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Research | Open | Published: 28 March 2019
Artemisinin-based combination therapy during pregnancy: outcome of pregnancy and infant mortality: a cohort study
Michael Nambozi1,
Halidou Tinto2,
Victor Mwapasa3,
Harry Tagbor4,
Jean-Bertin Bukasa Kabuya1,
Sebastian Hachizovu1,
Maminata Traoré2,
Innocent Valea2,
Marc Christian Tahita2,
Gifty Ampofo4,
Jozefien Buyze5,
Raffaella Ravinetto6,
Diana Arango5,
Kamala Thriemer5,7,
Modest Mulenga1,
Jean-Pierre van Geertruyden8 &
Umberto D'Alessandro ORCID: orcid.org/0000-0001-6341-50099
The World Health Organization (WHO) recommendation of treating uncomplicated malaria during the second and third trimester of pregnancy with an artemisinin-based combination therapy (ACT) has already been implemented by all sub-Saharan African countries. However, there is limited knowledge on the effect of ACT on pregnancy outcomes, and on newborn and infant's health.
Pregnant women with malaria in four countries (Burkina Faso, Ghana, Malawi and Zambia) were treated with either artemether–lumefantrine (AL), amodiaquine–artesunate (ASAQ), mefloquine-artesunate (MQAS), or dihydroartemisinin–piperaquine (DHA–PQ); 3127 live new-borns (822 in the AL, 775 in the ASAQ, 765 in the MQAS and 765 in the DHAPQ arms) were followed-up until their first birthday.
Prevalence of placental malaria and low birth weight were 28.0% (738/2646) and 16.0% (480/2999), respectively, with no significant differences between treatment arms. No differences in congenital malformations (p = 0.35), perinatal mortality (p = 0.77), neonatal mortality (p = 0.21), and infant mortality (p = 0.96) were found.
Outcome of pregnancy and infant survival were similar between treatment arms indicating that any of the four artemisinin-based combinations could be safely used during the second and third trimester of pregnancy without any adverse effect on the baby. Nevertheless, smaller safety differences between artemisinin-based combinations cannot be excluded; country-wide post-marketing surveillance would be very helpful to confirm such findings.
Trial registration ClinicalTrials.gov, NCT00852423, Registered on 27 February 2009, https://clinicaltrials.gov/ct2/show/NCT00852423
Pregnant women are more vulnerable to malaria than non-pregnant women because of altered immunity. Each year, about 85 million pregnant women in sub-Saharan Africa (SSA) are at risk of Plasmodium falciparum infection [1, 2]. Plasmodium falciparum malaria in pregnancy (either asymptomatic or symptomatic) can result in serious adverse outcomes for both the mother and the infant; maternal anaemia and placental malaria may result in low birth weight (LBW), miscarriage, stillbirth and infant death [3,4,5,6]. Effective and safe anti-malarial treatments decrease the occurrence of such adverse outcomes. The World Health Organization (WHO) recommends the use of artemisinin-based combination therapy (ACT) for the treatment of P. falciparum uncomplicated malaria during the second and third trimester of pregnancy [7]. All sub-Saharan African countries have already adopted and implemented such recommendation. However, there is limited knowledge on the effect of ACT use on pregnancy outcomes and infant's safety. Most of the available information originates from South-East Asia while there is little information from sub-Saharan Africa [8,9,10,11]. None of the studies in South-East Asia found evidence of fetal or maternal toxicity associated with artemisinin derivatives or ACT, with rate of abortion, congenital abnormalities, and stillbirths within normal community ranges [9,10,11].
The results of the safety and efficacy of four artemisinin-based combinations, namely artemether-lumefantrine (AL), amodiaquine-artesunate (ASAQ), mefloquine-artesunate (MQAS), dihydroartemisinin–piperaquine (DHA–PQ), in African pregnant women with malaria were recently reported [12, 13]. AL had the best tolerability profile, acceptable cure rates, but the shortest post-treatment prophylaxis, while DHA–PQ seemed the most suitable treatment in terms of safety and efficacy, including its longer post-treatment prophylaxis [12, 13]. Here, the effect of the four artemisinin-based combinations on pregnancy outcome, and on neonatal and infant morbidity and mortality are reported.
The study was an open label, randomized controlled clinical trial comparing the efficacy and safety of four artemisinin-based combinations in pregnant women with P. falciparum uncomplicated malaria in the second and third trimester of pregnancy. The trial protocol has been reported in detail elsewhere (NCT00852423) [14]. Briefly, the trial was carried out between June 2010 and April 2015 at seven sites across four countries, namely Burkina Faso, Ghana, Malawi and Zambia. Pregnant women in their second or third trimester were enrolled and randomized to one of four treatment arms (AL, ASAQ, MQAS and DHAPQ). Participants were followed up until day 63 and then were seen at delivery.
Infant follow-up
Mothers were asked to attend study health facilities with their babies at 4–6 weeks post-delivery and/or at the time of due vaccinations, 6 months later and at around the baby's first birthday. Infants were examined by a study nurse or doctor and their medical conditions, if any, managed as appropriate, including hospital admissions. Only congenital anomalies or birth defects and deaths were reported as serious adverse events (SAEs), and relevant information was collected by interviewing the mother and/or from hospital records. SAEs were codified using Medical Dictionary for Regulatory Activities (MeDRA) preferred term.
Perinatal mortality rate was defined as the number of perinatal deaths (stillbirths and early neonatal deaths) per 1000 total births [15]. Stillbirth was defined as a baby born dead after 24 weeks of gestation while miscarriage was defined as loss of the fetus at 24 weeks of gestation or earlier. Neonatal mortality rate was defined as the number of neonatal deaths (death during the first 28 days of life) per 1000 live births (first week of life: early neonatal death; 8–28 days of life: late neonatal death) [16]. Infant mortality rate was defined as the number of infant deaths (< 1 year of age) per 1000 live births. Placental malaria was classified as acute and chronic infection (presence of parasites with or without malaria pigment), past infection (presence of malaria pigment) and no infection (no parasites or malaria pigment).
The trial was approved by the ethics committee of the Antwerp University Hospital, Belgium, the relevant national or local ethics committees, and the national drug regulatory authorities of the four African participating countries.
The data analysis was based on an intention-to-treat (ITT) analysis, i.e. all infants born to mothers included in the study and randomized to one of the four treatments were included, regardless of the number of doses taken. Nevertheless, denominator of percentages varied according to the availability of information; this explains the variation of denominator by variable. Twins were excluded from the analysis as mortality is higher in this group [17]. Descriptive statistics were used to summarise socio-demographic and clinical characteristics of the mothers and infants. The difference between the treatment arms was calculated using logistic regression with fixed effects for treatment and country. The same approach was applied for the incidence of fever and other symptoms such as cough, diarrhoea, and difficulty in feeding at 4–6 weeks of life per 1000 live births. Continuous variables were compared between treatment groups using ordinary least square regression adjusted for country.
Incidence of SAEs in infants between treatment groups was compared by using a logistic regression model with fixed effects for treatment and country, to correct for possible imbalances in the reporting between countries.
Population-attributable fraction was used to assess the effect of placental malaria on LBW. The prevalence ratio (Pr) was set as the proportion of infected placentas (acute and chronic infections) with LBW divided by the proportion of uninfected placenta (past infections and uninfected) with LBW. The infected attributable fraction was calculated as the percentage of infected placenta with LBW that was due to malaria [(Pr − 1)/Pr] while the population-attributable fraction was the percentage of LBW cases that were due to malaria infection [18].
Infant mortality and hospital admissions rates were calculated as number of subjects with the event over the time at risk. The rate was compared between treatment arms using Poisson regression or negative binomial regression model [19] adjusted for covariates: country, treatment, maternal age, delivery (gestational age, Hb, parasite density, baby Hb), birth weight, birth asphyxia, mode of delivery, congenital malformation, gravidity, placental malaria, place of delivery, ITN use by mother or baby, intermittent preventive treatment (IPTp) use, hospital admission, malaria infection in new-born. In the univariate analysis, covariates were selected for inclusion in multivariable model if the p-value was ≤ 0.25. In the final model covariates with a p-value of > 0.2 were dropped step by step. Stata v14 (Stata Corp, USA) was used for all statistical analyses. The significant level was set at p ≤ 0.05.
A total 3258 out of the 3428 mothers enrolled had a recorded delivery outcome. Maternal characteristics such as gestational age (estimated by the total Ballard score), and maternal malaria infection status at delivery were not significantly different between treatment groups (Table 1). Fifty-two mothers delivered twins and were excluded from analysis. Out of the total recorded delivery outcomes, 3127 mothers (excluding mothers with twins) delivered live babies: 822 in the AL, 775 in the ASAQ, 765 in the MQAS and 765 in the DHAPQ arms. There was no difference in the proportion of live births, adjusted for country, between treatment groups (p = 0.85) (Table 2). There were 13 (0.39%) miscarriages and 78 (2.36%) stillbirths [12]. Among all live births, 118/3127 (3.8%) were lost during the 1-year follow-up while 6 mothers (0.2%) withdrew their consent.
Table 1 Gestational age and maternal malaria infection status at delivery
Table 2 Baseline characteristics of study infants at delivery (%)
Prevalence of LBW was 16.0% (480/2999), and was significantly more frequent among women with acute and chronic placenta malaria (21.0%, 152/723) than in those with past or no infection (13.7%, 259/1892) (p < 0.01). Nevertheless, LBW (p = 0.54) and mean birth weight were similar between treatment arms (Table 2). Prevalence of both cord blood anaemia and congenital malaria infection (malaria parasites in cord blood) was low and not significantly different between treatment arms. Similarly, there were few congenital abnormalities identified at birth (1.4%, 44/3065), with no statistically significant difference between study arms (Table 2) [12].
The overall prevalence of acute and chronic placental malaria was 28.0% (738/2646). Attributable fraction analysis suggests placenta malaria (acute and chronic) was responsible for 35% of the LBW among women with placental malaria infection (infected attributable fraction). At the prevalence found in this trial, the percentage of all LBW babies due to malaria (population-attributable fraction) was estimated at 13% (Table 3).
Table 3 Risk of LBW associated with placental malaria
Besides congenital abnormalities (almost half of them (46%, 23/50) polydactyly), the most commonly reported SAEs among infants were infections and infestations (Table 4), the most frequent being pneumonia (26.1%, 12/46), neonatal sepsis (21.7%, 10/46), sepsis (17.4%, 8/46), and malaria (8.7%, 4/46), with no statistically significant difference between treatment arms.
Table 4 SAEs in infants by treatment arm
Reported hospital admissions (episodes per 1000 live birth/year) were similar between treatment arms: AL: 90, ASAQ: 104, MQAS: 56, DHAPQ: 85 (p = 0.91) (Table 5).
Table 5 Incidence of hospital admissions, infant mortality
