AMSA International eNewsletter Issue #23 by AMSA International

ɽ ɯ ɲ ɪ ɫ ɸ ɴ ɫ ɹ ɹ ɳ ɫ ɪ ɯ ɩ ɯ ɴ ɫ

ɼ ɯ ɺ ɧ ɲ ɫ ɳ ɫ ɸ ɭ ɫ ɴ ɩ ɿ ɩ ɧ ɸ ɫ ɯ ɴ ɸ ɻ ɸ ɧ ɲ ɹ ɫ ɺ ɺ ɯ ɴ ɭ ɹ

ɯʔʔʖʆ ̧̨̙

ɺɧɨɲɫ ɵɬ ɩɵɴɺɫɴɺɹ̣ ̨̥ ̥̩ ̥̫

̦̩

̧̧ ̧̫

̨̧

)RUHZRUG 5HFHQW $FWLYLWLHV :LOGHUQHVV 0HGLFLQH 5HFHQW &KDSWHU $FWLYLWHV $06$ 8QLYHUVLW\ 3UR¿OH 3KRWRJUDSK\ :KLWH 3DSHU

ɬɵɸɫɽɵɸɪ̣

D^ /ŶƚĞƌŶĂƟŽŶĂů ĞEĞǁƐůĞƩĞƌ ŝƐ Ă ŵĞĚŝĂ ƚŚĂƚ ƉƌŽǀŝĚĞ ŝŶĨŽƌŵĂƟŽŶƐ ƌĞůĂƚĞĚ ƚŽ ƚŚĞ ĂĐƟǀŝƟĞƐ ŽĨ D^ ŵĞŵďĞƌƐ ĨƌŽŵ ǀĂƌŝŽƵƐ ĐŚĂƉƚĞƌƐ͘dŚŝƐ ĞEĞǁƐůĞƩĞƌ ĂůƐŽ ŝƐ Ă ƉůĂĐĞ ĨŽƌ ĞǀĞƌǇ ŝŶĚŝǀŝĚƵĂů ǁŚŽ ũŽŝŶĞĚ D^ ƚŽ ǀŽŝĐĞ ƚŚĞŝƌ ǁŽƌŬ ĂŶĚ ĂƐƉŝƌĂƟŽŶ ŝŶ ƚŚĞ ĨŽƌŵ ŽĨ ǁƌŝƟŶŐ͕ ŽƉŝŶŝŽŶ͕ ĂŶĚ ĞǀĞŶ ƉŚŽƚŽŐƌĂƉŚǇ͘ dŚĞ ŐŽĂů ŽĨ D^ /ŶƚĞƌŶĂƟŽŶĂů ĞEĞǁƐůĞƩĞƌ ŝƐ ĂƐ Ă ŵĞĚŝƵŵ ŽĨ ŝŶƚĞƌͲ ŚĂƉƚĞƌ ƚŽ ƐŚĂƌĞ ŝŶĨŽƌŵĂƟŽŶ ĂŶĚ ĞǆƉĞƌŝĞŶĐĞƐ ƚŚĂƚ ĂƌĞ ĞǆƉĞĐƚĞĚ ƚŽ ŐŝǀĞ ďĞŶĞĮƚ ĨŽƌ ĞĂĐŚ ŽƚŚĞƌ͘ dŚƌŽƵŐŚ ƚŚĞ D^ /ŶƚĞƌŶĂƟŽŶĂů ĞEĞǁƐůĞƩĞƌ ĂůƐŽ ŚŽƉĞĨƵůůǇ ǁŝůů ĂďůĞ ƚŽ ŐŝǀĞ ƵƉĚĂƚĞƐ ĂďŽƵƚ D^ /ŶƚĞƌŶĂƟŽŶĂů ĂĐƟǀŝƟĞƐ ƚŽ ĞǀĞƌǇ ĐŚĂƉƚĞƌ͘ tĞ ŚĂǀĞ Ă ŚŝŐŚ ŚŽƉĞƐ ƚŚĂƚ ƚŚŝƐ ĞEĞǁƐůĞƩĞƌ ǁŝůů ďƌŝŶŐ ƵƐ ŵŽƌĞ ĐůŽƐĞƌ ƚŽ ĞĂĐŚ ŽƚŚĞƌ͕ ǁŝůů ŐŝǀĞ ƵƐ ŵŽƌĞ <ŶŽǁůĞĚŐĞ ĂŶĚ &ƌŝĞŶĚƐŚŝƉ͕ ĂŶĚ ŵŽƌĞ ƚƌŝŐŐĞƌ ƵƐ ƚŽ ĚŽ ĂŶ ĐƟŽŶ͘ ĚŝƚŽƌŝĂů ŽĂƌĚ D^ /ŶƚĞƌŶĂƟŽŶĂů ĞEĞǁƐůĞƩĞƌ ϮϬϭϳͬϮϬϭϴ

ɸ ʆ ʄ ʆ ʏ ʕ ɧ ʄ ʕ ʊ ʗ ʊ ʕ ʊ ʆ ʔ ̶ɸʆʑʐʓʕ̸ ɧɳɹɧ̢ɯʏʕʆʓʏʂʕʊʐʏʂʍ $0'$ &RQIHUHQFH IRU $VLDQ &KDSWHU :ULWWHQ E\ 3ULPD &DNUD 5DQGDQD $06$ ,QGRQHVLD

D ǁŽƵůĚ ůŝŬĞ ƚŽ ƌĞǀŝĞǁ ƚŚĞ ƉƌŽŐƌĞƐƐ ŽĨ ƚŚĞŝƌ ƌĞĐĞŶƚ ĞīŽƌƚƐ͕ ŝŶĐůƵĚŝŶŐ 'ůŽďĂů WĂƌƚŶĞƌƐŚŝƉ ĨŽƌ ^ƵƐƚĂŝŶĂďůĞ WĞĂĐĞ ;'W^WͿ ĂƐ ǁĞůů ĂƐ D WůĂƞŽƌŵ ĨŽƌ EĂŶŬĂŝ dƌŽƵŐŚ ĂƌƚŚƋƵĂŬĞ ŝƐĂƐƚĞƌ͕ ĂŶĚ ĞǆƚĞŶĚ ƚŚĞƐĞ ŝĚĞĂƐ ƚŽ ƚŚĞŝƌ ŶĞǁ ĐŽŶĐĞƉƚ ͞tŽƌůĚ WůĂƞŽƌŵ ĨŽƌ ŝƐĂƐƚĞƌ DĞĚŝĐŝŶĞ͟

KŶ ϮϲͲϮϴ :ĂŶƵĂƌǇ ϮϬϭϴ D ; ƐƐŽĐŝĂƟŽŶ ŽĨ DĞĚŝĐĂů ŽĐƚŽƌ ŽĨ ƐŝĂͿ ŚĞůĚ Ă ŽŶĨĞƌĞŶĐĞ ĨŽƌ ƐŝĂ ŚĂƉƚĞƌ ϮϬϭϴ͘ dŚĞ ǁƌŝƚĞƌ Ăƚ ŽŶĐĞ >ŝĂŝƐŽŶ KĸĐĞƌ ƚŽ D ͕ D^ /ŶƚĞƌŶĂƟŽŶĂů ǁĂƐ ŝŶǀŝƚĞĚ ƚŽ ĂƩĞŶĚ ƚŚĞ ĞǀĞŶƚ ĂƐ Ă ŐƵĞƐƚ͘ /ƚΖƐ ĂŶ ŚŽŶŽƌ ĨŽƌ ŵĞ ƚŽ ƌĞƉƌĞƐĞŶƚ ŽƵƌ ůŽǀĞůǇ ŽƌŐĂŶŝǌĂƟŽŶ͘ D ŽŶĨĞƌĞŶĐĞ ǁĂƐ ŚĞůĚ ŝŶ ,ŽƚĞů ^ĞŶƚƌĂů͕ ƌŝĐŬĮĞůĚƐ͕ <ƵĂůĂ >ƵŵƉƵƌ͕ DĂůĂǇƐŝĂ͘ ĞƐŝĚĞ ŵĞ͕ KǀĞƌĂůů ŚĂŝƌƉĞƌƐŽŶ D^ /ŶƚĞƌŶĂƟŽŶĂů͕ tŽŶŐ ^ŽŽŶ <ƵĞŶ ǁĂƐ ĂůƐŽ ƉƌĞƐĞŶƚ͘ ƚ ƚŚŝƐ ĐŽŶĨĞƌĞŶĐĞ͕ D ǁŽƵůĚ ůŝŬĞ ƚŽ ƌĞǀŝĞǁ ƚŚĞ ƉƌŽŐƌĞƐƐ ŽĨ ƚŚĞŝƌ ƌĞĐĞŶƚ ĞīŽƌƚƐ͕ ŝŶĐůƵĚŝŶŐ 'ůŽďĂů WĂƌƚŶĞƌƐŚŝƉ ĨŽƌ ^ƵƐƚĂŝŶĂďůĞ WĞĂĐĞ ;'W^WͿ ĂƐ ǁĞůů ĂƐ D WůĂƞŽƌŵ ĨŽƌ EĂŶŬĂŝ dƌŽƵŐŚ ĂƌƚŚƋƵĂŬĞ ŝƐĂƐƚĞƌ͕ ĂŶĚ ĞǆƚĞŶĚ ƚŚĞƐĞ ŝĚĞĂƐ ƚŽ ƚŚĞŝƌ ŶĞǁ ĐŽŶĐĞƉƚ ͞tŽƌůĚ WůĂƞŽƌŵ ĨŽƌ ŝƐĂƐƚĞƌ DĞĚŝĐŝŶĞ͟ ǁŚŝĐŚ ǁŝůů ŚĞůƉ ĐŽŶƐŽůŝĚĂƚĞ ƚŚĞŝƌ ĨŽŽƚƐƚĞƉƐ ŝŶ ƚŚĞ ǇĞĂƌƐ ƚŽ ĐŽŵĞ͘ WĂƌƟĐŝƉĂŶƚƐ ŽĨ ƚŚĞ ĐŽŶĨĞƌĞŶĐĞ ǁĞƌĞ D ,ĞĂĚƋƵĂƌƚĞƌ͕ ŚĂŝƌƉĞƌƐŽŶ ŽĨ D ŚĂƉƚĞƌƐ͕ ƉĂƌƚŶĞƌƐ͕ D^ /ŶƚĞƌŶĂƟŽŶĂů͕ ĂŶĚ D^ Ͳ:ĂƉĂŶ͘ ĐƟǀŝƚǇ ƐƚĂƌƚĞĚ ǁŝƚŚ ƚŚĞ ĐŚĂƉƚĞƌΖƐ ĂĐĐŽƵŶƚĂďŝůŝƚǇ ƌĞƉŽƌƚ͘ ǀĞƌǇ D ŚĂƉƚĞƌ ƐŚĂƌĞĚ ƚŚĞŝƌ ĂĐƟǀŝƚŝĞƐ ǇĞĂƌůǇ͘ ^Ž ŵƵĐŚ ƉŽƐŝƟǀĞ ĂĐƟŽŶ ĚŝĚ ďǇ D ͘ EŽƚ ŽŶůǇ ĚŝƐĂƐƚĞƌ ƌĞůŝĞĨ͕ ďƵƚ ĂůƐŽ ŚƵŵĂŶŝƚĂƌŝĂŶ ĂŝĚ ĨŽƌ ƐŽĐŝĞƚǇ͘

dŚĞ ^ĞĐŽ WĂƌƚŶĞƌƐ D , ǇŽƵ ŬŶŽ D ŝƐ >ƵĐŬŝůǇ͕ ĂƐ ƚŚĞ & ƚŚĞŝƌ ĂƐƐ ŐƌŽƵƉ ; ǁĂƐ ŐŝǀĞ ĂďŽƵƚ ǁ ƐƵďƐŝĚŝĂ

/Ŷ ƚŚŝƐ Ž ŝŵƉƌŽǀĞ ƌĞůĂƟŽŶ ĂŶĚ ďƌŝĚ ĨƌŽŵ D ďĞĐŽŵĞ ƚŚĞƌĞ ǁ Ϳ WĂƌƚ ,ŝƌŽƚĂ Ĩƌ ŚĞůĚ ŝŶ E hŶŝǀĞƌƐŝ ĚĞůĞŐĂƚĞ

ŽŶĚ ĂŐĞŶĚĂ ǁĂƐ ƌĞĐĂůůŝŶŐ D ΖƐ 'W^W ;'ůŽďĂů ƐŚŝƉ ĨŽƌ ^ƵƐƚĂŝŶĂďůĞ WĞĂĐĞͿ ĂŶĚ ƚŚĞŝƌ ƉŚŝůŽƐŽƉŚǇ ďǇ ,ĞĂĚƋƵĂƌƚĞƌ ǁŚŝĐŚ ƉƌĞƐĞŶƚĞĚ ďǇ ƚŚĞŝƌ ĨŽƵŶĚĞƌ͘ ŝĚ Žǁ ƚŚĂƚ ƚŚĞ ĨŽƵŶĚĞƌ ŽĨ D^ /ŶƚĞƌŶĂƟŽŶĂů ĂŶĚ Ɛ ƚŚĞ ƐĂŵĞ ƉĞƌƐŽŶ͍ zĞƐ͕ ŚĞ ŝƐ ƌ ^ŚŝŐĞƌƵ ^ƵŐĂŶĂŵŝ͘ / ŚĂǀĞ Ă ƉŝĐƚƵƌĞ ǁŝƚŚ Śŝŵ͘ dŚŝƌĚ͕ D ƉĂƌƚŶĞƌ ƐƵĐŚ &ƵŬƵǇĂŵĂ ,ŽƐƉŝƚĂů /ŶƐƟƚƵƚĞ ŐĂǀĞ Ă ƐƉĞĞĐŚ ƌĞŐĂƌĚŝŶŐ ƐŽĐŝĂƟŽŶ ĂŶĚ ƉƌŽŵŽƟŽŶ͘ >ĂƐƚ ďƵƚ ŶŽƚ ůĞĂƐƚ͕ D^ D^ /ŶƚĞƌŶĂƟŽŶĂů͕ D^ Ͳ:ĂƉĂŶ͕ ĂŶĚ D^ Ϳ ĞŶ ĂŶ ŽƉƉŽƌƚƵŶŝƚǇ͘ tŽŶŐ ^ŽŽŶ <ƵĞŶ ;<ĞŶͿ ƐŚĂƌĞĚ ǁŚĂƚ D^ /ŶƚĞƌŶĂƟŽŶĂů ŝƐ͕ ĞǆĞĐƵƟǀĞ ĐŽŵŵŝƩĞĞ ĂŶĚ ĂƌŝĞƐ͘

