Essential Care for Every Baby (ECEB) is an evidence-based educational program designed to increase cognitive knowledge and develop skills of health care professionals in essential newborn care in low-resource areas. The course focuses on the immediate care of the newborn after birth and during the first day or until discharge from the health facility. This study assessed the overall design of the course; the ability of facilitators to teach the course; and the knowledge and skills acquired by the learners.. Data from a facilitator evaluation survey, a learner satisfaction survey, a multiple choice question (MCQ) examination, performance on two objective structured clinical evaluations (OSCE), and pre- and post-course confidence assessments were analyzed using descriptive statistics. Pre-post course differences were examined. Comments on the evaluation form and post-course group discussions were analyzed to identify potential program improvements.Testing occurred at 2 global sitesp < 0.001). Most participants demonstrated satisfactory skills on the OSCEs. Qualitative data suggested the course was effective, but also identified areas for course improvement. These included additional time for hands-on practice, including practice in a clinical setting, the addition of video learning aids and the adaptation of content to conform to locally recommended practices.Using ECEB course material, master trainers taught 12 facilitators in India and 11 in Kenya who subsequently taught 62 providers of newborn care in India and 64 in Kenya. Facilitators and learners were satisfied with their ability to teach and learn from the program. Confidence (3.5 to 5) and MCQ scores  improved  contains supplementary material, which is available to authorized users. Over the past two decades, there has been a significant reduction in under-5 mortality; however, rates of decline of neonatal mortality have been slower, and neonates <28 days) now account for 44 % of under-5 deaths , 2. Majo8 days noLow-cost interventions, including training in neonatal resuscitation and other elements of basic newborn care, have the potential to reduce deaths from the three main causes of neonatal mortality –8. The WIn 2010, a private-public consortium led by the American Academy of Pediatrics (AAP) introduced Helping Babies Breathe (HBB), a simplified, low-cost curriculum for teaching newborn resuscitation in resource-limited areas –21. ThisGiven the wide acceptance of HBB and in response to requests for a similar course for teaching other elements of essential newborn care, a group of neonatal care specialists in North America, in collaboration with international experts, developed a simplified educational program based on the educational principles used to develop HBB to teach providers the knowledge and skills necessary to deliver essential newborn care. It has a graphical design similar to HBB. The content of this program was based on WHO guidelines for newborn care as outlined in their publication Pregnancy, Childbirth, Postpartum and Newborn Care  and the The purpose of this study was to test and evaluate the ECEB program in a field setting and modify it as needed. We were specifically interested in learning whether the content could be easily taught and learned, whether facilitators and learners could improve their knowledge and skills, and whether the curriculum  was appropriately designed.http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/global/Pages/eceb.aspx. The highlights of the course design are presented in Fig. ECEB is a skills-based educational program intended to be taught over approximately 12 classroom hours. It is designed to be disseminated using a train-the-trainer cascade in which master trainers teach facilitators to deliver the course to providers. Facilitators would typically be experienced clinicians who also have expertise and experience as educators. The target provider audience for the program is facility-based health care workers who deliver newborn care. In this manuscript, they are referred to as learners. The program uses interactive learning strategies with proven effectiveness , 24 thatAfter the initial development of the ECEB program international experts reviewed it through a structured Delphi process. Following this there was a formal consultation with WHO with representation from the 6 regions. WHO experts also provided ongoing input.The program evaluation took place at sites in India and in Kenya. In India, US master trainers  trained facilitators who subsequently trained providers at two sites. The training of providers was observed by the US master trainers at both sites. In Kenya, US master trainers  trained facilitators who then taught providers in 23 rural health facilities. This training was not observed by master trainers. The evaluation methodology in this study was similar to the evaluations of the HBB  and AcutThe following tools and methods were used to evaluate the program:To evaluate the ease of using course materials for teaching, the facilitators completed a post-course survey (a) immediately at the end of their training and (b) after they had taught a course. There were 24 items on the post-training survey and 37 items on the second evaluation (after teaching a course). Each item was assigned a numerical score on a scale of 1 to 5 based on ease of use (low to high), and for each item a mean and standard deviation was calculated. Learners also completed a 10-item survey after completion of the course. See Table Confidence among facilitators and learners was measured using a 15-item questionnaire that was completed prior to and immediately after the course. See Table Cognitive knowledge was assessed by administering a 28 item MCQ examination. Successful completion was defined as 80 % (22 of 28) of the total correct answers. The MCQ exam was administered to learners and facilitators in Kenya pre and post-course, and to facilitators in India post-course only. See Table Skills and performance were evaluated post-course only, among facilitators and learners, using two OSCEs (A and B). OSCE A evaluated the skills necessary to provide basic care during the first day after birth, and OSCE B evaluated the skills necessary for managing babies with medical problems. Participants successfully completed OSCEs if they performed 15 of 20 items correctly on OSCE A and 12 of 16 items on OSCE B. See Table Qualitative data were collected on evaluation forms and through discussion groups held after the educational sessions. Focus groups addressed the change in confidence, overall curriculum design, ease of completing the MCQ exam and OSCEs and the relevance of these assessments. One focus group conducted in Kenya among parents of newborns focused exclusively on acceptability and feasibility of the Parents’ Guide. The discussion groups were conducted in the local language, audio-taped, transcribed and then translated into English. One master trainer conducted the group discussion for the facilitators, and then a facilitator and/or master trainer conducted focus group discussion for learners at each of the two study sites. These focus groups used some general probes including: “would you explain further?”; “would you give me an example of what you mean?”; “would you say more?”; “was there anything else?”; “I don’t understand”. The questions raised during the discussions included feedback on specific aspects of the course, performance of each part of the course, and the potential ways to improve the course. In addition, the facilitators and learners were asked about potential obstacles which can interfere with the course dissemination and suggestions were elicited for ways to overcome these barriers. As these data focused on perceptions about the course, group discussion data were analyzed for common themes, especially for recommendations for modifications of the course material.The study was approved by the University of Calgary, Conjoint Health Research Ethics Board and the respective sites’ ethics committees. Written informed consent was obtained from the facilitators and the learners before participation.Twelve facilitators were trained in India and 11 in Kenya. These facilitators trained 126 learners (62 in India and 64 in Kenya). Facilitators were neonatologists, pediatricians, medical officers and nurses from level 2 or 3 neonatal care units, while learners were nurses and clinical officers from district hospitals, private nursing homes and primary health centers. The learners at both the sites had not received formal training on essential newborn care as part of their clinical orientation or ongoing work. However, the components of essential newborn care had been taught as a part of the curriculum during undergraduate training of nurses and physicians at both the sites. The majority of Indian participants (Facilitator and Learner) had no prior HBB training, In Kenya, most Facilitator (81 %) and Learner participants (86 %) were HBB-trained.I can use facilitators guide to answer questions that learner’s may ask me’ generated a broader range of scores (range 1–5) in India but not in the Kenya study site (range 4–5). General comments about the program were mostly positive; examples include: “well planned”; “well organized.” However, some modifications for improvements in pictures and modification for local adaptation were suggested in the open-ended comments of the post-course evaluation. Facilitators also suggested possible improvements to the content of the Parent Guide and also the inclusion of more OSCEs (India). Most facilitators felt that they had sufficient ability, time and information to teach the course, and also felt that the learners would be able to use the course material and successfully complete the OSCEs and MCQ examination  increased  and in Kenya was 26.7 . All facilitators at both sites scored “pass” or higher Table .p < 001). Nine learners (30 %) passed the pre-course test while 26 learners (87 %) passed the post-course test. In Kenya, 62 learners completed pre- and post-course examinations. There was a significant improvement in the post-course compared to pre-course scores . Thirty learners (48 %) passed the pre-course test while 52 (84 %) passed the post-course test. The MCQ results overall suggest the course was effective in enhancing participants’ knowledge . Sixty-two learners participated in the OSCE A and 56 learners (90 %) passed. In Kenya, 11 facilitators completed the OSCE A and 9 passed with a mean score of 16.2 . Sixty-four learners participated in the OSCE A and 60 94 %) passed  passed. In Kenya, eight of 11 facilitators passed OSCE B. Among the 59 learners who completed the OSCE B, 54 (92 %) passed. Overall learners failed to categorize the baby as this was not explicit on the Action Plan.In India, a total of 3 focus groups  were conducted, and in Kenya, a total of 4 . Regarding the structure of the course, some learners suggested that more time should be devoted to teaching and practicing. Participants also suggested that videos and or pictures would add more value to the current structure of learning. In addition, they recommended changing some MCQ questions, making them more explicit or changing the options available. All learners felt that the material was simple, understandable, and easy to learn and teach. Some learners expressed a desire for more practical hands-on sessions, a need for more