Innovation and cooperative approach essential for One Health

Innovation and cooperative approach essential for One Health

by | Feb 9, 2016 | One Health, Reports

Innovation and cooperative approach essential for One Health

IFAH-OHA cooperative approach to further innovation in animal and public health is necessary. Hand-in-hand with consumer acceptance of new technologies, it is also essential to foster a harmonised and predictable regulatory framework in which innovation should be a key focus. With added challenges such as the development of antibiotic resistance or the spread of zoonotic diseases, it is clear that only by working together as one — locally, nationally, and globally — can we hope to attain optimal health for people, animals and the environment.

The One Health concept has been operative in animal health innovations for decades, but there is a clear need for further understanding and appreciation for the concept amongst the medical profession and the general public. We are pleased to see increasing collaboration between the WHO, OIE and FAO to identify high priority issues in the One Health arena and IFAH-Europe lends its full support to these efforts. With ever more people working in either the animal or public health sectors adopting a One Health mindset, there is greater opportunity to address challenges occurring at the interface between humans, animals and ecosystems, to facilitate the adoption of new technologies for animal and human disease and to communicate on the contributions of the animal health sector.

Excerpt originally appeared in the International Federation for Animal Health, Europe Annual report 2015. Available at: http://www.ifaheurope.org/annual-report-2015/

7

Updates direct to your Email

Enter your email address to receive notifications of new posts and opportunities by email.

Join 7,243 other subscribers

Post categories

Why is it that in the past there were very few diseases than today?

Why is it that in the past there were very few diseases than today?

by | Jan 22, 2016 | Ecosytem, One Health

Why is it that in the past there were very few diseases than today?

The ever increasing human population and greater global connectivity today, provides rapid dissemination of infectious diseases from the initial focus. Whereas in previous centuries a disease focus might have died out through failing to establish a chain of transmission, now it has the opportunity to rapidly recruit susceptible hosts on a global stage. To draw an analogy, there is now so much available tinder on the forest floor that the flickering early flame can rapidly be fanned into a forest fire. In support of this thesis, consider the following:

  • The human population of Earth took until 1800 to reach one billion; by 2000 it had
    exceeded six billion; and it reached the seven billion mark in 2011;
  • In 1800, the time taken to circumnavigate the globe by sailing ship was approximately one year. Today, no two cities served by commercial aircraft are more than 24 hours apart;
  • Annually, the world’s airlines carry a total approaching two billion passengers. At any one moment, about half a million people worldwide are flying in commercial aircraft ;
  • In 2011, there were 219 million passenger departures/arrivals at British airports;
  • In lieu of precise trade data, Billy Karesh of the Wildlife Conservation Organization in New York conservatively estimates that in east and southeast Asia, tens of millions of wild animals are shipped each year regionally and from around the world, for food or use in traditional medicine (Karesh and others 2005).

Wildlife often acts as a reservoir for diseases of domestic animal and humans see figure Figure 1.2 published in an article in Science in 2000 (Daszak et al. 2000).

Daszak et al 2000.jpg

Most emerging diseases exist within a host and parasite continuum between wildlife, domestic animal, and human populations. Few diseases affect exclusively any one group, and the complex relations between host populations set the scene for disease emergence. Examples of emerging infectious diseases that overlap these categories are canine distemper (domestic animals to wildlife), Lyme disease (wildlife to humans), cat scratch fever (domestic animals to humans) and rabies (all three categories). Arrows denote some of the key factors driving disease emergence (Daszak et al. 2000).

References

Daszak P, Cunningham AA, Hyatt AD. (2000) Emerging infectious diseases of wildlife-threats to biodiversity and human health. Science, 287: 443-449. Available at: http://science.sciencemag.org/content/287/5452/443.full

Gibbs EPJ. (2016): Week One Lecture notes for the course: An Introduction to trans-boundary diseases and their impact on trade and wildlife populations. University of Edinburgh-MSc One Health. Available at: https://www.learn.ed.ac.uk/bbcswebdav/pid-1677759-dt-content-rid-3167481_1/courses/ls_transboundary_diseases_2015/2015%202016/Week%201/Week%201%20Lecture%20Gibbs%20EM%20FINAL%202016copy.pdf

 

7

Updates direct to your Email

Enter your email address to receive notifications of new posts and opportunities by email.

