Advancing the Understanding of Environmental Transformations, Bioavailability and Effects of Nanomaterials, an International US Environmental Protection Agency—UK Environmental Nanoscience Initiative Joint Program

Nanotechnology has significant economic, health, and environmental benefits, including renewable energy and innovative environmental solutions. Manufactured nanoparticles have been incorporated into new materials and products because of their novel or enhanced properties. These very same properties also have prompted concerns about the potential environmental and human health hazard and risk posed by the manufactured nanomaterials. Appropriate risk management responses require the development of models capable of predicting the environmental and human health effects of the nanomaterials. Development of predictive models has been hampered by a lack of information concerning the environmental fate, behavior and effects of manufactured nanoparticles. The United Kingdom (UK) Environmental Nanoscience Initiative and the United States (US) Environmental Protection Agency have developed an international research program to enhance the knowledgebase and develop risk-predicting models for manufactured nanoparticles. Here we report selected highlights of the program as it sought to maximize the complementary strengths of the transatlantic scientific communities by funding three integrated US-UK consortia to investigate the transformation of these nanoparticles in terrestrial, aquatic, and atmospheric environment. Research results demonstrate there is a functional relationship between the physicochemical properties of environmentally transformed nanomaterials and their effects and that this relationship is amenable to modeling. In addition, the joint transatlantic program has allowed the leveraging of additional funding, promoting transboundary scientific collaboration.

Facilities for Centralized Isolation and Quarantine for the Observation and Treatment of Patients with COVID-19

The coronavirus disease 2019(COVID-19)pandemic increased the burden on many healthcare systems and in the process,exposed the need for medical resources and physical space.While few studies discussed the efficient utilization of medical resources and physical space so far.Therefore,this study aimed to summarize experiences related to facilities used for centralized isolation for medical observation and treatment during the COVID-19 pandemic in China and to provide suggestions to further improve the management of confirmed cases,suspected cases,and close contacts.In China,three types of facilities for centralized isolation(Fangcang shelter hospitals,refitted non-designated hospitals,and quarantine hotels)underwent retrofitting for the treatment and isolation of confirmed and suspected cases.These facilities mitigated the immediate high demand for space.Moreover,in order to minimize infection risks in these facilities,regulators and governmental agencies implemented new designs,management measures,and precautionary measures to minimize infection risk.Other countries and regions could refer to China’s experience in optimally allocating social resources in response to the COVID-19 pandemic.As a conclusion,government should allocate social resources and construct centralized isolation and quarantine facilities for an emergency response,health authorities should issue regulations for centralized isolation facilities and pay strict attention to the daily management of these facilities,a multidisciplinary administration team is required to support the daily operation of a centralized isolation facility,in-depth studies and international collaboration on the centralized isolation policy are encouraged.

Supranutrition of microalgal docosahexaenoic acid and calcidiol improved growth performance,tissue lipid profiles,and tibia characteristics of broiler chickens

