Kim Glas is the deputy assistant secretary for textiles and apparel within the International Trade Administration's Import Administration division.
Deputy Assistant Secretary Kim Glas and Under Secretary Francisco Sanchez tour Unifi's sewing thread manufacturing facility in Yadkinville, North Carolina on October 9, 2012.
I am visiting North Carolina today with the Under Secretary of Commerce for International Trade Francisco Sánchez to see first-hand two state of the art textile companies – Unifi and A&E. Recently, President Obama signed into law an important set of technical fixes to the U.S.-Dominican Republic-Central America (CAFTA-DR) Free Trade Agreement that will have a direct impact on jobs at these two companies and sewing thread manufacturers across this state and country.
When the Agreement with our Central American neighbors was negotiated in 2003, there was a definitional loophole that incentivized the use of non-U.S. sewing thread in the assembly of textile and apparel products. As a result of this loophole, U.S. sewing thread manufacturers have seen their business and employment shrink. The Obama Administration immediately set out to address a problem that severely impacted U.S. sewing thread manufacturers.
After years of hard work, President Obama recently signed legislation to close a loophole that has jeopardized businesses and jobs in the U.S. As a result, on Saturday, October 13th, these fixes will be implemented and will have a direct impact on many sewing thread manufacturers in North Carolina. We have every expectation that once the legislation is implemented that U.S. sewing thread producers like Unifi and A&Ewill be able to recapture market share in the critical market.
This is a prime example of what can be accomplished when industry, Congress, and the Administration work toward a common goal.


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Two-Day MotoGP Test Ends at Jerez With Honda Riders, Including Lorenzo, Fast
honda motogp jerez maverick vinales takaaki nakagami franco morbidelli
LCR Honda rider Takaaki Nakagami surprised with the quickest lap of the test. The final MotoGP test of 2018 was completed earlier today at the Jerez circuit. Good weather both days saw some very quick times. Just like the Valencia test last week, this test saw several riders, both rookies and...
Published on November 30 2018, 13:55
Source: www.motorcycledaily.com
Thankfully, day two of MotoGP testing at Phillip Island was a dry one. Following a good showing in second place in the wet yesterday, Maverick Viñales proved it wasn't a fluke by lapping fastest in the dry today. His margin of superiority wasn't much, though, as the top ten were all within one...
For some race fans, the news that the tire wars are back will be music to their ears. The trouble is, the new tire wars which broke out at Jerez are of a very different kind to the period before the advent of the spec tire, when different manufacturers went head-to-head in pursuit of outright...
MotoGP Testing Resumes At Sepang by staff Tuesday, February 26, 2013 The second official MotoGP preseason test of 2013 is underway at Sepang, as riders and teams return to Malaysia to tweak, thrash and tune Tuesday through Thursday. A look at what's at stake for the three factory teams and...
The test on Monday at Jerez was probably the most important test of the year so far. A chance to test the day after a race, in similar conditions, and with ideas born of the data from the first four races of 2016 to try out. There really was a lot to test: not just parts and setup, but also...
Jerez is an important punctuation mark in almost every Grand Prix season. Whether it kicks off the year, as it did ten or more years ago, or whether it marks the return to Europe after the opening overseas rounds, the racing at Jerez is always memorable and remarkable. Not always necessarily...
Backing It Up: Lorenzo & Rossi 1-2 At Jerez Post Race Test Aprilia to "avoid going down paths that lead nowhere" by staff Monday, May 04, 2015 These just in: Yamaha Successfully Completes Jerez Test Movistar Yamaha MotoGP?s Jorge Lorenzo and Valentino Rossi successfully concluded the one-day...
The Sepang MotoGP test proved to be most instructive, both for the fans, who got a first taste of what the 2018 season could look like, and for the factories, who put the first imaginings of this year's bikes – and especially engines – through their paces. We learned that Ducati has taken...

redpajama_set_name: RedPajamaCommonCrawl


Understanding the Financial Aid Award Letter; What are Your Options?
Parents who completed a College Costs Estimator should already have an idea of the cost of attending a college and what financial aid the student may be eligible for. For families who have not completed a College Costs Estimator, the financial aid award from the college may be their first realization of the cost of attendance. You may receive your first award this spring and a decision must be made no later than May 1 (for most colleges).
Note: Parents and students, put a priority on the completion of the degree/certificate. Attending college for a few semesters is not the goal. Students who have not completed their certificate/degree have the highest student loan default rate. They do not benefit from the higher paying jobs that require a degree but still must pay off their student loans. This has created a loan nightmare for many students without a degree.
Make sure you understand the financial aid award. If the student has received scholarships, are they renewable? Are there loans included in the award? You may want to call the university and see if you can expect to receive a similar award next year.
Loans are not the enemy, not understanding the payments and interest is the enemy. You would never sign a loan for a car or home without knowing what your payments are. Why would you not make sure you understand the payments on a student loan? Make an appointment with the financial aid office to discuss the loans you expect to take out for this program. Then make one with Career Services to find out what income you may expect upon graduation. Can you afford the payments for these loans with the intended career?
If the financial aid award is not going to work financially for your family, what are the options?
You may want to look for other schools that offer the same program at a lower cost. Is this certificate/degree offered at a community college where the student can commute?
Students who are working towards a Bachelor's Degree (four years) may also want to look into the option of a commutable college. Is there a community college the student could attend for the first two years and then transfer to the 4-year college? Students who attend a community college may want to look into working towards an Associate's Degree before transferring to a four-year college. If a student is eligible for the Indiana state grant program, Indiana currently has an additional need-based grant for students who complete their Associate's Degree before completing a Bachelor's Degree. This is a win/win, you may be eligible for the extra grant money and if something prevents you from completing the 4-year program, you already have an Associate's Degree. There often are good jobs for applicants with an Associate's Degree.
In Indiana, consider the Ivy Tech ASAP program, an 11-month accelerated Associate's Degree program. There are 16 ASAP programs throughout Indiana. The transfer scholarships available to ASAP students are significant. The coursework is spread over five eight-week terms, and classes are held from 9AM-5PM, Monday-Friday. Contact your local Ivy Tech campus for additional details if they offer the ASAP option.
What about the family who had an unusually high income in 2015, the tax year used for the most current FAFSA? If you do not expect to have incomes at this level again, what now? You may want to appeal to the financial aid office to make adjustments to the financial aid award. This is called a "professional judgement." Please view the March 2017 Monthly Feature Article for more information about professional judgements.
Preparation for college can be difficult at times. The financial aid office at the college can help you understand your financial questions and options. College is like many other events in life, it may be difficult at times, but the rewards can be vast and amazing. The final result includes a certificate/diploma which could be your ticket to job security and more possibilities for professional advancement. Make it happen!


Since the launch of our business in 2014, we will be adjusting our prices on our services for the first time. New prices will be effective on April 15, 2018 and can be seen by selecting the appropriate country at pricing link above.
As a part of branding and reputation of your business, one of the most underestimated details of your communication strategy is your company's voicemail greetings. Your business should be able to effectively explain your operating hours, right department to contact etc to your existing & potential customers without being boring or complicated.


Planning your own Grand Design? Make sure your self build project runs as smoothly as possible with our expert guides and advice, plus take inspiration from our self build homes case studies. From choosing a plot to funding and finding the right architect, you can ensure your own self build is a success.
From sustainable building materials to thermal energy efficient technology, we've rounded up a few of the best and most innovative green building ideas.
Research has shown that approximately one million people in the United Kingdom are taking part in their own building projects, be that self build homes, extensions, garden rooms, conversions or property renovation.
Normally a building project is undertaken to increase living space for family or entertaining requirements or to increase the value of a property. Sometimes, it's because of the builder's desire to create an outstanding piece of architecture that is appealing and different, whether it's constructed on an empty plot of land, or to extend an existing property.
The key to a successful self build is finding the right plot. Once a plot of land has been found, before starting a project, planning permission is required for building. While starting a self build project might sound an interesting challenge, be aware of the financial implications. Establishing a budget, and staying on budget can be a huge challenge in itself, and so it is important to get these in place from the beginning.
Finding the right architect for your self build will mean that you are able to create a brief to design the perfect family home, the spacious kitchen or the exciting tree house that you've always wanted.
The average self build can take up to a year just at the pre-planning stage, and then another year to complete on site, or sometimes more. It's important to not rush the pre-planning process, as rushing at the early stage of any building project could cause architectural or other problems in the future. Prioritise external areas of the building to be completed first; interior installations, improvements and decorative touches can be pushed back to after the build completion.


