Healthcare for Patients with Interstitial
Ming-Huei Lee1,2, Huei-Ching Wu2,3, Jen-Yung Lin4, Yung-Fu Chen3, John Y. Chiang5, Tan-Hsu Tan6
1Dept. of Management Infor. Syst., Central Taiwan University of Science and Technology, Taichung, Taiwan
2Department of Urology, Fong-Yuan Hospital, Department of Health, Executive Yuan, Taichung, Taiwan
3Dept. of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan
4Department of Computer Science and Information Engineering, Da-Yeh University, Changhua, Taiwan
5Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung. Taiwan
6Department of Electrical Engineering, National Taipei University of Technology, Taipei, Taiwan
Abstract—Interstitial cystitis (IC) is a chronic disease which
results of RAND interstitial cystitis epidemiology study showed
highly degrades the quality of life for patients. The objective of this
that female IC/BPS patients experience much higher level of
study is to adopt Internet intervention for caring IC patients to
sexual dysfunction (88% vs 43%), such as lack of sex interest
alleviate their pains and bothering syndromes. Healthcare
(64% vs 31%), arousal difficulties (61% vs 19%), and pain
education was conducted through Internet by asking the patients, divided into study and control groups, to check contraindications,
(67% in bladder; 52% in genital area vs 15%), compared to the
habits, and behaviors weekly to remind and consolidate important rules for promoting quality of life (QOL). Questionnaires,
The overall prevalence of IC/BPS is 0.68% in Finland ,
including SF-36, O’Leary-Sant symptom and problem indices, and
2.7-6.5% in the USA , and 1.1% for male and 2.4% for
VAS pain and urgency scales, were used to evaluate improvements
female in the Swedish population . However, it is likely
of quality of life before and after ICT intervention. The results
under-diagnosed and under-estimated according to a study
show that the QOL of patients in the study group with ICT intervention have been significantly improved compared to the
performed recently in the United States .
patients in the control group. The E-health system was
IC/BPS patients always suffer from sleep disorder, working
demonstrated to be effective in improving QOL of IC patients
limitation, and stress . It was reported that the physical and
through intervention of Internet healthcare education for the
mental status of the IC/PBS patients are significantly worse than
consolidation of healthy dieting habit and life style.
general population , greatly deteriorating their quality of
life. Serious isolation from regular social life, unable to work
Index Terms—Interstitial Cystitis (IC), Information and
normally, acquisition of depression, or commitment of suicide
Communication Technology (ICT), Mobile Phone, E-Health, Quality of Life.
was also observed in some patients [16,17]. The IC/PBS treatments are very diverse. Currently, there is no single therapy
which is effective in treating the disease. Clinically, the patients have been long annoyed by the disease making them suspect to
nterstitial cystitis /bladder pain syndrome (IC/BPS) is a
further supportive therapies, such as medication prescriptions or
Ichronic bladder disease characterized by suprapubic pain other invasive treatments. Most of the patients visit their
related to bladder filling, urgency, frequency, and nocturia in
physicians to seek only supportive therapies, resulting in the
the absence of proven urinary infection or other definable
waste of medical resource, deficiency of effective healthcare,
pathologic etiology . The cause of the disease is unknown.