neonatal simulators and the need for practice sessions in the clinical setting. Participants spoke about the importance of training both physicians and nurses in their workplace and aligning procurement of supplies and equipment with the recommended practices. They identified some potential changes needed in policies and procedures in order to translate the knowledge and skills gained into practice. The facilitators suggested that a few modifications in the content would be necessary so that the content would be consistent with approved local practices . They also suggested some pictorial modifications in the flip chart and more structured clinical examinations, rewording of some lines in the OSCEs and a universally adaptable referral note. Facilitators, Learners, and parents of newborns 6 weeks or younger enthusiastically embraced the Parent’s Guide, particularly the fact that it is colorful, graphically based, and reinforces key messages related to preservation of newborn health after discharge, including exclusive breast feeding, hygiene, and recognition of danger signs. Participants suggested that the Parent’s Guide might serve as a useful linkage between facility and community-based efforts to educate family and newborn care providers. The main points from the focus group discussion and course evaluation are provided in Fig. In addition to the formal evaluations described above, in both India and Kenya master trainers observed the program being taught by the newly trained facilitators. This observation allowed the master trainers to identify gaps in teaching and potential areas of improvement in teaching materials. The master trainers learned that it was difficult for learners to categorize babies after the first 90 min following birth, a required step in determining subsequent care. As a result of this observation, a page outlining this critical step was added to the Facilitator flip chart and Provider Guide.The ECEB program is a simplified educational program designed to facilitate the implementation of evidenced-based newborn care practices in resource-limited environments. In this manuscript, we report the results of a formative evaluation of the program at two international sites. At each site, we collected data during the training of new facilitators and during their subsequent training of community-level providers . Both facilitators and providers (learners) felt that the structure and content of the program were appropriate for their environments and suitable for teaching and learning. The program increased knowledge among providers, and nearly all facilitators and providers acquired sufficient skills necessary to perform essential newborn care. Given the simplicity of the program and its apparent suitability for a train-the-trainer strategy of dissemination, it may be an ideal program for increasing knowledge and skills of providers in essential newborn care in resource-limited environments.Confidence in performing newborn care practices was assessed by the administration of a survey. In India, before completing the course, facilitators were quite confident about their ability to perform nearly all tasks, while in Kenya, pre-course confidence among facilitators was somewhat lower. All facilitators in India and nearly all in Kenya indicated they were fully confident in their ability to perform all tasks after completing the program. Because providers who participated in this study were, in general, less educated and experienced than facilitators, their baseline confidence in performing newborn care was lower than facilitators’ confidence. However, among providers in both countries, increases in confidence in performing all aspects of essential newborn care were observed.In both India and Kenya, provider knowledge, assessed by the MCQ examination, improved significantly from pre-course to post-course. In Kenya, Facilitator knowledge also improved. These results suggest that overall the program was effective in helping participants acquire the intended knowledge. However, a few items were not answered correctly by a relatively large number of providers. This suggests that these particular topic areas may not have been adequately addressed in the training. An alternative explanation is that some practices may be misunderstood such as provision of Vitamin K in the Kenya. Learner feedback suggested that due to a combination of misunderstanding the relative risk of all newborns developing bleeding disorders in the absence of vitamin K injection; and frequent insufficient supplies of vitamin K, some learners held the erroneous assumption that only premature infants should routinely receive a vitamin K injection immediately after birth. It is also possible that specific country guidelines that may differ from the program content led to confusion, and the providers answered the questions based on the country guidelines and their usual practice. This may suggest the need to modify the program content to conform to evidence-based guidelines recommended by local health authorities (e.g. eye or cord care). Some providers may have had insufficient time to complete the examination due to limited language skills or literacy, or lack of familiarity with the MCQ format. Finally, we did not evaluate long-term retention of knowledge in this study. As has been observed with other training programs, it seems likely that some decrement in knowledge and skills will occur over time. In the Provider Guide, strategies for maintaining knowledge and skills are recommended.The results of the performances on the OSCEs suggest that completion of the ECEB course results in the acquisition of the skills necessary to provide essential newborn care among nearly all learners. Since the acquisition of skills was similar among facilitators and providers, the results suggest that the ECEB course is effective at teaching skills to a diverse group of health care professionals with varied clinical experience. However, up to 10 % of learners failed to achieve a passing score on one of the OSCESs. A passing score was intended to identify the skills necessary to deliver adequate essential newborn care. It is possible that some learners may need additional training to acquire these skills. It is also possible that the OSCEs are not a true measure of clinical skills. A few facilitators also failed to achieve a passing score, which could be due to inadequacies in OSCE’s. Following this beta testing, some modifications were made in the OSCEs. We plan to evaluate the impact of these changes.Opinions regarding potential areas for improvement of the program were also gathered during focus group discussions. This information suggested the need for some amendments in the program. One theme that emerged was the need to tailor the time devoted to the program to the background and needs of the learners. The course was designed to be conducted during 12 h of classroom instruction. Some participants expressed a need for more time for teaching and hands-on practice in the actual clinical setting. The ideal duration of the program may be variable and depend upon baseline levels of training and clinical expertise among learners. It appears that the program is acceptable, feasible, and effective at increasing knowledge and skills in essential newborn care among participants who are both HBB-trained and HBB-naïve. Some suggested the potential benefit of supplementing the classroom teaching with training in a clinical setting.The ECEB program is intended to establish adequate and uniform knowledge and skills among providers of newborn care. This an essential step in implementing newborn care practices. However, translation of knowledge of skills into practice will also require overcoming barriers to implementation, which might include inadequate commodities, ill-suited facilities and cultural barriers to adoption and change. We believe that the ECEB program will result in change in practices and outcomes only if it is incorporated into an implementation plan that includes monitoring and evaluation and quality improvement strategies to overcome barriers to implementation.There are several limitations to this study. Prior exposure to the teaching strategy used in ECEB varied between sites. In Kenya, facilitators had all been trained using the HBB program; in India, care at the time of birth had been taught using a similar but not identical program NSSK (Navjat Shishu Surkshya Karyakram). This difference may have influenced the relative change in acquisition of skills and knowledge between sites. Change in knowledge was not tested among all learners. A pre-training MCQ examination was not administered to facilitators because we assumed that they all had a high knowledge base. The pre-training MCQ examination was only administered to providers in one of the two Indian sites because of practical problems. We chose not to administer the OSCEs prior to training because performance on the OSCEs is somewhat dependent upon the sequence of care that is introduced in the ECEB program. Therefore, we did not believe that the OSCEs were a fair assessment of baseline skills. The OSCEs were used solely to test the assimilation of knowledge and adequacy of skills at the completion of training. Finally, we did not evaluate long-term retention of knowledge and skills, nor did we evaluate whether the knowledge and skills acquired during training would be translated into improved care.We hope that the ECEB program will be a vital resource for improving the health of newborns in low-resource environments. At the time of this writing, the program has been introduced to representatives from countries in Africa and South East Asia. These individuals were informed about the educational strategy and content of the program and advised about the need to adapt the program to be compliant with the policies for newborn care of their respective health authorities. We presume that their decisions about whether to use the program will be based on how the ECEB program might interface with or replace ongoing educational programs. We also recognize that the use of the ECEB program needs further investigation. Acquisition of knowledge and skills is an enabling step in improving care, but this step must be incorporated into a broader implementation strategy to effect change. To understand the potential impact of ECEB training, its effectiveness in changing processes and clinical outcomes must be tested in future studies. These studies should test effectiveness in the context of the accompanying elements of implementation.Our evaluation of the ECEB program, a simplified program for teaching essential newborn care, suggests that the program has several attributes of an ideal program to support implementation and adaptation of these practices in resource-limited environments. The program was judged by facilitators (teachers) to be easy to use and suitable for teaching in their environments. Learners (community-based providers) nearly all demonstrated adequate skills after training. The program appears to be appropriate for dissemination using a train-the-trainer strategy. Participants also highlighted the importance of additional practice and the need for changes in organizational systems in order to achieve improved patient outcomes. Successful translation into improved care will require strengthening of health care systems.


