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Revisiting typhoid fever surveillance in low and middle income countries: lessons from systematic literature review of population-based longitudinal studies
Vittal Mogasale1,
Vijayalaxmi V. Mogasale2,
Enusa Ramani1,
Jung Seok Lee1,
Ju Yeon Park3,
Kang Sung Lee3 &
Thomas F. Wierzba4,5
The control of typhoid fever being an important public health concern in low and middle income countries, improving typhoid surveillance will help in planning and implementing typhoid control activities such as deployment of new generation Vi conjugate typhoid vaccines.
We conducted a systematic literature review of longitudinal population-based blood culture-confirmed typhoid fever studies from low and middle income countries published from 1st January 1990 to 31st December 2013. We quantitatively summarized typhoid fever incidence rates and qualitatively reviewed study methodology that could have influenced rate estimates. We used meta-analysis approach based on random effects model in summarizing the hospitalization rates.
Twenty-two papers presented longitudinal population-based and blood culture-confirmed typhoid fever incidence estimates from 20 distinct sites in low and middle income countries. The reported incidence and hospitalizations rates were heterogeneous as well as the study methodology across the sites. We elucidated how the incidence rates were underestimated in published studies. We summarized six categories of under-estimation biases observed in these studies and presented potential solutions.
Published longitudinal typhoid fever studies in low and middle income countries are geographically clustered and the methodology employed has a potential for underestimation. Future studies should account for these limitations.
Typhoid fever is a serious systemic illness transmitted through fecal-oral route and known to affect population having limited water and sanitation infrastructure [1]. Presence of long-term carrier status and variable level of risk factors such as contaminated water, food and poor sanitation conditions in different geographical regions often causes patchy outbreaks and uneven disease distributions [2]. The disease is considered an important public health problem and the World Health Organization (WHO) has recommended vaccination with existing Vi polysaccharide vaccine targeting high-risk areas where typhoid fever is a problem [1]. For targeted vaccination strategies, it is essential to have a robust surveillance to understand the distribution of typhoid fever by geography and population groups. Besides quantifying disease burden, surveillance is helpful in tracking changes in level of incidence, anti-microbial resistance and the impact of typhoid fever control interventions. The importance of surveillance has increased with imminent availability of new generation typhoid conjugate vaccines [3], which may necessitate revisiting of WHO policies on vaccination strategies.
It is challenging to measure the real disease burden of typhoid fever based on a surveillance system. First, typhoid fever is common in locations with poor water and sanitation, where infrastructure and resources required for good surveillance are limited. Sustaining long-term effective surveillance needs continued commitment of health system and scarce resources. Second, because typhoid fever often clinically resembles other febrile illnesses, it is clinically misdiagnosed in many regions of the world where malaria and dengue are highly prevalent [1]. In remote and resource poor settings without laboratory surveillance systems, typhoid fever outbreaks as well as routine cases are under reported [4]. Third, the current typhoid fever diagnostics have limitations in terms of availability and reliability which exemplifies the misrepresentation of the disease [2]. Typhoid fever is often diagnosed clinically or using antibody titers in routine settings at hospitals and health facilities. The diagnostic sensitivity and specificity of antibody titer based tests is less than optimal [5]. Blood culture is highly specific but its sensitivity is lower, ranging from 40 to 80 % [6], and poses several operational and laboratory challenges [5]. Forth, only a proportion of all febrile cases at community may choose to visit health care facilities where surveillance is conducted underrepresenting true number of cases at the community. This is because people with febrile illness may opt for different service providers such as alternative health facilities, private practitioners, pharmacies, traditional healers or self-medication or no treatment [7].
Despite these challenges, global donors, policy and financing bodies and local decision makers look for precise information on size and seriousness of typhoid fever problem. Therefore, it is critical to identify and list studies that tried to minimize surveillance challenges while measuring the incidence of typhoid fever. Such studies will help in pinpointing the geographical locations where typhoid continues to be an important problem so that interventions can be targeted. We conducted a systematic literature review to identify blood culture-confirmed typhoid fever studies that try to represent the disease burden in underlying community. Based on the literature review we summarized the current challenges and future surveillance needs for improving the precision of disease burden estimates.
We performed the systematic literature review and presented results as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (please see additional file 1).
Search strategy and selection criteria
We undertook a systematic literature review of population-based, longitudinal studies of blood culture-confirmed typhoid fever conducted in low and middle income countries [8] published from 1st January 1990 to 31st December 2013 using a predefined protocol. The search involved PubMed and Embase as primary electronic databases for identification of publications. Pan American Health Organisation (PAHO) and WHO websites were utilized to identify additional publications. The key words used were ("typhoid" OR "typhoid fever" OR "Salmonella Typhi" OR "S. Typhi" OR "salmonella infection" OR "enteric fever") AND ("incidence" OR "rate" OR "frequency" OR "prevalence" OR "morbidity" OR "burden" OR "surveillance" OR "epidemiology"). The search was limited to English language and studies of human individuals. The detailed inclusion and exclusion criteria are given below (Table 1). The search was independently conducted by two researchers and the results were compared. Any differences between two researchers were resolved based on discussion and agreement, if unresolved, third independent researcher made the final decision. All selected papers were reviewed by a third researcher before data extraction to confirm its adherence to inclusion criteria and to limit the risk-of bias. In the final list, we included distinct population-based longitudinal studies that used blood culture for typhoid fever confirmation in incidence estimation irrespective of intensity of surveillance.
Table 1 Inclusion and exclusion criteria for systematic literature review
We used both qualitative and quantitative and methods in data analysis. First, we qualitatively scrutinized study methodology that could have influenced incidence rate estimates. Based on the description presented in the paper, we identified the potential reasons for typhoid fever underestimation and determine the potential correction approaches. Then, we extracted data related to typhoid fever incidence and hospitalization rates from selected studies and calculated incidence correction factors for each study. Finally, the incidence rates were presented based on two estimates: a) without correcting limitations of surveillance methods, and b) after correcting the limitations of surveillance methods.
We did not include incidence rates from clinical trials because they did not present sufficient details on surveillance to correct for methodological limitations. The hospitalization rate was estimated based on the number of hospitalizations among confirmed typhoid fever cases during the surveillance which was not corrected for its methodological limitations. We used meta-analysis approach in summarizing the hospitalization rates, where weighted mean was estimated by regions using random effects model. Qualitative information such as methodology, challenges faced, strengths and limitations were descriptively summarized for considerations in future surveillance.
Our systematic literature search resulted in 3747 English publications from 1990 to 2013 (Fig. 1). After reviewing titles and abstract 3635 irrelevant publications were excluded and full text articles for remaining 112 papers were obtained. Of them, 77 papers did not match inclusion criteria as they did not use blood culture for case confirmation and were excluded. Of 35 selected studies, 13 either did not represent a community or used modeling methods to estimate typhoid incidence. Finally we identified and analyzed data from 22 papers.
PRISMA diagram for systematic literature review conducted to identify population based longitudinal typhoid fever studies
The 22 papers presented population-based blood culture-confirmed typhoid fever incidence estimates from 20 distinct sites in low and middle income countries [9–30] (Fig. 2). Based on United Nations region classification [31], most of published estimates were from Asia, with five estimates from the Southern Asia region [15, 17–21, 29, 30], four from the South-Eastern Asia region [15, 22–25], and two from the Eastern Asia region [15, 16]. The rest of the estimates were collected from Africa, with three sites in the Eastern Africa region [13, 14], two from Northern Africa [9, 10] and one from Western Africa [11, 12]. Except four estimates from Chile [27, 28], Southern Africa [26] and Indonesia [22], rest had incidence data collected post 1990s. Three papers from Pakistan [15, 19, 20] presented incidence data for different time period from same sites. Similarly, two papers each presented data for different periods from same sites in Ghana [11, 12], India [15, 29], Bangladesh [18, 30], Indonesia [15, 23] and Vietnam [24, 25].
Geographical location of population- based longitudinal typhoid fever studies identified based on systematic literature review (Source: DIVA-GIS (http://www.diva-gis.org))
Of the 22 studies, eight were of clinical trials restricted to certain age groups such as school children and young adults while excluding children below 2 years [16, 20, 22, 25–29]. These trials described pre-existing known high incidence typhoid fever locations. The papers focused on clinical trial related descriptions, surveillance related information was often sketchy without detailed methodological information and were excluded from detailed analysis.
The descriptions on surveillance below included 14 papers representing 15 distinct sites. This includes multi-site studies [13, 15] and, multiple studies from same sites in Ghana [11, 12], Bangladesh [18, 30] and Pakistan [15, 19] which used standardized methodologies (Table 2). Of the total 15 studies, seven (46 %) were located urban sites, four (27 %) in rural and remaining four (27 %) in mixed urban-rural sites (Table 2). The surveillance period ranged from November 1995 to December 2010 while the duration of individual study varied from 4 months to 36 months. The studies covered 4.0 million populations for 281 months and identified 63,220 eligible cases. Analysis included 41,325 subjects who provided blood samples and 1149 were found positive for Salmonella Typhi infection.
Table 2 Typhoid fever annual incidence rate in population-based, longitudinal studies published from 1st January 1990 to 31st December 2013 (not corrected for blood culture sensitivity)
When full text papers of selected studies were meticulously reviewed, we identified several reasons to argue that longitudinal studies underestimate typhoid fever incidence owing to the study design and implementation, and categorized them into six groups (Table 3). The most common problem is that surveillance sites do not capture all febrile cases because there are multiple service providers at the community such as private practitioners, traditional healers etc. who are not included in the study. We note that most passive typhoid fever surveillance studies relied upon only public health facilities.
Table 3 Common biases in typhoid fever surveillance and potential solutions
A commonly used inclusion criterion, febrile syndrome (see Table 2) is another potential source of incidence underestimation. One of the studies in Kenya used two criteria (febrile illness and respiratory illness) in urban site and three criteria (febrile illness, respiratory illness and hospitalization) in rural sites [13]. Febrile criteria had identified only 60 and 27 % of total blood culture confirmed cases reported in urban and rural sites respectively. Respiratory criteria had identified additional 38 and 50 % cases in urban and rural sites respectively. The hospitalization criteria in rural site had identified additional 23 % of cases. Total 2 % of cases were detected among persons who did not match any of the criteria in urban site. The febrile definition of fever of 38 °C for ≥3 days may limit the number of cases identified as well. The study in Karachi reported that only 24 % of febrile episode identified from house to house visits had ≥3 days of fever [19] and the rest were not referred to index surveillance facility. In some other sites only a proportion of the potential typhoid fever cases are included. Only hospitalized cases were included in Agogo study [12] and the researchers estimated that only 50 % of the cases with inclusion criteria were enrolled in the study and applied a correction factor.
Sometimes only a fraction of people identified at community reach index surveillance facility as observed in Karachi where 30 % of 4198 febrile illness cases with more than 3 days of duration presented at the health facility [19]. Even if febrile illness cases reached health facility, the blood samples couldn't be collected from many eligible cases. In Dhaka, blood samples of only 72 % of eligible cases could be collected [30] for reasons such as parents not consenting and unavailability of logistics. Similarly, in New Delhi blood samples were collected from 84 % of eligible cases [17]. Sometimes a part of the cases are excluded from analysis because of data related or operational issues. Nearly 13 % of cases provided blood samples that were excluded in Agogo study because of incomplete data [12]. Finally, blood culture does not detect all typhoid fever cases due to lowered sensitivity related to duration of illness, amount of sample collected and problems with blood collection procedure particularly in younger children as well as prior intake of antibiotics. Of the 14 studies, eight presented information on prior intake of antibiotics [9, 10, 12, 18, 19, 21, 24, 30].
We identified potential resolutions (Table 3) for these limitations observed in each selected study, and estimated correction factors to account for under-estimation. Table 2 illustrates how denominators and numerators change when these under-estimation limitations are corrected. We present incidence rates using two methods: a) incidence based on raw surveillance data, b) surveillance methods adjusted incidence. The incidence rates are very different and amplified when corrected for surveillance limitations. The corrected incidence data was used in the estimation of global burden of typhoid fever [32].
We looked at the hospitalization rate in blood culture-confirmed typhoid cases from 14 selected population-based studies. The weighted mean hospitalization rates by regions using random effect models from eight studies [9, 10, 13, 15, 17, 18, 21, 30, 33] conducted in 13 sites were presented in Fig. 3. Hospitalization rate was highest in South-Eastern and Eastern Asia region which had passive surveillance. Hospitalization was least in Southern Asia where most sites had active surveillance. The active surveillance studies allow for detection of less severe cases and also likely to improve typhoid outcomes by identifying cases early. As observed in Kenya [13], hospitalization rates are likely to be higher in rural areas with poor access to healthcare, due to delays in receiving appropriate treatment. Of the 14 population-based, longitudinal studies, only one study had presented any deaths related to typhoid fever (CFR = 2.6 %; one death in 37 cases) [11].