During the 1-year follow up, when adjusting for country and other potential risk factors, babies born at home (IRR 1.44, 95% CI 1.02–2.03) (p = 0.04) or with a congenital abnormality (IRR 5.12, 95% CI 2.09–12.51) were more likely to be admitted in hospital. Infants sleeping under bed nets (0.36, 95% CI 0.21–0.62) (p < 0.01) were less likely to be admitted in hospital than those who were not (Table 6).
Table 6 Risks (incidence rate ratio) of infant mortality and hospital admission in PREGACT study
There were 70 deaths within the first month of life, representing 59.3% (70/118) of all infant deaths, with no difference between study arms (55.2% in AL, 74.1% in ASAQ, 41.7% in MQAS and 63.2% in DHAPQ) (p = 0.47). The large majority of neonatal deaths (71.4%, 50/70) occurred in the first week of life, at the mean age of 1.3 (SD 1.9) days, with no statistically significant difference between treatment arms (AL: 2.1; ASAQ: 1.5; MQAS: 0.3; DHAPQ: 1.0) (p = 0.19). Neonatal mortality (early and late) rate was 22.4 deaths per 1000 live births (AL: 19.5; ASAQ: 25.8, MQAS: 13.1; and DHAPQ: 31.4) (p = 0.21); perinatal mortality rate was 21.9 deaths per 1000 total births (AL: 17.9; ASAQ: 17.7, MQAS: 28.0; and DHAPQ: 24.2) (p = 0.77), with no significant difference between the treatment groups (Table 7). The overall infant mortality rate was 41.0/1000 live births per year, and similar between treatment arms (AL: 38.7, ASAQ: 38.0, MQAS: 33.4 and DHAPQ: 54.1) (p = 0.96) (Table 5). Infant mortality was significantly higher in Zambia than in Burkina Faso but not in Ghana or Malawi (Table 6).
Table 7 Perinatal and neonatal mortality, and morbidity during the first month of life by treatment (%)
When adjusting by country and other potential risk factors, LBW babies had an almost 2-fold higher risk of dying during the first year of life than other babies (IRR 1.78, 95% CI 1.03–3.06, p = 0.04). Babies born with birth asphyxia (IRR 10.89, 95% CI 4.48–26.46) (p < 0.01) and congenital abnormality (25.47, 95% CI 10.46–62.02) (p < 0.01) had significantly higher risk of dying than other infants (Table 6).
The PREGACT study aimed at evaluating the safety and efficacy of four artemisinin-based combinations when administered to pregnant women with malaria [12]. The follow-up included also the offspring's first year of life to identify any potential problem the treatment may have. Results are reassuring as no significant differences between study arms in terms of reported illness, hospital admissions or infant mortality were found. It is extremely difficult to estimate cause-specific mortality as most infant deaths occurred outside a health facility [20,21,22,23]. Some of the most frequent SAEs reported in this study, namely neonatal sepsis, respiratory infections and malaria, are also among the most common causes of infant deaths in malaria-endemic African countries, where infant mortality rates are the highest in the world [19, 20], and were probably among the most frequent cause of infant death.
More than two-third of all neonatal deaths occurred in the first week of life. In this age group, malaria is usually an indirect cause of death as it causes LBW which in turn increases the risk of dying in the first year of life [20, 24]. This is confirmed by the significant association between LBW and placenta malaria (acute and chronic) and the substantially higher mortality in LBW babies. Few trials have evaluated the effect of chemoprevention during pregnancy on miscarriages, stillbirths, perinatal deaths, neonatal or infant deaths, and usually these studies are underpowered to detect clinically important differences [25] or do not follow infants until their first birthday [26, 27]. Such a difference may be found when comparing an intervention to a placebo arm, as in Mozambique where IPTp with sulfadoxine–pyrimethamine (SP) was compared to a placebo arm [28]. Indeed, in this trial significantly fewer neonatal deaths, particularly early infant deaths, occurred in the intervention than in placebo group despite no difference in prevalence of anaemia, LBW or placenta malaria (active and past infection) [28]. However, infant mortality did not differ between study arms although among the 58 infant deaths reported, more than half occurred in the placebo arm [20]. When all women included in a trial receive a malaria-preventive intervention, significant differences in neonatal and/or infant mortality are unlikely to be found unless one of the interventions has either a negative or positive effect on infant survival. For example, a trial comparing IPTp with either SP (IPTp-SP) or mefloquine (MQ) did not report any difference in neonatal and infant mortality between the two arms as both treatments are efficacious against malaria [29]. Therefore, the similar outcomes in the four arms of our trial are not surprising as all treatments were extremely efficacious against malaria [12]. A difference may have occurred if any of the treatments tested would have had an adverse effect on the fetus or infant survival or if the four tested artemisinin-based combinations were compared to a non-ACT. Indeed, in Uganda spontaneous abortions and neonatal deaths were less frequent among women treated with AL than in those treated with quinine although the difference was not statistically significant [30]. In Mali, the proportion of stillbirths (4.8%) and neonatal deaths (2.9%) after 2-dose IPTp-SP were similar to those observed in this trial (2.36% and 2.24%, respectively), confirming the safety of the ACT when given during the 2nd or 3rd trimester of pregnancy [31]. The early concerns about an increased risk of stillbirth associated with mefloquine [32] were not confirmed subsequently by other studies on mefloquine alone or combined with artesunate [33,34,35]; birth defects and fetal loss rates were similar to background rates [36] or to other antimalarial treatments [12, 37].
Placenta sequestration of malaria parasites can lead to inflammatory response, particularly in first-time mothers who often have high density infections, and also affect development of the fetal circulation. This decreases the supply of nutrients and oxygen to the fetus, resulting in intrauterine growth retardation and LBW, which is a risk factor for higher infant mortality [38]. More than a quarter of women had an active placenta infection, mainly chronic ones, i.e. with both parasites and malaria pigment, while evidence of past (non-active) infection was found in more than 60% of women. As the trial recruited pregnant women with malaria, such a high prevalence is understandable. In addition, women were actively followed up during the 63 days post-treatment, and passively until delivery. Most women were treated during the second trimester and the early third trimester of pregnancy, and the treatment by itself could not prevent women to be re-infected near delivery. Indeed, longitudinal genotyping of P. falciparum isolates during gestation in Cameroonian pregnant women showed that 77% of placental parasites were acquired from 30 weeks' gestation onwards [38].
Fetal anaemia plays a role in neonatal survival [20, 39]. Cord blood anaemia was particularly low, just around 1% and similar in all treatment arms, although it increased the risk of infant death almost 3-fold, an association that was of borderline significance. Such low prevalence is surprising when considering that a recently published study on a trial assessing IPTp with either SP or MQ reported a prevalence of about 10%, with a definition of anaemia that was more conservative than in this study (Hb < 12.5 g/dl versus Hb < 14.0 g/dl) [29]. The reason for such difference is unclear.
The longer recall period between the post-partum visits, at 4–6 weeks, and then at 6 and 12 months could have affected the accuracy of information on morbidity. Nevertheless, it is unlikely the study team missed any infant death. Moreover, such recall bias would have equally affected the 4 study arms.
In summary, there were no major differences between treatment arms in terms of perinatal, neonatal and infant mortality, nor on the overall occurrence of SAEs in babies, indicating that any of the tested artemisinin-based combinations can be used for the treatment of malaria during the second and third trimester of pregnancy without any adverse effect on the baby. As women were treated only once, repeated treatments may have resulted in a different outcome. It is reassuring that repeated administration of DHAPQ as IPTp did not increase the occurrence of adverse birth outcomes, indicating that at least this ACT could be safely administered 2–3 times during the second and third trimester of pregnancy [27]. Although the number of women treated and infants followed up is substantial, smaller safety differences between artemisinin-based combinations cannot be excluded. Country-wide post-marketing surveillance would be very helpful in confirming that any of the 4 combinations tested can be safely used to treat malaria during pregnancy.
AE:
artemether-lumefantrine
artemisinin-based combination treatment
DHAPQ:
dihydroartemisinin–piperaquine
Hb:
Haemoglobin
IRR:
incidence rate ratio
interquartile range
ITN:
LBW:
LTFU:
lost to follow-up
MQAS:
mefloquine-artesunate
PRR:
pooled risk ratio
SAE:
serious adverse event
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PREGACT Consortium proposed the manuscript. MN, UDA and JPV wrote the manuscript. JB and MN did the statistical analysis. Manuscript was reviewed by MN, HT, VM, HT, JBBK, SH, MT, IV, MCT GA JB, RR, DA, KT, MM, JPV, UDA. All authors read and approved the final manuscript.
All participants; the field teams at each site where the trial was implemented; the PREGACT Consortium; at the ITM, M De Crop, C Schurmans, Y Claeys, J Menten, C Burm, D Van Melle, C Van Overmeir, G Gondol, A Erhart, J Verellen.
No competing interest stated except UDA who reports receiving grant support from Sigma-Tau Industrie Farmaceutiche Riunite.
The data that support the findings of this study are available from Institute of Tropical Medicine, Antwerp, Belgium, Clinical Trials Unit. Restrictions apply to the availability of these data due to ethical and privacy concerns. Data can however be made available after approval of a motivated and written request to the Institute of Tropical Medicine at ITMresearchdataaccess@itg.be/.
This study was approved by the Ethics Committee of the Antwerp University Hospital (Universitair Ziekenhuis Antwerpen (UZA)) and National Ethics Committee in Burkina Faso, Ghana, Malawi and Zambia. All study participants consented to participate in the study.
European and Developing Countries Clinical Trials Partnership, Email: info@edctp.org Web: http://www.edctp.org; and by the Malaria in Pregnancy Consortium, which is funded through a grant from the Bill and Melinda Gates Foundation to the Liverpool School of Tropical Medicine (LSTM)—UK; Directorate-General for Development Cooperation (DGDC)—Belgium, Netherlands-African Partnership for Capacity Development and Clinical interventions Against Poverty-related diseases (NACCAP)—Netherlands, and Medical Research Council (MRC)—UK.
The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript should be declared.
Michael Nambozi
, Jean-Bertin Bukasa Kabuya
, Sebastian Hachizovu
& Modest Mulenga
Institut de Recherche en Sciences de la Santé-Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
Halidou Tinto
, Maminata Traoré
, Innocent Valea
& Marc Christian Tahita
College of Medicine, Blantyre, Malawi
Victor Mwapasa
University of Health and Allied Science, Ho, Ghana
Harry Tagbor
& Gifty Ampofo
Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
Jozefien Buyze
, Diana Arango
& Kamala Thriemer
Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
Raffaella Ravinetto
Menzies School of Health Research, Darwin, Australia
Kamala Thriemer
Global Health Institute, University of Antwerp, Antwerp, Belgium
Jean-Pierre van Geertruyden
Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, Gambia
Umberto D'Alessandro
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redpajama_set_name: RedPajamaCommonCrawl


