9.5%), concluding that medicine students and residents do not recognize and are incapable of correctly calculating the risk indicators used in clinical trials [35].
\nIn a similar study carried out in faculties of a northern city of Peru (unpublished data), with 139 medicine students, among them a group that had finished a the Clinical Epidemiology course and another group that was finishing Classic Epidemiology; it was found that the most recognized indicator was NNH (number needed to harm) with 58.9%, followed by RRR (relative risk reduction) with 56.8%. Besides, 30.9% of the students recognized at least one indicator and 13.7% didn’t recognize anyone. However, this changed when they were asked to calculate the indicators, finding that ARR (35.9%) and RR (30.9%) were the ones with the most correct calculation. Likewise, 11.5% did adequately the calculation of at least one of them, and 56.1% didn’t do one of them correctly. A little more than 10% was able to recognize and calculate the risk indicators. Comparing both groups, there was a significant difference (p<0.05) at recognizing and calculating the indicators (Table 3)\n
\n\n | \n
Comparison of mean scores obtained
*Maximum score: 4. &Maximum score: 4. §maximum score: 8.
The medicine students usually start their courses enthusiastically, curious and willing to improve the human condition, but soon find themselves surrounded by a long and passive curriculum, where they have a small direct role in patient healthcare. There are courses that are hard for students to learn and the results tend to have an immediate effect on patient healthcare. Evidently, this goes beyond the fact that students apply the theory to artificial circumstances, situation that would improve if students used the EBM for the choosing of patient’s clinical problems, so that then they can locate and evaluate the appropriate articles that will help in the healthcare patients get. These activities might improve their critical skills and experiential approach as a real teamwork [36].
\nDunn K. and Col. in the last decade they were already channeling the teaching of EBM, looking to create competences in students such as (1) elaboration of researchable clinical questions, (2) access to the best and most recent literature, (3) evaluation and scoring of the literature for its validity and pertinence, and (4) cost-performance-benefit analysis and the interpretation of meta-analysis [37]. Rucker L also mentions the ‘EBM recipe’ [38] as a useful tool to bring EBM closer to healthcare, which consisted in posing clinical questions relevant during rounds at hospitals, which would later be solved by the students with the help of teachers. A similar progress occurs at the Canadian Institute of Health Research (http://www.cihr-irsc.gc.ca/), implementing a ‘teaching recipe’, which allows the resident to take note of the doubts from a concrete clinical case, and answer them following a methodology based on the PICO model (problem/pacient, intervention, comparison and result) and finally designate a date and a person in charge to deliver the answer.
\nAs it has been mentioned, evolution of clinical epidemiology started with the creation of scientific research, which has led to critical reading, database creation and its search engines, EBM and finally, information synthesis (Table 2). That means, in the beginning and in all of its evolution it is surrounded by research. But, what stands out is that, in 2005, in a study we realized in 1484 medicine students from 13 Peruvian faculties, we found that 53.7% had a good knowledge and 71.9% an adequate attitude towards research, as well as a relation between belonging to a research group and having a good knowledge (Díaz-Velez C et al) [39]. This suffered a reduction of 7% and 34.2% respectively in a later study by Cabrera-Enríquez JA et al, where also 68% did not do any extracurricular courses, and those who did, only 3.28% and 6.24% could do critical reading and statistics respectively, finding an association between the level of knowledge and attitude towards research (p<0.05) and only 51% had taken part, or was taking part, of a research. [6]
\nWhile the Latinamerican context is not the most adequate to train researchers, there are students societies that can help promote research even if one is undergraduate. The research lines in universities institutions are not always adequately developed. Moreover, they are not even clearly stipulated and the primary healthcare research is poorly developed, while hospital research gains more support, especially from pharmaceutical industries. If we add to this that publications at a local level are scarce (as a consequence of what’s stated before) and that 75% are done regarding topics which are not a regional or national priority, and knowing the social, ethnic and cultural differences that exist between communities, then what evidence do we have to answer our clinical doubts? [40]
\nIn this context, a good researcher’s attitude, with an integral approach of research, represents, in undergraduates and graduates as well, an alternative to build a solid researcher’s intelligence and attitude, in terms of capability for scientific work [41]. Besides, we must promote some activities, as the graduation by publication in undergraduate students as an alternative to increase the universities’ scientific production, an aspect we have been promoting as university teachers.
\nExamples of teaching EBM and research exist all around the world. We have the Accreditation Council for Graduate Medical Education, from the University of California, San Francisco, which includes EBM and practice based learning, among other basic competences. For that, the development of the ‘PRIME curriculum’ program (EBM/clinical research program) which uses didactic lectures, journal club, progress evaluation sessions and active tutoring that allows the residents to carry out a clinical research project during their residence [42].
\nThe first component of the ‘PRIME curriculum’ program (didactic lectures) motivates the development of topics such as: statistic power calculation, qualitative research methods, survey research, decision analysis and treatment threshold, cost-effectiveness analysis, ethical use of patients in research, community research and research process evaluation with international support, use of administrative data and spreadsheet management. The second component has weekly evening meetings of small journal clubs (diagnostic test evaluation, case-control studies, cohort studies, controlled randomized clinical trials, meta-analysis, decision analysis, cost-effectiveness analysis, clinical practice guidelines, etc.), which are made by students with a 15 minute duration, with a later debate moderated by the tutor. The third component consists on the trimestral presentation of interactive seminars (used to improve the ideas of the project’s author) of the projects done by the residents. So far, these experiences have been successful, perhaps due to the fact that residents that take part of the program have the explicit expectative that the results of their research will be published, and with that, teachers are more willing to spend their time as mentors. However, we believe that the exit relays greatly on the structured curricula, the willingness of the mentors and, above all, the enthusiasm of the residents [42].
\nThere are also other experiences in which the student is assigned to a team with a mentor (research team leader), a methodology tutor, expert clinicians and even biostatistics experts; in a research that coincides with the formation interest of the student, in which he learns about the research process. The mentor and the student meet weekly to develop and review the participant’s curricula, apart from analyzing the research thesis and clarifying doubts that are generated in the sessions, so that, at the end, the student can have the thesis manuscript ready in the form of an article journal and can be presented [43].
\nThe satisfactory fulfillment of the program gives the student the knowledge of the basic types of research design, including randomized clinical trials, cohort and case-control studies, quasi-experimental studies, concepts of health measurement and evaluation in the epidemiologic studies, capacity to critically evaluate medical literature and to use and interpret the various statistical programs for the data analysis [43].
\nHowever, there are limits to the EBM that, according to Cuestas E., might be: a) the frequently conflictive results of randomized and controlled trials (RCT); b) the inexistence of evidence in an enormity of topics; c) the questionable quality of many RCT and meta-analysis; and d) many time the RCT are not easy to conduct due to practical reasons, or impossible to do because of ethical reasons. Besides, it is necessary to integrate the best scientific evidence available with the preferences of the patient, with limits such as economic, social, ethnic, moral, cultural and health organization of the system [24].
\nIn the USA, the Internal Medicine Residence and Postgraduate Curriculum Working Group suggests that the EBM concepts should be an integral part of the undergraduate and residency curriculum, given that medicine students do not necessarily acquire these skills in classrooms or during medical or teaching rounds [44].
\nUnderstanding of how bias and chance can affect the accuracy of observations in individual patients.
Evaluation of the validity of original articles over diagnosis, prognosis, treatment and prevention.
Knowing the strengths and weaknesses of randomized clinical trials, case-control studies, cohort studies (prospective and retrospective) and meta-analysis.
Using practical strategies to judge the validity of clinical evidence synthesis (i.e. reviews).
Comprehension of the meaning, uses and limits of the statistic power, the values of ‘p’ and the confidence interval, relative risk, attributable risk and NNH (number needed to harm).
Knowing how to measure the patients’ preferences.
Comprehension and usage of the sensibility analysis and the cost-effectiveness analysis.
Comprehension of the way to calculate the pre-test disease probability and how to use the Bayes theorem to calculate the post-test probability.
Defining and using sensibility, specificity and likelihood ratio of the diagnostic information.
Knowing and being capable of detecting possible bias in calculations of sensibility and specificity.
Comprehension of the value of decision trees and decision making.
Opportunities for health professionals to obtain the education and training in clinical epidemiology have extended gradually. In South America, there is a group that promotes its development, LatinCLEN (Latinamerican Clinical Epidemiology Network), regional member of the International Clinical Epidemiology Network (INCLEN Trust http://www.inclen.org/), that is formed by research and Clinical Epidemiology training centers, as well as Clinical Epidemiology units around the world. (Table 4) [45].
\n\n | \n
Clinical Epidemiology World Network.
With all these things mentioned we can see that both disciplines (field epidemiology and clinical epidemiology) share the same methodology and tools, just that the application of them is done in different locations and the current medical approach must contemplate the application of clinical epidemiology in health establishments, patients, in those who research epidemiology, with its analytical designs and clinical trials allow the progress in treatment and management, as well as defining the quality of the auxiliary exams ever more sophisticated by means of the test of tests and its economic approach (cost-benefit, cost-utility, cost-effectiveness)
\nOne cannot forget the general population, for it is in the community where field epidemiology is applied, the descriptive study of the health situation with the analytical approach of the Situational Health Analysis, the study of epidemic outbreaks and the respective intervention, as well as the planning of hygiene and global prevention measurements for a better life quality and disease prevention.
