Ebp Chikv Paper

Applying Evidence to Chikungunya

Running head: APPLYING EVIDENCE TO CHIKUNGUNYA

Applying Evidence to Screen for Chikungunya Virus in Low Resource Settings Michelle D. Kelly University of San Francisco

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Applying Evidence to Chikungunya

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Applying Evidence to Secondary Prevention Outbreaks of Chikungunya Virus

Mosquito-borne arboviral diseases, such as malaria and dengue, are well known and highly studied, unlike the lesser-known chikungunya virus. Starting in 2003, reports of chikungunya viral outbreaks have been published in reputable French and Indian scientific literature (Ministry of Health [MOH] Malaysia, 2006; Pialoux, Gaüzère, Jauréguiberry & Strobel, 2007). Recent outbreaks indicate that the chikungunya virus is exported and there is a lack of basic surveillance and screening measures (Ledrans, Quatresous, Renault & Pierre, 2007; Ramchurn, Goorah, Makhan & Moheeput, 2008). Chikungunya is transmitted by Aedes mosquitoes in temperate regions and is most prevalent in areas of the world where only the most basic health services exist (World Health Organization [WHO], 2008). The word chikungunya is Swahili, and it means someone who bends inward because of a total body ache, and the person stooped over graphically depicts the clinical representation of the viral infection’s characteristic arthralgia. In a public health setting, diagnosis of chikungunya is a lengthy and inaccurate process based on subjective symptoms.. Clinical manifestations of chikungunya are fever and rash, which are akin to many other tropical diseases, like malaria (Ramchurn et al, 2008). Chikungunya has been identified by the classic pattern of migratory arthralgia reported in over 90% of patients (MOH Malaysia, 2008). However, the disease is only confirmed by the exclusion of other viral diseases through a series of blood and diagnostic tests which, if available, only exist in hospitals in major cities. A lack of sensitive, specific and timely methods to confirm a diagnosis of chikungunya

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translates into high health care utilization and long inpatient or home stays. This deficiency can lead to inaccurate, costly lab tests and potentially toxic pharmaceutical treatments (Pialoux, et al, 2007). Chikungunya is also spread from human to human and puts caregivers, health workers and communities at risk (Pialoux et al., 2007; WHO, 2007). Impact of Chikungunya and Significance to Nursing Chikungunya epidemics debilitate populations and strip them of valuable health resources, creating a burden comparable to rheumatoid arthritis in terms of disability-adjusted life years (Krishnamoorthy, Harichandrakumar, Kumari, & Das, 2009). The poorest of the world’s populations are more likely to become ill and die of preventable communicable diseases (WHO, 2005). Poor societies are particularly at risk for zoonotic diseases like chikungunya, which are most prevalent in Africa and India where basic health services are lacking. These populations suffer up to 30 times higher rates of morbidity and mortality than a non-vulnerable population (Toole, 1992). Vulnerable populations are of particular concern by nurses, not only because of their high risk factors, but because these groups are served by community health workers (CHWs) who may have little to no formal education and few, if any, resources. Clinical trials to research an effective chikungunya vaccine, provision of a rapid sensitive sero-test are far from implementation as these results are not yet conclusive or acceptable for any clinical practice (Pialoux et al., 2007). Gap in Prevention Guidelines In the low resource settings where chikungunya occurs, scarce resources must be targeted on primary and secondary levels of prevention and, yet, current research and recommendations are aimed at physicians in tertiary care setting, which are inaccessible to most vulnerable people.

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Recent outbreaks have spurred a series of chikungunya guidelines from nation states, (EpiSante in France and United States Center for Disease Control, regions (Eurosurveillence) and, to some extent, global collaboration under the auspices of the WHO. Within the last five years, the aforementioned governmental and international organizations have developed or revised guidelines specifically designed to meet the needs of public health and medical staff at the capital level for national surveillance and clinical management of chikungunya. These guidelines are not of practical use to community-level health workers in low resource countries. The Institute of Medicine (IOM) encourages that the use of established practice guidelines be customized to where the greatest impact on health care is likely to occur (2001). Applying the IOM’s strategy to chikungunya affected areas, the majority of health care is at the village level, the most basic level of care, where advance practice nurses are needed to translate research into field practice. In shaping guidelines, nurses are supporting CHWs and are able to contribute to improving the health status of the world’s most vulnerable populations. Need for Evidence-Based Screening Evidence-based practice guidelines on screening for chikungunya and providing health education in communities at risk for chikungunya are urgently needed. Specifically, there is a need to identify public health screening tools for chikungunya in affected and at-risk populations. This guideline for chikungunya screening must be both effective in, and appropriate for, CHW practice in low resources settings. This paper describes and critically appraises the recent literature on developments in chikungunya research and serves to formulate an evidence-based guideline for CHWs in low resource regions of the world. Literature Review