Whether it is originated from the bladder or other pelvic organs
The IC/PBS disease also imposes great economic loading for
or is a systematic disease is still not elucidated . Dyspareunia
the patients and their country. The cost induced includes direct
is also widely observed in female IC/BPS patients with pain as
healthcare expenditure, as well as indirect loss caused by
the most important finding significantly degrading the quality of
unemployment. It was reported that the direct cost in treating the
life [3,4]. It is estimated to occur in 49-90% of the IC/BPS
IC patients is 2-3 times more than non-IC patients with an
patients; among them, 54% intended to avoid intercourse most
increase of direct cost of 4000 US$ compared to their
of the time because of incurred sex pain . Sex pain is a strong
age-matched counterparts . An increase of indirect cost
indicator of poor quality of life for IC/BPS patients [6,7]. The
caused by unemployment and other social costs was also
symptoms may be effective to promote quality of life; (2) although IC is not a malignant disease, treatment of IC patients
A. Application of ICT in Health Care
needs a lot of healthcare resources and may cause a great burden
By taking poor compliance of self-management regimens into
for the country; and (3) intervention using mobile phone and
consideration, Celler et al.  proposed a Home Televare
Internet is effective in caring patients with chronic diseases in
System to monitoring physiological signs, scheduling and
outpatient and ambulatory settings. The objective of this study
reminding medication, and healthcare education. It was
is as follows: (1) to develop an E-health system by integrating
demonstrated to be effective in early identification of adverse
mobile phone and Internet for caring IC patients to alleviate
events to avoid hospital readmission or to reduce length of stay
their pains and symptoms; (2) to effectively care IC patients
in hospital. Izquierdo et al.  reported that the home
through the intervention of a IC/BPS healthcare team consisting
telemedicine system applied to transmit blood glucose and
of nursing case managers and urologists to improve the quality
blood pressure data of elder patients with Type 2 diabetes to a
of life of IC/BPS patients. In this study, nursing case managers
nurse case manager is effective in identifying and remediating
are responsible to communicate with IC/BPS patients through
urgent situations. It highly decreased their mortality and
short message service (SMS) provided by the mobile phone and
morbidity for a patient to adopt videoconference to
Internet to elevate healthcare efficiency by directly solving their
communicate with a nurse or dietitian for diabetes management
complaints or problems through real-time response. In addition,
and access website data for education every 4-6 months.
healthcare education can be reinforces through Internet by
Sehati et al.  tested an Internet-based ambulatory patient
asking the patients to check food contraindications, daily
monitoring system to continuously monitor 8 physiological
activities, and living habits weekly to remind and consolidate
signs and transmitted to a PDA through either wired link or
important rules for promoting quality of life.
wireless links (infrared or Bluetooth). The signals were then
transmitted to a central server for further processing and for storing in a relational database from the PDA. It demonstrated
the feasibility and need of a programmable system for remote
In this study, a web service designed for providing health
monitoring and advising in clinical setting. Recently, an
education and administrating questionnaires were used for
integrated wireless system was designed and proposed to
health care and health management of IC/BPS patients. The
monitor vital signs and locations of unattended patients at
information of educational material for IC patients was included
emergency department or disaster sites . In this system,
in the webpage of the Taiwan Interstitial Cyscitis Association
wireless vital signs (ECG and SpO2) monitoring,
geo-positioning, signal processing, targeted alerting, and
wireless caregiver interface modules were integrated to achieve the objective of caring overcrowded unattended patients. The
prototype was demonstrated to be capable of detecting alarms
The architecture of the web-based IC/BPS healthcare and
which showed vital conditions of unattended patients and their
management system (HMS) is shown in Fig. 1. As shown in this
locations so that the caregivers could immediately locate the
figure, the web service was installed in the web server to
respond or communicate with the mobile phone by
More recently, a system which used cellular phone based on
sending/receiving short messages through Hinet message center.
Internet to care obese patients with hypertension for improving
The IC/BPS HMS can be linked from the TICA website. The
their blood pressure, weight control, and serum lipids . The
data flow is illustrated as follow: Client Side Computer ↔
intervention was done by simply asking patients to record their
Socket to Air API ↔ Socket to Air Server ↔ Message Center
blood pressure and body weight weekly through Internet or by
↔ Mobile Phone. ASP .NET C# was adopted to develop the
cellular phone. Additional intervention was to send optimal
web service system. The MS IIS7 and MS SQL Express were
recommendations to the patients weekly. It was demonstrated
used to handle the web server and database management system,
that the intervention by sending simple messages through
cellular phone and Internet can significantly decrease blood
pressure, as well as effectively reduce body weight and waist circumference. The similar intervention was also shown to be effective in decreasing blood glucose levels of obese type 2 diabetes patients .
To the best of our knowledge, E-health system has never been
applied for caring patients with IC/BPS before. The motivations of this study are summarized as follows: (1) it is impossible to completely cure IC disease currently using a general treatment, an individual case might need different treatment from the
others, hence finding methods to alleviate the pains and
prostatis within a 3-month period; (9) bladder or ureteral calculi;
Table I shows the items used for health education. The
(10) active genital herpes; (11) uterine, cervical, vaginal, or
patients receiving ICT intervention were asked to check the
items weekly. Participants who forget to fill the form will be
cyclophosphamide or any type of chemical cystitis; (14)
noticed by email or simple mobile phone message.
tuberculous cystitis; (15) radiation cystitis; (16) benign or
malignant bladder tumors; (17) vaginitis; and (18) age less than 18 years.