ŽĐĐĂƐŝŽŶ͕ ďŽƚŚ D^ /ŶƚĞƌŶĂƟŽŶĂů ĂŶĚ D Ğ ƚŚĞŝƌ ƉĂƌƚŶĞƌƐŚŝƉ͘ tĞ ĞǀĞŶ ĐƌĞĂƚĞ D Ͳ D^ Ŷ ^ƚĂŶĚŝŶŐ ŽŵŵŝƩĞĞ͕ ŝŵƐ ƚŽ ĞŶŚĂŶĐĞ ĐŽŽƉĞƌĂƟŽŶ ĚŐĞ ƌĞůĂƟŽŶƐŚŝƉƐ͘ dŚĞ ŚĂŝƌƉĞƌƐŽŶ ŝƐ ƌ :ŽŶŐŵŝŶ >ĞĞ D <ŽƌĞĂ ǁŚŽ ŝƐ ĂůƐŽ ĂŶ D^ ůƵŵŶŝ͘ DĞ ĂŶĚ <ĞŶ ĞƐ ƚŚĞ ŵĞŵďĞƌ ŽĨ D Ͳ D^ ŐƌŽƵƉ͘ &ƵƌƚŚĞƌŵŽƌĞ͕ ǁĞƌĞ ĂŶ ƵƉĚĂƚĞ ĨƌŽŵ dƌŝƉůĞ ; D^ ͕ D ͕ D^ ƚŶĞƌƐŚŝƉ WƌŽŐƌĂŵ͕ ǁŚŝĐŚ ƉƌĞƐĞŶƚĞĚ ďǇ ƌ DĂŵŝ ƌŽŵ D ^ŝŶŐĂƉŽƌĞ͘ dŚĞ EĞĂƌĞƐƚ ƉƌŽũĞĐƚ ǁŝůů ďĞ EĞƉĂů͘ dŚĞ ƉĂƌƟĐŝƉĂŶƚ ŝƐ ĐŽŵŝŶŐ ĨƌŽŵ EĂƟŽŶĂů ŝƚǇ ŽĨ ^ŝŶŐĂƉŽƌĞΖƐ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚ͘ 'ŽŽĚ ůƵĐŬ ĨŽƌ ĞƐ͊

ǀĞƌǇŽŶĞ ǁŚŽ ŝŶǀŽůǀĞĚ ŝŶ ĐŽŶĨĞƌĞŶĐĞ ƉƌŽƵĚůǇ ƉƌĞƐĞŶƚƐ ƚŚĞŝƌ ĐƵůƚƵƌĞ͘ ĂŶĐŝŶŐ͕ ƐŝŶŐŝŶŐ͕ ĂŶĚ ƉůĂǇŝŶŐ ŝŶƐƚƌƵŵĞŶƚƐ͘ ,ŽŶĞƐƚůǇ͕ / ůŽǀĞ ƚŚĞ ƚƌĂĚŝƟŽŶĂů ƐŽŶŐ ĨƌŽŵ ^ƌŝ >ĂŶŐŬĂ͘ ZŚǇƚŚŵ ĂŶĚ ŵƵƐŝĐĂů ŵŽĚĞ ŵĂĚĞ ŵĞ ĨĞĞů ŚĂƉƉǇ͘ dŚĞ ǁƌŝƚĞƌ ƚŚŝŶŬƐ ŝƚΖƐ Ă ďŝŐ ĐŚĂŶĐĞ ĨŽƌ ĐƵůƚƵƌĂů ĞǆĐŚĂŶŐĞ͘ ĞƐŝĚĞ ĞŶƚĞƌƚĂŝŶŵĞŶƚ ƐĞƐƐŝŽŶ͕ ƚŚĞ ǁƌŝƚĞƌ ůĞĂƌŶƐ ƐŽ ŵƵĐŚ ĨƌŽŵ Ă ƉĂƌƟĐŝƉĂŶƚ ǁŚŽ ĚĞĮŶŝƚĞůǇ ŵŽƌĞ ĞǆƉĞƌŝĞŶĐĞĚ͘ dŚĞǇ ƐŚĂƌĞĚ ŝĚĞĂƐ ŽĨ ŚŽǁ ƚŽ ďƵŝůĚ ƌĞůĂƟŽŶƐŚŝƉ ďĞƚǁĞĞŶ ƚŚĞ ĂƐƐŽĐŝĂƟŽŶ ĂŶĚ ĐƌĞĂƚĞ ŐŽŽĚ ƉĂƌƚŶĞƌƐŚŝƉ͘ ƌ ^ĂĚĂƌ ďĚƵŶ EĂǇĞĞŵ ĨƌŽŵ D ĂŶŐůĂĚĞƐŚ ďĞĐĂŵĞ ƚŚĞ ŵŽĚĞƌĂƚŽƌ ŽĨ ƚŚĞ ƚǁŽ ĚĂǇƐ ĐŽŶĨĞƌĞŶĐĞ͘ KƌŐĂŶŝǌĞĚ ĂŐĞŶĚĂ ĂŶĚ ŽŶ ƟŵĞ ŚĞ ŵĂŶĂŐĞĚ ƚŽ ŚŽůĚ͘ >ĂƐƚ͕ ǁĞ ŚŽƉĞ D ĐŽƵůĚ ŵĂŝŶƚĂŝŶ ĞǀĞŶ ŝŵƉƌŽǀĞ ƚŚĞŝƌ ƉŽƐŝƟǀĞ ĂĐƟŽŶ͘ tŚĂƚ ƚŚĞǇ ĚŝĚ ĨŽƌ ƐŽĐŝĞƚǇ ǁĂƐ ƌĞĂůůǇ ŐƌĞĂƚ͘ dŚĞŶ ŚŽƉĞ D^ Ͳ D ƉĂƌƚŶĞƌƐŚŝƉ ďĞĐŽŵĞƐ ƐƚƌŽŶŐĞƌ ƚŚĂŶ ďĞĨŽƌĞ͘ ĞĐĂƵƐĞ ǁĞ ŚĂǀĞ ƚŚĞ ƐĂŵĞ ĚƌĞĂŵ ƚŽ ĐƌĞĂƚĞ Ă ďĞƩĞƌ ĨƵƚƵƌĞ͘

ɽɮɧɺ ɯɹ ɽɯɲɪɫɸɴɫɹɹ ɳɫɪɯɩɯɴɫ̴

tŝůĚĞƌŶĞƐƐ DĞĚŝĐŝŶĞ ŝƐ ƚŚĞ ďƌĂŶĐŚ ŽĨ ŵĞĚŝĐŝŶĞ ƚŚĂƚ ĂĚĚƌĞƐƐĞƐ ƉƌĞǀĞŶƟŽŶ͕ ĂƐƐĞƐƐŵĞŶƚ͕ ĂŶĚ ƚƌĞĂƚŵĞŶƚ ŽĨ ĂĐĐŝĚĞŶƚƐ ĂŶĚ ŝůůŶĞƐƐ ŝŶ ƚŚĞ ďĂĐŬĐŽƵŶƚƌǇ ǁŚĞƌĞ ƌĂƉŝĚ ĂĐĐĞƐƐ ƚŽ ƚŚĞ ŶĂƟŽŶĂů ϵϭϭ ƐǇƐƚĞŵ ŝƐ EKd ĂŶ ŽƉƟŽŶ͘ /ƚ ŚĂƐ ďĞĞŶ ĚĞĮŶĞĚ ĂƐ ƚŚĞ ƉƌĂĐƟĐĞ ŽĨ ŵĞĚŝĐŝŶĞ ǁŝƚŚ ůŝŵŝƚĞĚ ƌĞƐŽƵƌĐĞƐ ŝŶ ĂƵƐƚĞƌĞ ĞŶǀŝƌŽŶŵĞŶƚƐ͘ /ƚ ƌĂŶŐĞƐ ĨƌŽŵ ƚŚĞ ŝŶŝƟĂů ƚƌĞĂƚŵĞŶƚ ĂŶĚ ĞǀĂĐƵĂƟŽŶ ŽĨ ƉĂƟĞŶƚƐ ǁŝƚŚ ĂĐƵƚĞ ŝŶũƵƌŝĞƐ ƚŽ ƚŚĞ ŵĂŶĂŐĞŵĞŶƚ ŽĨ ŝůůŶĞƐƐĞƐ ĞǆƉĞƌŝĞŶĐĞĚ ďǇ ƉĂƟĞŶƚƐ ŽŶ ůŽŶŐ ƚĞƌŵ ĞǆƉĞĚŝƟŽŶƐ͘ ŽƵƌƐĞƐ ŝŶ ǁŝůĚĞƌŶĞƐƐ ŵĞĚŝĐŝŶĞ Ĩ Ž Đ Ƶ Ɛ Ž Ŷ ŵ Ă ũ Ž ƌ Ă Ŷ Ě ŵ ŝ Ŷ Ž ƌ ƚƌĂƵŵĂƟĐ ŝŶũƵƌŝĞƐ͕ ĞŶǀŝƌŽŶŵĞŶƚĂů Ɖ ƌ Ž ď ů Ğ ŵ Ɛ ͕ Ă Ŷ Ě Ğ ǆ Ɖ Ğ Ě ŝ Ɵ Ž Ŷ ŵĞĚŝĐŝŶĞ͘ ^ŬŝůůƐ ƚĂƵŐŚƚ ĞǆĐĞĞĚ ƚŚŽƐĞ ƌĞƋƵŝƌĞĚ ďǇ ƚƌĂĚŝƟŽŶĂů ĂŵďƵůĂŶĐĞ ĂŶĚ ƌĞƐĐƵĞ ǁŽƌŬĞƌƐ ĂŶĚ ŵĞĞƚ ƚŚĞ ƐƉĞĐŝĂů ŶĞĞĚƐ ŽĨ ƚƌŝƉ ůĞĂĚĞƌƐ͕ ŐƵŝĚĞƐ͕ ĂŶĚ ƌĞŵŽƚĞ ^ĞĂƌĐŚ Θ ZĞƐĐƵĞ ƚĞĂŵƐ͘

tŝůĚĞƌŶĞƐƐ DĞĚŝĐŝŶĞ ŝƐ Ă ƌĂƉŝĚůǇ ĞǀŽůǀŝŶŐ ĮĞůĚ ƚŚĂƚ ŝƐ ŝŶĐƌĞĂƐŝŶŐůǇ ŝŵƉŽƌƚĂŶƚ ĂƐ ůĂƌŐĞ ŶƵŵďĞƌƐ ŽĨ ƉĞŽƉůĞ ĂƌĞ ŝŶǀŽůǀĞĚ ŝŶ ŽƵƚĚŽŽƌ ĂĐƟǀŝƟĞƐ ĨŽƌ ĂĚǀĞŶƚƵƌĞ͕ ƐĐŝĞŶĐĞ͕ ƌĞĐƌĞĂƟŽŶ͕ ĞǆƉůŽƌĂƟŽŶ͕ ŝŶĚƵƐƚƌǇ͕ ĐŽŵďĂƚ͕ ĂŶĚ ĚŝƐĂƐƚĞƌ ƌĞůŝĞĨ͘

/ƚƐ ďƌŽĂĚ ƐĐŽƉĞ ŝŶĐůƵĚĞƐ͕ ďƵƚ ŝƐ ŶŽƚ ůŝŵŝƚĞĚ ƚŽ͗ dƌĂƵŵĂ ĂŶĚ ŵĞƌŐĞŶĐǇ DĞĚŝĐŝŶĞ ^ƉŽƌƚƐ DĞĚŝĐŝŶĞ ZĞƐĐƵĞ ĂŶĚ ǀĂĐƵĂƟŽŶ ŝǀŝŶŐ ĂŶĚ ,ǇƉĞƌďĂƌŝĐ DĞĚŝĐŝŶĞ ŝƐĂƐƚĞƌ DĞĚŝĐŝŶĞ

dƌŽƉŝĐĂů ĂŶĚ dƌĂǀĞů DĞĚŝĐŝŶĞ ǆƉĞĚŝƟŽŶ DĞĚŝĐŝŶĞ ,ŝŐŚͲ ůƟƚƵĚĞͬDŽƵŶƚĂŝŶĞĞƌŝŶŐ DĞĚŝĐŝŶĞ ^ƵƌǀŝǀĂů DĞĚŝĐŝŶĞ dĂĐƟĐĂů DĞĚŝĐŝŶĞ dĂŬĞŶ ĨƌŽŵ͗ ǁǁǁ͘ǁŝůĚůŝĨĞ͘ŽƌŐ

