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Health worker and policy-maker perspectives on use of intramuscular artesunate for pre-referral and definitive treatment of severe malaria at health posts in Ethiopia
Takele Kefyalew1,
Zelalem Kebede1,
Dawit Getachew1,
David Mukanga2,
Tessema Awano1,
Agonafer Tekalegne1,
Esey Batisso1,
Wasihun Edossa3,
Emebet Mekonnen4,
James Tibenderana5,
Ebenezer Sheshi Baba5,
Constance Shumba5,
Joaniter I. Nankabirwa5,6 &
Prudence Hamade7
The World Health Organization (WHO) recommends injectable artesunate given either intravenously or by the intramuscular route for definitive treatment for severe malaria and recommends a single intramuscular dose of intramuscular artesunate or intramuscular artemether or intramuscular quinine, in that order of preference as pre-referral treatment when definitive treatment is not possible. Where intramuscular injections are not available, children under 6 years may be administered a single dose of rectal artesunate. Although the current malaria treatment guidelines in Ethiopia recommend intra-rectal artesunate or alternatively intramuscular artemether or intramuscular quinine as pre-referral treatment for severe malaria at the health posts, there are currently no WHO prequalified suppliers of intra-rectal artesunate and when available, its use is limited to children under 6 years of age leaving a gap for the older age groups. Intramuscular artesunate is not part of the drugs recommended for pre-referral treatment in Ethiopia. This study assessed the perspectives of health workers, and policy-makers on the use of intramuscular artesunate as a pre-referral and definitive treatment for severe malaria at the health post level.
In-depth interviews were held with 101 individuals including health workers, malaria focal persons, and Regional Health Bureaus from Oromia and southern nations, nationalities, and peoples' region, as well as participants from the Federal Ministry of Health and development partners. An interview guide was used in the data collection and thematic content analysis was employed for analysis.
Key findings from this study are: (1) provision of intramuscular artesunate as pre-referral and definitive treatment for severe malaria at health posts could be lifesaving; (2) with adequate training, and provision of facilities including beds, health posts can provide definitive treatment for severe malaria using intramuscular artesunate where referral is delayed or not possible; (3) health workers at health centres and hospitals frequently use the intravenous route because it allows for co-administration of other drugs, but they find the intramuscular route easier to use at the health post level; (4) the reasons commonly cited against the management of severe malaria using intramuscular artesunate at health post level were: lack of capacity to manage complications and fear of irrational drug use; (5) use of intramuscular artesunate at health post level will require evidence on safety and feasibility before policy shift.
From the perspective of health workers, use of intramuscular artesunate as pre-referral treatment of severe malaria cases at the health post is possible but dependent on training and availability of skilled workers. Use of intramuscular artesunate as definitive treatment at health posts was not supported, however, operational research to establish its feasibility, safety and efficacy was recommended to guide any implementation of such an intervention.
Malaria is endemic throughout most of the tropics, with approximately 214 million cases and 438,000 deaths reported in 2015 alone [1]. About 88 % of cases and 90 % of deaths occur in the World Health Organization (WHO) African region, and 70 % of deaths are among children under 5 years of age [1]. In endemic areas, young children and pregnant women are at high risk for severe malaria [2, 3].
Severe malaria is a life threatening medical emergency that requires prompt and effective treatment to prevent death [1, 4]. Death from severe malaria often occurs within hours of admission to health facilities due to problems with patients accessing treatment in a timely manner. It is essential that therapeutic concentrations of a highly effective anti-malarial drug are achieved as soon as possible, and that there is access to curative treatments as close as possible to where the patient lives. Compared to most other malaria-endemic countries in Africa, malaria prevalence is relatively low in Ethiopia with the parasite prevalence estimated at 0.5 % in the recently concluded malaria indicator survey [5]. Ethiopia was ranked 10th in terms of estimated incidence of malaria in East Africa in 2015 [1]. However, despite a low prevalence, malaria is a major public health problem and is one of the four leading cause of illness in children under 5 years of age in Ethiopia [6].
The current WHO recommendation is to give a parenteral antimalarial drug to treat severe malaria for a minimum of 24 h irrespective of the patient's ability to tolerate oral medication, before giving the oral follow-up artemisinin-based combination therapy (ACT) [7]. The risk of death in severe malaria is greatest in the first 24 h, yet the transit time between referral and arrival at health facilities with access to parenteral treatments is usually long. Mortality in untreated severe malaria cases approaches 100 % [7], and especially in areas of low, unstable malaria transmission [8]. Ethiopia has unstable malaria transmission and, therefore, epidemics are serious public health emergencies.
Referral of severely ill patients is faced with many challenges including lack of transport, long distance to health facilities, lack of funds for transport, distances to be covered, lack of referral slip, poor communication and poor road networks [9]. WHO recommends that where complete treatment of severe malaria is not possible patients be given single dose of the recommended parenteral treatment before referral [7, 10]. It recommends that where complete treatment of severe malaria is not possible but injections are available, adults and children should be administered as referral treatment, a single intramuscular dose of artesunate or intramuscular artemether or intramuscular quinine, in that order of preference before referring to an appropriate higher health facility. Where intramuscular injections are not available, children under 6 years may be administered a single dose of rectal artesunate [7].
In developing countries, pre-referral care for severe illnesses such as severe malaria face major challenges due to frequent stock-outs or shortages of essential supplies, and poorly organized emergency treatment [11, 12]. The basic components of severe malaria case management are lacking in most health facilities including oxygen and blood transfusion [13].
The Ethiopian government is making efforts to increase access to care for the entire population. However, in many areas access to qualified specialist care is still limited. The Ethiopian health service is restructured into a three tier system: (1) primary health care unit consisting of a primary hospitals, health centres and health posts, (2) general hospitals, and (3) specialized hospitals (Fig. 1). The health posts are managed by two health extension workers who are recruited among high school graduates in local communities, and undergo a 1-year training program to deliver a package of preventive and basic curative services that fall under four main components: hygiene and environmental sanitation; family health services; disease prevention and control; and health education and communication. The health centres are staffed by around 20 professionals and provide preventive, curative, inpatient and ambulatory services, treatment of common psychiatric disorders, and dental services. Primary hospitals are staffed by around 53 professionals and provide preventive, curative, inpatient and ambulatory services, and emergency surgical services, including caesarean section and blood transfusion. They also serve as referral centres for health centres and practical training centres for nurses and paramedical health professionals. General hospitals are staffed by around 234 persons and provide inpatient and ambulatory services. They are also referral centres for primary hospitals and training centres for health officers, nurses, emergency surgeons and other categories of health workers. The specialized hospital is staffed by around 440 professionals and serves as a referral centre for the general hospitals and provides inpatient services.
Different tiers of the Ethiopia health system and the approximate population they cover
The health workforce density in Ethiopia increased from 0.84 to 1.3 per 1000 population between 2008 and 2013 indicating improvement in supply and availability of health workers. However, the doctor, health officer, nurse and midwife to population ratio is 0.7 per 1000 population, far behind the minimum threshold of 2.3 doctor, nurse and midwife to 1000 population ratio required to ensure high coverage with essential health interventions. Nevertheless, the health extension programme has over 38,000 health extension workers working in more than 16,000 health posts thereby reaching households with essential health packages [14, 15].
In the national strategic plan 2014–2020, Ethiopia has a target of 100 % access to effective and affordable malaria treatment and to achieve near zero malaria deaths by 2020 [6]. This requires improving diagnosis of malaria cases using microscopy or using multi-species rapid diagnostic tests (RDTs), and providing prompt and effective malaria case management at all health facilities level in the country. Most malaria cases are first seen and treated at health posts and health centre level. According to the national malaria treatment guidelines, patients arriving at a health post with severe malaria are given intrarectal artesunate or intramuscular artemether when intrarectal artesunate is unavailable [16]. Unfortunately, there are no prequalified manufacturers for rectal artesunate and its use is only recommended for children under 6 years [17]. WHO recommends intramuscular artesunate for pre-referral treatment [7], but this is not currently included in the national policy guidelines in Ethiopia [16] to be delivered by health extension workers in Ethiopia.
Intravenous injections require cannulation and may be beyond the level of skills found at health posts; however, intramuscular injections are administered at this level. Studies have shown that intramuscular artesunate is rapidly absorbed when used for managing severe malaria in contrast to artemether which is oil based and absorption may be delayed especially in shocked patients [18, 19]. Intramuscular and intravenous artesunate have also been reported to be equally effective in adults [20] and children [21].
In hard to reach areas where referral of severe malaria cases is not possible or delayed, the only option left to patients and caregivers is to return home and use whatever is available within their community, at great danger to lives [22]. For these settings could health posts that are closer to communities, and where health extension workers have been properly trained and equipped provide pre-referral treatment for severe malaria using intramuscular artesunate as recommended by WHO? Could they also provide definitive treatment (defined as the treatment plan for a disease that has been chosen as the best for a patient after all other choices have been considered) where referral is delayed or not possible, given that many already provide intramuscular treatments for other conditions? This study sought to explore the perspectives of health workers, and policy makers on the use of intramuscular artesunate as a pre-referral and definitive treatment for severe malaria at health post level in Ethiopia. This will provide valuable information on the policy considerations, possible challenges to such a policy, and mitigation measures.
The study was conducted in two regions of Ethiopia, southern nations, nationalities, and peoples' region (SNNPR), and Oromia from January to March, 2015. Participants were identified from health facilities serving nine malarious areas of the regions, Zonal offices, Regional Health Bureaus, Federal Ministry of Health and partners.
Oromia is the most populous region in Ethiopia with a total population of 32 million. SNNPR is the 3rd largest regional state with a total population of 18 million [6]. SNNPR and Oromia regions have the highest malaria burden in Ethiopia [23].
The major health problems of SNNPR and Oromia remain largely preventable communicable diseases and nutritional disorders. The health system priorities are health service delivery at household, community and facility level to improve maternal, neonatal, child, adolescent and youth health, nutrition, hygiene and environmental health, and to reduce/combat HIV/AIDS, tuberculosis and malaria and other communicable and non-communicable diseases [15].
Access to care remains a problem especially in rural areas where the population is characterized by poverty and poor health indicators. The Ethiopian government has endeavored to improve access to care by providing a community based service provided by health extension workers who after a year's training provide comprehensive preventive and curative services to these remote populations and by equipping health centres with ambulances to provide care for obstetric and other emergencies but referral from health post could be delayed due to poor infrastructure or other emergencies. The Ethiopia health care tiers are presented in Fig. 1.
This was a qualitative exploratory study that used in-depth interviews to collect data on the perspectives of health workers, and policy-makers on the use of intramuscular artesunate as a pre-referral and definitive treatment for severe malaria at health posts.
Sample size and sampling technique
A total of 101 respondents were interviewed. A list of all zones from the two regions regarded high burden by the Federal Ministry of Health was used and from this list nine zones with the highest burden were selected. The selected zones were the following: East Shoa, South west Shoa and Jima zone from Oromia region, and Gomgofa, Silti, Kembata Tembaro, Halaba, Wolayita and Hadiya zones from SNNPR. A zone is an administrative area below the region, and includes several districts or woredas.