The availability of new pneumococcal conjugate vaccines covering a broader range of serotypes, has seen many countries introduce these into their national immunisation program. When transitioning from 7-valent to 13-valent pneumococcal conjugate vaccines, Australia is one of a small number of countries that included a supplementary dose of the 13-valent pneumococcal conjugate vaccine to offer protection against additional serotypes to an expanded age group of children. An evaluation of the implementation and uptake of the 13-valent pneumococcal conjugate vaccine supplementary dose was undertaken in two local health districts (LHDs) in New South Wales, Australia.A self-administered postal survey of immunisation providers in the Northern New South Wales and Mid North Coast LHDs. Trends in vaccine ordering were examined. Coverage was assessed using data from the Australian Childhood Immunisation Register (ACIR).Of the 177 surveys sent, 125 were returned (70%). Almost all providers (96%) were aware of the 13vPCV supplementary dose program though took an opportunistic approach to program promotion and parental reminders. Supplementary doses of 13vPCV were ordered for 37% of the eligible cohort, mostly in the program’s first six months. Coverage as recorded on the ACIR was 27%, though was lower in older children and those not due for scheduled childhood vaccines. Of the children who received the 13vPCV supplementary dose, 3% received it at the same time as vaccines due at 12-months of age, and 44% at the time of those due at 18-months of age.Despite the high awareness of the program, reported coverage was lower than that for other PCV supplementary dose programs in Australia and internationally. This may be influenced by providers’ largely opportunistic approach to implementation, under-reporting to the ACIR or vaccine uptake. Lessons learned from this evaluation are relevant for future time-limited childhood vaccination programs. Prior to commencement, providers should be informed about the importance of catch-up/supplementary vaccination for their patients and their active role in promoting this. They should also receive program information before parents. An understanding of parental reasons for non-receipt of time-limited childhood vaccines and evaluation of the effect of aligning supplementary (or catch up) vaccination programs with the NIP schedule would be useful to inform future programs. In the last decade, vaccines have been introduced to Australia’s National Immunisation Program (NIP) to protect children against five additional diseases . In ordeWhen 7-valent pneumococcal conjugate vaccine (7vPCV) was introduced into Australia’s NIP for infants in 2005, the Australian Government funded a 1-year catch-up program in that year for children 2–23 months of age. The number of doses required for catch-up varied depending on the age at which the first dose had been given ,7. From Currently, 13vPCV is approved for use in over 120 countries, 60 of which offer it as part of national or regional immunisation programs.  However,Evaluations of time-limited catch-up or supplementary vaccination programs targeting infants, either in Australia or internationally, are limited and predominantly focus on measuring vaccine coverage and the impact on disease. Notwithstanding the importance of such evidence, effective implementation is also a significant factor influencing the success of these programs. ,17 This A self-administered postal survey of all immunisation providers in the NNSW and MNC LHDs was undertaken to determine awareness of the 13vPCV supplementary dose program and approaches to implementation. Immunisation providers were defined as general practices (GP), Aboriginal Medical Services (AMS) or community health centres (CH) with a NSW Ministry of Health vaccine account number (VAN) and listed on public health unit (PHU) records. These “immunisation providers” represented 93% (177/183) of all GP, AMS and CH centres in these LHDs.In-depth knowledge of the local immunisation coordinator, together with previous Australian NIP evaluations , informeThe Northern New South Wales Medicare Local and the North Coast PHU promoted the survey via advertisements in routine newsletters and weekly faxes, emails to lists of general practice nurses (PNs) and personal reminders at visits to GPs/AMSs.Completed surveys were scanned into Cardiff Teleforms v10.5.2® , which aIn addition to the survey, the Medicare Local and PHU provided detailed records of the type and date of education/promotion activities undertaken in relation to the 13vPCV supplementary dose program. Descriptive analysis was performed on these data to determine frequency of activity type  and month of implementation. Also, to determine generalisability of the survey findings, the Rural, Remote, Metropolitan Area classification (RRMA)  distribuThe NSW Ministry of Health (MOH) provided line-listings of PCV monthly orders placed by immunisation providers with a VAN in the NNSW and MNC LHDs. These covered the period from October 2010, 12 months prior to commencement of the supplementary dose program, to December 2012, the end of evaluation period and three months after the program end-date. It was not possible to separate orders of 7vPCV and 13vPCV or those for the supplementary dose program vs the routine NIP schedule. The North Coast PHU supplied the total number of PCV doses reported as wasted per month, from May 2011 to December 2012. The median of the available wastage data was deducted from the raw number of doses ordered each month. The monthly orders (less wastage) for the 12 months before and three months after the 13vPCV supplementary dose program were then averaged to give the ‘baseline’ ordering rate (doses) per month. The number of additional doses ordered per month during the supplementary dose program was estimated by deducting the baseline ordering rate from the number of doses ordered for each month of the program. Monthly totals of ordered doses (excluding wastage) were graphed to examine ordering trends prior, during and after the 13vPCV supplementary dose program.PHU records of live births by LHD were used to determine the number of eligible children, by month, for the 13vPCV supplementary dose program (born 1 October 2008 to 31 December 2010).Vaccination coverage was assessed using data from the ACIR as at 30 December 2012 . ReceiptReceipt of another vaccine on the same day as the 13vPCV supplementary dose was assessed by matching administration dates for eligible children during the program period. The method of notification to the ACIR for reported 13vPCV supplementary doses was obtained for the three provider types  from ACIR data as at 31 December 2012.The North Coast Area Health Service Human Research Ethics Committee approved this evaluation as a quality assurance activity. It was conducted without financial or other support from any vaccine manufacturing company or individual or entity acting on behalf of the vaccine manufacturing industry.Of the 177 surveys sent to immunisation providers, 125 were returned completed (70% response rate). Of the remaining 52 non-returned surveys, four were not returned due to service closure/amalgamation , five were returned incomplete  and 43 were not returned at all . The majority of non-responders were GPs , most of whom had not ordered 13vPCV during the survey period despite ordering other NIP vaccines during this time. Response rates did not differ significantly between the LHDs, though were higher amongst AMSs  and CH centres  than GPs .All providers in the survey sample were from the RRMA ‘rural zone’ R1–3) . The dis–3 . The Most respondents stored patient information only electronically , though a considerable number also used a mix of paper and electronic records  with community health centres being almost solely paper-based. Most  respondents used electronic patient management software, predominantly Medical Director®  or Best Practice® .Overall, 96% of respondents were aware of the 13vPCV supplementary dose program (weighted n = 120), with no significant difference by LHD or provider type. The majority of respondents were made aware of the program through up to three sources. Of those that found out about the program from a single source (n = 22), the most common were the letter from the Australian Government Chief Medical Officer (CMO) to providers  and the Medicare Local newsletter ; combined, these accounted for half  of the dual sources of awareness about the program. Other pre-defined sources of provider awareness about the program included the NSW Ministry of Health (MOH) website , information accompanying the vaccine delivery , the initial CMO letter to parents of eligible children sent in September 2011 , and face-to-face meetings held by the Medicare Local . No respondents became aware of the program through social media. For a GP, having a practice nurse (PN) did not significantly influence awareness of the program, as overall awareness was high.The survey examined the use of three specific resources to support implementation of this program: Australian Government provider guidelines , NSW MOHOf the providers who became aware of the program from NSW MOH , more than half 28/50, 56%) reported that they did not use the MOH fact sheet. In contrast, if providers found out about the program via the CMO letter posted to providers they were more likely to use the Australian Government provider guidelines that accompanied the letter  than those who found out about the program from other sources. When examining attitudes to information provided about the program, most respondents agreed the information they received was sufficient, easy to access and clear  of respondents did not actively promote the 13vPCV supplementary dose program to patients. Of the two-thirds of providers who did promote the program, most used one  or two  promotional resources. Brochures  and posters  were the most commonly used single resources. These resources were the most commonly used combination of resources . The Medicare Local and North Coast PHU undertook a variety of education and promotional activities that were predominantly implemented during the first two months of the program (October 2011 = 15% and November 2011 = 39%) and the second last month of the program (August 2012 = 15%). The Medicare Local included information about the program in monthly newsletters, group emails to health professionals and weekly faxes, all of which primarily targeted AMSs and GPs. Some Medicare Local staff also provided verbal information about the program at face-to-face group education sessions (n = 11) and routine visits to GPs and AMSs. Representatives of the vaccine supplier also visited GPs and AMSs and provided their 13vPCV resource pack.Not enough available staff to provide this reminder service; not really necessary as most parents have received a letter and they [eligible children] are all offered supplementary dose of Prevenar13® on presentation to the clinic. Most respondents indicated they regularly sent reminders for routine childhood vaccination  although over three-quarters  did not send written reminders specifically for the 13vPCV supplementary dose program. This was mainly as they felt parents already knew about the program from the CMO letter or were told about it when they visited an immunisation provider for routine childhood vaccination for an eligible child or siblings. Lack of time and staff and insufficient systems for generating reminders also influenced providers’ decisions not to send reminders for this program.Of the written parental reminders sent, all were from GPs and were predominantly coordinated by the PN . Reminders were mostly provided via a mailed letter/postcard , telephone  or a combination of both . No provider reported using short messaging services (SMS) or email to send reminders for the 13vPCV supplementary dose program. Irrespective of sending written reminders, the majority of providers verbally informed parents about this program at either the 18-month vaccination visit  or when an eligible child presented for any other health condition , or at both these opportunities .Parents of eligible children who had not had a supplementary dose of 13vPCV recorded on the ACIR (as at 7 August 2012) received a personal reminder letter from the CMO in late August 2012. Due to the timing of the provider survey, provider awareness and experiences following dissemination of this letter