RODRIGUEZ — Savannah A. Diaz and Jesus J. Rodriguez of Hermiston: a boy, Matthew Uriah Rodriguez.
HESS — Challis L. Bock and Lawrence E.V. Hess of Heppner: a girl, Victoria Lillie Hess.
MAYBEE — Whitney Maybee and Bart Maybee of Hermiston: a boy, Felix T. Augustus Maybee.


after the very unfortunate fire incident, our class could not proceed with our clay assignment so instead we made prints about our feelings and reflections from the fire. i wasn't in the fire i came in after they evacuated the building, but i saw people confused and scared trying to help each other (since so many of them left their stuff and know more about what exactly happened in the building. i was with my friend Deanna and i was helping her with everything i can; phone, jacket, and food. but Deanna was still in a bad mood. i was getting stressed out too and caught up in the moment seeing everybody's energy and it sort of effected me too even though i was not in the fire and i didn't lose anything. Deanna didn't thank me for the help i provided before she left with her friend, so i got a little annoyed and then i left. when my prof. asked for my experience and feelings from the fire, all i can think of is Deanna acting selfish, so that what i etched on the copper plate to express my experience of the fire.
in this second printing project i made prints about a myth that i made up combining two mythical creatures from greek mythology; hell's watch dog, Cerberus, and the Lernean Hydra. they're both the offsprings of Typhon and Echidna. combined the visuals of both of them; multiple headed dog with dragon like claws. in the first print i decided to go basic and only use black to see the original etching, then i noticed that the feet weren't as noticeable so i went over it again with the needle and did my second print using only purple ink. after that i decided to experiment with the ink and i mixed the purple ink with yellow, and it came out in this color that is not purple or yellow but some color in between. on my fourth print i decided to go further with the experimentation and use only yellow ink but i wasn't sure if it's gonna come out clear so i painted the paper with watercolors for a landscape illusion for the mythical creature. i did the same thing for my fifth and last print, but i added gold acrylic paint and instead paint chaotic background and make it seem as if the mythical creature was on fire. and in result that made only one head of its five show up and the rest were blurry and that served the chaotic feel of my last print.


All of my paintings and drawings are one-of-a-kind originals work of art. Everything is handmade, hand-drawn and hand painted by me, the artist. This product is already created and I will SHIP in 1-3 days. If you are my own customer and shop at my store let me know I will match price to my store price. Question please text me at 301-564-1451 I am in Maryland. Copyrights I have copyrights on all of my art work and they can not be reprinted, scanned or reproduced in anyway . Most of my painting are very large. 24X48 I sale them at my Store in Antique Row Kensington, Maryland. Please drop by when you are in Washington D.C area. or if you leave there.


The Groundhog is Coming: Are You Prepared?
His name is Punxsutawney Phil. He has been resting all winter but February 2nd is his day. It is right around the corner. The groundhog is coming. Soon, Phil will emerge from his hole in Punxsutawney, Pennsylvania and try to find his shadow. If he sees his shadow, he will run back into his hole, and winter will continue. If he doesn't see it, then spring will come early. As the Earth continues its annual elliptical journey around the sun, the planet will start to warm, and the plants in your yard, like the groundhog that heralds them, will awaken.
Are you prepared for an early spring?
While groundhog shadow spotting is something of an inexact science, there is always the very real chance that we may have an early spring this year. You know how it goes. One day you are walking down the icy streets in your boots, and next warm spring rains are causing crocuses to pop their tiny purple faces out of the ground. Spring is tricky, and it can sneak up on you: before you know it, your lawn will be filled with a patchwork of dead grass and thriving weeds if you are not properly prepared.
How can you prepare for the possibility of an early spring?
Are your power tools cleaned and charged? Is your lawn mower's blade sharp?
Do you have all of the supplies you need? Grass seed? Fertilizer? Soil?
Do you have a plan of attack? Have you decided where and when to plant the fruits, vegetables, and flowers in your garden?
Do you have plans to do something new in your yard this year? Are you going to build raised flowerbeds, or trim your topiaries into new and exciting shapes?
It's important to have a plan, have your supplies ready, and set a schedule for the season before Punxsutawney Phil has his say. A little preparation goes a long way when it comes to the care and feeding of your lawn.


text:
Drew Griffin is a Dick
In the past year, many good bad and ugly people have tried to define me. "Hey, everyone else is writing a story about stay-at-home-dads! Get on it!"
And they did. We were poker-playing monkeys for these journalistic zoologists. And what offended them most was our presumptuousness. How dare we try to define ourselves? Don't we know there are people who are paid to define us?
Marie Claire called us trophy husbands and status symbols, Dr. Laura said we destroy marriages, David Brooks said we weren't nurturing, and The Atlantic said we simply weren't necessary.
But finally, Josh Levs from CNN let a few blogging fathers have their say. Finally, fathers get to talk about daddy-blogging in particular and about modern parenthood in general. Unfortunately, what should have been a positive piece has turned into a ridiculous attack on blogging fathers and on stay-at-home fathers.
Here's some of the video.
Now, I'm saying the video above is some of the video because the actual CNN video includes a great line from Drew Griffin, CNN's own mustache-free Ron Burgundy. The three CNN hosts talk about the bad economy, and Griffin says, "Fortunately, we haven't been turned into stay at home dads just yet."
Other than this keeper, there are enough comments from Griffin to warrant the title of this post. He suspects, for example, that fathers don't read these blogs. Not sure where he gets that one from. Oh, and stay-at-home-dads shouldn't waste time writing and reading blogs, because they should spend their time watching their kids. Well, actually I have some spare time and I spend it reading and writing blogs. Or as I said on Twitter:
Categories: I Have Opinions
SciFi Dad September 30, 2010 at 7:42 AM
What kills me about these sorts of discussions is that they are reporting on something that they have NO understanding about, like NONE. So, instead of trying to understand, they simply sit back and disagree with what the bloggers are saying, even though they have no basis for their opinion.
JK September 30, 2010 at 8:57 AM
I've never heard of any of these CNN tools, and I don't care what they say about fatherhood. I've been a stay-at-home/work-at-home dad for 8 years. In that time I've been pity-ed, scorned, and snickered. I have also had at least enough sex to reproduce 2 more times and made enough money that my family lives comfortably (always below our means) and goes on a weeks vacation every year. Screw the new "re-examination" of manhood, and fatherhood this just means that men are out of work in middle America too, the difference? Many of these men can't cut it, just as many wives of stay at home dads couldn't cut a daily existence where the only goal, is to get out of the house without a baby fecality. Some women aren't cut out to be mothers but most CAN have a child, some men aren't cut out to be fathers but most CAN cause a child. Hopefully we can eventually get to a place where opinions about gender suitability for parenthood reach parity, and males on TV feel comfortable discussing something other than football.
Daddyo October 1, 2010 at 7:23 AM
I am not a stay at home dad, the longest I have been the stay at home parent was 5 weeks when my wife was on teaching rounds before graduating.
I have a huge amount of respect for mothers and fathers who stay at home with the children.
You are doing a fantastic job and kudos from me.
Jack Steiner October 1, 2010 at 4:45 PM
The world is filled with morons- some of them with cameras and microphones.
BloggerFather October 4, 2010 at 8:02 PM
SciFi Dad, not much to expect from those empty-headed bimbos. They're no better than the Fox News kind.
JK, see, although there have been stay-at-home-dads before I started blogging about it (can you imagine?), there is a sense of a gradual change in perception. As much as I don't care about perception, there are real life implications to the visibility of stay-at-home-dads, even if it's just the existence of changing tables in men's rooms. With the visibility, though, come attempts by professionals and other idiots to quickly define this phenomenon and move on to the next issue. Today it's stay-at-home dads, tomorrow it's the rise of vampire sub-culture among teenagers. Still, after the positive visibility comes the backlash (not just from a CNN tool, but even from some blogging fathers). I just had to speak out against the backlash, even if ultimately it matters little to my own life.
Daddyo, thanks. Although it's not easy, I know many of us can't imagine going back to work outside. (That's why we keep making those babies.)
Jack, I know. There are some good people out there, but the morons are always louder.
I've been learning a lot about the dad blog community this past weekend. I've always enjoyed your blog and I have huge amounts of respect for SAHDs. Also, I thought your Tweet rocked!
ericdbolton October 6, 2010 at 1:51 PM
News people don't know how to converse without a teleprompter it seems like.. Because when they try too.. They talk out their arse..
Kevin October 7, 2010 at 9:47 AM
I really wanted to chime in on this but I felt I'd be too much on my soapbox. Besides, you said it best in your post.
BloggerFather October 9, 2010 at 2:31 AM
Lee, thanks. And good luck.
Eric, empty-headed bimbos. Exactly like the Fox News crew. That should probably be the new CNN catchphrase.
Kevin, thanks! And if only one person Googles "Drew Griffin" and ends up here, then I did my job. You can say I'm a dreamer, but I believe that one day, people will say "Drew Griffin," and immediately think "Dick."
husgrund October 9, 2010 at 4:32 PM
I dont understand the attack at all. Blogging fathers / work at home fathers pay tax and can work hard. what is the problem
Leah October 11, 2010 at 3:11 AM
Hi, I'm a fellow blogger who just found that nifty site you did and added the facebook like widgit. I am not very code savvy and wondered if you would be so kind as to tell me what portion of code I need to remove in order for my widgit to show up on the home pages too (as you have done with yours). I would be soo appreciative! Oh, and I love your tweet about blogging instead of watching CNN. Too funny :)
Steve @ Captured Technology October 11, 2010 at 10:06 PM
He is a poor representative for the news profession.
BloggerFather October 12, 2010 at 12:42 AM
Hey Leah, no worries. I'm also not code savvy. For some reason, the post that had the Facebook box didn't include instructions on getting the box on the main page, but a similar post (with a Like button but without a box) did say how to do that. Here it is:
http://www.bloggerplugins.org/2010/04/facebook-like-button-for-blogger.html
You don't have to copy the final code from that page (because that means no box). Just find and delete the two red lines that disappear when you change Display from "On Post Pages" to "Everywhere." Let me know if it doesn't work.
Leah October 13, 2010 at 9:08 PM
I got it! Thanks so much for your help :)
BloggerFather October 14, 2010 at 2:13 AM
Cool. Looks good. Glad I could help.
Darius October 18, 2010 at 3:31 AM
What a dick.
News thrives off controversy just as flies thrive off of shit. But unlike flies, when what they thrive on doesn't actually exist, they always try to create it. And personally, I think the flies deserve more respect than reporters like this creep because they obviously get more constructive work done than he does. But it's CNN, just one of the many "news" stations known for not exactly setting any standards of fair or ethical journalism, which is why I don't bother watching the news either. I'd rather play with my kid.
I loved your tweet and your coverage of the issue.
Keep on keepin' on.
Hey, Darius, thanks for the comment. It's sad to think that people like him actually have the power to shape popular opinion. Although in the end, popular opinion doesn't really matter as well.
Keith Wilcox October 22, 2010 at 6:58 PM
I've gotta say that, while these hosts don't quite grasp what's going on in the dad community, I thought they asked some relevant questions. Griffin, being the interviewer, clearly has no idea what he's talking about and that's annoying. But, the 6 blogger panelists really did an awesome job and represented us well. So, I think they were the meat of the thing, and what they said was really good. But, you're right -- it would have been nice to hear a little less snark from the host.
Keith, for me it was just a shame that the two CNN hosts let their own insecurities get in the way of a good story. At least that's how I saw that. The fathers did a great job, I agree.
James (SeattleDad) October 25, 2010 at 5:04 PM
I know. What a dumb ass. It was a good story minus the peanut gallery Griffin and the other dude provided.
Promotional Parker Pens November 12, 2010 at 10:08 PM
I have been the stay at home parent was 5 weeks when my wife was on teaching rounds before graduating.
Excel 2007 Training December 13, 2010 at 1:53 AM
I think the flies deserve more respect than reporters like this creep because they obviously get more constructive work done than he does. But it's CNN, just one of the many "news" stations known for not exactly setting any standards of fair or ethical journalism, which is why I don't bother watching the news either.
Calgary Web Design December 13, 2010 at 3:01 PM
People all over the world make money for looking down on others.
Creative-Type Dad January 3, 2011 at 1:18 PM
What can I say -- I've stopped watching CNN years ago because their standards have turned into Perez Hilton-type journalism.
Roller Skating Wheels April 5, 2011 at 7:08 AM
I think the flies deserve more respect than reporters like this creep because they obviously get more constructive work done than he does.
A Family Hobby
Basanta