Background Docosahexaenoic acid(DHA)and calcidiol could be enriched in chicken for improving public nutrition and health.It remains unclear if supranutritional levels of DHA and calcidiol impair growth performance or metabolism of broiler chickens.This study was to determine singular and combined effects of high levels of supplemental DHA-rich microalgal biomass or oil and calcidiol on growth performance,concentrations of triglycerides,cholesterol,and nonesterfied fatty acids in plasma,liver,breast,and thigh,and biophysical properties of tibia.Methods In Exp.1,144 day-old Cornish chicks were divided into 4 groups(6 cages/treatment,6 birds/cage),and were fed a corn-soybean meal basal diet(BD),BD+10,000 IU calcidiol/kg(BD+Cal),BD HA),and BD+1%DHA-rich Aurantiochytrium(1.2 g DHA/kg;BD+D+Cal+DHA for 6 weeks.In Exp.2,180 day-old chicks were divided into5 groups,and were fed:BD,BD+DHA(0.33%to 0.66%oil,1.5 to 3.0 g DHA/kg),BD EPA/kg),BD+DHA+EPA(1.9%to 3.8%eicosapentaenoic acid-rich Nannochloropsis sp.CO18,0.3 to 0.6 g BD+DHA+calcidiol(6000 to 12,000 IU/kg diet),and+DHA+EPA+Cal for 6 weeks.Results Birds fed BD+Cal diet in Exp.1 and BD lower(P+DHA<0.05)+EPA diet in Exp.2 had higher(P<0.05)body weight gain(10%-11%)and gain:feed ratio(7%),and total cholesterol and triglyceride concentrations in plasma(18%-54%),liver(8%-26%),breast(19%-26%),and thigh(10%-19%),respectively,over the controls.The two diets also improved(P<0.05)tibial breaking strength(8%-24%),total bone volume(2%-13%),and(or)bone mineral density(3%-19%)of chickens.Conclusion Supranutrition of dietary calcidiol and DHA alone or together did not produce adverse effects,but led to moderate improvements of growth performance,lipid profiles of plasma and muscle,and bone properties of broiler chickens.

Climate &Sustainability Implications of Land Use Alterations in an Urbanizing Region: Raleigh-Durham, North Carolina

Urban climate is the most immediate manifestation of the warming global climate for the majority of people on earth. Nearly half of those people live in small to medium sized cities, an understudied scale in urban climate research. Widespread characterization would be useful to decision makers in planning and design for land use decisions. Using a multi-method approach, the mesoscale UHI in the study region is characterized and the secular trend over the last sixty years evaluated. Under isolated ideal conditions the findings indicate a UHI of 5.3℃ ± 0.97℃ to be present in the study area, the magnitude of which is growing over time.

Canine on the Couch:The New Canary in the Coal Mine for Environmental Health Research

Human health is intimately connected and tied to the health of our environment and ecosystem,with only a very small fraction of the risk for chronic diseases explained by genetics alone.Companion animals are prone to disease types that are shared with people,including cancers and endocrine disorders,reinforcing the thought that environmental factors contribute to the risks for chronic diseases.These factors include air and water pollution and the built environment.As such,there is increasing interest in pursuing research with companion animals,and specifically dogs,as sentinel species to inform comparative health assessments and identify risk factors for disease.Of the canine diseases for which environmental exposure research has been published,cancers have received the most attention.This review summarizes two main aspects of this comparative approach:(1)cancers that occur in dogs and which are similar to humans and(2)research investigating environmental exposures and health outcomes in dogs.The goal of this review is to highlight the diverse conditions in which pet dogs may provide unique perspectives and advantages to examine relationships between environmental exposures and health outcomes,with an emphasis on chemical pollution and cancer.Furthermore,this review seeks to raise awareness and stimulate discussion around the best practices for the use of companion animals as environmental health sentinels.

松花江干流治理工程生态护坡覆土改良研究

为有效解决松花江干流堤防生态护坡覆土土源不足及土源质量差的问题,本研究选取工程现场剥离的表层稻田土和工程废弃的砂土、黏土为研究对象,依据3种土壤分析测定的理化特性,设计9种不同配比的改良土壤进行覆土改良试验研究,通过对改良土壤的颗粒组成、水分特征、养分状况以及盆栽试验植物生长状况的测定、调查和综合对比分析,处理M(50%稻田土+25%砂土+25%黏土)和处理O(50%稻田土+10%砂土+40%黏土)均可作为松花江干流堤防生态护坡适宜的覆土改良配比。此配比的改良土壤在保证护坡植被正常生长的前提下,能够减少腐殖土用量50%,充分利用现场废弃土,有效降低工程建设成本,对黑龙江省河流堤防生态护坡建设具有较强的实践指导意义和广泛推广应用价值。对于改良土壤中速效氮缺乏和有机质含量不高的问题,可通过坡面种植豆科绿肥植物和添加废弃水稻秸秆等方法加以补充和改善。