Thirty health facilities from each of the two states (Oromia and SNNPR) were purposively selected to be included in the study if they had large numbers of severe malaria cases reported (according to the routine health facility data reports) and if were easily accessible by the study team.
A maximum of two health workers, one health worker involved in management of malaria on the day of the interview and one manager in the selected health facilities were included in the study. In Oromia state, given the busy schedules of the health workers, it was impossible to interview more than one staff at the selected facilities, and two of the selected facilities were not open on the survey day. In SNNPR, all selected facilities were functional and two health workers were interviewed at each of the facilities. At two of the facilities in SNNPR, the team was able to interview both the severe malaria ward manager and well as the health facility manager. In addition, the malaria focal persons from the Zonal health departments, Regional Health Bureau, Federal Ministry of Health, and development partners were also included in the study. The number of respondents interviewed within the different categories are presented in Table 1.
Table 1 Respondents selected by category and region
An interview guide was used to collect data from respondents. In-depth interviews were conducted by twenty research assistants with research experience and trained in data collection specifically for this study. The interviews were conducted in the local languages. The research assistants working in pairs approached the managers and asked permission to conduct the study in the health facilities and for guidance on the health workers to be interviewed. Informed consent was then sought from the health workers to participate in the study. Appointments were made for interviews with all other participants at zonal, regional, Federal Ministry of Health and development partners. The research assistants took notes and audio recordings during the interviews. Supervision and guidance to the field teams was provided by two co-investigators with experience conducting qualitative research. Daily supervision of interviewers and checking of completed interviews was done to ensure collection of accurate and complete data.
Audio-recorded data were transcribed and then translated from the local languages to Amharic and then into English. Senior researchers read the transcripts and identified emerging themes, and codes. The transcripts were then coded using Atlas.ti7 (Atlas.ti GmbH, Berlin) during the coding process; more codes were identified and discussed by the research team. These codes were merged into categories and then into themes reflecting the study objectives and other emerging issues. Thematic content analysis was employed.
Characteristics of the study population
A total of 101 respondents were interviewed (Table 1). Of these, 66 (66.7 %) and 31 (31.3 %) were from SNNPR and Oromia regions respectively. The majority (73/101; 72 %) of the participants worked at various health facilities providing treatment and care for severe malaria cases. Other participants were from Zonal and Regional health departments or district health offices (7), Health Bureau and Federal Ministry of Health (1) and partner institutions (3). 63 % of the participants were female, while the average age of participants was 28 years (standard deviation 6.3). 65 % of the participants held either a degree in public health or nursing; 27 % held a certificate or diploma; while 8 % held a Masters' degree. The average duration of service of the respondents in the health sector was 4.8 years.
Knowledge and views of participants on current treatment guidelines
Several respondents knew that the current recommended treatment for uncomplicated malaria is artemether–lumefantrine for Plasmodium falciparum and chloroquine for Plasmodium vivax. Many participants knew that as injectable artesunate is the drug of choice for treatment of severe malaria.
On the other hand, a few respondents did not know the drug of choice for treatment of severe malaria cases. This lack of knowledge was found at both health centres and among health extension workers.
Quinine is a drug of choice for treatment of severe malaria. Injectable artesunate is given when a patient is not responding to quinine (Health centre staff, Oromia region).
Information on use of rectal artesunate as pre-referral treatment at community/health post level was limited with the many of the respondents indicating that patients with severe malaria should be treated in hospital and health centres.
Health workers practices around the use of intramuscular or intravenous artesunate
Both respondents from health centres and hospitals said that injectable artesunate is commonly administered in their health facility and the intravenous route was the most commonly cited route for the administration of treatment for severe malaria. However, one participant from one health centre said that 'Intramuscular injection is a common route in her facility.'
Participants said that the 'intramuscular route is an alternative route for administration of injectable artesunate'. The most common sources of information stated by participants on intramuscular route of administration of injectable artesunate in descending order were: trainings, malaria case management guidelines, and fellow health workers.
Ninety-nine percent of the participants responded erroneously that 'Gluteal muscle is the site of administration for adult patients' and only a couple of respondents correctly responded that 'the deltoid and/or ventrolateral muscles are preferred site for intramuscular artesunate.'
Benefits of using intramuscular artesunate
Although the respondents especially those working at hospitals and health centres stated that they use intravenous artesunate, they noted that the intramuscular route is easier to administer.
Yes, intravenous needs cannula, but [for] intramuscular there is no need for cannula, simply dilute and give the dose (Health Centre staff, SNNPR).
The only challenges could be in getting the vein entry at one single shot [for intravenous] (Health Centre staff, SNNPR).
However, some participants thought intravenous artesunate is faster acting than intramuscular. Another benefit identified was that less intense training is required for health workers before they can rightly administer intramuscular artesunate.
Intramuscular artesunate is not used often because intramuscular action is slow when compared to the intravenous and also intramuscular artesunate causes pain (Health Centre staff, SNNPR).
Possible barriers to using intramuscular injection at post referral facilities
Participants stated that no challenges should be expected as intramuscular artesunate is already included in the treatment guideline at the health centre and hospital level but the confidence of using the intravenous route might affect the use of intramuscular injection.
…the prevailing skill and knowledge of health workers who have been using intravenous quinine for treatment of severe malaria may negatively influence the use of intramuscular artesunate. (Medical Doctor at hospital, Oromia region).
Some participants also anticipated low usage of intramuscular artesunate for treatment of severe malaria because intravenous medication facilitates the administration of other intravenous drugs.
If the patient was on open intravenous cannula for another purpose, we also use the intravenous route not to add another burden of intramuscular administration on the patient (District malaria focal person, SNNPR).
As I said, based on [the] patient's condition we choose the route. If [the patient is] critical and need[s] additional management, we prefer intravenous route. Otherwise, Intramuscular injections are better (Medical Doctor at District Hospital, SNNPR).
The participants expressed the opinion that quinine might continue to be used because of stock outs of injectable artesunate due to poor drug and supply management affecting the use of intramuscular artesunate. The health workers stated that client preference of intravenous route was also a barrier to the use of intramuscular injections.
Those clients who are admitted are not happy with intramuscular artesunate administration, so for patient satisfaction purpose we use intravenous artesunate. (District malaria focal person, Oromia).
Practicality of health extension workers providing care for severe malaria using intramuscular artesunate as definitive as well as pre-referral treatment
Participants said that lower health facilities especially health posts are not in a position to treat severe malaria using intramuscular artesunate because of the national policy doesn't support it, extension workers have limited knowledge and skills of managing severe malaria complications, there is limited availability of suitable facilities at the health post.
As lower level health facilities do not have inpatient beds and facilities; they cannot manage severe malaria patients. Since severe malaria is a complicated medical emergency, severe malaria cases should be referred to hospitals. (District hospital staff, SNNPR).
…it is difficult for them because there may be other comorbidities which needs treatments like infusions. So admitting the patient, it may be difficult. (Zonal malaria focal person, Oromia region).
Respondents suggested that with adequate training, and provision of beds and other facilities health posts would be able to manage severe malaria with intramuscular artesunate if referral was not possible and would also be able to provide pre-referral treatment with intramuscular artesunate.
It is possible for me to treat because I already give vaccination and depo [family planning injection] which I did not know how to give before my education and training (health extension worker, Oromia region).
Benefits and risks of managing severe malaria with intramuscular artesunate at lower level facilities
Participants were concerned that health extension workers would not be able to manage complications often associated with severe malaria.
If health extension workers manage patients with severe malaria, case fatalities of malaria will increase; intramuscular artesunate should only be provided as a pre-referral treatment at health post level (Participant, partner organization).
A few participants raised the potential risk of drug resistance due to irrational use of intramuscular artesunate, as it could be used for uncomplicated malaria.
Community health care workers cannot administer intramuscular artesunate for the treatment of severe malaria because of their educational status. Parasite may adapt [to] the drug if not administered properly. (Health worker, Oromia region).
Some respondents thought that given the accessibility of health posts to the community would empower them to manage severe malaria with intramuscular artesunate and this would save lives if referral was not possible or if there were delays in getting care.
Health posts are near to the community which does not require transportation. If a patient gets sick at night, health posts are the nearest health facility to the community, therefore allowing health post to treat severe malaria cases using intramuscular artesunate is advisable (Health centre staff, Oromia region).
I am very happy, because this particular area is highly malaria endemic, if patient go to Healthcentre, he/she may not get service rapidly because [the] Health centre serve[s] a lot of population, but we are serving small population so [it is] easy for us to serve kebele [village] population (health extension worker, SNNPR).
Policy implications
Participants involved in policy advice reported that intramuscular artesunate is already included in the treatment guideline for use at hospital and health centre level. Some of participants indicated that health extension workers can use intramuscular artesunate as pre-referral treatment, but not definitive treatment of severe malaria once trained. Malaria experts who formulate policy said it is possible to revise the national treatment guidelines to include intramuscular artesunate as pre-referral treatment at community level once evidence supports its feasibility.
The key findings from this study are: (1) majority of participants knew the contents of the current treatment guidelines for uncomplicated malaria and for severe malaria at hospital level and health centre level but many did not know about the use of rectal artesunate and intramuscular artesunate for pre-referral treatment; (2) provision of intramuscular artesunate as pre-referral and definitive treatment for severe malaria at health posts could be lifesaving in situations where referral is not possible; (3) with adequate training, and provision of facilities including beds, health posts can provide injectable artesunate as pre-referral medication, however, there was hesitation of using this as definitive treatment for severe malaria (4) health workers in health centres and hospitals prefer the intravenous route because it can be used for co-administration of other drugs but suggest that in the case of health extension workers the intramuscular route is easier; (5) the most common reasons cited for not supporting the definitive management of severe malaria using intramuscular artesunate at community level were; lack of capacity to manage complications of severe malaria cases at lower level health facilities and Fear of irrational use of the drug. (6) Intramuscular artesunate is already included in the national policy for health centres and hospitals, but pre-referral intramuscular artesunate at health post level will require evidence on safety and feasibility before policy shift.
The study findings are discussed under the themes of the Bowen feasibility framework [24], i.e. demand, acceptability, practicality, and integration (Fig. 2).
Adapted from Bowen et al. [24]
Key areas of focus for feasibility studies and possible outcomes