text:
NYC's Fifth Avenue Sees Steep Rent Decline as Tenants Struggle
The area on Fifth Avenue between 42nd and 49th streets saw a 25 percent decline in retail rents since 2018.
Flagship Barneys Madison Avenue Store Will Stay Open for Now
The department store's flagship New York location will remain open for at least another year.
Barclays Faces SEC Probe into Sales of Property-Backed Bonds
A former trader alleges the bank aggressively marketed a deal for bonds backed by hotels in a way that "could amount to securities fraud."
Qatar Wealth Fund Buys St. Regis Hotel That Invented Bloody Mary
QIA paid $310 million for the prominent Manhattan property. The Marriott sale comes after recent acquisitions by the company.
Forever 21 Plans to Close About 60 Fewer Stores After Rent Cuts
Rent concessions from landlords will help Forever 21 keep down its planned store closings.
Chicago Is the Greenest Place to Work in America
More than 71 percent of the city's office space has been certified green.
MGM Sets Year-End Target for Sale of MGM Grand in Las Vegas
The company expects to find a buyer for the hotel by the end of the year.
L.A.'s $1 Billion Trophy Tower Halted as China Pulls Back
As its Chinese developer struggled with finding money to finish the project, the Oceanwide Plaza in Los Angeles is now in limbo.
In One Empty Store, Retail Apocalypse Comes with Zombies
A glut of empty retail space is forcing landlords to get more creative than ever.
Two Companies Are Dominating the Battle for Warehouse Space
Between them, Blackstone and Prologis have made more than $38 billion in warehouse acquisitions in 2019.


Admittedly, the gala season in New York is exciting. I sometimes feel my heart racing when an extraordinary performance is given, or a bold fashion statement made. However, on Thursday, October 11, 2018, there was a little too much action in the Cipriani 42nd ballroom as the Global Lyme Alliance (GLA) held its annual dinner.
Cocktails started at 6:30 PM with a host of "celebrities" walking the red carpet including "The Real Housewives of New York" and Yolanda Hadid - the evening was off to a good, yet unremarkable start. Fast forward one hour and the ballroom is at a standstill. A 60-year-old man collapses on the floor and is unable to awaken. There are scores of doctors in the room who have trouble finding his pulse and are contemplating administering CPR. The speeches come to a halt, Yolanda Hadid rushes over to help, and an ambulance is called. Fifteen minutes later the man awakens, the ambulance arrives, and all is back to normal.
This was a dramatic start to a dinner that was full of surprises. The evening began with emcee Lori Stokes thanking attendees for participating. Chairman Robert Cobre, Vice Chairman of Credit Suisse, then described his family's fifteen-year struggle with Lyme and the post-traumatic stress disorder they still suffer. He said memories he had of kissing girls in a wooded canteen and walking through grass were now tainted by his family's battle with Lyme. He also pointed out it is called Lyme disease, not Lymes disease as it's often referenced.
Scott said GLA had partnered with a biotech company to develop a drug that kills ticks while being safe for humans. Moreover, a test is in the works that can adequately diagnose Lyme 90% of the time as opposed to the 50% accuracy rate of the current test; further explaining that illustrious Lyme doctor Steve Schutzer joined 28 experts in producing a test which detects DNA from microbes circulating in the blood that contain Lyme.
Everything was looking good as we were treated to the annual trapeze act where a gorgeous couple wow the crowd with daring moves - I was holding my breath after the fainting mishap. This dinner always has me in tears as I listen to the stories of people whose lives are drastically altered by a tick.
Tonight a gorgeous Yolanda Hadid, who last year announced she was in remission, took to the stage looking radiant in a white sequined skirt and top. This year she had not prepared a speech because she said her disease had returned -lamenting that she has only been Lyme free one year since her diagnosis in 2000. Yolanda said she was a "badass Dutch girl" and tearfully spoke of the thousands of children who can't afford adequate medical treatment. Hadid's heroism is remarkable; attending the gala despite receiving treatment all day. She said if she died within the next week this was the cause she would choose to fight for.
It is a remarkable achievement to use your celebrity platform to bring worldwide awareness to a scourge that effects over 300,000 people a year. Yolanda who has seen more than 106 doctors for her ailment said she was also advocating for her children Bella and Anwar who suffer from Lyme. While it is common knowledge that Lyme is not contagious, it is curious as to how three people in one family contract it. Searching the internet, I saw an interview with her ex-husband David Foster, who claimed the family probably got it from horseflies which can carry the disease (they are avid equestrians).
While Yolanda highlighted her struggle in depth when she was on the "Beverly Hills Housewives" tonight it was time for "The Housewives of New York" to film Ramona Singer being honored. Sonja Morgan, Dorinda Medley, and Tinsley Mortimer boisterously took part in the evening. Morgan was wearing a pretty black flowered dress that she was selling on the internet for $100 along with a couture line with prices ranging from $250-$1,200-I can finally afford "couture." These ladies are raking it in as they start clothing and handbag lines, write books and make celebrity appearances.
I was heretofore unaware that Ramona had suffered from Lyme as she appears healthy and energetic. When Ramona accepted her award she relayed that it was her sister who had contracted the disease - I then tuned out for the rest of her "speech" (for those interested I am sure you can watch the upcoming TV show for a recap.) During the evening the "Housewives" could be seen gathering around party planner extraordinaire Lawrence Scott who is himself a major socialite and philanthropist. Tonight he donated the magnificent decor which included gold tablecloths and elegant floral displays.
Another class act, men's designer Joseph Abboud, attends this dinner each year as his wife is a Lyme sufferer who has struggled with the disease for six years. Abboud who appears in his own commercials was dressed in casual chic - a dashing sweater-pant combination instead of a blase suit. As a silent film was shown depicting the agonizing battle of a young girl with Lyme much of the crowd was moved to tears.
Another tearful attendee was honoree Erin Walker who said she would have to read her speech since her brain was foggy from Lyme. Erin recounted how her husband 2016 PGA Championship Winner, Jimmy Walker, baffled doctors with his illness because Texas was not a Lyme hotspot. Jimmy experienced brain fog, depression, irritability and difficulty hitting a golf ball - leaving the family struggling for money. Erin was similarly diagnosed 8 months ago and said she experienced brutal headaches for a consecutive three months and had trouble walking. She said Lyme was a global crisis that needed to be addressed.
To help in this battle, a live auction was held with goodies such as a Napa Valley Wine Experience and Golf Getaway, followed by a dynamic performance by two-time Tony Award winner Sutton Foster. I headed out into the concrete jungle; relieved that there were no tick-bearing bushes in sight.