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Description and Critique of the Literature The majority of chikungunya research studies were found in peer-reviewed scholarly journals, with a retrospective cohort study design initiated after the onset of a chikungunya outbreak. Epidemiologists employ these types of studies, which are rapid and “designed to inform without delay” (Merill & Timmreck, 2006). Burns describes the difficulty researchers face in studying prevention as they are “measuring something that does not occur” (pp.X, 2009). In the literature on chikungunya, three themes were identified: 1) The need for surveillance and screening methods, 2) Capacity and quality of tools to confirm cases, 3) Estimating attack and case fatalities rates. Studies of outbreaks dominated the research, as chikungunya had spread to geographic locations that had not reported the disease in the past, and these populations are immuno-naive. Some contributing factors to this dispersion of the virus are global warming, increased travel and commercial trade (Donoso-Mantke & Niedrig, 2006). Scientists investigated chikungunya outbreaks in La Reunion, a French territory east of Madagascar, as well as India and Sri Lanka, where over one million people among the three areas were infected with chikungunya since 2003 (Ramchurn, et al., 2008). The epidemics were studied with normal international disease surveillance systems in place, and new tools were used after it was known that chikungunya was involved. Surveillance and Screening Methods Depoortere and Coulombier (2006) studied retrospective chikungunya morbidity reports from 10 countries to learn if an outbreak in La Reunion was moving into Europe. In their study, chikungunya-risk assessment for Europe was based on recommendations in Eurosurveillance, whose reputable and well published authors represented a recommendations task force from the

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European Centre for Disease Prevention (ECDP). The researchers acknowledged that their data was limited, as the Institut de Veille Sanitaire and Eurosurveillance editors solely provided their data on morbidity. The data was analyzed to rapidly estimate the risks of human-to-human transmission from travelers returning from La Reunion and other chikungunya epidemic areas into Europe. The authors concluded the virus had been imported to Europe, the scope was not known, and human-to-human transmission had not yet been identified. They emphasized that their findings indicated the importance of secondary prevention by: 1) Improving surveillance of chikungunya reporting, 2) Maintaining universal precautions, 3) Educating health staff, and 4) Screening and providing chikungunya information pamphlets to travelers moving in and out of known chikungunya epidemic areas. The study design used by Depoortere and Coulombier (2006) was appropriate for realtime epidemic investigation, however, there were significant gaps in the study’s explanation of both the data collection methods and the criteria and rationale to determine which data sets were included or excluded from their study. The researchers’ biases were not identified, and potential financial or other gains from the study’s findings were not disclosed. The research article did not provide information about the accuracy of the morbidity data or what classified a case as suspect or confirmed chikungunya illness. It is not known if there had been an established case definition in the regions submitting data to the ECDP and the ability of the various health staffs to reliably use a chikungunya case definition tool in their practice. The data is not likely to be an accurate representation of the epidemic in the entire population(s), as major variations of the aggregates’ access to care, active versus passive case findings by health staffs, and the sensitivity and specificity of diagnostic and laboratory testing among the countries studied. These countries