^ŽŽŶ <ƵĞŶ D ^ Ͳ D > z ^ /

'ƌĞĞƟŶŐƐ WĞŽƉůĞ ŽĨ dŽŵŽƌƌŽǁ͘ / Ăŵ ^ŽŽŶ <ƵĞŶ ;<ĞŶͿ ĨƌŽŵ DĂůĂǇƐŝĂ͕ ƚŚĞ KǀĞƌĂůů ŚĂŝƌƉĞƌƐŽŶ ŽĨ D^ /ŶƚĞƌŶĂƟŽŶĂů ĨŽƌ ƚŚĞ ƚĞŶƵƌĞ ϮϬϭϳͬϮϬϭϴ͘ ƵƌƌĞŶƚůǇ͕ / Ăŵ Ă ĮŶĂů ǇĞĂƌ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚ ŽĨ dŚĞ EĂƟŽŶĂů hŶŝǀĞƌƐŝƚǇ ŽĨ DĂůĂǇƐŝĂ ;hŶŝǀĞƌƐŝƟ <ĞďĂŶŐƐĂĂŶ DĂůĂǇƐŝĂ͕ h<DͿ͘ KǀĞƌ ƚŚĞ ƉĂƐƚ ĚĞĐĂĚĞƐ͕ ƚŚĞƌĞ ŚĂƐ ďĞĞŶ Ă ƚƌĞŵĞŶĚŽƵƐ ŝŶĐƌĞĂƐĞ ŝŶ ĞŶǀŝƌŽŶŵĞŶƚĂů ƌĞĐƌĞĂƟŽŶ ƐƵĐŚ ĂƐ ŵŽƵŶƚĂŝŶ ďŝŬŝŶŐ͕ ƐŶŽǁďŽĂƌĚŝŶŐ͕ ƐĞĂ ŬĂǇĂŬŝŶŐ͕ ŵŽƵŶƚĂŝŶĞĞƌŝŶŐ͕ ƌŽĐŬ ĐůŝŵďŝŶŐ͕ ŝĐĞ ĐůŝŵďŝŶŐ ĂŶĚ ƐŽ ŽŶ͘ ĚǀĞŶƚƵƌĞ ĂĐƟǀŝƟĞƐ ŝŶ ǁŝůĚĞƌŶĞƐƐ ĂƌĞĂƐ ŚĂƐ ŐƌŽǁŶ ŝŶ ƉŽƉƵůĂƌŝƟĞƐ ƚŚƌŽƵŐŚŽƵƚ ƚŚĞ ǁŽƌůĚ͕ ǁŝƚŚ ŵŽƌĞ ĂŶĚ ŵŽƌĞ ƉĞŽƉůĞ ƐĞĞŬŝŶŐ ĨŽƌ ͞ĞǆƚƌĞŵĞ͟ ĂŶĚ ͞ĞĐŽĐŚĂůůĞŶŐĞ͟ ƐƉŽƌƚƐ͕ ůĞĂĚŝŶŐ ƚŽ ŝŶĐƌĞĂƐĞĚ ƌŝƐŬ ŽĨ ŝŶũƵƌǇ ĂŶĚ ŝůůŶĞƐƐ͘ /Ŷ ƌĞƐƉŽŶƐĞ ƚŽ ƚŚĂƚ͕ ƚŚĞ ĚǇŶĂŵŝĐ ĂŶĚ ĞǀŽůǀŝŶŐ ĮĞůĚ ŽĨ ǁŝůĚĞƌŶĞƐƐ ŵĞĚŝĐŝŶĞ ŚĂƐ ĚĞǀĞůŽƉĞĚ ĂŶĚ ďĞĐŽŵĞ ŝŶĐƌĞĂƐŝŶŐůǇ ƌĞĐŽŐŶŝƐĞĚ ĂƐ Ă ŵĞĚŝĐĂů ƐƵďƐƉĞĐŝĂůƚǇ͘ Ɛ ƚŚĞ ƐĂǇŝŶŐ ŐŽĞƐ͕ ŝƚ ŝƐ ŶŽƚ ǁŚĂƚ ŚĂƉƉĞŶƐ ƚŽ ǇŽƵ ƚŚĂƚ ŵĂƩĞƌƐ͕ ďƵƚ ŚŽǁ ǇŽƵ ƌĞĂĐƚ ƚŽ ŝƚ ƚŚĂƚ ĐŽƵŶƚƐ͘ tŝůĚĞƌŶĞƐƐ ŵĞĚŝĐŝŶĞ ƌĞƋƵŝƌĞƐ ƵƐ ƚŽ ŚĂǀĞ ďƌŽĂĚ ŬŶŽǁůĞĚŐĞ ĂŶĚ ƚĞĂĐŚĞƐ ƵƐ ŽŶ ŚŽǁ ƚŽ ƚĂĐŬůĞ ŵĞĚŝĐĂů ĞŵĞƌŐĞŶĐǇ ƐŝƚƵĂƟŽŶ ƚŚĂƚ ŝŶǀŽůǀĞ ƉƌŽůŽŶŐĞĚ ƉĂƟĞŶƚ ĐĂƌĞ͕ ƐĞǀĞƌĞ ĞŶǀŝƌŽŶŵĞŶƚ ĂŶĚ ŝŵƉƌŽǀŝƐĞĚ ĞƋƵŝƉŵĞŶƚ ǁŚĞŶ ƚŚĞ ŚĞůƉ ŝƐ ŵŝůĞƐ ĂǁĂǇ ĂŶĚ ϵϭϭ ĐŽŶƚĂĐƚƐ ŶŽ ůŽŶŐĞƌ ĨƵŶĐƟŽŶ͘ /Ŷ ŽƚŚĞƌ ǁŽƌĚƐ͕ ǁŝůĚĞƌŶĞƐƐ ŵĞĚŝĐŝŶĞ ƉƌŽǀŝĚĞƐ ŵĞĚŝĐĂů ŵĂŶĂŐĞŵĞŶƚ ŝŶ ŶŽŶͲŵĞĚŝĐĂů ƐĞƫŶŐ͘ /ƚ ĞŶĐŽƵƌĂŐĞƐ ĂĚĂƉƟŶŐ ƚŚĞ ƵƐĞ ŽĨ ĐŽŵŵŽŶ ŵĞĚŝĐĂů ŬŶŽǁůĞĚŐĞ ƚŽ ƵŶĐŽŶǀĞŶƟŽŶĂů ƐĞƫŶŐƐ͘ /ƚ ĐŚĂůůĞŶŐĞƐ ĂŶĚ ŵŽƟǀĂƚĞƐ ŵĞĚŝĐĂů ƉƌŽǀŝĚĞƌƐ ƚŽ ŵĂǆŝŵŝƐĞ ƚŚĞŝƌ ĂďŝůŝƚǇ ƚŽ ǁŽƌŬ ĐƌĞĂƟǀĞůǇ ǁŝƚŚ ůŝŵŝƚĞĚ ƌĞƐŽƵƌĐĞƐ ĂŶĚ ĨƵŶĐƟŽŶ ŝŶ ĚŝĸĐƵůƚ ĞŶǀŝƌŽŶŵĞŶƚ͘ dŚĞƌĞĨŽƌĞ͕ ĚĞǀĞůŽƉŝŶŐ ƚŚĞ ƐŬŝůůƐ ƌĞƋƵŝƌĞĚ ŝŶ ǁŝůĚĞƌŶĞƐƐ ŵĞĚŝĐŝŶĞ ŝƐ Ă ǀĂůƵĂďůĞ ƉƌĂĐƟĐĞ ĨŽƌ Ăůů ĚŽĐƚŽƌƐ ĂƐ ŝƚ ĞǀĞŶƚƵĂůůǇ ŝŵƉƌŽǀĞƐ ŽŶĞΖƐ ĐůŝŶŝĐĂů ƐŬŝůůƐ͕ ĂďŝůŝƚǇ ƚŽ ŝŵƉƌŽǀŝƐĞ ŝŶ ĞŵĞƌŐĞŶĐǇ ƐŝƚƵĂƟŽŶƐ ĂŶĚ ƚŚŝŶŬ ŽƵƚ ŽĨ ƚŚĞ ďŽǆ͘

DŝĐŚĞůůĞ ZĞǇĞƐ D^ ͲW,/>/WW/E ^

,Žǁ ĂƌĞ ǁĞ ŐŽŝŶŐ ƚŽ ďƌŝŶŐ ůŝŐŚƚ ŽŶ ŝƐƐƵĞƐ ŽĨ ŚĞĂůƚŚĐĂƌĞ ŝŶĞƋƵŝƚǇ ŝŶ ǁŝůĚĞƌŶĞƐƐ ŵĞĚŝĐŝŶĞ ŝŶ Ă ƚŚŝƌĚ ǁŽƌůĚ ĐŽƵŶƚƌǇ ůŝŬĞ ƚŚĞ WŚŝůŝƉƉŝŶĞƐ͍ DǇ ŶĂŵĞ ŝƐ DŝĐŚĞůůĞ EŚĂƚ >Ǉ ZĞǇĞƐ͕ Ă ƐĞĐŽŶĚ ǇĞĂƌ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚ͘ / Ăŵ Ă ŵĞŵďĞƌ ŽĨ ^ KW, ĐŽŵŵŝƩĞĞ ŽĨ & hͲEZD& D^ ͘ tŚĞŶ / ǁĂƐ ĂŶ ƵŶĚĞƌŐƌĂĚ ƐƚƵĚĞŶƚ͕ / ŵĞƚ ƚŚĞƐĞ ŝŶĚŝŐĞŶŽƵƐ ƉĞŽƉůĞ ĐĂůůĞĚ >ƵŵĂĚƐ ĨŽƌ Ă ŐŝŌͲŐŝǀŝŶŐ ĞǀĞŶƚ ŝŶ ĂĐůĂƌĂŶ ĐŚƵƌĐŚ͘ / ǁĂƐ ĂƐƐŝŐŶĞĚ ĂůŽŶŐ ǁŝƚŚ ŽƚŚĞƌ ƐƚƵĚĞŶƚƐ ƚŽ ŝŶƚĞƌĂĐƚ ǁŝƚŚ ƚŚĞŵ ĂŶĚ ůĞĂƌŶ ĂďŽƵƚ ƚŚĞŝƌ ƚƌĂĚŝƟŽŶĂů ŵĞĚŝĐŝŶĞ͘ ^ŽŵĞ ŽĨ ƚŚĞŵ ĐŽƵůĚŶΖƚ ƐƉĞĂŬ &ŝůŝƉŝŶŽ ƐŽ ƚŚĞǇ ŚĂĚ ƚŚĞŝƌ ƚƌĂŶƐůĂƚŽƌ ƚŽ ŚĞůƉ ƵƐ ƵŶĚĞƌƐƚĂŶĚ ǁŚĂƚ ŬŝŶĚ ŽĨ ƉƌĂĐƟĐĞƐ ƚŚĞǇ ŚĂĚ͕ ŚĞĂƌŝŶŐ ƚŚĞŝƌ ƐƚŽƌŝĞƐ ŽĨ ŚĂǀŝŶŐ ƚŽ ƚƌĂǀĞů ĨŽƌ ĚĂǇƐ ǁĂůŬŝŶŐ ŵŝůĞƐ ĨƌŽŵ ŵŽƵŶƚĂŝŶ ƚŽ ŵŽƵŶƚĂŝŶ Žƌ ƌŝǀĞƌ ũƵƐƚ ƚŽ ŐĞƚ ƚŚĞŝƌ ůŽǀĞ ŽŶĞƐ ƚƌĞĂƚĞĚ ǁĂƐ ŚĞĂƌƚͲďƌĞĂŬŝŶŐ͘ tĞ ƐĞĞ ŽŶ ƚŚĞ ƚĞůĞǀŝƐŝŽŶ Žƌ ŶĞǁƐ ĂďŽƵƚ ŚŽǁ ŵŽƐƚ ƉĞŽƉůĞ ŝŶ ƚŚĞ ŝƐŽůĂƚĞĚ ƉůĂĐĞƐ ĚŽ ŶŽƚ ŐĞƚ ƚŚĞ ƉƌŽƉĞƌ ƚƌĞĂƚŵĞŶƚ Žƌ ĚŽ ŶŽƚ ĞǀĞŶ ƐĞĞ Ă ĚŽĐƚŽƌ͘ Ƶƚ ƚŽ ŚĞĂƌ ŝƚ ĮƌƐƚ ŚĂŶĚ ĨƌŽŵ ƚŚĞ ƉĞŽƉůĞ ǁŚŽ ĞǆƉĞƌŝĞŶĐĞĚ ŝƚ ƚŚĞŵƐĞůǀĞƐ ŝƐ ĚŝīĞƌĞŶƚ͕ ǇŽƵ ĐĂŶ ƐĞĞ ƚŚĞŝƌ ĚĂŝůǇ ƐƚƌƵŐŐůĞƐ͘ tŚĂƚ ƐƚƌƵĐŬ ŵĞ ƚŚĞ ŵŽƐƚ ǁĂƐ ŽŶĞ ŽĨ ƚŚĞŵ ƚŽůĚ ŵĞ ŚŽǁ ƚŚĞǇ ƵƐĞ ŚĞƌďĂů ŵĞĚŝĐŝŶĞ ĨƌŽŵ ĚŝīĞƌĞŶƚ ƉůĂŶƚƐ ůŝŬĞ ůĂŶƐŽŶĞƐ ƚŽ ƚƌĞĂƚ ŚĞůŵŝŶƚŚ ŝŶĨĞĐƟŽŶƐ ďĞĐĂƵƐĞ ŝƚ ǁĂƐ ĞŶĚĞŵŝĐ ƚŽ ƚŚĞŵ ĞƐƉĞĐŝĂůůǇ ƚŚĞ ĐŚŝůĚƌĞŶ͘ /ƚ ǁĂƐ ƐŝŐŶŝĮĐĂŶƚ ƚŽ ŵĞ ďĞĐĂƵƐĞ ŝƚ ǁĂƐ ŽƵƌ ƚŚĞƐŝƐ ƐƚƵĚǇ͕ ƚŽ ƵƐĞ ƚŚĞ ďĂƌŬ ŽĨ ůĂŶƐŽŶĞƐ ŽŶ ƐĐĂƌŝĂƐŝƐ͘ /Ŷ Ă ĐŽƵŶƚƌǇ ǁŚĞƌĞŝŶ ŵŽƐƚ ƉĞŽƉůĞ ŝŶ ƚŚĞ ƌƵƌĂů ĂƌĞĂƐ ƵƐĞ ƚƌĂĚŝƟŽŶĂů ŚĞƌďĂů ŵĞĚŝĐŝŶĞ͕ / ƚŚŽƵŐŚƚ ƚŚĂƚ ŵĂǇďĞ ǁĞ ƐŚŽƵůĚ ŚĂǀĞ ŵŽƌĞ ƐƚƵĚŝĞƐ ĂŶĚ ĨŽƌŵƵůĂƟŽŶ ŽŶ ƚŚĞƐĞ ŝŶĚŝŐĞŶŽƵƐ ƉůĂŶƚƐ ǁĞ ŚĂǀĞ ŝŶƚŽ ŵĞĚŝĐĂƟŽŶ ůŝŬĞ ŚŽǁ s/ƚĞǆ ŶĞŐƵŶĚŽ Žƌ ůĂŐƵŶĚŝ ƐƚĂƌƚĞĚ͘ tĞ ŚĂǀĞ ƚŽ ƚŚŝŶŬ ŽĨ ǁĂǇƐ ŽŶ ŚŽǁ ƚŽ ŝŶĐŽƌƉŽƌĂƚĞ ƚŚĞƐĞ ƚƌĂĚŝƟŽŶĂů ƉƌĂĐƟĐĞƐ ĂŶĚ ĂĚĚƌĞƐƐ ƚŚĞ ŝŶĞƋƵŝƚǇ ŽĨ ŚĞĂůƚŚĐĂƌĞ ŽŶ ŝƐŽůĂƚĞĚ ĂƌĞĂƐ ŝŶ Ă ǁĂǇ ƚŚĂƚ ǁĞ ĐĂŶ ĂůƐŽ ŵĂŬĞ ŽƵƌ ŽǁŶ ƐĐŝĞŶƟĮĐ ďƌĞĂŬƚŚƌŽƵŐŚƐ ǁŚŝĐŚ ĐŽƵůĚ ďĞŶĞĮƚ ŽƵƌ ƉĞŽƉůĞ͘ ĞĐĂƵƐĞ ƚŚĞ ŚĞĂůƚŚĐĂƌĞ ŝŶĞƋƵŝƚǇ ƉƌŽďůĞŵ ŝŶ ƚŚŝƐ ĐŽƵŶƚƌǇ ŝƐ ŶŽƚ ŽŶůǇ ůĂĐŬ ŽĨ ŵĂŶƉŽǁĞƌ Žƌ ƌĞƐŽƵƌĐĞƐ͕ ŝƚ ŝƐ ĂůƐŽ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚƐ ůĞĂƌŶŝŶŐ ŵŽĚĞƌŶ ŵĞĚŝĐŝŶĞ ĂŶĚ ůĂĐŬ ŽĨ ƵŶĚĞƌƐƚĂŶĚŝŶŐ ŽŶ ŚŽǁ ƚŽ ƵƐĞ ƚŚĞŝƌ ŬŶŽǁůĞĚŐĞ ŽŶ ǁŝůĚĞƌŶĞƐƐ ŵĞĚŝĐŝŶĞ ďĞĐĂƵƐĞ ŽĨ ǁŝĚĞ ĚŝƐƉĂƌŝƟĞƐ ďĞƚǁĞĞŶ ƐŽĐŝĂů ŐƌŽƵƉƐ ĂŶĚ ƚŚĂƚ ŝƐ ǁŚǇ ǁĞ ƐŚŽƵůĚ ĂĚĚƌĞƐƐ ƚŚŝƐ͘

