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Biology Cathy Walton

Factors affecting the emergence of mosquito-borne zoonotic viruses: using dengue and chikungunya as case studies: a portfolio.

Contents Page

Introduction

Biological Science Review Context Piece Feedback 6 7 12

New Scientist Context Piece 14 15

Creative Piece Context Piece Evaluation and Discussion 18 19 20

Oral Presentation Context Piece Feedback 25 26 29

Reflective Piece

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References

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Introduction According to the Oxford English Dictionary (2013), communication is defined as The transmission or exchange of information, knowledge, or ideas, by means of speech, writing, mechanical or electronic media, etc. and implies shared understanding of that which is being communicated by those who are communicating. Thomas (2006) suggests that for this reason, communication plays an important role in both the delivery of scientific knowledge, but also increasingly in the provision of healthcare information to the general public. Whilst science communication is primarily responsible for communicating science to the public to increase their general understanding of important scientific topics; health care information is more persuasive in nature, seeking to instigate changes in a persons behaviour. Health care campaigns tend to incorporate a range of fields, and according to Logan (2008), borrow communication strategies from not only science communication, but from psychology, advertising and social marketing too. Tobey (1971) suggests that during the first half of the 20 century, the interest in promoting healthcare and science information was linked to both public spirited and parochial driven desires to increase the publics exposure to scientific research. There had already been a number of attempts to circulate scientific knowledge from as early as the days of Galileo. However, it has been argued that the recent mass popularization of science communication was to combat the negative reputation science had created for itself during the Second World War (Kurath & Gisler 2009) caused by the development of atomic weapons. Public surveys carried out in the early 1970s suggested that the cause of this public backlash against science was linked to a deficit of scientific knowledge amongst the general public (Kurath & Gisler 2009). In 1985, the Committee on the Public Understanding of Science (COPUS) was established to promote science to the public to inspire both positive attitudes towards science, and to enrich the lives of the individuals (Bodmer 2010). This regulatory body encouraged the rather onesided communication of science from the scientist to the public, but also encouraged a number of other initiatives. These included the introduction of science in schools, and the creation of the annual COPUS-Science museum book prize in 1988 (Gregory & Miller 1998). In 2000, a government paper named Science and Society was produced. The report highlighted the failure of this deficit model approach, particularly in response the BSE/CJD outbreak in the early 1990s. The government failed to make the risk of BSE in humans public knowledge, with Keith Meldrum, the chief veterinary officer claiming that British beef was safe for consumption. The report indicated a severe crisis of trust between governmental spokespersons representing science and the public after it was eventually declared that there was indeed a link between BSE & CJD (Gregory & Miller 1998). The report suggested that this model failed to appreciate the publics attitudes, and that the era of the public understanding of science was [simply] no longer enough (Parliamentary Office of Science and Technology (2003). Wilsdon & Willis (2004) suggests that since then, the style of scientific communication has been forced to change from the patronizing voice of the deficit
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approach, to discourse, to facilitate public engagement across a range of scientific projects. Logan (2008) suggests that health care communication also followed a similar one way information transfer (Finnegan & Viswanath 1990) from doctor to patient. In the early 1970s, however, it was soon realised that many diseases were linked to behaviours, such as smoking and heart disease. This caused health communication scholars to adopt more sophisticated methods of communication in order to successfully instigate changes in peoples behaviour (Finnegan & Viswanath 1990). Complex theories of behaviour had to be considered, including how a person perceives risk and the influence of particular forms of advertising. Health campaigns had to also address a number of barriers that prevented health information from reaching its audience. Such barriers included the content of the messages, the appropriate use of media, and the background of the people the message was intended for (Logan 2008). This allowed particular communication strategies to be chosen that would best encourage people to respond to particular health messages. Despite this, many argue that the communication of health information has not been majorly successful in instigating changes in audience behaviours. Dutta-Bergman (2005) suggests that healthcare campaigns also fail to reach the most at-risk audiences, such as those people with low socioeconomic status and poor levels of education (Adler et al., 1994), particularly in developing countries across the world. One notable example of this is the conflagration of HIV across the developing world. A study by Bertrand et al., (2006) reviewed 24 campaigns from 1990 to 2004 attempting to change HIV/AIDs related behaviour in less economically developed countries, and found very few statistically significant results. In order to increase the success of healthcare campaigns, newer models of health care communication have been called for to target more specific individuals. These campaigns will likely have to consider sociocultural factors such as education and literacy (Logan 2008). Dutta-Bergman (2005) also suggests health care campaigns may also need to work alongside the community in order to create a social responsibility for health particularly in more impoverished areas, to increase the reception of health campaigns messages in the future. In addition to creating better communication models, another particularly promising area in the development of the field is the through the use of additional written, or visual information to reinforce messages of health campaigns. According to Kenny et al., (1998), within 5 minutes of leaving the doctors clinic, people retained 30% more information when given additional information. Educational leaflets have been shown to effectively reinforce information provided by healthcare practitioners and increase the success rate of a number of healthcare campaigns (Petti & Scully 2007). The increased popularity and availability of health information on the Internet has also enabled unique opportunities for self-education and the ability to empower active participants in their healthcare (Purcell, Wilson & Delamothe 2002)

The changing focus, particularly in the western world, from infectious diseases to more chronic diseases has changed healthcare demands from disease treatment to preventative medicine. Logan (2008) suggests that by reinforcing health information using a range of communication strategies and media channels, we may not only help to limit the costs of treating such diseases, but may also improve outcomes of certain diseases in the future. Thus whilst fundamentally different, the changing fields of both healthcare and science communication illustrate the importance of understanding how the public perceive and process unfamiliar information. By not only better understanding these processes, but also by increasing the accessibility of science through the creation of appropriate scientific literature; there is an opportunity to educate the minds of the global community in preparation for any threats to our health that may emerge. The literature review created for the purposes of this project highlights such an emerging threat. It was entitled A discussion of the epidemiological factors affecting mosquito-borne zoonotic viruses using dengue & chikungunya as case studies; and the likely future for these viruses, as these diseases are becoming increasingly prevalent across the global community. The purpose of this portfolio was to highlight the dangers of these diseases and the factors that have contributed to their emergence to a range of audiences through different types of media. The four media channels were a Biological Sciences Review article, a New Scientist article, a creative free piece (where a leaflet and website were created), and an oral presentation. The Biological Sciences Review article created reviews the immunology of one particular mosquitoborne zoonotic virus, dengue. Infection by one of the four strains of the virus can lead to a debilitating illness known as dengue fever. However, upon infection with a different serotype of the virus, a person can go on to develop a serious condition known as dengue haemorrhagic fever. The article examines the mechanisms behind this, and the reasons as to why there are no vaccines currently available for this disease. The New Scientist article is an informative and engaging article that highlights viruses that have emerged over recent years. It also discusses the role of urbanization, particularly across the developing world, as a significant factor for this disease emergence. The creative piece is an educational resource that promotes awareness of the dengue virus to people aged 18-24 who intend to travel to endemic areas. This is because, according to Baumrind (1987) young people in this age group are much more likely to engage in riskier behaviour. Pizam et al., (2004) also suggests that young people are more likely to sporadically venture into the unknown whilst travelling, increasing their chances of encountering dangerous physical, social or health related situations. Finally, the presentation covers the main anthropogenic factors that are associated with mosquito derived disease emergence. It covers land use changes, including deforestation and urbanization, but also discusses the role of the globalization and the potential future for these viruses.