Respondents felt that the provision of intramuscular artesunate as pre-referral but not definitive treatment for severe malaria at health posts could be lifesaving. Intramuscular artesunate has been shown to be highly effective in the management of severe malaria [20–22, 25–28] and WHO recommends the use of intramuscular artesunate where possible as pre-referral treatment. This WHO recommendation together with the study findings would effectively support the use of intra-muscular artesunate as pre-referral treatment at the health post, however, it was clear that this can only be possible with adequate training and with supporting evidence of safety and feasibility. Although evidence from trials of neonates with severe bacterial infection demonstrate that where referral is not possible, care provided near home can be life-saving [28], respondents in this study were not in agreement with health extension workers using intramuscular artesunate as definitive treatment citing the lack of knowledge to manage severe malaria complications as a limitation to this.
The health workers in this study were aware that the national malaria treatment guidelines recommend the use of intramuscular artesunate as definitive treatment at health centres and hospitals. However, many of the study participants were not aware of the WHO recommendation to use intramuscular artesunate and rectal artesunate as pre-referral treatment even when the use of rectal artesunate as a pre-referral treatment is in the policy guidelines for Ethiopia.
The study also found that healthcare workers find it easier to administer injectable artesunate via the intramuscular route compared to the intravenous route. Given the need to find a vein and use a cannula to establish a line, it is clear why the healthcare workers find using the intramuscular route easier. Jin and others [29] report findings from a study comparing preference of administering different medication using different routes; looking at the intramuscular route versus the intravenous route and conclude that the preference varies from drug to drug. On the other hand, Ntuku and colleagues [30] in a study conducted in the Democratic Republic of Congo report that healthcare workers find use of intramuscular artesunate easier to administer than quinine which is similar to these study findings although no comparison was made with other drugs.
Lack of capacity to manage complications of severe malaria cases, and fear of irrational use of the drug were cited as reasons for not supporting the use of intramuscular artesunate as definitive treatment of severe malaria at the health post level. Concerns that health extension workers might use injectable artesunate to manage uncomplicated malaria or administer suboptimal doses are fears that need to be further explored. Little work has been done on the safety of injections provided by lay health workers [31]; most of the work is heavy on lay health workers providing injectable contraceptives and shows they can be safely delivered [32, 33]. It was recommended that operational research to further explore the safety, feasibility and efficacy of using intramuscular artesunate as definitive and pre-referral treatment be conducted to support use of intramuscular artesunate to manage severe malaria cases at the health post level especially in situations when access to higher level care is difficult or impossible. These studies will provide evidence for policy recommendations on the use of injectable artesunate at the health post level which is currently not supported by both the WHO and the Ethiopia policy guidelines.
The study findings indicate that the respondents felt that using intramuscular artesunate as definitive treatment at the health-post may not be possible as management of severe malaria is beyond just providing the antimalarial, but also included management of complications which the health extension workers may not be in position to do. Although the proximity of the health post to the community, and the relative ease of administration of intramuscular artesunate were stated as points that may make it a potential option to be explored. Respondents noted that introduction of intramuscular artesunate at the health post could be hindered by inadequate and unskilled health workers, lack of equipped facilities, and lack of knowledge among health post workers to manage complications resulting from severe malaria. Indeed, many of the respondents stated that with adequate training, health centre can provide definitive treatment for severe malaria using intramuscular artesunate, however, they suggested that health posts should only provide pre-referral intramuscular artesunate and not definitive treatment. The Ethiopia national malaria policy provides for definitive management of severe malaria using intramuscular artesunate at the health centre and hospital level but not the health post.
Many health workers believe the intravenous route provides flexibility to administer other injectable drugs for comorbidities, is less painful, and is convenient to the patient. Moreover, because of previous experience using the intravenous route to deliver quinine health workers maybe more inclined to favour intravenous over intramuscular delivery. Most respondents felt that the intramuscular route was easier to use than the intravenous route due to problems inserting the cannula. Health extension workers are unlikely to have the skill to use intravenous drugs but can be trained to use intramuscular drugs. Jin and others [29] argue that if the safety and efficacy of the two injection routes are equivalent, clinicians should pay attention to patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs. Given Ethiopian's health services are highly resources constrained (in terms of supplies, personnel, space and other resources), the intramuscular route when possible provides a cost efficient option from a public health point of view that may contribute to more equitable access to care although this was not extensively explored as part of this study.
Pre-referral intramuscular artesunate at health post level will require evidence on safety and feasibility before policy shift.
Integration is the extent to which an idea, programme, process or measure can be incorporated within an existing system. The study findings indicate that injectable artesunate is already widely in use at hospitals and some health centres, with intravenous being the most commonly used route. From an integration perspective, in order to clarify for health workers when to use the intravenous or intramuscular route a standard operating procedure should be developed on the use of injectable artesunate.
Antero-lateral aspect of the thigh muscle is the preferred site of intramuscular administration of artesunate [6], yet other sites which are no longer recommended were mentioned by most of the respondents. This indicates the need for capacity building to ensure health workers know and use preferred safe sites for intramuscular administration.
Study limitations may include: (1) health facilities were selected purposively based on accessibility during the study period. It is possible that respondents from these facilities might have different views compared to those from areas that were inaccessible; (2) the interview guide was structured with questions on use of intramuscular artesunate by health extension workers before those related to use at the health centre level. This might have negatively influenced the way some respondents answered questions related to use of intramuscular artesunate at the health centre level, if they held the view that health extension workers should not use injectable artesunate; (3) as in most qualitative studies, the results of this study may not be generalizable but may be transferable to similar settings; (4) translation from local languages to Amharic and then to English may have affected interpretation of the results to some extent.
Intramuscular artesunate is easier to administer, is widely used at hospitals, and is already in the national policy for use as definitive treatment at the health centre and hospital level in Ethiopia. From the perspective of health workers in this study, use of intramuscular artesunate as pre-referral treatment of severe malaria cases at the health post is possible but dependent on training and availability of skilled workers. Use of intramuscular artesunate as definitive treatment at health posts was not supported due to lack of skills by the health extension workers to manage complications associated with severe malaria, and operational research to establish its feasibility, safety and efficacy of use of injectable artesunate as pre-referral and definitive treatments at the health post was recommended to guide any implementation of such an intervention.
SNNPR:
southern nations, nationalities, and peoples' region
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Ursu I, Kumar M. Providing timely access to pre-referral treatment for severe malaria: how ready is the market in sub-Saharan Africa? Afr Health 2015. Accessed from: http://www.mmv.org/newsroom/publications/providing-timely-access-pre-referral-treatment-severe-malariahow-ready-market. Accessed 11 May 2015.
Hien TT, Davis TM, Chuong LV, Ilett KF, Sinh DX, Phu NH, et al. Comparative pharmacokinetics of intramuscular artesunate and artemether in patients with severe falciparum malaria. Antimicrob Agents Chemother. 2004;48:4234–9.
Phu NH, Tuan PQ, Day N, Mai NT, Chau TT, Chuong LV, et al. Randomized controlled trial of artesunate or artemether in Vietnamese adults with severe falciparum malaria. Malar J. 2010;9:97.
Hien TT, Phu NH, Mai NT, Chau TT, Trang TT, Loc PP, et al. An open randomized comparison of intravenous and intramuscular artesunate in severe falciparum malaria. Trans R Soc Trop Med Hyg. 1992;86:584–5.
Nealon C, Dzeing A, Muller-Romer U, Planche T, Sinou V, Kombila M, et al. Intramuscular bioavailability and clinical efficacy of artesunate in gabonese children with severe malaria. Antimicrob Agents Chemother. 2002;46:3933–9.
Bedford KJ, Sharkey AB. Local barriers and solutions to improve care-seeking for childhood pneumonia, diarrhoea and malaria in Kenya, Nigeria and Niger: a qualitative study. PLoS ONE. 2014;9:e100038.
Federal Ministry of Health. Health sector development program IV Annual performance report, version 1, 2012/2013. 2013.
Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner DB, et al. How we design feasibility studies. Am J Prev Med. 2009;36:452–7.
Cao XT, Bethell DB, Pham TP, Ta TT, Tran TN, Nguyen TT, et al. Comparison of artemisinin suppositories, intramuscular artesunate and intravenous quinine for the treatment of severe childhood malaria. Trans R Soc Trop Med Hyg. 1997;91:335–42.
Ha V, Nguyen NH, Tran TB, Bui MC, Nguyen HP, Tran TH, Phan TQ, Arnold K. Severe and complicated malaria treated with artemisinin, artesunate or artemether in Viet Nam. Trans R Soc Trop Med Hyg. 1997;91:465–7.
Kremsner PG, Adegnika AA, Hounkpatin AB, Zinsou JF, Taylor TE, Chimalizeni Y, et al. Intramuscular artesunate for severe malaria in African children: a multicenter randomized controlled trial. PLoS Med. 2016;13:e1001938.
Tshefu A, Lokangaka A, Ngaima S, Engmann C, Esamai F, Gisore P, et al. Simplified antibiotic regimens compared with injectable procaine benzylpenicillin plus gentamicin for treatment of neonates and young infants with clinical signs of possible serious bacterial infection when referral is not possible: a randomised, open-label, equivalence trial. Lancet. 2015;385:1767–76.
Jin JF, Zhu LL, Chen M, Xu HM, Wang HF, Feng XQ, et al. The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection. Patient Prefer Adherence. 2015;9:923–42.
Ntuku HM, Ferrari G, Burri C, Tshefu AK, Kalemwa DM, Lengeler C. Feasibility and acceptability of injectable artesunate for the treatment of severe malaria in the Democratic Republic of Congo. Malar J. 2016;15:18.
Glenton C, Khanna R, Morgan C, Nilsen ES. The effects, safety and acceptability of compact, pre-filled, autodisable injection devices when delivered by lay health workers. Trop Med Int Health. 2013;18:1002–16.
Prata N, Gessessew A, Cartwright A, Fraser A. Provision of injectable contraceptives in Ethiopia through community-based reproductive health agents. Bull World Health Organ. 2011;89:556–64.
Stanback J, Mbonye AK, Bekiita M. Contraceptive injections by community health workers in Uganda: a nonrandomized community trial. Bull World Health Organ. 2007;85:768–73.
Conceived and designed the experiment JIN, JT, ESB, PH. Performed the experiment TK, ZK, DG, TA, AT, EB, WE, EM. Analysed the data TK, ZK, DM, CS, JN, PH. Drafted or revised the paper TK, ZK, DM, JT, ESB, CS, JN, PH. All authors read and approved the final manuscript.
Malaria consortium would like to acknowledge the Health Bureaus of Oromia and SNNPR states for their collaboration in conducting this study. We would also like to extend our gratitude to zonal and district health officers for their support during the conduct of the research. We thank all participants of government and partner institutions. JN is supported by the NURTURE project which is funded by NIH, Grant Number D43TW010132.
All datasets on which the conclusions of this manuscript rely will be made publicly available at http://www.malariaconsortium.org/pages/who_we_are.htm?gclid=CIm_2fC30cwCFXMz0wod3rMAqA.
This manuscript does not contain any individual person's data in any form and consent for publication is not applicable.
Ethical approval was obtained from regional ethical review boards of Oromia state and SNNPR state. Written informed consent was obtained from all study participants prior to participation in the study.
This research work was funded by UNITAID through Medicines for Malaria Venture.
Malaria Consortium Ethiopia, Addis Ababa, Ethiopia
Takele Kefyalew, Zelalem Kebede, Dawit Getachew, Tessema Awano, Agonafer Tekalegne & Esey Batisso
Science and Health Impact Group, Kampala, Uganda
David Mukanga
Oromia Regional Health Bureau, Addis Ababa, Ethiopia
Wasihun Edossa
SNNPR Health Bureau, Hawassa, Ethiopia
Emebet Mekonnen
Malaria Consortium Uganda, Kampala, Uganda
James Tibenderana, Ebenezer Sheshi Baba, Constance Shumba & Joaniter I. Nankabirwa
Makerere University College of Health Sciences, Kampala, Uganda
Joaniter I. Nankabirwa
Malaria Consortium UK, London, UK
Prudence Hamade
Takele Kefyalew
Zelalem Kebede
Dawit Getachew
Tessema Awano
Agonafer Tekalegne
Esey Batisso
James Tibenderana
Ebenezer Sheshi Baba
Constance Shumba
Correspondence to Joaniter I. Nankabirwa.
Kefyalew, T., Kebede, Z., Getachew, D. et al. Health worker and policy-maker perspectives on use of intramuscular artesunate for pre-referral and definitive treatment of severe malaria at health posts in Ethiopia. Malar J 15, 507 (2016). https://doi.org/10.1186/s12936-016-1561-6
Severe malaria
Intramuscular artesunate
Intra-rectal artesunate
Health post
Health extension worker