text:
PLOS Neglected Tropical Diseases is the top Open Access tropical medicine journal, featuring an International Editorial Board and increased support for developing country authors.
Commitment To Capacity
Community-based mass treatment with azithromycin for the elimination of yaws in Ghana—Results of a pilot study
Abdul Aziz Abdulai,
Roles Conceptualization, Formal analysis, Investigation, Supervision, Writing – original draft, Writing – review & editing
Affiliation West Akim District Health Administration, Ghana Health Service, Asamankese, Ghana
Patrick Agana-Nsiire,
Roles Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Supervision, Writing – original draft, Writing – review & editing
Affiliation National Yaws Eradication Programme, Ghana Health Service, Accra, Ghana
Frank Biney,
Roles Data curation, Investigation, Writing – original draft, Writing – review & editing
Affiliation District Hospital Laboratory, Ghana Health Service, Asamankese, Ghana
Cynthia Kwakye-Maclean,
Roles Conceptualization, Investigation, Supervision, Writing – original draft, Writing – review & editing
Sardick Kyei-Faried,
Roles Project administration, Supervision, Writing – original draft
Affiliation Disease Control Department, Ghana Health Service, Accra, Ghana
Kwame Amponsa-Achiano,
Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing
Affiliation Expanded Programme on Immunization, Ghana Health Service, Accra, Ghana
Shirley Victoria Simpson,
Roles Investigation, Supervision, Writing – original draft, Writing – review & editing
Affiliation Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
George Bonsu,
Roles Data curation, Investigation, Supervision, Writing – original draft, Writing – review & editing
Sally-Ann Ohene,
Roles Project administration, Supervision, Writing – original draft, Writing – review & editing
Affiliation World Health Organization Country Office, Accra, Ghana
William Kwabena Ampofo,
Roles Supervision, Writing – original draft, Writing – review & editing
Yaw Adu-Sarkodie,
Affiliation School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
Kennedy Kwasi Addo,
Kai-Hua Chi,
Roles Investigation, Methodology, Writing – original draft, Writing – review & editing
Affiliation Laboratory Reference and Research Branch, Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
Damien Danavall,
Cheng Y. Chen,
Roles Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing
Allan Pillay,
Sergi Sanz,
Roles Formal analysis
Affiliation Barcelona Institute for Global Health, Hospital Clinic – University of Barcelona, Barcelona, Spain
Ye Tun,
Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing
Affiliation Center for Global Health, Centers of Disease Control and Prevention, Atlanta, Georgia, United States of America
Oriol Mitjà,
Roles Formal analysis, Writing – review & editing
Affiliations Barcelona Institute for Global Health, Hospital Clinic – University of Barcelona, Barcelona, Spain, Department of Community Health, Lihir Medical Centre, Lihir Island, Papua, New Guinea
Kingsley Bampoe Asiedu ,
Roles Conceptualization, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing
* E-mail: asieduk@who.int
Affiliation Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
[ ... ],
Ronald C. Ballard
Roles Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing
[ view less ]
William Kwabena Ampofo
https://doi.org/10.1371/journal.pntd.0006303
Abdul Aziz Abdulai Patrick Agana-Nsiire ... Ronald C. Ballard
The WHO yaws eradication strategy consists of one round of total community treatment (TCT) of single-dose azithromycin with coverage of > 90%.The efficacy of the strategy to reduce the levels on infection has been demonstrated previously in isolated island communities in the Pacific region. We aimed to determine the efficacy of a single round of TCT with azithromycin to achieve a decrease in yaws prevalence in communities that are endemic for yaws and surrounded by other yaws-endemic areas.
Surveys for yaws seroprevalence and prevalence of skin lesions were conducted among schoolchildren aged 5–15 years before and one year after the TCT intervention in the Abamkrom sub-district of Ghana. We used a cluster design with the schools as the primary sampling unit. Among 20 eligible primary schools in the sub district, 10 were assigned to the baseline survey and 10 to the post-TCT survey. The field teams conducted a physical examination for skin lesions and a dual point-of-care immunoassay for non-treponemal and treponemal antibodies of all children present at the time of the visit. We also undertook surveys with non-probabilistic sampling to collect lesion swabs for etiology and macrolide resistance assessment.
At baseline 14,548 (89%) of 16,287 population in the sub-district received treatment during TCT. Following one round of TCT, the prevalence of dual seropositivity among all children decreased from 10.9% (103/943) pre-TCT to 2.2% (27/1211) post-TCT (OR 0.19; 95%CI 0.09–0.37). The prevalence of serologically confirmed skin lesions consistent with active yaws was reduced from 5.7% (54/943) pre-TCT to 0.6% (7/1211) post-TCT (OR 0.10; 95% CI 0.25–0.35). No evidence of resistance to macrolides against Treponema pallidum subsp. pertenue was seen.
A single round of high coverage TCT with azithromycin in a yaws affected sub-district adjoining other endemic areas is effective in reducing the prevalence of seropositive children and the prevalence of early skin lesions consistent with yaws one year following the intervention. These results suggest that national yaws eradication programmes may plan the gradual expansion of mass treatment interventions without high short-term risk of reintroduction of infection from contiguous untreated endemic areas.
In this study, we provided a single round of total community treatment (TCT) with azithromycin to the population of a sub-district in Ghana (16,287 people) that is endemic for yaws and surrounded by other yaws-endemic communities to determine whether a sustained decrease in yaws prevalence could be achieved up to one year after the intervention. The efficacy of TCT was assessed by performing a clinical evaluation and serological testing of any yaws-like lesions found as well as serological screening of asymptomatic schoolchildren aged 5–15 years pre-TCT and at one year post-TCT. The results indicate that after a single round of high coverage TCT (89%) with azithromycin, the prevalence of active and latent yaws was significantly reduced. We also found that the use of a dual point-of-care immunoassay to detect non-treponemal and treponemal antibodies among school-going children is a practical alternative to laboratory-based serological testing to evaluate the effectiveness of yaws interventions in resource-poor settings.
Citation: Abdulai AA, Agana-Nsiire P, Biney F, Kwakye-Maclean C, Kyei-Faried S, Amponsa-Achiano K, et al. (2018) Community-based mass treatment with azithromycin for the elimination of yaws in Ghana—Results of a pilot study. PLoS Negl Trop Dis 12(3): e0006303. https://doi.org/10.1371/journal.pntd.0006303
Editor: Andrew S. Azman, Johns Hopkins Bloomberg School of Public Health, UNITED STATES
Received: September 7, 2016; Accepted: February 6, 2018; Published: March 22, 2018
This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: WHO provided funding and logistics for the study. Ghana Health Service provided personnel, transport and infrastructure for the study. CDC, Atlanta provided laboratory supplies. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Yaws is a chronic, relapsing, neglected tropical disease caused by Treponema pallidum spp. pertenue, a spirochaete closely related to that which causes syphilis [1]. The disease is currently reported from 13 of the 85 countries previously considered endemic in the 1950s, with an estimated 89 million people living in the affected districts [2]. Yaws is usually acquired by children in impoverished communities in tropical and subtropical countries when traumatized skin comes into contact with another person's early infectious lesion exudate, often during play. The disease affects mostly children aged under 15 years. The frequency of infection appears to be higher in boys than in girls [3].
Primary yaws lesions develop at the site of initial inoculation after an incubation period of 9–90 days. These lesions are initially papules, which can develop into papillomata and eventually ulcerate, and are most frequently found on the lower legs and ankles and, less frequently, on the skin of the upper limbs and elsewhere on the body. If left untreated, the disease may progress to the secondary stage, which is characterized by multiple skin lesions as well as osteitis and periostitis of the bones underlying the skin lesions. Untreated disease may spontaneously resolve clinically and enter a period of latency prior to the development of non-infectious gummas of the skin, cartilage and bone, resulting in the destructive, often disfiguring, lesions of late yaws [4].
During the 1950s and 1960s, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) led a global campaign to eradicate the disease by providing mass treatment to affected communities using single intramuscular injections of long-acting penicillin. The strategy was based on the need to screen at least 90% of the population, treat the entire reservoir of treponemal infection (including those with clinical disease, latent infection and contacts) and to perform periodic surveys at 6–12 months to identify and treat missed, new and imported cases [5]. The criteria for eradication were defined by the WHO Expert Committee on Venereal Infections and Treponematoses in 1960 as the absence of an indigenous infectious case in the population for three consecutive years and absence of any new seroreactor aged under 5 years [6]. The implementation of the global yaws eradication programme between 1952–1964 reduced the prevalence of infection by approximately 95% (from 50 million to 2.5 million cases) worldwide, indicating that the mass treatment approach using benzathine penicillin was highly successful [7]. In some countries such as Haiti and Nigeria, experience showed that one round of mass treatment with coverage of > 90% significantly reduced the prevalence of infectious cases by approximately 98% within 12 months [8, 9]. Despite the success of the campaign, the ultimate goal of eradication could not be achieved owing to several factors including the failure of many countries to adequately integrate active surveillance activities into the local health system after the mass treatment campaigns ended, complacency, limited resources, lack of political will and many new competing health priorities including the shifting of the dedicated mobile teams for yaws eradication to deal with diseases such as smallpox and cholera [5]. This situation led to the resurgence of yaws in several countries in the late 1970s, prompting the World Health Assembly to adopt resolution WHA31.58 [10] which called on countries to take the necessary measures to interrupt transmission at the earliest possible time. Despite the possibility that yaws transmission has ceased in a number of countries that were endemic in the 1950s but not confirmed, only India has recently been formally certified by WHO as yaws-free [11]. The disease still remains endemic in many countries in West and Central Africa, South-East Asia and the Western Pacific [12].
In 2012, the finding that a single oral dose of azithromycin was as effective as injectable penicillin for the treatment of yaws [13] prompted WHO to revisit the global eradication of the disease. In 2012, WHO published a roadmap on neglected tropical diseases that targeted yaws eradication by 2020 [14]. In the same year, WHO devised a new yaws eradication strategy (the Morges Strategy) [15]. The strategy recommends total community treatment (TCT, equivalent to mass treatment for other neglected tropical diseases) of affected communities with single doses of azithromycin followed by ongoing active surveillance, case-finding and treatment of missed, new and imported cases and their contacts (household, neighborhood and school playmates) through a health system approach. Depending on the initial treatment coverage and accessibility to the endemic communities, the strategy recommends repeat surveys to identify and treat any new infectious cases or in response to localized outbreaks (using total targeted treatment, TTT). The feasibility of global yaws eradication and the progress made in implementing the Morges Strategy have previously been reported [16, 17].
In 2015, the first empirical data of the impact of mass treatment with azithromycin on disease transmission became available. A study carried out in Lihir, Papua New Guinea (PNG) demonstrated that mass treatment with azithromycin to the population of yaws-endemic island communities resulted in a significant decrease in the prevalence of clinically early yaws lesions and a decrease in reactive serological markers for the disease [17]. Similar findings have emerged from a study in the Solomon Islands that evaluated the secondary benefits of mass treatment of trachoma using 20 mg/kg azithromycin on the prevalence of yaws [18]. However, despite the encouraging results obtained in these countries, focused mass treatment campaigns are, theoretically, more likely to succeed in isolated island communities where the risk of reintroduction of infection in the treated population from untreated adjoining communities is less likely. Since the disease is also endemic in many countries with affected communities spread over a contiguous land mass, it is also important to determine whether high coverage with azithromycin mass treatment in a defined area can result in a sustained decrease in infectious yaws up to one year after the intervention. This is also important, since the resources available to yaws eradication programmes in many countries are limited, resulting in an inevitable delay or progressive expansion of the implementation of the programme to adjoining endemic areas that could act as a source of re-infection for the initial target communities.
In this study, we aimed to assess the impact of a single round of TCT with azithromycin using two markers of infection among school-going children in the target communities before and one year after the intervention. We measured the prevalence of dually seropositive for non-treponemal and treponemal serological markers, and the prevalence of active yaws-like lesions among children. A secondary objective was to establish the etiology of active yaws-like lesions among schoolchildren using sensitive molecular techniques and to assess the occurrence of mutations associated with azithromycin resistance among T. pallidum spp. pertenue positive lesions in the local population.