Biological Science Review The Biological Science Review is a magazine published by Philip Allan for Hodder Education. The magazine consists of a mixture of articles, of varying styles and descriptions that are aimed at students undertaking their A Levels. By reading the magazine, it is expected that the students will build on and enhance the knowledge learnt throughout their biological education to prepare them for university interviews and beyond. The article created for the purposes of this portfolio is entitled The Deadly Dangers of Dengue. It is written with Unit 1 of the AQA syllabus, entitled Biology and Disease, in mind. Within the unit, the students cover the basic principles of immunology including; what an antigen and antibody is, the process of phagocytosis, the differences between B and T cells and the role of plasma and memory cells in the immune response. The article created discusses the role of the immune system in fighting an infection caused by the dengue virus. It also discusses the consequences of when the immune system is overwhelmed. There were a number of aims for this piece of writing. The initial notion was to build on and develop this particular part of the unit. This should help give the students a broader context of immunology, which would allow them to consolidate the knowledge learnt in the syllabus. The article should also hopefully provide examples for the synoptic paper the students sit in their A2 year. The second aim was to get the severity of the disease across to the students in a simplistic yet interesting way to generate an interest for the subject of immunology. This is because as discussed throughout this entire report, the threat of emerging viruses is increasing across the globe. By encouraging interest in the topic or even influencing them to go into the field of biology, the students can greater appreciate the risks associated with such diseases. The final aim was to try and get across the difficulties scientists face when dealing with such diseases. This was an attempt to broaden the students horizons and generate awareness as to why it is we do not have treatments and vaccinations for all diseases, to maybe even inspire the students in do something about this issue in the future.

The Deadly Dangers of Dengue

Figure 1 Dengue virus seen under electron microscope

Dengue fever is a short, flu like illness caused by the dengue virus. However, some people can go on to develop dengue haemorrhagic fever that can be fatal. Why is this the case? Sickness, high temperature, headaches and muscle pain these are the symptoms of dengue fever. Even worse is when this little understood disease turns fatal. It is estimated that the dengue virus currently affects 100 million people worldwide. Worryingly this virus, previously restricted to areas such as Africa and Asia, is now becoming increasingly common across the world. Studies suggest that a further 2.5 billion people are now considered to be at risk from the virus. Dengue fever arises after infection by one of four strains of the dengue virus (see figure 1) following the bite of an infected Aedes aegypti mosquito. After provoking an immune response, a person develops immunity to the viral strain that caused the infection. It is thought that receiving a bite from another mosquito carrying a different strain of the virus; an infected person can go on to develop dengue haemorrhagic fever through an unusual process known as antibody dependent enhancement. The symptoms of this are more severe than normal dengue fever and include bleeding, organ damage and in some cases death. To understand how dengue haemorrhagic fever develops, we need to first review the main features of the immune system.

http://wellcometrust.files.wordpress.com/2012/01/dengue-virus- sanofi1.jpg?w=600

Box1 Dengue Strains

Originally it is thought that the dengue virus first evolved in either Africa or Asia and adapted to thrive in the Aedes mosquito, infecting primates in the forests. When human populations began to expand, forests were cut down to make space for agricultural land. In doing so, humans exposed themselves to the infected mosquito and became infected with the dengue virus themselves. The virus then started to spread across the continent alongside human and mosquito movement. Interestingly, it is thought the four strains evolved separately, but are said to have similar viral structures, and cause the same symptoms upon infection.
Aedes mosquito moving from infecting primates to infecting man
http://www.nature.com/nrmicro/journal/v5/n7/images/nrmicro1690-f2.jpg

The Immune Respone

The Immune System

Upon exposure to infectious pathogens such as viruses and bacteria, our bodys defence is mainly provided by our immune system. This is made up of two separate responses. Our innate immune system is the first line of defence. It includes physical barriers such as our skin, biochemical barriers such as our stomach acid, and immune cells such as macrophages. This system is pre-existing, and helps to provide immediate protection against invading pathogens. Some of these pathogens cannot be effectively cleared by our innate immune system, and so require the action of our adaptive immune system. Included in our adaptive immune system are B cells and T cells. These cells take time to be produced, but are generated in response to particular pathogens to tailor a specific immune response. These cells also help to provide long-term protection against future infections by the same pathogen. What Happens During a Dengue Infection? When a dengue-infected mosquito bites a person, it pierces the skin and injects the virus into the blood. The virus is then free to migrate and infect cells of the body such as dendritic cells (DCs). Once inside the dendritic cells, the virus can replicate itself using the cells internal machinery to produce more viral particles, leading to further infection. Once infected, the dendritic cells also become activated and travel towards lymph nodes to initiate an immune response to clear the virus from the body (see figure 2). Cells such as macrophages are activated to remove the virus by phagocytosis. Occasionally, the dengue virus can also infect these macrophages. So, as the infected cells move around the body, the virus is spread, leading to increased levels of the dengue virus in the body.

As the dengue virus replicates, it takes over cells of the innate immune system such as macrophages, and eventually destroys them. However, the
http://www.sciencedirect.com/science/article/pii/S0188440905001852

immune system has other mechanisms to clear the virus and help the body to recover from the infection. The infected dendritic cells secrete a number of molecules known as cytokines that can activate cells of the adaptive immune system. Once activated, a specific type of T cell known as a helper T cell can start to orchestrate the immune response. Another type of T cell, known as a killer T cell is also activated and can directly kill infected cells. B cells are also stimulated to produce virus specific antibodies. These antibodies are able to strongly bind to molecules on the surface of the virus and Figure 2 Mosquito injecting dengue into the blood. The neutralise it, blocking its activity. These processes virus infects the DCs and activates them. The DCs then
move towards the lymph node.

collectively help to clear the dengue virus from from the body. What is Different About Dengue Haemorrhagic Fever? After the initial infection, a person develops immunity against the dengue strain responsible, by the generation of strain specific memory B and T cells. These cells can induce a faster immune response to clear the same dengue strain the next time it invades. However, this immunity does not protect the person against infection by any of the three remaining dengue strains. Furthermore, previous infection appears to increase the chance of contracting dengue haemorrhagic fever. A number of scientists have suggested that the process of antibody dependent enhancement is responsible for this. They suggest that infection by a second dengue strain results in the production of antibodies by memory B cells specific to the first dengue strain. This unusual process is thought to occur, as the viral strains appear to be identical to the cells of the adaptive immune system. However, as these antibodies are not specific for the new dengue strain, they cannot neutralise the viruses activity. The antibodies bound to the virus can also bind to receptors on macrophages (see figure 3). This increases the uptake of the dengue virus into these cells and results in the production of more viral particles than in the first infection. As the immune cells are eventually are destroyed, an infected person is less able to fight back against the virus the second time around. As the body becomes overwhelmed with viral particles, blood vessels begin to rupture, organs start to fail and shock sets in; the life threatening symptoms of dengue haemorrhagic fever take hold.

Figure 3 Antibody mediated dengue viral uptake

Treatment and Vaccination There are currently no specific treatments for dengue fever, although pain relief can help ease the symptoms. The virus will usually be cleared by the immune system and the patient will start to feel better around 2 weeks after the initial infection. If the patient develops dengue haemorrhagic fever, they will often need to be admitted to hospital for careful monitoring. Patients severely affected by the disease may also require a blood transfusion or an IV drip to replace any fluids lost throughout the infection. The only method of protection from the dengue virus is preventing exposure to the mosquito that carries the virus, as a vaccine does not currently exist. Research is also examining ways of reducing the mosquito population to stop dengue from spreading. The use of chemical pesticides and the introduction of natural mosquito predators are currently being investigated. However, it is thought that increasing rainfall as a result of climate change is likely to increase the number of mosquito breeding grounds and increase the global spread of dengue in the future. It is expected that such strategies will only slow down the spread of the virus until an appropriate vaccine can be produced. Despite the rapid advances in the field, many drug companies have so far failed in the quest to produce an effective vaccine. The difficulty in creating a dengue vaccine lies in the need to induce immunity against of all 4 strains of the virus simultaneously, to protect against the development of dengue haemorrhagic fever. Recent results of a study in the US have shown promising results. Unfortunately, the study is still in the early stages and any effective vaccine produced may take years to reach the global market. But as the virus spreads, the pressure for a vaccine grows. Scientists are racing against time to develop a vaccine in order to protect our global community from the deadly dangers of the dengue virus.