Weighted mean hospitalization rates using random effects model in selected population- based longitudinal typhoid fever studies classified by regions
In this systematic literature review we have presented prospective population-based, blood culture-confirmed typhoid fever surveillance results. In 24 years' worth of literature, beside clinical trials, there were only 14 published studies from 15 sites. This indicates typhoid fever surveillance is not a priority despite millions of people affected. The information from some parts of the world such as South America are outdated and generated from clinical trials. The information from Africa is too minimal and comes from four countries only. There are more sites from Asia, yet its geographical representation is minimal. Large countries like India have only two sites. We show that within regions and even within countries, there is considerable variation in incidence rate estimates. One can argue that some of the variations in incidence may be attributed to strength of surveillance system that measured incidence rates. This was demonstrated at one of the surveillance sites, where involvement of private practitioners resulted in large increase in incidence rates [34].
We listed several critical points that affect the measurement of typhoid fever incidence. This included under estimation biases resulting from skewed health care utilization, limitations of eligibility criteria, sampling limitations, failure to collect blood samples, missing data and poor sensitivity of blood culture. Here we suggest how these limitations, if addressed, can improve community representativeness of surveillance (Table 3).
Surveillance sites not capturing all target population is one of the key under estimation biases that can be addressed by adding additional components to the surveillance. A baseline census followed by an active surveillance where periodic house to house visits are made to ensure all individuals with inclusion criteria could be identified and referred to index health facilities eliminates this caveat. An active surveillance allows for the identification of less clinically severe cases and may yield accurate representation of community level incidence. Such studies are often accompanied by periodic demographic census that documents migrations, births and deaths in target population. Census allows for the accurate measurement of follow-up period in person years which increases measurement precision. Based on periodic census in Dhaka study [30], it is reported that on an average individuals stayed about 10 months in 1 year surveillance. If only onetime baseline census is conducted one would overestimate the denominator calculated in person years resulting in underestimation of the incidence. But active surveillance needs dedicated staff and costs are high; likely to introduce a bias in typhoid outcomes because cases are identified quickly and treated. As periodic demographic census and active surveillance is resource intensive, having a health care utilization survey along with census is an option to lower the cost and reasonable alternative. Based on a community survey, the study from Zanzibar estimated that only 10.6 % of febrile illness cases in the target community visited the index surveillance site at Chake Chake District Hospital and applied a correction factor for the incidence [14]. Similar health care utilization survey was used in other sites as well [9, 10, 12, 13].
Surveillance inclusion criteria not capturing all typhoid fever cases is another key under-estimation bias identified. Broadening the inclusion criteria to include respiratory illness and hospitalizations in addition to febrile criteria as done in Kenya [13] is one approach to capture missing typhoid fever cases. However, these additional inclusion criteria are not specific for typhoid fever, may result in screening and testing large number of extra cases making it resource intensive. Besides enhancing the surveillance intensity, conducting health care utilization and expanding inclusion criteria, most useful measure that can limit under estimation bias is good documentation during surveillance (Table 3). It is crucial to carefully document what proportion of eligible people are a) not visited the surveillance sites, b) not included in the sampling, c) not consented for blood collection, d) could not draw blood sample, e) dropped out from the analysis. Documenting the antibiotic intake prior to blood sample collection that inhibits bacterial growth and correcting for blood culture sensitivity is another crucial factor. Until recently, most studies used a correction factor assuming 50 % blood culture sensitivity [14]. It is not sure if this number accounts factors that influence blood culture sensitivity. Documenting the history of intake of antimicrobials prior to the collection of blood samples and analyzing its implication on culture positivity is an important measure to understand blood culture sensitivity. Beyond this, it is crucial to standardize blood culture methods in multi-site studies along the side of good measures for quality control. In this regard, automated blood culture systems such as the Bactec or other commercial systems may be more reliable than studies using in-house blood culture methods.
Future studies should consider above limitations in designing the typhoid surveillance so that more precise estimation of incidence is possible. One should carefully plan surveillance to represent community either through active surveillance approaches, or setting-up of health facilities close to community for the purpose of case detection, or adjusting for health care utilization of the facility or by involving most health service providers in the defined geographical region. Dropouts at different steps of surveillance process should be documented carefully so that it can be corrected. As community based prospective surveillance is basis for global and regional typhoid fever disease burden estimates, correcting for these factors are essential [32]. The country, regional and global level disease burden estimates are powerful information for decisions on policy, financing, vaccination strategies as well as for advocacy; more precise information is valuable. Moreover, a new generation typhoid conjugate vaccine with hopes to have protection for children <5 years [3], warrants decision makers to look into new option for typhoid vaccination .
This study has limitations. Our search was confined to English language only. However, we do not think we missed many papers because a previous systematic literature review on typhoid incidence studies [35] did not find papers in Spanish, Italian, French, and Portuguese from 1980 to 2009. This review is subjected to publication biases as we did not search for unpublished information. We have presented incidence correction based on the information reported in the paper and we couldn't correct for unreported information or factors that studies did not mention or accounted for.
In conclusion, longitudinal typhoid fever studies are available only from selected geographical pockets in low and middle income countries despite its public health importance. The incidence is heterogeneous across the sites, so was the methodology of surveillance which potentially contributed to under estimation biases. Future longitudinal typhoid fever studies should consider the methodological limitation presented in this review at their study design. A precise estimation of typhoid fever incidence accounting for methodological under estimation has policy, financing and advocacy implications.
All the data used are presented in the manuscript.
LMICs:
low and middle income countries
PAHO:
Pan American Health Organisation
WHO. Typhoid vaccines: WHO position paper. Wkly Epidemiol Rec. 2008;83(6):49–59.
WHO. Background document: the diagnosis, treatment and prevention of typhoid fever. Geneva, Switzerland: World Health Organization; 2003.
Szu SC. Development of Vi conjugate - a new generation of typhoid vaccine. Expert Rev Vaccines. 2013;12(11):1273–86.
Neil KP, Sodha SV, Lukwago L, O-Tipo S, Mikoleit M, Simington SD, et al. A Large Outbreak of Typhoid Fever Associated With a High Rate of Intestinal Perforation in Kasese District, Uganda, 2008–2009. Clin Infect Dis. 2012;54(8):1091–99.
Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006;333(7558):78–82.
Bhutta ZA. Typhoid fever: current concepts. Infect Dis Clin Pract. 2006;14(5):266–72.
Kaljee LM, Pach A, Thriemer K, Ley B, Ali SM, Jiddawi M, et al. Utilization and accessibility of healthcare on Pemba Island, Tanzania: implications for health outcomes and disease surveillance for typhoid fever. The American journal of tropical medicine and hygiene. 2013;88(1):144–152.
Country and Lending Groups: by income. World Bank; 2011. http://data.worldbank.org/about/country-classifications/country-and-lending-groups. Accessed 03 May 2012.
Crump JA, Youssef FG, Luby SP, Wasfy MO, Rangel JM, Taalat M, et al. Estimating the incidence of typhoid fever and other febrile illnesses in developing countries. Emerg Infect Dis. 2003;9(5):539–544.
Srikantiah P, Girgis FY, Luby SP, Jennings G, Wasfy MO, Crump JA, et al. Population-based surveillance of typhoid fever in Egypt. Am J Trop Med Hyg. 2006;74(1):114–119.
Marks F, Adu-Sarkodie Y, Hunger F, Sarpong N, Ekuban S, Agyekum A, et al. Typhoid fever among children, Ghana. Emerging infectious diseases. 2010;16(11):1796–1797.
Nielsen MV, Sarpong N, Krumkamp R, Dekker D, Loag W, Amemasor S, et al. Incidence and characteristics of bacteremia among children in rural Ghana. PLoS One. 2012;7(9):e44063.
Breiman RF, Cosmas L, Njuguna H, Audi A, Olack B, Ochieng JB, et al. Population-based incidence of typhoid fever in an urban informal settlement and a rural area in Kenya: implications for typhoid vaccine use in Africa. PLoS One. 2012;7(1):e29119.
Thriemer K, Ley B, Ame SS, Deen JL, Pak GD, Chang NY, et al. Clinical and epidemiological features of typhoid fever in Pemba, Zanzibar: assessment of the performance of the WHO case definitions. PLoS One. 2012;7(12):e51823.
Ochiai RL, Acosta CJ, Danovaro-Holliday MC, Baiqing D, Bhattacharya SK, Agtini MD, et al. A study of typhoid fever in five Asian countries: disease burden and implications for controls. Bull World Health Organ. 2008;86(4):260–268.
Yang HH, Wu CG, Xie GZ, Gu QW, Wang BR, Wang LY, et al. Efficacy trial of Vi polysaccharide vaccine against typhoid fever in south-western China. Bulletin of the World Health Organization. 2001;79(7):625–631.
Sinha A, Sazawal S, Kumar R, Sood S, Reddaiah VP, Singh B, et al. Typhoid fever in children aged less than 5 years. Lancet. 1999;354(9180):734–737.
Brooks WA, Hossain A, Goswami D, Nahar K, Alam K, Ahmed, N, et al. Bacteremic typhoid fever in children in an urban slum, Bangladesh. Emerg Infect Dis. 2005;11(2):326–329.
Siddiqui FJ, Rabbani F, Hasan R, Nizami SQ, Bhutta ZA. Typhoid fever in children: some epidemiological considerations from Karachi, Pakistan. Int J Infect Dis. 2006;10(3):215–22.
Khan MI, Soofi SB, Ochiai RL, Habib MA, Sahito SM, Nizami SQ, et al. Effectiveness of Vi capsular polysaccharide typhoid vaccine among children: a cluster randomized trial in Karachi, Pakistan. Vaccine. 2012;30(36):5389–5395.
Owais A, Sultana S, Zaman U, Rizvi A, Zaidi AK. Incidence of typhoid bacteremia in infants and young children in southern coastal Pakistan. Pediatr Infect Dis J. 2010;29(11):1035–9.
Simanjuntak CH, Paleologo FP, Punjabi NH, Darmowigoto R, Soeprawoto, Totosudirjo H, et al. Oral immunisation against typhoid fever in Indonesia with Ty21a vaccine. Lancet. 1991;338(8774):1055–1059.
Punjabi NH, Agtini MD, Ochiai RL, Simanjuntak CH, Lesmana M, Subekti D, et al. Enteric fever burden in North Jakarta, Indonesia: a prospective, community-based study. Journal of infection in developing countries. 2013;7(11):781–787.
Lin FY, Vo AH, Phan VB, Nguyen TT, Bryla D, Tran CT, et al. The epidemiology of typhoid fever in the Dong Thap Province, Mekong Delta region of Vietnam. The American journal of tropical medicine and hygiene. 2000;62(5):644–648.
Lin FY, Ho VA, Khiem HB, Trach DD, Bay PV, Thanh TC, et al. The efficacy of a Salmonella typhi Vi conjugate vaccine in two-to-five-year-old children. The New England journal of medicine. 2001;344(17):1263–1269.
Klugman KP, Koornhof HJ, Robbins JB, Le Cam NN. Immunogenicity, efficacy and serological correlate of protection of Salmonella typhi Vi capsular polysaccharide vaccine three years after immunization. Vaccine. 1996;14(5):435–8.
Black RE, Levine MM, Ferreccio C, Clements ML, Lanata C, Rooney J, et al. Efficacy of one or two doses of Ty21a Salmonella typhi vaccine in enteric-coated capsules in a controlled field trial. Chilean Typhoid Committee. Vaccine. 1990;8(1):81–84.
Levine MM, Ferreccio C, Cryz S, Ortiz E. Comparison of enteric-coated capsules and liquid formulation of Ty21a typhoid vaccine in randomised controlled field trial. Lancet. 1990;336(8720):891–4.
Sur D, Ochiai RL, Bhattacharya SK, Ganguly NK, Ali M, Manna B, et al. A cluster-randomized effectiveness trial of Vi typhoid vaccine in India. N Engl J Med. 2009;361(4):335–344.
Naheed A, Ram PK, Brooks WA, Hossain MA, Parsons MB, Talukder KA, et al. Burden of typhoid and paratyphoid fever in a densely populated urban community, Dhaka, Bangladesh. Int J Infect Dis. 2010;14 Suppl 3:e93–99.
UN. Composition of macro geographical (continental) regions, geographical sub-regions, and selected economic and other groupings; Geographical region and composition. 2011. http://unstats.un.org/unsd/methods/m49/m49regin.htm. Accessed 02 Feb 2014.
Mogasale V, Maskery B, Ochiai RL, Lee JS, Mogasale VV, Ramani E, et al. Burden of typhoid fever in low-income and middle-income countries: a systematic, literature-based update with risk-factor adjustment. The Lancet. Global health. 2014;2(10):e570–580.
Poulos C, Riewpaiboon A, Stewart JF, Clemens J, Guh S, Agtini M, et al. Cost of illness due to typhoid fever in five Asian countries. Trop Med Int Health. 2011;16(3):314–323.
Khan MI, Sahito SM, Khan MJ, Wassan SM, Shaikh AW, Maheshwari AK, et al. Enhanced disease surveillance through private health care sector cooperation in Karachi, Pakistan: experience from a vaccine trial. Bulletin of the World Health Organization. 2006;84(1):72–77.
Buckle GC, Walker CL, Black RE. Typhoid fever and paratyphoid fever: systematic review to estimate global morbidity and mortality for 2010. J Glob Health. 2012;2(1):10401.
We thank Dr. Jin Kyung Park, International Vaccine Institute for statistical assistance. This work was funded by the Bill and Melinda Gates Foundation (Grant no. 417.01). International Vaccine Institute receives core funding by the Governments of Korea and Sweden.
Policy and Economic Research Department, International Vaccine Institute, SNU Research Park, 1 Gwanak-ro, Gwanak–gu, Seoul, 151-742, South Korea
Vittal Mogasale, Enusa Ramani & Jung Seok Lee
Epidemiology Department, International Vaccine Institute, Seoul, South Korea
Vijayalaxmi V. Mogasale
Biostatistics and Data Management Department, International Vaccine Institute, Seoul, South Korea
Ju Yeon Park & Kang Sung Lee
Development and Delivery Unit, International Vaccine Institute, Seoul, South Korea
Thomas F. Wierzba
PATH, 455 Massachusetts Avenue NW, Suite 1000, Washington, DC, USA
Vittal Mogasale
Enusa Ramani
Jung Seok Lee
Ju Yeon Park
Kang Sung Lee
Correspondence to Vittal Mogasale.
VM conceived the study and wrote the manuscript; VVM, ER, and VM did the systematic literature reviews; VM, VVM, ER, JYP, JSL & TFW did the analyses or interpreted results; KSL developed GIS map; TFW gave critical inputs throughout the study and reviewed the manuscript. All authors have read and approved the final version of the manuscript.
PRISMA 2009 Checklist. (DOC 63 kb)
Mogasale, V., Mogasale, V.V., Ramani, E. et al. Revisiting typhoid fever surveillance in low and middle income countries: lessons from systematic literature review of population-based longitudinal studies. BMC Infect Dis 16, 35 (2015). https://doi.org/10.1186/s12879-016-1351-3
Under-estimation