The study protocol was approved by the ethics committee of the Ghana Health Service, Ministry of Health (GHS-ERC-05/01/13). Written informed consent was obtained from parents and where they were unable to provide consent, teachers provided written consent on their behalf, which is normal practice for mass treatments campaigns in Ghana. Prior to the initiation of mass treatment with azithromycin, information sessions were held with the regional directorate of health services, the district political authorities and communities about the study in order to gain their support. The local radio was used to inform the entire district about the mass treatment campaign. Health workers and village volunteers distributed the WHO yaws picture booklets [19] to households and schools as part of the social mobilization effort.
Study area and population
We conducted a prospective observational study in the Abamkrom sub-district, West Akim district of the Eastern Region of Ghana between October 2013 and December 2014. The sub-district is highly endemic for yaws (Fig 1) [20]. The total population of the sub-district in mid-2013 was estimated to be 16,287 people, i.e. 7.7% of the population of the district as a whole (212 282 people). The eligible population for mass treatment was everyone older than 6 months of age, excluding pregnant women (as decided by the local study team), 15,310 people in total. The sub-district has 5 health centres, 24 primary schools and 36 communities. The total population of children 5–15 years registered in primary schools that were targeted for impact assessment surveys was 2,909 children. Each community has a village health volunteer who is responsible for monitoring and reporting health events. These volunteers are used for mass drug administration for other neglected tropical diseases. The total eligible population (aged ≥ 6 months) living in the 36 communities was targeted to receive mass treatment with azithromycin as part of the study. The school attendance rate in the sub-district among children aged 5–15 years has been estimated to be 47.6%.
Fig 1. Maps showing position of Abamkrom sub-district within the West Akim district in Ghana and geographical distribution of schools sampled pre- and post-TCT.
https://doi.org/10.1371/journal.pntd.0006303.g001
Mass azithromycin treatment
Prior to the implementation of the study, the health workers and village volunteers were trained on the objectives of the study, recognition of yaws-like lesions, implementation and data collection tools. The TCT programme was conducted by 13 teams of two trained volunteers drawn from affected communities who were supervised by local health-care workers or members of the national yaws eradication programme. During a five-day period in November–December 2013, the teams offered azithromycin tablets (purchased by WHO from Medopharm, Chennai, India) at a single oral dose of 30 mg/kg per body weight (maximum 2 g) to all members of the 36 targeted communities aged 6 months and above at no cost to the participants. The tablets (500g strength) were administered to the eligible population according to age as described in the WHO Morges Strategy document [15]. For children aged under 6 years, the tablets were crushed and mixed with water. The volunteers directly observed treatment of participants, maintained tally sheets; they marked the fingers of treated participants with indelible ink to document the administration of the medicines, and observed participants for approximately one hour after ingestion of the medication, reporting any adverse events that could be related to azithromycin treatment. The supervisors collected the tally sheets daily and followed up any adverse drug reactions reported by volunteers. TCT coverage rates were calculated using the number of persons treated according to the tally sheets divided by the total population.
School and participants selection
We used cluster sampling with individual schools as the cluster unit. Eligibility for inclusion was met by 20 primary schools with a population larger than 100 children among 24 schools located in the sub-district. The schools were randomly assigned to either the pre- or post- TCT evaluation surveys. Therefore, the sets of schools for pre- and post- TCT surveys were mutually exclusive and schools could not be chosen repeatedly for more than one survey. Every child present at the time of our visit to the schools selected was invited to participate in the study.
The primary outcome was prevalence of sero-positivity, defined as dually non-treponemal and treponemal antibody positivity using a point-of-care test among symptomatic or asymptomatic children. Secondary outcomes, were the prevalence of suspected yaws, defined as a child with a history of residence in an endemic area who presented with clinically active (visible) yaws-like lesions, and the prevalence of serologically-confirmed yaws, defined as a suspected case with a dually-positive serological test result for non-treponemal and treponemal antibodies.
In October 2013, before the mass treatment campaign (November–December 2013), we conducted a baseline assessment survey in 10 randomly selected primary schools and every child present, 943 children in total, was enrolled. One year after the intervention (November–December 2014), every child from a further group of 10 randomly selected schools, 1211 children in total, were selected for an identical post-intervention assessment of impact survey. Fig 1 shows the geographical distribution of these schools within the sub-district and Fig 2 the flowchart of the study design.
Fig 2. Flowchart of school and pupil selection.
During both assessments, all children were examined clinically for skin lesions consistent with early infectious yaws (i.e. skin papilloma, chronic solitary or multiple skin ulcerations) and a specimen of capillary blood was collected from all, symptomatic and asymptomatic, participants to perform a point-of-care immunoassay for antibody to yaws infection. All children with active yaws-like lesions detected during either the initial or post-TCT assessments or those who were asymptomatic but had a dually non-treponemal and treponemal antibody-positive result on initial field screening were treated with a single dose of azithromycin (30 mg/kg) and followed up for adverse events.
A point-of-care immunoassay, developed for the serological diagnosis of syphilis, that can simultaneously detect both non-treponemal and treponemal antibodies (DPP Syphilis Screen and Confirm Assay, Chembio Diagnostic Systems, Medford, NY, USA) [21–23] was used to test 10 μl samples of capillary blood obtained by finger prick from each of the schoolchildren who were included in the selected pre- and post-TCT schools. In each case, the child's finger was cleaned with an alcohol swab, the skin punctured with a lancet and the capillary blood collected in a pre-graduated micropipette supplied in the test kit. Thereafter the test was performed directly in the field according to the manufacturer's instructions.
Surveys to determine the etiology of active yaws-like lesions and mutations for azithromycin resistance
We conducted clinical surveys to collect lesion swabs for PCR testing before and one year after TCT. Due to the low number of T. pallidum PCR positive cases detected in Abamkrom sub-district before the intervention, we decided to extend the baseline study to the entire West Akim district (8 sub-districts, 212 282 people). We had 8 teams, one in each sub-district, that examined the skin of schoolchildren aged less than 15 years of age. The sampling for this study was non-probabilistic; teams visited enough schools and enrolled all consecutive eligible children to achieve 150 symptomatic children sampled. If they identified any skin lesion, the child was invited for diagnosis, swab sample collection and treatment after their parents or guardians provided written informed consent. Similar procedures were used for post-TCT surveys that were conducted only in the Abamkrom sub-district.
Children with suspected yaws had their lesions photographed and specimens taken directly from the largest papilloma or ulcer after cleansing with sterile saline using either a sterile plastic curette (Ear Curette, Sklar Instruments, West Chester, PA, USA) or sterile dacron-tipped swabs (Medical Wire & Equipment, Corsham, UK) for PCR testing. PCR-confirmed yaws was defined as a suspected case with a positive PCR detection of DNA of the polymerase I gene and/or the T. pertenue-specific 23S rRNA gene sequence on material collected from suspected lesions [24].
Scrapings from papillomata and swabs taken from the bases of skin ulcerations were expressed into 1.2 ml of Assay-Assure nucleic acid transport medium (Thermo Fisher Scientific, Waltham, MA, USA). All specimens were stored frozen at −20°C before shipping, on dry ice, to the WHO Collaborating Centre for Reference & Research in Syphilis Serology at the Centers for Disease Control in Atlanta, GA, USA. Genomic DNA was extracted from 350 μl aliquots of assay-assure samples using the iPrep PureLink gDNA blood kits (Life Technologies, Grand Island, NY, USA) and iPrep purification instrument.
The specimen DNAs were originally screened with TaqMan-based real-time 4-plex polymerase chain reaction (PCR) targeting tp858 and two areas of the tprl (tp620) [25]. However, due to the discovery of primer binding site mutation (i.e. some strains may be undetectable by the PCR used), [26] we changed to a more sensitive PCR strategy and all specimens were re-tested using a real-time PCR targeting the DNA polymerase I gene (polA, tp0105) of pathogenic treponemes (which detects all 3 T. pallidum subspecies) [24] and a real-time 3-plex PCR that detects the two 23S rRNA point mutations (A2058G and A2059G) associated with macrolide resistance in T. pallidum described previously [27]. If a specimen tested positive by polA-PCR and/or 23S rRNA PCR (wild type or mutant), then we used the TaqMan-based real-time 4-plex PCR to differentiate T. pallidum spp. pertenue from spp. pallidum and endemicum [25]. A nested-PCR and sequencing of a portion of tp858 were used to resolve discrepant results among those three assays and to confirm the presence of T. pertenue–specific DNA sequences.
All DNA samples were tested for Haemophilus ducreyi (which had previously been detected in yaws-like lesions in PNG, Ghana, Vanuatu and the Solomon Islands [28–31]) and Mycobacterium ulcerans (the causative bacterium of Buruli ulcer, known to be endemic in the region) using specific sequences (hemolysin gene, HdhA) and Insertion Sequence (IS) 2404 respectively in a real time duplex PCR [32,33]. Genomic DNA samples purified from H. ducreyi or a M. ulcerans culture (kindly provided by Dr. Anthony Ablordey, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana) were used as the positive controls for PCR assays. At least one no-template-control (NTC) and one positive control were included in every test run. The analytical sensitivity of the duplex PCR assay is approximately 10–100 copies per reaction and the analytical specificity was assessed using DNA from a panel of organisms including commensal and pathogenic microbes found in the genitourinary tract and as part of the normal skin flora. All real-time multiplex PCR assays were performed on a Rotor-Gene Q real-time PCR instrument (Qiagen Inc.,Valencia, CA, USA).
In addition, serum samples were obtained from venous blood collected from all children with active lesions, for laboratory-based testing. These were stored frozen at −20°C and transported on dry ice to the WHO Collaborating Centre for Reference & Research in Syphilis Serology, where they were tested using a quantitative rapid plasma reagin (RPR) test (Alere North America, Inc., Orlando, FL, USA) and a T. pallidum passive particle agglutination assay (TPPA, Fujirebio Diagnostics Inc., Malvern, PA, USA).
Data were entered in Microsoft Access software, version 15.0 (Microsoft, Redmond, WA, USA) at the Ministry of Health, Ghana. The integrity of the data was verified by using a double data entry process. The primary outcome was change in prevalence of dual seropositivity following TCT, secondary outcomes were changes in rates of prevalence of suspected cases with lesions and change in prevalence of cases with lesion and seropositivity. We calculated that a sample size for the pre- and post-TCT surveys of at least 854 schoolchildren aged 5–15 years (EPI INFO 2000 sample size calculator) was required to detect a reduction by 45% in yaws seroprevalence among students before and after TCT intervention with a 95% confidence interval (CI) and 80% power. A design effect of 2 for the cluster sampling method was used to calculate the power [34,35]. The average number of children among the 24 schools of the subdistrict is 145.5, therefore we considered that at least 10 schools had to be sampled at each survey.
We calculated prevalence rates and 95% confidence intervals using the clustered sandwich estimator to control the variability of clusters. We evaluated the changes in yaws seroprevalence, and prevalence of yaws-like lesions among the schoolchildren sampled before and one year after TCT using logistic regression models controlling the variance-covariance matrix (VCE) corresponding to the parameter estimates. We reported the standard errors of parameter estimates as the square root of the variances of the VCE. For these, we use the option cluster in the calculus of Odds Ratios with the logistic regression models. We calculated Odds Ratios (post- compared to pre- TCT) for positive serology or clinical findings. The differences in the prevalence rates were considered statistically significant when two-sided p-values were less than 0.05. The statistical analysis was performed with Stata StataCorp. 2017 (Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC)
Mass treatment with azithromycin
During the 5-day community-based mass treatment campaign, 14 548 (89%) of 16,287 residents in the sub-district received a single oral dose of azithromycin. Individuals who were not eligible for treatment (977, 6.0%), or absent during the mass treatment (762, 4.7%) accounted for 10.7%. of the total population (16 287) of the sub-district. There were no severe adverse events attributable to the study drug; only 45 (0.3%) of the 14 548 participants treated reported mild to moderate self-limiting adverse events including abdominal discomfort, nausea and vomiting.