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included six each in the Indian Ocean and Asia, as well as the United Kingdom, Belgium, the Czech Republic and Norway. Data from epidemic records from several points of care have very limited comparability. Active case finding by community health workers recorded as suspect chikungunya in morbidity registers are equated with the same level of diagnostic accuracy of an advanced clinical practitioner in a hospital. Lastly, La Reunion and other tropical areas with active chikungunya viral outbreaks are located in elite European tourist destination spots, where the appearance of chikungunya cases has political and economic implications because those communities rely on tourist dollars for their livelihoods. The extent of these influences on the actual reporting of the disease is not known. Despite this study’s overall lack of rigor, unknown bias and uncontrolled variables in the data, the ECDP’s four recommendations for secondary prevention of chikungunya are advisable, as building solid reporting systems, following blood precautions, and increasing awareness of health staff and the public are very acceptable interventions, even with the limited evidence available in this study. Capacity of Laboratories The basics for the screening of any infection rely on the quality of the screening tool; an accurate tool will report true cases screened as positive, which is of particular importance with the chikungunya virus. In 2007, Donoso-Mantke and Niedrig implemented a landmark study out of the Robert-Koch Center for Biological Studies in Berlin. The center was reputed as leading European laboratories in setting high standards of quality, having successfully identified laboratory capacities in Europe with West Nile virus in 2004. Given the occurrence of the exotic chikungunya virus in several European countries, the Robert-Koch Center was a good candidate for studying the quality of laboratory testing in Europe. The researchers utilized WHO to invite

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its partners, as well as reference laboratories belonging to the European Commission, and held registration in the European Network for Laboratory Diagnostics of Imported Viral Diseases (ENIVD), a non-profit consumer protection organization. Laboratories were invited to participate in the free, confidential external quality assurance (EQA) study. The self-selected laboratories (n=24) represented 15 European nations, and a majority of the sample was considered to be regional reference sites for specialized communicable disease testing. Participants received 12 blinded samples of all known types of chikungunya antibodies, as well as negative controls, without special education or procedures mandated by the researchers. Researchers wanted to test the capacity of labs to diagnose chikungunya with the procedures already in use, and the labs conducted testing with a variety of methods, reagents and assays. The EAQ findings show diagnostic accuracy of chikungunya was very limited in several European reference labs. The labs had not detected the high viral loads, nor were they able to discriminate among viral strains or conduct the test without the required reagent. The ENVID acknowledged that this undertaking was the first quality testing of chikungunya in Europe, and clearly even the reference laboratories were not at the industry standards. The ENVID added that diagnostic capacity needed improvement. Limitations of the study were the lack of descriptions in the methodology and analysis. An explanation of how the blinded samples were coded and what was known about the level of technical skills of the various laboratory staff were absent. Only a summary of the findings was presented, and without statistical data. There was no mention of how the low diagnostic quality of laboratory testing of chikungunya affects the reliability of surveillance data coming out of

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Europe. Estimating Morbidity and Mortality Retrospective studies are operative ways to look at communicable disease patterns (Merill & Timmreck, 2006). In 2008, researchers examined rates of mortality data pre-, during and post-chikungunya epidemic in the nine districts of Mauritius to project case fatality rates (CFR). Reporting accuracy for mortality rates is higher than that of morbidity data, thus mortality rates are less likely to be skewed by effects of an epidemic (Ramchurn et al., 2008). The researchers accessed six years of government mortality records to calculate average crude mortality rates (CMR); these rates were compared to the mortality data during the chikungunya outbreak. A p-value was used to identify statistical differences between the observed and predicted CMRs, and a 2% assumed prevalence of chikungunya was used. The study concluded that observed CMRs were a statistically sound means by which to estimate chikungunya CFRs as rates of excess mortality, retrospectively correlated with the reported CFRs in the nine districts. More explanation of confounding variables, such as deaths due to pneumonia during colder seasons and nutrition-related morbidities likely in the preharvest time of year. There are limits to using government data as the sole source of information since very poor, marginalized or undocumented populations are often excluded. Like Ramchurn et al. (2009), chikungunya research is also derived from public health surveillance data. Ledrans, Quatresous, Renault and Pierre (2007) looked at mechanisms of comprehensive epidemic monitoring and a means to estimate incidence. Their design is a descriptive population-based study, which aimed to identify epidemic trends and used a combination of case reports, as well as active and retrospective case-seeking by health staff from