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"Tasted as a final blend, the inky colored 2015 Ventoux la Quintessence is a step up over previous vintages, and I suspect it will be the greatest vintage for this cuvee to date. Not harvested until the 18th of October (which is average to early for this terroir... they finished on October 31st in 2013), it has sensational purity and polish, with full-bodied richness, a big mid-palate, ultra-fine tannin and killer notes of creme de cassis, blackberries, licorice and graphite. Count me as a fan and it's anther wine that will see its 20th birthday in fine form."
"A compact style, with notes of roasted alder and juniper coating the dark fig and black currant paste flavors. Shows woodsy grip through the finish, while licorice root and tobacco accents fill in liberally. A touch austere from the wood!"
"Made by Pierre Seillan of Verité in Sonoma (the estate was purchased by the Jackson Family in 2003) from 50- to 60-year-old vines on clay and limestone, the 2015 Lassegue is composed of 70% Merlot, 20% Cabernet Franc and 10% Cabernet Sauvignon. Deep garnet-purple colored, it opens with expressive black forest cake, preserved plums and blackberry pie notes with an undercurrent of mocha, grilled meats, sandalwood and cigar box plus a waft of lavender. Medium to full-bodied, rich and densely packed with opulent layers of spiced black fruit preserves and chocolate box notions, it has wonderfully plush yet firm tannins and a lovely suggestion of background acid, finishing long and fragrant."
"The 2015 Fonréaud is a blend of 51% Cabernet Sauvignon, 45% Merlot and 4% Petit Verdot cropped at 38Hl/Ha. It has a clean and fresh raspberry coulis, cranberry and strawberry scented bouquet with cedar and tobacco scents interwoven. The palate is medium-bodied with crisp tannin, good depth, nicely structured but not unapproachable. It feels long and tender in the mouth with a crisp saline finish. This Listrac is just as good as it was at last year's Cru Bourgeois tasting."
"Tasted at the Cru Bourgeois annual tasting, the 2015 Fonreaud offers impressive, engaging blackberry and briary scents on the nose, well defined and focused with just a slight reduction that works in its favor. The palate is medium-bodied with firm but fine tannin, plenty of spice-tinged black fruit mixed with graphite and cedar toward the structured finish. I admire the length of this Listrac and I suspect it will give many years of pleasure. Sign me up! Tasted September 2017."
"This is a real Puligny with lemons and cooked apples. Hints of straw and limestone. Full- to medium-bodied, layered and clean. Bright finish. A beauty. Savory and salt at the end. Drink now."
"Focused, charming and open, sporting peach, apple and butterscotch flavors. The acidity shines through on the crisp finish. Should come together nicely in a year. Drink now through 2023."
"The Chassagne-Montrachet unveils a pale gold colour. The nose is powerful and gourmet offering aromas of yellow peach, marzipan and brioche. The palate is generous and supple with well-integrated oaky hints."
"Defined flavors of apple, lemon and mineral are deftly shaded by spicy oak in this tightly knit white that's intense and long, with an equilibrium that should gain cohesion over the next year or so. Best from 2020 through 2027."
"This is a solid Vaillons showing wonderful depth of fruit and mineral character. Full and dense with so much zest and beauty. Love the finish that just melts at the end."
"A pure, chiseled style, with tarragon and verbena notes streaking through, while lemon curd and white peach flavors hold the core. Flint and gooseberry accents chime in on the finish. Drink now through 2020."
"Very fresh, with a racy set of lemon peel, white peach and gooseberry flavors streaming through, flanked by light honeysuckle and chamomile notes. Ends with a precise finish."