德日美英等发达国家循环经济模式的比较研究与启示

工业化迅速发展所带来了资源的短缺与环境污染的加剧。西方发达国家非常重视发展循环经济,尤其是德、日、美、英和欧盟等发达国家或地区,逐步形成了自己的发展模式。我国正处于经济社会快速发展阶段,发展循环经济,逐步实现工业文明向生态文明的转变是发展的主题,因而学习、借鉴发达国家发展循环经济的理念以及在立法、实施等方面的实践经验具有重要意义。

The structure of turbulent flow through submerged flexible vegetation

The hydrodynamics of turbulent flow through submerged flexible vegetation is investigated in a flume using acoustic Doppler velocimetery(ADV)measurements.The flow characteristics such as the energetics and momentum transfer derived from convcntional spectral and quadrant analyses are considered as the flow encounters a finite vegetation patch.Consistent with numerous canopy flow experiments,a shear layer and coherent vortex structures near the canopy top emerge caused by Kelvin-Helmholtz instabilities after the flow equilibrates with the vegetated layer.These in stabilities are commonly attributed to velocity differences between non-vegetated and vegetated canopy layers in agreement with numerous experiments and simulations conducted on dense rigid canopies.The power-spectral density function for vertical velocity turbulent fluctuations at different downstream positions starting from the edge of the vegetation layer are also computed.For a preset water depth,the dominant dimensionless frequency is found to be surprisingly invariant around 0.027 despite large differences in vegetation densities.The ejection and sweep events significantly contribute to the Reynolds stresses near the top of the vegetation.The momentum flux carried by ejections is larger than its counterpart carried by the sweeps above the canopy top.However,the momentum flux carried by sweeps is larger below the top of the canopy.

Hurricane disturbances, tree diversity, and succession in North Carolina Piedmont forests, USA

Windthrow plays a critical role in maintaining species diversity in temperate forests. Do large-scale strong wind events(i.e., tropical cyclones, including hurricanes,typhoons and severe cyclonic storms) increase tree diversity in severely damaged forest areas? Do hurricanes(tropical cyclones that occurs in the Atlantic Ocean and northeastern Pacific Ocean) lead to altered relative abundance of shade-tolerant and shade-intolerant species? Did historic hurricanes alter the succession trajectory of the damaged forests? We used nearly 70-year tree demographic data to assess the effects of two major hurricanes on woody species diversity in Piedmont forests, North Carolina, USA. Species richness(S) and Shannon–Wiener's diversity index(H') were used to evaluate the changes in tree diversity. The changes in composition were assessed with Nonmetric Multidimensional Scaling. The pre-hurricane successional phase can strongly influence both the damage severity and subsequent responses. Although there is often an immediate drop in diversity following a hurricane, understory tree diversity quickly increases to levels that exceed those prior to the disturbance. This leads to an increase in diversity in stands that were substantially damaged. Hurricanes significantly decrease the dominance of shade-intolerant canopy species while increasing preestablished, more shade-tolerant species. We conclude that large, and infrequent hurricanes help to maintain local tree diversity, but also accelerate the increase in dominance of understory species such as red maple and beech.

Urinary cystatin C:pediatric reference intervals and comparative assessment as a biomarker of renal injury among children in the regions with high burden of CKDu in Sri Lanka