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Adapted from [http://www.nature.com/nrmicro/journal/v5/n7/pdf/nrmicro1690.pdf]

Key points
The dengue virus is currently problematic across tropical and subtropical regions. After being bitten by an infected mosquito, a person may develop dengue fever. People who are infected with a second dengue strain may go on to develop life threatening dengue haemorrhagic fever. The incidence of dengue is expected to increase in the future, highlighting the need for an effective vaccine.

Terms explained
Adaptive immune system The second line of defence generated in response to particular pathogens and includes B cells and T cells. Antibody A protein produced in response to a specific antigen, which either neutralises it or targets it for destruction. Antibody dependent enhancement The production of antibodies in a primary infection increases viral replication in a secondary infection. Antigen A substance that induces an immune response in the body. B cell A type of white blood cell that makes antibodies. Cytokines Molecules made and released in response to pathogens, which is important for innate and adaptive immune cell activation. Dendritic cell A type of cell that is found in most tissues and can activate immune cells. Immunity - A state of immunological protection caused by the production of memory cells through previous exposure to a pathogen or through vaccination. Innate immune system The first line of defence against pathogens that is naturally present in the body and includes dendritic cells and macrophages. Macrophage An immune cell involved in removing and engulfing pathogens and dead cells by a process known as phagocytosis. Pathogen A bacterium, virus or microorganism that can cause disease. T cells A type of white blood cell that may be either a T helper cell that controls the immune response, or a killer T cell, which can directly kill virally infected cells.

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Feedback The Biological Science Review article was given to a first year tutorial group. They were asked to assess a number of aspects of the article, suggest ways of improving areas that needed further clarity and decide if it was suitable alongside the A-level syllabus. The manuscript was only successfully evaluated by four members of the tutorial group, therefore the results are not representative of the wider demographic that would likely read the article, but a number of useful comments were provided (see table 1). Questions Asked Have you read BSR? Does the manuscript make it clear how it relates to the A-level specification? For a student studying biology and applying to university, the manuscript is Do the concepts need further clarity? How did you find the manuscript? Was the style? Was it? Are the illustrations? Other comments to help Improve the piece Easy to read About right Interesting to read Good More about dengue turns into DHF Adequate* Make manuscript more formal try to be less vague Table 1 Review comments received from first year tutorial group (* indicates further comments that will be discussed in the report) Easy to read Too relaxed Dull* Engaging About right Interesting to read Adequate Engaging About right Interesting to read Adequate* More attention to detail Yes* No No Yes* About right About right About right About right Student 1 Once or twice Directly relates Student 2 Once or twice Marginally relates Student 3 Yes, a few times Directly relates Student 4 Once or twice

When the students were asked to evaluate the manuscript, all the respondents said they had read the Biological Science Review at least once. This suggests that the students understand the purpose of Biological Science Review and can therefore make informed comments on the article produced for this portfolio.

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When asked how the manuscript related to the A-level syllabus, half the students said that it directly relates, one didnt reply and one suggested that it only marginally related. The students were then asked whether the manuscript was either interesting or dull to read. Of the students, three said that it was interesting, and one said that it was dull because the science behind the dengue virus is common A-level knowledge. On inspection, it was found that the same person contradicting their statement, suggesting that the only marginally relates to the syllabus, even though it was dull because they had covered it before. All of the students suggested that the manuscript was about the right level for a student applying to university, with half of the students agreeing that it was easy to read, and the other half suggesting that the article was engaging. The illustrations used in the piece were also mostly regarded as adequate, although student 4 suggests that whilst the images were informative, some were a little small. Student 2 also suggested that figure 3 (the image of viral uptake) was unnecessary. The students were also questioned as to whether any of the issues discussed in the article needed further clarity. Student 1 and student 4 did suggest that one section of the article, where dengue turns into dengue haemorrhagic fever, was difficult to follow and needed further explanation. Finally, the students were asked if they could provide any comments to help improve the piece. Student 4 called for more attention to detail, commenting on the inconsistent capitalisation of dengue throughout the article, and the incorrect use of apostrophes in figure 2. It was also mentioned that not all the words emboldened were in the Terms Explained box at the end of the article. Student 2 also suggested that the manuscript was too relaxed and called for the article to be less vague. These comments have been considered and the changes made to the original article can be seen in the reflective piece at the end of this report.

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New Scientist New Scientist is a weekly online, and print magazine published by Reed Business International in the UK. The magazine does not just consist of biological articles, but also contains physics, maths and chemical articles of varying depths. Its audience are not exclusively from a science background, but according to the New Scientist website, the magazine caters for approximately 750,000 global consumers who can appreciate the level of science and the journalistic nature of the stories. The New Scientist article produced for this portfolio is entitled Rise of the Viruses. It gives examples of some diseases that have hit the headlines over the last couple of years, including West Nile and Chikungunya, and discusses the role of urbanisation in mosquito-transmitted disease emergence. The topic of urbanisation was chosen as the main focus for this piece, as it is a factor in disease emergence that is likely to be the most relatable for the readers of New Scientist, but other factors are also considered. The main aim of the piece was to write an informative article in the New Scientist style about the risks of emerging mosquito-transmitted diseases. It was also meant to engage the reader, by using some journalistic tips learnt over the course of this project, to promote enthusiasm for the topic. This is because such diseases are increasing in prevalence across the globe and infecting millions of vulnerable and unsuspecting citizens. It is therefore morally responsible for a high impact magazine such as New Scientist to bring this topic into the public eye to promote interest and awareness of such diseases. This increased knowledge and enthusiasm could simply translate into an interesting conversation over a meal, more informed choices over holiday destinations, or potentially into pressure for funding to support the work of the scientists in this field.