Looking To Upgrade Your 4WD Suspension In Perth?
Then we have the mechanics, the insight, the equipment and the workshop to overhaul your new suspension system and give you a brand new driving experience. At Coastals we have been installing and maintaining 4×4 suspension systems for years. As a bunch of fellow four-wheelers, we can't help but check on our own whenever there's space free in the 4WD Perth Coastal Shop.
What's under your 4wd and how it's performing is integral to know if you want your rig in optimum condition. Just because it's out of sight, definitely doesn't mean it should be out of mind. In terms of your 4X4's performance, nothing is more important than a well sorted and reliable suspension setup. There's a dizzying array of aftermarket stuff available, all with their own pros and cons. If you want a reliable tourer, this corner has probably been your first port of call when it comes to accessorising your rig. Whilst you might be able to skimp in other areas, when it comes to the suspension it is definitely a case of getting what you pay for.
For the first time, 4×4 buyer upgrading your suspension can greatly improve your driving experience and make off-road travel much more comfortable. However, you should definitely consult a professional with experience in four-wheel suspension before deciding on a new setup or attempting to install one yourself. Each vehicle has its own height specifications which can affect how you should approach a new suspension set up. Avoid potential heartbreak by consulting with Coastals to ensure you don't hamper your vehicle and burn an unnecessary hole in your pocket. We also do modifications to make sure your 4×4 is the best it can be.
Whether you are an experienced off-roader or a first-time buyer looking to upgrade your 4×4 suspension Perth be sure to contact Coastals. We have everything you need at a competitive price and can fitout your new 4×4 vehicle quickly and efficiently. If you're unsure what type of lift you should get for your vehicle, don't hesitate to give us a call. We are always happy to help and advise. So don't delay, give us a call today.