Background Cystatin C(Cys-C)is an emerging biomarker of renal diseases and its clinical use,particularly for screening the communities affected by chronic kidney disease of unknown etiology(CKDu),is hindered due to the lack of reference intervals(RIs)for diverse ethnic and age groups.The present study aimed to define RIs for urinary Cys-C(uCys-C)for a healthy pediatric population in Sri Lanka and in turn compare the renal function of the residential children in CKDu endemic and non-endemic regions in Sri Lanka.Methods A cross-sectional study was conducted with 850 healthy children(10-17 years)from selected locations for reference interval establishment,while a total of 892 children were recruited for the comparative study.Urine samples were collected and analyzed for Cys-C,creatinine(Cr)and albumin.Cr-adjusted uCys-C levels were partitioned by age,and RIs were determined with quantile regression(2.5th,50th and 97.5th quantiles)at 90%confidence interval.Results The range of median RIs for uCys-C in healthy children was 45.94-64.44 ng/mg Cr for boys and 53.58-69.97 ng/mg Cr for girls.The median(interquartile range)uCys-C levels of children in the CKDu endemic and non-endemic regions were 58.18(21.8-141.9)and 58.31(23.9-155.3)ng/mg Cr with no significant difference(P=0.781).A significant variation of uCys-C was noted in the children across age.Conclusions Notably high uCys-C levels were observed in children with elevated proteinuria.Thus,uCys-C could be a potential biomarker in identifying communities at high risk of CKDu susceptibility.

Impact of two different types of El Nino events on the Amazon climate and ecosystem productivity

Aims The Amazon basin plays an important role in the global carbon budget.Interannual climate variability associated with El Nino can affect the Amazon ecosystem carbon balance.In recent years,studies have suggested that there are two different types of El Ninos:eastern-Pacific(EP)El Nino and central-Pacific(CP)El Nino.The impacts of two types of El Nino on the Amazon climate and Amazon ecosystem are analyzed in the study.Methods A composite method has been applied to highlight the common features for the EP-and CP-El Nino events using observational data,IPCC-AR4 model output.Potential impacts of the two different types of El Nino on ecosystem carbon sequestration over the Amazon have been investigated using a process-based biogeochemical model,the Biome–BioGeochemical Cycles model(Biome–BGC).Important Findings Below-normal rainfall is observed year round in northern,central and eastern Amazonia during EP-El Nino years.During CP-El Nino years,negative rainfall anomalies are observed in most of the Amazon during the austral summer wet season,while there is average or above-average precipitation in other seasons.EP-and CP-El Nino events produce strikingly different precipitation anomaly pattern in the tropical and subtropical Andes during the austral fall season:wetter conditions prevail during EP-El Nino years and drier conditions during CP-El Nino years.Temperatures are above-average year round throughout tropical South America during EP-El Nino events,especially during austral summer.During CP-El Nino events,average or slightly above-average temperatures prevail in the tropics,but these temperatures are less extreme than EP year’s temperature except in austral fall.These precipitation and temperature anomalies influence ecosystem productivity and carbon sequestration throughout the Amazon.Using the Biome–BGC model,we find that net ecosystem production(NEP)in the EP-El Nino years is below average,in agreement with most previous studies;such results indicate that the Amazon region acts as a net carbon source to the atmosphere during EP-El Nino years.In the CP-El Nino years,NEP does not differ significantly from its climatological value,suggesting that the Amazon forest remains a carbon sink for the atmosphere.Thus,even if CP-El Nino events increase in frequency or amplitude under global warming climate as predicted in some Global Climate Models,the Amazon rainforest may remain a carbon sink to the atmosphere during El Nino years in the near future.

Household perceptions and subjective valuations of indoor residual spraying programmes to control malaria in northern Uganda