could not be examined as part of this evaluation.Ordering trends for all PCVs in the NNSW and MNC LHDs are presented in Figure The majority of providers  reported that they routinely notified 13vPCV supplementary doses to the ACIR. The most common methods for this, as illustrated by both the ACIR and survey data, were direct transfer from practice software/online claiming  or entered directly on the ACIR website  . The main challenge was the initial lack of a specific field code for 13vPCV on both patient management software and the ACIR forms (electronic and paper). Other reported challenges included lack of awareness or time to report and uncertainty about how to enter the new vaccine correctly.Haemophilus influenzae type b [Hib] vaccine). Furthermore, 44% of children who received the 13vPCV supplementary dose received it at the same time as the vaccine given at 18 months of age (varicella).Data from the ACIR indicate that 27% of the eligible cohort (children aged 12–35 months between October 2011 and September 2012) in NNSW and MNC LHDs received a supplementary dose of 13vPCV during the 12 months of the program. Uptake was similar in both LHDs  and was lower than the average for all NSW . Coverage was higher in children 12–23 months of age (36.3%) than those 24–35 months of age (14.8%). Uptake was highest in the first two months of the program, and then declined throughout, with an increase in the final month of the program  ordered in the program’s first six months. Coverage as recorded on the ACIR was low (27%), most likely reflecting a combination of under-reporting and low uptake, the latter particularly in older children and those not due for an NIP-scheduled vaccine.The evaluation was conducted in two rural areas of one Australian state with known lower than average uptake of childhood vaccines and a higher than average proportion of registered conscientious objectors to vaccination  . DespiteOnly a minority of respondents remained unaware of the 13vPCV supplementary dose program. However, there were no particular characteristics common to these providers highlighted in the available data so their lack of awareness may have simply been a result of the information getting lost in the large volume of material received by primary care providers, particularly GPs . HoweverMost providers who were aware of the program came to know about it through multiple sources, reflecting the provision of information by multiple stakeholders who support NIP implementation in Australia and highlighting the important role of the Australian Government and Medicare Locals  in disseMost providers did not send written parental reminders about this program, mainly as they felt the CMO letter to parents was sufficient. Coverage data illustrate increases in uptake at the time CMO letters were sent to parents (September 2011 and August 2012). There is considerable evidence of the effectiveness of personally addressed reminder letters to parents in increasing childhood vaccination uptake , particuOrdering data were not able to be separated by vaccine type (7vPCV vs 13vPCV) and were only available by month, thus limiting the assessment of trends over time and the ability to link definitively with program-related activities. Provider-level ordering trends could not be identified due to considerable heterogeneity in ordering patterns. More precise data on vaccine type was not available and tracking of individual doses were not possible, both of which limited the capacity to determine if an ordered dose of 13vPCV was administered as a supplementary dose. Despite these limitations, ordering data were useful to estimate the maximum uptake of the 13vPCV supplementary dose and to monitor demand for the vaccine. Routine monitoring and feedback of ordering data to program implementation staff throughout a time-limited vaccination program has the potential to facilitate timely identification of decreases in demand and enable corrective action as required.Linking ordering patterns to programmatic activity retrospectively provides valuable insight into drivers of vaccine demand. The greatest amount of vaccine was ordered early in the program, which is a likely reflection of the ‘newness’ of the program. Programmatic activity related to this includes initial receipt of program information by parents/providers, providers preparing for anticipated parental demand, and a peak in the number of children eligible for vaccination. There is evidence to suggest that parental action is greatest in the first two months following commencement of a new vaccination program, thus increasing demand, which is also seen in this program . Peaks iTo boost demand outside of the start and end months of a new time-limited vaccination program, future programs may benefit from re-distribution of program information and resources to providers, along with personalised reminders to parents of unvaccinated children. This would ideally be done mid-way through the program and it appears the most effective method for this is direct mail from the Government reinforced by local health staff .The prominence of electronic notification to the ACIR, either directly from patient management software or via the ACIR website, is consistent with the increase in electronic notifications nationally . AlthougA definitive date for inclusion of a specific code for 13vPCV on the ACIR was not able to be determined, though survey respondents reported that there were delays in availability of this code that caused confusion for some providers. Most commonly respondents in this situation indicated they would use a generic code (‘other vaccine’) to notify the supplementary dose of 13vPCV. Due to limitations in the analysis of ACIR data, doses entered as ‘other vaccine’ are unable to be definitively included in coverage estimates from the ACIR, thus reducing reported coverage. However, explorative examination of the ‘other vaccine’ category on the ACIR indicates this would not fully account for the low reported coverage, which is most likely due to a combination of low uptake and under-reporting.Under-reporting is a known limitation of the ACIR data, though the extent of this in recent years and for catch-up or supplementary dose vaccination programs is not currently known . The difThe 13vPCV supplementary dose program provides protection for the six additional pneumococcal serotypes not covered in 7vPCV. As over 90% of children would have some protection against pneumococcal disease from their primary course of 7vPCV , there cUptake of the 13vPCV supplementary dose was higher in younger (aged 12–23 months) than older (aged 24–35 months) eligible children. This has also been observed in the United States (12–23 months of age 58% vs 24–59 months of age 32%) where reasons for this are thought to include parental perception of a greater disease risk in younger children and these children having more opportunities for vaccination as they visit health providers more frequently than older children . This maSeveral comments from the provider survey illustrated circumstances where parents declined the 13vPCV supplementary dose as it was ‘another vaccine’ at 12 months of age. However, offering the 13vPCV supplementary dose at the 18-month NIP schedule point appeared effective, with nearly half (44%) of the children recorded on the ACIR as receiving a 13vPCV supplementary dose also received their 18-month NIP vaccine at the same time. The time and cost involved in making a separate appointment for a supplementary vaccine and having only one other vaccine administered concurrently were likely incentives for concurrent administration at 18 month NIP schedule point. Parental attitudes towards the 13vPCV supplementary dose program and reasons for non-vaccination were not in the scope of this evaluation, though would be beneficial to understand in order to further explain reasons for low uptake.Despite a high level of provider awareness, use of national resources to implement the program and reported high rates of electronic notification of administered doses to the ACIR, uptake of the 13vPCV supplementary dose was lower than for other comparable PCV catch-up vaccination programs. This was influenced by several factors, including; providers’ opportunistic approach to implementation, under-reporting of administered vaccines to the ACIR and parents’ passively or actively declining vaccines for their child.This evaluation highlights several factors to consider when implementing future time-limited vaccination programs. Prior to vaccine distribution, it is important to ensure provision of program information to providers before patients. A follow-up targeted mail-out of key program information and resources mid-way through the program is likely to enhance demand. To facilitate notification, timely addition of vaccine-specific codes to reporting forms/software is important, as is educating providers about the importance of, and correct way to, report administered vaccines. Given the high proportion of eligible children vaccinated in the first six months of the program, consideration should be given to the duration of catch-up and supplementary dose programs, though this has to be weighed against cost-effectiveness and provision of ample opportunity for vaccination. Further evaluation of the effect of aligning supplementary (or catch up) vaccination programs with the NIP schedule is needed. This should include review of national data on timing of vaccine receipt as well as the effect on parents need to return for a separate appointment and prospects for opportunistic vaccination.


Fixture plays an important part in constraining excessive sheet metal part deformation at machining, assembly, and measuring stages during the whole manufacturing process. However, it is still a difficult and nontrivial task to design and optimize sheet metal fixture locating layout at present because there is always no direct and explicit expression describing sheet metal fixture locating layout and responding deformation. To that end, an RBF neural network prediction model is proposed in this paper to assist design and optimization of sheet metal fixture locating layout. The RBF neural network model is constructed by training data set selected by uniform sampling and finite element simulation analysis. Finally, a case study is conducted to verify the proposed method. N-2-1” (N > 3) locating principle, which indicates that the “N-2-1” locating principle is more suitable for sheet metal location than “3-2-1” principle. Apparently, in order to apply “N-2-1” locating principle to fixture locating layout design, the key is to find the optimal number of locators as well as their positions so as to reduce sheet metal part deformation.Sheet metal part is widely used in aviation industry and automotive industry due to its high strength and light weight . HoweverTo solve the problem above, many scholars and technicians carried out a lot of research. Kashyap and Evries  analyzedN-2-1” locating principle. Rex and Ravindran :After the sample data is selected and normalized, the training and testing work for neural network can be conducted. Due to the nonlinear mapping relationship between the input and output, the initial weights play a great role in deciding whether the training work can achieve a local minimum or can converge. Therefore, evenly distributed decimal empirical value should be chose as the initial weights. Then, the above network is simulated and calculated with MATLAB, and the nonlinear mapping between the input and output is realized. The flowchart of the prediction model for sheet metal fixture locating layout is depicted in N = 4” is analyzed. As shown in 3, and the physical properties of material are listed in N = 4” locating points on the primary datum plane are RP-1, RP-2, RP-3, and RP-4. The “2” locating points on the second datum plane are RP-5 and RP-6. And the “1” locating point on the third datum plane is RP-7. Set the coordinates of the fixed locating points RP-1, RP-2, RP-3, RP-5, RP-6, and RP-7 as , , , , , and . The locating point to be optimized is RP-4 and its coordinate is .In this section, the prediction model based on BP/RBF neural network for sheet metal fixture locating layout design and optimization is illustrated by an aluminum alloy sheet metal part, and its fixture locating scheme given “The training and testing data sets, as shown in Tables I = 2), which, respectively, represent the x and