Join 7,243 other subscribers

Post categories

Is there rationale for WHO shifting investment from infectious to NCDs?

Is there rationale for WHO shifting investment from infectious to NCDs?

by | Jan 16, 2016 | My Write Ups, One Health, Public health

Is there rationale for WHO shifting investment from infectious to NCDs?

 Introduction

This blog entry will try and elucidate the shift in investment from infectious to non-communicable diseases by the World Health Organisation (WHO) drawing successes from the Millennium Development Goals 6: “To combat HIV/AIDS, malaria, and other diseases”. Initially this blog entry will provide an overview of the management strategies and progress that has been made in addressing infectious diseases (using the “big three diseases” of the MDG 6 as examples). It will then highlight the financial investment from the different Global Health Actors towards these ‘big 3 diseases’ as compared to the other diseases and in conclusion determine if the WHO shift in investment is justifiable or not.

The term ‘infectious diseases’ (IDs) does not refer to a homogeneous set of illnesses but rather to a broad group of widely varying conditions (Saker, Lee, Cannito, Gilmore, & Campbell-Lendrum, 2004) that are transmitted from a person, animal or inanimate source to another person either directly, with the assistance of a vector or by other means, while non-communicable diseases (NCDs) are diseases or conditions that affect individuals over an extensive period of time and for which there are no known causative agents that are transmitted from one affected individual to another (Daar et al., 2007). If diseases are infectious, then they present in a pandemic (e.g. H1N1 influenza), epidemic (e.g. measles), or endemic (e.g. malaria) form, while if non-communicable as acute (e.g. accidents) or chronic (e.g. cancer) form (Roger, 2005).

For the purpose of this blog entry infectious diseases will be classified according to the causative agent, namely: Bacterial (e.g. Tuberculosis), parasitic (e.g. Malaria) and viral (e.g. HIV/AIDS).

Management strategies and progress against infectious diseases

Generally, control of infectious diseases can be directed either at the agent, the route of transmission, the host or the environment and sometimes a combination of the control strategies (Roger, 2005). The general methods of control are summarized in Figure 1 below.

Prevention principles

We will now focus on the progress and management efforts that have been used to combat infectious diseases but mainly drawing management strategies from HIV/AIDS, Malaria and Tuberculosis.

HIV/AIDS

Progress

On the global context the annual number of people newly infected and dying from HIV has greatly reduced, see Figure 2 below.

HIV progress

Based on the MDG Report 2015 (UNDP, 2015), in the last 15 years, Africa has made significant strides in combating HIV/AIDS. The progress in reducing the mortality rate and the pandemic status of HIV/AIDS has encompassed all five of Africa’s geographical sub-regions, see Table 1 below.

HIV in Africa progress

Management

Progress in HIV/AIDS rests on a number of factors including: improvement in testing, counselling and access to antiretroviral therapy; the reduction in mother-to-child transmission; the increase in prevention through the use of condoms and treatment as prevention; and the improvement in the general awareness and knowledge of the disease, including a better understanding of the link between HIV and tuberculosis. Engaging men in the fight against HIV also proved a winning strategy (UNDP, 2015).

Malaria

Progress

In the World Malaria Report 2015 (WHO, 2015f) it is highlighted that there has been a dramatic decline in the global malaria burden over the past 15 years (2000-2015) whereby 57 countries have reduced their malaria cases by 75%, with the global incidence and mortality rate reducing by 37% and 60%, respectively, see figure 3 below.

Malaria incidence

Management

Progress was made possible through the massive rollout of effective prevention and treatment tools: Vector control interventions, use of insecticide-treated bed-nets, quality-assured artemisinin-based combination therapy and rapid diagnostic tests have expanded in Africa over the past 10 years. However, specific efforts to protect pregnant women and children against malaria are progressing rather slowly (WHO, 2015f).

Tuberculosis

Progress

The MDG target of halting and reversing TB incidence by 2015 was achieved globally, in all six WHO regions and in 16 of the 22 high TB burden countries (WHO, 2015b). Since 2000, the global community has experienced a downward trend in tuberculosis prevalence, incidence and death rates (WHO, 2015b) see Figure 5 below.