\nFinally, we can say that the importance of clinical epidemiology in clinical research is recognized in ways that the classic epidemiology hasn’t been able to achieve, but is prone to the knowledge of health professionals and its constant evolution makes it stay valid, this way an integral manage of the epidemiology will be carried out, both communal and individual, thus resulting in preventive medicine and public health.
\nDuring health professionals’ daily practice, the need to keep informed about the new scientific evidence comes up as a responsibility towards patients and, of course, to oneself. It is not strange to see yourself in front of a patient with a specific pathology to which certain treatments haven’t had effect, and asking yourself: what is new to treat this condition? Or, on the other hand, in front of a research, lecture or speech about any topic, trying to have the most updated information about the topic. Considering its etymologic origin, the word ‘investigation’ comes from the Latin word
To do research there are informatics tools, mainly through internet, that ease up the daily work of a researcher, from sources of information to friendly interfaces, of easy access and navigation, bibliographic references managers and statistic applications that allow us to do calculations that would turn very complex if we did it the conventional way.
\nSearch resources to which we normally turn to are general search engines (Google, Yahoo, Altavista, Metacrawler, etc.) Google (http://www.google.com) has the biggest demand, but the health information available in this engines may come from a non-reliable source, so it is important to distinguish which are the most adequate websites to find the health related information, which implies to evaluate the quality of these websites, an activity that sometimes is quite tedious for the researcher [46–49].
\nGoogle y Google Scholar.
Given the wealth of information it retrieves the conventional search engine Google, and considering the existence of dubious sources, Google implemented Google Scholar (Google Scholar) oriented search scientific references (http://scholar.google.es), which are listed in order of relevance, and provide information about the source, year of publication, authors, times the number that have been cited and other versions of the publication, and also, you can access related articles (mentioning or are cited by the text), the content in HTML, PDF, DOC or other format, it is recommended to do the advanced search preference (Figure 4).
\nAmong the great online Medicine bibliographic databases we have MEDLINE, produced since 1966 by the National Library of Medicine (NLM) [50] in the USA. MEDLINE is the largest article bibliographic source in biomedical sciences we have at hand. The database is made up by cited articles by three indexes: Index Medicus, Index to Dental Literature and International Nursing Index. Currently it is the most consulted database by global researchers. A study applied to Spanish speaking biomedical professional researchers referred us to a 34.1% [51].
\nMEDLINE includes general topics, such as microbiology, health prevention, nutrition, pharmacology and environmental health. However, the covered categories by the database include anatomy, organisms, diseases, drugs, techniques, equipment, psychiatry, biologic sciences, physical sciences, social sciences and education, technology, food, industry, humanities, and communication sciences. All of these related to health. The search is done via PUBMED: http://www.pubmed.gov (Figure 5). Here, the searches are in English base on Boolean operators: AND, intersection, automatic term mapping; OR, conjunction and isolation; NOT, excludes the final term; uses a MeSH (Medical Subject Headings) controlled vocabulary and the subheadings described by the Index Medicus, where most of the abstracts have the link to the editorial where the full text article can be found [52].
\nPubmed specialized search engine of the National Library of Medicine (MEDLINE).
Another large database, not as extensive as MEDLINE, is ‘Literatura Latinoamericana y del Caribe en Ciencias de la Salud’ (Latinamerican and the Caribbean Literature on Health Sciences - LILACS)[53]. It can be accessed through the Virtual Health Library (Regional Medicine Library – BIREME)[54]: http://www.bireme.br, the same that includes other sources of information in biomedical sciences. One of them is the catalogue of the Library hosting the Panamerican Health Organization (PAHO) and the World Health Organization (WHO). Here you can access full text articles that are included in the Scientific Electronic Library Online (SciELO)[55]: http://www.scielo.org, which includes Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Spain, Mexico, Portugal, Venezuela, Public Health, Social Sciences and developing initiatives like Bolivia, Paraguay, Peru, South Africa and Uruguay (Figure 6).
\nLatinamerican and the Caribbean Literature on Health Sciences (LILACS), Virtual Health Library and Scientific Electronic Library Online (SCIELO).
An important resource is the Cochrane Library: (http://www.bibliotecacochrane.org/) (Figure 7), whose aim is to prepare, keep and spread systematic reviews regarding the effects of healthcare, mostly base on controlled clinical trials, and are highly structured and systematized, for they include the evidence according specific quality criteria.
\nCochrane Library
Health Inter Network Access to Research Initiative (HINARI) in: http://extranet.who.int/hinari/en/journals.php (Figure 8) is a program established by the WHO, in partnership with publisher, and gives an easier access to one of the most extensive biomedical and health literature collections. It contains more than 8 500 information resources, in 30 different languages, which are available for health institutions in more than 100 countries [56].
\nHealth Internetwork Access to Research Initiative (HINARI).
Global representative health organizations, such as the PAHO, offer in their website important links, as well as free access to their publications (http://new.paho.org/) [57] (Figure 9). The WHO allows us to access important articles on disease control, vigilance systems and public health. The information is in three languages, including Spanish (http://www.who.int/en/) (Figure 9) [58].
\nThe Center for Disease Control and Prevention (CDC), whose objective is to promote health and wuality of life, gives updated information on the control of disease, lesions and disabilities (http://www.cdc.gov/) (Figure 9)[59].
\nPanamerican Health Organization, World Health Organization, The Center for Disease Control and Prevention (CDC).
To access a consensus, the National Guideline Clearinghouse (http://www.guideline.gov/ ) (Figure 10) contains evidence-based clinical guidelines of the main medical societies in the USA and Canada, National Institute of Clinical Studies, National Institute of Health and Medical Research Council (NHMRC) which collects the CLG developed in Australia (http://www.clinicalguidelines.gov.au/ ) (Figure 10), National Institute for Health and Clinical Excellence (NICE), an independent agency of the UK’s NHS in England and Wales (http://www.nice.org.uk ) (Figure 10) or the Scottish Intercollegiate Guidelines Network (SIGN) which develops these products for the UK’s NHS in Scotland (http://www.sign.ac.uk/) (Figure 10) [60].
\nThe Nacional Guideline Clearinghouse (AHRQ), National Institute of Clinical Studies (NHMRC), National Institute for Health and Clinical Excellence (NHS) y el Scottish Intercollegiate Guidelines Network (SIGN).
Other informatic applications for access to information on health, are represented by social networks, like Twitter, to promote research, disseminating scientific knowledge and funding opportunities, and being very useful for students, researchers and health professionals. [61,62]
\nA bibliographic reference (BR) is a minimal group of data that allows the identification of a publication or a part of the same. There are as many types of BR as information sources. Among them, journal articles, electronic articles, books, chapters of books, thesis, norms, technical documents, videos, etc.
\nIn turn, every BR is made up of diverse fields, some compulsory and other optional, which structure changes according to the BR format. However, in practice, every journal chooses its own format of citing and BR, being the most used: American Psychological Association (APA), Modern Language Association (MLA), National Library of Medicine (NLM), Vancouver style, among others.
\nAiming to standardize the great diversity of formats available, in 1978, the Vancouver Group, later International Committee of Medical Journal Editors (ICMJE), requested the National Library of Medicine to estipulate the rules to write the BR [63], and in 1991, the NIH published the
Taking into account the need to manage the BR in a more efficient and agile way, endless softwares have been made available for the management of BR, being the most socialized in the world the Endnote [65]. It is commercial software for references and images, whose main function is to store, manage and search bibliographic references in a personal reference library. Besides, it allows organizing images including graphics, tables, pictures and equations, assigning each image its own caption and keywords. However, there are other free access resources, like Zotero [66], which is a Firefox-Mozilla Add-on, created by the University of Washington as an improved and free version. This software will let us automatically store our search results from Pubmed, build our BR library, and cite everyone in direct communication with Microsoft Word, Outlook, etc.
\nApplications of Zotero.
A statistical package is a program or set of programs that allow sub applied to the same data file an unlimited set of statistical procedures in sync, without leaving the program. Among the statistical applications of special interest to the investigation, is the EPIDAT [67], which is a free program developed by public and led to epidemiologists and other health professionals to manage tabular data, allowing us to make a descriptive analysis, data filtering and imputation, sampling, parameters inference, contingency tables, matching and consistency, diagnostic tests, rates adjustment, demographics, logistic regression, survival analysis, probability distributions, Bayesian analysis, meta-analysis, monitoring public health, measuring health inequalities, economic evaluation methods, etc. [68].
\nOne of the most popular and used statistical packages is the SPSS, which is a statistical analysis and data management in a graphical environment system, using descriptive menus and simple dialog boxes that do most of the work, consisting of a simple interface, a data editor, with features such as multidimensional pivot tables, high-resolution graphics, database access, data processing, electronic distribution, and online help. Other programs of great usefulness are Stata, R, among others [69]
\nSoftware Statistics
Despite some theories, methodologies and tools currently used by social epidemiology date back to the 17th century, it hasn’t been until the past century’s last decades that it has consolidated as a scientific discipline. And, like any young discipline, it faced the questioning characteristic of its not well defined scope [8,9]. Some skeptics argued that the term ‘social epidemiology’ was redundant, because epidemiology is inherently a social term. However, the contributions made by Durkheim (1987), John Cassel (1976), Geoffrey Rose (1992) or Mervyn Susser (1994, 1996, 1998), to mention some of the most important; set the basis of the social determinants and health status of the population approach [9].