Background:Insecticide-based tools remain critical for controlling vector-borne diseases in Uganda.Securing public support from targeted populations for such tools is an important component in sustaining their long-run effectiveness.Yet little quantitative evidence is available on the perceived benefits and costs of vector control programmes among targeted households.Methods:A survey was administered to a clustered random sample of 612 households in Gulu and Oyam districts of northern Uganda during a period of very high malaria transmission and following a pilot indoor residual spray(IRS)programme.A discrete choice experiment was conducted within the survey,in which respondents indicated their preferences for different IRS programmes relative to money compensation in a series of experimentally controlled,hypothetical choice sets.The data were analysed using conditional logit regression models to estimate respondents’willingness to accept(WTA)some amount of money compensation in lieu of foregone malaria risk reductions.Latent class models were used to analyse whether respondent characteristics predicted WTA.Results:Average WTA is estimated at$8.94 annually for a 10%reduction in malaria risk,and additional co-benefits of IRS were estimated to be worth on average$54–$56(depending on insecticide type)per round of IRS.Significant heterogeneity is observed:Four in five household heads in northern Uganda have high valuations for IRS programmes,while the remaining 20%experience costly side effects of IRS(valued at between$2 and$3 per round).Statistically significant predictors of belonging to the high-value group include respondent gender,mean age of household members,participation in previous IRS,basic knowledge of mosquito reproduction,and the number of mosquito nets owned.Proxies for household income and wealth are not found to be statistically significant predictors of WTA.Conclusions:This study suggests that the majority of people in areas of high malaria transmission like northern Uganda place a high value on vector control programmes using IRS.However,there is significant heterogeneity in terms of the perceived side effects(positive and negative).This has implications for sustaining public support for these programmes in the long-term.

Recipes for the Derivation of Water Quality Parameters Using the High-Spatial-Resolution Data from Sensors on Board Sentinel-2A,Sentinel-2B,Landsat-5,Landsat-7,Landsat-8,and Landsat-9 Satellites

Satellites have provided high-resolution(<100 m)water color(i.e.,remote sensing reflectance)and thermal emission imagery of aquatic environments since the early 1980s;however,global operational water quality products based on these data are not readily available(e.g.,temperature,chlorophyll-a,turbidity,and suspended particle matter).Currently,because of the postprocessing required,only users with expressive experience can exploit these data,limiting their utility.Here,we provide paths(recipes)for the nonspecialist to access and derive water quality products,along with examples of applications,from sensors on board Landsat-5,Landsat-7,Landsat-8,Landsat-9,Sentinel-2A,and Sentinel-2B.We emphasize that the only assured metric for success in product derivation and the assigning of uncertainties to them is via validation with in situ data.We hope that this contribution will motivate nonspecialists to use publicly available high-resolution satellite data to study new processes and monitor a variety of novel environments that have received little attention to date.

A Prospective Cohort Study of Antimony Exposure and Cognitive Impairment in Older Adults—China,2017–2021

What is already known about this topic?Antimony(Sb)has been identified as a new neurotoxicant that impacts neurological functions in animal studies.However,its effects on the human population remain unknown.What is added by this report?The study reveals that there is an association between exposure to Sb and a higher incidence of cognitive impairment in older adults.The dose-response curve demonstrates that the risk of cognitive impairment consistently increased with higher levels of Sb exposure without a discernible threshold.What are the implications for public health practice?Reducing exposure to Sb may have a beneficial effect in delaying or preventing the onset of cognitive impairment.This intervention has the potential to significantly decrease the disease burden associated with cognitive impairment,ultimately contributing to social development.

Sustaining the gains made in malaria control and elimination

Significant progress has been made in the last 25 years to reduce the malaria burden,but considerable challenges remain.These gains have resulted from large investments in a range of control measures targeting malaria.Fana and co-authors find a strong relationship between education level and net usage with malaria parasitemia in pregnant women,suggesting the need for targeted control strategies.Mayala and co-workers find important links between agriculture and malaria with implications for inter-sectoral collaboration for malaria control.

Uncertainty analysis of forest carbon sink forecast with varying measurement errors:a data assimilation approach