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Philip Rycroft, Permanent Secretary, Department for Exiting the European Union
Host PwC
Apply by Friday 22 February 2019
Join us to hear from Philip Rycroft, Permanent Secretary for the Department for the Exiting of the European Union. In this briefing you will:
hear how the Department for the Exiting of the European Union is currently preparing for Brexit, and allow you to discuss the potential impacts and opportunities that this will bring
hear Philip's priorities for his department
hear about Philip's leadership journey
Philip Rycroft was appointed as Permanent Secretary at the Department for Exiting the European Union in October 2017. As Permanent Secretary, he has responsibility for leading the department in all its work on the Government's preparations for Brexit.
Before taking up this role, he was Second Permanent Secretary at DExEU.
Philip was appointed Second Permanent Secretary, Head of UK Governance Group in the Cabinet Office in June 2015, with responsibility for constitutional and devolution issues, and retains this role.
From 2012 to 2015 he was the Director General in the Deputy Prime Minister's Office, supporting the Deputy Prime Minister across the full range of his policy interests. Prior to that, he was Corporate Affairs Director at Hutchison Whampoa (Europe) Ltd.
Tamara Finkelstein, Permanent Secretary, Defra

redpajama_set_name: RedPajamaCommonCrawl


Italian Mannerist Painter, 1503-1572 Italian painter and poet. He dominated Florentine painting from the 1530s to the 1560s. He was court artist to Cosimo I de' Medici, and his sophisticated style and extraordinary technical ability were ideally suited to the needs and ideals of his ducal patron. He was a leading decorator, and his religious subjects and mythological scenes epitomize the grace of the high maniera style.