TB trends

Management

The changes in tuberculosis prevalence and death rates mirror the rate of detection and treatment success under the DOTS approach which remains at the heart of Stop TB strategy which entails: Political commitment with increased and sustained financing; Case detection through quality-assured bacteriology; standardized treatment, with supervision and patient support; an effective drug supply and management system and Monitoring and evaluation system, and impact measurement (WHO, 2015d). Between 2000 and 2014, TB treatment alone saved 35 million lives among HIV-negative people; TB treatment and antiretroviral therapy saved an additional 8 million lives among HIV-positive people (WHO, 2015b).

Investment in infectious and non-communicable diseases 2000-2014

Development assistance for health (DAH) Disbursement

In 2000, the international community put global health high on the development agenda. Three distinct Millennium Development Goals focused on health issues in the developing world. At the forefront was the fight against child mortality, maternal mortality, and three infectious diseases: HIV/AIDS, malaria, and tuberculosis (TB). The formation of the MDGs was followed by major increases in global health financing flows. Rapid growth took hold from 2000 to 2010, following the launch of the MDGs. From 2013 to 2014, Development assistance for health (DAH) dropped by 1.6% (IHME, 2014). From the purchase of antiretroviral drugs and long-lasting insecticide-treated nets to support for disease-specific planning and programming, DAH has funded an array of activities in pursuit of MDGs 4, 5, and 6  with the very least proportion (1.48% of total) directed towards the non-communicable diseases.

Figure 8 below shows that UN agencies, including UNICEF, WHO, and UNAIDS, concentrated their DAH contributions most substantially on Maternal, newborn and child health (43.6%), but also supported work on other infectious diseases (11.3%), HIV/AIDS (6.6%), and Sector wide approaches/health sector support (5.3%), and to a minor extent non-communicable disease (1.8%), tuberculosis (1.1%), and malaria (0.9%). The investment on non-communicable diseases is generally low across all funding sources as compared to the MDG focus areas diseases.

DAH for health focus

Interestingly, the WHO programme budget allocation for communicable/infectious diseases has been declining for the past 2 financial years while the programme budget for non-communicable has been increasing see Table 2 below.

WHO budeget

Change in disease burden from infectious to non-communicable diseases?

Historically, infectious diseases (IDs) have been the most important contributor to human morbidity and mortality (WHO, 2002) until recent times, when dominance has shifted to non-communicable diseases (Beaglehole & Bonita, 2008) as shown in Figure 9 below. This dominance of NCDs could be as a result of low investment as we have established from the previous section above.

Projected deaths

Non-communicable diseases (NCDs) are one of the major health and development challenges of the 21st century, in terms of both the human suffering they cause and the harm they inflict on the socioeconomic  fabric of countries (Suhrcke, Nugent, Stuckler, & Rocco, 2006), particularly low-and middle-income countries (WHO, 2014), see Figure 10.

Chronic diseases

The number of deaths from non-communicable diseases is double the number of deaths that result from a combination of infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions, and nutritional deficiencies (Daar et al., 2007). Over the coming decades the burden from NCDs is projected to rise particularly fast in the developing world (WHO, 2005a). Non-communicable diseases (NCDs) are now recognized as a development issue.

Conclusion: Is there a necessity for WHO to shift from infectious diseases?

This far we can actually conclusively agree that the success in the progress of the MDG diseases (HIV/AIDS, Malaria and Tuberculosis) was as a result of heavy financial investment from several sources as development assistance for health (DAH) (IHME, 2014). This clearly confirms the fact that health interventions are largely based around economics; disease with the greatest perceived burden tend to be where most resources are targeted. This clearly affirms the statement, “Many may suggest that infectious diseases are suitably managed in terms of financial investment”

The huge emphasis placed on the burden created by HIV/AIDS, Malaria and Tuberculosis in the original 1990 Global Burden of disease study by (Murray & Lopez, 1996) had the unintended consequence, over the last two decades, of committing the majority of resources towards combating these three diseases, “ignoring” investment in the other diseases and of major concern resulting to the rising trend in non-communicable diseases.

The increased investment in non-communicable diseases by the World Health Organisation and statement by Dr. Margaret Chan (Director General of WHO) which stated, “Worldwide, NCDs have overtaken infectious diseases as the leading cause of mortality. This shift challenges traditional development thinking, which has long focused primarily on infectious diseases and maternal and child mortality as priorities for international action. We continue to support this focus, but need to make space for additional challenges” (WHO, 2015e); certainly informs us that the shift in focus is a timely investment to address the rising challenge of non-communicable diseases but what is required of the WHO is to develop a balanced approach of tackling both infectious and non-communicable diseases.