ŝīĞƌĞŶƟĂů ƩĂŝŶŵĞŶƚ͗ tŚĂƚ ŝƐ ŝƚ ĂŶĚ ǁŚǇ ĚŽĞƐ ŝƚ ŵĂƩĞƌ͍

,ĂǀŝŶŐ ĞŶǀŝƌŽŶŵĞŶƚĂů ĐŚĂŶŐĞƐ ĂŶĚ ƐŽĐŝĂů ƐƵƉƉŽƌƚ ďǇ ƐĞŶŝŽƌƐ ĂŶĚ ďǇ ĞĚƵĐĂƚŽƌƐ ǁŽƵůĚ ŵĂŬĞ Ă ďŝŐ ĚŝīĞƌĞŶĐĞ ŝŶ ŶĂƌƌŽǁŝŶŐ ƚŚĞ ŐĂƉ ŝŶ ĂƩĂŝŶŵĞŶƚ ďǇ ƉƌŽŵŽƟŶŐ ŝŶĐůƵƐŝǀĞŶĞƐƐ ĂŶĚ ĨĞĞĚďĂĐŬ ĨƌŽŵ ƚŚĞ ĚŽĐƚŽƌƐ͘ ƌ tŽŽůĨ Ğƚ͘ Ăů ďĞůŝĞǀĞ ƚŚĂƚ ƚŚĞƌĞ ĂƌĞ ŵĂŶǇ ǁĂǇƐ ǁĞ ĐĂŶ ĚŽ ƚŽ ƌĞŵŽǀĞ ƉƌĞũƵĚŝĐĞ ĂŶĚ ƵŶĐŽŶƐĐŝŽƵƐ ďŝĂƐ ĂŶĚ ĨƌŽŵ ƚŚĞƌĞ͕ ǁĞ ĐĂŶ ďĞŶĞĮƚ ĨƌŽŵ ƚŚĞ ĚŝǀĞƌƐŝƚǇ ŽĨ ƚŚĞ ŵĞĚŝĐĂů ƉƌŽĨĞƐƐŝŽŶ͘ /ƚ ŝƐ ŵǇ ƉůĞĂƐƵƌĞ ĂƐ ĂŶ ƐŝĂŶ ŝŶƚĞƌŶĂƟŽŶĂů ŵĞĚŝĐĂů ƐƚƵĚĞŶƚ ƐƚƵĚǇŝŶŐ ŝŶ ƚŚĞ h< ƚŽ ďƌŝŶŐ ƚŚŝƐ ŵĂƩĞƌ ƵƉ ĂŶĚ ƚŽ ƐŚĂƌĞ ƚŚŝƐ ĂĚǀĂŶĐĞŵĞŶƚ ŝŶ ƚĂĐŬůŝŶŐ ĚŝīĞƌĞŶƟĂů ĂƩĂŝŶŵĞŶƚ ǁŝƚŚ ŵǇ ĨĞůůŽǁ ŵĞĚŝĐĂů ĐŽůůĞĂŐƵĞƐ ŝŶ ƐŝĂ ŽĨ ƚŚĞ ĐŚĂůůĞŶŐĞƐ ƚŚĂƚ ŽŶĞ ĨĂĐĞƐ ĚƵƌŝŶŐ ƚŚĞŝƌ ŵĞĚŝĐĂů ƵŶĚĞƌŐƌĂĚƵĂƚĞ Žƌ ƉŽƐƚͲŐƌĂĚƵĂƚĞ ƚƌĂŝŶŝŶŐ ŚĞƌĞ ŝŶ ƚŚĞ h<͘ /ƚ ŝƐ ĨƵŶĚĂŵĞŶƚĂů ĨŽƌ ŝŶĚŝǀŝĚƵĂůƐ ŽĨ ŵŝŶŽƌŝƚǇ ĞƚŚŶŝĐŝƚǇ ƚŽ ŬŶŽǁ ƚŚĂƚ ƚŚŝƐ ŶŽƚ ŽŶůǇ ŚĂƉƉĞŶƐ ƚŽ ƚŚĞŵƐĞůǀĞƐ͕ ďƵƚ ĂůƐŽ ƚŽ ŵĂŶǇ ŽƚŚĞƌƐ ǁŽƌŬŝŶŐ ŝŶ ƚŚĞ h<͘ dŚŝƐ ŵŽǀĞŵĞŶƚ ƚŽ ƚĂĐŬůĞ ƚŚĞ ŐĂƉ ŝŶ ĂƩĂŝŶŵĞŶƚ ŝŶ ŵĞĚŝĐĂů ĞĚƵĐĂƟŽŶ ƚĂŬĞƐ ǇĞĂƌƐ ƚŽ ďĞĂƌ ĨƌƵŝƚ ďƵƚ / ďĞůŝĞǀĞ ƚŚĞ ĮƌƐƚ ƉĂƌĂŵŽƵŶƚ ƐƚĞƉ ƚŚĂƚ ǁĞ ĐĂŶ ĚŽ ĂƐ ƚŚĞ ĨƵƚƵƌĞ ĚŽĐƚŽƌƐ͕ ƚŚĞ ůĞĂĚĞƌƐ ŽĨ ƚŽŵŽƌƌŽǁ͕ ŝƐ ƚŽ ĂĐŬŶŽǁůĞĚŐĞ ƚŚĂƚ ƚŚŝƐ ŐĂƉ ĂĐƚƵĂůůǇ ĞǆŝƐƚƐ ƚŽǁĂƌĚƐ ŝŵƉƌŽǀŝŶŐ ŵĞĚŝĐĂů ĞĚƵĐĂƟŽŶ ŝŶ ƚŚĞ h<͘ ĞĂŶ KǁǇĂŶŐ ŝƐ Ă ϰƚŚ ǇĞĂƌ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚ ŝŶ YƵĞĞŶΖƐ hŶŝǀĞƌƐŝƚǇ ĞůĨĂƐƚ͕ hŶŝƚĞĚ <ŝŶŐĚŽŵ͘ ,Ğ ŝƐ ƚŚĞ ĐƵƌƌĞŶƚ sŝĐĞ KǀĞƌĂůů ŚĂŝƌƉĞƌƐŽŶ ;/ŶƚĞƌŶĂůͿ ŽĨ D^ Ͳ/ŶƚĞƌŶĂƟŽŶĂů͘ ,Ğ ŚĂƐ ďĞĞŶ ĂĐƟǀĞ ŝŶ D^ ĨŽƌ ƚŚĞ ƉĂƐƚ ϯ ǇĞĂƌƐ͕ ŶĂƟŽŶĂůůǇ ĂŶĚ ŝŶƚĞƌŶĂƟŽŶĂůůǇ͘ ,Ğ ŚĂƐ Ă ͘^Đ͘ ŝŶ ^ƵƌŐĞƌǇ ĂŶĚ ŶĂĞƐƚŚĞƐŝĂ ĨƌŽŵ /ŵƉĞƌŝĂů ŽůůĞŐĞ >ŽŶĚŽŶ ĂŶĚ ŚŝƐ ĐƵƌƌĞŶƚ ŵĞĚŝĐĂů ŝŶƚĞƌĞƐƚƐ ĂƌĞ KƌƚŚŽƉĂĞĚŝĐƐ ĂŶĚ ^ƉŽƌƚ ^ƵƌŐĞƌǇ͘ ZĞĨƌĞŶĐĞƐ͗ ;ϭͿ͗ ŚƩƉƐ͗ͬͬǁǁǁ͘ďŵĂ͘ŽƌŐ͘ƵŬͬĐŽůůĞĐƟǀĞͲǀŽŝĐĞͬƉŽůŝĐǇͲĂŶĚͲƌĞƐĞĂƌĐŚͬĞĚƵĐĂƟŽŶͲƚƌĂŝŶŝŶŐͲ ĂŶĚͲǁŽƌŬĨŽƌĐĞͬĚŝīĞƌĞŶƟĂůͲĂƩĂŝŶŵĞŶƚ ;ϮͿ͗ ŚƩƉƐ͗ͬͬǁǁǁ͘ŐŵĐͲ ƵŬ͘ŽƌŐͬ'D ͺhŶĚĞƌƐƚĂŶĚŝŶŐͺ ŝīĞƌĞŶƟĂůͺ ƩĂŝŶŵĞŶƚ͘ƉĚĨͺϲϯϱϯϯϰϯϭ͘ƉĚĨ ;ϯͿ ŚƩƉƐ͗ͬͬǁǁǁ͘ŐŵĐͲƵŬ͘ŽƌŐͬϮϬϭϲͺϬϰͺϮϴͺ&ĂŝƌWĂƚŚǁĂǇƐ&ŝŶĂůZĞƉŽƌƚ͘ƉĚĨͺϲϲϵϯϵϲϴϱ͘ƉĚĨ

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RECENT CHAPTER ACTIVITY

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Phillipines

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z Ϯ

dŚŝƐ ĞǀĞŶƚ ǁĂƐ ĂƩĞŶĚĞĚ ďǇ ŽǀĞƌ ϯϬϬ ĚĞůĞŐĂƚĞƐ ĂƌŽƵŶĚ /ŶĚŽŶĞƐŝĂ͘ dŚĞ ĞǀĞŶƚ ƐƚĂƌƚĞĚ Žī ǁŝƚŚ ƚŚĞ tĞůĐŽŵŝŶŐ WĂƌƚǇ ǁŚĞƌĞ ĚĞůĞŐĂƚĞƐ ŐŽƚ ƚŽ ŵĞĞƚ ĞĂĐŚ ŽƚŚĞƌ͕ ƐŽŵĞ ŵĞĞƟŶŐ ĨŽƌ ƚŚĞ ĮƌƐƚ ƟŵĞ ĂŶĚ ŽƚŚĞƌƐ ŵĞĞƟŶŐ ŽůĚ ĨƌŝĞŶĚƐ͘

ĂǇ Ϯ ǁĂƐ ŬŶŽǁŶ ĂƐ ƚŚĞ ƐƚƵĚǇ ĚĂǇ ǁŚĞƌĞ ƚŚĞƌĞ ǁĞƌĞ ^ĞŵŝŶĂƌƐ ĂŶĚ ^ŵĂůů ůĂƐƐ dƌĂŝŶŝŶŐ ƐĞƐƐŝŽŶƐ ŚĞůĚ ƚŽ ĞĚƵĐĂƚĞ ĂŶĚ ĂůƐŽ ŚĞůƉ ĚĞůĞŐĂƚĞƐ ƚŽ ƌĞĐĂƉ ŽŶ ŵĞƚŚŽĚƐ ƚŽ ƉƌŽĚƵĐĞ ƚŽƉ ĐůĂƐƐ ƉĂƉĞƌƐ͘ dŚĞ ŶŝŐŚƚ ĞŶĚĞĚ ǁŝƚŚ Ă ƵůŝŶĂƌǇ ƐĞƐƐŝŽŶ ǁŚĞƌĞ ĚĞůĞŐĂƚĞƐ ŚĂĚ ƚŚĞ ŽƉƉŽƌƚƵŶŝƚǇ ƚŽ ƚƌǇ ŽƵƚ ĚŝīĞƌĞŶƚ ĨŽŽĚƐ ĨƌŽŵ :ĂŬĂƌƚĂ͘ ^ŽŵĞ ŽĨ ƚŚĞ ĚĞůĞŐĂƚĞƐ ŽƉƚ ƚŽ ŐĞƚ ƌĞĂĚǇ ĨŽƌ ƚŚĞŝƌ ďŝŐ ĚĂǇ ĂŚĞĂĚ ǁŚŝĐŚ ǁĂƐ ƚŚĞ ŽŵƉĞƟƟŽŶ &ŝŶĂůƐ͘