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Canadian Cannabis Producers Decline 14.8%…
Canadian Cannabis Producers Decline 14.8% in November
Exclusive article by Alan Brochstein, CFA
After sinking more than 25% in October, the Canadian Cannabis LP Index declined another 14.8% in November to 799.72:
The index had run up from 2018 lows in mid-August after the announcement of the C$5 billion investment by Constellation Brands (NYSE: STZ) into Canopy Growth (TSX: WEED) (NYSE: CGC) ahead of the legalization in Canada on October 17th and then reversed in mid-October. An increase in the supply of stock due to new LPs going public and capital raises from existing ones, disappointment in the initial roll out of legalization, a failure of deals involving Diageo and Coca-Cola to materialize and overall market weakness has left the index down 20.4% in 2018 and 9.5% above the August lows:
One benefit to the decline in prices has been that LPs have stopped selling new shares. Additionally, there were no new listings for any LPs going public during the month. Management changes increased, with Invictus MD Strategies (TSXV: GENE) (OTC: IVITF) replacing its CEO with a member of the Board of Directors and Emerald Health (TSXV: EMH) (OTC: EMMBF) seeing both its CEO and CFO depart, with the Chairman, Avtar Dhillon, assuming the role of President. Invictus also announced the acquisition of GTEC Holdings (TSXV: GTEC) (OTC: GGTTF) in an all-stock deal as well as the acquisition of a privately-held LP in British Columbia. Terra Tech (OTC: TRTC) and Golden Leaf Holdings (CSE: GLH) (OTC: GLDFF) entered into a non-binding agreement to merge. Many of the LPs reported financials during the month, including four of the five largest LPs. Much of the news during the month focused on international expansion. Finally, the industry was reminded of the importance of compliance, as Health Canada moved towards revoking the license of Agrima Botanicals, a subsidiary of Ascent Holdings (CSE: ASNT) (OTC: PGTMF).
The index, which included 45 publicly-traded licensed producers that traded in Canada at the end of October, with equal weighting, is rebalanced monthly. Each of the members is also included in a sub-index, with four in the Canadian Cannabis LP Tier 1 Index twenty-seven in the Canadian Cannabis LP Tier 2 Index and fourteen in the Canadian Cannabis LP Tier 3 Index during the month.
Tier 1, which includes the LPs that are generating sales of at least C$4 million per quarter, fell 16.8% in November and is now up 13.1% year-to-date. This group included Aphria (TSX: APHA) (NYSE: APHA), Aurora Cannabis (TSX: ACB) (NYSE: ACB), CannTrust (TSX: TRST) (OTC: CNTTF) and Canopy Growth. Within the group, Aphria had the worst return at -33.1%. It has been the poorest performing major LP in 2018 thus far, declining 43.8. Canopy Growth's 51.8% year-to-date return, the only positive performance among major LPs, leads the group. It declined the least during the month among the major LPs.
Tier 2, which includes the remaining LPs that are permitted to generate sales, declined 10.3% and is now down 24.9% year-to-date. Cronos Group (TSX: CRON) (NASDAQ: CRON), Green Organic Dutchman (TSX: TGOD) (OTC: TGODF), HEXO Corp (TSX: HEXO) (OTC: HYYDF) and Supreme Cannabis (CSE: FIRE) (OTC: SPRWF) all managed gains, while Golden Leaf Holdings, TerrAscend (CSE: TER) (OTC: TRSSF) and THC Biomed (CSE: THC) (OTC: THCBF) all declined more than 25%. Despite the decline, TerrAscend remains the best performing LP in 2018, up 126%.
Tier 3, which includes the LPs that are licensed to cultivate but not yet approved to sell, fell 23.0% and is now down 21.3% year-to-date. The best performer from this group was BlissCo (CSE:BLIS) (OTC: HSTRF), which gained 4.8%. Ascent Industries, facing revocation of its license, performed the worst among the group with its 52.6% decline.
The returns for the overall sector varied greatly, with only Cronos Group gaining more than 20%, while six declined by more than 30%:
For December, the overall index had no changes. BlissCo moved from Tier 3 to Tier 2 after having received an amendment to its license that permits sales. Readers should be aware that Tilray, with no Canadian listing, is not eligible for inclusion in the index, which is denominated in Canadian dollars.
In the next monthly review, we will summarize the performance for December and discuss any additions or deletions. Be sure to bookmark the pages to stay current on LP stock price movements within the day or from day-to-day.
Get ahead of the crowd by signing up for 420 Investor, the largest & most comprehensive premium subscription service for cannabis traders and investors since 2013.
Based in Houston, Alan leverages his experience as founder of online communities 420 Investor, the first and still largest due diligence platform focused on the publicly-traded stocks in the cannabis industry. With his extensive network in the cannabis community, Alan continues to find new ways to connect the industry and facilitate its sustainable growth. At New Cannabis Ventures, he is responsible for content development and strategic alliances. Before shifting his focus to the cannabis industry in early 2013, Alan, who began his career on Wall Street in 1986, worked as an independent research analyst following over two decades in research and portfolio management. A prolific writer, with over 650 articles published since 2007 at Seeking Alpha, where he has 70,000 followers, Alan is a frequent speaker at industry conferences and a frequent source to the media, including the NY Times, the Wall Street Journal, Fox Business, and Bloomberg TV. Contact Alan: Twitter | Facebook | LinkedIn | Email
ACB, agrima botanicals, apha, Aphria, ascent industries, asnt, aurora cananbis, blis, BlissCo, CannTrust, Canopy Growth, CGC, cnttf, CRON, Cronos Group, Emerald Health, emh, EMHTF, Gene, ggttf, GLDFF, GLH, Golden Leaf, Golden Leaf Holdings, GTEC, GTEC Holdings, hstrf, Invictus, ivitf, pgtmf, trst, WEED
Aphria Cannabis Net Revenue Grows 7% Sequentially to C$68 Million in Fiscal Q2
Global Cannabis Stocks Advance 62% in Q4 to End 2020 with a Gain