y coordinates of RP-4. The output layer has one neuron (K = 1), that is, the evaluation function value F(X) for sheet metal deformation. According to the general empirical formula J = 2 · I + 1 = 5, the hidden layer has five neurons (J = 5).In summary, referring to the flowchart of the prediction model for sheet metal fixture locating layout, the prediction models based on BP neural network and RBF neural network are established separately with the help of MATLAB neural network toolbox . In BP nTherefore, the response surface model describing the mapping relation between the fixture locating layout scheme and sheet metal part deformation can be established by fixture locating layout and the responding deformation evaluation function. In other words, given a locating layout scheme, the sheet metal part deformation can be obtained. The response surfaces of the neural network prediction models are shown in A prediction model based on RBF neural network for sheet metal fixture locating layout design and optimization is developed, and the prediction accuracy meets the need of general engineering.Once the proposed prediction model is applied to fixture locating layout optimization in the near future, it can replace the finite element simulation for sheet metal deformation. Thus, the calculation amount is reduced and therefore the efficiency of fixture locating layout design and optimization is improved.Compared with the BP neural network trained and tested with the same sample sets, the RBF neural network based prediction model is of higher precision and more stable.In order to assist the design and optimization of sheet metal fixture locating layout, this paper establishes an RBF neural network prediction model to describe the mapping relationship between sheet metal fixture locating layout and responding deformation. The major contributions of this paper include the following:


Leptospirosis is an important but largely under-recognized public health problem in the tropics. Establishment of highly sensitive and specific laboratory diagnosis is essential to reveal the magnitude of problem and to improve treatment. This study aimed to evaluate the diagnostic accuracy of a recombinant LigA protein based IgM ELISA during outbreaks in the clinical-setting of a highly endemic country.A prospective study was conducted from October 2011 to September 2013 at a national referral hospital for infectious diseases in Manila, Philippines. Patients who were hospitalized with clinically suspected leptospirosis were enrolled. Plasma and urine were collected on admission and/or at discharge and tested using the LigA-IgM ELISA and a whole cell-based IgM ELISA. Sensitivity and specificity of these tests were evaluated with cases diagnosed by microscopic agglutination test (MAT), culture and LAMP as the composite reference standard and blood bank donors as healthy controls: the mean+3 standard deviation optical density value of healthy controls was used as the cut-off limit (0.062 for the LigA-IgM ELISA and 0.691 for the whole cell-based IgM ELISA). Of 304 patients enrolled in the study, 270 (89.1%) were male and the median age was 30.5 years; 167 (54.9%) were laboratory confirmed. The sensitivity and ROC curve AUC for the LigA-IgM ELISA was significantly greater than the whole cell-based IgM ELISA  on admission, but not at discharge. The specificity of LigA-IgM ELISA and whole cell-based IgM ELISA were not significantly different (98% vs. 97%). Among 158 MAT negative patients, 53 and 28 were positive by LigA- and whole cell-based IgM ELISA, respectively; if the laboratory confirmation was re-defined by LigA-IgM ELISA and LAMP, the clinical findings were more characteristic of leptospirosis than the diagnosis based on MAT/culture/LAMP.The newly developed LigA-IgM ELISA is more sensitive than the whole cell-based IgM based ELISA. Although the final diagnosis must be validated by more specific tests, LigA-IgM ELISA could be a useful diagnostic test in a real clinical-setting, where diagnosis is needed in the early phase of infection. Leptospirosis is an important but largely under-recognized public health problem in the tropics. A sensitive, specific and practical point-of-care laboratory test is needed to improve clinical management in resource-limited settings. We developed a recombinant LigA protein based IgM assay (IgM ELISA) and evaluated the diagnostic accuracy of the test during outbreaks in the clinical-setting of a highly endemic country, the Philippines. Sensitivity and specificity of LigA-IgM ELISA and the whole cell-based IgM ELISA, which is included in WHO guidance, were evaluated with cases diagnosed by the standard serological test, MAT, culture and loop-mediated amplification (LAMP) as the composite reference standard and blood bank donors as healthy controls. The sensitivity and the area under the receiver operating characteristic curve for the LigA-IgM ELISA was significantly greater than those of the whole cell-based IgM ELISA on admission. When we re-defined the laboratory confirmation by LigA-IgM ELISA and LAMP, the clinical findings were more characteristic of leptospirosis than the diagnosis based on MAT/culture/LAMP. Our results suggest that LigA-IgM ELISA could be a useful diagnostic test in a real clinical-setting and help timely initiation of antibiotics to prevent severe outcomes of leptospirosis. Leptospira spp. The disease is an important public health problem in low- and middle-income countries in the tropics, especially in Southeast Asia and Latin America, including the Philippines [Leptospirosis is a ubiquitous zoonosis caused by over a hundred serovars of the pathogenic spirochetes, lippines –3. Accorlippines ,5 and anlippines . The implippines . The dislippines . EstabliLeptospira DNA using conventional or real time PCR had a higher sensitivity than culture and is useful for early diagnosis [Leptospira DNA.Studies have shown that the detection of iagnosis . More reiagnosis –11. LimiL. biflexa serovar Patoc, with which sera from patients with leptospirosis cross-reacted, and these assays are believed to be genus-specific and detect IgM antibodies from patients, regardless of infective serovars or serogroups [Leptospiral immunoglobulin-like (Lig) proteins are surface-exposed outer membrane proteins, which bind to extracellular matrix proteins and are present only among pathogenic species [MAT is the current reference standard serological diagnostic test in leptospirosis, and most studies defined laboratory-confirmed cases based on MAT. MAT method is time-consuming and requires specialist laboratory expertise . As an arogroups . The disrogroups –20. Lept species . LigA pr species ,11,22. TIn the Philippines leptospirosis is highly endemic. Outbreaks of leptospirosis occur during typhoon seasons particularly in urban slum areas such as Metro Manila ,6. In thA prospective observational study was conducted at a national referral hospital for infectious diseases in Manila, Philippines during three leptospirosis outbreak seasons; October to December in 2011, September to October in 2012 and August to September in 2013. Hospitalized patients were approached for enrollment if they had 1) fever plus at least 2 other signs and symptoms of leptospirosis  and 2) history of exposure to floodwater or animals [g for10 min and the pellets were subjected to DNA extraction using the DNeasy Blood & Tissue Kit (Qiagen) according to the manufacturer’s instructions. Two milliliter of the urine samples was centrifuged at 500 × g for 5 min to remove the precipitates, prior to a high-speed centrifugation . The resulting pellets were resuspended in 20 μl of 10 mM Tris–HCl (pH 8.0) containing 1 mM EDTA (TE) and then boiled for 10 min. The supernatant of the boiled sample was used as a template for Lepto-rrs LAMP.Two milliliters of the plasma samples were centrifuged at 16,000 × Escherichia coli BL21 and purified as described previously [The C-terminal portions of LigA (amino acid position 708–1224) fused with GST or GST alone was expressed in eviously .Leptospira antibodies in patient serum samples [The MAT was performed for detecting anti- samples  using a  samples ,25. Thes samples .Culture was performed using Korthof’s medium. After the sample collection, 1–2 drops of blood were put into Korthof’s medium and cultivated at 30°C up to 13 weeks. The cultures were examined weekly by dark-field microscopy. Positive cultures were identified by MAT and PCR.rrs LAMP was performed using previously described primers and conditions [Lepto-nditions . The DNAo-phenylenediamine dihydrochloride solution (OPD tablet (Sigma) in 6 ml distilled, deionized water containing 0.02% hydrogen peroxide) was added and settled for 5 min, and the reaction was stopped by adding 50 μl per well of 1 M sulfuric acid solution. Absorbance at 492 nm of each well was quantitated in a microtiter-plate reader.The microtiter plates  were coated with anti-human IgM (Jackson ImmunoResearch) at the concentration of 180 ng per well in 50 μl of 100 mM sodium phosphate, pH 8.0 overnight at 4°C. Excess binding sites of the well were blocked with 200 μl per well of 20 mg/ml of BSA in 20 mM Tris, 150 mM NaCl, 0.05% Tween 20, pH 7.5 (TBST) for 1.5 h at room temperature (RT), after which the BSA solution was removed. The plate was then rinsed three times with 300 μl per well of TBST. Patient plasma samples diluted 100-fold with ELISA buffer (TBST containing 10 mg/ml of BSA) were added in a total volume of 50 μl per well and incubated for 1 h at RT. After the plasma was rinsed six times with 200 μl per well of TBST, 4 μg/ml of LigA/GST or 2 μg/ml of LigA/GST in ELISA buffer was added in a total volume of 50 μl per well and incubated for 1.5 h at RT. The antigen solution was then rinsed out as above, and rabbit anti-GST IgG solution (Santa Cruz) diluted at 200-fold with ELISA buffer was added and incubated for 1 h at RT. The antibody solution was then rinsed out as above, then replaced with 50 μl per well of peroxidase-conjugated goat anti-rabbit IgG solution (Bio-Rad) diluted 5000-fold with ELISA buffer and incubated for 1 h at RT. The goat anti-rabbit IgG solution was then rinsed out as above. Finally, 50 μl of L. biflexa serovar Patoc antigen coating plate was prepared according to the WHO guidance [The guidance . The plaet al [The sample size was calculated according to the method developed by Flahault et al . For an rrs LAMP was positive for plasma or urine sample. A case was defined as severe if s/he had acute renal failure , liver dysfunction , pulmonary hemorrhage, or died during hospitalization.The Standards for Reporting of Diagnostic Accuracy (STARD) reporting guidelines were followed . A case Clinical characteristics were compared between groups using chi-square tests or Fisher’s exact tests for categorical variables and t-tests or Mann-Whitney U test for numerical variables. The ELISA optical density (OD) values were compared between the laboratory-confirmed cases and the blood donor controls using receiver operating characteristic (ROC) analyses. The sensitivities and specificities, with 95% confidence intervals, of each ELISA test was calculated using the mean+3 standard deviation (SD) value of blood donor controls as the cut-off limit for defining a positive result .This study was approved by the Research and Ethics Review Committee of the San Lazaro Hospital and the Institutional Review Board of the Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan. Informed written consent was obtained from all participants.In total, 349 cases hospitalized with clinically suspected leptospirosis were approached but clinical samples could not be collected from 45 patients during the peak of 2013 outbreak because of overwhelming workload . Consequst blood samples were collected from 292 cases (83.7%) on admission, the 2nd blood samples were collected from 164 cases (47.0%) on discharge and paired 1st and 2nd samples were collected from 162 cases (53.3%). The median duration from onset to the 1st sample collection and the 2nd sample collection varied widely: 6.5  days and 11.2  days, respectively. Urine samples were collected from 195 cases (55.9%). Among the 304 cases tested for MAT and LAMP, 134 (44.1%) were positive by MAT, 58 (19.1%) were positive by LAMP in either plasma or urine or both, and 25 (8.2%) were positive by both MAT and LAMP. LAMP positive plasma samples were found only among samples collected at 9 days or earlier after the disease onset, whereas