Lubricating the clutch needle bearing ensures maximum power from your Stihl chainsaw.
Although the clutch shoes of a Stihl chainsaw should never be greased, the needle bearing that fits inside the chain sprocket, which is part of the clutch mechanism, may need occasional lubrication. When you open the chainsaw's throttle and the clutch engages, the sprocket spins around the engine crankshaft, and the needle bearing, which is a small ring fitted with ball bearings, provides a smooth ride for it. If the bearings seize, then friction created by the spinning sprocket could burn out the engine. So periodically lubricating the needle bearing is part of essential maintenance for the chainsaw.
Prevent the Stihl chainsaw's engine from starting unexpectedly by pulling the wire off the spark plug. Set the saw on a flat surface, and disengage the brake by pulling the brake bar toward the handle.
Loosen the two bolts holding the clutch cover in place by using a socket wrench, and unscrew the bolts with your fingers. Take off the clutch cover. Remove the chainsaw's guide bar and chain.
Work the E-clip off the end of the engine crankshaft with a flat-head screwdriver. The chain sprocket doubles as the clutch drum. Pull the clutch drum from the engine crankshaft. It should slide off. Work it off with the screwdriver if it's stuck.
Remove the needle bearing from inside the hub of the clutch drum. Shake the needle bearing next to your ear, and listen for the sound of the ball bearings hitting each other inside the needle bearing. Replace the needle bearing if you hear nothing when you shake it.
Squeeze a small amount of lubricating grease onto a cotton swab, and work it around the inside of the needle bearing. Put the needle bearing back into the clutch drum. Slide the clutch drum back onto the engine crankshaft, and return the E-clip to its correct position on the engine crankshaft.
Put the guide bar and chain back on the chainsaw. Return the clutch cover, and tighten with your fingers the two bolts that hold the cover in place. Adjust the chain tension. Tighten the bolts, using the socket wrench. Attach the spark plug wire to the spark plug.
A 9/16-inch socket wrench fits the nuts holding the clutch cover on most Stihl chainsaws. The multipurpose tool that came with the chainsaw also can be used.
Keep the grease away from the clutch shoes, which are the parts of the clutch attached to the engine. If grease gets on them, the clutch will slip and the chain won't spin.
Deziel, Chris. "How to Grease the Clutch on a Stihl Chainsaw." Home Guides | SF Gate, http://homeguides.sfgate.com/grease-clutch-stihl-chainsaw-101402.html. Accessed 18 April 2019.