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Rise of the Viruses The city is infested. Dead birds litter the ground. The mercury swells to 41c for the third day running, doing little to appease the 1.2 million residents already suffering at the hands of weeks of drought. Mosquitoes are also rife; breeding in stagnant water and swarming in their thousands, they spread a mysterious illness from birds carrying the disease to humans, and causing the death of 48 people in a matter of weeks. This story sounds strikingly similar to a number of devastating outbreaks witnessed in developing countries across the globe. Worryingly, however, this is not a developing country. This is Dallas, Texas, and it is infected with West Nile virus. Living in the western world, we rarely think much about exotic diseases. After all, we are privileged to access a range of treatments and vaccinations, which has shifted our concerns to more chronic diseases, such as heart disease and cancer. Over the last 30 years, however, a whole host of exotic diseases, particularly those inflicted by viruses and carried by mosquitoes, have become increasingly prevalent across the world. Whilst many of these mosquito carried diseases are not fatal, they can weaken the body and cause excruciating and potentially lifelong symptoms. The loss of working hours combined with increased medical costs as a result of the infection often cripples the national economy, sending the country into a massive downward spiral. Alongside this, the historic reluctance of drug companies to invest in the treatment of these so called neglected tropical diseases has placed us in a difficult situation. These diseases are currently incurable, and look to be on course to hit the western world in the not so distant future. Chikungunya, a virus once confined to the forests of Africa, has recently ravaged parts of the Indian Ocean Islands. Yellow fever, a virus of old, has re-emerged to terrorise parts of Latin America, whilst dengue rips through a number of tropical paradise retreats. But what is it that has allowed these new and emerging viruses to break free from their tropical restraints and wreak havoc upon unsuspecting citizens across the world? Scientists have suggested the reasons are numerous, but the process of urbanisation is a key player in the rise of these exotic viruses. For thousands of years, the worlds population lived mostly in small country villages, surrounded by large expanses of untouched forest. Native diseases smouldered amongst the trees, infecting any unfortunate adventurer and causing small endemic outbreaks when disturbed. Following the Second World War, however, a rapid period of urbanisation across much of the developing world, provided opportunities for the viruses and their vectors to move out of the forests, and into the cities. In theory, it seems implausible that mosquito transmitted viruses should thrive and proliferate in a city environment. After all, a number of elements necessary for the mosquito life cycle are absent, including a lack of prey and suitable breeding grounds. However, for a number of countries, this is

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seldom true.

Urbanisation can enhance mosquito derived disease emergence particularly across

poorer regions of the developing world. For starters, cities allow a large number of people, on which urban dwelling mosquitoes feed, to live close together. This gives the female bloodsuckers more opportunities to draw a blood meal and transmit whichever disease she has festering within her salivary glands to an unsuspecting host. Some species of mosquito have also become well adapted to life in urban environments. Aedes aegypti, the mosquito responsible for a number of devastating dengue outbreaks witnessed over recent months, are able to breed in the smallest amounts of water that can collect. In cities surrounded by vast areas of sordid slums, running water and waste disposal are but a pipe dream. Slum conditions therefore provide ideal environments for these mosquitoes to multiply, and for the dengue virus they carry to thrive. Mosquitoes are also often at the mercy of their surroundings with regards to controlling their temperature sensitive physiology. The urban heat island effect generated within cities can often raise the local temperature by up to 5c compared to neighbouring countryside. Higher temperatures have been found to accelerate mosquito larvae development and send adults into a feeding frenzy. The influx of migrant workers into towns and cities may also influence the spread of exotic diseases. Migrants may bring with them brand new pathogens or variations of old diseases. A lack of immunity in a city to a particular form of a virus never previously encountered can result in outbreaks of epidemic proportions. This can be made worse by other circulating diseases, such as HIV that can cripple immunity and exacerbate the spread of infection. These factors, therefore implicate urban centres as increasingly important epicentres for exotic viral outbreaks. Coupled with urbanisation, the process of globalisation and the movement of people across the world has given exotic diseases new opportunities to spread. The changing global climate has also granted diseases, previously confined to warm tropical countries, a ticket to spread further a field and wreak havoc on unsuspecting towns and villages across much of the western world. These factors were thought to play a role in the passage of West Nile from its Ugandan origins to New York City in the summer of 1999. The virus has since become established, and emerges following years of milder winters and scorching summers; conditions that allow the Culex mosquito that carries the virus to flourish. Commerce too, has a lot to answer for. The accidental transportation of mosquitoes in a shipment of used car tyres has seen one particular species numbers positively explode across the US. The mosquito, Aedes albopictus, can transmit diseases such as Chikungunya much more effectively than most other mosquito species, and can also survive in much cooler climates. Aedes albopictus may also be able to carry other viruses, such as Japanese encephalitis, and yellow fever. The director of the Liverpool School of Tropical Medicine, Professor Janet Hemingway, expressed her concern to the

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Guardian, stating, because of these factors we could get [these diseases] coming all the way through Southern Europe, or even the UK . Ernest Gould, Professor of Virology at Oxford University told New Scientist, these diseases may already be infecting and killing simply because no-one is looking for them . To protect ourselves from the threat of these emerging viruses, the answer it would seem, is clear; the mosquito population needs to be reduced to prevent disease transmission. Mosquito control programmes could theoretically reduce numbers, and are currently undertaken at small-scale levels in emergency situations. However, combined with the fluctuating weather patterns that favour mosquito replication; the reality of up scaling such an effort, particularly in todays economic climate, makes it unlikely that such programmes alone could provide a solution to this increasing important health concern. So, until appropriate treatments become available, surveillance of mosquito movements across a number of high risk areas may be the next best step. This will not only help to provide early warnings of disease outbreaks, but increase the response time to control vast outbreaks. Surveillance will also allow researchers to observe a number of other factors that contribute to disease transmission in order to limit the extent of outbreaks in the future. Thus, the potential for an outbreak of exotic diseases across the world increases year on year. Speaking to New Scientist, David King, the UKs chief scientific adviser says that, even though noone knows what major diseases may arise, surveillance may help us better respond to unexpected exotic outbreaks until appropriate treatments can be produced. Whilst Dallas recovers from its battle with West Nile, the clock is ticking for the rest of the world to learn how to win the war against the rise of these exotic viruses.
2 1

As quoted by Granby (2004) in the Guardian quoted in New Scientist (2006)

2 As

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Creative Piece The creative piece developed for this portfolio is a dual resource consisting of a patient information leaflet, produced with the Mac programme Pages and a website, created with Softchalk. to PowerPoint and then print-screened and uploaded to Softchalk. The aim of this dual resource is to educate young travellers, aged 18-24 to the risks of the dengue virus. This disease was chosen as numerically, dengue is the most common viral disease carried by mosquitoes and has overtaken malaria in infection rates in people returning from South-East Asia (Wilder-Smith 2012). Wilder-Smith (2012) also indicates that infection by the dengue virus accounts for up to 2% of all illness reported by travellers returning to the UK. These statements suggest a possible lack of knowledge on this subject, which could be overcome by educating people to the risks of this disease. The age range (18-24 years) was chosen because, according to research, adults in this age group are more likely to engage in riskier behaviour and will often fail to consider adverse outcomes to their actions (Baumrind 1987) (Pizam et al., 2004). preventative measures (Rothenberg, Potterat & Woodhouse 1996). The information in the leaflet highlights the risk of dengue, whilst allowing for the inclusion of graphics to enhance the look of the piece and reinforce statements made. If the travellers wanted to know more information, a link is provided to the website. This reiterates the information provided in the leaflet in more detail and answers more questions. It is also linked to the CDC interactive dengue map, which allows users to check if theyre travelling to a high-risk area, and provides an interactive quiz where people could test the knowledge learnt through using this resource. The website is also accessible by smart phone. The piece was evaluated by my peers, to determine its effectiveness in communicating the risks of dengue. They were given a pre and post resource questionnaire to see if, by using the resource their knowledge of the dengue virus improved. They were also asked to provide comments so that the resource could be improved upon in the future. It was also evaluated by select number of healthcare professionals including; a community pharmacist, two practice nurses and two GPs who assessed whether this resource would be useful in the clinic. The evaluation was performed by two separate questionnaires, and the results are included in the evaluation. This is likely to increase their chances of infection by circulating diseases present within a particular area if they fail to follow correct As Softchalk is limited in its design capabilities, the website pages were designed in Keynote, exported

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Leaflet

What is Dengue?