LAMP positive urine samples were seen throughout , but this difference was not observed in the 2nd samples   for the LigA-IgM ELISA and Patoc-IgM ELISA were 0.062 and 0.691, respectively. The sensitivity of LigA-IgM ELISA was significantly higher than that of Patoc-IgM ELISA in the 1st samples on admission: 69.5%  vs. 54.3% (95% CI 48.3–60.3), respectively; p<0.01. The sensitivities were not significantly different in the 2nd samples taken at the time of discharge: 93.8 vs. 92.0; p = 0.81. Using the blood donor samples as negative control, the specificity was calculated and found high in both assays, 98% (95%CI 96.0–100.0) and 97% (95%CI 94.6–99.5), respectively. The AUC of the ROC curve for the LigA-IgM ELISA was significantly higher than that of Patoc-IgM ELISA in the 1 = 0.18) .When sensitivity of LigA-IgM ELISA and Patoc-IgM ELISA was compared according to MAT-positive serogroups , the senThe demographic and clinical characteristics at the time of admission of the whole 304 cases clinically suspected of leptospirosis were compared, according to the laboratory results Tables  and S1. Of the 158 MAT-negative cases, 53 (33.5%) were positive by the LigA-IgM ELISA while 28 (17.7%) were positive by the Patoc-IgM ELISA while 12 (9.0%) of the 134 MAT-positive cases were negative by the LigA-IgM ELISA and 10 (7.4%) were negative by the Patoc-IgM ELISA. If the laboratory confirmed cases were defined as those positive by LAMP and LigA-IgM ELISA, the clinical characteristics of cases were more typical of the classic descriptions of leptospirosis when compared with those defined by culture, LAMP and MAT. Cases were clearly associated with jaundice, calf pain, neutrophilia, thrombocytopenia, and renal dysfunction, and there were further associates with myalgia and dyspnea, hypotension, a tendency to have anuria, and a coagulation disorder.Leptospiral DNA was detected both in plasma and urine samples: 45 in plasma samples, 22 in urine samples, and 9 in both plasma and urine samples . The meaThe sensitivities of each of the diagnostic methods were plotted in relation to the duration from disease onset . In the This is the first hospital-based prospective study, evaluating the diagnostic accuracy of the LigA-IgM ELISA for leptospirosis. The study was conducted in a busy government referral hospital serving the poorest people in a highly-endemic area of Metro Manila. There were several large outbreaks during the study period. Our results demonstrated that LigA-IgM ELISA has a high clinical value because a) it had a higher sensitivity than the Patoc-IgM ELISA, especially in the first 10 days after onset, and b) leptospirosis was diagnosed in a substantial number of patients, whose diagnosis would have been missed by the conventional laboratory confirmation with MAT.Leptospira-based IgM ELISA for 4–6 years after infection [The whole cell-based serology assays are commercially available, but previous studies have demonstrated that they have a low sensitivity, especially in the early phase of leptospiral infection and low specificity ,29. The nfection .To reducSeveral studies have evaluated the performance of LigA-IgM ELISA. The sensitivity has varied depending on sample population studied, the duration from the disease onset and also the definition of the composite reference standard. For an appropriate evaluation, we need to use several diagnostic assays to provide an adequate composite reference standard and a sufficiently large sample size. Very few studies fulfilled such criteria. Srimanote et al, reported a sensitivity of LigA-IgM ELISA was over 94% in both acute and convalescent phase when the cases were defined by a positive MAT result, but their sample size was very small (n = 46) and detection of pathogen was attempted only by culture . Chen etL. borgpetersenii  but higher against L. interrogans  when compared with the whole cell-based ELISA. A recent study suggested that L. interrogans expresses genes of both LigA and LigB but L. borgpetersenii has only LigB [L. borgpetersenii may explain the lower sensitivity. It is plausible that, although the LigB molecule has the same repeated immunoglobulin-like domains where antibodies bind to, the C-terminal 80 kDa domain of LigB might mask the antibody epitope regions [Our results suggested slight differences in sensitivity of the LigA-IgM ELISA depending on the infecting serogroups. Although the differences were not statistically significant, the sensitivity of LigA-IgM ELISA tended to be lower against nly LigB ,33. A la regions .Leptospira serovar strains alive. Culture requires up to 13 weeks to have results and can be rendered negative by antibiotic pre-exposure. To overcome these limitations, in this study, we used a LAMP assay that does not demand sophisticated laboratory equipment and that gives a result within 2 hours with almost equivalent sensitivity to real-time PCR. When we applied a new definition by LAMP and LigA-IgM ELISA and compared with culture/LAMP/MAT, we identified a patient population whose clinical symptoms and signs were more compatible with leptospirosis than culture/LAMP/MAT. We propose that the LAMP/LigA ELISA combination is practical and reasonable for laboratory confirmation in the clinical setting.Culture and MAT is still regarded as the composite reference standard for leptospirosis referral laboratory confirmation. This definition has a number of limitations in the clinical setting. Both tests demand well-established laboratory where specific culture media is available for leptospirosis and the MAT assay needs an experienced laboratory technician with several There are several limitations in this study. The study was conducted in a busy government hospital, many patients were discharged within seven days after admission and did not return to the clinic, thus convalescent samples were often not available at the optimum time of at least two weeks apart. This is a reflection of a real clinical setting. The majority of our patients were males reflecting the high incidence of leptospirosis among males in our setting . HoweverIn summary, the findings of this study indicate that LigA-IgM ELISA can be a good diagnostic tool with high sensitivity especially in early phase of illness. We propose that a combination of molecular and serology assays can improve diagnosis and help timely initiation of antibiotics to prevent severe outcomes of leptospirosis in an endemic area.S1 Checklist(DOC)Click here for additional data file.S1 Table* Statistically significant; p<0.05.(DOC)Click here for additional data file.S1 FigP: LAMP of plasma; U: LAMP of urine.(TIFF)Click here for additional data file.S2 Figst samples; b. LigA-based IgM ELISA in 2nd samples; c. Patoc-based IgM ELISA in 1st samples; d. Patoc-based IgM ELISA in 2nd samples. The area under ROC curve of LigA-based and Patoc-based IgM ELISA were 0.90 and 0.82, respectively in 1st samples (p<0.01) and 0.97 and 0.99, respectively in 2nd samples (p = 0.18).a. LigA-based IgM ELISA in 1(TIF)Click here for additional data file.S3 FigP: LAMP of plasma; U: LAMP of urine. Each dot represents single plasma sample. Horizontal lines indicate median values.(TIF)Click here for additional data file.


Iran is one of the ten most earthquake prone countries in the world. Earthquakes not only cause new psychological needs among the population but particularly so when one considers vulnerable groups. This in - depth study was conducted with the aim of assessing psychosocial needs six months after an earthquake happened in the west of the county in Lorestan province.This is a qualitative study using focus group discussion that focuses mainly on the vulnerable groups  after an earthquake in Boz-azna; a village in Lorestan province in western part of Iran.Results of the psychosocial assessment indicated feelings of anxiety and worries in four vulnerable groups. Horror, hyper-excitement, avoidance and disturbing thoughts were observed in all groups with the exception of the elderly. Educational failures, loneliness and isolation were highlighted in children. All groups encountered socio-economic needs that included loss of assets and sense of insecurity and also reproductive problems were reported in women's group.Modification of a protocol on psychosocial support considering the context of the rural and urban areas with emphasis on the specific needs of the vulnerable groups is an appropriate strategy in crisis management. It seems that appropriate public awareness regarding assistance programs can be effective in reducing stress and needs of disaster survivors. For centuries, natural disasters and the ways of controlling them have been consistently considered by human beings. In the past decades, approximately 86% of the total deaths caused by disasters were attributed to natural disasters. Seventy five percent of deaths were Asians. Natural disasters cause an average annual loss of 87 billion dollars Unfortunately, Iran is a country prone to natural disasters and is known as a one of the most vulnerable countries in the world. Approximately 21 types of 40 known natural disaster types in the world occur in Iran. Generally, Iran is considered one among the 10 most disaster-prone countries in the world (Results of the study conducted by Kato and colleagues (1995) for the purpose of assessing the mental effects of the earthquake in Hanshin Awaji in Japan showed that survivors experienced sleep disorders, depression and increased irritability. Anxiety disorders were the most common complication reported immediately following the earthquake which gradually declined a month after Recommendations made by the World Health Organization (WHO) on the area of mental health has stated that psychosocial support for earthquake victims must be community-based and appropriate to the culture of the region and should also consider the needs of specific groups such as women, children, elderly, disabled etc .Limited studies have been implemented concerning the disorders following a disaster in Iran and results of these studies have just provided a view of common injuries and needs of survivors. A study conducted in relation to mental disorders of survivors of an earthquake in the north of Iran –Rudbar– in 1990 showed that 68% of the subjects studied were affected with major depression of which 38% suffered severe types of depression . AnotherOccurrences of mental illness years after natural diaster in children have had the same prevalence in adults. In a study conducted by Yasami and associates in the year 1997-1988, the mental pathology in the southern region of Khorasan and Ardebil were compared with the control group. In general, psychopathology among adults was 3 times higher and among the children 2 times higher than control group. About forty seven of children and 46.5% of adults suffered moderate to severe PTSD a year after the earthquake tragedy. Also, in the study conducted in Bam, 82% of adults and 84% of children  suffered from psychological problems. Based on Watson's scale, percentage of adults and children who suffered from PTSD were 65% and 78% .In this study, the authors have decided to conduct an in-depth qualitative study using a more detailed method in order to assess the psychosocial needs of specific groups  based on their words after the earthquake in Lorestan in 2006. In this earthquake, three persons were killed in this village.th of March 2006, suffered 80% of the damages. Selection of individuals participating in group discussions was based on following criteria as; member of vulnerable groups and opinions of the healthcare providers of Boz-azna health center considering appropriate access to survivors respectively.This qualitative study was conducted using focus group discussion. The reason for using this method is its speed in operation and in finding more information with the presence of more individuals with less time. Location of the study was in Boz-azna village, situated 25 kilometers from Boroujerd which during the earthquake that occurred on 11Target groups consisted of four vulnerable groups considered: (a) Women between the ages of 15 and 49, (b) children of both sex ages 11 to 14, (c) the elderly of both sex who were older than 60 years of age, and lastly, (d) the disabled of both sex. Participants of each focus group discussion were between 6 persons (in elderly) and 12 persons (in women). By using guide questionnaires, each focus group discussion was at least 90 minutes duration and the number of all focus group discussion was based on achieving data saturation. Each focus group discussion, with the permission of the participants, was recorded with the use of a tape recorder and transcribed at the end of each session. Data analysis was manually done using the inductive deductive content analysis method based on the study objectives.For objectivity (conformability) of data, the following methods were used by the members of the team; researchers’ credibility, prolonged engagement, persistent observation, good communications with the overview of the supervisors , use of additional comments from colleagues (peer debriefing) and reviewing of the hand-written notes. All ethical issues such as acquisition of consent from all participants of the focus group discussions, maintaining participant's anonymity, confidentiality and the right to withdraw anytime from the study have been taken into consideration.Results on the psychosocial needs of vulnerable groups after the Lorestan earthquake have been segregated and presented into the following manner: women, children, elderly and disabled people.