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text:
Arctiocossus ligatus is a moth in the family Cossidae. It is found in Australia and South Africa.

References

Natural History Museum Lepidoptera generic names catalog

Cossinae
Moths described in 1865
Moths of Africa
Moths of Australia

redpajama_set_name: RedPajamaWikipedia


Once Hayes & Partners have produced survey drawings, we use these as a basis for our design proposals and present sketch options to you. Once you have confirmed a preferred route, we will develop proposals which we will review with you, at which stage it may be necessary to incorporate minor amendments to reflect your requirements.
If your application involves a Listed Building, or is in a Conservation Area, you may need to appoint a Historic Buildings Consultant to produce a Heritage Statement and Impact Assessment to support the proposals. We usually obtain quotations for this and then appoint a specialist on your behalf.
If your project involves a building of significant historical interest you may need to discuss proposals with, and obtain support from, Historic England (formerly English Heritage). We would manage this process for you, if required.


text:
Golf: England's Danny Willett wins Masters after stunning Spieth meltdown
Danny Willett (right) is helped into his green jacket by Jordan Spieth after winning the 2016 Masters Tournament at the Augusta National Golf Club.PHOTO: EPA
Danny Willett reacts after his final putt on the eighteenth hole during the final round of the 2016 Masters Tournament.PHOTO: EPA
http://str.sg/4kMy
AUGUSTA (REUTERS) - Englishman Danny Willett took advantage of a stunning meltdown by defending champion and runaway leader Jordan Spieth after the turn to win his first major title by three shots at the Masters on Sunday.
Three strokes behind the pacesetting Spieth going into the final round at Augusta National, an ice-cool Willett closed with a five-under-par 67 to end a 17-year title drought by European golfers at the year's opening major.
Willett, a four-times winner on the European Tour competing in his second Masters, birdied three of the last six holes to cap off a bogey-free display in sun-bathed but cool conditions and post a five-under total of 283.
Golf: Danny Willett - who is the Yorkshireman who won the 2016 Masters?
He became only the second Englishman to win the coveted Green Jacket, following three-times champion Nick Faldo, and ended a barren title run by Europeans dating back to Spaniard Jose Maria Olazabal's second victory here in 1999. "It's been crazy," Willett, 28, said before being helped into the coveted Green Jacket by last year's champion, Spieth. "You can't really describe the emotions and feelings. "We all go out there and try to play good golf. Fortunately today was my day. It was a very surreal day when you look back at the ebb and flows." Willett's participation at this year's Masters had been in doubt last month with his wife scheduled to give birth on Sunday, but their baby boy arrived early – 12 days ago.
Spieth, bidding for a second consecutive wire-to-wire win at the Masters and a third major title, had to settle for a share of second place after carding an adventurous one-over 73 that included a quadruple bogey and seven birdies.
NIGHTMARE SEVEN
Jordan Spieth reacts to his third shot going into the water hazard on the 12th hole. PHOTO: AFP
The American world number two had stormed five strokes in front with nine holes to play and victory seemingly assured when he bogeyed the 10th and 11th before running up a nightmare seven at the par-three 12th. "It's tough, it's really tough," Spieth told CBS Sports about his stunning three-hole collapse, his voice cracking with emotion. "Pretty sure I'll be disappointed with that one. "A very tough 30 minutes for me that hopefully I will never experience again." Finishing level with Spieth at two under was England's former world number Lee Westwood who, still seeking a first major title after recording 17 top-10 finishes during a stellar career, returned a 69.
England's Paul Casey (67) and Americans J.B. Holmes (68) and Dustin Johnson (71) tied for fourth at one under while Rory McIlroy, seeking to complete a career grand slam of the majors, returned a 71 to share 10th place.
After three rounds of strong gusting winds, the players were greeted by the coldest temperatures of the week but the calmest conditions as Sunday's final round got under way with an abundance of compelling possible storylines in the melting pot.
For the first nine holes, Spieth was his usual unflappable self as he mixed five birdies with a lone bogey and several clutch putts to reach the turn five strokes clear at seven under, seemingly in total command.
However, the 22-year-old Texan bogeyed the 10th, after bunkering his approach, and also the 11th, after his tee shot sailed right into the trees, before the tricky 12th took an even more severe toll.
After hitting successive shots into the waters of Rae's Creek in front of the 12th green, Spieth found a back bunker with his fifth en route to a mind-boggling seven, falling back into a tie for fourth at one under.
Though he did well to rebound with birdies on both par-fives, the 13th and 15th, he also bogeyed 17 after bunkering his approach and was never able to catch Willett, who picked up shots at the 13th, 14th and 16th to give himself a cushion.
GOLF PLAYERS


text:
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Home> News and events> Rosetta reaches its destination
Rosetta reaches its destination
After flawlessly completing a 10th rendezvous braking manoeuvre since 7 May, Rosetta arrived today at its destination and is now 100 km from the nucleus of comet 67P/Churyumov-Gerasimenko.
De 775 m/s à 1 m/s
The nucleus of 67P imaged by the OSIRIS-NAC camera on 3 August from a distance of 285 km; the resolution is 5.3 m/pixel. Credits: ESA/Rosetta/MPS for OSIRIS Team MPS/UPD/LAM/IAA/SSO/INTA/UPM/DASP/IDA.
When it woke up from deep space hibernation on 20 January, Rosetta found itself some 9 million km from the nucleus of comet 67P/Churyumov–Gerasimenko and closing in at a speed of nearly 775 m/s. Since 7 May, 10 rendezvous braking manoeuvres have reduced its velocity relative to the nucleus to 1 m/s, i.e. 3.6 km/h.
The last rendezvous manoeuvre was successfully completed today and Rosetta is now accompanying the nucleus on its elliptical orbitas the two bodies—one natural, one man-made—hurtle around the Sun at a speed of close to 55,000 km/h, 405 million km from Earth.
A first in space
"After 10 years, 5 months and 4 days travelling towards our destination, looping around the Sun 5 times and clocking up 6.4 billion kilometres, we are delighted to announce finally 'we are here'," said ESA's Director General Jean-Jacques Dordain today. "Europe's Rosetta is now the first spacecraft in history to rendezvous with a comet, a major highlight in exploring our origins. Discoveries can start."
For CNES President Jean-Yves Le Gall, "This historic rendezvous is a world first for science eagerly awaited by the global space community for 10 years. Today, Rosetta went into orbit around comet Churyumov-Gerasimenko. The science phase of the mission can now begin, with the high point in November when the Philae lander touches down on the comet's nucleus. CNES is especially proud to have been involved from the outset more than 20 years ago in this exceptional adventure made possible by the European Space Agency."
Flying in front of the nucleus
A long exposure (330 seconds) by the OSIRIS-WAC camera from a distance of 550 km shows the comet's activity. Credits: ESA/Rosetta/MPS for OSIRIS Team MPS/UPD/LAM/IAA/SSO/INTA/UPM/DASP/IDA.
Rosetta is currently flying 100 km ahead of the comet, escorting it on its elliptical path around the Sun at a great vantage point to permanently observe the sunlit side with the nucleus spinning at the rate of one rotation nearly every 12.4 hrs. Over the coming weeks, the spacecraft will edge closer to study the gravitational field of the nucleus and determine the tiny body's mass as precisely as possible to allow engineers to refine the probe's final orbital sequence. Ultimately, Rosetta is set to go into a circular orbit 10 km from the surface of the nucleus and then descend to just 5 km to release the Philae lander.
At the same time, Rosetta's instruments will subject the comet to close scientific scrutiny in order to identify a landing site for Philae this autumn. The date currently scheduled is 11 November, but the landing may occur earlier or later. The goal now is to identify 5 possible landing sites by the end of August and select a primary site by mid-September. The team at the Science Operations and Navigation Centre (SONC) at CNES in Toulouse is responsible for this crucial task of determining the site that best matches all of the mission's technical and scientific constraints.
Rosetta is an ESA mission with contributions from its member states and NASA. Rosetta's Philae lander is provided by a consortium led by DLR, the German Aerospace Centre, the Max Planck Institute for Solar System Research (MPS), CNES and ASI, the Italian space agency. Rosetta is the first mission in history to orbit a comet, escort it on its course around the Sun and deploy a lander on its surface.
*The scientific imaging system OSIRIS was built by a consortium led by the Max Planck Institute for Solar System Research (Germany) in collaboration with CISAS, University of Padova (Italy), the Laboratoire d'Astrophysique de Marseille (France), the Instituto de Astrofísica de Andalucia, CSIC (Spain), the Scientific Support of the European Space Agency (The Netherlands), the Instituto Nacional de Técnica Aeroespacial (Spain), the Universidad Politéchnica de Madrid (Spain), the Department of Physics and Astronomy of Uppsala University (Sweden), and the Institute of Computer and Network Engineering of the TU Braunschweig (Germany). OSIRIS was financially supported by the national funding agencies of Germany (DLR), France (CNES), Italy (ASI), Spain (MEC), and Sweden (SNSB) and the ESA Technical Directorate.
Rosetta on CNES website
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Cats are instinctive animals and they cannot be kept quiet for long, the Tricky Tumble interactive cat toy is the best distraction they can have. The toy is highly interactive and helps the cat develop its natural instincts.
The Tricky Tumble interactive cat toy consists of a rolling ball with a wand attached to it, the wand has a feather attached at the top end. When switched on, themotor spins the wand in a random pattern and creates twirling movement with feathers. This makes the cat feel as if there is a prey to be hunted down. The ball can be filled with cat treats which comes out of the holes on the ball, so that it attracts the pet and also rewards the pet who is working so hard. This is a simple yet effective interactive cat toy that is interesting and entertaining for your pet cat.
The toy is made of sturdy eco-friendly ABS plastic and is absolutely safe for pets. It works on 2 AA batteries.
Tricky Tumble Interactive Cat Toy has been manufactured by Iconic Pet, creator of high-quality products.