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Books/Movies
Best Christmas Books for Kids
**Enter to win $500 in PayPal cash in the Christmas Cash Spectacular! See the details later in this post! Christmas is coming, and as intentional parents seeking to point our children to Jesus in every holiday, one way of enjoying the holiday, teaching its meaning, and creating memories is through reading the many wonderful Christmas … Read more Best Christmas Books for Kids
Categories Books/Movies, Holidays, Intentional Parenting Tags Celebrating holidays, Redeeming holidays Leave a comment
Walking with God in the Season of Motherhood: Summary and Review
Walking with God in the Season of Motherhood: Review and Summary This past summer, I had the privilege of working through Melissa B. Kruger's encouraging devotional Bible study called Walking with God in the Season of Motherhood. Broken into eleven chapters, each chapter includes sections of days one through five, so that one … Read more Walking with God in the Season of Motherhood: Summary and Review
Categories Books/Movies, Christian Encouragement, Intentional Parenting, Motherhood Tags Christianity, parenting Leave a comment
The Pumpkin Patch Parable: Book Review
We choose not to celebrate Halloween, commemorating Reformation Day instead, but we love fall and pumpkins and having fun at pumpkin patches. Our third child was born in October, so we called her Pumpkin even before birth. When she was almost two, I found a delightful book at the library, which tells the story of … Read more The Pumpkin Patch Parable: Book Review
Categories Books/Movies, Holidays, Intentional Parenting Tags Celebrating holidays, parenting Leave a comment
Robbing Anne of Green Gables
It is with sadness that I have learned that Netflix has come out with a new series called Anne with an E "based" on the beloved Anne of Green Gables book series for girls. (Disclaimer: I have not seen the Netflix version, and here is why.) Now we all know that books are better than any movie version of them and that no movie will follow the book exactly, but the 1985 version with Megan Follows is beautiful, virtuous and humorous, a Canadian classic, and at least captures the spirit of the Anne of Green Gables books. Set at the end of the Victorian age, Anne is an eleven-year-old orphan with an irrepressible spirit, who embodies the creativity, joy, foolishness, flightiness, and innocence of girlhood. Despite a flaring temper and tendency towards vanity, Anne demonstrates a strength of character.
The Netflix version is a series that departs far from the books, delving into Anne's life before she is adopted by Matthew and Marilla Cuthbert. Lucy Maud Montgomery, the author, only alludes to Anne's early childhood. There is a reason she leaves out what might not be beautiful, for little girls – and big girls for that matter – don't need to hear the ugliness of an unloved little girl's life. But according to reviews and comments of other viewers, the Netflix version, which is directed by Moira Walley-Beckett, portrays a gothic, gritty glimpse of Avonlea where people act as strangers rather than the warm, if flawed community of the books. Anne suffers from disturbing flashbacks, which show her supposed appalling abuse at the hands of the Hammonds and in the orphanage, and there is a scene where Anne explains sexual matters to Diana by describing how Mr. Hammond had a pet mouse in his front pants pocket. Instead of rising above her past, Anne is unkind and bullies the hired hand, Jerry. Other characters are quite different too: when Marilla thinks Anne has lost her brooch, she sends Anne back to the orphanage. Diana is the daughter of wealthy English immigrants rather than the home-grown farm girl, and Gilbert must go to work in the shipyards of Charlottetown when his father dies and leaves him an orphan. Other scenes portray a mugging, attempted kidnapping, attempted suicide, pedophilia, homosexuality, financial ruin, and other light-hearted, age-appropriate topics – NOT! Over it all, is a loud cry of feminism from both Marilla and Anne. If Wally-Beckett wanted to delve into psychological and emotional issues that were not part of a post-Victorian culture and turn Anne into a feminist heroine, why not just set it in modern times in an inner city? Instead, Wally-Beckett spent much care in creating the details of the early 1900s on Prince Edward Island (apparently with striking cinematography) to make viewers think they were getting the same Anne, and yet, she completely changed the plot and robbed us of the dear Anne of L.M. Montgomery. Why?! L.M. Montgomery did not give us the grim and tragic worlds of Charles Dickens (think Oliver Twist) or Fyodor Dostoyevsky, and that is why pre-teen and teen girls love her books; they are beautiful, good, and full of hope.
I recently read the authorized version of Anne's early years called Before Green Gables by Budge Wilson to see if it was appropriate for my daughter, since it is in the adult section of the library. I decided it wasn't time for my daughter to read this. While it handles Anne's early years with grace, it is still not the charming, pleasurable story of L.M. Montgomery's books. In this version, Anne does not experience abuse, but she is neglected and treated essentially as a slave and a burden. Yet, there are characters who show her love along the way – an older daughter of the Thomases, a man who sells eggs and teaches her new vocabulary, a teacher, and a midwife who also helps the Hammonds. If Walley-Beckett wanted to explore Anne's pre-Green Gables years, she could have used this lighter version, which still holds a sense of hope.
Do such reinterpretations pushing a modern agenda really help us dwell on what is lovely and pure? Does a new dark, feminist twist on the story and modern agenda reflect truth and joy? While the original books may seem a bit too naïve in regards to the emotional baggage an orphan comes with, there is nothing wrong with our little girls enjoying a Victorian moral heroine. Even as an adult, in reading the Anne books together with my children, Anne has reminded me that I once was a whimsical child and has given me a better appreciation of my creative but irresponsible daughter. I'd much rather my daughters read about Anne and see her grow into a responsible, family-loving woman than have them grow attached to some of the popular "heroines" of late. Think of Miley Cyrus, who seemingly innocent during her Hannah Montana years, has since pursued all sorts of lewd displays of "entertainment" and immoral behavior. Also, though I appreciate her sentiments about kindness and body image, Olympic gold medal gymnast Aly Raisman is no one to be emulated either, for she recently posed topless and stated: "I think being a role model is about being a kind person… Women do not have to be modest in order to be respected." Sorry, I disagree, for in God's kingdom, modesty and morality are important in glorifying and enjoying Him. But the point is, it is okay for our young daughters to enjoy seeing the world through the rose-colored glasses of an ever hopeful and joyful heroine like Anne. Why rob us of that in this new version and forever spoil our image of Anne, who wishes to be called Cordelia and to be loved?
So I have no intention of watching this new Netflix version of Anne of Green Gables and fill my mind with these images. Instead, I prefer to stick with not just Victorian, but biblical values, and think on what is true, noble, right, pure, lovely, admirable, excellent and praiseworthy. And I look forward to watching the 1985 version with my daughters!
Jus' Classical is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.
Anne Of Green Gables movies (1985)
Anne of Green Gables book series
Homeschooling: Why We Home Educate
Why We Educate Classically: The Power of Christian, Classical Education
Why We Participate in Classical Conversations
The Purpose of Classical Education
Memorization: Why It Is Important and How It Is Mentally Liberating
11 Reasons Kids Need Music More Than Ever
15 Reasons to Celebrate Reformation Day
Categories Books/Movies, Intentional Parenting Tags movie review Leave a comment