“I feel anxious and think at any time an earthquake will occur again and the scene of the earthquake would come rushing back into my imagination”Anxiety and worry “I felt so alone and I’m depressed”Depression Fear “My sister hates to talk about the incident since she has felt more scared”“People easily get angry and fight over something worthless”Aggression “all mental pressures, work and take care of the children have been burdened by women, taking care of the children when you are homeless and living in tents”Psychological pressure “We never thought that an earthquake would be so devastating, and at present we still feel scared. We were very scared specially when we saw those fatalities… we felt very sick”Fear: ” My son would scream even to the slightest sound”Hyper arousal:“After the earthquake, the children were no longer motivated to study even those who were top in their class”Educational failure: “The children said that they lost their hope, depression is overwhelming, one child was crying due to the death of her grandmother”Depression: “Students feel lonely and isolated”Loneliness and isolation: “My thoughts are all about earthquakes, I see the incident in my mind”Disturbing thoughts: “no one wants to talk about earthquake or even repeat the word of earthquake”Avoidance: “I always think that the incident will happen anytime”Anxiety: “For 3 to 4 months I never went near my destroyed house, I was so terrified. we afraid of darkness”Fear: “We were frightened of our own house, everything was destroyed, and she always screened where her kids were, where her kids have gone? Under the collapse”Fear: “My child who had spinal cord damages bothered so much, it was terrible, he has become hyperactive and we are worried all the time”Anxiety: “We are even afraid of the loud sound of a car”Hyper arousal: “we brought him several times to the hospital overnight, thoughts of the death comes to his mind and it is so terrible”Disturbing thoughts: “she is so confused, she seems to be out of her mind and suddenly goes out of her home”Psychological pressures: “it was a horrible experience, we suddenly lost our house”Loss of money and properties: “We lived in a tent for many days and it was hard”Loss of comfort and convenience: “During the night when we had to go out, we had to go in a group of 2-5 persons because we afraid of wolves and foxes that had eaten the chickens.Need to security: Reproductive problems:a-“for three days after earthquake, we didn’t have any pill for contraception”.Insufficient contraceptive facilities b-“living in a tent and daily stress after earthquake, disrupted the personal and marital relationship”Interfere with spouse “Our houses were destroyed and our toys were missing until a few days later, authorities gave new toysSense of insecurity- “After earthquake, we couldn’t find any book, we didn’t have school uniforms”Need to accessibility to educational services – our village has been destroyed, our houses are not in good condition, our buildings have been destroyed, our animals are under the collapse, our household appliances have been gone, we have no more home furnishings”Loss of money and properties – “ we were living in the tents for many days, we do not have anywhere to go”, “our houses are still under construction”, we had to live in tents until summer”Problems regarding comfort and convenience- “ “we suddenly lost all of things”Economic problems: :” My husband is still sick and after earthquake I expected to have more help”. “we had to live in tents until summer and it was hard for disabled people”Need to access to welfare facilities“ immediately after earthquake there wasn’t sufficient services for the disabled for example there was no special place prepared for them such as tents with toilet and bath facilities but after short time, they provided some of them”, “a personnel from the social welfare used to visit us once a monthNeed to access to services for the disabled: In times of crisis such as earthquake, secondary effects create special needs for vulnerable groups such as women, children, elderly and disabled people. If these needs are not planned and managed properly, a broader and deeper tragedy may occur and the social aftershocks and deep psycho-social trauma would present their effects for years to come. Women who lost their husbands and assumed responsibilities towards for their siblings that survived on one hand and the violence, addiction and irresponsibility's of their husbands on the other hand, have been exposed to severe psychosocial traumas . It seemAnother vulnerable group is the elderly, who live alone and are unable to receive assistance from other sources and therefore will be more susceptible to psychosocial problems . An overThe last groups of individuals which are considered vulnerable are the disabled which due to their multiple disabilities should be given more special welfare assistance (Based on the policy, temporary accommodation in the Lorestan earthquake was removed. It was due to simple reconstruction in rural area and good climatic conditions. Although this decision had advantages and disadvantages, but enough information could support victims and reduce stress, especially in vulnerable groups .It seems that designing and implementing the new protocol regarding to psychosocial needs in vulnerable groups after disaster can be very useful in preventing the psychological problems.Finally, it is important to note that participation of all vulnerable groups in social activities is extremely useful in regaining their lost identity and morale .


Patients who develop critical arrhythmia during left ventricular assist device (LVAD) perfusion have a low survival rate. For diagnosis of unexpected heart abnormalities, new heart-monitoring methods are required for patients supported by LVAD perfusion. Ventricular electrocardiography using electrodes implanted in the ventricle to detect heart contractions is unsuitable if the heart is abnormal. Left ventricular impedance (LVI) is useful for monitoring heart movement but does not show abnormal action potential in the heart muscle.To detect detailed abnormal heart conditions, we obtained ventricular electrocardiograms (v-ECGs) and LVI simultaneously in porcine models connected to LVADs.In the porcine models, electrodes were set on the heart apex and ascending aorta for real-time measurements of v-ECGs and LVI. As the carrier current frequency of the LVI was adjusted to 30 kHz, it was easily derived from the original v-ECG signal by using a high-pass filter (cutoff: 10 kHz). In addition, v-ECGs with a frequency band of 0.1 – 120 Hz were easily derived using a low-pass filter. Simultaneous v-ECG and LVI data were compared to detect heart volume changes during the Q-T period when the heart contracted. A new real-time algorithm for comparison of v-ECGs and LVI determined whether the porcine heartbeats were normal or abnormal. Several abnormal heartbeats were detected using the LVADs operating in asynchronous mode, most of which were premature ventricle contractions (PVCs). To evaluate the accuracy of the new method, the results obtained were compared to normal ECG data and cardiac output measured simultaneously using commercial devices.The new method provided more accurate detection of abnormal heart movements. This method can be used for various heart diseases, even those in which the cardiac output is heavily affected by LVAD operation. Ventricular assist devices (VADs) were developed to improve survival in patients with advanced heart failure -5. The uWhile electrocardiograms (ECGs) are necessary for diagnosis of arrhythmia, the additional leads and electrodes from the ECG device are uncomfortable for a patient who is already connected to a VAD. In addition, the VAD may interfere with the ECG, preventing accurate monitoring of the heart -13. SomeIt is possible to record v-ECGs simultaneously with LVI, which is expected to provide valuable data for diagnosing arrhythmia. The increment of LVI during the R-T period can be derived from the v-ECGs. In addition, the changes in LVI signals during systole can be predicted under the assumption that the heart contraction and LVAD inlet pressure are stable with no changes caused by abrupt conditions or physiological factors. Therefore, discrepancies between the predicted impedance and the measured LVI can be interpreted as changes in heart performance since the initial recording. Using this comparison, we have successfully detected reduced heart performance coinciding with a PVC on an ECG.In this study, LVI and v-ECG data were collected using electrodes linked to the hearts of three pigs connected to VADs. The predicted increases in LVI were calculated under simple conditions when the decrease in ventricle blood volume occurred due to heart co1ntraction during the R-T period and LVAD inflow. In addition, the R-T period and LVAD inflow period were determined from v-ECGs and the LVAD controller. During the experiment, multiple PVCs were observed using conventional ECGs. When the PVCs occurred, the measured LVI changes during R-T periods were lower than the predicted values. The results of this experiment confirm that the LVI decrements during the R-T period coincided with abnormal heartbeats, which could not be observed using v-ECGs or LVI alone.The electrodes were placed at the inlet and outlet of the VAD, in contact with the apex and aortic tissue, as shown in Figure For v-ECGs, a reference electrode was placed on the aorta, while the measurement electrode was placed on the apex. This method has a similar direction of measurement to aVF in ECG measurements, but with different polarity and magnitude because the implanted electrodes are closer to the heart than the external electrodes used in conventional ECGs. The range of measurement of the v-ECGs was 0.1 – 120 Hz, and the gain was 1000, which are similar values to those of conventional ECGs. The amplified signal was saved in 16-bit resolution through an analog-to-digital converter (ADC) with a sampling rate of 250 Hz. LVI was measured by running a high-frequency current at 30 kHz at 0.1 mA through the electrodes placed on the apex and the aorta. LVI values were highest at the end of ventricular contraction or influx into the VAD, and lowest before heart contraction.Figure Measured v-ECGs show a negative R-wave value due to the inward sodium current of heart cells at depolarization prior to contraction. The T-wave has a positive value on the v-ECGs before relaxation due to the calcium and potassium current at repolarization. As shown in Figure During the R-T period, the decrease in LV volume is determined by blood flow into the LVAD and the aorta through the aortic valve. The LV volume decrease can be measured by the change in LVI during the R-T period. The average inflow of a LVAD can be estimated using the LVAD’s operating conditions and the total blood outflow from the LV can be measured by the thermodilution method. Changes in cardiac impedance are also affected by heart outflow. The blood flow through the aortic valve can be obtained by subtracting the total blood outflow of the LVAD from the change in cardiac volume during the R-T period. In addition, the blood flow through the aortic valve can be measured using an ultrasonic blood flow meter. However, measurement using a blood flow meter is possible for