References

Beaglehole, R., & Bonita, R. (2008). Global public health: a scorecard. Lancet, 372, 1988–1996. doi:DOI:10.1016/S0140-6736(08)61558-5

Daar, A. S., Singer, P. A., Leah Persad, D., Pramming, S. K., Matthews, D. R., Beaglehole, R., . . . Bell, J. (2007). Grand challenges in chronic non-communicable diseases. Nature, 450(7169), 494-496.  Retrieved from http://dx.doi.org/10.1038/450494a

IHME. (2014). Financing Global Health 2014: Shifts in Funding as the MDG Era Closes. Retrieved from Seattle, WA: http://www.healthdata.org/policy-report/financing-global-health-2014-shifts-funding-mdg-era-closes

Murray, C. A., & Lopez, A. D. (1996). The Global Burden of Disease: The Havard School of Public Health on behalf of The World Health Organisation and The World bank.

Roger, W. (2005). Communicable Disease Epidemiology and Control: A Global Perspective (Second ed.): Oxfordshire, U.K. ; Cambridge, Mass. : CABI Pub. .

Saker, L., Lee, K., Cannito, B., Gilmore, A., & Campbell-Lendrum, D. (2004). Globalization and infectious diseases: A review of the linkages. Retrieved from http://www.who.int/tdr/publications/documents/seb_topic3.pdf

Suhrcke, M., Nugent, R. A., Stuckler, D., & Rocco, L. (2006). Chronic Disease: An Economic Perspective. Retrieved from London: http://www.nature.com/nature/journal/v450/n7169/full/450494a.html

UNDP. (2015). MDG Report 2015: Lessons learned in implementing the MDGS. Retrieved from http://www.undp.org/content/dam/rba/docs/Reports/MDG%20Report%202015_ENG.pdf

WHO. (2002). World health report 2002. Retrieved from Geneva,: http://www.who.int/whr/2002/en/whr02_en.pdf?ua=1

WHO. (2005a). Preventing Chronic Diseases: A Vital Investment. Retrieved from Geneva: http://www.who.int/chp/chronic_disease_report/contents/en/

WHO. (2005b). Preventing Chronic diseases: a vital investment-Part one. Retrieved from http://www.who.int/chp/chronic_disease_report/contents/part1.pdf?ua=1

WHO. (2013). Proposed Programme Budget 2014-2015. Retrieved from http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_7-en.pdf

WHO. (2014). Global status report on noncommunicable diseases 2014.  Retrieved from http://www.who.int/nmh/publications/ncd-status-report-2014/en/

WHO. (2015a). Global health sector response to HIV, 2000-2015: Focus on innovations in Africa. Retrieved from Geneva: http://apps.who.int/iris/bitstream/10665/198148/1/WHO_HIV_2015.40_eng.pdf

WHO. (2015b). Global tuberculosis report 2015. Retrieved from France: http://apps.who.int/iris/bitstream/10665/191102/1/9789241565059_eng.pdf?ua=1

WHO. (2015c). Proposed programme budget 2016-2017. Retrieved from http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_7-en.pdf

WHO. (2015d). Tuberculosis (TB): The five elements of DOTS.   Retrieved from http://www.who.int/tb/dots/whatisdots/en/

WHO. (2015e). WHO Director General addresses the place of noncommunicable diseases in strategies and agendas. Director-General.  Retrieved from http://www.who.int/dg/speeches/2015/ncd-development-cooperation/en/

WHO. (2015f). World malaria report 2015. Retrieved from Geneva: http://apps.who.int/iris/bitstream/10665/200018/1/9789241565158_eng.pdf

7

Updates direct to your Email

Enter your email address to receive notifications of new posts and opportunities by email.