ɫ ɸ ɧ ɩ ɺ ɯ ɼ ɯ ɺ ɯ ɫ ɹ ̯

ɴɫɹɯɧ

Ɛ dƌĂŝŶŝŶŐ Θ ŽŵƉĞƟƟŽŶ ϮϬϭϴ

z ϯ ĂǇ ϯ ǁĂƐ Ă ďŝŐ ĚĂǇ ĨŽƌ ƚŚĞ ĮŶĂůŝƐƚ ĂƐ ƚŚĞǇ ŚĂĚ ƚŽ ƉƌĞƐĞŶƚ ƚŚĞŝƌ ǁŽƌŬ ŝŶ ĨƌŽŶƚ ŽĨ ƚŚĞ ũƵĚŐĞƐ͘ dŚĞƌĞ ǁĞƌĞ Ă ŚƵŐĞ ƋƵĂŶƟƚǇ ŽĨ ĞǆĐĞůůĞŶƚ ĐƌĞĂƟŽŶƐ ďƵƚ ƚŚĞƌĞ ĐĂŶ ŽŶůǇ ďĞ ŽŶĞ tŝŶŶĞƌ ĨŽƌ ĞĂĐŚ ĐĂƚĞŐŽƌǇ͘ ĂǇ ϯ ĞŶĚĞĚ ǁŝƚŚ Ă &ĂƌĞǁĞůů WĂƌƚǇ ǁŚŝĐŚ ǁĂƐ ĂůƐŽ ĂƩĞŶĚĞĚ ďǇ D^ Ͳ ůƵŵŶŝ ŵĞŵďĞƌƐ͘ &ŝůůĞĚ ǁŝƚŚ ƐĐƌƵŵƉƟŽƵƐ ĨŽŽĚ͕ ƚŚĞ ĚĞůĞŐĂƚĞƐ ƌĞƚƵƌŶĞĚ ďĂĐŬ ƚŽ ƚŚĞ ŚŽƚĞů ƚŽ ƉƌĞƉĂƌĞ ĨŽƌ ƚŚĞ ĮŶĂů ĚĂǇ͘

z ϰ ĂǇ ϰ ĂůƐŽ ŬŶŽǁŶ ĂƐ ƚŚĞ ůĂƐƚ ĚĂǇ ŽĨ ƚŚĞ ĞǀĞŶƚ͘ dŚĞ ĞǀĞŶƚ ĨŽƌ ƚŚŝƐ ĚĂǇ ǁĂƐ ƚŚĞ ^ŽĐŝĂů ĐƟŽŶ ǁŚĞƌĞ ĚĞůĞŐĂƚĞƐ ŚĂĚ ƚŚĞ ĐŚĂŶĐĞ ƚŽ ŐŽ ƚŽ ZƵƐƵŶĂǁĂ WĞƐĂŬŝŚ ĂŶĚ ƚĞĂĐŚ ƚŚĞ ĐŚŝůĚĞŶ ĂďŽƵƚ ƌĞĐǇĐůŝŶŐ ĂŶĚ ďĂƐŝĐ ŚǇŐŝĞŶĞ͘ dŚĞ ĞǀĞŶƚ ĞŶĚĞĚ ǁŝƚŚ Ă ƐĞŶĚͲŽī ĂŶĚ Ăůů ĚĞůĞŐĂƚĞƐ ŵĂĚĞ ƚŚĞŝƌ ǁĂǇ ďĂĐŬ ƚŽ ƚŚĞ ĂŝƌƉŽƌƚ ĂŶĚ ƚŽ ƚŚĞŝƌ ƌĞƐƉĞĐƟǀĞ ĚĞƐƟŶĂƟŽŶƐ͘ ůů ŝŶ Ăůů ƚŚŝƐ ǁĂƐ Ă ŐƌĞĂƚ ĂŶĚ ŵŝŶĚ ďŽŐŐůŝŶŐ ĞǀĞŶƚ ƚŚĂƚ /Ζŵ ƐƵƌĞ ǁĂƐ Ă ŐƌĞĂƚ ĞǆƉĞƌŝĞŶĐĞ ĨŽƌ ƚŚĞ ĚĞůĞŐĂƚĞƐ͘

LIVE LIFE, GIVE LIFE:

ORGAN DONATION AWARENESS & SIGN UP CAMPAIGN LESLEE CRUZ, VAN ALDRIN RAMOS, AND CEZ LESTER REYES

Organ Dona<on is s<ll considered taboo in our country, with only 0.21% out of the 101 million Filipinos listed as donors. That is why last September 21, 2017, AMSA FEU-NRMF held its first ever Organ Dona<on Awareness Conference with the aim of raising awareness about the importance and benefits of deceased organ dona<on and transplanta<on and to address the significant need for organ donors in the country. Different speakers of different backgrounds and special<es were invited to help achieve the said objec<ves. Among them were Dra Benita S Padilla, head of the Human Organ Presenta<on Effort (HOPE), Ms. Marie Feliciano and Ms. Rose>er Balce, RN., both transplant coordinators of the Human Organ Presenta<on Effort (HOPE), Dr. Hermingildo H. Gan, Former President of Philippine Neurological Associa<on, Dr. Francisco E. Sarmiento III, program manager of the Philippine Network for Organ Sharing (PHILNOS)

Dra. Bernardita C. Navarro, treasurer of t h e Eye B a n k Fo u n d a< o n o f t h e Philippines, A>y. Suzy Claire Selleza, Lawyer from Adamson University College of Law, Rev. Fr. Eugene Cagoco, FEU NRMF’s university chaplain, and Dra Linda Tamesis, former chief of clinics and former dean of FEU NRMF, respec<vely.

This event was aênded by 250 1st-3rd year medical students of the university, each having contras<ng opinions and views regarding the topic. They were able to aênd the four hour discussion composed of basic informa<on about organ dona<on such as its advantages and disadvantages, its current sta<s<cs and its legality, the programs currently being implemented to broaden the public’s awareness, as well as the new proposed laws that will help the program be more effec<ve, the different standpoints from the medical, legal and religious point of view, and an open forum wherein students, doctors and speakers were able to clarify some of the issues. Aside from that, an organ donor registra<on booth was opened up which enables the students to become a registered o r g a n d o n o r u n d e r t h e P h i l i p p i n e Department of Health Registry.

â&#x20AC;Š

Overall, the campaign was a success and students lea with a new vantage point about the topic. Jonathan Tawag, a ďŹ rst year student, stated that since this is not commonly discussed in depth in schools, he was able to learn more about this which helped alleviate the s<gma surrounding it. The organizers and the speakers hope that this may serve as a stepping stone in improving the status of organ dona<on in our country. Dr. Jose Rizal once said that one only dies once, and if one does not die well, a good opportunity is lost and will not present itself again, so let us make sure that we live ours meaningfully un<l the very end.

â&#x20AC;Š

page 21 page 7

A M S A U N I V E R S I T Y P R O F I L E â&#x20AC;©

AMSA UNIVERSITAS PEMBANGUNAN NASIONAL A s i a n

M e d i c a l S t u d e n t s ’

A s s o c i a < o n U n i v e r s i t a s Pembangunan Nasional “Veteran” Jakarta, known as AMSA-UPN, is a n o n p r o fi t a n d s c i e n < fi c organiza<on which is affiliated to Badan Ekseku<f Mahasiswa Fakultas Kedokteran Universitas Pembangunan Nasional “Veteran” Jakarta and AMSA-Indonesia.

AMSA-UPN was founded on October 10, 2005 and is currently l o c a t e d i n D r . W a h i d i n S u d i r o h u s o d o B u i l d i n g , U n i v e r s i t a s P e m b a n g u n a n Nasional “Veteran” Jakarta.

â&#x20AC;Š

Currently, AMSA-UPN create events such as: 1. MEDC (Medical English Debate

3. AMSA-UPN Anniversary AMSA-

Club) MEDC is a debate training

UPN has a long history in UPN, and

program for every member of

this annual event is our celebra<on

AMSA-UPN for the purpose of

of the years gone by. It also serves

preparing us for na<onal debate

purpose of <ghtening the bond

compe<<ons in the future.

between members of AMSA-UPN

2. PASTOE (Pass the TOEFL) Being a medical student in a rapidly changing world requires some basic knowledge, one of which is the lingua franca, english. PASTOE is a program for the members of AMSA-UPN designed to train the ability to speak, write, and use english, both for daily and professional use.

and members of AMSA-Indonesia District 2 whom we invite every year.

Upcoming Even 1.

AMSEP Hos<ng AM

4. AMSA-UPN Charity AMSA-UPN

looking forward to host ou

observers are assigned to the task of

AMSEP program. It will b

crea<ng a charity at the end of the

August and we will be excha

tenure before they become full

Taipei Medical University, Ta

members. it reminds us the very

is a precious opportunity

purpose of AMSA: to help people in

elevate ourselves in the

need, even when weâ&#x20AC;&#x2122;re s<ll medical

m a k i n g A M S A - U P N

students.

organiza<on.

MSA-UPN is

AMSA District Gathering In

ur very ﬁrst

this year’s tenure, AMSA-UPN will be

be held in

hos<ng AMSA District Gathering. It is

anging with

an event where member of AMSA

aiwan. This

district 2 can gather and get to know

for us to

each other more. This event will be

hopes of

held in Tidung Island, which is a

a b e ^ e r

tropical island located in North

Jakarta. It will deﬁnitely be a short gateway from our hec<c life as medical students.

â&#x20AC;©

photo graphy

â&#x20AC;©

â&#x20AC;Š Farida Ulfa

17:00 Someone said that a journey begins with a single step. But some<mes it is okay to take a rest, take a deep breath and enjoy every second of your life in your own way.

â&#x20AC;Š Si+ Zakiaturrahmah

ad. It is be^er to fail in originality than to succeed in limita<on.

â&#x20AC;Š

Si+ Zakiaturrahmah

. Take a risk, face it, resolve it, learn from it, tell it

â&#x20AC;Š

Damarja+ Nugroho

6:00 am The feelings when you have to get up in the early morning to catch the sunrise and surrounded by the fog is the best feeling ever.

â&#x20AC;©

WHITE PAPER

â&#x20AC;Š

New Strategies Of Mother-to-Child Transmission Of HBV InfecSon Authors Papitchaya Rongdejpratheep Thanachot Nacharoenkul Nutachat Treerasoradaj Pischaporn Ketkaew

Medical School Faculty of medicine Vajira hospital, Navamindradhiraj university Advisor Chayanee Se^hapramote Busaba Supawat Vajira hospital Special advisor Kuntharee Traisrisilp Muenphinit

â&#x20AC;Š

Prevalence of hepaSSs B virus in Thailand

Chronic hepa<<s B virus (HBV)

infec<on is an important global health problem. According to World Health Organiza<on (WHO) es<mates, more than 240 million people worldwide are chronically infected with HBV. [1] HBV i n f e c < o n c a n c a u s e l i v e r d i s e a s e , i n c l u d i n g l i v e rc i r r h o s i s

u n i v e r s a l H B V v a c c i n a < o n fo r newborns was integrated into the EPI in 1992 (Fig 1). [3] Immuniza<on with HBV vaccine prevents the development of persistent carrier.[1]Although the prevalence in South-East Asia is decreasing, pockets of high endemicity remain in high risk group and migrants from area with high prevalence. [2]

andhepatocellular carcinoma which is the 10th leading cause of death.[2] Nowadays, South-East Asia, especially Thailand, is considered an intermediate to high hepa<<s B endemic area, with prevalence of up to 10%. [2]

In the past Thailand was an area

highly endemic for hepa<<s B virus

Fig 1. The implementa<on of universal HB immuniza<on in 1988-1992. From: Banks, T., and others (2016).

(HBV) infec<on. A na<onal policy led to the ini<a<on of a pilot project to reduce HBV infec<on by incorpora<ng

In 2014, HBV carriers were found

the HBV vaccine into the Expanded

a p p r o x i m a t e l y 3 . 4 8 % o f T h a i

Program on Immuniza<on (EPI),

popula<on, which consisted of

beginning in 1988 in the two provinces

63,954,350 individuals. This represents

of Chaing Mai and Chon Buri. In 1990

approximately 2.2 million people who

the recommended schedule was

are HBsAg carriers(Table 1, Fig 2). [3]

expanded to 12 provinces, and

â&#x20AC;Š

chance is only up to 5%. For this Table 1. The approximate number of HBV carriers by age in Thai popula<on. From: Banks, T., and others (2016)

reason, ver<cal transmission, also called mother-to-child transmission (MTCT), during pregnancy, has been recognized as the most important phase for the preven<on of chronic HBV infec<on.[8]

Mother-to-child transmissions

of HBV infec<on are three possible routes: transplacental transmission ( i n t r a u t e r i n e t r a n s m i s s i o n ) , Fig 2. Es<ma<on of the numbers of HBV carriers in the Thai popula<on. From: Banks, T., and others (2016)

i n t r a p a r t u m t r a n s m i s s i o n a n d p o s t p a r t u m t ra n s m i s s i o n , l i ke b r e a s n e e d i n g . [ 8 ] I n t r a u t e r i n e

Mechanism of transmission of HBV

transmission accounts for only a

Hepa<<s B virus is transmi^ed

minority of cases of HBV transmission.

between people through contact with

In fact, its rate is 3.7% in a sample of

infected blood and body ďŹ&#x201A;uid such as

402 newborn infants of HBsAg-posi<ve

blood transfusion, mother to child

mothers. [9] However, it is considered

transmission, sharing needing, and

to be the most important reason for

sexual transmission. [4] According to

f a i l u r e o f p a s s i v e - a c < v e

previous studies [5,6,7], newborns

immunoprophylaxis in preven<ng

have 90% chance to become chronic

MTCT.[8] This is because some fetuses

carriers aaer infec<on with HBV and, in

that contact HBeAg early in embryonic

children less than 3 years old, the

development become immunologically

chance is up to 50%, but in adults the

tolerant to the an<gen.[10]

Intrapartum transmission is

recognized as the most important route (as high as 34%) of HBV MTCT in the state of nature.[11] Nonetheless, breasneeding is not a risk factor for HBV infec<on for its incidence is very low aaer universal passive-ac<ve immunoprophylaxis for newborns from

FFig3. Vaccina<on program of pediatric infec<ous disease society of Thailand from: h^p:// www.healthcaremedicalclinic.com/pdf/ pdf11.pdf

HBsAg posi<ve mothers. Current policy and current pracScal manual 1. Immunoprophylaxis provided to

immunoprophylaxis process also includes

newborns from non-HBV infected

at least two more doses of HBV vaccine at

mothers

1 month and 6 month aaer birth.[8]

A c co rd i n g to va c c i n a< o n

Combina<on HBIG and at least 3

program of pediatric infec<ous disease

dose of HBV vaccine is more eﬀec<ve in

society of Thailand, infants usually

reducing MTCT than HBIG or the HBV

receive HBV vaccina<on aaer delivery,

vaccine alone. [12]

1 month and 2 month. (Fig3)

HBsAg in pregnancy can be

detected by conﬁrmatory test and rapid 2. Immunoprophylaxis provided to

diagnos<c test. The results demonstrate

newborns from HBV infected mothers

that the current clinical strategy of HBIG

WHO and most guidelines suggested

aaer conﬁrmatory test was not cost

that newborns from HBsAg posi<ve

eﬀec<ve when compared to HBIG aaer

mothers should receive both Hepa<<s

rapid diagnos<c test (RDT).However, HBIG

B v a c c i n e a n d H e p a < < s B

aaer RDT s<ll has several limita<on in this

immunoglobulin (HBIG) within 12

study such as Quality of HBV (poor

hours aaer delivery, and complete

d i a g n o s < c a c c u ra c y ) , H B I G s u p p l y

problems, and home births.[13] Moreover,

include prepragnancy screening, the

the use of tenofovir to reduce ver<cal

treatments for mothers during

transmission of HBV should be considered

pregnancy and eﬀorts for both

due to their improvedeﬃcacy and

newborns and their mothers aaer

poten<al cost beneﬁts.[14]

birth.