Travel Advice

Dengue is a common viral infection transmitted by the bite of an infected Aedes mosquito. It is caused by the dengue virus, of which there are four strains, DEN-1, DEN-2, DEN-3 and DEN-4. Dengue is widespread across tropical and sub tropical regions, particularly South East Asia, Latin America and the Caribbean. One bite by an infected mosquito can lead to u like symptoms, including fever, nausea and fatigue. Some people can develop much more lethal complications if they are bitten a second time. This is known as

Before You Travel

As there is no vaccine to prevent dengue, the only protection is to reduce your chances of getting bitten.

After Your Travels

If you develop symptoms of dengue after you return to the UK, make an appointment to see a health care professional. If you have contracted dengue, the infection will usually clear within 1-2 weeks. Bed rest, paracetamol and drinking plenty of uids will help to manage your symptoms. If you develop DHF, you will need to be admitted to hospital. This may be as a precautionary measure, or you may require a blood transfusion, or a drip to replace uids that may have been lost.

Speak with either your pharmacist or GP to discuss your trip, purchase items for your travel kit, and see if you will require anything extra, such as anti-malarial medication or vaccinations.

During Your Travels

Apply insect repellent. Those containing DEET are recommended by most health practitioners. Insect repellent should also be applied after sun tan lotion. Try to book accommodation that has air conditioning. Wear loose, long sleeved clothing.

dengue haemorrhagic fever (DHF).

This can result in bleeding under the skin, or from the nose Patients may also vomit blood, or pass blood when they go to the toilet.

App ro peop ximatel y 40 le re the turn 6 U the K infec ed to den ted gu b 2010 e virus y in alon e.

Avoid places of stagnant water, 1-2 hours after dawn and before dusk when the mosquitoes that carry the disease are most active.

19

Website Login to blackboard first; then follow this link to access the resource: https://online.manchester.ac.uk/bbcswebdav/xid-7444366_1

20

Evaluation + Discussion 25 surveys were given to my peers to evaluate this resource, from both a scientific background and a non-scientific background, and 16 were successfully returned. They were asked to complete a pre and post resource questionnaire to see first, how many people have heard of the dengue virus, and second to see if, by using this resource, their knowledge increased. The post resource questionnaire also questioned whether people found the resource interesting, if the language was appropriate, if the level of detail was right and whether the images contributed to the pieces. Further comments that could be used to improve the resource in the future were also requested. The resource was also given to five healthcare professionals, including two GPs, a community pharmacist and two practice nurses. They were asked whether dengue was a disease that was discussed with patients, and whether the clinic already had reference material for the disease. It also asked for comments on the pieces to improve the resource in the future and if the resource would be of use in their clinic. Peer Evaluation The peer evaluated pre-resource questionnaire consisted of eight marked questions, including what is dengue and how is the virus spread. The correct answer was scored as 1 and an incorrect or dont know answer was scored as 0. The questions were repeated in the post resource questionnaire to see if the participants knowledge had increased. The results are recorded in table 2.

Pre-Test Score Person 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7 Person 8 Person 9 Person 10 Person 11 Person 12 Person 13 Person 14 Person 15 Person 16 Mean Score 2 0 6 0 2 5 2 0 0 2 2 0 5 0 0 0 1.625

Post-Test Score 7 8 8 8 8 8 7 8 7 7 5 8 8 6 7 8 7.375

Table 2 Scores achieved by each participant prior to using the resource, and after using the resource.

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The data showed that prior to using the resource, the mean score was 1.63, and after the score increased to 7.4. The results were analysed by a paired T test and compared to the critical value for 15 degrees of freedom (1.753 for 0.05 significance). A t value = -10.883 was obtained, which indicated that the resource had significantly improved the knowledge of the participants. The post resource questionnaire also asked for feedback on the style and language of the resource. 100% of the respondents suggested that the resource was both interesting, and that the style of both pieces was about right. 100% of the participants also suggested that the images used helped to improve the look of the resource. The questionnaire also asked the age of the participants and whether the level of detail was appropriate. As the resource was aimed at young travellers aged 1824, this age range was paid particular attention to. However, it was found that 100% participants (which included one participant aged 25-30, and one aged 31-35) stated that the level of detail was appropriate for each piece. The participants were also asked which part of the resource they found more useful, and if they were going away, which would they be more likely to use. For both questions, 50% indicated that the leaflet, 21% said the website, and 29% said both. The post-resource questionnaire queried what the best features of the resource were, and a number of positive comments were given. The responses for the leaflet included praise for the layout, and the use of images. It was described by one as being eye catching and informative. Another also described it as, short and to the point, giving all the important information without being long and dull. Another participant also stated that the information was clearly presented and broken up into different sections with different fonts[which] made the leaflet much more user friendly. The website also received a number of positive comments. A common statement made was that the information was concise and to the point, and some of the participants also stated the fact that the website was accessible by mobile phone was a useful feature. Other comments received suggested that the resource is a little bit scary. Another said, I like the images they make me a little scared so I want to read more. Comments were also called for to see how the resource could be improved. A recurring issue that arose was that the navigation of the website needed improving. Participants suggested that the navigation bar was not obvious when it changed to incorporate different sub headings and that the navigation tools at the bottom of the page had to be used instead. One participant suggested the theme of the leaflet did not translate well onto the website, and that it was too white. Another participant also questioned why the website text was saved as an image. They suggested this makes it difficult to load the website on some computers and does not allow participants to directly copy and paste the information into other documents. Thus, based on the quantitative data, the aims of this piece appear to have been met; the knowledge of the participants has significantly increased, and they are now aware of the existence of the dengue

22

virus. If these participants ever travel to an endemic region and acquire flu like symptoms in the future, they would hopefully be more likely to seek treatment rather than ignore it. One of the limitations of this project however, is that it is difficult to discuss its long-term success. In order to protect themselves against the dengue virus, changes to the participants behaviour would need to be instigated to prevent themselves from being bitten in the first place. However, according to Sutton (1992), the use of scare tactics and the level of fear felt by the audience of a particular health message corresponds to the level of behavioural change. The qualitative feedback suggested that some participants found the threat of dengue to be scary. Therefore, it is more likely that these participants will take in the messages of the resource, and be more likely to protect themselves appropriately if they enter an endemic area in the future and seek help should they require it. Healthcare Professional Evaluation. The questionnaire completed by the healthcare professionals differed to the peer evaluated questions. It asked if they were aware of dengue and whether they were aware that, statistically, dengue is the most common viral mosquito infection. Whilst 100% all these professionals had knowledge of this disease, none of them were aware of its prevalence across the globe. The next question asked if dengue was a disease these professionals discussed with their patients. The two GPs said that their travel clinic nurse dealt with such exotic conditions but were not sure about the details of the consultation. The community pharmacist and the practice nurses said that they did not give out information about the disease to their patients, as they were unaware that it was such a major issue. The healthcare professionals were then questioned as to whether they had reference materials in their clinic, which highlighted the dangers of exotic diseases such as dengue, and whether this resource would be useful to their patients. All the respondents stated they had no reference materials, as they printed off information from other websites such as NaTHNaC when required. It was also mentioned that it was difficult to hold information on every disease in a small clinic setting. However, they did state that this resource would be useful for their patients, with one professional commenting, The simple language and eye catching nature would be particularly good for our younger patients. Finally, recommendations to improve the resources were called for. One respondent suggested that, as the website was not restricted by space, the website should have slightly more detail on the condition, although as it stands, it provides excellent information in a helpful format. The only other comments made were regarding difficulties with the website navigation.