\nSocial epidemiology is defined as the branch of epidemiology that studies the social distribution and social determinants of the health, implying that the purpose of its study is the identification of socio-environmental exposures that can be related to a wide range of physical and mental health problems [63]. To put it simpler, what distinguishes the action of a conventional epidemiologist from a social epidemiologist is the level of causal thinking. While the first one thinks: why does a person get sick?, identifying the best statistic tool to evaluate the association between a risk factor and the disease, the second one wonders: why is a society not healthy?, making out that factors which determine collective health are not individual, but that social determinants which have a direct impact on the health status of a population exist [8].
\nThe concepts of social epidemiology have been evidenced since the findings of John Grant (1662), who identified social variations of mortality that was quantified on England chapels on the 17th century. Villerme (1830) and Virchow (1848) identified the social class and the working conditions as crucial determinants for sickness and health. Since then, these findings constitute the theoretic foundation necessary to try to resolve the persistency and even the recent increase in social inequities in health. While some communicable diseases have been eradicated, other have emerged or re-emerged. The epidemiologic transition has changed the disease profile to favor the chronic or non-communicable diseases, and the social inequities of health prevail [9]. This makes it necessary to incorporate social variables like direct determinants of disease or population disability [70].
\nThis approach widens the need to use theories, and especially multidisciplinary techniques, to answer the new questions and rethink the answers to questions that were posed before. Theories like the social capital, particular of economy, can now be applied to resolve social epidemiology problems. Tools such as the multilevel analysis (multilevel regression models), first designed for social sciences (especially pedagogic research) and that were introduced into epidemiology in the beginning of the 80s, are now being spread as powerful analysis tools [71].
\nEven though field epidemiology and social epidemiology have the same epistemological, methodological and practical bases [4], in some situations they can be considered as the two extremes of a spectrum, between the practical application of the information for action on an individual territory and the usage of the information for the elaboration of theories about the macro-social economic and political determinants, with few or hard practical application [4]. It is necessary then, to highlight some differences over the practical development of these disciplines and the implications these carry.
\nTaking into account this duo action-reflection, we could say that on one hand, field epidemiology it is developed an individual analysis of the diseases risk factors, searching for its application in the field to control the outbreaks, aided by strategies such as epidemiologic vigilance. On the other hand, social epidemiology seeks to analyze social factors (considered social determinants) and their distribution in populations as aggregate variables that have are more distantly related but crucial in the behavior of diseases in population groups [4].
\nIt is important to mention than the places where both disciplines take place are different. While the first one acts in confined environments, the second one tries to take on broader territories, in which the public politics’ implementation and design are necessary for health management. Social epidemiology focuses its concerns in the generation of evidence, to avoid health inequities, and its effect in the socio-environment conditions that increase a population’s risk of getting ill. Otherwise, field epidemiology centers its work in the search for recognizable risk factors on an individual and collective level, to attend immediate healthcare problems such as epidemic outbreaks. However, the limit between these two disciplines is diffuse, so the challenge for young professionals in epidemiology is exactly to strengthen an integral and multidisciplinary profile to guarantee the generation of the best evidence that will allow answering to diverse problems of public health in all the levels
\nThe role of the theoretical background to guide the direction of addressing the main research question in general in epidemiology, and particularly in social epidemiology, is unquestionable. The main theories that have given base over time to the foundation of social epidemiology can be summarized in: the psychosocial theory, the theory of social production of a disease, and the ecosocial theory of disease and its multilevel dynamic perspectives [72]. These theories not only allow to define the social epidemiology and to draw work lines in its field, but also to direct the dynamic and connections between the individual-biologic levels, along with our social existence.
\nMost efforts to generate new methodological paradigms in social epidemiology are based in the generation of models that seek for the best way to incorporate the social factor in biomedical research. The simplest and most common model to incorporate these social processes considers them as distal antecedents of the biological cause of disease [73]. This implies that the distal social factors are related with a disease through common causal paths. Then, for example, the educative levels (distal social factor) are related to an inadequate diet and this, in time, may be related to many diseases like cardiovascular disease or cancer. Despite this focus would contribute evidence for the prevention, adding these distal social factors would not be entirely necessary if we had an adequate knowledge of the biological factors, so we could indirectly eliminate the social gradient, taking part only the proximal factors.
\nA second model considers social factors as biological factors modifiers, in a way that these two would interact, generating biological processes that lead to disease. This model if genetic-environmental interaction implies that the presence of genetic factors is not enough to make a disease express itself, but that it depends of the environmental context in which it raises. Analogously, the influence of social factors depends on the underlying genetic conditions of the individual [73].
\nThe third model considers social factors as an integral part of two biological systems, with the capacity to modify functional and structurally the biological aspects of individuals. This way, social experiences are able to generate direct changes in biological systems, being a fundamental piece on the understanding of these complex systems [73].
\nCurrently, epidemiology constitutes an emerging field with an enormous potential to generate improvements in public heath, for it becomes evident that social factors and group dynamics affect the health status [74]. Understanding the biological phenomenon related to disease is necessary, but it is also vital to understand how society influences in biology, aiming to modify the illness risk. Social understanding is fundamental in the process of change and reduction of the burden of disease [75].
\nIn the poor countries, people die unnecessarily. In rich countries, this also happens. This is explained by a social gradient that generates high mortality rates among those who have unfavorable socio-economic conditions, for which it is also considered unnecessary. The term inequity has a moral and ethical dimension: it means to differences that are unnecessary and avoidable, but also considered unfair and arbitrary. So, to be able to describe a specific situation as inequitable, the cause must be examined and judged as unfair in the context of what is happening to the rest of society. The crucial evidence to know if the resulting health differences are considered unfair seems to largely depend if the people chose the situation that caused the ill health or if that was basically out of their direct control [76]. Therefore, in the contexts where the fundamental and necessary execution of the autonomy and personal freedom is impossible, the health is powerfully affected, and it is the social conditions that determine the degree of these fundamental needs limits [75].
\nThe health inequities analysis is based in the social epidemiology, to reinforce the important role of the environment as cause of the disease. A typical example is the modification of the disease profile that happens in migrant population when they change their resident environment [75]. And this environment is the own social context in which diverse factor interact to favor the development of diseases. The analysis and understanding of the dynamic that governs the interactions of individual and social factors would allow us to modify the inequities and improve the health. Besides, we must take into account some considerations: there is the need to act over the social gradient that limits the people’s autonomy and freedom, to adopt healthy surroundings, but one must not focus the efforts only on the poorest sectors, but in the whole social gradient aspect [76]. This way we can generate health politics that will cover all the sectors in an integral way, with a proportionally bigger impact in the least favored sectors. This politics generation must be sustained in the systematic application of the best evidence, relating knowledge with action and opening new opportunities for the prevention [77].
\nLatin America is considered the region with the largest inequities on the planet. It’s the continent where, according to multiple studies, the polarizations are larger in diverse fields, and the access to opportunities is notably different for the different social sectors; and maybe where the difference is more notorious is in health, which belongs to the most basic human rights category [78].
\nThere have been considerable progresses in the health matter in Latin America. However, there are serious problems that show the presence of an acute pattern of inequity. The national averages show progress, but when they are broken down to socioeconomic levels, regions, gender and ages, there can be observed wide sectors of the population with serious problems [78].
\nIn this context, the clinical epidemiology has the commitment to measure the impact of the healthcare interventions, where the clinical trials rarely are reported by socioeconomic levels, given that the population’s health and the clinical epidemiology support evaluating the efficacy, effectiveness and cost-effectiveness are very importan to define the impact of healthcare in health inequities [17].
\nIn Peru, this type of analysis is being carried out more frequently since the beginning of the past decade. For example, in the year 2002, the Grupo de Análisis para el Desarrollo (Group of Analysis for the Development - GRADE), led by Dr. Martin Valdivia, did a study about the health inequities in Peru, using socio-economic indicators taken from socio-demographic national surveys and evaluating its strength to generalize the results [79].
\nThe descriptive analysis establishes that the largest inequity is in the children’s chronic malnutrition and the usage of health services in general. About 30% of the rural children of the poorest decile suffer from chronic malnutrition, but this rate is
Currently, the tendency of science is focused in the generation of evidence to contribute in its development and has an impact on the patient’s health. This approach of Evidence Based Medicine (EBM) is shown mainly in healthcare, related to drugs and medical devices. However, it is admitted that the community interventions through Public Health deserve to be recognized as transcendent elements that have had an impact in the population’s health. In this way, it is necessary to recognize the existence of research that advocate to evidence the impact of Public Health’s diverse activities.
\nThe Evidence Based Public Health (EBPH) maintains a cause-effect logic, and allows to add the health determinants, like lifestyles, culture and environment, in a scientific context, because many times it’s them who characterize the good or bad performance of a certain intervention. This way, EBPH is a new tendency that has been joining efforts to give the best information for the most efficient politics decisionmaking.