Demographics of the surveyed schoolchildren
Of the 943 children examined at schools before the community-based mass treatment campaign, 487 (51.6%) were male, and a similar proportion of males was found among those examined at schools after the TCT (632 /1211, 52.2%). The mean (SD) age of the pre-TCT schoolchildren (10.5 [2.5] years) compared with that of the post-TCT children (9.4 [3.6] years) was not significantly different.
Pre- and post-TCT clinical and serological results
The prevalence rate of dual seropositivity in the DPP test decreased significantly, from 103/943 (10.9% 95% CI 6.5–17.5) among children in the pre-TCT survey to 27/1211 (2.2%, 95%CI 1.3–3.7; OR 0.19, 95%CI 0.09–0.37) in the post-TCT survey (Table 1). In addition, the prevalence rate of serology confirmed yaws-like active lesions among schoolchildren was significantly reduced from a pre-TCT rate of 54/943 (5.7% 95%CI 3.2–9.9) to 7/1211 (0.6% 95%CI 0.2–1.6; OR 0.10, 95%CI 0.25–0.35) in the sample of schoolchildren examined one year following the TCT.
Table 1. Changes in seroprevalence, prevalence of skin lesions and serologically confirmed skin lesions among schoolchildren in the Abamkrom sub-district of Ghana, before and one year after TCT with 30 mg/kg azithromycin.
https://doi.org/10.1371/journal.pntd.0006303.t001
Results of PCR on lesion swabs to determine etiology
The results of PCR testing obtained from the children with active lesions in the extended intervention area pre- TCT are shown in Table 2. Among 158 children with active skin lesions sampled before mass treatment, 29/158 (18.4%) tested positive for T. pertenue-specific DNA sequence (none of which contained mutations associated with azithromycin resistance) and 45/158 were H. ducreyi positive including 7/158 lesions that were dually T. pertenue and H. ducreyi-PCR positive. M. ulcerans-specific DNA sequences were not detected in any specimen obtained from lesions, either pre- or post-TCT. In the Abamkrom sub-district 3/53 (5.7%) sampled cases pre-TCT were T. pertenue-PCR positive (Table 3), compared with 0/49 (0.0%) of specimens sampled one year after mass treatment while the proportion of H. ducreyi-positive ulcers remained largely unchanged.
Table 2. Patterns of seroreactivity (RPR and TPPA laboratory-based tests) among children with active skin lesions consistent with yaws, by detection of T. pertenue and H. ducreyi-specific DNA sequences, pre- TCT in the entire West Akim district (8 sub-districts).
Table 3. Results of PCR in specimens collected in the Abamkrom sub-district.
Of the 158 blood samples collected pre-TCT from children with active lesions that underwent serological testing at the CDC laboratory (Table 2), 57 (36.1%) showed reactivity in both the non-treponemal and treponemal tests, and 8 (5.1%) were reactive for treponemal antibody alone. Among dually reactive specimens, only 7/57 (12.3%) had RPR titres ≤1:4, while the remaining 50/57 (87.7%) sera exhibited titres between 1:8 and 1:128. The agreement between T. pertenue-PCR and serologic assays was high. However, RPR and TPPA were positive in 31 children with lesions that were T. pertenue-PCR negative (24 all PCR tests negative, 7 H. ducreyi-PCR positive; false positivity rate 31/63, 49.2%) which can be explained because serology remains detectable in serofast status.
Our study demonstrates that the provision of mass azithromycin administration given as a single oral dose of 30 mg/kg, up to a maximum dose of 2 g, is effective in reducing both the rates of seropositivity and the presence of serologically positive skin lesions consistent with yaws. Our results support the findings of earlier publications from PNG [17] and the Solomon Islands [18] and for the first time provides information on the efficacy of the Morges Strategy in an area that was geographically contiguous with neighboring endemic areas, unlike the previous studies. In addition, we used potentially more operationally feasible approach compared to the studies in the Pacific countries to measure the impact of one round TCT by focusing on the school-going population. However, we suggest that if this approach is used, school attendance rate should be >75% like in lymphatic filariasis surveys.
One year after TCT, we recorded a reduction in the prevalence of active yaws-like skin lesions among schoolchildren living in the targeted communities which was consistent with a reduction of passively detected suspected yaws cases in the same sub-district area (from 103 cases in 2012 to 20 in 2014) recorded in the routine reporting system (DHIMS2) of the Ministry of Health. Although the sample size was extremely small, we were unable to detect T. pallidum spp. pertenue using PCR test in any lesions that were clinically diagnosed as yaws seen in a survey conducted one year after TCT.
The population coverage that was achieved in the Ghanaian population reported here (89%) was slightly higher than that achieved in the PNG study (84%) [17]. The impact observed in both studies was very large consisting of a reduction by 90% of active yaws, but in Ghana we observed a lack of T. pertenue-PCR positive lesions (albeit small number of positives detected pre-TCT in the Abamkrom subdistrict) which could be related to the higher coverage rate achieved in Ghana or to the initial lower burden of infection in the present study or both when compared to PNG.
Recent studies on yaws conducted in PNG [28], Ghana [29], Vanuatu [30] and the Solomon Islands [31] have identified H. ducreyi as an important cause of skin ulcers in yaws endemic communities. Isolates of H. ducreyi obtained from skin lesions from children in Ghana are fully sensitive to azithromycin in vitro and the antibiotic is frequently used to treat chancroid, a sexually transmitted infection also caused by H. ducreyi. In our study, the overall prevalence of lesions caused by H. ducreyi was greatly reduced after TCT. However, unlike yaws, the relative proportion of H. ducreyi-positive ulcers remained essentially unchanged following TCT. It seems logical to speculate that community mass treatment with azithromycin may have less impact on lesions caused by this bacterium than those caused by T. pallidum spp. pertenue. We raise two possible explanations: Firstly, H. ducreyi strains that cause skin lesions in children may be more infectious than T. pallidum spp. pertenue. Secondly, in common with sexually transmitted H. ducreyi infections, non-sexual transmission of H. ducreyi does not appear to engender protective immunity to subsequent re-infection, unlike the transient immunity that occurs following treponemal infection [36, 37].
Our study has some limitations. First, the use of school-going children as a sampling methodology may introduce bias because the poorest children, who are at most risk of the disease, may not attend school. However, school-sampling is generally considered a good and convenient sub-population sample for other NTDs and routine surveillance data from DHIMS2 confirmed the overall decrease of yaws-like cases seen in the sub-district one year after the mass treatment. Further studies to compare the impact of interventions on school versus community-based populations are clearly indicated. Second, we selected two different groups of schools for pre- and post-TCT assessments, rather than returning to the original schools to determine the impact of TCT on the children who were seen initially. We considered that the additional survey for clinical and serological screening, and treatment of positive cases, that these schools would receive was effectively an additional public health intervention that is not a normal part of the larger interventions that the study aimed to evaluate. We therefore randomly selected a different group of schools for the post-TCT evaluation one year later to avoid measuring the potential impact of a double treatment. Third, the DPP point-of-care test that was used in this study lacks some sensitivity at low titres compared with conventional laboratory-based testing [23]. However, we believe that since the DPP test is capable of detecting non-treponemal antibody in more than 90% of cases with RPR titres ≥ 1:8 (which have previously been more closely associated with proven infectious lesions) [17] the benefits of field testing outweigh the logistics of providing a more reliable laboratory-based service which may not be readily available in impoverished yaws-endemic regions. Indeed, the lack of sensitivity of the DPP test at low titre could actually be a benefit since, in this study, confirmed low-titre RPR seropositivity (≤ 1:4), which could be missed when using the DPP test, was not associated with any lesion actively shedding T. pertenue. Finally, to determine the sample size for our surveys, we used a design effect of 2 based on previous experience in the Solomon Islands and Fiji [34,35], but which is lower than the design effect used in similar studies on NTDs [38]. In our study, the findings are still statistically strong after accounting for clustering; therefore, we believe that the design effect used was not a major limitation. However, a comprehensive review of sampling methods for yaws should be made to provide appropriate guidance for future intervention studies.
It seems clear, from the results of this intervention study, that yaws-like lesions caused by H. ducreyi or other unknown pathogens may continue to persist after a single-round of mass treatment giving the erroneous impression to both the affected population and health authorities alike that yaws has not been eliminated from a previously endemic community. This situation is compounded by the finding that H. ducreyi-positive lesions may be associated with dually positive non-treponemal and treponemal serological results in children with latent yaws or serofast status. Azithromycin is one of the antibiotics recommended for the treatment of sexually transmitted H. ducreyi infections [39,40], and it is also effective in the treatment of cutaneous ulcers in children caused by H. ducreyi [41]. In the long term, it may be necessary to devise appropriate "syndromic" management protocols for non-yaws / non-H. ducreyi lesions following the successful elimination of yaws through TCT. Further studies on the etiology of these yaws-like skin lesions in various yaws-endemic regions around the world are required.
In conclusion, our findings provide additional evidence that one round of TCT with azithromycin with high coverage ~ 90%, as part of the WHO Morges Strategy, is highly effective in providing a sustained and significant decrease in the prevalence of yaws 12 months after mass treatment from endemic communities, even if they adjoin other untreated endemic areas. Because 6-monthly resurveys using field staff may be costly, perhaps, if the initial coverage is >90%, in some places, a practical approach is to use trained village volunteers for ongoing active community surveillance and health promotion activities for yaws, especially, in the post-TCT phase similar to the experience of the guinea worm eradication programme [42]. Although our study is limited in size to allow us to make any firm recommendations regarding the ideal intervals between mass treatment and number of rounds required to interrupt transmission, we have presented some evidence to support the notion that with high coverage, a single round of TCT followed by TTT may be adequate and any additional TCT rounds to interrupt transmission may be carried out at intervals longer than 6 months. Further studies are needed to address these important issues. We also believe that the point-of-care DPP test applied to a sample of school-going children is a practical and convenient alternative to laboratory-based serological testing of a sample of the whole population to evaluate the effectiveness of yaws interventions in resource-poor settings. However, in view of the first report of macrolide resistance in yaws [43, 44], vigilance and close monitoring of cases are required. It is important that health workers to take specimens from any active skin lesions (papilloma and ulcer) of dually seropositive cases that are not healed or occur after TCT for PCR testing to definitely confirm yaws and detect any azithromycin resistance that may emerge among T. pertenue strains and to warrant the treatment of such cases with benzathine benzylpenicillin.
S1 Table. Deindentified data-set of the pre-TCT survey to estimate seroprevalence of yaws (Table 1).
https://doi.org/10.1371/journal.pntd.0006303.s001
(XLSX)
S2 Table. Deindentified data-set of the post-TCT survey to estimate seroprevalence of yaws (Table 1).
S3 Table. Deindentified data-set of the pre-TCT survey to determine the etiology of skin lesions in West Akim district (Table 2).
S4 Table. Deindentified data-set of the pre-TCT survey to determine the etiology of skin lesions in Abamkrom sub-district (Table 3).
S5 Table. Deindentified data-set of the post-TCT survey to determine the etiology of skin lesions in Abamkrom sub-district (Table 3).
The authors would like to thank all the health workers, community leaders, schoolteachers and schoolchildren in the Abamkrom sub-district, West Akim District of the Eastern Region of Ghana for their cooperation and support for the study. We thank Mr Alexei Mikhailov, Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland for creating the maps. The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of their respective institutions.
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36. Ballard R, Hook EW III. Syphilis. In: Unemo M, Ballard R, Ison C, Lewis D, Ndowa F, Peeling R, editors. Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus. Eds. Geneva: World Health Organization 2013: 107–29.
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44. Mitjà O, Godornes C, Houinei W, Kapa August, Paru Raymond, Abel Haina et al. Re-emergence of yaws after single, mass azithromycin treatment followed by targeted treatment: a longitudinal study. Lancet 2018; published online Feb 7. http://dx.doi.org/10.1016/S0140-6736(18)30204-6
Is the Subject Area "Yaws" applicable to this article?
Lesions
Is the Subject Area "Lesions" applicable to this article?
Is the Subject Area "Schools" applicable to this article?
Is the Subject Area "Polymerase chain reaction" applicable to this article?
Is the Subject Area "Serology" applicable to this article?
Is the Subject Area "Schoolchildren" applicable to this article?
Is the Subject Area "Ghana" applicable to this article?
Is the Subject Area "Treponema pallidum" applicable to this article?