3. An<viral prophylaxis with nucleoside/

1. Preven<on HBV infec<on in mother

nucleo<de analogs

According to Thailand Prac<ce

the best way to eliminate HBV-related

Guideline for Management of Chronic

disease. Passiveimmuniza<on using

Hepa<<s B and C 2015, pregnant women

HBIG provides temporary immunity,

with HBV DNA in blood greater than

where as ac<ve immuniza<on, safe

2,000,000 IU/ml have to treat HBV

and eﬀec<ve, by the vaccine yields

infec<on by class B an<viral drugs, that is

long-term immunity.[17,18]

tenofovir, or telbivudine to reduce MTCT of

HBV infec<on in newborns. [15]

such as screening the blood products,

Moreover, mothers with liver

proper steriliza<on of injec<on

underlying diseaseare closely monitored

needles and syringes, and avoidance

the liver func<on test. Those who have

of risky behaviors, such as parental

ac<ve disease or advanced ﬁbrosis should

drug abuse, ta^oo, or skin piercing,

be considered treatment with tenofovir, or

may preclude. Educa<on to avoid

telbivudine.[16]

these high-risk behaviors should be

Suggest new policy Aim: Reduc<on of MTCT of HBV

Preven<on of MTCT of HBV, which

is based on its mechanism, is the best way for reducing MTCT of HBV. The strategies

Preven<on by immuniza<on is

Other preven<on strategies,

advocated in addi<on to vaccina<on. [17,18]

D u e to b i rt h rate f ro m

adolescent mothers, 15-19 year-old mother, in Thailand is approximately 5.38% in a sample of 2,404,152 aldolescent mothers[19], HBV

vaccina<on programs for adolescents can

Conclusion

prevent exposure to HBV by sexual contacts or

other risk behaviors. [17,18]

serious health problem, par<cularly

2. Premarital tes<ng/ Prepregnancy screening

For preparing pregnancy, women should

be counseled and screened for HBsAg by a ﬁnger prick blood sample as screening test.[20] Addi<onal venous blood samples are collected from women with posi<ve screening test for conﬁrmatory HBsAg tes<ng and addi<onal HBV markers.[21]

Prepragnancy screening should be

usually test to reduce MTCT of HBV infec<on, therefore this test should be available, accessible, sensi<ve, speciﬁc, non-invasive and cost-eﬀec<ve.[21] Suggest further research

According to our new policy, advoca<on

of preven<on of MTCT of HBV before pregnancy is the best way to reduce HBV infec<on. For this part, we suggest an interes<ng idea which needs more supported evidences to conﬁrm to be a new policy. Periodical HBIG adminitra<on during pregnancy antenatal HBIG administra<on to the mother on the newborn's serological status, which b e c o m e av a i l a b l e d u r i n g t h e r e c e n t years,seems to reduce MTCT of HBV, as well as

HBV infec<on is the worldwide

South East Asia, like Thailand. HBV infec<on in pregnancy is not only a u n i q u e c h a l l e n ge b u t a l s o a n important opportunity to prevent MTCT of HBV.

The Best preven<on of mother-

to-child transmission of HBV infec<on is preven<on of HBV infec<on in mother by educa<on to women of reproduc<ve age, which are the target group, to avoid high-risk behaviors and get vaccina<on properly.In case of infec<on and carriage, prepregnancy management is considered to reduce viral DNA levelas much as possible during pregnancy.

Antenatal HBIG to the mothers

is interes<ng alterna<ve during the recent years. This reduces MTCT of HBV, as well as preven<ng newborns to hepa<<s B-posi<ve mothers, but s<ll needs future supported evidences.

References [1] A. Goyal, J.M. Murray, The impact of vaccina<on and an<viral therapy onhepa<<s B and hepa<<s D epidemiology, PLoS One 9 (2014) e110143. [2] Banks, T., Kang, J., Wa^s, I., Tyrosvou<s, M., Min, A., Tun, N., Keereecharoen, L., Simmawong, W., Wanya<p, S., Hanboonkunupakarn, B., Nosten, F. and McGready, R. (2016). High hepa<<s B seroprevalence and risk factors for infec<on in pregnant women on the Thailand-Myanmar Border. The Journal of Infec<on in Developing Countries, 10(04), p.384. [3] Posuwan N, Wanlapakorn N, Sa-nguanmooP, Wasi^hankasem R, Vichaiwa^ana P, Klinfueng S,et al. (2016) The Success of a Universal Hepa<<s BImmuniza<on Program as Part of Thailand’s EPI aaer22 Years’ Implementa<on. PLoS ONE 11(3):e0150499. doi:10.1371/journal.pone.0150499. [4] Eke AC, Eleje GU, Eke UA, Xia Y, Liu J. Hepa<<s B immunoglobulin during pregnancy for preven<on of mother-to-child transmission of hepa<<s B virus. Cochrane Database of Systema<c Reviews 2017, Issue 2. Art. No.: CD008545. DOI:10.1002/14651858.CD008545.pub2. [5] D. Lavanchy, Hepa<<s B virus epidemiology, disease burden, treatment, andcurrent and emerging preven<on and control measures, J. Viral. Hepat. 11(2004) 97–107. [6] D. Lavanchy,Worldwide epidemiology of HBV infec<on, disease burden,and vaccine preven<on, J. Clin. Virol. Oﬀ. Publ. Pan Am. Soc. Clin. Virol. 34(Suppl 1) (2005) S1–3.

[7] L. Ma, N.R. Alla, X. Li, O.A. Mynbaev, Z. Shi, Mother-to-child transmission ofHBV: review of current clinical management and preven<on strategies, Rev.Med. Virol. 24 (2014) 396–406. [8] Yi, P., Chen, R., Huang, Y., Zhou, R. and Fan, X. (2016). Management of mother-to-child transmission of hepa<<s B virus: Proposi<ons and challenges. Journal of Clinical Virology, 77, pp.32-39. [9] Borgia, G. and Gen<le, I. (2014). Ver<cal transmission of hepa<<s B virus: challenges and solu<ons. Interna<onal Journal of Women's Health, p.605. [10] Gambarin-Gelwel M. Hepa<<s B in pregnancy. Clinics ofLiver Disease 2007;11:945–63. [11] Degli Espos< S, Shah D. Hepa<<s B in pregnancy: challenges and treatment. Gastroenterol Clin North Am. 2011;40(2):355–372, viii. [12] Wong VC, Ip HM, Reesink HW, et al. Preven<on of the HBsAg carrier state in newborn infants of mothers who are chronic carriers of HBsAg and HBeAg by administra<on of hepa<<s-B vaccine and hepa<<s-B immunoglobulin: doubleblind randomised placebo-controlled study. Lancet 1984; 1: 921–6. [13]Goldstein ST, Zhou F, Hadler SC, Bell BP, Mast EE, Margolis HS. A mathema<cal model to es<mate global hepa<<s B disease burden and vaccina<on impact. Int J Epidemiol. 2005;34(6):1329–39 [14]Thio CL, Guo N, Xie C, Nelson KE, Ehrhardt S. Global elimina<on of motherto-child transmission of hepa<<s B: revisi<ng the current strategy. LancetInfect Dis. 2015;15(8):981–5.

[15] สมาคมโรคตับแห่งประเทศไทย. (2558). Thailand prac<ce guideline for management of chronic Hepa<<s B and C 2015. นนทบุรี .ห้างหุ้นส่วนจำกัด

ภาพพิมพ์. [16] Piratvisuth T. Op<mal management of HBV infec<on during pregnancy. Liver Interna<onal. 2013;33:188-194. [17] Chang M, Chen D. Preven<on of Hepa<<s B. Cold Spring Harbor Perspec<ves in Medicine. 2015;5(3):a021493-a021493. [18] Kwon S, Lee C. Epidemiology and preven<on of hepa<<s B virus infec<on. The Korean Journal of Hepatology. 2011;17(2):87. [19] สํานักงานคณะกรรมการพัฒนาการเศรษฐกิจและสังคมแห่งชาติ (2556). แม่วัย ใสความท้าทายการตั้งครรภ์ในวัยรุ่น. กรุเทพฯ. บริษัทแอดวานส์ปริ้นติ้งจํากัด.

[20] Shivkumar S, Peeling R, Jafari Y, Joseph L, Pai NP. Rapid point-of-care ﬁrstline screening tests for hepa<<s B infec<on: a meta-analysis of diagnos<c accuracy (1980–2010). Am J Gastroenterol. 2012;107: 1306–1313. [21]Chotun N, Preiser W, van Rensburg C, Fernandez P, Theron G, Glebe D et al. Point-of-care screening for hepa<<s B virus infec<on in pregnant women at an antenatal clinic: A South African experience. PLOS ONE. 2017;12(7):e0181267. [22] Shi Z, Li X, Ma L, Yang Y. Hepa<<s B immunoglobulin injec<on in pregnancy to interrupt hepa<<s B virus mother-to-child transmission: a meta-analysis. Interna<onal Journal of Infec<ous Diseases 2010; 14(7): e622-e634. [PubMed]

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[23] Devine A, Harvey R, Min A, Gilder M, Paw M, Kang J et al. Strategies for the preven<on of perinatal hepa<<s B transmission in a marginalized popula<on on the Thailand-Myanmar border: a cost-eďŹ&#x20AC;ec<veness analysis. BMC Infec<ous Diseases. 2017;17(1). [24] United Na<on Childrens' Fund. Situa<on analysis of adolescent pregnancy in Thailand. November 15, 2017. (2015). [25] Iloeje, U., Yang, H., Jen, C., Su, J., Wang, L., You, S. and Chen, C. (2017). Risk and Predictors of Mortality Associated With Chronic Hepa<<s B Infec<on. [26] Dunkelberg, J., Berkley, E., Thiel, K. and Leslie, K. (2014). Hepa<<s B and C in pregnancy: a review and recommenda<ons for care. Journal of Perinatology, 34(12), pp.882-891.

Appendix Appendix A This graph shows cost-eﬀec<veness plane with vaccine only as the base case comparator for infec<ons averted. The cohort costs represent US$21,673.15 for the vaccine only strategy, US$40,533.86 for the HBIG aaer conﬁrmatory test and US$47,477.10 for the HBIG aaer RDT strategy. [23]

Fig 4. cost-eﬀec<veness plane From: Angela D., and others. (2017)

Appendix B This graph shows the trends in the propor<on of births among adolescents by region from 2004 to 2013. The regions featured in the trend comparison include Bangkok, the Central Region, the Northern Region, the Northeastern Region, and the Southern Region. Mul<ple regions show a pa^ern of increasing propor<ons of births to adolescent mothers aged 10-19 between 2004 and 2012. [24]

Fig 5. The propor<on of births among adolescents From: h^ps://www.unicef.org/thailand/ 160614_SAAP_in_Thailand_report_EN.pdf

Appendix C This table shows the HBsAg-posi<ve subjects had an adjusted all-cause mortality risk that was 1.7 <mes greater than for HBsAg-nega<ve subjects. HBsAg-posi<ve individuals were at a signiﬁcantly greater risk of mortality from liver cancer and chronic liver disease and cirrhosis than HBsAg-nega<ve individuals. [25]

Table2. Risks of Total Mortality and Cause-Speciﬁc Mortali<es From: Iloeje, U., and others. (2017) Appendix D This table shows immunoprophylaxis of neonates with HBIG + HBV vaccine is superior to monotherapy with either agent alone for preven<on of MTCT of HBV infec<on. [26]

Table 3. The percentage of HBV infec<on in neonates via MTCT. From: Dunkelberg, J., and others. (2014).

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Appendix E This table shows European Associa<on for Study of the Liver (EASL) recommenda<on for an<viral therapy for HBV-infected women who desire pregnancy.[26]

Table 4. Management for mother with liver underlying disease From: Dunkelberg, J., and others. (2014). Appendix F This table shows prevalence of HBV infected inVajira hospital from 2012 to 2016. The HBsAg posi<ve pregnant women are accounted for 2.21% of all pregnant women who came to Vajira hospital. Year Pregnant women who have HBsAg positive Total number of pregnant women

2012

2013

2014

2015

2016

3114

2634

2539

2524

2371

Table 5. Prevalence of HBV infected pregnant women. Appendix G This table shows the number of couples who got prepregnancy counseling in Vajira hospital compared with all pregnant women who came to Vajira hospital. This data was collected from 2012 to 2016. Year Couples who have prepregnancy counseling Total number of pregnant women

2012

2013

2014

2015

2016

186

201

198

122

129

3114

2634

2539

2524

2317

Table 6.The number of couples who got the prepregnancy counselingin Vajira hospital

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Taiwan Tainan City

Maternal and Neonatal Health: Dealing with Adolescent Pregnancy

Authors Po-Chin Kuo, Ying-Yu Wang

lNaSonal Cheng Kung University

IntroducSon: The Consequences of

quite similar to those of previous studies.

Adolescent Pregnancy

The birth outcomes of the youngest group were signiﬁcantly poorer than the others

Adolescent pregnancy is an important

(Table 1).

issue for several reasons.

First, adolescent pregnancy

i n c re a s e d r i s k o f s u ﬀe r i n g f ro m

aﬀects teenagers physically. According to

depression, isola<on and sense of

sta<s<cs in the US, over a quarter of

loneliness.(5) A research found that girls

pregnant teens choose abor<on to get

ranging from 15 to 19 experienced

rid of their hardships. Adolescent

postpartum depression at a rate twice as

p re g n a n c y a l s o i m p o s e s s e ve ra l

high as women aged 25 and older(6).

pregnancy complexi<es such as anemia,

hypertension, and placenta previa(1)(2).

Na<onal Campaign to Prevent Teen and

Reported by WHO, these complica<ons

Unplanned Pregnancy of the U.S., about

are the second cause of death for 15-19

one fourth of pregnant teenagers drop

year-old girls globally(3). Reported in

out of school, and only 51 percent earn a

m a ny st u d i e s , c h i l d re n b o r n to

high school diploma compared to 89

adolescent mothers also have higher rate

percent of female students who did not

of premature birth, low birth weight, and

give birth as a teen. Thus, they oaen

other adverse birth outcomes(4). The

d o n ’ t co m p l ete h i g h e r l eve l s o f

authors also conducted an analysis on

educa<on, limi<ng their income over

this phenomenon. We extracted data

<me.

from a computer database on deliveries

or fetal extrac<ons during a 3-year period

only an intra-genera<on issue. The

between January 2014 and December

children of teenage mothers are more

2016 at Na<onal Cheng Kung Hospital. A

likely to have lower school achievement

total of 3967 women were included in

and to quit school, have more health

this study. Our results shown below were

problems, be incarcerated at some <me

Next, teenage mothers have

Furthermore, according to the

Yet, adolescent pregnancy is not

d u r i n g a d o l e s c e n c e , a n d f a c e

Current status of Taiwan

unemployment(7). Addi<onally, girls born

to teenage mothers are more likely to

adolescent pregnancy in Taiwan is up to

become teen mothers themselves(8).