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cases reported by a vector team. Use of non-specific indicators by mortality surveillance to predict normal mortality and estimated deaths due to the chikungunya virus. The Ledrans et al. (2007) study had strong points, but there were also gaps in methodology that lowered the quality of evidence provided. The sampling method employed in this research was acceptable, as case finding is the most ethical way to locate positive cases in an epidemic scenario. However, the actual diagnosis of chikungunya was made by health staff with unknown abilities and without inter-rater reliability. No screening tool, such as a case definition, was mentioned, and serological confirmation was not used. The unknown quality of the screening tool(s) and screeners in this study makes the findings unreliable. Summary of the Literature The public health studies located on the topic of chikungunya lacked the rigor and validity of multiple clinical trials. Expert opinion dominated the recent research and is considered the lowest level of evidence in research, requiring further quantitative work to be conducted to increase the results’ credibility (Craig & Smith, 2007). Recent guidelines on the clinical management of chikungunya were not directly applicable to the majority of health workers in low resource regions. Nonetheless, the available studies offer a basis of knowledge, which could be applied to prevent chikungunya. The identified themes were surveillance and screening methods, laboratory capacity to confirm cases, and forecasting epidemic rates with retrospective data. The guidelines in Appendix A are for the secondary prevention of chikungunya and aim to meet the needs of their intended audience, the community-based health worker. Implementation of the Guideline

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Relationships are essential for the successful implementation of the Chikungunya Awareness and Prevention Guideline for Community Level Health Workers. There are limits in the rigor of evidence-based research on which this guideline is built; yet, the guideline is a pilot and ready to be adapted to the needs and strengths of the community. The facilitators of the implementation need to work hand-in-hand with stakeholders in developing a network of working relationships with communities at risk for chikungunya. Parallel to the development of community contacts, regional and international organizational networks are also needed for financial and political support. Starting small with five to eight communities at risk for chikungunya, the research must aim for close oversight in building models of community-based, measurable and sustainable programs. Implementation requires a three-pronged strategy: Assessment, monitoring and evaluation of the guidelines’ impact. To begin, one must determine where the need is: Which areas of Africa, India and Sri Lanka are predicted to face importation of the chikungunya virus in the next rainy season? Epidemic forecasts of chikungunya are available through Eurosurveillance, EpiSante and WHO. Once regions are mapped out, one assesses the level of need in the community: How important is the prevention of chikungunya in the hierarchy of needs in the community? If there are food gaps or major security issues, it is not likely these communities will be able to afford the energy a chikungunya pilot would require. Just as important is identifying all the stakeholders and the available materials. Chikungunya affects working adults, and employers can be surveyed to assess possible partnerships. It is also useful to coordinate with other prevention activities such as sanitation, vector control and immunization. Bringing in a community-based worker with chikungunya

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experience to work with a pilot program is useful, as is transplanting a CHW from an at-risk area into an endemic area to be trained. The actual feasibility of implementation is reliant on several factors being in place. There must be a functioning health information system, access to high-risk groups, an understanding of population movements, funding for a minimum of two years, availability of a trained workforce and material resources, and possibilities for supervision and monitoring of activities. Many prospects for implementation exist; for example, community awareness of chikungunya can be increased through dissemination of information by radio stations, schools systems and newsletters. Monitoring and evaluation require the development of objectives and metrics. What are we measuring and how will we measure it? Outcome measures would be based on the severity of the problem, available resources and the level of health care in the area or host country. The effectiveness of this guideline is ultimately measured by a lack of predicted morbidity as compared to a baseline prevalence and incidence of chikungunya. Examples of prevention metrics: • Number of communities informed of chikungunya risk • Number of prevention activities carried out before rainy season • Number of health workers attending the prevention workshop • Number of health posts with chikungunya-case definition on site • Number of presumed chikungunya cases identified • Number of households at risk screened Conclusion Nursing and public health have an opportunity to take the most current research findings

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into practice at the village level across the globe. Research proves that surveillance; screening and community education are the most effective methods for health workers in low resources areas to lessen the impact of chikungunya. However, reports illustrate that these methods are not being utilized to nearly the degree that is necessary to manage the disease. In conclusion, these appropriate guidelines for community-based health workers provide effective methods that will significantly impact the spread and human cost of chikungunya.

References Burns, N. & Grove, S. (2009). The Practice of Nursing Research: Conduct, Critique, & Utilization (5th Ed). St. Louis, Elsevier Saunders. Charrel N., de Lamballerie, X, Raoult D. (2007) Chikungunya outbreaks -- the globalization of vectorborne diseases. N Engl J Med; 356(8): 769-71. Craig, J. & Smyth, R., (2006) The Evidence-Based Practice Manual for Nurses (2nd Ed). St. Louis,Churchill, Livingstone Elsevier.