redpajama_set_name: RedPajamaCommonCrawl


text:
class SorceryCore < ActiveRecord::Migration
  def change
    create_table :accounts do |t|
      t.string :email,            :null => false
      t.string :crypted_password, :null => false
      t.string :salt,             :null => false

      t.timestamps
    end

    add_index :accounts, :email, unique: true
  end
end

redpajama_set_name: RedPajamaGithub


Viewtech Financial Services, Inc. ("Viewtech"), originally called Volt Energy Systems, was a division of Volt Information Sciences, Inc. ("Volt"/NYSE:VOL), a current Fortune 1000 company.  Formed in 1974, principally to provide energy utility industry staffing for meter reading, energy audits and other utility conservation programs, Viewtech evolved over the years, by changing both the name of the company, as well as its core business focus.  In 1993, the newly titled Volt VIEWtech, Inc., branched out into the areas of computer, internet and finance-based energy and water conservation program administration, making an important critical niche for itself.


The organizational context is very important. It forms the backbone of all (management) tasks that need to be performed in order to reach the desired level of performance. Not taking them seriously will severely hamper the performance of the organization. Each tab on this page focuses on one of the key aspects, important in creating the proper performance backbone.
Competence function: the structure sets the conditions for developing and exploiting specialist knowledge and competences that are an intrinsic part of the individuals and (specialist) groups.
No one size fits all. Successful, high performance organizations are able to shift to the right form, also called operating logic, to facilitate strategy execution. They do this by continuously balancing the external market opportunities and the efficiency of internal resources. Organizations with a structural misfit or minimal fit are heading for failure or will at best struggle to even get mediocre results.
How different strategies require different structures can be explained by making use of two examples. In the Miles & Snow definition of corporate strategy organizations can choose a "defender" strategy aimed at defending their current market positions with a limited, but stable product line. These companies usually are focused on cost efficiencies through economies of scale, are coordinated centrally based on a plan. In terms of operating logic these companies for which economies of scale are more important than the economies of scope (actively searching for new market opportunities) a functional organization structure will be best suited. On the opposite, a "prospector" strategy, aimed at actively looking for new markets and new (product opportunities) not so much the economies of scope, but the economies of scale are more important. A centralized, planned, functional structure in this case will not work; it will hinder the responsiveness needed to be first in new markets. "Prospector" strategies are best supported by an operating logic that is characterized by decentralized decision making, managed primarily on performance (not cost efficiency), with highly flexible and adaptive processes and more geared towards learning.
Although all of this makes perfect sense, how come not all organizations have a fit to (new) strategy structure? Next to coordination function a structure also has a social function. There is a natural tendency where people identify themselves with the position (of power) that they hold in the structure. When changes are needed due to a change in conditions and strategy, these people will fight change in fear of losing this position. A second reason is the fact that some structures are in place, not because of the economic logic, but to deal with personal issues between staff members. In this case the problem between two or more staff members has created a structure that (partly) resolves this problem. The structure has been created to resolve an internal problem, not to serve opportunities.
To be a high performance organizations means that management has to continuously ensure a tight fit between the market opportunities and the resource efficiency. Management of high performance organizations understand the impact of structure and are capable of aligning this structure based on the economic rationale, irrespective of personal issues within the organization.
Culture is a powerful factor within organizations since it influences the behavior of all people within the organization. Culture is not created singlehandedly, it is a collective programing based on strong basic assumptions. These assumptions are formed as a result of influences both from inside and outside of the organization. They are almost never explicitly known; this is what makes it difficult to fundamentally change culture.
Culture develops based on business success, shaping the perception of what works well. What happens then is that culture finds its way into the management system of the organization. What has worked well so far is integrated into the vision and strategy, company values, reward systems, organization/accountability structure etc. It starts to actively influence people's behavior. This makes it very difficult to challenge the basic assumptions. The risk of not challenging these basic assumptions makes it more and more difficult to develop new business models when the old one becomes obsolete.
Making explicit why the current business model is no longer valid. This can be done by stating the basic assumptions of the old model, why it has been successful in the past and why the basic assumptions are no longer valid.
Thirdly, the new business model needs to be fixated into the management structure; in effect the management system needs to be redesigned in order to adequately support the new business model.
High performance organizations need to master the process of identifying old and obsolete business models and implementing new ones through purposeful redesign of the management system.
A lot of the performance management focus is on IT, having supportive information systems in place. These systems need to provide information on actual performance (performance measures, (K)PI's) as well as input for analysis and decision making. In many organizations numerous efforts are made to implement the latest in ERP systems, data warehousing and reporting solutions, all to support the daily operations and decision making.
In many organizations the implementation of these systems is factually run by the IT department, although formally the business is responsible. These efforts mostly result in an operational IT system, that does not (fully) meet the information requirements of running a performance driven business. The new systems still provides one-sided information (backward looking, financial and some operational). The vast amount of data results in a data overload for decision makers, and the information provided does not fully match the information needed. Most of the time this results in a re-definition of the performance measures in line with the limitations of the system, not to a change in technology.
What is happening in many less performing organizations is that information management is viewed as Information TECHNOLOGY management. This results in a technology driven approach to information management that takes technology as a given, instead of information requirements. High performance organizations understand that the information layer is separate from the hardware and applications and needs to be managed separately. For the actual information management to work technology is needed and this technology should be aligned, based on the information layer.
High performance organizations are capable of having the business information needs clearly defined by the business. Information needs are meticulously defined in line with the business model, operating logic and operations. The need for Information Technology (hardware and applications) needed for now and in the near future is then carefully defined by the IT specialists together with the business information specialists. Ultimately it is the business that decides on the technology chosen to limit any deviation from the originally defined information needs. Doing this is far from easy; that is way a high performance organization employs highly trained business staff, that have business experience, are well-trained in information management, and are able to clearly communicate with the hard-core technology staff.
Performance in the end is achieved through action. In the case of organizations it is done through processes. Performance is reached by operating effective and efficient processes. This is why high performance organizations focus on continuously improving/adjusting their processes in a systematic way.
High performance organizations have a business process management system in place that is aimed at defining, measuring, monitoring and improving processes. High performance organizations have clearly assigned accountability for key end-to-end (cross functional) business processes to business process owners. These process owners are capable of organizing skills, knowledge, tools, techniques and supporting systems in such a way that they can maintain and support this continuous improvement cycle.
I am not advocating the use of Lean or six sigma techniques per se. This would be only part of what needs to be organized. Rushing into yet another Lean/Six Sigma initiative will only temporarily improve your processes, it will not automatically result in long lasting high performance processes. What needs to be done first is to clearly set process ownership and to organize the continuous improvement process; this means getting the right skills and knowledge on-board and defining the improvement process. Only once this has been done, can one start with selecting a supporting technique and tool set. High performance organizations master this process.
Select the most appropriate tools and techniques (e.g. Lean/Six Sigma) to support your Process Management Approach.
Leadership has been a buzz word for the last few years. In the past four to five years leadership has been a recurring theme in many management publications, including the Harvard Business Review. This indicates that leadership is viewed as a key ingredient to making an organization excel and perform, especially in times of crisis. It is especially during these difficult times that staff are looking at senior management to show leadership and guide the organization towards a more prosperous future.
Instinctively there appears to be a difference between management and leadership, or between a manager and a leader. Although there is certainly an overlap there are a distinct differences in leadership and management in the true sense of the word. One difference is that leadership always affects (a group) of people, where management need only to be concerned with the management of things (e.g. management of IT, management of treasury/money, management of sales). Of course many managerial roles include a responsibility for people management, management doesn't necessarily include a responsibility for people. Second, management and management responsibility are closely linked to the formal structure of the organization, it's role and related power is formalized and person independent. Leadership on the other hand is intrinsic, part of person and not formalized.
Next to these differences some people claim that there is a significant overlap in leadership and management: good leadership always includes responsibility for managing. This states that (a responsibility for) management is part of leadership, but not vice-versa. When managers start developing leadership (by influencing, guiding people not merely based on the power relationship) the clear line between management and leadership start to fade.
Passion: a leader has a passion for what he or she does. Passion is an internal drive to reach certain goals. Passion is a powerful motivator also for others. It also helps the leader to persevere.
Integrity: leaders act on the basis of self-knowledge, candor and maturity. A leader knows his strengths and weaknesses and acts accordingly. Leaders knows about his faults and assets and deals with them directly. Candor is based on aligning ones actions with ones beliefs, convictions and principals. Leaders will never sell out on their core beliefs to please another. Leaders need to mature. They mostly mature form having learned to being a follower, having learned to be dedicated, observant and capable of working together and learning from others.
Trust: trust is a basic ingredient for being a leader. Trust is not so much of an ingredient as it is a product of leadership. Trust needs to be earned from the followers; without trust a leader cannot function.
Curiosity and daring: Leaders have a natural tendency to wonder about everything, want to learn as much as they can, are willing to experiment, try new things and take risks. Leaders are not worried about failure, the embrace failure as an opportunity to learn.
It is leadership that makes the new possible. As we have seen in other parts of the framework, continuously looking for new opportunities and adjusting the organization accordingly is what brings organizations actual performance. Leaders are not necessarily born as leaders. Leaders are made, most of the time self-made, propelled by a strong passion and strong personal qualities, having learned from successes but mostly of actions that did not turned out well.
High performance organizations firstly understand the power of leadership; second they have the ability to clearly identify leadership potential and develop it to the desired level of maturity.
The title of this section might not be covering all that I would like to stress as being important for high performance. I do not want to claim that teams need to be the only way to organize. Instead of teams as a way to structure I want to clearly state the importance of the people within the organization. It are the people, their skills, capabilities and them working together in such a way that (performance) objectives are reached.
Fluid/flexible working relationships: HPO are focused on adapting quickly to the changing environment. One way of doing this is organizing staff and their capabilities fluidly. This means that staff with the required capabilities can be freed up immediately and work together with others on initiatives. HPO's do not have strict functional boundaries or silos; people move freely from one (temporary) position to another.
Learning organization: HPO's are organizations that actually practice active learning. They have implemented a solid learning and knowledge management system. This system captures the lessons learned and make them available to all people within the organization. Furthermore HPO's have a learning system based on the knowledge needs of tomorrow, ensuring that staff is ready to deal with the new situation effectively.
Delegated authority: within HPO's staff is trusted with making their own decisions. Staff is much closer to the daily operations and to seize opportunities and resolve issues. People are trusted to make the best decision since they are adequately trained and have quick and easy access to all available knowledge.
Shared values & identity: in HPO's change is a constant. Since objectives and results change, people need to have a solid anchor point to guide their behavior. Using shared values and maintaining a clear (common) identity helps to continuously align staff behavior and stimulates people to actively working together, learning from each other and helping each other in completing certain tasks.
In order to transform ideas and good intentions into tangible results, some investment will be needed. Next to investments in tangible assets such as property, plant & equipment or stocks, also investment in intangible assets is needed. For most new strategic initiatives success will depend on having the right capabilities in place to change the organization, its products or services and its management system.
New strategic initiatives require investment and those strategic initiatives need to be monitored to ensure the money is well spent in that it delivers the expected results at the estimated costs. So next to having the actual money available to invest, a high performance organization needs to implement a method of tracking the business case for change. The way that current accounting systems are set up do not easily facilitate this kind of monitoring. All costs are either charged to certain cost accounts, as operational expenses (OPEX) or capitalized (CAPEX). As a consequence strategic initiatives are started but prove to be difficult to control. What is needed is a system of tracking the costs and benefits of these strategic initiatives separately.
In their book "The Execution" premium Kaplan and Norton introduce "STRATEX" as a separate expense category, next to OPEX and CAPEX, to monitor all expenses for strategic initiatives. STRATEX is introduced as a way to rigorously track the investment in new or adjusted strategic directions (both in terms of expenses and benefits). On the expense side this results in a third type of budget, next to operational and capital expenditures. It results in more cost transparency and will give management more control over the company's funds and fund allocation. When measuring the actuals against the STRATEX management is able to adequately respond and make necessary changes in case the STRATEX budget is being exceeded. This type of monitoring enables management to pro-actively manage its strategy/strategic initiatives.
I am not propagating to introduce STRATEX in all companies. What I am stating is that all high-performance organizations need to monitor the (financial) success of their strategy and strategic initiatives, as they do with their current CAPEX. This can only be done when a system is in place that collects all data on investment and progress and is used by management to adequately steer the organization towards its goals. Having this third type of expense category will mean that some strategic expenses now being invisibly included in OPEX and CAPEX will need to re-allocated. The process itself will work along the same lines as budgeting for operational and capital expenditures. First the strategic initiatives will need to be identified and defined. This means that will need to be broken down in phases and tasks. Next, estimates of both the expenses and benefits will need to be made. Expenses will need to be classified into specific sub categories. This is a more bottom-up approach. A top-down approach could also be opted to set a budget. Based on experience management could determine the STRATEX budget based on a certain percentage of total sales. This budget can then be used by various strategic initiatives.