12.95‰, higher than 4‰ in Japan, 2.8‰

Last but not least, looking at this

in Korea, and 8‰ in Singapore, which

i s s u e f ro m a h i g h e r l eve l , te e n

implies the importance of this issue

childbearing in the US cost taxpayers at

(Figure 1). That is, an adolescent

least $9.4 billion in 2010, according to an

pregnancy occurs in every two hours just

analysis by The Na<onal Campaign. Most

beside us. Following up teenage girls who

of the costs are associated with nega<ve

became pregnant in Taiwan in 2015, 22%

consequences for the children of teen

of them drop out of school, which implies

mothers, including health care, foster

that adolescent pregnancy has had a

care, incarcera<on, and lost tax revenue.

severe impact on young mothers. What’s

This implies that adolescent

more, comparing the fer<lity rates of

pregnancy is not only a ma^er of oneself,

teenage girls of diﬀerent regions in

but an issue related to maternal and

Taiwan in 2016, the rate in eastern

neonatal health and also every one of us.

Taiwan is almost 2 <mes higher than the

Thus, confron<ng this problem is cri<cal

average rate (Figure 2). Therefore,

and essen<al at this ma^er of point.

resources, sex educa<on and so on must

According to sta<s<cs of 2012,

be unequal from regions to regions apparently.

Table 1. Perinatal outcomes by maternal age. Data are presented as mean ± standard Fig. 1. Adolescent pregnancy rate in Asian devia<on or %. *, one-way ANOVA. developed countries.

Thus, we hope that by coming up with innova<ve ideas, this issue can be well addressed, not only to promote wellbeings of adolescents, but also future genera<ons.

Fig. 2. Adolescent pregnancy rate in diﬀerent regions of Taiwan. Now, let’s focus on policies that have been implemented in Taiwan. First of all, in several health centers, health professionals provide “Teens’ 9 Outpa<ent Service” for adolescents from 10 to 19, and also pregnant women under 24. The service includes health checks, medical treatments and physical and mental consulta<on. Secondly, to promote safe sex among students, a number of universi<es have set

Fig. 3. Fer<lity rate of 15-19 years old girls in Taiwan in the past decade.

Since the polices proposed by

the government do not seem eﬀec<ve, we decided to inves<gate the reasons within. Thus, we conducted a survey among 1550 people (male 27.1%, female 72.9%

15-18yrs 16.3%,

up condom-vending machines on campus.

19-22yrs 62.4%, 23yrs and above

Besides, Health Promo<on Administra<on

21.3%). Surprisingly, 52.8% of subjects

has set up an e-learning website regarding

don’t know the fact that there are

sexual educa<on. Ministry of the Interior

condom-vending machines on campus

has also set up a dedicated phone number

(Figure 4). Moreover, 65.6% have never

(0800-257085) for adolescent pregnancy

heard of any services regarding

consulta<on. However, in spite of these

adolescent pregnancy provided by the

services, which has already been provided

government (Figure 5). We infer that

for a decade, there is no obvious decrease in

low u<lity rate is the main reason why

fer<lity rate of teenage girls (Figure3).

the fer<lity rate of teenage girls has

remained the same for the past decade.

Proposed Policies

Consequently, we are willing to propose

several new policies to tackle this

would want to achieve through our

problem.

proposed policy, one is to reduce the

There are two main goals we

rate of adolescent pregnancy, and the other is to improve consequences of adolescent pregnancy, including birth o u t c o m e , e c o n o m i c a n d s o c i a l condi<ons, and so on. Our proposed policies are divided into four aspects, family, hospital, government and school. For family: Fig. 4. Percentage of students who have heard of condom-vending machines in universi<es.

Family is the root of everyone,

not to men<on its role in sex educa<on. Surprisingly, according to our survey, 59.3% of subjects have “never” talked to their family members about sex, and 32.2% of them “seldom” do so (Fig. 6). Inves<ga<ng in “who” people have talked about sex to, our survey showed that 76.7% of subjects have talked to friends, 63.6% to their boyfriend/ girlfriend, 30.4% to internet friends, while only 25.5% to parents, which is unexpectedly fewer than internet

Fig. 5. Percentage of students who have heard of services regarding adolescent pregnancy provided by the government. (The sum of the total percentage is over 100% due to the design of mul<-select ques<on.)

friends (Fig. 7). Therefore, we should put emphasis on the educa<ng role of family.

Firstly, schools can assign

interac<ve homework, which should be completed by both students and parents together. This interac<ve assignment includes several missions, for example, “sex Fig. 6. Percentage of subjects who have talked about sex to family members.

talk” enables parents to understand the thoughts of their kids and provides a chance to educate teens with correct concepts; “situa<onal ques<ons” s<mulate teens to imagine situa<ons they may be involved in, and opinion exchanging e n a b l e s p a re nt s to re a c h a consensus with their kids.

Furthermore, lectures for

Fig. 7. Percentage of subjects who have talked about sex to diﬀerent characters. (The sum of the total percentage is over 100% due to the design of mul<-select ques<on.)

parents are equally important. We

For schools:

invite the professionals to deliver

lectures about how to educate kids

that students who confront adolescent

regarding sex. Lectures remind

pregnancy don’t know who and where to ask

parents of being concerned with

for help, and then keep escaping the reality,

who their children are associated

leading to unplanned pregnancy then adverse

t o , a n d g r a s p i n g t e e n s ’

birth outcome.

whereabouts in the daily life.

Holding lectures together with

“mobile medical truck”, oﬀering consulta<on

parent-teacher conferences must be

for teenage students of every school in a

a good strategy for parents to

rou<ne. “Every student of every school” gets

par<cipate in.

a chance to be involved because we don’t

According to our survey, we can infer

Consequently, ﬁrst we propose a

want to miss any poten<al cases.

On the truck, a student and healthcare

shortcomings. According to our survey,

professionals will be doing Q&A,

only 47.4% know there are condom-

regarding physical and mental problems

vending machines on campus, and some

students are faced with. However, there

said, “It is almost impossible of u<lizing

will be a curtain between the student

condom-vending machines on campus

and healthcare providers, to keep

because no one wants to be gossiped

students anonymous. With full privacy

about.” To improve its eﬃciency and

and mutual trust, students must be

u<lity, we design vending machines

much more willing to talk about their

combining condoms, test kits with food

worries. In this way, poten<ally

and drinks. In this way, poten<al

pregnant teenage students are able to

customers can purchase without

receive immediate assistance and

concern. If possible, we hope to make

sugges<ons when they feel disoriented,

the “all-in-one vending machine”

and healthcare professionals on the

prevalent, not only in “every university”,

truck can also make referrals for them

but also in public areas of rural places

to other healthcare centers such as

where condoms are not so accessible.

“ Te e n s ’ 9 O u t p a < e n t S e r v i c e ”

men<oned earlier. In addi<on, this is as

a “baby-si ng program”. Encouraging

w e l l a n e ﬀ e c < v e w a y f o r t h e

teens to have baby-si ng experience is

government and school nurses to track

a means for them to understand that

condi<ons of each school, and even

caring for a baby is not an easy task. It

follow up every case.

requires responsibility, economic

Next, we want to set up “all-in-

support, and much more which may

one vending machines”, which sell

bring huge impacts to life. Being

products including condoms, free test

conscious of the burdens to be loaded,

kits, and also food and drinks, on every

sexually ac<ve teens will deﬁnitely be

campus. Although the government has

more careful.

set up condom-vending machines in a f e w s c h o o l s , t h e r e a r e s o m e

Besides, we would like to design

Finally, we hope to rearrange

Furthermore, pop up of sexually

t h e s e x- e d u c a < o n c u r r i c u l u m .

educa<onal websites before entering

Educa<on is the most basic means of

porn web pages can be useful. Pop ups

eradica<ng unsafe sex. Currently,

appearing at cri<cal moments can

students do not receive complete sex

strengthen the concept of safe sex

e d u c a < o n . B o t h c o n t ra c e p < v e

which are normally not elaborated in

techniques and sexual abs<nence

porn websites and videos. Possibly, pop

should be taught thoroughly, to make

ups of educa<onal websites can reduce

st u d e nt s we l l - p re p a re d b efo re

the probabili<es of viewing porn

involving in sexual rela<onships. If

websites.

rela<ve curriculums can start from

primary schools, we believe that the

we suppose that supervising Internet

adolescent pregnancy rate can

p o r n o g r a p h y s h o u l d b e t h e

decrease in near future.

responsibility of the government.

From the viewpoint of a ci<zen,

Hence, the government should provide For government:

teenagers with a carefree Internet

environment.

The ﬁrst point to men<on is

free installment of Internet guardians for families with teenagers. Many

For hospitals:

sexual informa<on on the Internet are

incorrect and not yet appropriate for

teens-specialized outpa<ent service.

teens to consume at their age. Thus,

Among healthcare centers which

internet guardians is an eﬃcient

provide “Teens’ 9” currently, almost 50%

method to block teenagers from

of them are in major hospitals. However,

viewing improper content before they

it is inconvenient for students from

are physically prepared for sex and

remote areas, which may reduce their

mentally mature to dis<nguish

desire of going for consulta<on.

between good and bad.

First of all, we want to improve

Thus, prevalence of teens-specialized

Conclusion & PromoSon of Our

outpa<ent service should be raised to at

Policies

least 1-district-1-service, for instance.

Next, we propose “full-scale

Without eﬃcient promo<on, it

prenatal care”. We infer that adverse

would be a waste of both government

birth outcomes of adolescent pregnancy

services and our well-designed policies.

are not only because of maternal

In order to target people of diﬀerent

physical condi<on, but also result from

ages, we propose various means to

economic and social factors. Lack of

promote these resources.

ﬁ n a n c i a l s u p p o r t m a k e s t e e n s

unavailable to go for regular prenatal

we suppose that educa<on, Facebook

visits, resul<ng in worse birth outcome,

a d v e r < s e m e n t a n d c e l e b r i t y

including low birth weight, low Apgar

endorsement are possible methods to

score, and preterm birth men<oned

ins<ll correct no<ons.

above. Therefore, we encourage

h o s p i t a l s t o p r o v i d e p r e n a t a l

“Educa<on is the most powerful

examina<ons at a lower price for

knowledge which you can use to

teenage mother-to-be. Also, we

change the world.” It would be cliché to

introduce the 1-mom-1-case manager

e m p h a s i z e t h e i m p o r t a n c e o f

system. Each mother is assigned a case

educa<on, yet there’s no denying that

manager to assist her during the whole

educa<on is the most fundamental way

period of pregnancy. A case manager can

to change the mindset of people. Thus,

not only remind pregnant teenage girls

we think that sexual knowledge should

of rou<ne prenatal checks, but also

be taught at a younger age in school

follow up infants’ social condi<ons

nowadays, since teens as young as 13

consequently, just in case that more help

are reported on the news to get

or referral is needed.

pregnant. Also, sexual educa<on

For teenagers and young adults,

Nelson Mandela once quoted,

lessons should be listed in the curriculum and carried out thoroughly.

Facebook is now the most

on parent-teacher mee<ngs. Through

popular social networking site in the

informa<on provided by professionals,

world. According to ﬁgures provided in

parents can get a clearer view on how

Wikipedia, Facebook has more than 2

to approach their oﬀspring with this

billion monthly ac<ve users as of June

issue.

2017. By targe<ng teenagers through

their proﬁle, educa<onal sexual

with adequate methods of promo<on,

knowledge could occasionally pop up

the resources provided by government

where adver<sement used to occupy.

and polices raised by us can be widely

With the help of Internet, we are sure

known by majority of the popula<on.

that teenagers in school and those who have dropped out of school can get hold of sexual knowledge they would need to know.

Celebrity endorsement is also a

widely-used method in the adver<sing ﬁeld. Yet, it has seldom been applied in the ﬁeld of sex educa<on. We believe that if celebri<es could record clips regarding safe sex and resources provided to pregnant teenagers, youngsters would be much more interested.

As for parents and other seniors,

we believe that posters, brochures and Line, the mobile messaging app, are eﬀec<ve ways to approach them. Posters and brochures about techniques on how to talk about sex with children could be put up on school bulle<ns or handed out

All in all, we ﬁrmly believe that

References (APA style) (1)

Chantrapanichkul P. & Chawanpaiboon S. (2013). Adverse pregnancy

outcomes in cases involving extremely young maternal age. Int J Gynaecol Obstet, 120(2), 160-4. (2)

Aviram A., Raban O., Melamed N., Hadar E., Wiznitzer A.& Yogev Y.

(2013). The associa<on between young maternal age and pregnancy outcome. J Matern Fetal Neonatal Med, 26(15),1554-8. (3)

Department of maternal, newborn, child and adolescent health (MCA),

World Health Organiza<on, Progress report 2014-15. (4)

Kuo CP., Lee SH., Wu WY., Liao WC., Lin SJ. & Lee MC. (2010). Birth

outcomes and risk factors in adolescent pregnancies—results of a Taiwanese na<onal survey. Pediatr Int., 52(3), 447–52. (5)

Hodgkinson S., Colantuoni E., Roberts D., Berg-Cross L. & Belcher H.

(2010). Depressive Symptoms and Birth Outcomes among Pregnant Teenagers. J Pediatr Adolesc Gynecol, 23(1), 16–22. (6)

Kingston D., Heaman M., Fell D. & Chalmers B. (2012). Comparison of

Adolescent, Young Adult, and Adult Women’s Maternity Experiences and Prac<ces. Pediatrics, 129(5). (7)

Hoﬀman SD. (2008). Kids Having Kids: Economic Costs and Social

Consequences of Teen Pregnancy. The Urban Ins+tute Press. (8)

Cook S. & Cameron S. (2015). Social issues of teenage pregnancy.

Obstetrics, Gynaecology & Reproduc+ve Medicine. 25(9), 243-8.

â&#x20AC;©

White Paper Context

Peking Union Medical College West China School of Medicine, Sichuan University Regional Chairperson Ding Yingjing

+86 15921430345& zzh20120156@gmail.com Authors: (In alphabeScal order)

He Ruixin(+86 13258104356&heruixin1996@qq.com) Li Yingna(+86 18215620708&yingnali0408@gmail.com) Liu Jianghao(+86 18813062500&liu-jh14@mails.tsinghua.edu.cn) Wan Ruoyu (+86 18328084750&scuwry@gmail.com) Wang Haoyuan(+86 13060060375&1052640540@qq.com)

Table of Contents

To decelerate this trend, China

1. Current Condi<on of the Maternal and

Community Party's Central Commi^ee

Neonatal Popula<on aaer “Two-Child

declared to end one-child policy and

Policy” in China

launch two-child policy in October,

2. Sugges<ons on the Policies about Maternal and Neonatal Health

2015. Under the new policy, married couples will be allowed not one, but

3. Expected Eﬀects of the Policies

two children.