We might oppose voluntary active euthanasia even while we support the permissibly of physician assisted suicide because there appears to be a causal distinction between the actions. Carefully describe Brock's two responses to this view.
One might think that the importance of autonomy as a reason for voluntary active euthanasia diminishes in certain circumstances (like advanced age or terminal illness). Carefully explain both this view and Brock's response.


The perfect Android telephones in 2018 are means greater than they had been a 12 months in the past, with additional advanced low-delicate cameras, sooner processors and improved design. Better but, just a few of those telephones might be discovered at cheaper costs, too. Mind you, each cameras are very, superb. In my amateurish opinion, the iPhone is a bit larger at most points. However the Galaxy fashions, with their wider-angle lens, are a tad better at selfies.
Samsung's Galaxy Observe eight is a powerhouse of a telephone with a premium value. It comes with an enormous 6GB of RAM inside, enough to plug it in and use it like a mini-laptop. It comes with a stylus pen for taking notes on the display, and has the Bixby digital assistant to take voice instructions.
It has been nearly a yr that I've had this cellphone. I uncover it simple to use and has features I can really use. i take advantage of the attribute for longer lasting battery life and it doesn't seem to impact anything and retains me charged all day with time leftover. I would utterly advocate it to anybody getting a brand new phone.
It includes a 16MP rear going via digital camera.
As for raw options, the Galaxy S8 Plus is not too faraway from our Finest General decide, the same old Galaxy S8. This suggests the S8 Plus provides fast effectivity with an octa-core sixty 4-bit processor and 4GB of RAM, whereas moreover along with must-have options resembling a entrance-facing eight-megapixel digital camera and a 12-megapixel digicam on the again.
The Note 9 has the same twin 12-megapixel cameras, with the same image top quality, because the Galaxy S9+. The main sensor has an adjustable aperture to allow sort of delicate to reach the sensor, and the secondary digital camera has a 2x telephoto lens for taking photographs of more-distant objects. The image high quality is nearly almost as good as that of the Pixel 2, however Samsung tends to overexpose some pictures even with HDR enabled, and the camera app itself is more complicated to make use of than Google's.
Deep down, Android units are in the end associated.
Superbly designed. Here's the other factor to know regarding the Palm cellphone: it is very a lot a Verizon cellphone. From the best way through which that it is being purchased to the software program program that's on it to the extensive suite of accessories being developed for it at launch, it has the provider's fingerprints all through it.
Fantastically designed. The Cedar CT5 Rugged Smartphone affords you the rugged sturdiness you need at a value that won't make you bat a watch. Supplied at a cheap price with amount reductions obtainable, the CT5 is nice for equipping an enormous crew with rugged telephones, or providing a top quality product to 1 or two customers. Either manner, the CT5 is an apparent economical reply to your Android-based mostly, rugged information assortment and communication wants.
It's also possible to participate in the in-app boards to interact with individuals having associated targets. Imagine it or not, that is the easiest Google app that you must add in your fitness regime. This new smartphone is solely generally known as Palm" and it's mainly a smaller smartphone that uses the cellphone quantity out of your bigger, predominant smartphone.


text:
using System.Security.Policy;
using BootstrapComponents.Common;
using BootstrapComponents.Core;

namespace BootstrapComponents.Components.Buttons
{
    public class ButtonSettings
    {
        public Size Size { get; set; }
        public bool BlockLevel { get; set; }
        public bool IsDisabled { get; set; }
        public Category Category { get; set; }
        public ButtonTag Tag { get; set; }
        public string LinkUrl { get; set; }

        public ButtonSettings()
        {
            Size = Size.Md;
            Category = Category.Default;
            Tag = ButtonTag.Button;
        }

        public ButtonSettings ExtraSmall() { return SetSize(Size.Xs); }
        public ButtonSettings Small() { return SetSize(Size.Sm); }
        public ButtonSettings Medium() { return SetSize(Size.Md); }
        public ButtonSettings Large() { return SetSize(Size.Lg); }

        public ButtonSettings SetSize(Size size)
        {
            Size = size;
            return this;
        }

        public ButtonSettings Block() { return SetBlockLevel(); }
        public ButtonSettings SetBlockLevel(bool blockLevel = true)
        {
            BlockLevel = blockLevel;
            return this;
        }

        public ButtonSettings Disabled() { return SetDisabled(); }
        public ButtonSettings SetDisabled(bool disabled = true)
        {
            IsDisabled = disabled;
            return this;
        }

        public ButtonSettings Primary() { return SetCategory(Category.Primary); }
        public ButtonSettings Success() { return SetCategory(Category.Success); }
        public ButtonSettings Info() { return SetCategory(Category.Info); }
        public ButtonSettings Warning() { return SetCategory(Category.Warning); }
        public ButtonSettings Danger() { return SetCategory(Category.Danger); }
        public ButtonSettings Inverse() { return SetCategory(Category.Inverse); }
        public ButtonSettings Link() { return SetCategory(Category.Link); }

        public ButtonSettings SetCategory(Category category)
        {
            Category = category;
            return this;
        }

        public ButtonSettings Url(string url) { return SetLinkUrl(url); }
        public ButtonSettings SetLinkUrl(string url)
        {
            LinkUrl = url;
            return this;
        }

        public enum ButtonTag { A, Button }
    }
}

redpajama_set_name: RedPajamaGithub


Locate any details of Societe Generale branch in India.
IFSC code: and MICR code: ; SOCIETE GENERALE address : , - ; Branch code is , Contact Number: , SOCIETE GENERALE Timings: Monday to Friday: 10 AM to 4 PM, Saturday - 10 AM to 4 PM(Except 2nd and 4th Saturday).
Societe Generale offers two online money transfer services, the NEFT and RTGS, which make transferring funds in India convenient and secure. When transferring funds using these services, the individual is required to enter the IFSC code of his bank branch as well as of the recipient' bank branch.
Each bank branch is assigned an IFSC code to avoid errors in the cash transfer process.
All IFSC codes are made up of 3 components- the bank name, the number "0" and the branch code.
The code for the Societe Generale Delhi branch located in New Delhi is SOCGE0INDL01, where "SOCGE" is the bank name, "0" is left blank and "INDL01" is the specific branch code.
How to Search for Societe Generale IFSC Code and MICR Code?
The IFSC codes for Societe Generale branches can be found printed on the cheque leaves as well as on the first page of passbooks issued by the concerned branch.
The IFSC and MICR codes can also be found online on the bank's website. Another way to look for the IFSC codes is through a website like BankBazaar, which has the IFSC & MICR codes for all banks at the click of a button.
Go to the BankBazaar homepage and select the "Bank IFS Code" option. Select the bank, district, city and branch name from the options provided, after which the IFSC code will be displayed on screen.
How to Transfer Money Using Societe Generale's NEFT and RTGS?
With the NEFT and RTGS services by Societe Generale, transferring money to any bank account across the country is quick, convenient and safe. There are no limits to the number of transactions that can be made in a day using these services.
The National Electronic Fund Transfer is a wireless fund transfer service that can be used to send money to any NEFT enabled bank branch in a matter of hours.
The system is secure and individuals can access it wherever they are, making it a convenient way to transfer funds wherever you are.
Available during banking hours, an NEFT transfer request is processed in hourly batches. Requests received after banking hours are processed on the next working day.
The quickest money transfer medium in the country, RTGS services are available to Societe Generale customers during banking hours.
Requests received after banking hours or on bank holidays would be processed on the subsequent working day.
The minimum amount for these irrevocable transfers is Rs. 2 lakh, with the request being processed as soon as it is received.
Societe Generale is a French bank based in Paris. The bank was established in 1864 and provides a range of financial products and services through its retail banking, commercial banking and wealth management divisions.