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Depoortere, E., & Coulombier, D. (2006). Chikungunya risk assessment for Europe: recommendations for action. Eurosurveillance, 11(19):pii=2956. Retrived online on April 15th 2009, from: http://www.eurosurveillance.org/viewarticle.aspx?articleid=2956 Donoso-Mantke O. & Niedrig M. (2007). Laboratory capacity for detection of chikungunya virus infections in Europe. Eurosurveillance, 12(37): 3267. Retrieved online on April 15th, 2009 from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3267 Institute of Medicine 2001 Report Brief. Crossing the Quality Chasm: A New Health System for the 21st Century, 1-8. Retrieved online on April 9th, 2009 from: http://www.iom.edu/report.asp?id=5432. Krishnamoorthy, K., Harichandrakumar, K.T., Krishna Kumari, A., L.K. & Das, L.K. (2009). The Burden of Chikungunya in India: Estimates of disability adjusted life years (DALY) lost in 2006 epidemic. Journal of Vector Borne Diseases. 46(1), 26-35. Retrieved online on April 2nd, 2009 from: http://www.doaj.org/doaj? func=abstract&id=381588 Ledrans M, Quatresous I, Renault P. & Pierre V. (2007). Outbreak of Chikungunya in the French Territories, 2006: Lessons learned. Eurosurveillance. 12(36), 3262. Retrieved online on April 15th, 2009 from: http://www.eurosurveillance.org/ViewArticle.aspx? ArticleId=3262Eurosurveillance Merill, R.M. and Timmreck T. C. (2006). Introduction to epidemiology (4th Ed.). Sudbury, MA: Jones and Bartlett

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Ministry of Health Malaysia, (2006). Surveillance and Management of Chikungunya Disease. Disease Control Division. 1-7. Pialoux, G., Gaüzère, B., Jauréguiberry,S., & Strobel, M. (2007). Chikungunya, an epidemic arbovirosis. The Lancet. 7(5), 319-327. Ramchurn S, Goorah SS, Makhan M, Moheeput K.( 2008). Excess mortality as an epidemic intelligence tool in chikungunya mapping. Eurosurveillance. 13(7), 8039. Retrieved online on April 15th, 2009 from: http://www.eurosurveillance.org/ViewArticle.aspx? ArticleId=8039 Toole. M., (1992). Centers for Disease Control. Famine-Affected, refugee, and displaced populations: Recommendations for public health issues. MMWR. 41(No. RR-13), 16469. Center for Disease Control (CDC) (2006). Chikungunya fever diagnosed among international travelers: United States, 2005-2006. MMWR Morbidity and Mortality Weekly Report. 55(38), 1040-1042. http://wonder.cdc.gov/wonder/prevguid/p0000113/p0000113.asp World Health Organization. (2008). Guidelines on Clinical Management of Chikungunya Fever, 1- 18. Retrieved online on April 10th, 2009 from: http://www.searo.who.int/en/showdetailsnew.asp?code=B3234 World Health Organization (2004). Malaria Epidemics: Forecasting, Prevention, Early Detection and Control: From Policy to Practice 1-52. Retrieved online on April 10th, 2009 from:

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http://www.helid.desastres.net/?e=d-010who--000--1-0--010---4-----0--0-10l--11en5000---50-about-0---01131-001-110utfZz-8-00&a=d&c=who&cl=CL4&ld=Js13420e#selectedcldoc World Health Organization (2005). Malaria Control in Complex Emergencies : An Inter-Agency Field Handbook, 1-239. Retrieved online on April 10th, 2009 from: http://www.helid.desastres.net/?e=d-010who--000--1-0--010---4-----0--0-10l--11en5000---50-about-0---01131-001-110utfZz-8-00&a=d&c=who&cl=CL4&ld=Js13424e#selectedcldoc