Join 7,243 other subscribers

Post categories

MRSA in humans and animals in Kenya (an overview)

MRSA in humans and animals in Kenya (an overview)

by | Jan 16, 2016 | Antimicrobial resistance, My Write Ups, One Health, Zoonoses

MRSA in humans and animals in Kenya (an overview)

Introduction

Staphylococcus aureus is an important bacteria because of its ability to cause a wide range of diseases and adapt to diverse environments. The bacteria causes infection to both humans and animals by colonizing their skin, skin glands and mucous membranes, resulting to septicemia, meningitis, and arthritis in man and mastitis in the bovine, as well as poultry limb infections [1]. Methicillin-resistant Staphylococcus aureus (MRSA) is a type of staphyloccocal bacteria that is resistant to beta-lactams. It is a common cause of healthcare-associated infections in both developed and developing countries, though limited information is available from the latter [2] [3].

MRSA Resistance mechanisms

The resistance of S. aureus against methicillin is caused by expression of Penicillin binding protein 2A (PBP2A) encoded by the mecA gene [4]. PBP2A has low affinity for beta-lactam antibiotics such as amoxicillin, methicillin and oxacillin, rendering these antibiotics ineffective in treating infections caused by Staphylococcus aureus. Lately, a new methicillin resistance mechanism gene, mecC has been reported in isolates from humans and animals [5]. This therefore means that MRSA is not only associated with prior exposure to a health care facility but also raises concerns for infections originating from the community and veterinary species, and there is a possibility of a cross-infection with animals being potential sources of MRSA infection to humans [6].

MRSA the Kenyan perspective

In 1997, documented rates of MRSA in Kenya were 28 percent of all S. aureus tested in city hospitals. A separate hospital-based study during the same year found the prevalence of MRSA to be 40 percent of all S. aureus infections. In 2006, MRSA was found in 33 percent of S. aureus isolates at another hospital based study [2]. Resistance, therefore, may indicate illegal use of drugs by the public. A survey of farmers in Kenya found that the majority conflated treatment with prevention, effectively replacing hygiene and feeding practices as standard disease prevention with disease treatment [2]. Patterns of resistant Staphylococcus aureus in cattle imply a significant difference in resistance profiles of large and small scale farms, with smaller producers using nearly twice the amount of antibiotics per animal compared with larger producers [7]. The prevalence of multidrug resistance, at 34 percent on small farms, was likewise almost double the rate found at large farms [2].

The dillemma

There is evidence that MRSA infection increases the risk of mortality, morbidity, medical care costs and loss of productivity. The increased medical care costs accrued directly as expenses caused by extension of hospital stay, additional diagnostic or therapeutic procedures, and additional antibiotic use while loss of productivity is due to absence from work during hospitalization. At the same time, published data  concerning  the  antibiotic  susceptibility  patterns  of  MRSA  in  sub-Saharan  Africa  are extremely limited, and few studies on it have been conducted in Kenya [2] [3]. Many studies on MRSA in Kenya are mainly cross-sectional with a focus to determine the prevalence, identifying the antibiotic resistance but they have not focused on the zoonotic significance of MRSA. There is need to understand on how the resistance to MRSA is changing over time so as to be able to clearly visualize the mechanism and transfer of resistance genes in the population [3].

Zoonotic directionality of resistance

It is therefore important not only to determine the antibiotic resistance, but also determine what and who is causing this resistance in humans and animals belonging to the same household and also determine the temporal and spatial change of this resistance over time. This is because, by understanding the dynamics and the epidemiology of MRSA infection over time it will be possible to develop more informed prevention and control strategies, develop more sound policies including education on the rational use of antibiotics to the public.  At the same time it is important to  fill the knowledge gap [3] (especially from a developing country setting) in the zoonotic directionality of MRSA.

References 

Waldvogel, F.A., Staphylococcus aureus, in Principles and practices of infectious disease, G.L. Mandell, D. R.G., and B. J.E., Editors. 2000, Pennsylvania, USA.: Churchill Livingstone, Philadelphia, . p. 1754-1777.

Global Antibiotic Resistance Partnership-Kenya Working Group, Situation Analysis and Recommendations: Antibiotic Use and Resistance in Kenya, S. Kariuki, Editor. 2011, Center for Disease Dynamics, Economics & Policy: Washington, DC and New Delhi.

WHO, Antimicrobial resistance global report on surveillance. 2014. p. 1-256.

Wielders, C.L.C., et al., mecA Gene Is Widely Disseminated in Staphylococcus aureus Population. J. Clin. Microbiol., 2002. 40(11): p. 3970-3975.