text:
Religious/moral/ethical conflicts
2019-JAN/MAR: Vaccines, Anti-vaxxers,
Immunization Programs, and
Potential Epidemics:
2019-JAN: Measles Outbreak in Washington State:
During the week of 2019-JAN-20, Jay Inslee (D), the governor of Washington State, responded to a measles outbreak by declaring a state of emergency.
On JAN-28, health officials reported 36 confirmed cases and 11 suspected cases of measles across Clark and King counties, WA. It is no coincidence that Clark County, in South-West Washington near Portland, OR-- where all but one of the children with measles lives -- has the lowest vaccination rate in the state. According to The Oregonian, more than 22% of public school students there did not complete their vaccinations. 10 Among those who are confirmed to be infected with measles, 25 are under the age of 10, nine are between the ages of 11 and 18 years old, one is between the ages of 19 and 29 years, and one is in his 50s. At least 31 of the confirmed cases had never been vaccinated for measles. The only child in King County, in central West Washington near Seattle with measles is known to have caught it from someone in Clark County. 1
Dr. Saad B. Omer, a professor of global health at Emory University, said:
"We are close to the so-called herd immunity threshold." 1
The threshold value is 92% in the case of measles. If the vaccination rate against a disease is this value or higher, then such a large percentage of people have been made immune to the disease that the rubella virus will have difficulty finding unvaccinated individuals to infect. Thus, a small outbreak will probably fizzle out. A large-scale outbreak is unlikely to occur.
The measles-mumps-rubella (MMR) immunization rates for children in Clark County, WA, as of 2018-DEC-31 were only :
81% of children aged 1 to 5-year-olds, and
78% of children 6 to 18-year-olds. 13
This is well below the herd immunity threshold, so a major epidemic is quite possible.
Unfortunately, there exists a minority of immunocompromised people who cannot be vaccinated for medical reasons. A very high percentage of other children need to be vaccinated in order to have the overall population reach the herd immunity threshold.
Professor Omer said:
"I don't want to be alarmist. We have robust immunization programs ... and the [Centers for Disease Control and Prevention] have a very proactive program to counter these outbreaks. These ... keep things at bay, but there is still a concern." 1
By FEB-06, at least 55 people in Washington and neighboring Oregon had developed measles. Fifty of them are in Clark County, WA; one is in King County, WA, and four are in Multnomah County, in Northwest OR, near Portland.
Bernadette Pajer, who co-founded a co-founder of Informed Choice Washington, the main anti-vaccine group in the state, said:
"It shouldn't be called an outbreak. I would refer to it as an in-break, within a community." 12
She argued that the measles has only spread only within a small, self-contained group.
2019-FEB: Measles Outbreak in New York State:
In New York state, 209 cases have occurred since 2018-OCT. Some of the unvaccinated children who are involved caught measles during their visit to Israel where a major outbreak of the disease is occurring.
A mother who is opposed to vaccination asked for advice from an anti-vax group.
"My 3-year-old is not vaccinated and there is currently a measles outbreak in my state. Any suggestions for precautions I can take to protect her would be very much appreciated."
She received many answers. Many were humorous, sarcastic and/or vicious. She probably did not expect some of them, :
"She's 3 years old. ... never been vaccinated for anything? Well ... that's middle aged ... she's lived a good life."
"You could expose her to a weakened or inactive strain of the virus so that her immune system is better equipped to recognize and combat the actual virus she' inevitably will come into contact with with ... which will decrease the likelihood of her getting sick. Oh, wait."
"Just between us. ... this kid is not your favorite, right?"
"Do not take them to a medical doctor. Facebook is the MOST RELIABLE source of medical information -- particularly when it comes to vaccine science."
"Precautions? Don't get to attached to that child."
"I was vaccinated, but I also ate kale once. I'll let you decide why I've never had the measles."
"Unvaccinated children are like dark humor. ... They never get old."
"I'll be over here with my autistic son, listening to his interesting stories, and you, anti-vaxxers, can listen to your children's' eulogies."
"[Try] milk bones dog treats. I give them to our dog and he's never had the measles."
"What's funny is the vast majority of anti-vaxxers are vaccinated themselves. So they are safe, but put their kids at risk."
And my personal favorite:
"Bring her to the edge of the flat earth. The air is cleaner there."
Vaccines and the anti-vaccination movement:
The measles vaccine was first made available in the U.S. during the 1960s. By the year 2000, the disease was believed to have been eliminated in the country. However, an anti-vaccination movement, which is particularly strong in the U.S. Northwest, has been successful at having vaccine exemption laws passed in some states. They allow parents to decide to leave their children unvaccinated. This permitted a resurgence of the disease. 350 cases were reported across the U.S. in 2018, an increase of almost three times the number detected in 2017.
Those individuals opposed to vaccination are referred to as anti-vaxxers. Many of them believe that a link exists between vaccinations and the rise in autism in children. Symptoms of autism are often not detectable among very young children. They appear suddenly. Sometimes, by coincidence, they might appear shortly after the child has been vaccinated. This has caused some parents to link the two events and to firmly conclude that there is a cause-and-effect relationship between vaccination and autism. Some have blamed Thimerosal, a preservative used in vaccines, as being responsible for causing autism.
During 1995, a British gastroenterologist, Andrew Wakefield, MD, joined 12 co-authors and published the results of a pilot study on measles in the Lancet -- the leading British medical journal. It discussed a possible link between the measles-mumps-rubella (MMR) vaccine, bowel disease, and autism. Their paper stated that they could not demonstrate a causal relationship between MMR vaccine and autism. However, Wakefield released a video stating that a cause and effect relationship did exist.
Various media picked up the story. Many parents became frightened about the possibility that the vaccine could generate autism in their children. Vaccination rates sank.
Dr. Richard Horton, who was then editor of the Lancet, claimed that the group's research was "fatally flawed." Later, the Lancet formally retracted the paper. The UK General Medical Council banned Wakefield from practicing medicine in Britain. A British journalist, Brian Deer, reported evidence that Wakefield had falsified data. 2 He called Wakefield's work an "elaborate fraud."
The Lancet article triggered many studies into the safety of vaccinations:
The Centers for Disease Control reports on many studies, including:
"Three large epidemiological studies that analyzed data from US health maintenance organizations, the UK General Practice Research Database, and the entire country of Denmark failed to find an association between exposure to thimerosal-containing vaccines and autism." 3
Studies by the National Academies of Sciences Engineering Medicine I have also shown that the vaccine-autism link does not exist.
The Immunization Action Coalition promotes vaccinations and has hyperlinks to many videos, handouts, statements, and web sites. They have also concluded that vaccines do not cause autism. 5
The World Health Organization (WHO) issued a list of ten serious threats to global health in 2019-JAN that could jeopardize millions of lives. They said that:
"Vaccine hesitancy -- the reluctance or refusal to vaccinate despite the availability of vaccines -- threatens to reverse progress made in tackling vaccine-preventable diseases."
"Vaccination is one of the most cost-effective ways of avoiding disease -- it currently prevents 2-3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccinations improved." 6
Julia Belluz, writing for Vox, reported that the vast majority of U.S. children are vaccinated. But the number of unvaccinated babies in the country has increased from 0.3% in 2001 to 1.3% in 2015.
Peter Hotez, director of the Texas Children's Hospital Center for Vaccine Development at Baylor College of Medicine has an autistic child named Rachel, and has written a book about the experience. He has worked professionally on the development of two vaccines. He said:
"There are pockets across the US where you have a 20-fold increase [of refusal to vaccinate], like we've seen in parts of Texas. Although, nationally, immunization rates may not have changed that much, we have pockets where 20 to 40 percent of kids aren't vaccinated, and that gets you into trouble with measles and other [vaccine-preventable] infections. ..."
"From my experience, a majority of vaccine-hesitant parents are not deeply dug in. They've gotten misinformation from anti-vaccine web sites and social media, or they've heard something unsavory about vaccines from friends and relatives. I believe my book might reach those individuals. Then there's another group, maybe 10 to 20 percent who are deeply dug in and believe all of the fake conspiracy theories. Those individuals are really difficult to reach." 7
He notes that:
" ... after smallpox was eradicated in the late 1970s, measles became the leading killer of children in the world: two-and-a-half million children [then] died annually of measles. Now, through aggressive vaccination programs, we've brought that down to under 60,000-70,000 deaths a year -- still a lot of deaths, but more than a 90% reduction. Now I'm worried we're going to reverse those gains because of this anti-vaccine movement in Europe and the US. That's going to extend elsewhere.' 8