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Latest Sectarian Attack in Chitral
Ismaili holy site torched
Daily Times, December 1, 2006
PESHAWAR: Unknown miscreants burnt down a holy site belonging to the Ismaili community in Chitral district, which has seen sectarian violence in the past, police said on Thursday. The incident took place on November 25 when an Ismaili place of worship was reduced to ashes in Rech village, Torkhow tehsil, 170 kilometres away from Chitral city. "We are investigating the incident," DSP Headquarters Sultan Bacha told Daily Times over the phone from Chitral. Police have not arrested anyone yet and Bacha declined to say whether the incident was linked to past sectarian violence. Prince Karim Aga Khan, the spiritual leader of the Ismaili sect, has spent billions of rupees on community development projects across the district and continues to invest in the development of the area. staff report
The Debate in Boston about Two Pakistani Imams
Arrests of local imams divides community on law enforcement
Dueling petitions spark debate over immigration
By Kristin Erekson :Jewish Advocate - Thursday November 30 2006
Two Bostonians expanded the debate on immigration rights to the Web last week as they created an online petition in support of the recent arrests of local Muslim leaders.
Imams Hafiz Muhammed Masood of the Islamic Center of New England in Sharon and Hafiz Abdul Hannan of the Islamic Society of Greater Lowell in Chelmsford, along with Masood's 24-year-old son, Hassan, were released on bail from the Plymouth County House of Correction last Tuesday.
The Pakistan natives were among 33 individuals taken into custody around the country as part of an ongoing investigation into a visa fraud scheme. The plan allegedly helped large numbers of illegal aliens fraudulently obtain religious worker visas to enter or remain in the states, according to a statement released by the U.S. Immigration and Customs Enforcement.
Local bloggers "…
Muslims in America - All's well that ends well?
Lawyer wrongly arrested in bombings: 'We lived in 1984'
CNN: November 29, 2006
PORTLAND, Oregon (CNN) -- The U.S. Justice Department said Wednesday it is paying $2 million and apologizing to an Oregon lawyer wrongly accused of being involved with the 2004 train bombings in Madrid, Spain.
Brandon Mayfield was arrested in Portland on a material witness warrant in May 2004, less than two months after the bombings.
According to an FBI affidavit at the time, his fingerprint was identified as being on a blue plastic bag containing detonators found in a van used by the bombers.
The FBI's fingerprint identification was wrong, however, and Mayfield was released several days later.
The bombings of four commuter trains March 11, 2004, killed 191 people and wounded more than 1,800.
Mayfield charged he was a victim of profiling because the Portland-area attorney was a Muslim convert.
He and his family later sued the U.S. government for damages.
"We lived in 1984," Mayfield told rep…
Pakistani Journalists in the Line of Fire
Journalists err, militants punish
By Iqbal Khattak
Daily Times, November 29, 2006
PESHAWAR: "Let me chop off his head who has reported that I have surrendered to the army," late Taliban commander Nek Muhammad said a day after his April 24, 2004, deal with the army that was dubbed a "capitulation" by the media.
The remarks frightened a group of journalists, among them this correspondent, who were interviewing Nek Muhammad in the Kaloosha area of South Waziristan a day after the Shakai deal, which collapsed on foreign terrorists' issue within months. The journalists looked at each other with pale faces after hearing from Nek Muhammad that their necks depended on their reporting from Waziristan.
On our way back to Wana after meeting Nek Muhammad, my BBC colleague and I were laughing to recover from the unbelievable moments since we did not know how our organisations interpreted the deal. People in Peshawar, Islamabad, Lahore or Karachi may not realise it, but it is very difficult for journa…
Inside Chitral
Pakistan's Chitral District: A Refuge for al-Qaeda's Top Leadership?
By Hassan Abbas
Terrorism Focus - Jamestown Foundation
Volume 3, Issue 46 (November 28, 2006)
In the hunt for Osama bin Laden and other top al-Qaeda leaders, security services continue to focus on Pakistan's Chitral district in the North-West Frontier Province (NWFP). Chitral became a concern after the release of a bin Laden videotape from September 2003 in which trees native to the Chitrali mountain range were evident. Extensive search operations for the al-Qaeda leader and fellow operatives by Pakistani and U.S. forces were conducted in the area in February-March 2003 (Dawn, March 7, 2003). More recently, in May there were claims that the Federal Bureau of Investigation had established an office in Chitral to monitor militant activities in the district (The Nation, May 1). Other links to the district include Abu Khabaib, an Arab explosives expert who has been spotted several times in the hills of Chitral. …
Pakistan growth creates wealth gap: BBC
Pakistan growth creates wealth gap
By Paul Moss
BBC News, The World Tonight : November 28, 2006
Salman has a way with words. He also has a snappy dress sense, and a keen knowledge of the communications industry. He should be going places.
In fact, Salman was going places, a rising success at the firm where he's been working in Karachi for the past two years.
That was until they brought the new guy in.
"He didn't know anything about the industry," Salman explains.
"But he comes from an important Pakistani family, one with land, power. Our aristocracy.
"The family made a call to my firm, told them to hire this guy, and that was that."
Salman says that since the new arrival was put in charge of his department, morale and output have both plummeted.
And he has particular reason to be bitter.
He is one of a growing number of Pakistanis who have lived abroad, but decided to come back to work in their homeland, and try to make their mark on its newly-growing e…
Politics, not religion, at the heart of growing Muslim-West divide
UNITED NATIONS: Alliance of civilizations
Politics, not religion, at the heart of growing Muslim-West divide, new report argues
(ISTANBUL, TURKEY 13 November) The key reasons for the growing divide
between Muslim and Western societies are not religious, but political, concludes a report presented to Secretary-General Kofi Annan today in Istanbul.
On receiving the report, the Secretary-General said: "We need to get away from stereotypes, generalizations and preconceptions, and take care not to let crimes committed by individuals or small groups dictate our image of an entire people, an entire region, or an entire religion.
"We should start by reaffirming -- and demonstrating -- that the problem is not the Koran, nor the Torah or the Bible. Indeed, I have often said the problem is never the faith - it is the faithful, and how they behave towards each other."
In its report, the High-level Group of the Alliance of Civilizations maintains that although religion is of…
Armitage in the News again: Not for threatening Pakistan!
Afghanistan may destabilise Pakistan, India: Armitage
SINGAPORE: Failure to restore peace to Afghanistan may jeopardise stability in neighbouring Pakistan and have a knock-on effect on India, said former US deputy secretary of state Richard Armitage on Monday.
Calling on the international community to pay more attention to Afghanistan, Armitage said persistent violence in that country might wreck Pakistani President Pervez Musharraf's efforts to defeat forces of religious extremism at home.
"I want to call your attention to Afghanistan. The stakes in Afghanistan are actually larger in the near term than they are in Iraq," said Armitage at a seminar for conflict mediators in Asia.
Continued clashes in Afghanistan could also have knock-on effects on India, which may already perceive itself to be surrounded by failed or failing states such as Nepal, Sri Lanka and Bangladesh, he said.
Afghanistan is currently enduring its bloodiest period since US-led coaliti…
Bajaur Bombing?
US carried out madrasah bombing
The Sunday Times November 26, 2006
THE bombing of a Pakistani madrasah last month, in which 82 students were killed, was carried out by the United States, a Pakistani official has admitted, writes Christina Lamb.
The madrasah in the tribal agency of Bajaur was bombed during a visit to Pakistan by the Prince of Wales amid allegations that it was being used to train suicide bombers.
"We thought it would be less damaging if we said we did it rather than the US," said a key aide to President Pervez Musharraf. "But there was a lot of collateral damage and we've requested the Americans not to do it again."
The Americans are believed to have attacked after a tip-off that Ayman al-Zawahiri, the deputy leader of Al-Qaeda, was present. Local people claimed the victims included boys as young as 12 and that the tribal area had been negotiating with the Pakistan government for a peace deal.
Pakistani officials insist they were shown satellite images of people traini…
Changing Realities of Asia
VIEW: The Asian age —Dr Ayesha Siddiqa
In India, Hu spoke about Beijing's desire to befriend India and find an amicable solution to resolve their bilateral disputes. Hu also offered India bilateral cooperation in the field of civil nuclear energy, which is a major step in reducing the overall tension between the two countries
It is after ages that Islamabad was decorated with such fervor to receive a foreign dignitary. The main roads were lit up at night and the garbage cleaned, all to welcome the Chinese President, Hu Jintao. The gracious welcome signified the importance of China's friendship for Pakistan.
Islamabad's relationship with Beijing has remained reasonably steady since the early 1960s, especially in terms of the supply of conventional and non-conventional military technology. In the past seven years, Islamabad has also generously welcomed Chinese investment in Pakistan and made room for Chinese companies to exploit Pakistan's real estate, agric…
Tariq Ramadan on Islam and the West
Watch Tariq Ramadan talking about Islam and the West: click here
For views of Tariq Ramadan, visit his website: Click here
Cutting the holy fathers down to size: how?
Yesterday's battles
By Ayaz Amir: Dawn, November 24, 2006
WAS there no Islam before the Hudood Ordinance, 1979? Will there be no Islam after this iniquitous law is amended? What storm of absolute nonsense are the mullahs trying to whip up?
Not that they are succeeding but that's beside the point. We have other problems that need attending to. But trust our talent for irrelevance to raise a tempest over non-issues.
Some of our more imaginative clerics have warned that the Women Protection Bill (which amends the Hudood law) will lead to sexual anarchy. Funny and not a little titillating. Sexual anarchy in God's own republic? Ghalib comes to mind: "Keh khushi say mar na jatay gar aitbar hota..." (Wouldn't we die of joy were we to believe this.)
To see the way we go on about things relating to women, it would seem that women are our biggest problem, bigger than democracy, bigger than anything else. The more we have segregated and separated them, the more they seem to ride our imagination. Natu…
Indian-Islamic Civilization and Persian Language
AUTHORS: Preserving links
By Asif Farrukhi
Dawn: November 19, 2006
Down to earth and unassuming, Professor Latif Ullah is a reserved and simple man. He shuns publicity and stays away from the limelight. He is the author of five books related to Sufism and poetry and has translated some eight books from Persian into Urdu. Not associated with any of the so-called learned bodies, he carries out his intellectual pursuits with a remarkable degree of independence and personal devotion. This is how I have been seeing him for a long time now; neither green in sawan nor dry in bhadon.
"What's in a name," he may ask. Some of his books carry the name Professor S.M. Latifullah, which may sound ponderous in Urdu. He was named Mohammed Latif Ullah by his father but later on added Sohail himself. His full name is documented on his passport, but is hardly ever used. His matriculation certificate states his date of birth as July 1928, but he thinks that it is most probably an estimate. Born in the state …
Ground Realities in Pashtun region
US faces snowballing Afghan war, says Orakzai
Says US, Nato and Kabul closing their eyes to reality | 50,000 more troops needed | Hopes for treaty in Bajaur
ISLAMABAD: The United States and NATO face a snowballing war in Afghanistan and will suffer a military disaster unless they back peaceful means to end the conflict, NWFP Governor Ali Mohammad Jan Orakzai said on Friday.
He said Washington, NATO and the Afghan government were "closing their eyes" to the reality that a military-based strategy was making matters worse. "Either it is lack of understanding or it is a lack of courage to admit their failures," Orakzai said. "Like in Iraq, it was the lack of courage to admit their faults. They have admitted them now but at very great cost." Rather than fighting just the Taliban, Orakzai said, NATO forces now faced a wider revolt from Afghanistan's Pashtun ethnic majority that had grown alienated because of indiscriminate bombings, economic deprivation and a lack of representation. "T…
Empowering Muslim Women - From New York!
Bid To Bring Female Voice To Islamic Law Ben Arnoldy
Muslim Women From 25 Countries Meet In New York, Forming Council
Christian Science Monitor:November 21, 2006
For centuries, devout Muslims have looked to the fatwa — an opinion based on religious reasoning of a learned individual or committee — for direction on how to resolve moral dilemmas ranging from the mundane to the sublime. And for centuries, Muslim women have conceded the ground, for the most part, to the men who issue these opinions.
That's beginning to change.
Meeting in New York over the weekend, Muslim women from 25 countries began laying groundwork for the first international all-female council formed to issue fatwas. Their idea: to ensure that women's perspectives on Islamic law become part of religious deliberation in the Muslim world — particularly on issues such as domestic violence, divorce, and inheritance.
"There's this growing sense on the part of literate Muslim women ... that there is a vital need…
Pashtun Jirga for Peace: Will it Work under the Circumstances?
Jirga for peace
By Rahimullah Yusufzai: The News, November 24, 2006
The Pakhtun amn (peace) jirga hosted by the Awami National Party (ANP) in Peshawar on November 20 was the first of its kind and it seems there will be a few more in the coming months. The event brought together Pakhtun politicians, religious scholars, intellectuals, ex-bureaucrats and diplomats, and artistes, all sharing the carpeted stage despite having conflicting political views. Some of the participants were non-Pakhtun but they belonged to the North-West Frontier Province (NWFP) and as such were sons of the soil.
Almost all the speakers highlighted the pain that they had suffered due to the continuing violence in the Pakhtun-inhabited areas across the 2,500-kilometre long Durand Line border in Afghanistan and Pakistan. They voiced the yearning of the Pakhtuns for peace in a region that has been turned into a battlefield by the world and regional powers. It was pointed out time and again from the stage that bloodshed…
India-China Relations Warming up
Hu favours Council seat for India
Amit Baruah
The Hindu, November 24, 2006
Both sides moving in the "right direction" on civilian nuclear cooperation, say officials
NEW DELHI: Chinese President Hu Jintao has gone "beyond" the support extended by Premier Wen Jiabao to India for a permanent seat in the United Nations Security Council, according to senior South Block officials.
Mr. Hu told Prime Minister Manmohan Singh on Tuesday that China would be happy to see India in the Council, the officials said on Thursday.
Referring to a provision in Tuesday's joint declaration that India and China should have regular summits, they said the idea was to have annual meetings in either of the two countries. From the Chinese side, either the President or the Premier could be present.
"Negatives" discussed
While maintaining that relations with China required "careful management," the officials warned that if negatives were allowed to dominate, the relations…
What is going to happen in Iraq?
Secret story of US retreat in Iraq
Daily Times Monitor: November 23, 2006
LAHORE: According to credible Iraqi sources in London and Amman, a secret story of America's diplomatic exit strategy from Iraq is rapidly unfolding, The Huffington Post reports.
The report says that key events include: First, James Baker told one of Saddam Hussein's lawyers that Tariq Aziz, former deputy prime minister, would be released from detention by the end of this year, in hope that he will negotiate with the US on behalf of the Baath Party leadership. The discussion recently took place in Amman, according to the Iraqi paper al-Quds al-Arabi.
Second, Secretary of State Condoleeza Rice personally appealed to the Gulf Cooperation Council in October to serve as intermediaries between the US and armed Sunni resistance groups not including Al Qaeda, communicating a US willingness to negotiate with them at any time or place. Speaking in early October, Rice joked that if then-Secretary of Defence Donald Rumsfeld …
"Arms for Peace" Fair
Pakistan holds 'arms for peace' fair
By Syed Shoaib Hassan BBC News, Karachi
Pakistan is bolstering its position as a trading zone for small arms and military hardware through arms fairs that have become a regular feature in recent years.
The International Defence Exhibition and Seminar (Ideas) fair, held every
two years in the southern port city of Karachi, provides a platform for Pakistan to display its products, ranging from light arms to tanks and missiles.
The fair also attracts major manufacturers of arms and military support equipment from around the world.
Since 2000, when the first Ideas fair was held, the number of participants has grown both in number and prestige.
This year's participants include, among others, Northrop Grumman, Raytheon, Lockheed Martin, Saab, Rolls Royce and Thales.
Some governments also have an official presence. The UK is represented by the Ministry of Defence.
'Global security'
"We are looking to promote industrial cooperatio…
Disappearing Journalists: Who is Behind all this?
Disappearing journalists
The Nation, November 22, 2006
The International Federation of Journalists (IFJ), which represents more than half a million journalists in over 115 countries, has described the state of press freedom in Pakistan as "rapidly skidding towards lawlessness," and entering a state of crisis. During the last six months, Pakistan has seen four journalists killed and each of the four cases remains unsolved. The younger brothers of two journalists were brutally murdered, as if to teach the older brothers a lesson. In addition, four journalists were reportedly detained and tortured by intelligence agencies.
The latest victim of what Amnesty International calls "enforced disappearances" is Dilawar Khan Wazir, a BBC Urdu service reporter in Pakistan's tribal region of South Waziristan. He has not been heard of since leaving Islamabad for home on the morning of Monday, November 20. On November 1, the body of Mohammad Ismail, Islamabad bureau chief for Pakistan Pre…
Honoring Nobel Laureate Dr. Abdus Salam
EDITORIAL: The tragedy of our treatment of Dr Abdus Salam
Dr Abdus Salam (1926-1996) died ten years ago. He was the first Pakistani to get a Nobel Prize in 1979. But he might be the last if we continue to allow our state to evolve in a way that frightens the rest of the world. Our collective psyche runs more to accepted 'wisdom' than to scientific inquiry; and even if we were to display an uncharacteristic outcropping of individual genius the world may be so frightened of it that it might not give us our deserts.
We are scared of honouring Dr Salam because of our constitution which we have amended to declare his community as 'non-Muslim'. When Dr Salam died in 1996 he had to be buried in Pakistan because he refused to give up his Pakistani nationality and acquire another that respected him more. But the Pakistani state was afraid of touching his dead body. He was therefore buried in Rabwa, the home town of his Ahmedi community whose name is also unacceptab…