\nThe practice of EBM in the hospital environment benefits doctors and students, for it collaborates in the obtaining of evidence selected for its quality, informatics value and relevance for the user (for example, the services produced by McMaster premium service literature [PLUS] as well as the ACP Journal Club Plus). One of the current benefits is that it allows concentrating opinions related to methodological quality and potential relevance for its use. This way, the McMaster University has developed the program ‘McMaster Online Rating of Evidence’ (MORE), in which it allows the professional to have literature of the most technical quality and relevance. This is through a classification given by professionals from diverse latitudes from around the world. Beside, these services present clear and relevant results, and offer to visualize comments or criticism, independently for the management of said information [76]. This information, according to the analogy used, tells us that ‘the EBM and nuclear fission can be very powerful when they are appropriately used and dangerous if not’, because the fact that EBM separates describing, the underlying quality of the evidence, the magnitude of the effects or the applicability of any of the results in the context, the values and the preferences of the patients should not be considered [80].
\nTherefore, there is no doubt that EBM has allowed to progress in the medical practice. However, the application in the Health System has been inconsistent, meaning that the EBM would improve the health of the population. The differences in the health systems, globally, on the healthcare of the population, limit the capacity to incorporate easily the progress of the EBM, or often to certain discriminating point by economic or politic limitations [81]. Nevertheless, it is important to point out that it has been found in primary healthcare a relation between the high knowledge of EBM and a better quality of healthcare [82]. Although, when evaluating EBM at workplace, as a method of formative performance evaluation, there is not much evidence that shows the impact on the education of the doctors and their performance [83].
\nIn relation to the use of EBM, one can point out that the public hospitals there is a favorable attitude. Besides, it is recognized that doctors who practice the EBM show a more prone attitude to change information and counseling through mutual collaboration networks [84,85]. Doctors recognize also the gap that exists between the EBM applications to clinical practice, for it is difficult to avoid the clinical experience, colleague’s opinions or some scientific studies, which are not EBM, in their decision making. The confidence in decision making based on clinical experience increases with the time of service. However, there are few doctors that inform that clinical experience should be the only one used. Most doctors estimated that EBM practice should be guided by local evidence collected from local practice, because it will allow to back up their actions in clinical practice [86]. Therefore, the fact of automanaging the evidence would help the patient’s, for example, chronic diseases and to pay attention to the unhealthy factors of a community, which could be added in the EBM to create a wider paradigm [81].
\nRegarding this, it should be noted the experiences from Canadian family doctors (where the EBM was born) who report positive attitude toward EBM, recognizing that it improves patient’s healthcare and considering that the research findings are useful in the management of everyday patients. However, in clinical practice, the decision making can be influenced by a demanding patient, that can call for some detection test (OR: 5.15; IC95%: 2.9-9.2). Though this relation was not kept regarding the therapeutic, it is important to value the preferences of the patient and the clinical context seems to reflect more precisely the clinical reality of EBM and primary healthcare doctors [87].
\nThe EBM is a methodology to evaluate the published clinical research, and its use is starting to be considered as a referent for knowledge and in the clinical practice evaluation, Its methodology is mainly based in the usage of evidence, like systematic reviews and meta-analysis, through which it seeks to offer answers to concrete clinical questions, this answer being backed up by statistic evidence. The application of EBM has multiple benefits, but also has various difficulties in clinical practice for it is hard to hold it freely, without taking into account the cultural, academic and socio-economic environment of every latitude. Therefore, its correct use is a challenge for contemporary medicine [10]. This approach of EBM allows the health provider (health professional) to use it in favor of his clinical practice, like in the hospital environment. Athough it is not compulsory, its utilization serves in health teams committed to improve hospital healthcare.
\nThis EBM approach, applied to the Public Health interventions, it is not adequately adjusted, because EBm uses as a gold standard the clinical trials, whose use in public health is of difficult extrapolation for when it is applied to the population, it demands other variables to be considered that may directly influence over the expected outcome [83]. To this situation, the EBPH approach collaborates to concentrate efforts to sustain evidence that backs up the health politics and community interventions, though there are known limitations of the EBPH’s use of evidence for using observational studies that have been systematically underestimated by EBM as a reference. Currently, models of technical evaluation have been developed, serving as a filter for evidence and collaborating to improve the selection of more methodological stringency studies to be used in Public Health.
\nAmong some of the evaluation models for effectiveness of the Public Health interventions, many maintain common aspects. However, there still isn’t a global consensus regarding it. Some strategies can be noted, lie the TREND (Transparent Reporting of Evaluations with Non randomized Designs), which evaluates the severity of publications which inform of Public Health interventions. The MOOSE (Meta-analysis Of Observational Studies in Epidemiology), for the reading of observational studies meta-analysis, or the STROBE (STrenghtening the Reporting of OBservational studies in Epidemiology), for cohorts and case-control studies, can complement the ability to improve the systematization of information related to Public Health interventions [11].
\nIn general, it can be said that the EBM and EBPH have a common origin, which is the use of epidemiology as a decisive tool for the selection, evaluation and recommendation of evidence for its use, whether in hospital clinical practice of the social environment, which is Public Health.
\nIt can also be said that there are obstacles in the incorporation of research in the politics, apart from limited budgets. Although the politic makers could benefit of the EBM if they train in said approach, to help them identify and evaluate high quality information. This way, researchers and those who are designing health politics can make a synergy for the best decision making for the population and the country. This can be used as generation and intervention experience exchange networks for future health politics [88].
\nEpidemiology as such helps the health sciences to understand the diverse causal mechanisms where the cause-effect relation aids to evidence factors that determine health problems. This way, Public Health is one of the specialties that uses it as an essential tool to show reliable evidence that will help understand the diverse health problems that populations have. However, at the moment of structuring the causal map, in many of the public health causal factors it can be seen that they rely on social determinants. And, on the other hand, that the public health problematic is multifactorial. The analysis shows us that this is the epidemiology’s challenge to obtain a critical causal path that collaborates to understand that the modification of an event sequence (factors) can be stimulated to generate the expected outcome in the health problems of a population, being this event sequence the critical causal path.
\nAccording to what it is stated, a group of steps that aid to develop this critical causal path will be explained, which will be used as an axis for the diverse approaches of the public health’s interventions.
\nStep 1: Recognize the public health problem: The problem evaluation approach in public health can be obtained from different sources, primary or secondary. Primary sources are the most difficult to be obtained, because they demand resources and time to be able to get scientific studies that collect the divers health problematic. In general, given the technical and political circumstances, it is more viable to use secondary sources, which collaborate to problematize the health status of a population. This way, one of the main management tools used according to the geographic space is the Health Situation Analysis (HAS), whose methodology allows to evaluate three important aspects: social determinants (socio-economic, cultural, lifestyle, commerce, environmental, etc. aspects), morbidity and mortality (Child mortality rate, Maternal death rate, main diseases and death causes, etc) and the social answer (health systems, health establishments, human resources in health, equipment, etc.) which, when analyzed in an integral way, can issue the main health problems of a certain geographic space, as well as its interaction with the intervention carried out by the Nation. At the end, it must be highlighted the health problem that must be taken in tis real context.
\nStep 2: Causal map with an evidence approach. It is the evidence systematic evaluation that explains the health problem related to its causes and the effects it can generate. When graphed in a causal map, it aids to show the cause-effect relation, and being back up by scientific evidence, it makes the health decision maker to have a wider spectrum of the multiple causality of the health problem. Then, it helps to maintain a multifactorial perspective of the public health problems. In the design of the causal map one should provide the most scientific evidence there exists, doing a bibliographic research using the informatics tools and main scientific portals, without putting aside the selection and evaluation of the articles with the methodological severity already noted in the EBPH.
\nAs an example, it can be shown in Figure 13, the causal map of the health problema: “Chronic malnutrition in children under 5 years old from rural zones”.
\nCausal map of chronic malnutrition in children under 5 years old from rural zones.
\n | \n
Evidence of the causal map of chronic malnutrition in children under 5 years old from rural zones.
Following the direction of the arrows in the causal map, the cause-effect logic can be defined, and the numbers attached to the arrows represent the scientific evidence that support said causal relation, which can be compiled in an evidence table as it is shown in Table 5.
\nSo, showing the interaction of variables in relation to a health problem, the decision maker of health policy can see in the bottom of causal map, which it can fall on social determinants, such as low socio-economic status, and often it is not feasible his intervention from short to medium term. On the other hand, we can see that variables are likely to be modified, and that the modification of these stimulates the changing chain of whom it has direct causal association. Under this perspective the formulation of a critical causal pathway can be based.
\nStep 3: Build critical causal pathways: Many times in the search for evidence in Public Health to develop interventions that will reduce health problem, one must have clear interaction of the direct and indirect variables that are related to health problems, in order to provide technical support on what you want to modify. Thus the critical causal pathway contributes to show schematically the interaction of the direct and indirect variables to health problems and allows the decision maker to choose to evaluate the various critical paths that can be noted in health interventions. Regarding the causal map example of Figure 14, one can observe the causal pathway designed as an example of a way of assessing a probable health intervention, which pretends to check how the intervention with fortified food programs can collaborate to reduce chronic malnutrition in children under 5 years old
\nCritical causal chain of the fortified food program to reduce the chronic malnutrition in children under 5 years old from rural zones.