Dr Hotez' book is titled: "Vaccines Did Not Cause Rachel's Autism: My Journey as a Vaccine Scientist, Pediatrician, and Autism Dad." 9 Arthur L. Caplan, of the NYU School of Medicine, writes the book's forward, saying -- in part:
"When Peter Hotez -- an erudite, highly trained scientist who is a true hero for his work in saving the world's poor and downtrodden -- shares his knowledge and clinical insights along with his parental experience, when his beliefs in the value of what he does are put to the test of a life guiding his own child's challenges, then you must pay attention. You should. This book brings to an end the link between autism and vaccination."
2019-MAR: Fear of measles in New York City suburb:
A measles outbreak in Spring Valley, Rockland County, NY has alarmed many residents and degraded relationship between the ultra-Orthodox Jewish community there and other residents. Scores of people there have become infected with measles recently. Public health officials traced the outbreak to ultra-Orthodox families whose children have not been vaccinated. Public fear has degraded relationships between the Hasidic community and the rest of the population, producing a fear of a rise in anti-semitism.
The first cases of measles in Rockland County involved families who had visited Israel where an epidemic is underway. After the disease spread, unvaccinated students who went to some public schools with low vaccination rates were excluded from attending. This barred about 6,000 students from school during 1018-DEC.
On 2019-MAR-29, county officials took what may be an unprecedented step for any U.S. municipality. They announced a state of emergency and barred unvaccinated persons under 18 years-of-age from public places, including schools, religious buildings, shopping centers, stores, restaurants, movie theatres, busses, etc. 14
Rockland County contains five towns with a total population of slightly over 300,000 people. About 31% of the population is Jewish and includes one of the largest concentration of ultra-orthodox Jews in the U.S.
Aron B. Wieder is a legislator in Rockland County and a prominent member of the Hasidic community. He said:
"The conception that is out there is completely distorted, and that is, that the Orthodox community for the most part don't vaccinate their children. ... That is not true. The county executive had a moral obligation to point these things out."
During the previous six months, there have been over 17,000 vaccinations using the measles-mumps-rubella vaccine, Between 2018-OCT and 2019-MAR-29, there have been 157 cases of Measles recorded.
Unfortunately, some Jewish information hotlines are feeding misinformation about vaccination -- accusing it of causing autism in children. Ultra orthodox Jews often have no Internet access, and so cannot obtain reliable information about vaccines.
Some readers of a New York Times article posted written comments. Ellen Tabor of New York City wrote:
"This Jewish doctor has had it with people refusing to listen to Science. Whoever they are, if they do not accept Science, do not accept that America is not a bunch of unconnected enclaves (dare I say, ghettos?) but a community of people whose paths cross at random, then they are poor citizens. Some decisions cannot be left to individuals because the harm they cause spreads to the community at large. The refusal to vaccinate is one of these wrong decisions. 'Respect for religious diversity' is no excuse for spreading illness. The State should mandate vaccinations, and I heartily approve of Rockland's decision to require children to be vaccinated, for their protection and for ours. Jewish law mandates health and protecting the body. What all fundamentalist communities do in the name of religion is a sin." 14
Elham Khatami, "Anti-vaccination movement has fueled measles outbreak in Washington, experts say," Think Progress, 2019-JAN-29, at: https://thinkprogress.org/
"Do Vaccines Cause Autism?, History of Vaccines, 2018-JAN-25, at: https://www.historyofvaccines.org/
"Science Summary: CDC Studies on Thimerosal in Vaccines," Centers for Disease Control, undated. File download at: https://www.cdc.gov/
"Immunization Safety Review: Vaccines and Autism," National Academies of Sciences, Engineering, and Medicine, at: http://nationalacademies.org/
"Autism Resources," Immunization Action Coalition, 2017-JAN-21, at: http://www.immunize.org/
Holly Yan, "Superbugs and anti-vaxxers make WHO's list of 10 global health threats," CNN Health, 2019-JAN-21, at: https://www.cnn.com/
Julia Belluz, "This autism dad has a warning for anti-vaxxers," Vox, 2019-JAN-27, at: https://www.vox.com/
Andrew Anthony, "Peter Hotez: 'What happens when the anti-vaccine movement moves into India?,' The Guardian, 2018-DEC-08, at: https://www.theguardian.com/
Peter J. Hortez, "Vaccines Did Not Cause Rachel's Autism: My Journey as a Vaccine Scientist, Pediatrician, and Autism Dad," Read reviews or order this book safely from Amazon.com online book store.
"Clark County measles outbreak grows to 16 confirmed cases, 5 suspected,"
Karolina Wv, "Anti-Vaxx Mom Asks How To Protect Her Unvaccinated 3-Year-Old From The Measles Outbreak, Internet Delivers," Bored Panda, 2019-FEB-01 (approx.), at: https://www.boredpanda.com/
Lena Sun & Maureen O'Hagan, " 'It will take off like a wildfire': The unique dangers of the Washington state measles outbreak," Washington Post, 2019-FEB-06, at: https://www.washingtonpost.com/
"What are the immunization rates for children in Clark County?," Clark County Public Health, 2019, at: https://www.clark.wa.gov/
Sarah Maslin Nir and Michael Gold, "An Outbreak Spreads Fear: Of Measles, of Ultra-Orthodox Jews, of Anti-Semitism," New York Times, 2019-MAR-29, at: https://www.nytimes.com/
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Requesting asylum is supposed to be free. But corruption in Tijuana means many have to pay
A group of asylum seekers walks to the El Chaparral port of entry in small numbers to be processed into the United States on May 3, 2022, as part of an exemption program to Title 42.
(Alejandro Tamayo/The San Diego Union-Tribune)
Some asylum seekers are having to pay hundreds or thousands of dollars to access the U.S. Title 42 exemption process and request protection at the San Ysidro Port of Entry. It is not clear whom the money is benefitting
By Kate Morrissey
Dec. 11, 2022 5 AM PT
When a Russian family, threatened because of their opposition to the war in Ukraine, recently arrived in Tijuana, they tried every tactic they'd heard of to reach the United States and request asylum.
After being turned away at the border, they found a Telegram channel, where they were told that an organization could help them cross at the port of entry on foot with permission from Customs and Border Protection — but they would have to pay. The price was $2,000 per person.
Multiple sources have told the Union-Tribune about similar issues of extortion and corruption in the temporary program for processing some asylum seekers while Title 42, a U.S. pandemic border policy, remains in effect. None of them were willing to be named, citing serious safety concerns related to organized crime.
Title 42 is a policy that broadly blocks asylum seekers and other migrants without proper travel documents from entering the United States, and it allows border officials to expel those who do cross either to the country they crossed from or their home countries.
However, earlier this year, the Department of Homeland Security partnered with local nonprofits to identify particularly vulnerable asylum seekers in Tijuana and elsewhere along the border. The organizations submit the cases to CBP for approval on a case-by-case basis for exemptions to Title 42. Once approved, Tijuana-based asylum seekers are given a date to appear at the San Ysidro Port of Entry's PedWest and enter the United States.
San Ysidro Port Director Mariza Marin told the Union-Tribune in September that 180 people are allowed to cross each day through the exemption program. The various partner organizations each have a set number of slots within that 180 each day.
The people within those organizations control who gets on the list and in many ways control who has access to requesting asylum while Title 42 is in effect.
Asylum seekers are not supposed to have to pay to request protection — it is considered a basic human right in the U.N.'s Universal Declaration of Human Rights. The asylum system determines who among arriving migrants qualifies as a refugee.
While there are costs to the nonprofits that do the logistical work for Title 42 exemptions of identifying particularly vulnerable asylum seekers and bringing them to the border — such as transportation or staff wages — those costs are not supposed to be passed on to the asylum seekers. The exemption process is supposed to be free for the migrants because it is meant to identify and protect the most vulnerable.
While asylum seekers are still able to access the Title 42 exemption process for free through certain organizations, the Union-Tribune has since August received a growing number of reports of asylum seekers having to pay. It's unclear who is ultimately benefiting from the money or if it is going to the same people in every case.
CBP deferred to the Department of Homeland Security when asked via email about reports of corruption in the program, and DHS did not respond to a request for comment.
When asked about payments in the exemption process in September, Marin said that CBP works with multiple nonprofits rather than one to try to mitigate the issue and that the agency works closely with the State Department when migrants tell officers about such security concerns.
"The most important thing is that there is accessibility to a legal pathway. That was closed for quite a while," Marin said. "It's difficult for CBP, being a domestic agency, to change the threat picture and what goes on in Tijuana."
Migrants march to the San Ysidro Port of Entry protesting the end of Title 42 on May 22, 2022 in Tijuana.