Candid Career - Environmental Scientist, Environmental Systems Analysis, Inc.
Environmental Scientist, Environmental Systems Analysis, Inc.
Charlotte is an Environmental Scientist with Environmental Systems Analysis, Inc in Annapolis, Md. Charlotte plays a key role in monitoring the effect of new construction on the surrounding environment and making sure developers are meeting federal regulations. This is a great career for someone looking to merge the environment with science!


PT. DEEN DAYAL UPADHYAY INTER COLLEGE was established in 1998 and it is managed by the Pvt. Unaided. It is located in Rural area. It is located in RAJPUR block of KANPUR DEHAT district of Uttar Pradesh. The school consists of Grades from 9 to 12. The school is Co-educational and it doesn't have an attached pre-primary section. The school is N/A in nature and is not using school building as a shift-school. Hindi is the medium of instructions in this school. This school is approachable by all weather road. In this school academic session starts in April.
The school has Private building. It has got 0 classrooms for instructional purposes. All the classrooms are in good condition. It has 2 other rooms for non-teaching activities. The school has a separate room for Head master/Teacher. The school has Pucca boundary wall. The school has have electric connection. The source of Drinking Water in the school is None and it is functional. The school has 8 boys toilet and it is functional. and 8 girls toilet and it is functional. The school has a playground. The school has a library and has 500 books in its library. The school does not need ramp for disabled children to access classrooms.The school has no computers for teaching and learning purposes The school is not having a computer aided learning lab. The school is Not Provided providing mid-day meal.


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Pope Innocent III
Lotario di Segni
Lotario de' Conti
Italian nobility; his family were the counts of Segni, Italy. Related to Pope Gregory IX and Pope Alexander IV. Nephew of Pope Clement III. Received his basic education in Rome, Italy, theological education in Paris, France, legal training in Bologna, Italy. Created cardinal in 1190 by Pope Clement III.
Innocent brought the doctrine that since the spirit take pre-eminence over the body, and since the Church rules the spirit and earthly monarchs rule the body, earthly monarchs must be subject to the pope. Immediately upon election, he set out to make the pope an ecclesiastical ruler of the world with secular political power.
Innocent recognized the future Holy Roman Emperor Frederick II as king of Sicily after Frederick's mother, Empress Constance, accepted papal authority over Sicily. On Constance's death, Innocent took Frederick as his ward. He arbitrated the dispute between Philip of Swabia and Otto IV in Germany in favor of Otto in 1201, then in 1207 in favor of Philip, then after Philip's murder he crowned Otto emperor in 1209. He excommunicated Otto in 1210, and ordered the election of Frederick as German king in 1212.
In England, Innocent set aside the two rival claimants and had Stephen Langton elected archbishop of Canterbury. King John, seeing a pattern of interference with his authority by pope and clergy, persecuted the Church. Innocent placed England under interdict, excommunicated John in 1209, and threatened to depose him. The people and barons supported the pope, and John submitted, receiving England and Ireland in fief from the pope, and promising annual tribute to the Vatican. The pope stood with John against the barons when they forced him to grant the Magna Carta; Innocent declared it null as exacted by force, and as a vassal's promise made without his overlord's approval.
Innocent was the virtual lord of Christian Spain, Scandinavia, Hungary, and the Latin East. Philip II of France resisted his political influence, but bowed to his authority over Philip's desire for divorce. Innocent reclaimed the Patrimony of Saint Peter, the duchy of Spoleto, the Marches of Ancona, and the Ravenna district, and was recognized as overlord by Tuscany; northern Italian cities maintained their independence.
Innocent called the Fourth Crusade which never made it to the Holy Land, but instead attacked Christians on the island of Zara and in the Byzantine Empire. He excommunicated the crusaders, but used their conquest to spread the Latin rite over the empire of Constantinople. The effort failed, and the schism between East and West worsened.
Innocent initiated the Albigensian mission, dispatching Blessed Peter of Castelnau and Saint Dominic de Guzman to evangelize them, and the Albigensian Crusade following Blessed Peter's martyrdom. He supported the Teutonic Knights in the incursions along the Baltic. He called the Fourth Lateran Council on 15 November 1215. He approved and supported the orders and missions founded by Saint Dominic and Saint Francis of Assisi. Approved the Hospitallers of the Holy Ghost on 23 April 1198. Approved the Trinitarians on 17 December 1198. Approved the Humiliati in June 1201. Sent missionaries to Prussia. Built the hospital Santo Spirito in Sassia, which still stands. Constantly held papal court, with a good name for impartiality. Wrote extensively, and his De contemptu mundi (On the Contempt of This World) was widely read in the Middle Ages. His theory of papal monarchy had a profound effect on the development of the papacy.
1160 at Anagni, Italy as Lotario di Segni
Papal Ascension
16 June 1216 at Perugia, Italy
buried in the cathedral at Perugia
body transferred to the Lateran in December 1899
beatifications
Blessed William of Maleval
canonizations
Saint Belina
Saint Cunegundes
Saint Gilbert of Sempringham
Saint Homobonus of Cremona
Saint Jón Helgi Ögmundarson
Saint Procopius
Saint Wulstan of Worcester
Innocent the Great, by Charles Harry Clinton Pirie-Gordon
"Pope Innocent III". CatholicSaints.Info. 22 October 2018. Web. 18 January 2022. <>


Heating, ventilation and air conditioning, or HVAC, systems are intricate devices as they heat and cool your home. With all three operating elements in one unit, you'll have a system that will warm, cool and dehumidify your home.
The air from your HVAC system moves to each room of your house through ducts. When you install an HVAC unit, you'll have a handy and quiet way to provide comfortable temperatures throughout your home year-round.
When you have a central air conditioner or heat pump unit, you have a split system as the device includes an outside element, which is the condenser, along with an indoor mechanism called the evaporator coil.
During the operation of your system, the unit will transfer air from one section to another. For instance, when you use the AC unit, the system will remove warmth from your home's inside air and shift it outdoors. After it removes the heat from your home, it will circulate the remaining cool air with a fan.
Your system also contains a substance called refrigerant, which transports heat within the unit. The compressor in your HVAC system has the job of altering the unit's vaporous refrigerant into a gas that contains high temperatures and pressure. When the gas moves through the condenser coil, the vapor will lose heat. During the condenser's processing of the gas, the substance increases in temperature and pressure while it becomes a liquid. The liquid will then move through your unit's copper tubing and into the evaporator coil.
Once the refrigerant reaches the evaporator coil, it expands, which reduces the liquid's temperature and pressure. After the gas becomes a low temperature, reduced pressure gas, it will soak up the warmth from the air that is moving in your home's ducts. At the same time, the gas is shifting back to your HVAC system's compressor.
During the air cooling process, your AC unit will also remove the moisture from your home's air. While the warm air moves over your system's evaporator coil, it is unable to contain the water. Therefore, the moisture shifts towards the exterior of your system's coils and through the drain. You can compare the process to the condensation that occurs on the outside of a glass of ice water.
When your HVAC system heats your home during cold weather, it will take warmth from the outdoor air. If you have a geothermal unit, then it will remove heat from the ground. Once the unit extracts the heat, it will shift the warm air indoors to the evaporator coil, which will distribute the heat throughout your home.
Your HVAC system will pull the heat for your home from cold exterior air. Even if the winter air temperature is 30 degrees, it will contain heat. Keep in mind that air without any amount of heat will be colder than -200 degree Fahrenheit. Therefore, your system can pull a lot of heat from the winter air in your climate. Once the unit draws cold air into the heat exchanger, it will alter the cold temperature air into warm air. Your system's fan will then send the air into your home.
If you live in a cold weather environment, then your system may have a back-up heating device, which will help your system heat the cold air.
When you have an HVAC system installed in your home, the device will need ductwork to distribute the air within your residence. Your ductwork will contain bendable tubes that include insulation. When your home contractor installed your ducts, he or she placed them across the floor of your attic and underneath your home.
If you live in an older home, then you may consider contacting our service experts to complete a leak test. Keep in mind that you spend approximately 44 percent of your home's energy on heating and cooling. Therefore, you'll want to ensure that your ducts are not leaking. When we complete an assessment of your ducts, we'll review your system's design as improper duct planning can cost you energy dollars.
In some cases, ducts can be too small for the space they must heat and cool. Additionally, ducts can be too large, which can cause air intended for one room to be sent to the room with larger ducts.
Depending on your area's climate, you may choose to install a packaged AC unit, which unites the condensing system and the evaporator coil. We would install your packaged unit outside. Once we evaluate your residence, we can recommend the best system for your climate and home.
When you contact our company for AC maintenance, we can show you the different elements of your HVAC system.