\n | \n
Evidence that sustains the causality relationship
Furthermore, it is important to contextualize the propositions of health interventions with economic aspects of each one, and the methodologies, as economic assessments developed by each country. That brings us to rethink that one must recognize that the health problems or health interventions that are probable to be carried out are greatly influenced by socio-political considerations, but that despite the political and circumstances it is our desire, as technical authorities, to show, in the most objective, efficient and effective way in this task, with the support of scientific information through the MBE or SPBE (Table 6)\n
\nClinical epidemiology and field epidemiology share the same methodology and tools, differing in individual application and the population respectively, but are complementary to public health.
\nThe EBM is demanded by patients for a better diagnosis and treatment, in addition to recognizing the importance of clinical epidemiology in the development and promotion of research, progress that is driven by the software tools that facilitate the researchers’ performance and in modern times it is essential to know and apply them.
\nSocial epidemiology studies the social distribution and social determinants of health states ranging from individual levels (risk factors) to social phenomena (social determinants), seeking answers to the complex dynamics behind social distribution of health and in that context is EBPH an important tool to improve the analysis of public health interventions that can help to improve decision-making at the policy makers of a country\'s health.
\nFinally clinical epidemiology has enormous potential to generate real and positive changes in public health, becoming a challenge for new professionals in epidemiology and public health for their increasing and complex development
\nWe acknowledge Víctor Calderón Chávez y Vannessa Elizabeth Sánchez Vélez, for their support in the review of the writing and to Agimiro Yangua Jaramillo for the elaboration of the manuscript figures.
\nNepal is an agrarian country and 60.4% of its population is dependent on agriculture and it contributes to 26.8% of national GDP [1, 2]. Commercialization of agriculture is needed to accelerate the economic growth in the country, which is largely subsistence type. Since Nepal has entered World Trade Organization (WTO) as a member country in 2004, it is necessary to exploit the globalized trade for the nation [3]. Most of the people who are engaged in agriculture are rural dwellings and they are the prime driver of the agriculture of the country, Nepal. However, the commercialization of agriculture demands high-value inputs, which are often associated with higher use of improved, and hybrid cultivars, machinery, fertilizers, pesticides, etc.
Pesticides are those chemical substances that are used to control pests of an agricultural and urban setting. These substances include fungicides, insecticides, rodenticides, herbicides, molluscicides, nematicides, miticides, avicides, etc. Insecticides are used for a very long time to deter, minimize, and manage insect pests in an agricultural field, forest land, and in human settlements. In agricultural crop production only, insects and other pests cause around 35% yield decline [4].
The role of insecticides to reduce the insect pests attack on various crops, damage to the health of humans and livestock is crucial. Due to the advantage of the rapid action of these chemicals over target organisms, these are widely being used all over the world. Nepal could not be an exception regarding the use of chemical insecticides. Insecticides encompass a broad range of chemicals that are toxic not only to insects but also to other organisms. These chemicals often lead to pesticide resistance, the resurgence of insect pests, and the decline of beneficial organisms, along with the detrimental impact on human health and the environment [5]. Unscientific use of pesticides is of major concern to the farmers of the developing countries and Nepal could not be the exception, which further exacerbates the situation.
Phytophagous insects only do the damage to grown crops, on average of 35–40%. Sometimes, it exceeds more than that based on the severity of the pest [6]. Commercial growers mainly depend on various insecticides to get rid of the various insect pests. But, the exact amount of import of these insecticides, their use, and the effect on human health and the environment is of major concern to Nepalese agriculture [7].
A rigorous and thorough study was done to collect and synthesize information on the topic of the review. Different research papers, review articles, reports, governmental websites, and their publications were studied and screened for data compilations. Gathered data were coded in the MS-Excel and subsequent tabulation and column graphs were generated.
The use of insecticides started in Nepal in early 1950s with intention of control of malaria, especially to eradicate the disease transmitted by mosquitoes for the Gandaki Hydropower Project [8]. First introduced chemicals to Nepal were Paris green, gramaxone, nicotine sulfates, Dichloro-diphenyl –trichloroethane (DDT), and these all were brought from the USA. These chemicals were followed by other organochlorines, organophosphates, carbamates, and synthetic pyrethroids [8, 9]. In the agricultural field, pesticides were started to use in the early sixties. This is the era of the green revolution where farmers were instructed to get maximum yield from a crop by using higher inputs such as improved seeds, chemical fertilizers, pesticides, etc. Until that period, farmers were unaware of the chemicals and insecticides to manage the various insect pests of agricultural crops. At the time, farmers have a preference over broad-spectrum pesticides due to the effective work to knock down the pests [10]. Nepal does not produce any insecticides till now but imported primarily from six countries, that is, India, China, Malaysia, Singapore, Italy, and Japan [3]. Till now, 54 types of insecticides were introduced to Nepal with 14 bio-pesticides, which are depicted in Tables 1 and 2. Organochlorines and some other highly toxic chemical pesticides were banned in Nepal, which are shown in Table 3. Insecticides were registered in 1787 commercial names by Plant Quarantine and Pesticide Management Center (PQPMC) under the Department of Agriculture, Nepal. In Nepal, there are altogether 16,110 retailers, 5 pesticide formulators, 37 pesticide applicators, and 286 pesticide importers [11]. Traders of pesticides are mainly concentrated in the commercial agricultural areas such as in plain regions, in the valley, and in and around the major cities of the country. Still, pesticide business has not penetrated the mid-hills, hills, and larger rural areas of the country.
S. No. | Insecticide chemical group (in use) | Common names |
---|---|---|
1 | Organophosphate | Acephate, Azamethiphos, Chlorantraniliprole, Chlorpyrifos, Dimethoate, Ethion, Malathion, Phenthoate, Profenofos, Quinalphos, Temephos |
2 | Carbamates | Propoxur, Thiodicarb |
3 | Synthetic pyrethroids | Cypermethrin, Permthrin, Alphacypermethrin, Alphamethrin, Bifenthrin, Beta-cyfluthrin, Cyfluthrin, Etofenprox, Fenvalerate, Flumethrin, Lambda Cyhalothrin |
4 | Nicotinoid | Acetamiprid, Dinotefuran, Imidacloprid, Nitenpyram, Thiacloprid, Thiamethoxam |
5 | Avermectin | Abamectin, Emamectin benzoate |
6 | Methyl | Amitrazz |
7 | Organic thiophosphate | Azamethiphos |
8 | Nereistoxin analogue | Cartap hydrochloride |
9 | Halogenated pyrroles | Chlorfenapyr |
10 | Thioureas | Diafenthiuron |
11 | Benzoylurea | Diflubenzuron |
12 | Pyrazole | Fipronil |
13 | Pyridine compound | Flonicamid, Pymetrozin |
14 | Diamide | Flubendiamide |
15 | Isoxazoline | Fluralaner |
16 | Oxadiazine | Indoxacarb |
17 | Spinosyns | Spinosad |
18 | Tetronic acid | Spriomesifen |
19 | Tetramic acid | Spriotetreamat |
20 | Insect growth regulator | Novaluron, Lufenuron, Cyromazine, Chlorfluazuron, Buprofezin |
21 | Dazomet | — |
Registered pesticides in Nepal till 14 July, 2020.
S. No. | Common name | Origin |
---|---|---|
1 | Neem based | |
2 | Bacteria | |
3 | Bacteria | |
4 | Bacteria | |
5 | Bacteria | |
6 | Fungus | |
7 | Fungus | |
8 | Fungus | |
9 | Fungus | |
10 | Fungus | |
11 | Fungus | |
12 | Fungus | |
13 | Nematode | |
14 | Nuclear polyhedrosis virus | Virus |
List of bio-pesticides registered in Nepal.
S. No. | Banned pesticides | Decision year | S. No. | Banned pesticides | Decision year |
---|---|---|---|---|---|
1 | DDT | 2001 | 13 | Monocrotophus | 2006 |
2 | BHC | 2001 | 14 | Methyl Parathion | 2006 |
3 | Aldrin | 2001 | 15 | Endosulphan | 2012 |
4 | Dieldrin | 2001 | 16 | Phorate | 2015 |
5 | Endrin | 2001 | 17 | Carbofuran | 2019 |
6 | Heptachlor | 2001 | 18 | Dichlorvos | 2019 |
7 | Chlordane | 2001 | 19 | Triazophos | 2019 |
8 | Mirex | 2001 | 20 | Carbaryl | 2019 |
9 | Phosphamidon | 2001 | 21 | Benomyl | 2019 |
10 | Organo Murcuric Fungicides | 2001 | 22 | Carbosulphan | 2019 |
11 | Lindane | 2001 | 23 | Dicofol | 2019 |
12 | Toxapheone | 2001 | 24 | Aluminium Phosphide 56% | 2019 |
Banned pesticides in Nepal.
In average, consumption of pesticide inactive ingredient is very low, that is, 0.396 kg/ha compared to other countries such as India (0. 481 kg/ha), China (2.0–2.5 kg/ha), Japan (10.8 kg/ha), Europe (1.9 kg/ha) and USA (1.5 kg/ha) [12]. But, in highly commercial agricultural areas have much higher use of pesticides than the national average.