The Click and Play Bundle is a great deal on fun! Get 4 fantastic games to play. With match 3, tower defense and time management games in this pack, there's something for everyone. Don't wait. Download the Click and Play Bundle today!


text:
God-talk in the New Testament
Here is a link to a good post by my friend, Larry Hurtado. It is his reflection on over 30 years of critiques of his work. Critics have accused his work of being either Arian or proto-Calcedonian. Both accusations are drawn from later church controversies and should not be read back into the New Testament. If Hurtado can be accused of anything, it is doing history not theology. He's not averse to theology; he just thinks the later categories invade historical reconstructions too often.
Or you can cut-and-paste this URL: https://larryhurtado.wordpress.com/2016/07/19/jesus-and-god/
How God Became Jesus
I'm heading to San Diego to attend the Annual Society of Biblical Literature meeting. I'm meeting with former and future publishers, scholars, and a variety of former students. One of my duties while there is to preside over a session of a program unit called The Extent of Theological Diversity in Earliest Christianity. The session will offer a panel review of Bart Ehrman's new book, How Jesus Became God: The Exaltation of a Jewish Preacher from Galilee. The title and subtitle tells you the essential story; Ehrman suggests that Jesus was understood first as Jewish itinerant teacher from Galilee; only later did his disciples claim he is divine. How much time goes by he does not say, but apparently he thinks in some circles it happened early even though it took centuries for the language to be worked out in church councils. Accordingly, Jesus didn't regard himself as divine in any sense, nor did his earliest disciples. Jesus was, in fact, an apocalyptic prophet who announced the end of the current evil age. He did believe and describe himself as the coming king of God's future reign, the Messiah of God. Once the disciples came to believe that Jesus had conquered death and was exalted to God's right hand, they came to hold to his divinity. It is an important new book, some say his most significant book to date.
The book is published by HarperOne, an imprint of Harper Collins. Interestingly, when Bart's book was being prepared, someone got the idea to commission a group of other scholars to respond to the book. This happened at Zondervan, which is now part of the Christian Publishing Group of . . . yep, Harper Collins. Nice stroke. Both ways, they win. "Heads, I win. Tails, you lose." So editors at Zondervan appointed Michael F. Bird of Ridley College in Melbourne, Australia to edit the book, and he assembled an impressive group of internationally recognized scholars to answer various aspects of Bart's book. Their book is entitled How God Became Jesus The Real Origins of Belief in Jesus' Divine Nature. On the cover it also says it is "a response to Bart D. Ehrman." The scholars Bird assembled include: Craig Evans, Simon Gathercole, Charles Hill, Chris Tilling. Each scholar takes on a different challenge. For example, Craig Evans addresses the question of burial practices at the time of Jesus. Ehrman claims Jesus was not buried; instead, in keeping with what happened with other crucified persons, Jesus' corpse became food for scavengers. If there was no burial, there could be no empty tomb, so those traditions must have been invented by early Christians convinced Jesus somehow conquered death. Professor Evans presents evidence that crucified people were occasionally buried and makes the further claim that Jesus must have been one of them. This is the way it goes. Point. Counterpoint.
Both books make an important contribution to the study of early Christianity, in particular how early Jesus' followers came to regard him as divine. In the history of the west and of the Christian church this may well be one of its most significant chapters.
How Did Jesus Become God?
I am fortunate to be chair of an SBL Program Unit called: "The Extent of Theological Diversity in Earliest Christianity."
Here is our description as listed on the SBL site:
Description: Focusing on the evidence for Jesus' death and resurrection as a narrative used to shape the identity of emergent communities, and on the alternatives to this narrative preserved in early Christian sources, this Consultation explores the origin, nature and extent of theological diversity in earliest Christianity from the beginnings until approximately 180 CE. By fostering a conversation involving the testing of various reconstructions of early Christian history against the range of relevant evidence, the unit seeks to bring greater precision to the study of "orthodoxy and heresy in early Christianity."
This fall one of the two sessions we will sponsor seeks to address the question: "How Did Jesus Become God?" Bart Ehrman has written a book on the topic and it will be published in March 2014 by HarperCollins. Here is the full title: How Jesus Became God: The Exaltation of a Jewish Preacher from Galilee. Ehrman has agreed to let us offer a session in review of his book. We are in the process of putting together the panelists for the review session. Ehrman will give a response to his reviewers. I haven't seen the book yet. I am still waiting for my advance copy.
Ironically, a daughter company of HarperCollins, Zondervan, commissioned a book in response which is scheduled to be published this spring as well. Michael Bird pulled together a group of contributors to "answer" Ehrman's historical reconstruction. Other than himself these include Simon Gathercole, Chris Tilling, Craig Evans, and Charles Hill. Zondervan will release the book this March as well under the title: How God Became Jesus: The Real Origins of Belief in Jesus' Divine Nature—A Response to Bart Ehrman. Apparently HarperCollins shared the electronic manuscript of Ehrman's book with Zondervan in order to provide—what can only be described as—a timely response. I'd be interested in how all of this happened. If you compare the front covers of each book, you can see how similar they are.
Needless to say this promises to be a great conversation over an important and controversial topic.
Here are some of the people we are talking with about being on the panel. I'll announce the final panel in about a month:
Bart Ehrman, University of North Carolina, Chapel Hill
Larry Hurtado, University of Edinburgh
Dale Martin, Yale University
Michael Bird, Ridley Melbourne College
James McGrath, Butler University
Craig Evans, Acadia Divinity College
If you are planning on being at SBL in San Diego in November 2014, be sure to look up our group and join us for the dialogue.