A total of 80 patients were recruited from the urological clinic
WEEKLY CHECK FOR CONSOLIDATING THE BEHAVIOR PROMOTED BY HEALTH
of a hospital located in central Taiwan and randomly assigned to
Please check “Yes” or “No” based on your experience during the past week.
either the study group (N=40) or the control group (N=40).
Among them, 7 patients in the study group and 8 in the control
Do you drink 1500 c.c. of water or so daily?
group were excluded because they failed to fill the
Do you eat banana, pine apple, citrus fruit, or other food
questionnaires in either pre- or post- test. Only the data of 65
containing a great amount of potassium. Do you drink any beverage which contains alcohol, coffee,
patients, 33 in the study group and 32 in the control group, were
used for further analysis. In addition to regular treatment,
Do you smoke? Have you done mild aerobic exercise, such as yoga, hiking,
patients in the study group were asked to self-manage their diets
and life styles by responding health education questions weekly
Do you wear cozy, loose clothes, and put on underwear
so that their compliance in following the suggestions in the
If you don’t have pain or sexual intercourse, please check “Unavailable”,
provided materials can be checked. This intervention is
otherwise check “Yes” or “No” according to your personal experiences. Y N NA
expected to be useful for changing and consolidating their
I have bathed the whole lower abdomen with warm
habitual behavior. In contrast, only routine treatment was
water (40oC) more than once a day, each lasting for
15 minutes, or placed a heat pad over the abdomen to
administrated to the patients for the patients of the control group.
keep it warm to relieve uncomfortable symptom.
The study was approved by the IRB of Taichung Hospital,
I have tried to relax my body muscles through meditation to decrease the activation of sympathetic
Department of Health of Taiwan. Table II compares the
nervous system and tension, or used a heat pad to
demographic information of the patients in the study and control
groups. It can be observed that there is no significant difference
I have used lubricant (ointment) to relieve
uncomfortable feeling during intercourse.
(p>0.05) between two groups with regard to age, marriage, and
When feeling uncomfortable during intercourse, I
have changed the posture to the top position to
maneuver the force exerted and alleviate the feeling
of pain. I have washed and cleaned the vulva and keep them
COMPARISON OF DEMOGRAPHIC INFORMATION BETWEEN STUDY AND
I have bathed the whole abdomen with warm water
(40oC) for 20 minutes to decrease the occurrence of pelvic pain.
Demographic Information Control (N=32) Study (N=33) p-valueC. Subjects and Disease Diagnosis
Currently, the diagnosis of IC/BPS disease is still challenging
that evidence-based diagnosis of the disease is still insufficient
. In this study, the diagnosis was based on the inclusion and exclusion clinical criteria proposed by National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK)
In this study, information and communication technology
guideline . The inclusion clinical diagnosis criteria include
(ICT) was adopted as the intervention to elevate healthcare
cystoscopic observations, i.e. glomerulations and/or classic
quality of IC/BPS patients. The questionnaires, including SF-36
Hunner’s ulcer and symptoms, i.e. bladder pain and/or urinary
health survey, visual analogue scales (VAS) for the
urgency, in the absence of other bladder diseases. Exclusion
measurement of pain and urgency, and O’Leary-Sant symptom
clinical diagnosis criteria are as follows: (1) bladder capacity
and problem indices, were administrated to measure the patient
greater than 350 c.c. on awake cystometry; (2) absence of and
perception of health status before (pre-test) and after (post-test)
intense urge to void with the bladder filled to 100 c.c. during
ICT intervention spanning a period of 2 months.
cystometry using a fill rate of 30-100 cc/min; (3) demonstration
The questionnaire results of pre- and post-tests were
of phasic involuntary bladder contractions on cystometry using
compared to observe if any difference in improvement of
the fill rate described in number (2); (4) duration of symptoms
quality of life between the study and control groups. The
less than 9 months; (5) absence of nocturia; (6) symptoms
outcome of the ICT intervention was evaluated based on the
relieved by antimicrobials, urinary antiseptics, anticholinergics,
improvement of the health status of the participating patients.