Since insecticides are imported highly from foreign countries based on higher demand, farmers are using those chemicals in their fields injudiciously. Comparatively use of insecticides and other pesticides used in Nepal are lower than in developed countries, but the real problem is in the commercial pocket areas where growers are using exceedingly higher than they needed. There is a wider perception to the farmers that they have got the only chemical measures to control insect pests. Lack of awareness and knowledge of farmers, lack of alternatives of insect pests’ management other than chemicals, lack of governmental regulation and monitoring policies and actions for pesticide use are some of the reasons for improper and excessive use of insecticides in Nepal [13]. Insecticide use is reported much higher in vegetables compared to cereal crops and others. Since the vegetable growers are commercial, they tend to use insecticides more often. One study reported that more than 85% of insecticides imported were used in vegetable crops to deter various insect pests and oftentimes farmers are using insecticides even the insects are not at a damaging level. It is reported that a higher concentration of insecticides residues, that is, Cypermethrin than the permissible limit was detected in tomato and brinjal. The same study also showed that the concentration of Deltamethrin was higher in cowpea and was followed by cauliflower, tomato, and brinjal [14]. The residues of carbamate and organophosphate group of insecticides were observed in the vegetables sampled from the leading vegetable market of Nepal located in the heart of the capital city, Kathmandu. Tomato and cowpea were having higher residues of insecticides and these were grown in the commercial pocket of vegetables of Nepal, that is, Sarlahi and Kavre districts. The same study has revealed that 21.38% of tomato samples and 18.75% of cowpea samples were of sub-standard quality among the samples which were tested positive in pesticide residue analysis using the reagent kit method were [15]. The trend of insecticide use is increasing in Nepal by 10–20% per year and this signifies the prevailing crisis of Nepalese agriculture not only in terms of economic losses but also of associated detrimental effects [16].
It is reported that 25% of farmers of plain regions, 9% of mid-hills, and 7% of mountains use pesticides in their fields, and their usage in these ecological zones of Nepal is depicted inFigure 1 [17]. It is also reported that insecticides application is significantly higher in cotton and tea plantation in Nepal and it is worthwhile to mention that, compared to the cereal crops, use of insecticides and other pesticides is significantly higher in vegetables and other commercial/cash crops, as shown in Figure 2 [11]. In Kavrepalanchok district, near to the capital city, farmers were using insecticides 1–3 times whereas the same farmers were using 2–15 times in vegetables such as cabbage, potato, tomato, bitter gourd, cucumber, etc. It is even comparable to the share of pesticides in the production of various crops. Wheat has no pesticide application whereas, pesticide application in bitter gourd accounts for an 8.41% share in crop production [18] Farmers have reported the use of a cocktail spray of insecticides. Some farmers have also malpractice of dipping green vegetables in insecticide solutions such as malathion, mancozeb, etc. for a shiny and fresh look to fetch a good price in the market [12]. Farmers are very unaware and they hardly care for the waiting period to pick their harvest before they take it to the market. And, these products are purchased by the consumer and immediately taken for their food requirement and this makes the case more worsen [15].
Crop wise pesticide use (a. i. gm/ha) in Nepal (Source: PQPMC, 2021).
Ecological scenario of pesticide use in Nepal (Source: PQPMC, 2021).
Farmers of Nepal are very unaware of pesticide risk and it is the case of the area where people are engaged in conventional agriculture. In one survey conducted in Gaidahawa Rural Municipality of Rupandehi district, about 73% of the vegetable farmers have the practice of reusing the leftover pesticides. In the farmers’ field, researchers have reported that farmers have left the pesticide containers and packets in the open field, without thinking about the risk those containers possess [19]. Among the various pesticides reported in the area, chlorpyrifos was with higher concentration, that is, 177 μg/kg from the soil samples collected from three different depths of soil, that is, 0–5 cm, 15–20 cm, and 35–40 cm. DDT although banned in Nepal from 2001, its residues were found at all depths of the soil, which shows its persistent nature in the environment [19, 20]. The DDT mean concentration at 35–40 cm soil depth from the above-mentioned research area was found higher than 10 μg/kg, which is more than the threshold value for the safety of various soil organisms. Other insecticides such as Profenofos and imidacloprid were also found in the soil samples abundantly at different soil samples and found to be toxic to different soil organisms [19].
Insecticides can be used in a variety of forms, including liquid, concentrated, powder, dust, particle, aerosol, and fog, to control various insect pests of various crops. Those chemicals sprayed in a crop’s field will move and transfer to the environment via water, wind, and absorption. It can be transferred to long distances and in various forms. A large part of the most commonly used insecticides do not reach their target insect and may be affecting non-target organisms or polluting the environment. Non-target organisms include not only other insects, but also vertebrates such as wildlife, humans, and domestic animals. Insecticides can enter non-target habitats or ecosystems and affect non-target organisms [20]. Since food is a basic need and the practices of insecticide use do have a greater impact on human health. The most contaminated insecticides group, that is, carbamate and organophosphates are neurotoxic and are acetylcholinesterase inhibitors. These insecticides belong to the toxicity categories I and II. These are categorized under the most dangerous insecticides to the non-target organisms including humans and the environment [21]. These chemical insecticides may have contaminate on the environment such as soil, water (surface and ground), various flora and fauna, etc.
Since the import of pesticides including insecticides is increasing every year. The import of pesticides in the year 2013/14 was 454 tons but now, in the year 2019/20, import has been increased to 681 tons as shown in Figure 3 [11]. The residues of those chemicals on the soil and water are accumulating every year. One research has highlighted the moderate risk of cancer to the public where the soil is contaminated with organochlorine residues such as DDT and endosulfan [22]. This signifies not only the impending to the human health but also to the rich flora and fauna of the country itself. This sort of unsustainable practices in agriculture could be the cause of the loss of rich fauna which includes 17,097 species [23]. Various biotas inhabiting the soil such as bacteria, fungi, nematodes, earthworms, soil-inhabiting insects, and other arthropods with the presence of other organisms help to maintain the quality of soil and provide major ecosystem services for maintaining soil health and ultimately the quality of food production. The malpractices of insecticides along with other hazardous pesticides could have a detrimental effect on those organisms and ultimately deteriorate the quality and quantity of food production [19]. Another research conducted at Biratnagar of Nepal reported the presence of DDT and endosulfan in soil. The research also suggested that the use of DDT is still ongoing in the region but endosulfan residues were of past use [22].
Scenario of yearly pesticide import into Nepal (Source: PQPMC, 2021).
These insecticides exposure to humans causes detrimental health defects such as hormonal imbalance, immune suppression, lower intelligence, reproductive anomaly, damage on kidney, liver, neural regions, and cancer. Farmworkers who have also exposure to insecticides get the symptoms of headache, drowsiness, dizziness, skin irritation, muscular twitching, respiratory discomfort, etc. [24, 25].
It is reported that the estimated health cost of the pesticide user individual who has got exposure to pesticides is Nepalese Rupee (NPR) 287. Of the total household expenditure, pesticide-induced health costs take 0.2% of annual household expenditure and 10.32% of annual health care expenditure [26].
More than the optimal concentration of insecticides also has unprecedented results human health and their expenditure on health care. One unit increase in insecticide concentration, that is, by 1 ml/L of water, would cause increased sickness cases by 6.8% and health costs by nearly NPR 30. Similarly, more hours of insecticide or any other pesticides application would bring unintended results to the health of the farmers and their expenditure [26].
It is also upsetting to mention the intentional or suicidal attempts of pesticide poisoning are common in Nepal. Most of the time, insecticides; mainly organophosphate are used by suicidal attempters. The most commonly used insecticides for self-pesticide poisoning were methyl parathion, dichlorvos, aluminum phosphide, and zinc phosphide [27].
It is speculated that the insecticide reduction will cause a decline in the yield of the crops. But, it is not the case of the countries which are following a reduction in pesticide use because of their focus on the ecology of pests and agro-ecosystem. In that scenario, their production has been affected as speculated. Sweden has reduced pesticide use by 68% and public health poisonings by 77%. Their cutoff to the pesticides did not cause increased crop losses by the various pest species including insects. Indonesia also has reduced pesticide use by 65% and on the contrary, their production of rice has increased by 12%. India is also practicing the same and reducing the use significantly over the past years. But, Nepal is doing the opposite [25]. We are quite increasing the pesticide use for the sake of higher production, but, we are not aware of the fact that we are using unwarranted pesticides. Farmers, the ones who are not trained with the Integrated Pest Management (IPM) practices, are spraying the chemical pesticides more often than the ones who are trained. It is found that the trained farmers are spraying the pesticides 2.7 more times than the optimal whereas; the ones who are not trained are spraying 4.4 times of control [27]. This suggests the need of organizing community-based IPM training and environmental awareness programs about harmful effects of pesticides and sharing the know-how of insect pest management other than chemicals. It is also reported that Nepalese farmers are willing to pay higher prices (53–79%) than the current pesticide costs to mitigate the detrimental effect on their health and environment, and this clearly shows that they are willing to adopt alternative measures of pest management. But, the IPM programs of Nepal do have a contribution to the reduction of pesticide use but do not have a significant contribution to the reduction of health damages associated with the pesticides [25].