Aims Accurate forecast of ecosystem states is critical for improving natural resourcemanagement and climate change mitigation.Assimilating observed data into models is an effective way to reduce uncertainties in ecological forecasting.However,influences ofmeasurement errors on parameter estimation and forecasted state changes have not been carefully examined.This study analyzed the parameter identifiability of a process-based ecosystem carbon cycle model,the sensitivity of parameter estimates and model forecasts to the magnitudes of measurement errors and the information contributions of the assimilated data to model forecasts with a data assimilation approach.Methods We applied a Markov Chain Monte Carlo method to assimilate eight biometric data sets into the Terrestrial ECOsystemmodel.The data were the observations of foliage biomass,wood biomass,fine root biomass,microbial biomass,litter fall,litter,soil carbon and soil respiration,collected at the Duke Forest free-air CO_(2)enrichment facilities from 1996 to 2005.Three levels ofmeasurement errorswere assigned to these data sets by halving and doubling their original standard deviations.Important Findings Results showed that only less than half of the 30 parameters could be constrained,though the observations were extensive and themodelwas relatively simple.Highermeasurement errors led to higher uncertainties in parameters estimates and forecasted carbon(C)pool sizes.The longterm predictions of the slow turnover pools were affected less by the measurement errors than those of fast turnover pools.Assimilated data contributed less information for the pools with long residence times in long-term forecasts.These results indicate the residence times of C pools played a key role in regulating propagation of errors from measurements to model forecasts in a data assimilation system.Improving the estimation of parameters of slowturnover C pools is the key to better forecast long-term ecosystem C dynamics.

Effects of silver nanoparticle size,concentration and coating on soil quality as indicated by arylsulfatase and sulfite oxidase activities

Recently, the nanotechnology industry has seen a growing interest in integrating silver nanoparticles(AgNPs) into agricultural products, which increases soil exposure to these particles. This demands an investigation into the effect of AgNPs on soil health. Changes in soil enzyme activities upon exposure to AgNPs can serve as early indicators of any adverse effects that these particles may have on soil quality. This study aimed to determine the effects of AgNP size, concentration, coating, and exposure time on the activities of two sulfur cycle enzymes, arylsulfatase and sulfite oxidase. To investigate the sensitivity of soil enzyme activity to AgNP contamination, silt loam soil samples were treated with 30, 80, and 200 nm-sized AgNPs coated with citrate, lipoic acid,and polyvinylpyrrolidone at 1, 10, and 100 mg Ag kgsoil, with the changes in enzyme activities monitored at 3 h, 3 d, and 30 d after treatment. For comparison, the effects of silver(Ag) ions on the enzyme activities were studied under similar treatment conditions. For most of the concentrations tested, the inhibitory effects of AgNPs on different enzymes differed, with a much stronger effect on sulfite oxidase activity than on arylsulfatase activity. The AgNP concentration and exposure time played much important roles than coating type and particle size in the effects of AgNPs on soil enzyme activities.

Industrial solid waste flow analysis of eco-industrial parks： implications for sustainable waste management in China

Sustainable waste management in the industrial ecology perspective brings enormous challenges to the existing methodology of waste analysis at the industrial park （IP） scale. In this study, a four-step method was proposed for industrial solid waste （ISW） flow analysis of eco-industrial parks （EIPs） and applied to two IPs in eastern China. According to a park-wide census of 619 industrial enterprises and 105 questionnaires by a survey from 2006 to 2008, the results indicated that： 1） at the enterprise scale, more than 60% of enterprises were small- ISW-generation enterprises which encountered great difficulties on effective waste management; 2） at the IP scale, though the two IPs have set up their own environmental management systems and passed the ISO 14001 certification, the efficiencies of the ISW manage- ment systems have yet to be improved in the industrial ecology perspective; and 3） at the regional scale, more than 97% of ISW flowed within the provincial region, indicating that the provincial governments prevented the wastes from flowing into their own ＂back yard＂. Effective waste management should be placed in a broader perspective. Approaches to sustainable waste management may include wastes exchange, efficient waste and information flow, virtual EIP, waste minimization clubs and regionalization of waste management.