or antispasmodics; (7) frequency of urination while awake of
Figure 2 depicts the experimental procedure. As shown in this
less than eight times a day; (8) diagnosis of bacterial cystitis or
figure, ICT intervention provides health education for
R: Weekly Health Education F: Questionnaires F1: SF-36 Survey F2: O’Leary-Sant Symptom and Problem Indices F3: VAS Pain & Urgency Scales
consolidating healthy dieting habit and life-style. Since all the
applied to compare the improvement of health status and
recruited patients are female, the control variables used to
symptoms between the study and control groups. SAS was
eliminate variations between two groups include demographic
adopted as the tool for statistic analysis.
information, i.e., age, education, and marriage status. O’Leary-Sant symptom and problem indices and visual
analogue scale (VAS) pain and urgency scales were used to
Table III compares the SF-36 health survey of the IC/BPS
quantify disease severity of the patients.
patients between the study and control groups before ICT
intervention. It can be found that, except general health, there is
no significant difference (p>0.05, unpaired Student’s t-test) for the other 7 items between the two groups. The disease severity
IC/BPS patients are very sensitive to diets, such as foods,
quantified with O’Leary-Sant indices and VAS scales before
drinks, supplements, and spices [28-31]. Hence, to educate the
ICT intervention is compared in Table IV. As shown in the table,
patients in consuming healthy comestibles and preventing
the disease severity presents no significant difference (p>0.05,
contraindications is expected to be effective in preventing their
Student’s t-test) between patients in two groups.
recurrence. A web service was designed to promote healthy
diets and life styles for the patients by asking them to check and follow the diets and life styles suggested by the physician. The
service can be accessed by the patients after login to the web site
COMPARISON OF SF-36 HEALTH SURVEY FOR PATIENTS BETWEEN CONTROL
AND STUDY GROUPS BEFORE ICT INTERVENTION
of TICA (Taiwan Interstitial Cystitis Association) through an
Internet browser. The participating patients were asked to fill
the questionnaire of health education once a week to consolidate
their concepts of healthy diets and life-styles promoted by the
educational materials. We hypothesize that the patients will
learn to eat healthy diets and live with healthy life-styles to
prevent reoccurrence of IC/BPS outbreaks through repetitive
health education. The case manager can also learn the diets and
life-styles of individual patients through the web service. If the
Note: Unpaired Student’s t-test with *p<0.05.
patients forget to check the health educational materials, the
system will automatically send messages to remind them. Table
I lists the diets and life-styles suggested by the physician in the
COMPARISON OF DISEASE SEVERITY BETWEEN STUDY AND CONTROL GROUPS
F. Statistic Analysis and Outcome Evaluation
Descriptive statistics were used to analyze the demographic
information, disease severity, and questionnaires of the
recruited patients, while the inferential statistics (student’s t-test)
Table V compares the SF-36 health survey conducted after
ICT intervention with survey done before ICT intervention
It was reported that around 90% of the IC/BPS patients
for the patients in the control group. It can be observed that,
complain sensitive to diet foods, e.g. citrus fruits, tomatoes,
except the social function construct, all the other 7 constructs
foods containing vitamin C, drinks, e.g. coffee, tea,
demonstrate significant improvement. In contrast, as shown in
carbonated and alcoholic beverages, and spicy foods [28,30].
Table VI, all the 8 constructs of the SF-36 survey show
Gleason et al.  reported that high but lower caffeine intake
significant improvement after ICT intervention for the
is associated with a moderate increase in the incidence of
urgency inconsistence, which is consistent to the finding of
Jura et al. . The education materials presented in Table I
COMPARISON OF SF-36 HEALTH SURVEY FOR PATIENTS OF CONTROL GROUP
intend to remind the patients not to eat food containing a great
(N=32) BEFORE AND AFTER ICT INTERVENTION
amount of potassium as well as drink containing caffeine.
As reported by Lailly et al. , a good habit or behavior,
such as eating, drinking, or exercising behavior, will be
formed in a median time of 66 days ranging from 18 to 254
days for participants with good fits. Hence, the IC participants
were asked to check and follow the healthy dietary behavior
and life style suggested in the health education form weekly.
It is effective to consolidate their healthy behavior to prevent
re-occurrence or deterioration of the disease.
Note: Student’s pair t-test with *p<0.05 and **p<0.01.
In conclusion, the E-health system was demonstrated to be
effective in improving QOL of patients with IC/PBS through
intervention of Internet healthcare education for the consolidation of healthy dieting habit and life style.