For the first time in Nepal’s history, the pesticide act was enacted in 1991, regulations were approved in 1993, and pesticide board was formulated in 1994 [18, 28]. Currently, Pesticides Management Act, 2019 was enacted which provisioned registration of bio-pesticides and also included the provision of facilitating warehouses for storing the date expire, band, and obsoleted pesticides in seven provinces of Nepal. It also included the provision of bringing back the pesticides which are spoiled, banned, or obsolete pesticides. It also included the provincial pesticide committee. Punishment was also provisioned in the act and upon defiance of these laws minimum of 25 thousand Nepalese Rupee (NPR) penalty, one-month prison, and maximum 200 thousand NRS penalty, and one-year prison was provisioned. Overall, the pesticide act regulates the manufacture, import, sale, transport, distribution, and use of pesticides in the country. This enabled the registration of pesticides, monitoring and inspection of pesticides, registration of importers and traders, and banning of highly toxic pesticides to minimize the exposure to humans, livestock, and other associated environmental components [29]. But, there is a great scope for proper inaction of law so that the widespread misuse of chemical pesticides in the country either by the importers, traders, and applicators could be minimized greatly. Since Nepal shares an open border with India, there are unintended pesticide imports to the country and many of them are more toxic, banned, and unregistered. Tracking the trade with India is oftentimes difficult since a porous border gives the opportunity to the persons who are involved in illegal trades.
Nepal is also a signatory country for WHO and follows the rules, regulations, and treaties proposed by them. Recently as directed by WHO, the country has banned 1a and 1b types of extremely hazardous pesticides. As a responsible member, Nepal has signed international treaties like the Basal convention, Stockholm convention, and Rotterdam convention, which have aimed to minimize the use of persistent and toxic pesticides [3].
Since Nepali farmers do not have much more information and knowledge about the methods of pest management other than chemicals. But, the Nepal Government and Department of Agriculture have started to prioritize the IPM program. Integrated Pest Management (IPM) is a pest control strategy that aims to combine various techniques of pest management such as mechanical, physical, cultural, biological, and chemical to minimize the risks possessed by the pest in a given ecosystem [30]. IPM always considers the use of chemicals as a last resort and before using chemicals, it seeks out all the possible alternatives for insect pest management.
Since 1999, the Nepalese government has used the Farmer Field School approach to strengthen farmers for cultivating healthy crops with decisions based on an understanding of the field agroecosystem with having eyes on beneficial organisms such as predators and parasites of insect pests. A Farmer Field School, also known as a school without walls, is a school that teaches basic agroecology and crop management skills. A group of farmers gathers in one of their own fields to observe, discuss, record, and analyze real-world field problems from crop planting to harvest. This field school is based on the concept of “learning by doing” rather than “seeing is believing”. The FFS was specially designed for farmers to learn and adopt IPM practices to their diverse and ever-changing ecological conditions [31]. Several crop season-long FFS have been organized in Nepal in recent years to provide knowledge and know-how on IPM to vegetable farmers in the hope of reducing their use of pesticides [32].
IPM farmer’s field schools in the country have positive impacts on the farmers for using a lesser amount of pesticides. This was evident in the Bhaktapur district of the country, which is also well known for commercial vegetable production, and seasonal and off-seasonal vegetables are produced here. As reported, farmers were using a significantly higher amount of pesticides where mean active ingredient (a.i.) of fungicides and insecticides were 2373 and 1963 g respectively and on average use of pesticide use was 2011 g a.i./ha. Among the used pesticides to cruciferous vegetables, the share of insecticides was more, that is, 76% which was followed by fungicides (19%) and unknown were 5%. The participants of IPM farmer’s field school had reduced significantly lower amounts of pesticides compared to non-participants. It was reported the 36% lesser amount of pesticides due to the effect of participation of IPM farmer’s field school [32]. In another report, pesticide application by the farmers was decreased by 40% upon participation in farmer’s field school [33]. This obviously shows the importance of these programs organized by governmental institutions.
Bio-pesticide could be a viable alternatives for Nepalese farmers since it will not be toxic to humans, other organisms, and the environment at large. There are altogether 14 registered bio-pesticides in Nepal which are effective to manage various insect pests and in some instances, other pests too of various crops. In Nepal, the use of bio-pesticides started commercially roughly after 2000. The share of bio-pesticides in the year 2019/20 is 0.005% of the total quantity of pesticides imported and used. This shows the predominantly higher use of conventional pesticides compared to commercial bio-pesticides. But, the use of locally available plant resources for pest control is a long practiced tradition of the farmers of Nepal. Many plants possess pesticide properties and these are all available all around the country. Three hundred and twenty four species of botanicals are found in Nepal only and among them, 23 species have special importance to the farming community of Nepal. The most common plants used as pesticides are as follows: Neem (
Although Nepal shares larger scope of isolation of different micro-organisms from the soil of Nepal, it offers only the formulation of two funguses, that is,
Nepal, an agrarian country located in Southeast Asia is going to face unprecedented changes in human health, environment, and ecosystems due to more use of insecticides to deter insect pests in the farmer’s field. Large amounts of insecticides are imported from foreign countries. These chemicals certainly have negative impacts on the farming community and the environment at large. The situation seems even worse because of a lack of knowledge and skills related to the safety aspects of the farming community about the use of insecticides and its negative effects not only to the consumers but on them too. Many researches have confirmed the presence of undesirable residues of insecticides in vegetables, fruits, and other agricultural commodities. Incidences of human diseases such as immune dysfunction, kidney failure, cancer, etc. are also increasing in the country which somehow has a direct or indirect relation to the more use of insecticides in the field. Because farmer knowledge and behavior can reduce the ecological risk of pesticides, programs such as IPM training and farmer’s field school (FFS), etc. could be determined to change the status quo. Prioritizing the botanicals by the Nepal government and its respective agricultural agencies to the area where there is no practice of using conventional pesticides has special significance to protect the health of humans, various flora and fauna, and the environment.
The author wishes to appreciate the contribution of all the individuals and organizations who are constantly working on pesticides, their residues, effects, and mitigation in Nepal, and who has helped the author directly and indirectly in preparing this manuscript.
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The effect of factors (such as, nanoparticle size, nanofluid concentration, flowrate of nanofluid and geometry of channel containing nanofluid) influencing the efficiency of PV systems has been discussed. Collective results of different researchers indicate that the efficiency of the PV/T systems (using nanofluids as coolant) increases with increasing flowrate. Efficiency of these systems increases with increasing concentration of nanofluid up to a certain amount, but as the concentration gets above this certain value, the efficiency tends to decline due to agglomeration/clustering of nanoparticles. Pertaining to the most recent studies, stability of nanoparticles is still the major unresolved issue, hindering the commercial scale application of nanofluids for the cooling of PV panels. Eventually, the environmental and economic advantages of these systems are presented.",book:{id:"6514",slug:"microfluidics-and-nanofluidics",title:"Microfluidics and Nanofluidics",fullTitle:"Microfluidics and Nanofluidics"},signatures:"Hafiz Muhammad Ali, Tayyab Raza Shah, Hamza Babar and\nZargham Ahmad Khan",authors:[{id:"187624",title:"Dr.",name:"Hafiz Muhammad",middleName:null,surname:"Ali",slug:"hafiz-muhammad-ali",fullName:"Hafiz Muhammad Ali"},{id:"229676",title:"Mr.",name:"Hamza",middleName:null,surname:"Babar",slug:"hamza-babar",fullName:"Hamza Babar"},{id:"241251",title:"Mr.",name:"Tayyab",middleName:"Raza",surname:"Raza Shah",slug:"tayyab-raza-shah",fullName:"Tayyab Raza Shah"},{id:"241252",title:"Mr.",name:"Zargham Ahmad",middleName:null,surname:"Khan",slug:"zargham-ahmad-khan",fullName:"Zargham Ahmad Khan"}]},{id:"59009",doi:"10.5772/intechopen.72505",title:"Thermal Transport and Challenges on Nanofluids Performance",slug:"thermal-transport-and-challenges-on-nanofluids-performance",totalDownloads:1729,totalCrossrefCites:4,totalDimensionsCites:15,abstract:"Progress in technology and industrial developments demands the efficient and successful energy utilization and its management in a greater extent. Conventional heat-transfer fluids (HTFs) such as water, ethylene glycol, oils and other fluids are typically low-efficiency heat dissipation fluids. Thermal management is a key factor in diverse applications where these fluids can be used, such as in automotive, microelectronics, energy storage, medical, and nuclear cooling among others. Furthermore, the miniaturization and high efficiency of devices in these fields demand successful heat management and energy-efficient materials. The advent of nanofluids could successfully address the low thermal