text:
Swastika Mukherjee Shares Filming Experience Of Qala, Says, 'I Felt So Helpless'
Every frame of Qala carried a sense of heartbreak for Swastika Mukherjee. Mukherjee portrays Urmila Manjushree in the most recent OTT drama. She is a chillingly cruel mother whose daughter longs for her acceptance and love. Triptii Dimri and Babil also played lead roles in the movie.
Before director Anvitaa Dutt offered her the role, according to actor Swastika Mukherjee, the two had extensive conversations that lasted all day about everything but the movie. However, the emotional dam broke when the actor read the Qala script five days later.
In a recent interview, the actor added, "Anvitaa and I had previously discussed her vision for the movie, so when she gave me the script and I heard the narration, I felt as though I already knew these characters and the setting. Even though I've worked on a lot of movies, this time I cried. I've never experienced it before."
Swastika Mukherjee On Qala, Says, 'I Felt So Helpless':
The actor claimed that even on paper, Qala moved her so deeply that she couldn't help but feel helpless as she tried to comprehend the strained bond between the mother and daughter. "Can't these people talk? I kept telling Anvitaa. Can we do nothing about it? Although I was aware that it was a story, I kept asking her to write something else instead of this. Can't we see them in a better space? Because I felt so helpless."
Suggested Reading: Deepika Padukone Set To Unveil The FIFA World Cup Trophy
In order to portray Urmila flawlessly, she brought that sense of helplessness with her to the film's shooting, which, in her words, "sailed her through." But when her daughter watched the movie and felt equally broken, it all came flooding back a few months later. "I felt miserable being outside of their world, and I really wanted to act. My daughter was howling on the phone when she called me after watching the movie. Why couldn't they just talk, she kept asking."
The actor is aware of the rarity of what Qala offered her as a performer. Even if she reads ten scripts a year, only two of them amaze her. Qala was one of them.
QalaSwastika Mukherjee
Patriarchy On Plane: Women Cannot Escape Harassment Even In The Air


You know, I considered putting a pic on!
It was quite alarming I feel quite silly now!
I had all sorts running through my head and as always google makes it so much worse!
I'm just cleaning the rat cage and there is some bright blue poop in the litter box!
They only thing I can imagine they have blue is thier chew toys would this turn thier poop blue?
They don't have anything blue in thier diet they seem fine behaviour wise.


text:
namespace DefaultNamespace
{
    using System;

    class BB
    {
        public static bool[] m_static1 = new bool[7];
        public BB[] Method1()
        {
            return new BB[7];
        }
        public bool[] m_field2;
    }

    class DD
    {
        public static BB m_static2 = new BB();

        public static int Main()
        {
            try
            {
                new BB().Method1()[2].m_field2 = BB.m_static1;		//Normally, must throw NullReferenceException
            }
            catch (NullReferenceException)
            {
                return 100;
            }
            return 1;
        }
    }
}

redpajama_set_name: RedPajamaGithub


I am Peter Aufschnaiter. I am leading the expedition.
أنا بيتر أوفشيناتر أنا أقود البعثة.
I am sure I am no good to you.
انا متأكدة انني غير جيّدة إليك.
I am Mr. Wong. I am best man in wedding.
Well, I am a college grad. I am sure I could find something.
I am brave enough to admit that I am very scared to die.
I am telling you guys, I am close to snapping.
I am deeply touched by this generous gesture, and I am immensely grateful.
I am packed here. I am doing this.
I am quite confident I am feeling better now.
I am here, and I am incredibly eager to talk about college.
I am meeting and I am showing.
I am learning that who I am is not so bad.
And I am so lucky I am marrying him.
و أنا محظوظة للغاية أنني سأتزوج به.
I am both, and I am neither.
النتائج: 95707. المطابقة: 95707. الزمن المنقضي: 906 دقائق.


text:
MCQ Questions for Class 9 Civics Chapter 4 Electoral Politics with Answer
Mod Education are Provided for CBSE RBSE NCERT MCQ Questions for Class 9 Civics Chapter 4 Electoral Politics with Answers Pdf free download. MCQ Questions for Class 9 Social Science with Answers were prepared based on the latest exam pattern
MCQ Questions for Class 9 Civics Chapter 4
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MCQ Questions for Class 9 Civics Chapter 4 Electoral Politics with Answers
How many seats are reserved in the Lok Sabha for the Scheduled Castes and Scheduled Tribes?
Our country is divided into
(a) 500 constituencies
(b) 543 constituencies
(c) 550 constituencies
(d) 552 constituencies
Answer: (b) 543 constituencies
The number of Lok Sabha constituencies in Uttar Pradesh is
The number of Lok Sabha constituencies in Delhi is
Answer: (d) 7
The minimum age required for being a voter is:
(c) 18 years
(d) 15 years
Answer: (c) 18 years
Who appoints the Chief Election Commissioner of India?
(a) The Chief Justice of India
(b) The Prime Minister of India
(c) The President of India
(d) The Law Minister of India
Answer: (c) The President of India
Who led the 'Nyaya Yudh'?
(a) Chaudhary Charan Singh
(b) Chaudhary Devi Lal
(c) Ajit Singh
Answer: (b) Chaudhary Devi Lal
Which of these is not a feature of Indian democracy?
(a) India has the largest number of voters in the world
(b) India's Election Commission is very powerful
(c) In India, everyone above the age of 18 has a right to vote
(d) In India, the losing parties refuse to accept the electoral verdict
Answer: (d) In India, the losing parties refuse to accept the electoral verdict
What is meant by the term 'constituency'?
(a) Place where the copy of constitution is kept
(b) A particular area from where voters elect a representative to the Lok Sabha / Vidhan Sabha
(c) A body of voters
Answer: (b) A particular area from where voters elect a representative to the Lok Sabha / Vidhan Sabha
In India, elections for which of these bodies are held after every five years?
(a) Rajya Sabha
(b) Lok Sabha and Vidhan Sabha
(c) Vidhan Parishad
(d) Only Lok Sabha
Answer: (b) Lok Sabha and Vidhan Sabha
What is an election held for only one constituency to fill the vacancy caused due to the death or resignation of a member called?
(a) By-election
(b) Mid-term election
(c) General election
Answer: (a) By-election
Constituencies called 'wards' are made for the election to
(a) Parliament
(b) State Legislative Assembly
(c) State Legislative Council
(d) Panchayats and municipal bodies
Answer: (d) Panchayats and municipal bodies
Which of these is not a part of the district and local level bodies?
(a) Panchayats
(b) Municipalities
(c) Corporations
(d) Lok Sabha
Answer: (d) Lok Sabha
for voting, the voter has to show which of these as identity proof?
(a) Ration card
(b) Driving license
(c) Election Photo Identity Card
Answer: (c) Election Photo Identity Card
What is the details the candidates have to give in the legal declaration before contesting the elections?
(a) Serious criminal cases pending against them
(b) Details of assets and liabilities of the candidate and his or her family
(c) Educational qualification of the candidate
Name the body which conducts the elections in India
(a) Supreme Court
(c) Cabinet
(d) Election Commission
Answer: (d) Election Commission
When on election duty, under whose control does the government officers work?
(a) Central Government
(b) Election Commission
(c) District Magistrate
(d) District Court
Answer: (b) Election Commission
What does the term 'incumbent' mean?
(a) The current holder of a political office
(b) The candidate contesting the election
(c) The outgoing candidate of the dissolved House
Answer: (a) The current holder of a political office
The Election Commission is:
(a) An elected body
(b) An appointed body
(c) An independent body
(d) both (b) and (c)
Answer: (b) An appointed body
Which of the following statement is incorrect?
(a) All citizens above the age of 21 can vote in an election
(b) Every citizen has the right to vote regardless of caste religion or gender
(c) Some criminals and persons with unsound mind can be denied the right to vote in rare situations
(d) It is the responsibility of the government to get the names of all eligible voters put in the voters list
Answer: (a) All citizens above the age of 21 can vote in an election
What is the age of a person who can contest election for the Lok Sabha in India?
Answer: (a) 25 years
Voter's List is also known as:
(a) Election Number
(b) Voter Identity Card
(c) Electoral Roll
Answer: (c) Electoral Roll
Which of the following statements is against the democratic process of elections?
(a) Parties and candidates should be free to contest elections
(b) Elections must be held regularly immediately after the term is over
(c) The right to vote should be given to the selected people only
(d) Elections should be conducted in a free and fair manner
Answer: (c) The right to vote should be given to the selected people only
Reserved Constituencies ensures
(a) Right to equality
(b) Proper representation to all religious groups
(c) Proper representation to the weaker sections of society
Answer: (c) Proper representation to the weaker sections of society
Who has given the slogan 'Garibi Hatao'?
(a) Indira Gandhi
(b) Rajiv Gandhi
(c) Sonia Gandhi
(d) Pt. Nehru
Answer: (a) Indira Gandhi
(d) The people of India
The number of seats reserved for Scheduled Castes in the Lok Sabha is:
Categories Class 9 Social Studies Tags 9 Social Science MCQs, 9 SSt MCQ, 9 sst mcqs, class 9 sst, MCQ Class 9 Civics Chapter 4 Post navigation
MCQ Questions for Class 9 Civics Chapter 3 Constitutional Design with Answers
MCQ Questions for Class 9 Civics Chapter 5 Working of Institutions with Answer


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Patay Pál (1888–1971) református lelkész
 Patay Pál (1914–2020) régész, harangkutató

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