Appendix a

Applying Evidence to Chikungunya

GUIDELINE TITLE Chikungunya Awareness and Prevention Guideline for Community Level Health Workers GUIDELINE STATUS This is the first release of the guideline and submitted for review. SCOPE DISEASE/CONDITION Chikungunya Virus GUIDELINE CATEGORY Communicable Disease: Risk Assessment Prevention, secondary CLINICAL SPECIALTY Public Health INTENDED USERS Community level health workers in low resource areas Community Health Workers (CHW) Health Educators Nurses Public Health staff GUIDELINE OBJECTIVES • Provide health workers chikungunya effective secondary prevention recommendations in low resource practice settings • Promote rationale use of material in low resource settings TARGET POPULATION Populations in Low Resource Areas Impoverished and / or displaced populations in Africa, India, an Sri Lanka. INTERVENTIONS AND PRACTICES CONSIDERED Secondary Prevention of Chikungunya at the Village Level Screen Identify at risk groups Use case definition Maintain surveillance data and mapping Test Serological testing

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Treat Health education MAJOR OUTCOMES CONSIDERED Prevent Morbidity Reduce burden of chikungunya disease on communities Empower community level health workers METHODOLOGY METHODS USED TO COLLECT/SELECT EVIDENCE Search of Electronic Databases April 2009 METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE Weighting According to a Rating Scheme (Scheme Given) RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE Levels of Evidence Level Ia: Evidence obtained from meta-analysis or systematic review of randomized controlled trials Level Ib: Evidence obtained from at least one randomized controlled trial Level IIa: Evidence obtained from at least one well-designed controlled study without randomization Level IIb: Evidence obtained from at least one other type of well-designed quasiexperimental study. Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities METHODS USED TO ANALYZE THE EVIDENCE One expert review of published articles METHODS USED TO FORMULATE THE RECOMMENDATIONS Expert Opinion DESCRIPTION OF METHODS USED TO FORMULATE THE RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS Grades of Recommendations A: There is good evidence to recommend the clinical preventive action. B: There is fair evidence to recommend the clinical preventive action. C: The existing evidence is conflicting and does not allow making a

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recommendation for or against use of the clinical preventive action; however other factors may influence decision-making. D: There is fair evidence to recommend against the clinical preventive action. E: There is good evidence to recommend against the clinical preventive action. I: There is insufficient evidence (in quantity and/or quality) to make a recommendation, however other factors may influence decision-making. METHOD OF GUIDELINE VALIDATION -pending External Peer Review RECOMMENDATIONS Secondary Prevention Practice Recommendations 1. Screen Recommendation 1.0 Identify at risk groups, start 3 months before rainy season starts (Level of Evidence = IV; Grade of Recommendation = B) Intervention Assess human migration and market movement patterns to and from known chikungunya risk areas Case finding in identified risk groups and geographic areas (Level of Evidence = IV; Grade of Recommendation = B) Recommendation 1.1 Screen suspect cases of chikungunya and populations from known chikungunya areas (Level of Evidence = IV; Grade of Recommendation = B) Intervention Use case definition differentiating chikungunya from other diseases (Level of Evidence = IV; Grade of Recommendation = B) Recommendation 1.2 Maintain surveillance data and mapping (Level of Evidence = III; Grade of Recommendation = B) Intervention Assure surveillance system is in place and working Recommendation 1.3 Prevent human-to-human transmission (Level of Evidence = III; Grade of Recommendation = B)

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Intervention Universal precautions for all persons at risk Including health workers, birth attendants, caregivers 2. Test Recommendation 2.0 No serological testing at village level (Level of Evidence = IIA; Grade of Recommendation = B) Interventions Educate health staff on poor quality of testing Re-enforce universal precautions 3. Treat Recommendation 3.0 Health education (Level of Evidence = IV; Grade of Recommendation = B) Interventions Increase Community Awareness Health teaching for at risk and suspect cases will receive information on what chikungunya is and how to prevent transmission BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE POTENTIAL BENEFITS Promote existing or increase community health workers knowledge of and abilities to prevent chikungunya Prevent morbidity of chikungunya Prevent human-human chikungunya transmission Provide preventions strategies that are with in the resource and capacity means of low resource regions. Reduce chikungunya DALYs. POTENTIAL HARMS Invalidate or disrespect community health workers who have positive prevention strategies in place. Impose outside demands on health workers when they have other life sustaining priorities (for example harvesting)

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