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Response to feedback Based on the qualitative feedback received by both my peers, and the health care professionals, there are some changes that could be made to the resource to improve it in the future. Whilst the results of the peer evaluated survey suggested that the leaflet is the most appropriate media channel, the limited space in the healthcare clinics means that the professionals giving the advice would be more likely to direct their patients to information available on the web. Thus, if the website was to be used in the future, a programme that can support more design and technical features would need to be used. This is because, whilst Softchalk is easy to use, it is limited in its design capabilities. This should also allow for the creation of a better and more obvious navigation bar to improve the accessibility of the website, but also prevent having to upload the text as images in order to create a more exciting design. The evaluation of the piece could also be improved to gather more constructive criticism. Whilst 25 surveys were provided to the experimenters peer group, only 16 were returned. The comments are therefore not representative of the intended audience of this piece, but also may be subject to experimenters bias. These participants may not have provided honest feedback and so if this project were repeated in the future, it would need to be evaluated by other, neutral participants. This could be achieved by taking advantage of the universitys announcement system and providing an incentive for other students to provide feedback. This would provide a greater sample size, but also should encourage more constructive criticism to further develop this resource. Another idea would be to question the same participants again after a designated time span to see if they had retained the information learnt through using the resource. Whilst the analysis suggested the participants knowledge had increased, it is unknown what the true impact of the resource was. This information could used to test the scare tactics hypothesis and determine if the resource truly has the potential to instigate changes in the participants behaviour in order to protect them from the dangers of this disease.

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Oral presentation The oral presentation produced for this portfolio was created specifically for a scientific audience. The presentation was given to Catherine Walton, the supervisor of this project and her lab group, which included masters students, PhD students and postdocs. The audience already had a level of knowledge regarding some aspects of the topic of the presentation, particularly in the genetic background of mosquitoes. The presentation given to this group was entitled the Anthropogenic Factors Affecting MosquitoBorne Viral Disease Emergence, and covered some of the main factors linking human activities to the emergence of mosquito-transmitted diseases. It discusses the role of land use changes including deforestation and urbanisation, but also the effects of globalisation on disease emergence. It also discussed the potential future for these viruses. It was arranged for the 8 of March 2013 at 3pm in
th

the Michael Smith Building, belonging to the University of Manchester. The main aim was to discuss in some detail, the factors implicated in mosquito-transmitted diseases and explain some of the scientific theory at the forefront of these ideas. The presentation was hopefully of some interest to these scientists, to perhaps broaden their current understanding or introduce new ideas, which could be potentially considered in related work in the future.

25

Presentation Slides

Anthropogenic Factors Affecting mosquito-borne viral disease emergence

Factors

Land use change" -Deforestation" -Urbanisation! Globalisation" -Travel & Commerce!

Land use change

Deforestation!

Deforestation driven by demand for forest products, agricultural land and an expanding human population" !

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Land use change

Deforestation!
Changes disease ecology! Direct Effects" -direct exposure" -loss of biodiversity" -change of habitat! Indirect Effects" -adaption to new environment!

Land use change

Urbanisation!

Prior to WWII, mostly scattered settlements! Large scale ecological transformation followed! !

Land use change

Urbanisation!

Close Proximity! Peri-urban slums" - Urbanised diseases ! Migration! Microclimate!

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Globalisation
Travel !

Moves pathogens from previously conned environmental niches!

Globalisation
Commerce !

Trade has resulted in the global distribution of viral vectors!

Conclusion
A whole host of other factors contribute to disease emergence" -weather patterns" -natural disasters" -genetic mutation! The Future?" " !

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Feedback to student following oral presentation Title of presentation: Anthropogenic factors affecting mosquito-borne viral disease emergence. Student: 7237538 Date: 8 March 2013. Comments: Content: Extremely good. Showed really good background knowledge. On the whole, able to answer questions knowledgeably. Slides were excellent just the right amount of material on them and they were visually engaging. It would have been nice to put on the name of the author for some of the figures. Appropriate language/pitched at the right level: Pitched at the right level. What was a bit confusing was mention of lots of different diseases and lots of different mosquitoes that responded differently to environmental change. This needed more explanation or needed to be simpler because it is hard for the audience to keep up with different viruses/mosquitoes/effects of environment
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Structure: Structure was very clear and logical. Confidence and manner: Lacked a bit of confidence which was unjustified as the student clearly knew the material very well and had prepared very well. Impact: Delivery was satisfactory. Everything was said clearly and well but it could have been more engaging. Again, this stemmed for a bit of a lack of confidence (unjustified) rather than any lack of preparation. The student was clearly very well prepared and I think this did help in that there were no awkward pauses, etc. Non-verbal: This was fine. Could have been a bit more eye contact with audience than there was. Timing and Delivery: Kept to time. Could have talked a little less and a little more slowly in parts especially the complex bits involving lots of vectors, viruses and effects of environmental change. Overall: The content and structure were extremely good. The student communicated the material well, although she did seem a bit nervous.

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Reflective Piece Having been working on this project from the beginning the semester 1, I feel I have identified a range of skills and weaknesses within myself, which I have been able to improve upon through a number of devised strategies. I believe that prior to this project my time management skills were quite effective. Previous experience of writing my 2
nd

year dissertation, demonstrated how I was able to keep to a strict plan, allowing me

to finish the piece of work a week prior to the deadline. However, the challenges of final year have pushed me to improve upon this ability. Whilst writing my dissertation, I created a GANTT chart, which allowed me to keep on schedule. I repeated this whilst writing my literature review and included all other upcoming deadlines. This allowed me to forward plan and prioritise work. Leaving the weekends free allowed me incorporate any unforeseen pieces of work such as that given in tutorial or pieces of work, which required additional research. This appeared to be successful and was repeated with the creation of the portfolio pieces. This allowed two pieces of work to be finished before their individual deadlines (the 28 Feb for the BSR article, and the 8 March for the presentation respectively) and the other two before the beginning of the Easter break to allow ample time to evaluate the resources and to produce the portfolio. However, I do feel that further improvements to my time management can still be made. I felt that have I have struggled with reading the literature effectively, to reduce the amount of time taken to understand the point of each article. I devoted two hours in the evening to focus on reading through articles to take out key points and messages. Although it has not hindered my project much, and it is something I feel I have started to improve on, further improvements need to be made. Printing off the papers and closing down my computer should prevent distractions and will allow me to make even better use of my time in the future. Throughout the course of my project, I also feel I have learnt to write and express my ideas in much clearer and concise manner. Whilst writing my literature review, I found myself struggling, writing awkward and long-winded sentences. However, I made an appointment to speak with Chris Simms, the FLS writing fellow, and also attended a creative writing session in February. Both of these provided invaluable tips, which I have used to create my portfolio pieces. The general consensus from the comments received from my Biological Sciences Review and my creative piece confirms this. The feedback indicates that the pieces were both interesting and easy to read, that they were written in an appropriate register and the style was right for publication. However, one criticism I did receive from the evaluation of my Biological Science Review article was that the section on how dengue becomes dengue haemorrhagic fever was a little difficult to follow. I changed the structure of one paragraph and tried to include a little more detail on the subject, whilst
th th