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Arizona 250 GT Major General Liz Cosson
Richard Larter
computer generated image, synthetic polymer paint and gel-glitters on polyester canvas (support: 163.0 cm x 111.0 cm)
In 2001 Major General Elizabeth Cosson received the Conspicuous Service Cross, a military award for her achievements as the Chief of Staff, Peace Monitoring Group, Bougainville. She was appointed a Member of the Order of Australia (Military Division) on Australia Day 2011 for exceptional service. Cosson wears both medals in this portrait.
Elizabeth Cosson AM CSC (b.1958) enlisted in the Australian Army in 1979. In 2007 she became the first woman to be promoted to the rank of Major General in the Australian Army. Throughout her distinguished military career, Cosson held significant logistics and administrative positions, including serving in East Timor. In 2006, she reported on the repatriation of Private Kovco's body from Iraq. The following year, she was appointed head of National Operations. Cosson retired from the defence force in November 2010 and joined the Australian Public Service.
Artist Richard Larter OAM (1929 - 2014) received the Medal of the Order of Australia in June 2011 for service to the visual arts. Larter scanned drawings, photographic enlargements and collaged cut-outs and transferred them onto canvas using an 'Arizona 250 GT' UV flatbed printer. The helicopters reference Cosson's commendation for her work in improving the availability and deployment of Black Hawk helicopters in Cambodia.
Gift of the artist 2013
© Richard Larter/Copyright Agency, 2022
Richard Larter (age 84 in 2013)
Elizabeth Cosson AM CSC (age 55 in 2013)
Richard Larter (2 portraits)
(View all 5)
1. Richard Larter, 2004 R. Ian Lloyd. © R Ian Lloyd/Copyright Agency, 2022. 2. Self portrait with pin-up, 1965 Richard Larter. © Richard Larter/Copyright Agency, 2022. 3. Pat Painting No 1, 1983 Richard Larter. © Richard Larter/Copyright Agency, 2022. 4. Arizona 250 GT Ron Radford and Shiva #1, 2011 Richard Larter. © Richard Larter/Copyright Agency, 2022.
Magazine article by Dr Christopher Chapman, 2008
Christopher Chapman describes the art and life of Australian artist Richard Larter.


I've been quilting since 2006, but my passion for fabric has always been there. I remember watching my mom sew garments and quilts and was just fascinated by the process. While shopping with her, I would touch fabric and think what I could make with it. That passion and creativity stayed with me and has grown to an obsession.
My mom taught me how to sew some basic clothing items and I remember feeling so great with what I created. Then I made curtains, bedding, and pillows. If I could dream it, I could make it. Then a friend taught me about quilts. At the time we lived in South Korea where we were stationed with the Army. I loved everything about the quilt process and the rest was history.
We offer longarm quilting services to include computerized edge to edge, custom quilting and machine basting. In addition we create custom t-shirt quilts and memory quilts.
I grew up an Army Brat. My dad spent 20 years active duty Army and 20 years as a civilian employee serving his country. We moved many times, but enjoyed every minute of it. The Dandelion is the national flower of all military children (aka BRAT).
We bloom where we are planted and thrive!
Length of quilt times width of quilt equals square inches multiplied by price per square inch equals total cost of quilting.
Call for custom quilt pricing.
Please refer to pricing for additional charges.
Copyright © 2018 Dandelion Quilt Company - All Rights Reserved.


text:
Q: What is the image of the map $\hom(V,V) \to \hom(\wedge^k V,\wedge^k V)$? The title says it all. For the uninitiated: Any map $f:V \to W$ induces a map $\wedge^k V \to \wedge^k W$ by $v_1 \wedge \cdots \wedge v_k \mapsto f(v_1)\wedge \cdots \wedge f(v_k)$, so $\wedge^k(-)$ is a functor from vector spaces to itself.
I have a map $\varphi:\wedge^k V\to \wedge^kV$ and I have reason to suspect that this map does not come fram a map $\psi:V \to V$.
I'm not sure how to prove this. It seems that any map in the image of $\wedge^k(-)$ must satisfy some kind of Plücker relations (similar to those of the Grassmannian), since if $\varphi \in \hom(V,V)$ is represented by the matrix $(x_{ij})$, then its image in $\hom(\wedge^k V,\wedge^k V)$ has matrix $(\det_{IJ}(x_{ij}))$, where $\det_{IJ}$ means take the determinant of the submatrix with indices $I$ and $J$.
I tried asking Macaulay2 to compute the ideal of relations, but even in the case $\dim V=4$ and $k=2$, it does not seem to be a feasible computation:
R = QQ[x_1..x_16]
M = genericMatrix(R,4,4)
I = minors(2,M)
numgens I
>> 36
S = QQ[y_1..y_36]
f = map(R,S,gens I)
ker f
>> ......???? <- to much for M2!

Is there some strategy to determine if my map comes from $\hom(V,V)$ other than computing these relations? If not, are the relations between the $k\times k$-minors of a $n\times n$-matrix known?
Thanks.