COMPARISON OF SF-36 HEALTH SURVEY FOR PATIENTS OF STUDY GROUP
(N=33) BEFORE AND AFTER ICT INTERVENTION
This study was supported in part by Taichung Hospital under
grant no. CTU100-PC-002 and National Science Council of
Taiwan under grant no. NSC100-2410-H-166-007-MY3.
 Nickel JC, Tripp D, Teal V, Propert KJ, Burks D, Foster HE, Hanno P,
Note: Student’s pair t-test with *p<0.05 and **p<0.01.
Mayer R, Payne CK, Peters KM, Kusek JW,Nyberg LM, Interstitial
Cystitis Collaborative Trials Group. Sexual function is a determinant of
In Table VII, the improvement of SF-36 survey between
poor quality of life for women with treatment refractory interstitial cystitis.
the control and study groups is compared. Except the
constructs of role physical and role emotional, the degree of
 Moutzouris D-A, Matthew E. Falagas ME (2009) Interstitial Cystitis: An
Unsolved Enigma, Clin J Am Soc Nephrol 4: 1844-1857.
improvements for the study group is significantly higher than
 Zaslau S, Riggs DR, Perlmutter AE, Jackson BJ, Osborne J, Kandzari SJ
the control group (p<0.05), indicating the effectiveness of the
(2008). Sexual dysfunction in patients with painful bladder syndrome is
age related and progressive. Can J Urol 15, 4158-4162.
 Wehbe SA, Whitmore K and Kellogg-Spadt S. Urogenital Complaints and
Female Sexual Dysfunction (Part 1). J Sex Med 2010; 7:1704-1713.
COMPARISON OF IMPROVEMENT OF SF-36 HEALTH SURVEY FOR PATIENTS
urologist/urogynecologist. In: Goldstein I, Meston CM, Davis SR, Traish
AM, eds. Women’s sexual function and dysfunction: Study, diagnosis and treatment. Vol. 17. London: Taylor and Francis; 2006:708-14.
 Nickel JC. Interstitial cystitis-An elusive clinical target? J Urol
 Tincello DG, Walker AC. Interstitial cystitis in the UK: Results of a
questionnaire survey of members of the Interstitial Cystitis Support Group.
Eur J Obstet Gynecol Reprod Biol 2005;118:91-5.
 Laumann EO, Paik A, Rosen RC (1999) Sexual dysfunction in the United
States: prevalence and predictors. JAMA 281:537-544.
 Bogart LM, Suttorp MJ, Elliott MN, Clemens JQ, Berry SH (2011)
Prevalence and Correlates of Sexual Dysfunction Among Women With
Bladder Pain Syndrome/Interstitial Cystitis. Urology 77, 576–580.
 Leppilahti M, Sairanen J, Tammela TL, Aaltomaa S, Lehtoranta K,
Note: Unpaired t-test with *p<0.05, **p<0.01, and ***p<0.001.
Auvinen A, Finnish Interstitial Cystitis-Pelvic Pain Syndrome Study
Group. Prevalence of clinically confirmed interstitial cystitis in women: A population based study in Finland. J Urol 2005;174:581-3.
 Berry SH, Elliott MN, Suttorp M, Bogart LM, Stoto MA, Eggers P, Nyberg
L, Clemens JQ (2011) Prevalence of symptoms of bladder pain syndrome/interstitial cystitis among adult females in the United States. J Urol 186: 540-544.
 Altman D, Lundholm C, Milsom I, Peeker R, Fall M, Iliadou AN, Pedersen
NL (2011). The genetic and environmental contribution to the occurrence of bladder pain syndrome: an empirical approach in a nationwide population sample. Eur Urol 59, 280-285.
 Konkle KS, Berry SH, Elliott MN, Hilton L, Suttorp MJ, Clauw DJ,
Clemens JQ (2012) Comparison of an interstitial cystitis/bladder pain syndrome clinical cohort with symptomatic community women from the RAND Interstitial Cystitis Epidemiology study. J Urol 187(2),508-512.
 Forrest, J. B. (2006). Epidemiology and quality of life. J Reprod Med, 51(3)
 Michael, Y. L., Kawachi, I., Stampfer, M. J., Colditz, G. A., Curhan, G. C.