Halifax partner Rick Dunlop has written a piece for NOW! Nova Scotia detailing five key issues that employers should keep in mind leading up to the legalization of marijuana, effective July 1, 2018. He notes that, while the impact on Canadian workplaces has been given little attention by federal and provincial legislation, marijuana legalization will still affect employers and employees alike, and it is important to plan ahead.


The drive from Florence to Rome is pretty straightforward, just hop on the A1 and jet three hours south. But you should be making a road trip out of it, so skip eating at the roadside autogrill and extend your drive. Pick one or two of our favorite pit-stop towns along the way for 12th century churches, Under the Tuscan Sun filming locations, and tagliatelle with truffles.
One of Tuscany's oldest towns, it's topped by an 800-year-old stone castle; one of its many churches dates to the 12th century.
In cooler months, the stewed wild boar from L'Asinello outside of town is the Tuscan comfort dish you want to eat.
Venture into the Misericordia church to see the 500-year-old wooden organ, one of the oldest in Italy, by master Giovanni Piffero.
Art lovers will want to see the Benvenuto di Giovanni frescoes at the San Biogio rectory; the Medicis used to live in the town's 14th-century castle.
This is Chianina-beef territory; we like the steaks (and old movie posters on the wall) at Da Forcillo.
At the top of the town's hill are the ruins of an Etruscan temple dating to 800 B.C.; they're not well publicized, so ask a local to direct you.
Though Under the Tuscan Sun put it on the tourist map, it remains a dreamy postcard town, with cobblestoned streets and cafe-lined squares.
Osteria del Teatro, near the cloisters of San Francesco, for pesto ravioli.
Check out Busatti, a family-owned linen producer that makes fabric for sheets and throws on century-old shuttle looms.
The town's San Francesco monastery was founded by Saint Francis of Assisi in 1212; you can tour its vegetable and cypress gardens.
A stylish crowd eats at L'Osteria Vecchia da Nilo (you can spot Valentino's estate on the hill).
In summer, when the town fills up with day-trippers, book an upstairs table at Nilo—downstairs is social Siberia.
It's all about the Duomo, the striped 14th-century cathedral with its Instagrammable frescoes by Fra Angelico and Luca Signorelli. The crowds here will be much thinner than in Florence.
Trattoria dell'Orso does a mean tagliatelle with truffles.
The Duomo is open all day from March through October and closed at lunch November through February. Eat early in summer and visit at lunchtime.
This medieval hill town, with 16th-century towers and a Renaissance-era aqueduct, sees very few travelers.
Trattoria da Saviglia does Rome-worthy cacio e pepe, but we go for the veal stew.
The town's five palaces date to the 14th century, and each is marked by the oval-crested coat of arms belonging to the once-prominent Albertis.


In large 10 quart pan brown off the 2 # of ground beef and half the onion.
Add in the chili seasoning and all other packs of seasoning found in Chili kit.
Add other half the onion and half of peppers cook for an additional 15 minutes.
For serving add a small handful for corn chips add chili and top it off with shredded cheese and enjoy.