30

trying not to overwhelm the students with unnecessary information. It changed from; as these antibodies are not specific for the new dengue strain, they are only able to weakly bind to the virus and are unable to deactivate it. The antibodies bound to the virus can also bind to receptors on macrophages (see figure 3). This increases the ability of dengue virus to infect the macrophages, leading to increased levels of viral replication and the life threatening symptoms of dengue haemorrhagic fever To; as these antibodies are not specific for the new dengue strain, they cannot neutralise the viruses activity. The antibodies bound to the virus can also bind to receptors on macrophages (see figure 3). This increases the uptake of the dengue virus into these cells and results in the production of more viral particles than in the first infection. As the immune cells are eventually destroyed, an infected person is less able to fight back against the virus the second time around. As the body becomes overwhelmed with viral particles, blood vessels begin to rupture, organs start to fail and shock sets in; the life threatening symptoms of the dengue haemorrhagic fever take hold. I believe this better explains the topic and rectifies this problem. One feedback comment made also suggested that the style of the manuscript is too relaxed. However, after going back and assessing the language in previously published articles I feel that the comment is unfounded, leading me to ignore it. The comments also pointed out small errors such as incorrect use of apostrophes and inconsistent capitalisation of dengue. The terms adaptive immunity and innate immunity were also not included in Terms Explained box. The original article has now been corrected to include these points and to increase the standard of the article. One particular aspect that I feel I have not been able to develop to a level I am satisfied with throughout this project is my oral presentation skills. Whilst I am comfortable structuring an argument using PowerPoint, I have always slightly struggled with my nerves whilst giving presentations. Despite being well prepared and having booked a library study room to practise my presentation in front of a number of friends; the feedback received from my portfolio presentation suggests that my nerves are still an issue. In the future, I will need to make a real conscious effort to breathe and speak more slowly in order to reduce my nerves. This could be achieved through the use of particular relaxation techniques such as breathing deeply, and visualising the audience as a group of interested friends, rather than a group of menacing individuals. The use of a Dictaphone would also enable me to record practise presentations to assess if Im speaking too quickly, and to point out where other improvements can be made. Confidence in public speaking is useful asset for any job I may apply to, and is therefore is a skill I intend to keep on improving. Acknowledgments I am forever thankful for the help and support given to me throughout the course of this project by my supervisor Cathy Walton, and for the creative assistance provided by Siobhan Nelson, who helped with the design of my creative piece. I am also thankful for those friends and colleagues who took the time to read through this manuscript and provide valuable feedback for my report.

31

References: Introduction Adler E, Boyce T, Chesney M, Cohen S, Folkman S, Kahn R, Syme L (1994) Socioeconomic Status and Health: The Challenge of the Gradient. American Psychologist. 49, 15-24

Baumrind D (1987) A Developmental Perspective on Adolescent Risk Taking in Contemporary America. Adolescent Social Behaviour and Health 37, 93-125.

Bertrand J, OReilly K, Denison J, Anhang R, Sweat M (2006) Systematic review of the effectiveness of mass communication programs to change HIV/AIDs-related behaviours in developing countries. Health Education Research. 21, 567-597. Bodmer W (2010) Public Understanding of Science: The BA, the royal society and COPUS. Notes & Records of The Royal Society. 64, s151-s161. Bucchi M (2008) "Of deficits, deviations and dialogues Theories of public communication of science, in Trench B & Bucchi M (2008), Handbook of Public Communication of Science and Technology. New York. Routledge. 57-76. Dutta-Bergman M (2005) Theory and Practice in Health Communication Campaigns: A Critical Interrogation. Health Communication. 18, 103-122 Finnegan J & Viswanath K (1990) Health and Communication: Medical and Public Health Influences on the Research Agenda, in Ray E & Donohew L, Communication and Health: Systems and Applications. New Jersey. Lawrence Erlbaum. 9-24 Gregory J & Miller S (1998) Science in Public: Communication, Culture and Credibility. Cambridge. Perseus Publishing. Kenny T, Wilson R, Purves I, Clark J, Newton L, Newton D, Moseley D (1998) A PIL for every ill? Patient information leaflets (PILs): a review of past, present and future use. Family Practice. 15, 471479. Kurath M & Gisler P (2009) Informing, involving or engaging? Science communication, in the ages of atom-bio- and nanotechnology. Public Understanding of Science. 18, 559-573 Logan, R (2008) "Health Campaign Research", in Trench B & Bucchi M (2008) Handbook of Public Communication of Science and Technology. New York. Routledge. 77-92.

32

Oxford 2013)

English

Dictionary

(2013)

(Available:
nd

http://www.oed.com/view/Entry/37309?redirectedFrom=communication#eid - Last accessed 2

April

Parliamentary Office of Science and Technology (2003) Science and Society: Three years on. (Available: http://www.parliament.uk/documents/post/13-may-proceedings.pdf - Last accessed 8 April 2013) Petti S & Scully C (2007) Oral cancer knowledge and awareness: Primary and secondary effects of an information leaflet. Oral oncology. 43, 408-415. Pizam A, Jeong G-H, Reichel A, van Boemmel H, Lusson J M, Steynberg L, State-Costache O, Volo S, Kroesbacher C, Kucerova J, Montmany N (2004) Journal of Travel Research. 42, 251-260. Purcell G, Wilson P, Delamothe T (2002) The quality of health information on the Internet. BMJ. 324, 557. Thomas R (2006) Health Communication. Boston. Springer US. Tobey R (1971) The American Ideology of National Science. Pittsburgh. University of Pittsburgh Press. Wilsdon J, & Willis R (2004) See-through Science: Why Public Engagement Needs to Move Upstream. London. Demos
th

33

Biological Science Review Ho Lj, Wang JJ, Shaio MF, Kao CL, Chang DM, Han SW, Lai JH (2001) Infection of Human Dendritic Cells by Dengue Virus causes Cell Maturation and Cytokine Production. The Journal of Immunology. 166, 1499-1506. Nature (2013)
th

Host

Response

to

the

Dengue

Virus

(Available: Last

http://www.nature.com/scitable/topicpage/host-response-to-the-dengue-virus-22402106 accessed April 29 2013)

Navarro-Snchez E, Desprs P, Cedillo-Barrn L (2005) Innate Immune Reponses to Dengue Virus. Archives of Medical Research. 36, 425-435. NIH (2013) NIH-developed candidate dengue vaccine shows promise in early-stage trial (Available: http://www.nih.gov/news/health/jan2013/niaid-23.htm - Last accessed 3 April 2013) Rothman A (2003) Immunology and Immunopathogenesis of Dengue disease. Advances in Virus Research. 60, 397-419. Wood P (2011) Understanding immunology. 3 Edition. Dorchester. Dorset Press. Whitehead J, Blaney J, Durbin A. Murphy B (2007) Prospects for a dengue virus vaccine. Nature Reviews. 5, 518-528.
rd rd

34

New Scientist Alirol E, Getaz L, Stoll B, Chappuis F, Loutan L (2010) Urbanisation and infectious diseases in a globalised world. Lancet Infectious Diseases. 10, 131-141 Epstein P (2001) West Nile Virus and the Climate. Journal of Urban Health 78, 367-371. Granby E
st

(2004)

Tropical

disease

fears

for

the

med

(Avaliable: Last

http://www.guardian.co.uk/travel/2004/jul/31/travelnews.guardiansaturdaytravelsection accessed 31 March 2013)

Hawley W, Reiter P, Copeland R, Pumpuni C, Craig G (1987) Aedes albopictus in North America: Probable Introduction in Used Tires from Northern Asia. Science 36, 114-116. Maurice J (1993) Fever in the urban jungle: Across the globe, the mosquitoes that carry yellow fever are returning in force. Will we be able to cope if the disease strikes a major city (Available: http://www.newscientist.com/article/mg14018953.700-fever-in-the-urban-jungle-across-the-globe-themosquitoes-that-carry-yellow-fever-are-returning-in-force-will-we-be-able-to-cope-if-the-diseasestrikes-a-major-city.html?full=true - Last accessed 1 May 2013) New Scientist
st st

(2006)

Beware

Europes

Unknown

Viral

Nasties

(Avaliable: -

http://www.newscientist.com/article/mg19025503.300-beware-europes-unknown-viral-nasties.html Last accessed 31 March 2013)

Patz J & Norris D (2004) Land Use Change and Human Health in DeFries R, Asner G, Houghton R (2004) Ecosystems and Land Use Change. Washington DC. American Geophysical Union. Patz J, Daszak P, Tabor G, Aguirre A, Pearl M, Epstein J, Wolfe N, Kilpatrick A, Foufopoulos J, Molyneux D, Bradley D (2004) Unhealthy Landscapes: Policy recommendations on land use change and infectious disease emergence. Environmental Health Perspective. 112, 1092-1098.