(2000). Quality of life among women with interstitial cystitis. J Urol, 164(2), 423-427.
 Ratner, V. (2001). Interstitall cystitis: A chronic inflammatory bladder
condition. World J. Urol,19, 157-159.
 Oravisto, K. J. (1975). Epidemiology of interstitial cystitis. Ann Chir
 Clemens, J. Q., Meenan, R. T., O'Keeffe-Rosetti, M. C., Gao, S. Y.,
Calhoun, E. A. (2006). Medical costs and medication use in women with interstitial cystitis. J Urol, 175 Suppl, 94-95.
 Wu, E. Q., Birnbaum, H., Mareva, M., Parece, A., Huang, Z., Mallett, D.
(2006). Interstitial Cystitis: Cost, treatment and co-morbidities in an employed population. Pharmacoeconomics, 24(1), 55-65.
 Celler, B. G., Lovell, N. H. & Basilakis J. (2003) Using information
technology to improve the management of chronic disease, MJA, 179, 242-246.
 Izquierdo, R., Meyer, S., Starren, J., Goland R., Teresi, J., Shea & S.
Weinstock, R. S. (2007) Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus, Therapeutics & Clinical Risk Management, 3(3), 485-489.
 Sehati, S., Fung, R. C. Y. & Nealon J. (2007) An Internet-enabled,
ambulatory patient monitoring and advice syste,, J Telmedicine & Telcare, 13(Supp. 1) 59-62.
 Curtis, D. W., Pino, E. J., Bailey, J. M., Shih, E. I., Waterman, J., Vinterbo,
S. A., Stair, T. O., Guttag, J. V., Greens, R. A. & Ohno-Machado, L. (2008) SMART- An integrated wireless system for monitoring unattended patients, J Am Med Inform Assoc, 15, 44-53.
 Park, M. J., Kim, H. S & Kim, K. S. ( 2009) Cellular phone and
Internet-based individual intervention on blood pressure and obesity in obese patients with hypertension, Int J Med Inform, 78, 704-710.
 Kim SI & Kim HS (2008) Effectiveness of mobile and Internet intervention
in patients with obese type 2 diabetes. Int. J. Med. Inform., 77: 399-404.
 Hanno PM, Burks DA, Clemens JQ, Dmochowski RR, Erickson D, et al.
(2011) AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 185(6):2162-2170.
 Gillenwater JY, Wein AJ. Summary of the National Institute of Arthritis,
Diabetes, Digestive and Kidney Diseases Workshop on Interstitial Cystitis, National Institutes of Health, Bethesda, Maryland , August 28–29, 1987. J. Urol. 1988; 140: 203–6.
 Friedlander JI, Shorter B, Moldwin RM (2012) Diet and its role in
interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU Int. 109(11):1584-91.
 Gleason JL, Richter HE, Redden DT, Goode PS, Burgio KL, Markland AD
(2012) Caffeine and urinary incontinence in US women. Int Urogynecol J. DOI 10.1007/s00192-012-1829-5
 Bassaly R, Downes K, Hart S (2011) Dietary consumption triggers in
interstitial cystitis/bladder pain syndrome patients. Female Pelvic Med Reconstr Surg. 17(1):36-39.
 Jura YH, Townsend MK, Curhan GC, Resnick NM, Grodstein F (2011)
Caffeine intake, and the risk of stress, urgency and mixed urinary incontinence. J Urol. 185(5):1775-80.
 Lailly, P, Van Jaarsveld, C. H. M., Potts, H. W. W. & Wardle, J. (2010)
How are habits formed: Modeling habit formation in the real world, Eur J Soc Psychol, 40, 998-1009.
Martyn T. Sama and Richard Penn Introduction Onchocerciasis is the world’s second leading infectious cause of blindness with an estimated 123 million people under risk, and about 18 million people in the world suffering a grave burden imposed by the disease (WHO 1997a). In Africa, some 17.5 million people are infected with Onchocerca volvulus (WHO Technical Report Series no.852). It is es
RASHAUN P. SOURLES 4750 E. 53rd St., Unit 103 Minneapolis, MN 55417 Tweet @rashaunps STRATEGIC BUSINESS DEVELOPMENT & MARKETING MANAGER Comprehensive experience in sales, marketing and new business development—including personal client relations, project leadership and total account management. Skilled in strategic planning and high-impact, target marketing; deter