4. Appendix A: Data and Graphs

Aaer two-child policy came into eﬀect,

5. Appendix B: Reference Materials

a total of 17.86 million babies were born in 2016, an increase of 1.31

1. Current Status of the Maternal and

million over that in 2015. [1] The new

Neonatal PopulaSon aber “Two-Child

total represents the highest annual

Policy” in China

number of newborns since 2000,

China’s one-child policy, ﬁrst

according to government data. This

introduced in 1979, had been carried out

drama<c increase in births gives rise

for more than thirty years and caused a

to severe shortage of pediatricians in

sharp downturn in the fer<lity rate from a

China. According to China’s Na<onal

peak of about six births per woman from

Planning and Family Commission,

1960 to 1965. That number had cratered to

there is less than one pediatrician for

about 1.5 births per woman from 1995 to

every 2,000 children in China in

2014. However, the policy also led to

average. But in the U.S., the same

severe shrink of China’s workforce. In 2014,

number of children share three

the poten<al workforce fell by 3.71 million.

doctors. China has 220 million children

At the same <me, the popula<on over sixty

under 14. If China wants to match the

is exploding. According to U.N. projec<ons,

U . S . r a < o , a n o t h e r 2 0 0 , 0 0 0

it is expected to be doubled by 2050. China

pediatricians will be needed.

is growing old before it grows rich, and the

strains on China’s nascent pension

women are rushing to have children

programs will be enormous.

aaer China ushered in the two-child

At the same <me, Chinese

era. A large part of them are aged

2. Proposed Policies about Maternal

between 35 and 45. They missed the

and Neonatal Health

best age for pregnancy because of one-

2.1 Set up pediatric and obstetric

child policy but s<ll hope to have a

bachelor degrees

second child. However, women who

postpone childbearing do face some

c o n d i < o n o f C h i n e s e m e d i c a l

special risks, including: infer<lity and

educa<on that a medical student has

miscarriage, premature delivery and

to take more than ten years to get his

s<llbirth, gesta<onal diabetes, bleeding

PhD and even more years to become a

complica<ons, etc. As a result, China

qualiﬁed doctor, fewer students

also calls for more experienced

choose to major in clinical medicine.

obstetricians to cope with the

Besides, the medical environment is

problems. In 2015, The State Council

not so well, especially pediatrics. As

announced a ﬁve-year health plan that

children are the kernel of tradi<onal

a i m s t o i n c r e a s e a v e ra g e l i fe

family, parents some<mes can be a

expectancy by one year to 77.3 years

li^le overprotec<ve, which means

by the end of 2020. [2] The plan said

pediatricians are more likely to meet

China would need to employ an extra

with doctor-pa<ent disputes. [3]

140,000 obstetricians and midwives to

meet the rising demand aaer the country scrapped its one-child policy.

C o n s i d e r i n g t h e c u r r e n t

Set up pediatric and obstetric bachelor degrees.

Add pediatrics and obstetric

However, China fails to recruit all

r e l a t e d c o u r s e s t o t h e i r

obstetricians required by far.

curriculum system on the basis of basic clinical courses, such as anatomy, physiology. λ

P ro v i d e m o re c h a n c e s fo r students to get internship in pediatric and obstetric hospitals.

2 . 2 I n c r e a s e i n c o m e o f

paediatricians

Formulate proper service price of paediatricians

Basically, major income of

Chinese doctors consists of two

2.3 Correct media opinion

parts: the fundamental salary and

2.3.1 New Media

bonus. There is li^le diﬀerence in

the former part across the whole

websites, WeChat, blog and so on. They

na<on, whereas the la^er part

share characteris<cs listed as below: born

varies greatly according to several

in 21st century; owning more and more

aspects among which departmental

users, most of whom are young. There

d i ﬀe re n< a< o n ca n n eve r b e

are 889 million ac<ve users of WeChat

neglected. Chinese pediatricians

un<l 2016, 85% of whom are in age range

earn less below the average salary

of 18-35. [5] Undoubtedly, most people

of doctors,with heavier working

aged 18-35 are using WeChat, and they

load and pressure above the

are exactly pre-mothers and pre-fathers

average. [4] Compared with other

in coming 10 years, thus propaganda

na<ons across the whole world,

among them is extremely powerful.

income of Chinese pediatricians is

New media here refers to

Provide symptoms for self-limited

r e l a < v e l y l o w e r t h a n m a n y

diseases and diseases which must be

countries, considering purchasing

treated in hospital.

power parity and average wages,

Chinese government has been implemen<ng diﬀerent ac<va<ng

symptoms oaen asked. λ

policies in order to s<mulate the development of pediatricians in China. λ

Establish perfect distribu<on policy of healthcare industry steadily and increase the basic

Urge for parents` a^en<on on Start online appointments via WeChat or oﬃcial websites.

Push <ps of health care daily to WeChat users.

2.3.2 TradiSonal Media

Reciprocally, tradi<onal media

here refers to newspaper, television,

Add more professional reports within common understanding.

While repor<ng conﬂic<on

radio, and so on. They share common

among pa<ents and doctors, be

characteris<cs listed as below: exis<ng

righteous.

for at least 20 years; owning

While repor<ng na<onal policies

decreasing users, most of whom are

( s u c h a s i n c r e a s i n g i n

middle aged or elder people. All

pediatrician enrollment), be

tradi<onal media is suﬀering a sharp

more detailed.

running oﬀ of readers. Regular readers of newspaper drops from 70%

2.4 Improve clinic environment

(in 2011) to less than 40% (in 2016).

2.4.1 Maintain treatment order:

[6]As

for contents, we carried out a

research on medical or health relevant contents in major newspaper from 6

Dispatch staﬀ members to guide the pa<ents.

A l l ow l i m i te d n u m b e rs o f

diﬀerent ci<es, covering both

pa<ents and family members to

developed and developing areas in

enter.

China. According to our results,

among all news, there is only 1

Recruit social and student volunteers.

professional report concerning

2.4.2 Facility improvement:

hyperglycemia in puerpera, with

several adver<sements and <ps on health care. λ

Try to delete adver<sements while proﬁts can be maintained.

Tips on health care now mainly cover elders, thus try to add some <ps for newborns and pregnant mothers.

A d a p t h o s p i t a l ex p a n d i n g project.

Improve hospitals’ interior environment.

2.4.3 Ensure raSonalized scheduling

3. Expected Eﬀects of the Policies

& TransparenSze assessment system

3.1 Set up pediatric bachelor degree

3 . 1 . 1 . I n c r e a s e t h e a m o u n t o f

Workload coordina<on of

expert clinic and general outpa<ent

pediatricians.

service. The fairness of night shia

s c h e d u l i n g i n o u t p a< e nt a n d

degree means students can spend less

emergency departments problems

<me than they used to to be a qualiﬁed

a r e i m p o r t a n t i n h o s p i t a l s ’

doctor. On one hand, this could be

management . Nowadays ﬂexible

a^rac<ve to some students who want to

scheduling system are s<ll using in

major in clinical medicine but cannot

most child clinics, leaving li^le

aﬀord so much <me and money. On the

assured private relaxing <me for

other hand, with this policy adopted, we

especially pediatricians.

[7]

Majoring in pediatric bachelor

What’s

need less <me to cul<vate a qualiﬁed

more, workload assessment between

pediatrician, which can also alleviate the

diﬀerent physicians and diﬀerent

emergence caused by deﬁciency of

majors is not fair in almost all

pediatricians. [8]

hospitals.

3 . 1 . 2 . C u l S v a t e h i g h - q u a l i ﬁ e d

Adapt ﬁxed scheduling instead

paediatricians

of ﬂexible scheduling

Set up a limit for scien<ﬁc paper’s contribu<on in assessment system (such as at most one paper every three years can be considered into assessment and promo<on, others can only be regarded as personal research) S e t u p r i s k p r e v e n < o n

medical students can spend more <me

mechanism for pediatricians λ

Security staﬀ

Surveillance camera facility

Majoring in pediatricians means

on pediatrics, indica<ng that they can command the clinical skills required in pediatrics beêr than students who get the chance to learn specific knowledge on their postgraduate stage. Once medical students have confirmed their goals, the alloca<on of their <me will be targeted. In other words, medical students can clearly know what kind of

problems they might meet and try to

3.2.2 Reduce “grey income”, improve

solve these problem more ac<vely. So,

overall image

there is no doubt that they'll be be^er-

prepared for their future working

policy and the rela<vely fair salary, it

environment than normal medical

will be much more possible to

students. [9] Moreover, their ability to

eliminate some nega<ve phenomena

handle diﬀerent kinds of doctor-

for medical industry, receiving extra

pa<ents disputes appropriately with

money from pa<ents included. It is

accumulated experience and crea<ng a

quite important for Chinese society

b e ^ e r m e d i c a l e n v i r o n m e n t i s

nowadays, when a harmonious

predictable.

doctor-pa<ent rela<onship is expected

With the standardized income

urgently. [10] 3.2 Increase income of pediatricians 3.2.1 Standardize the distribuSon

3.3 Correct media opinion

policy of healthcare industry

3.3.1 New Media

T h e m a i n r e a s o n b e h i n d

C o n t r o l l i n g n u m b e r o f

departmental imbalance of medical

pa<ents, releasing pressure for

industry in China lies in the bonus.

doctors, including pediatricians.

S o m e d e p a r t m e n t s , i n c l u d i n g

Children oaen crying rather than

pediatricians, are less likely to maintain

answering doctors` ques<ons, <me of

without outer investment due to its

asking reduced due to parents` pre-

property, not to men<on gaining proﬁts.

a^en<on, also reducing possibility for

Therefore, it is no wonder these doctors

children to lie (key reason for invalid

cannot receive a considerable bonus,

treatment). Se ng encouragement

regardless the fact that they are

for doctors` well-designed <me

deﬁnitely under great pressure. Thus,

schedule, to reduce <me-was<ng.

upliaing the level of fundamental salary

Establishing special columns, to oﬀer

is essen<al in ensuring the reasonable

access to basic knowledge on

income of paediatricians.

newborns and moms for the public regularly.

3.3.2 TradiSonal Media

Reducing some misleading and

unprofessional informa<on. If any informa<on is found to be false, criminal responsibility shall be i nve s< gate d a n d d e a l t w i t h i n accordance with the law. Establishing special columns, to offer access to basic knowledge on newborns and moms for the public regularly. Erec<ng a beêr impression of doctors. All nega<ve news on doctors must be examined before publishing. Enlarging effects of na<onal policies, such as pediatrician enrollment. As the same, all nega<ve news on such policies must be examined before publishing. Appendix A: Data and Graphs

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Table 1 Demand for Pediatricians in Each Province (Municipality, Autonomous Region), 2016-2020

Note: East China includes Beijing, Tianjin, Hebei, Liaoning, Shanghai, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong and Hainan, with a total number of 11 provinces (municipality); Middle China includes Shanxi, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei and Hunan, with a total number of 8 provinces; West China includes Inner Mongolia, Chongqing, Guangxi, Sichuan, Guizhou, Yunnan, Tibet, Shaanxi, Gansu, Qinghai, Ningxia and Xinjiang, with a total number of 12 provinces (municipality, autonomous region).

Table 2 Insuﬃciency of Pediatricians in Each Province (Municipality,

Autonomous Region), 2016-2020

Note: There are differences between predic<ve formulas for countrywide and provincial (municipality`s, autonomous region`s) popula<on. During calcula<ng countrywide number of married women, number of women in different age ranges and ra<o of women in different age ranges are used. But during calcula<ng provincial (municipality`s, autonomous region`s) number of married women, formula “number of married women aged above 15 * countryside number of married women aged between 20 and 44 / countryside number of married women aged above 15” is used. Thus, sum of provincial (municipality`s, autonomous region`s) demands for pediatricians doesn`t perfectly match countryside demand for pediatricians.

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Table 3 RaSo of Supply and Demand for Pediatricians in Each Province (Municipality, Autonomous Region), 2016-2020

Table 4 2016 to 2020 Current status and needs of obstetric beds in China and other provinces (autonomous regions and municipaliSes)

Note: According to the number of obstetric beds in China and provinces (districts and municipali<es) in 2013, the gap between supply and demand was calculated (Table 3, table 4). From 2016 to 2020, there were about 73478 ~ 99004 obstetric beds in China to cope with the birth peak(supply / demand ra<o 0.76 ~ 0.81), the exis<ng obstetric bed number cannot meet the " two child" policy requirements. Among them, the number of obstetric beds needed to be reallocated in the central region is the largest, followed by the eastern region, the central region is mainly reﬂected in the absolute value of maternity beds inadequate, while the eastern part of the region is mainly shown as a shortage of high-quality resources (structural shortage). Speciﬁc provinces (regions, municipali<es), Hebei, Jiangsu, Anhui, Jiangxi, Henan, Hubei, Hunan, Canton

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Table 4 2016 to 2020 Current status and needs of obstetric beds in China and other provinces (autonomous regions and municipaliSes)

Appendix B: Reference Mate10 References [1] Report on WeChat Users & Environment, 2017 [2] Data from CVSC-TNS RESEARCH [3] See appendix file Newspaper Research on 6 Different Ci<es [4]28th, Jan. 2016 of the Xinhua News Agency [5] Hvistendahl M (2010) Has China Outgrown The One-Child Policy?Science329: 1458–1461. [6] Hvistendahl M (2010) Demography. Of popula<on projec<ons and projec<les. Science 329: 1460. [7] Ding QJ, Hesketh T (2006) Family size, fer<lity preferences, and sex ra<o in China in the era of the one child family policy: results from na<onal family planning and reproduc<ve health survey. Bri<sh Medical Journal 333: 371–373. [8] Hesketh T, Lu L, Xing ZW (2005) The effect of China’s one-child family policy aaer 25 years. N Engl J Med 353: 1171–1176. [9] McMichael AJ (2004) Environmental and social influences on emerging infec<ous diseases: past, present and future. Philosophical Transac<ons of theRoyal Society of London Series B-Biological Sciences 359: 1049–1058. [10] Bedford T, Cobey S, Beerli P, Pascual M (2010) Global Migra<on Dynamics Underlie Evolu<on and Persistence of Human Influenza A (H3N2). Plos Pathogens 6.

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