efficiency of HTFs since nanofluids have shown many interesting properties, and the distinctive features offering extraordinary potential for many applications. Nanofluids are engineered by homogeneously suspending nanostructures with average sizes below 100 nm within conventional fluids. This chapter aims to focus on a detail description of the thermal transport behavior, challenges and implications that involve the development and use of HTFs under the influence of atomistic-scale structures and industrial applications. Multifunctional characteristics of these nanofluids, nanostructures variables and features are discussed in this chapter; the mechanisms that promote these effects on the improvement of nanofluids thermal transport performance and the broad range of current and future applications will be included.",book:{id:"6514",slug:"microfluidics-and-nanofluidics",title:"Microfluidics and Nanofluidics",fullTitle:"Microfluidics and Nanofluidics"},signatures:"José Jaime Taha-Tijerina",authors:[{id:"182402",title:"Dr.",name:"Jose",middleName:"Jaime",surname:"Taha-Tijerina",slug:"jose-taha-tijerina",fullName:"Jose Taha-Tijerina"}]},{id:"57228",doi:"10.5772/intechopen.71002",title:"Thresholding Algorithm Optimization for Change Detection to Satellite Imagery",slug:"thresholding-algorithm-optimization-for-change-detection-to-satellite-imagery",totalDownloads:1654,totalCrossrefCites:6,totalDimensionsCites:11,abstract:"To detect changes in satellite imagery, a supervised change detection technique was applied to Landsat images from an area in the south of México. At first, the linear regression (LR) method using the first principal component (1-PC) data, the Chi-square transformation (CST) method using first three principal component (PC-3), and tasseled cap (TC) images were applied to obtain the continuous images of change. Then, the threshold was defined by statistical parameters, and histogram secant techniques to categorize as change or unchanged the pixels. A threshold optimization iterative algorithm is proposed, based on the ground truth data and assessing the accuracy of a range of threshold values through the corresponding Kappa coefficient of concordance. Finally, to evaluate the change detection accuracy of conventional methods and the threshold optimization algorithm, 90 polygons (15,543 pixels) were sampled, categorized as real change/unchanged zones, and defined as ground truth, from the interpretation of color aerial photo slides aided by the land cover maps to obtain the omission/commission errors and the Kappa coefficient of agreement. The results show that the threshold optimization is a suitable approach that can be applied for change detection analysis.",book:{id:"6126",slug:"colorimetry-and-image-processing",title:"Colorimetry and Image Processing",fullTitle:"Colorimetry and Image Processing"},signatures:"René Vázquez-Jiménez, Rocío N. Ramos-Bernal, Raúl Romero-\nCalcerrada, Patricia Arrogante-Funes, Sulpicio Sanchez Tizapa and\nCarlos J. Novillo",authors:[{id:"213505",title:"Dr.",name:"René",middleName:null,surname:"Vázquez-Jiménez",slug:"rene-vazquez-jimenez",fullName:"René Vázquez-Jiménez"},{id:"213527",title:"Dr.",name:"Raúl",middleName:null,surname:"Romero-Calcerrada",slug:"raul-romero-calcerrada",fullName:"Raúl Romero-Calcerrada"},{id:"213529",title:"Dr.",name:"Rocío N.",middleName:null,surname:"Ramos-Bernal",slug:"rocio-n.-ramos-bernal",fullName:"Rocío N. Ramos-Bernal"},{id:"213530",title:"MSc.",name:"Patricia",middleName:null,surname:"Arrogante-Funes",slug:"patricia-arrogante-funes",fullName:"Patricia Arrogante-Funes"},{id:"213531",title:"Dr.",name:"Carlos J.",middleName:null,surname:"Novillo",slug:"carlos-j.-novillo",fullName:"Carlos J. Novillo"},{id:"221412",title:"Dr.",name:"Sulpicio",middleName:null,surname:"Sánchez-Tizapa",slug:"sulpicio-sanchez-tizapa",fullName:"Sulpicio Sánchez-Tizapa"}]},{id:"61556",doi:"10.5772/intechopen.74426",title:"Microfluidics and Nanofluidics: Science, Fabrication Technology (From Cleanrooms to 3D Printing) and Their Application to Chemical Analysis by Battery-Operated Microplasmas-On-Chips",slug:"microfluidics-and-nanofluidics-science-fabrication-technology-from-cleanrooms-to-3d-printing-and-the",totalDownloads:1851,totalCrossrefCites:6,totalDimensionsCites:10,abstract:"The science and phenomena that become important when fluid-flow is confined in microfluidic channels are initially discussed. Then, technologies for channel fabrication (ranging from photolithography and chemical etching, to imprinting, and to 3D-printing) are reviewed. The reference list is extensive and (within each topic) it is arranged chronologically. Examples (with emphasis on those from the authors’ laboratory) are highlighted. Among them, they involve plasma miniaturization via microplasma formation inside micro-fluidic (and in some cases millifluidic) channels fabricated on 2D and 3D-chips. Questions addressed include: How small plasmas can be made? What defines their fundamental size-limit? How small analytical plasmas should be made? And what is their ignition voltage? The discussion then continues with the science, technology and applications of nanofluidics. The conclusions include predictions on potential future development of portable instruments employing either micro or nanofluidic channels. Such portable (or mobile) instruments are expected to be controlled by a smartphone; to have (some) energy autonomy; to employ Artificial Intelligence and Deep Learning, and to have wireless connectivity for their inclusion in the Internet-of-Things (IoT). In essence, those that can be used for chemical analysis in the field for “bringing part of the lab to the sample” types of applications.",book:{id:"6514",slug:"microfluidics-and-nanofluidics",title:"Microfluidics and Nanofluidics",fullTitle:"Microfluidics and Nanofluidics"},signatures:"Vassili Karanassios",authors:[{id:"60925",title:"Prof.",name:"Vassili",middleName:null,surname:"Karanassios",slug:"vassili-karanassios",fullName:"Vassili Karanassios"}]}],mostDownloadedChaptersLast30Days:[{id:"53106",title:"Dynamical Particle Motions in Vortex Flows",slug:"dynamical-particle-motions-in-vortex-flows",totalDownloads:2264,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Circular vortex flows generate interesting self-organizing phenomena of particle motions, that is, particle clustering and classification phenomena. These phenomena result from interaction between vortex dynamics and relaxation of particle velocity due to drag. This chapter introduces particle clustering in stirred vessels and particle classification in Taylor vortex flow based on our previous research works. The first part of this chapter demonstrates and explains a third category of solid-liquid separation physics whereby particles spontaneously localize or cluster into small regions of fluids by taking the clustering phenomena in stirred vessels as an example. The second part of this chapter discusses particle classification phenomena due to shear-induced migration. 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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. 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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. 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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:"10",type:"subseries",title:"Animal Physiology",keywords:"Physiology, Comparative, Evolution, Biomolecules, Organ, Homeostasis, Anatomy, Pathology, Medical, Cell Division, Cell Signaling, Cell Growth, Cell Metabolism, Endocrine, Neuroscience, Cardiovascular, Development, Aging, Development",scope:"Physiology, the scientific study of functions and mechanisms of living systems, is an essential area of research in its own right, but also in relation to medicine and health sciences. The scope of this topic will range from molecular, biochemical, cellular, and physiological processes in all animal species. Work pertaining to the whole organism, organ systems, individual organs and tissues, cells, and biomolecules will be included. Medical, animal, cell, and comparative physiology and allied fields such as anatomy, histology, and pathology with physiology links will be covered in this topic. Physiology research may be linked to development, aging, environment, regular and pathological processes, adaptation and evolution, exercise, or several other factors affecting, or involved with, animal physiology.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/10.jpg",hasOnlineFirst:!1,hasPublishedBooks:!1,annualVolume:11406,editor:{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null,series:{id:"10",title:"Physiology",doi:"10.5772/intechopen.72796",issn:"2631-8261"},editorialBoard:[{id:"306970",title:"Mr.",name:"Amin",middleName:null,surname:"Tamadon",slug:"amin-tamadon",fullName:"Amin Tamadon",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002oHR5wQAG/Profile_Picture_1623910304139",institutionString:null,institution:{name:"Bushehr University of Medical Sciences",institutionURL:null,country:{name:"Iran"}}},{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón",slug:"juan-carlos-gardon",fullName:"Juan Carlos Gardón",profilePictureURL:"https://mts.intechopen.com/storage/users/251314/images/system/251314.jpeg",institutionString:"Catholic University of Valencia San Vicente Mártir, Spain",institution:null},{id:"245306",title:"Dr.",name:"María Luz",middleName:null,surname:"Garcia Pardo",slug:"maria-luz-garcia-pardo",fullName:"María Luz Garcia Pardo",profilePictureURL:"https://mts.intechopen.com/storage/users/245306/images/system/245306.png",institutionString:null,institution:{name:"Miguel Hernandez University",institutionURL:null,country:{name:"Spain"}}},{id:"283315",title:"Prof.",name:"Samir",middleName:null,surname:"El-Gendy",slug:"samir-el-gendy",fullName:"Samir El-Gendy",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRduYQAS/Profile_Picture_1606215849748",institutionString:null,institution:{name:"Alexandria University",institutionURL:null,country:{name:"Egypt"}}},{id:"178366",title:"Dr.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",institutionString:"Kafkas University",institution:{name:"Kafkas University",institutionURL:null,country:{name:"Turkey"}}}]},onlineFirstChapters:{paginationCount:13,paginationItems:[{id:"82457",title:"Canine Hearing Management",doi:"10.5772/intechopen.105515",signatures:"Peter M. 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