35

Creative Piece Baumrind D (1987) A Developmental Perspective on Adolescent Risk Taking in Contemporary America. Adolescent Social Behaviour and Health 37, 93-125. Malaria Hot Spots (2012) Malaria. It only takes one bite. (Available: http://malariahotspots.co.uk/ Last accessed 25 April 2013) NHS (2012) Dengue (Available: http://www.nhs.uk/conditions/dengue/pages/introduction.aspx Last accessed 21 April 2013) NHS 2013) Pizam A, Jeong G-H, Reichel A, van Boemmel H, Lusson J M, Steynberg L, State-Costache O, Volo S, Kroesbacher C, Kucerova J, Montmany N (2004) Journal of Travel Research. 42, 251260. Rothenberg R, Potterat J & Woodhouse D (1996) Personal Risk Taking and the Spread of Disease: Beyond Core Groups. The Journal of Infectious Diseases 174, s144-s149. Sutton S (1992) Shock Tactics, and the Myth of the Inverted U. British Journal of Addiction 87, 517-519. Wilder-Smith A (2012) Dengue Infections in Travellers. Paediatrics and International Child Health. 32, 28-32. Images 1960 Anchorage
rd st th

(n/d)

Travel

Health

Essentials

(Available:
th

http://www.nhs.uk/Livewell/travelhealth/Pages/Travelhealthkit.aspx - Last accessed 18

April

High

50

th

Reunion

(2012)

(Available:

http://www.1960-ahsLast

reunion.com/AHS%20images/Index%20page%20images/Greeting-at-airport-web.jpg accessed 3 April 2013) California 2013) Institute of Technology (2006) Aedes aegypti

(Available:
rd

http://aedes.caltech.edu/images/Aedes_aegypti_during_blood_meal.jpg - Last accessed 3

April

36

End the neglect (2012) (Available: http://endtheneglect.org/wp-content/uploads/2012/12/denguemap21.jpg - Last accessed 3 April 2013) GL Stock Images (2009)
rd rd

(Available:

http://images.graphicleftovers.com/13280/49738/49738_125.jpg - Last accessed 3 April 2013) Iasa (2013) Welcome to the Thailand Use
rd

Group

(Available:

http://www.iasaglobal.org/images/iasa/thailand.jpg - Last accessed 3 April 2013) Insure & Away (n/d) Before you travel (Available: http://www.insureandaway.co.uk/before-youtravel/ - Last accessed 3 April 2013) Kent Police (2013)
rd rd

Plan

before

you

travel

(Available:

http://www.kent.police.uk/advice/personal/travelling_abroad/images/Maps%20and%20pins%20sq uare.jpg - Last accessed 3 April 2013) Layout Sparks (n/d) (Available: http://images2.layoutsparks.com/1/134070/black-white-skullsdanger.jpg - Last accessed 3 April 2013) National April 2013) New 2013) PNAS (2003) Dengue virus envelope glycoprotein structure: New insight into its interactions during viral entry. PNAS. 100, 6899-6901. The Guardian (n/d) (Available: http://static.guim.co.uk/sysrd rd

Geographic

(n/d)

(Available:

http://images.nationalgeographic.com/wpf/mediard

live/photos/000/586/overrides/capoeira-ipanema-brazil_58696_990x742.jpg - Last accessed 3

York

Times

(2008)

The

War

of

Dengue

Fever

(Available:
rd

http://www.nytimes.com/2008/11/04/health/04denguefever.html?_r=0 - Last accessed 3

April

images/Guardian/Pix/pictures/2008/11/16/doctor10a.jpg - Last accessed 3 April 2013) The Post (2012) New Lagos Traffic Law Now Operational (Available: http://thepost-ng.com/newlagos-traffic-law-now-operational/ - Last accessed 3 April 2013) Thomas Net (2013) Aedes aegypti: a little bug that causes big problems (Available: http://news.thomasnet.com/green_clean/2012/01/17/why-save-the-mosquitoes-will-never-showup-on-bumper-stickers/aedes-aegypti/ - Last accessed April 3 2013)
rd rd

37

Tiny Mosquito (n/d) (Avaliable: http://www.tinymosquito.com/aedes.jpg - Last accessed 3 2013)

rd

April

38

Oral Presentation Alirol E, Getaz L, Stoll B, Chappuis F, Loutan L (2010) Urbanisation and infectious diseases in a globalised world. Lancet Infectious Diseases. 10, 131-141. Gushulak B & MacPherson D (2004) Globalization of Infectious Diseases: The Impact of Migration. Clinical Infectious Disease. 38, 1742-1748. McMichael A (2004) Environmental and social influences on emerging infectious diseases: past, present and future. Philosophical Transactions of the Royal Society, Biological Sciences. 359, 10491058. Morse S (1995) Factors in the emergence of infectious diseases. Emerging Infectious Diseases, 1, 7 15. Nigeria World News (2013) Lagos Plans to Wipe Out Slums (Available: http://www.nigeria-newsworld.com/2013/02/lagos-plans-to-wipe-out-slums.html - Last accessed 3 April 2013) Patz J & Myers S (2009) Emerging Threats to Human Health from Global Environmental Change. Annual Review of Environment and Resources. 34, 223-252. Patz J, Daszak P, Tabor G, Aguirre A, Pearl M, Epstein J, Wolfe N, Kilpatrick A, Foufopoulos J, Molyneux D, Bradley D (2004) Unhealthy Landscapes: Policy recommendations on land use change and infectious disease emergence. Environmental Health Perspective. 112, 1092-1098. Polis (2011) Deforestation Bill in Brazil: Responsibility of Urban Citizens and Planners (Available: http://www.thepolisblog.org/2011/05/deforestation-bill-in-brazil.html - Last accessed 3 April 2013 Tatem A, Hay S, Rogers D (2006) Global traffic and disease vector dispersal. PNAS. 103, 6242-6247. Vanwambeke S, Lambin E, Eichhorn M, Flasse S, Harbach R, Oskam L, Somboon P, van Beers S, van Benthem B, Walton C, Butlin R (2007) Impact of Land-use Change on Dengue and Malaria in Northern Thailand. Ecohealth. 4, 37-51. Weaver S & Reisen W (2010) Present and future arboviral threats. Antiviral Res 85, 328-345. Wilcox B & Gubler D (2005) Disease ecology and the global emergence of zoonotic pathogens. Environmental Health and Preventative Medicine. 10, 263-272.
rd rd

39

WWF 2013) Yanoviak

(2013)

Deforestation

for

Cattle

Ranching

in

the

Amazon

(Available:
rd

http://worldwildlife.org/photos/deforestation-for-cattle-ranching-in-the-amazon - Last accessed 3 April

(2006)

Research

Tree
rd

holes/Phytotelmata

(Avaliable:

http://www.canopyants.com/treehole.html - Last accessed 3 April 2013) YBT (2009) No Mosquitoes Campaign (Available: http://ybtclub.blogspot.co.uk/ - Last accessed 3 April 2013)
rd

40