Paterson, G.K., et al., The newly described mecA homologue, mecALGA251, is present in methicillin-resistant Staphylococcus aureus isolates from a diverse range of host species. J. Antimicrob. Chemother., 2012. 67(12): p. 2809-2813.

Ferreira, J.P., et al., Transmission of MRSA between Companion Animals and Infected Human Patients Presenting to Outpatient Medical Care Facilities. PLoS ONE, 2011. 6(11): p. e26978.

Shitandi, A. and A. Sternesjö, Prevalence of Multidrug Resistant Staphylococcus aureus in Milk from Large and Small Scale Producers in Kenya. Journal of Dairy Science, 2004. 87: p. 4145-4149.

7

Updates direct to your Email

Enter your email address to receive notifications of new posts and opportunities by email.

Join 7,243 other subscribers

Post categories

Proceedings of Pathways Kenya 2016

Proceedings of Pathways Kenya 2016

by | Jan 15, 2016 | Ecosytem, One Health

Proceedings of Pathways Kenya 2016

Pathways Kenya 2016-3

The conference Pathways Kenya 2016 (http://sites.warnercnr.colostate.edu/pathways/), took place from January 10-13, 2016 in Nanyuki, Kenya.

This conference and training program was designed to address the myriad of issues that arise as people and wildlife struggle to coexist in a sustainable and healthy manner.

Their mission is to increase professionalism and effectiveness in the human dimensions of fisheries and wildlife management field.

The schedule, associated abstracts and proceedings are available online (schedule:http://programme.exordo.com/pathways2016/).

Source

Communication via email subscription at: Network for Evaluation of One Health

 

7

Updates direct to your Email

Enter your email address to receive notifications of new posts and opportunities by email.

Join 7,243 other subscribers

Post categories

Pregnant women advised to avoid animals that are giving birth

Pregnant women advised to avoid animals that are giving birth

by | Jan 12, 2016 | One Health, Public health, Zoonoses

Pregnant women advised to avoid animals that are giving birth

Public Health Wales is reminding pregnant women to avoid close contact with animals that are giving birth.
Pregnant women who come into close contact with sheep during lambing or other farm animals that are giving birth may risk their own health, and that of their unborn child, from infections that such animals can carry.
Therefore Public Health England, the Department of Health, the Department for Environment, Food and Rural Affairs, the Animal and Plant Health Agency and the Health and Safety Executive, in association with the Welsh Government and Public Health Wales, the Scottish Government and Health Protection Scotland and the Departments of Agriculture and Rural Development (DARD) and of Health, Social Services and Public Safety (DHSSPS) in Northern Ireland have issued annual advice for a number of years that women who are or may be pregnant should avoid animals that are giving, or have recently given, birth.
Although the number of human pregnancies affected by contact with an infected animal is extremely small, it is important that pregnant women are aware of the potential risks and take appropriate precautions.
These risks are not only associated with sheep, nor confined only to the spring (when the majority of lambs are born). Cattle and goats that have recently given birth can also carry similar infections.
To avoid the possible risk of infection, pregnant women should:
  • not help ewes to lamb, or provide assistance to a cow that is calving or a nanny goat that is kidding;
  • avoid contact with aborted or new-born lambs, calves or kids or with the afterbirth, birthing fluids or materials (e.g. bedding) contaminated by such birth products;
  • avoid handling (including washing) clothing, boots or any materials  that may have come into contact with animals that have recently given birth, their young or afterbirths. Potentially contaminated clothing will be safe to handle after being washed on a hot cycle;
  • ensure contacts or partners who have attended lambing ewes or other animals giving birth take appropriate health and hygiene precautions, including the wearing of personal protective equipment and clothing and adequate washing to remove any potential contamination.
Pregnant women should seek medical advice if they experience fever or influenza-like symptoms, or if concerned that they could have acquired infection from a farm environment.
Farmers and livestock keepers have a responsibility to minimise the risks to pregnant women, including members of their family, the public and professional staff visiting farms.
Further advice is available to download from the document: More information on the following document... Q&A for pregnant women during lambing season

Source

Article originally appeared on the Public Health Wales Health Protection Division website on 11th January available at: http://www.wales.nhs.uk/sites3/news.cfm?orgid=457&contentid=39978

7

Updates direct to your Email

Enter your email address to receive notifications of new posts and opportunities by email.

Join 7,243 other subscribers

Post categories