Mojave desert tortoise(Gopherus agassizii)thermal ecology and reproductive success along a rainfall cline

Desert resource environments(e.g.microclimates,food)are tied to limited,highly localized rainfall regimes which generate microgeographic variation in the life histories of inhabitants.Typically,enhanced growth rates,reproduction and survivorship are observed in response to increased resource availability in a variety of desert plants and short-lived animals.We examined the thermal ecology and reproduction of US federally threatened Mojave desert tortoises(Gopherus agassizii),long-lived and large-bodied ectotherms,at opposite ends of a 250-m elevation-related rainfall cline within Ivanpah Valley in the eastern Mojave Desert,California,USA.Biophysical operative environments in both the upper-elevation,“Cima,”and the lower-elevation,“Pumphouse,”plots corresponded with daily and seasonal patterns of incident solar radiation.Cima received 22%more rainfall and contained greater perennial vegetative cover,which conferred 5°C-cooler daytime shaded temperatures.In a monitored average rainfall year,Cima tortoises had longer potential activity periods by up to several hours and greater ephemeral forage.Enhanced resource availability in Cima was associated with larger-bodied females producing larger eggs,while still producing the same number of eggs as Pumphouse females.However,reproductive success was lower in Cima because 90%of eggs were depredated versus 11%in Pumphouse,indicating that predatory interactions produced counter-gradient variation in reproductive success across the rainfall cline.Land-use impacts on deserts(e.g.solar energy generation)are increasing rapidly,and conservation strategies designed to protect and recover threatened desert inhabitants,such as desert tortoises,should incorporate these strong ecosystem-level responses to regional resource variation in assessments of habitat for prospective development and mitigation efforts.

Utilization and expenses of outpatient services among tuberculosis patients in three Chinese counties:an observational comparison study

Background:The China-Gates TB project Phase II implemented case-based payment reform in three Chinese counties in 2014,designed specifically for patients diagnosed with Tuberculosis(TB).This study aimed to examine the changes in utilization and expenses of outpatient services before and after the reform implementation,among TB patients in the three counties in China.Methods:We collected quantitative data using surveys in 2013(baseline year)and 2015(final year).We used outpatient hospital records to measure service utilization and medical expenses of TB patients.We conducted qualitative interviews with local health authorities,officers of health insurance agencies,and hospital managers(n=18).We utilized three focus group discussions with hospital staff and TB doctors and nurses.The x^2 tests and Mann-Whitney U tests were used to analyse quantitative data,and the thematic analysis using a framework approach was applied to analyse qualitative data.Results:Dantu and Yangzhong counties enacted TB-specific case-based payment method in 2014.Jurong County maintained global budget payment but raised the reimbursement rate for TB care.Compared to the baseline,the percentage of TB patients in Dantu and Yangzhong with eight or above outpatient visits increased from 7.5 to 55.1%and from 22.1 to 53.1%in the final survey,respectively.Jurong experienced the opposite trend,decreasing from 63.0 to 9.8%.In the final survey,the total outpatient expenses per patient during a full treatment course in Dantu(RMB 2939.7)and Yangzhong(RMB 2520.6)were significantly higher than those in the baseline(RMB 690.4 and RMB 1001.5,respectively),while the total outpatient expenses in Jurong decreased significantly(RMB 1976.0 in the baseline and RMB 660.8 in the final survey).Health insurance agencies in Dantu and Yangzhong did not approve the original design with outpatient and inpatient expenses packaged together,revealed by qualitative interviews.Furthermore,staff at designated hospitals misunderstood that health insurance agencies would only reimburse actual expenses.Many TB doctors complained about their reduced salary,which might be due to decreased hospital revenue generated from TB care after the payment method reform.Conclusions:The intended effect on cost containment of case-based payment was not evident in Dantu and Yangzhong.In Jurong,where the global budget payment system maintained with the reimbursement rate enhanced,we found an effect on cost containment but the quality of TB care might be compromised.The TBspecific case-based payment method could be redesigned to combine payment on outpatient and inpatient expenses and to set an appropriate payment standard for TB care during a full treatment course.Local health insurance agencies have to provide explicit explanations on the payment method.TB care providers should be provided with proper incentives.Monitoring and evluaiton on the quality of TB care should be undertaken at regular intervals.