(Carlos Moreno/For The San Diego Union-Tribune)
Deterrence and corruption
Though Title 42 is scheduled to end on Dec. 21 under a judge's order, that is not likely to make the issue disappear. Some politicians are already trying to find ways to preserve its asylum restrictions, and the Biden administration is appealing the order.
It's also not yet clear what asylum processing will look like if the policy does lift. The United States has long used deterrence policies to restrict access to its soil and to the asylum system.
Title 42 is not the first time that the United States has restricted asylum access in a way that gave control to various groups in northern Mexico. Nor is it the first time that corruption concerns have surfaced in the resulting process to access asylum screenings.
When wait lists to request asylum in the United States became managed by Mexican immigration agents in the years before the pandemic, human rights researchers noted instances of corruption in those processes, as well.
With bigger organized crime groups taking more active interest in migration at the U.S.-Mexico border, there are concerns that the money involved in Title 42 exemption processing will ultimately end up benefiting them, too.
"The overall framework of this is that our restrictive asylum policies have been putting money in the pockets of organized crime over the last few years," said Adam Isacson of the Washington Office on Latin America, a human rights research and advocacy organization. "We've been enriching organized crime this way for a while. This is just a new dimension to it."
Many human rights advocates have argued that the only way to prevent corruption and extortion in the asylum process is to make asylum screenings accessible to anyone fleeing their homeland who approaches a U.S. port of entry. That is generally required under U.S. and international law, but it has not been the reality at the border for years, even before the pandemic.
Even without the payments, finding the exemption process can be difficult for asylum seekers.
Asylum seekers wanting to apply for the exceptions have little reliable information to go on, oftentimes counting on word of mouth, social media or the chance of stumbling upon the right shelter. CBP does not have an official website or tip sheet, and from what the Union-Tribune has witnessed, officers also don't provide that information to asylum seekers who approach the border.
Twenty-nine asylum seekers prepare to leave a Tijuana shelter on May 2, 2022, to be taken to the U.S. border as part of the Title 42 exemption program.
There is no consistency in how to access the organizations that determine who will be submitted to CBP for approval, and it is not clear how the different groups determine who is eligible or who should be prioritized among the many waiting asylum seekers in Tijuana. At least one organization chosen by DHS partners with Tijuana shelters to determine who will be next to go in. Another organization has an online form that can be filled out to start the process, and at least one uses Telegram.
With so many in desperate situations, the wait times have grown long.
Shelters known for having access to the process sometimes have dozens of asylum seekers camped outside, waiting for their chances to get on the lists. One shelter director told the Union-Tribune that the wait time for people in his care has at least doubled since the exemption process began earlier this year.
As the waits grow, so does the potential for corruption in the process.
Paying for access
Because of the potential danger in discussing corruption in the Title 42 exemption process, the extent of it is not fully clear, but details are beginning to emerge.
Several asylum seekers from Latin America told the Union Tribune about certain shelters charging for access to the exemption process or to be placed higher on the wait list.
A nonprofit that helps identify vulnerable cases found out recently that someone was selling its contact information to asylum seekers for thousands of dollars. The organization asked not to be named because of safety concerns.
Border Angels, one of the organizations working with the shelters to identify exemptions, has stopped working with multiple shelters because of corruption concerns, according to Edward Orendain, the nonprofit's interim executive director.
Multiple sources said that many Russian asylum seekers in particular have had to pay for access. In October, 2,865 Russians entered through the San Diego port, according to the most recent data from CBP.
The day after Thanksgiving, a Russian-language YouTube channel uploaded a 25-minute edited video interview in which Phil Metzger, pastor of Calvary San Diego church and president of Most v USA, discusses the exemption process. The Most v USA organization, whose name roughly translated from Russian means "Bridge to the USA," focuses on helping Russian and Ukrainian speakers cross.
At one point in the conversation, interviewer Alex Moore, whose channel focuses on information for Russian speakers coming to the United States, calls the situation scary.
Phil Metzger, pastor at Calvary San Diego, is photographed at his church in Chula Vista in 2020. He also helps Russian- and Ukrainian-speaking asylum seekers access the Title 42 exemption program through the organization Most v USA, which in Russian roughly translates to "Bridge to the USA."
(Nelvin C. Cepeda/The San Diego Union-Tribune)
"Well, it is a dangerous border," Metzger says in the video in English. "Our people are totally safe. That's why it costs money."
It is not clear from the video whose pockets the money ends up in or how the payments work. Moore, speaking in Russian, brings up concerns from his followers about $2,000 payments, but he does not push Metzger for many details.
"We are operating in Mexico, and it's not a safe border," Metzger says in the video. "It is one of the busiest borders in the world. The amount of drugs makes it a very dangerous border, and there are people who control borders. We have to partner to make sure people coming across are safe. People are not paying for a future case — nope, unfortunately no. They're just operating, and we had to work with these people to make sure that things stayed safe for our Russian speakers that are crossing."
Metzger calls the people who are getting paid "opportunists." He declines to further identify them in the video.
"I don't know how much I want to say about who they are or who they aren't because I don't know. I just know that there's a lot of power on that side that I just don't control," Metzger says in the video, which appears to have been filmed Nov. 21. "But I have one control. I control who goes across, so I have to negotiate to keep those people safe. I have to negotiate with those who are in power."
In the video, Metzger describes the way that Russian-speaking asylum seekers can get help crossing with Most v USA.
The process begins on the social media platform Telegram, he says. From there, asylum seekers get connected with the Most v USA call center. He says the organization receives more than 1,000 messages per day.
"We're going to get their information. 'Where are you right now? Who are you? What kind of passport do you have?'" Metzger says in the video. "If all the information fits, then we move them to the second phase, and the second phase for us to collect all of their passport information for CBP and to get them prepared for a date that we will give them to be able to cross into America. We work directly with CBP on all of this."
The day before they cross, he notes, they must test negative for COVID. Then they meet at the border to get processed by CBP, he says.
When questioned about his statements in the video just over a week later, Metzger told the Union-Tribune his organization does not charge people in order to cross with the Title 42 exemptions or negotiate with anyone.
"I've heard there's groups doing that. We're not doing that," Metzger said in a phone interview. "We work with people — our main focus where we have fees is when they're in the States, helping them with political asylum cases. That's a totally separate thing."
When asked further about his organization's consulting work, he was unable to provide information about fee amounts.
He told the Union-Tribune that some people who crossed with his organization said that they had had to pay at some point along their journey. He said he would rather shut the program down than have it be unsafe for the people crossing.
"Every day people are using our company to scam people. Every single day," he told the Union-Tribune. "Every day we work hard to try to stop that from happening because it's just what's happening. People are paying money to people here or there, right, left and center. Now for us we do a lot of consulting that has nothing to do with the border crossing itself."
He did not directly answer a question from the Union-Tribune about whether he had brought his concerns about safety in the program to CBP.
"I mean, this is happening in Mexico, so it's a Mexico focus," he said at first.
Then he denied knowing anything about the Title 42 exemption program.
"I'm not trying to be ignorant or anything, but I don't even know what that is exactly," he said.
Russians have long gotten information about how to request asylum in the United States from YouTube channels. As of Thursday, the video had more than 34,000 views, and the comments were filled with Russian speakers thanking both the interviewer and Metzger.
Toward the end of the video, Moore calls Metzger a hero. Metzger denies the label.
Throughout, he emphasizes how much he cares about the asylum seekers.
"We pray for them, everybody. We care for them," Metzger says in the video. "We think that this whole situation is terrible, and we're trying to make something safe out of something that could be really bad, very difficult. Because one person calling — this is their life and we try to remember that every time, because we get a thousand of those every day."
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