only a few minutes because the ascending aorta is an unsuitable location for an ultrasonic flow-meter probe due to the narrow thoracic cavity and the complexity of the vessels. Outside the R-T period, when heart contraction does not occur, LV inflow through the mitral valve can also affect the volume and impedance of the LV and make analysis of LVI difficult because no appropriate method for measurement of LV inflow is available. Therefore, changes in LVI outside the R-T period were not considered in this study.LVI values are obtained at R- and T-waves and then the differences between these values are used to calculate the LVI changes, as shown in Figure Here, the average VAD inflow can be calculated from VAD operating conditions . The totThe total average blood flow or thermodilution cannot be measured continuously; however, if it is assumed to be maintained at a stable value, it can be used to predict LV volume and LVI change by using equation Animal experiments using three pigs (Yorkshire) weighing 35 – 40 kg were performed with the approval of the Institutional Review Board of Kangwon National University and in compliance with the Ethics and Regulations for Animal Studies. The animals were placed on the operating table in the supine position, and 10 mg/kg intramuscular ketamine was injected to induce anesthesia. Anesthesia was maintained during the surgical procedure and the sensor-signal-monitoring period by a constant supply of 1 – 2% inhaled isoflurane through an endotracheal tube. The inlet cannula  was connected to the LV apex, and the outlet cannula  was connected to the ascending aorta through a median sternotomy. Mean ABP was 47.7  ±  11.0 mm Hg before LVAD perfusion and 48.7  ±  8.3 mm Hg during LVAD perfusion, mean heart rate (HR) was 86.7  ±  14.4 beats/min before LVAD perfusion and 92.3  ±  4.7 beats/min during LVAD perfusion, mean CO was 3.4  ±  0.4 L/min before LVAD perfusion and 1.9  ±  0.6 L/min during LVAD perfusion, and mean LVAD outflow was maintained at 1.3  ±  0.3 L/min. In all experiments, the animals survived for 3 h after starting the LVAD operation and were then euthanized by an overdose of anesthetic.The inlet and outlet cannulas of the LVAD  were connected to the animal’s LV and aorta, respectively, and the other ends of the cannulas were connected to the inlet and outlet ports of the pump for use as a pulsatile LVAD ,19. The Three additional electrodes were attached to both forelegs and the left rear leg of the animals to compare the v-ECG measurements with those of conventional ECGs , and ABP was measured at the carotid artery. After connecting the cannula, v-ECG data were measured by the amplifier of the LVAD. All measured data were immediately sent to a data-acquisition device  through the analog channel.The v-ECG in Figure The LVI shown in Figure The predicted heart volume in Figure This study was performed to detect abnormal contraction of the heart by observing the impedance of the LV. During these experiments, abnormal contractions were observed during asynchronous perfusion with a pulsatile VAD. No previous study has indicated that the pulsatile LVAD can induce abnormal heartbeat in asynchronous mode. However, such conditions alter the load on the heart, and changes in cardiac load increase the risk of arrhythmia. In cases in which arrhythmia is observed, an implantable cardioverter-defibrillator (ICD) could be applied to the LVAD patient to treat advanced critical arrhythmia. In addition to the change in load, sudden stretching of the cardiac muscle may also stimulate the muscle and cause arrhythmias, such as PVC. Although these experiments did not indicate a close correlation between stretching and PVC occurrence ratio, it is possible that these PVCs may be due to irregular volume changes caused by a pulsatile LVAD.P-value was below 0.05; therefore the accuracy of this method appears adequate for detecting abnormal heartbeat. Distinguishing the R-T period is a crucial part of LVI measurement. To determine whether the presence or absence of PVC affects recognition of the R-T period, CO and the beginning and end of a waveform were compared. The algorithms successfully recognized the R-T period regardless of the occurrence of PVC. The hypothesis that the difference between the predicted and actual LVI values is due to a change in cardiac performance requires the assumption that the VAD maintains a constant output. Although actual VAD output can be affected by a patient’s hemodynamic state, recently developed monitoring methods could increase the accuracy of impedance prediction [Previously, LVIs were measured using continuous flow VADs. In previous studies using continuous flow VADs, the LVI and the amount of blood in the ventricles were considered to be correlated. Unlike these previous experiments using continuous flow VADs, those involving pulsatile VADs showed relatively complex changes in LVI patterns. As the measurement location and methods used in this study were identical to those in previous studies, the same correlation was expected to be present using pulsatile flow VADs. The precise correlation between LVI and ventricular volume may differ between individual animals, because the amount of LV muscle and the irregular inflow from the LA responsible for changes in LVI can differ according to the animal’s state. Despite difficulties in analyzing original LVI, unexpected decreases in R-T impedance changes could be compared with predicted values obtained using the new algorithm, and the differences could facilitate identification of abnormal heart contraction. The actual LVI was 18 ~ 24 ohms and the actual impedance changes were 2 – 3 ohms. Abnormal LVI changes at PVC were 29.5%  ±  12.4% smaller than normal. Abnormal performance of the heart was defined as a decrease in performance to below 50%. Using this as the definition of abnormal heartbeat, the ediction .Although many arrhythmias were observed during the experiment, most were PVCs. PVCs showed various temporal waveforms in ECGs depending on their origin in the heart. PVCs have not been considered a critical abnormality, because they rapidly disappear, are difficult to detect, and do not show distinct symptoms in ABP and HR. The algorithm presented here shows that heart activity changes during PVCs and that these short-term changes can be detected by this algorithm. However, additional experiments are required to verify its ability to detect other types of arrhythmia.This study proposes a new approach to the analysis of heart activities by using ventricular contractions, rather than the action potentials used in conventional ECGs. Comparison of v-ECGs and impedances yielded relatively accurate values for LVI increase (R-T period) as well as effective monitoring during events such as PVCs. This may aid in overcoming the limitations of monitoring the heart and VAD by using solely flow rate and pressure, allowing more detailed monitoring of the heart for functional diagnosis. In addition, by comparing the experimental data with conventional flow, pressure, and ECG readings, the method proposed here was shown to be the most reliable means of measuring the ventricular volume, and therefore determining that of the heart. This method is expected to be applicable as a biomonitoring technique in extracorporeal circulatory systems using cannulas, such as extracorporeal membrane oxygenation (ECMO), as well as an effective method for mointoring VAD patients.


After the Wenchuan earthquake in 2008, the Zipingpu concrete faced rockfill dam (CFRD) was found slabs dislocation between different stages slabs and the maximum value reached 17 cm. This is a new damage pattern and did not occur in previous seismic damage investigation. Slabs dislocation will affect the seepage control system of the CFRD gravely and even the safety of the dam. Therefore, investigations of the slabs dislocation's mechanism and development might be meaningful to the engineering design of the CFRD. In this study, based on the previous studies by the authors, the slabs dislocation phenomenon of the Zipingpu CFRD was investigated. The procedure and constitutive model of materials used for finite element analysis are consistent. The water elevation, the angel, and the strength of the construction joints were among major variables of investigation. The results indicated that the finite element procedure based on a modified generalized plasticity model and a perfect elastoplastic interface model can be used to evaluate the dislocation damage of face slabs of concrete faced rockfill dam during earthquake. The effects of the water elevation, the angel, and the strength of the construction joints are issues of major design concern under seismic loading. Ms = 8.0) occurred on May 12, 2008, in Wenchuan, Sichuan Province, China. After Wenchuan earthquake, field investigations showed that there were extensive dislocations of face slabs along construction joints between the second and third stages. The phenomenon of dislocation of face slabs was previously summarized [A large earthquake  . The GEOThe same 3D finite element mesh of the Zipingpu CFRD used in the construction process simulation was adopted for the dynamic analysis . In totaAs no bedrock acceleration time histories were recorded at the dam site during Wenchuan earthquake, bedrock acceleration time histories measured at Mao Town, which is located 75 km from Zipingpu Dam, were adopted as input ground motions . The accThe dynamic responses of the Zipingpu CFRD, including the acceleration and the dam settlement during earthquake, were described in the previous study . In thisDuring the Wenchuan earthquake, the reservoir water elevation was at 828.76 m, which was lower than the construction joint elevation (EL. 845 m) between stages II and III slabs. In this study, the water elevation was taken as EL. 828 m and 878 m (full reservoir elevation) to study its influence. The simulated dislocation distribution of the construction joints between stages II and III slabs with the water elevation of EL. 828 m, at the end of the earthquake shaking, is illustrated in However, it should be noted that even less dislocation when the water elevation was higher than the joint elevation, it is very dangerous since seepage would have occurred and affected significantly the dam's safety. It is therefore concluded that face slabs of CFRD need to be reinforced at the construction joints, using measures such as stretching rebar buried in the top of the dam, in order to increase the seismic resistance.As shown in As mentioned in the section of parametric identification, the dynamic shear strength of the construction joints was considered to be lower than the whole casting concrete. In the above analysis, the dynamic shear strength of the construction joints was assumed as 0.545 MPa. In this section, the dynamic strength of the construction joints was taken as 0.545 MPa, 1 MPa, 2 MPa, and 2.73 MPa (without construction joints) to research its impact on the slabs dislocation.The Zipingpu dam is the highest CFRD over 150 m to be subjected to strong earthquake shaking, and the slabs dislocation is one of the typical damage phenomena not found in previous earthquake. This event provides a rare opportunity to verify the seismic design and safety evaluation procedures for high CFRDs. The 3D dynamic response of the Zipingpu dam during the Wenchuan earthquake was simulated based on a modified generalized plasticity model for rockfill materials in gaining additional insight into the effects of water elevation, angle, and strength of the construction joints on the performance of the slabs dislocation during earthquake loading.The dislocation phenomenon that occurred during the Wenchuan earthquake was successfully captured by the proposed numerical procedure; however, the calculated magnitude was smaller than the measured magnitude. This discrepancy may have arisen from the linear elastic assumption of the concrete slabs and the simple shear failure model of construction joints employed in this study.The effects of the water elevation, the angle, and the strength of the construction joints are issues of major design concern under seismic loading. Reinforcement at the construction joints should be enhanced to restrain the dislocation damage of the slabs. Furthermore, the angle of the construction joints should be designed and constructed as normal to the slabs, which will also decrease the slabs dislocation to a great extent.