A: The (Zariski closure of the) image of your map is studied in the following paper of Bruns and Conca:
http://arxiv.org/abs/0705.3399
They stratify this closure by two numerical invariants rank and "small rank" and show that they correspond to $GL(V) \times GL(W)$ orbits. I never read the paper carefully, so I don't know if it will be of any use, but hopefully there are some interesting things in there for you.

redpajama_set_name: RedPajamaStackExchange


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Young People at the Horniman
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Crossing Borders 2015: local communities come together at the Horniman
Happening at the Horniman	Community	Volunteering
Joanna Slusarczyk and Lucia Cortelli tell us about Crossing Borders, an event at the Horniman bringing together local communities.
On Saturday 7th February, the Horniman hosted an event bringing together local community groups of newly-arrived migrants and refugees.
We were asked to volunteer on that day and decided to join in.
We became volunteers at the Horniman to learn how a museum engages its audience and local communities with its vast collection. It was also relevant to our studies at UCL in Anthropology and Museum and Gallery Education.
We had never volunteered on a Crossing Borders event and we were looking forward to working with the members of the many associations involved.
In fact, Crossing Borders began in 2003 and has grown each year due to the increasing participation of local community groups working with refugees and asylum seekers. This year the event included a wide range of exciting activities, from storytelling to live theatre performances.
Upon our arrival at the museum, other volunteers and member of staff were already decorating the galleries with bunting created by the collaboration between the Youth panel and new arrivals at Pan-Intercultural Arts as well as shopping bags created by families of the Indoamerican Refugee Migrant Organisation and the family learning team.
In the conservatory, others were setting up the tables for the food to be served at lunchtime, free of charge to all participating community groups.
Before the opening time, we helped the members of Streatham Women's Sewing Group transforming Gallery Square with a giant colourful dress, which provided inspiration for the family activity. The dress was a collaborative artwork conceived by artist Fion Gunn and craftswoman Ifrah Odawa and was inspired by personal memories of how important life occasions were marked by different dressed in the lives of the members' mothers.
The activity was to design and make your own outfit using colourful fabrics, the finished designs were displayed on the wall in the museum. Gallery Square was busy with families creating artworks and enjoying the social and inclusive atmosphere, our group of volunteers was trying to help with the activity and make a contribution to the smooth running of all the events.
Later, Gallery Square was reshuffled into a performance space for the Paper Project at the Oval House Theatre. These artists from different cultural backgrounds performed an experimental piece of theatre called "I Was a Child Somewhere Else", demonstrating the journey from childhood to adulthood.
They used a series of symbolic props such as egg shells and odd shoes to demonstrate the journeys undertaken by many people who wish to build a new life for themselves in a new country. The performance was dedicated to the undocumented children living in the UK who are precluded university or a career.
The audience waited in anticipation for the other performance, which occurred later in the afternoon. Fairbeats!, together with families from Action for Refugees in Lewisham, sang lyrics they had written themselves, in an energized and exciting song sharing performance.
In the meanwhile, in the Hands on Base there was a screening of Seeking Refuge. This is a series of animated films created by Mosaics Films for the BBC. Director Andy Glynne says the aims of the films are clear: "At the very least I hope that it increases awareness within children," he says. "It's about showing engagement, empathy and understanding of what it's like for people who are fleeing their own homelands because of persecution."
In the same room, films were alternated with storytelling. Sally Pomme Clayton led interactive storytelling sessions with visitors and members of the Southwark Day Centre for Asylum Seekers. Using pictures taken by the participants of an ongoing photography project, the story teller engaged members of the public to tell their own stories using the photographs as well as to listen to stories from different cultures.
Visitors to the museum thoroughly enjoyed the event and all activities on the day were welcomed with enthusiasm. A local grandmother who attended the event told us that the Horniman is brilliant for community events because it brings people from different backgrounds together. As volunteers we also enjoyed taking active part in this event and witnessing the exchanges and encounters that took place on the day in a spirit of inclusion and openness.


Let me start by saying I am not a fan of this style of camera for wildlife photography and I doubt you will catch any pro photographers using them. You really cannot compare bridge cameras with a DSLR setup, otherwise why would anyone carry around heavy equipment or spend thousands of pounds on photography gear, but there is no doubt they are good Cameras for the purpose they are intended.
There is no doubt Superzooms and Bridge Cameras do have a place in some peoples kit back or pocket and I do understand that for those people who don't want the hassle of carrying heavy gear, can't afford a DSLR, need a small camera when travelling for example or are happy with a record shot and aren't particularly fussed about pin sharp feather detail, flight shots and so on, then these cameras fit the bill and fine. I also appreciated the versatility of a big zoom range from wide angle to telephoto and i also except that as these cameras get better and technology advances the image quality and noise reduction at high ISO's achievable with these portable powerful little cameras continue to improve.
I do not have a large degree of experience with these cameras but for a while I have owned a Fuji Finepix HS20 EXR (16MP, 30x Optical Zoom) on which i can base some experience. At Arundel Wildfowl and Wetlands Trust I gave it its first proper outing with wildlife in mind the birds in the collection here are at close range which wasn't particularly realistic in wildlife photography terms but testing this camera in various situations here gave me a good idea of its capabilities.
I am a DSLR owner and obviously this will never be my first choice for wildlife. However the results at close range and in ideal shooting conditions are comparable with DSLR images when pixel peeping at 100%, not surprisingly it struggles in poor shooting conditions and that's when differences become obvious. It is noisy at high ISOs but technological advances will no doubt continue to combat this across all styles of camera; however it does have lots of bells and whistles to deal with these kinds of issues and some interesting and potentially useful features for wildlife.
It does serve a purpose on a day out when perhaps you don't want the hassle of carrying all the DSLR gear but you do want the ability to capture a record shot or if you are lucky a good quality image, after all at close range in good light it's capable of producing a decent image. Full HD Video is ok quality but it hunts wildly to find focus rendering video unusable as far as I'm concerned. With16mp there's plenty of scope for cropping to enlarge and still retaining enough detail for large prints. A newer more expensive bridge camera would I'm sure take this even further and combat some of the issues I have with this one but I had set a budget of £250 and this fitted all the specifications I required.
I can't help but compare the results with the high quality DSLR images I am used to viewing on my computer; yes if you are a few feet from your subject you will get good shots with any set-up. My guess is that as soon as you start to test one of these super-zoom cameras with bad light, distance, fast moving subjects, and so on, that's when you'll notice a big difference. So yes, at your local park taking pictures of Canada Geese, Ducks, Pigeons, Gulls and Robins the results from these kinds of cameras can be ok. There is no doubt these cameras have a place in modern photography and for the average Jo taking holiday snaps and pictures of the kids or even the birder/photographer not looking for high quality images a bridge camera may be all you will ever need, after all there is no doubt you can crop to enlarge and produce a canvas or poster with a picture from one of these style of cameras. Wildlife photography as you'll no doubt know will test you and your camera to its limit and there'll be many situations when a superzoom just won't cope.
My problem is that what these cameras are claiming they can do is in my view unrealistic, superzooms claiming a telephoto lens of 1200mm equivalent magnification! Well be honest, stabilised or otherwise, we all know that taking a photo at that sort of magnification is going to be hard to eliminate camera shake with any setup not on a tripod.
You will need a high shutter speed to freeze any movement of the camera or subject and to get one you will need a lot of light, yes you can up the ISO to help you out but at what cost, the chances are if you get a sharp image it'll be noisy. What you are most likely to get, due to the low shutter speed that's not fast enough to freeze the action, is a blurred image!
I'd expect most of these cameras to be virtually unusable at the higher half of their claimed range on average uk light conditions, I'd expect to be better off getting a good quality camera with a realistic zoom and cropping the picture. It's clearly better to have a sharp image you can crop than a frame filling blurred image because you cranked the zoom up to 50x and couldn't hold it still in a light breeze.
Having said that if a bridge camera / superzoom is for you then there is an extensive range these days. The Canon PowerShot SX50 HS (12.1 MP, 50x Zoom) seems a popular choice. My advice would be not to go for a something like a 50x zoom and instead go for something less than half that magnification with a higher pixel count giving you more scope to crop the image.


Florida native Blazel returns with a brand new EP simply titled, "Growth". The 5-track EP gives Blazel the opportunity to showcase his talents, and his artistic growth, featuring production from No1, Drewrich, and Chef Melz. Take a listen to the short body of work below, and stay tuned for more as Blazel is preparing to heat up the spring.